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According to Mahoney (1995), an individual’s cognitions are viewed as covert behaviors, subject to the same laws of learning as overt behaviors. Since its inception, cognitive-behavior modification has attempted to integrate the clinical concerns of psychodynamic psychotherapists with the technology of behavior therapists (Mahoney, 1995). Cognitive-behaviorists have demonstrated an interrelationship among cognitive processes, environmental events, and behavior, which is conveyed in the context of one’s social behavior. Psychotherapists in North America endorse cognitive-behavioral interventions as the second most widely used treatment approach (i.e., with an eclectic approach being endorsed as first) (Bongar & Buetler, 1995). The cognitive processes that serve as the focus of treatment in CBT include perceptions, self-statements, attributions, expectations, beliefs, and images (Kazdin, 1994). Most cognitive-behavioral based techniques are applied in the context of psychotherapy sessions in which the clients are seen individually, or in a group, by professional therapists. Intervention programs are designed to help clients become aware of their maladaptive cognitive processes and teach them how to notice, catch, monitor, and interrupt the cognitive-affective-behavioral chains to produce more adaptive coping responses (Mahoney, 1994). Donald Meichenbaum is one of the founders of cognitive-behavioral modification and was voted one of the "top ten most influential psychotherapists of the century" in a survey reported in the American Psychologist (interestingly, four of the ten therapists were cognitive-behaviorists) (Bongar & Buetler, 1995). Meichenbaum is a clinical psychologist who has invented and utilized some of the most operationally defined techniques of cognitive-behavioral therapy. Meichenbaum’s most famous piece of work, Cognitive-Behavior Modification: An Integrative Approach is considered a classic in the field of CBT. Meichenbaum bridged the gap between the clinical concerns of cognitive-semantic therapists (e.g. Albert Ellis and Aaron Beck) and the technology of behavior therapy. He was greatly dissatisfied with behavior therapy techniques because they overemphasized the importance of environmental events (antecedents and consequences) and therefore underemphasized, and often overlooked, how a client perceives and evaluates those events (Meichenbaum & Cameron, 1974). The disorders successfully treated by cognitive-behavioral methods include: depression, anxiety disorders, social phobias, bulimia nervosa, conduct disorder in children, schizophrenia, relapse prevention with substance abuse, marital distress, and Post Traumatic Stress Disorder (PTSD) (Bongar & Buetler, 1995). As an expert in the treatment of PTSD, Meichenbaum has treated all age groups for trauma suffered from violence, abuse, accidents, and illness. Meichenbaum describes seven essential tasks encompassing a cognitive-behavioral therapeutic approach, which he finds crucial for a successful outcome in all forms of psychotherapy. These tasks are described sequentially and they take place over the course of therapy; being addressed as the client and the therapist sample techniques from them as needed. Most CBT clients are able to complete their treatment in just a few weeks or months - even for problems that traditional therapies often take years to resolve, or are not able to resolve at all. According to Meichenbaum (1996), the quality and nature of the therapeutic alliance between the client and the therapist accounts for more variance in treatment outcome studies than does any other set of variables (except client characteristics). It is essential that the first task of therapy be to develop a therapeutic alliance and encourage clients to tell their stories (Meichenbaum, 1996). The development of a therapeutic alliance and a working collaborative client-therapist relationship is critical in all forms of psychotherapy. A genuine, compassionate, empathic, emotionally-attuned, nonjudgmental, stance by the therapist facilitates a healthy therapeutic alliance and encourages the clients to tell their story at their own pace. Meichenbaum (1977) believes that a therapeutic relationship is the glue that makes the therapeutic procedures work. Following the client restating his/her story, the therapist highlights what exactly the client did to cope, survive, and even thrive despite the ongoing stress resulting from the experience. The second task of cognitive-behavioral treatment is to educate clients about the presented clinical problem (Meichenbaum, 1996). For example, if a client seeks therapy because of anxiety, the therapist would explain to the client what anxiety behaviorally looks like and would inform the client of the cycles of anxiety. The client must then become an observer of his/her own behavior. Through heightened awareness and attention, the client may monitor his/her thoughts, feelings, physiological reactions, and interpersonal behaviors (Meichenbaum 1977). The tests that are administered and reviewed with the clients, the self-monitoring procedures used by clients, the information provided to the clients about their presenting problem, and the information conveyed about relapse prevention (coping techniques and warning signs) are all elements of the educational process (see Appendix A). Although this is only the second task of CBT, it is revisited throughout the therapeutic process as the client continues to be educated about his/her presenting problem and learns new adaptive coping skills. During the third task, the therapist helps the clients reconceptualize their problems in a more hopeful fashion. In this step, the therapist enables his/her clients to reorganize their thought processes of their predicaments in problem-solving-oriented terms that will lend them to helpful solutions. Meichenbaum (1996) stresses the important role of hope by observing that clients seeking cognitive-behavioral treatment demonstrated a 60% to 80% symptomatic alleviation of depression within the first four therapy sessions due to reconceptualizing their stories. This occurred well before the usual introduction of techniques specific to the treatment of depression, such as cognitive restructuring. However, reconceptualizing or reframing a problem alone rarely helps clients achieve the functional level they seek (Meichenbaum, 1996). The fourth task of therapy is ensuring that clients attain the necessary coping skills. In this step, the therapist teaches clients a variety of intrapersonal and interpersonal coping skills to help them manage problematic situations. These skills include: self-monitoring, relaxation