> Let us now look at cognitive behavior therapy. And the last presentation was on behavior therapy. And really, the distinctions between behavior therapy and cognitive behavior therapy, or CBT, are very fine, and nowadays frequently, the word behavior therapy has really been consumed in the word cognitive behavioral therapy. I mainly had two chapters on this, because if I had one it would be humongously long. But I want you to note that there are a lot of overlapping and blending. And of all the therapies, cognitive behavioral therapy is probably the most popular approach and the most often-practiced in the widest number of settings, and that's probably because it offers so many things that fit in with the sign of the time of cost effectiveness and getting people in and out as quickly as possible. Brief therapy is in nowadays, and being able to demonstrate indeed that the therapy is working is in. And CBT, cognitive behavioral therapy, does both. It's cost-effective, it tends to be brief, and it shares with behavior therapy the emphasis on empirical validation. So CBTers are very interested in using strategies and techniques that have support from the research literature. One thing I want to stress is that behavior therapy and cognitive behavior therapy do not ignore the quality of the therapeutic relationship. I want to stress that again. It doesn't ignore the therapeutic relationship. As a matter of fact, behavior therapists and cognitive behavior therapists will assert that to do effective cognitive behavioral work, to do effective therapy, you have to have a quality relationship. You need rapport. The client needs to trust the therapist. The therapist needs to be present, engaged, involved, active, you see. So it's not enough just to be skilled at having a whole armamentarium of counseling skills that are cognitive behavioral to implement on a path of client. You really need a good working alliance. And it goes by different words -- working alliance, therapeutic relationship, therapeutic alliance, a good client-therapist relationship, but it's all basically the same, meaning that the therapist and the client have to be on the same page. They have to have quality relationship if the therapy is really to take root and work. So keep that in mind. By the way, Carl Rogers with person-centered therapy, Rogers would say, all you need is primarily the relationship. That in itself and the three factors, remember the realness of the therapist, the unconditional positive regard, and empathy, and communicating those attitudes and way of being to the client, was sufficient to bring about change. Now, cognitive behavior therapists will say, it's necessary to have those core therapeutic conditions that Rogers talked about, but not sufficient. You need a set of concrete empirically supported skills, and you need knowledge to know what techniques to use with what clients. So hope you can see that. Going to talk about three different big branches of cognitive behavior therapy -- Albert Ellis's Rational Emotive Behavior Therapy, Aaron and Judy Beck's Cognitive Therapy, and Donald Meichenbaum's Cognitive-Behavior Modification. There are a lot of other approaches that are considered cognitive behavioral, but those are three of the bigger ones, and so I'm mentioning those. Albert Ellis, briefly. Albert Ellis believed that -- and all of these agree to this -- that thinking is what causes our emotional and behavioral problems. Ellis would say the route to changing peoples' dysfunctional behavior then, or your dysfunctional feelings, if you want to call it that, is to change your thinking. So Ellis and most of the cognitive therapists, would say, well, if you've got a behavioral or emotional problem, what you need to do is change the beliefs that you hold, particularly faulty beliefs, or as Ellis would call them, irrational beliefs. And then if you change your irrational beliefs, Ellis would say, then you'll change behavior and emotion. The experiential approaches, which I talked about earlier, person-center, existential and Gestalt, those therapies say the route to change is primarily working emotionally. Emotionally-focused therapies say, one way to change people is by working on their feelings. If you change what people are feeling, then their thoughts and their behaviors change. Well, you see we're holistic beings, so if you change what you're feeling you're going to probably change how you're thinking and behaving. If you change what you're thinking, you'll probably change behavior and emotion. And if you change your behavior, you're bound to experience emotional and behavioral changes. So being holistic integrative beings, if you change one aspect of human functioning, others will change also. Ellis has what's called an ABC theory. Let's say you apply to graduate school and you don't get in and then you get depressed and then you start telling yourself, see, I'm a no goodnick. This proves I'm basically inferior, and I should never go on to graduate school. Ellis would say, it's not the fact that the graduate school didn't accept you that you have dysfunctional beliefs or behaviors, but it's your belief. So A is the activating event; in other words, you apply to graduate school, you don't get in. B is your belief about that, about not getting in. And C is the consequence. So C might be, see, this proves I'm innately inferior and I'm never going to apply to another graduate school. Well, you could change your belief and say, maybe they're only accepting 12 people, and 212 applied. So it doesn't have to do with my lack of wisdom. Maybe it has to do with a very few spots. You see, if I change my thinking my way and say, I'm going to apply to another university, or I'll apply again, or I'll put myself on a waiting list. So I think Ellis has a lot to offer here, because he teaches his clients how to actually confront vigorously their what he calls irrational beliefs. Irrational beliefs are things that we hold to dearly and tenaciously, like, I must be approved of everyone universally, everyone has to like me, I can never make a mistake, any endeavor that I hope to achieve like graduate school, if I have a detour in the road, that's awful and I can't stand it. Ellis would say all those are demanding, absolutistic beliefs that lead us to a path of problems, and he would say if we could change our thinking and not be quite so rigid in our thinking and simply substitute demands for preferences, I'd prefer to get into a graduate school of my choice; if I don't get in it, tough, I'll find another graduate school that will accept me, you see. I should mention that there are a lot of ways of doing REBT besides Ellis's way. He tended when he was alive -- he died a couple of years ago, in '94, he was active right 'til the end. He was a show person. He was an actor. He would get up on stage and he was very charismatic. He had a way of turning people off. He was quite abrasive. He peppered his language with four-letter words, didn't utter a sentence without some kind of foul language that would turn off some people. But I never saw him attack his client. He challenged their beliefs. He would say, where did you pick up that nutty thought? But he wouldn't attack them personally. But you don't have to be like Ellis to practice REBT. You can again like Carl Rogers, not all people can practice the way Rogers practiced, and not everybody can or should be followers of Ellis -- God help us. Ellis, he was unique, and you don't want to copy his style. And he would even say, you can find your own style; just so long as you don't cave in to wanting to be liked and approved by your client. By the way, Ellis used to say, your client doesn't have to like you or approve of you, and you don't need to establish a warm, empathic relationship. In fact, Ellis might say that if your relationship is too warm and you're too exuding of warmth, you might not be hard enough and tough enough of a client. So there's some differences. But Ellis did say, in agreement with Rogers, unconditional positive regard is essential. So Ellis would teach his clients to accept themselves in spite of the fact that they were human beings with human frailties. He'd say, accept your imperfections and don't be so hard on yourself. Ellis is constantly encouraging his clients to lighten up on themselves and to take reality with a larger grain of sand. And he used all kinds of interesting cognitive, emotive and behavioral techniques. Like he would actively argue with clients about where did you pick up that idea, to challenge their beliefs. He would also use a lot of humor to get people to kind of lighten up on their internal self-critique. Let me move on to another type of cognitive therapy. It's called cognitive therapy with Aaron Beck, who is the founder. Aaron Beck did a great amount to popularize cognitive therapy, and it's a branch of cognitive behavioral. He's now in his early 90s, and his daughter, Judith Beck, is a co-founder and a co-director of the Beck Institute. And she's very active in writing books, giving workshops, and doing trainings. So both Becks, the father and the daughter, are very active in promulgating and teaching therapists how to use cognitive therapy. I should say that this approach has a lot of empirical support. Aaron Beck did a great deal to help people who are suffering from depression overcome depression largely with cognitive methods, cognitive change. Aaron Beck, but he's very different than Ellis, where Ellis would attack your faulty beliefs and argue with your faulty beliefs. Aaron Beck and Judy Beck take a more laid-back Socratic approach, and they would say, okay, you think you have to be perfect and you failed statistics and you're saying you ought to drop out of the doctoral program because you failed statistics that shows that you're innately inferior and you shouldn't go on for a doctoral degree. Where's the evidence for that? Who told you that you have to pass every course the first time? So they don't so much teach clients about faulty thinking, or they would call it inaccurate thinking or automatic thoughts, but they work collaboratively with you as a client to examine your thoughts to see how your thoughts might be leading you into problematic areas in your life. So depression and anxiety, the Becks would say that's largely due to cognitive errors that we make. So they have a lot of very specific approaches that they teach their clients. This is really a psycho-educational approach that's time limited, structured, and provides the therapists with feedback from the client at each session. So every session in cognitive therapy starts with agenda building, what are we going to talk about today, and the client and the counselor together will collaboratively identify what they're going to talk about. Then there's a session, the therapist does some teaching, the therapist talks about where did you have problems in your last week of living, and then the end of the session, homework is almost always assigned, but that's done collaboratively. Rather than the therapist saying, for next week I want you to, the therapist says, how can we ensure that you'll put in to practice some of the things you learned today at school, at work, at home during the week? So the last ten minutes or so are used in a session to design actually homework. Then the next session they'll check in to see how that homework went. Another approach is called Cognitive-Behavior Modification, Donald Meichenbaum, and he's very prominent today. He gives workshops all over the country and internationally, and he's doing a lot on post-traumatic stress syndrome. PTSD, a lot with returning veterans and people who have suffered trauma. He's using what he calls stress inoculation training, which is behavioral and cognitive, to help people work through areas of past injury. So he's primarily cognitive behavioral, but he would argue that he's very interested in peoples' thinking and feeling. In fact, he'll say thinking and feeling are two sides of the coin, that if you flip the coin, one side is cognition, but the other side is feeling. So Meichenbaum would says he's very interested in having his clients talk about their emotional pain. So a veteran who has issues about horrible memories, can't sleep and all that, he'll want them to relive that and talk about that. And Meichenbaum did a lot about stories that people tell one another about their lives and about their events. And Meichenbaum goes back to his mother, and he said, my mother would tell stories and she would embellish it and give every single detail. It gave him some ideas of how he could start therapy by listening to the stories of his clients. But he's very experiential, very relationship-oriented. He would say, you can't do good therapy without having a very good connection with your clients. And very funny, and very dynamic, and very active and very collaborative. So Don Meichenbaum is a contemporary cognitive behavioral therapist. This approach, as well as behavior therapy, are ideally suited for working in multi-cultural counseling situations, because you're really working with a psycho educational approach, time-limited approach. You're adapting the technique to the particular characteristics of the client, and to the client's culture. So this approach, all of these approaches, Beck, Ellis, and Meichenbaum, are very aware of what is the client's culture and how might the client's culture and problem be related? And there's a respect for understanding the client's culture and using techniques that are congruent with the client's culture. So a good CBT therapist is not going to use a technique that would offend a client. If the client says, I'd have a hard time with that role play, the therapist isn't going to say, I insist you do that. So behavior therapy and CBT offers a lot by way of working in all aspects of diversity, not just cultural diversity. So hopefully you'll see that there's a lot from CBT that you can use irrespective of your theory. You may be primarily existential or person-centered and want to incorporate some CBT techniques, and that's perfectly okay, so long as you do so with awareness. So this is a good theory, and I hope you come to appreciate it.