retraining, self-instructional training, cognitive restructuring, assertiveness training, and relapse prevention skills. Cognitive restructuring procedures are designed to modify the client’s thinking and the premises, assumptions, and attitudes underlying the client’s thoughts (Meichenbaum, 1977). The goal of self-instructional training is to teach impulsive clients to spontaneously provide themselves with inhibitory cues at incipient stages (Meichenbaum, 1977). Meichenbaum and Goodman (1971) provide evidence that cognitive self-instructional training was successful in decreasing impulsive responding, confirming that when a client utilizes self-instructions, behavior change occurs and treatment effectiveness is enhanced. If standard behavior therapy procedures are augmented with a self-instructional package; greater treatment efficacy, more generalization, and greater persistence of treatment effects are obtained (Meichenbaum & Goodman, 1971). The first step in Meichenbaum’s approach of self-instruction is to help the client identify his/her negative statements that the client makes to him/herself. Next, the client learns self-talk to counteract the negative self-statements in the presence of stressful situations. Third, the client is taught to self-instruct the steps for taking appropriate action. Finally, the client is instructed to make self-reinforcing statements immediately after he/she has successfully coped with the stressful situation (Martin & Pear, 1999). These learned skills will inevitably bolster the client’s self-esteem and sense of self-worth. Psychologists can depend on their subjects to talk, even if only to themselves; whether relevant or irrelevant, the things people say to themselves determine the rest of the things they do (Meichenbaum, 1977). The fifth task is for the therapist to encourage clients to perform personal experiments. Each client needs to gather data that demonstrates an empowering and enabling self-concept, which can confirm positive change due to the therapeutic process (Meichenbaum, 1996). This is accomplished through working with clients so that they will view their automatic thoughts as hypotheses worthy of testing, rather than as God-given assertions. Clients are encouraged to adopt the stance of a scientist so that they can view their coping efforts as experiments that are designed to provide them with evidence that can be used to unfreeze their maladaptive thoughts about themselves and the world (Meichenbaum, 1996). For example, a therapist can have clients write out their predictions of how they think they will do when performing an experiment of assertive behavior. Following the experiment, the client can compare their prior hypothesis to what actually occurred. The data obtained from the personal experiments also shows the therapist and the client whether their therapy techniques are working. The sixth task of therapy is to ensure that clients take credit for changes they have brought about. Clients may resist therapy by dismissing, discounting, and negatively reframing the outcomes of their personal experiments; clients do not readily accept their collected data as truthful evidence (Meichenbaum, 1996). It is critical for clients to take credit for the change and to provide self-explanations of how they brought about the change. A specific intervention that therapists can employ to ensure that their clients do take responsibility for and ownership of the changes they have brought about is to ask the clients what they specifically did to foster the improvements. The final step in CBT involves the therapist and client engaging in conduct relapse prevention. The final task should be an educational exchange about possible lapses and setbacks. The therapist explains to the client that lapses should be expected and anticipated, and should be viewed as opportunities for the client to practice their coping skills, rather than occasions to catastrophize (Meichenbaum, 1996). In addition, these final sessions serve the purpose to educate the client to anticipate high-risk situations, recognize their warning signs, and to further develop coping techniques. The therapeutic objectives for the cognitive-behavioral therapist are to make clients aware of the bi-directional, transactional, and reciprocally deterministic nature of their behaviors, and of the ways in which they may be biased and maladaptive (Bongar & Buetler, 1995). Cognitive-behavioral therapy proposes that if a therapist wishes to assist a client to change his/her behavior, there is a need for the client to develop awareness of unconscious maladaptive thoughts and feelings and their effects on behavior (Bowers & Meichenbaum, 1984). The treatment goal of the cognitive-behavioral therapist is to develop a therapeutic means of accomplishing the above described learning processes in a nondidactic, user-friendly, collaborative, emotionally meaningful, experientially based fashion. In addition to being one of the founders of the cognitive revolution in psychotherapy and a major proponent of the cognitive-behavioral perspective, Meichenbaum devoted seven years to intensive research with clients living with PTSD. According to Meichenbaum (1994), traumatic events can shatter one’s basic assumptions about the world and can violate and invalidate one’s core beliefs. These events also over-sensitize one to trauma-related cues that feeds into, and is in turn, affected by the ruminations, flashbacks, and avoidance behaviors that characterize PTSD. Meichenbaum (1994) was fascinated with how people described their experiences and how their accounts changed over time. This fascination prompted Meichenbaum to publish a clinical handbook for the specific treatment of PTSD, in which he has elaborately described the three phases of therapy for this specific population. The first phase is to establish a therapeutic relationship (as described above in the first task of CBT). During this process, the therapist educates the client about PTSD, validates the client’s experience, and assesses the impact of the trauma. The second phase is to address the target symptoms. At this point, the therapist will identify the stressors, the client’s reactions to the stressors, implement a relaxation training regime, perform systematic desensitization, and assess whether the client is in need of medications. Meichenbaum (1994) describes the four features of relaxation training that are crucial for the implementation of systematic desensitization. First, the client learns to control his/her breathing rate by slowly inhaling, holding to a point of comfort, and slowly exhaling through the mouth. The second step is for the client to use self-regulatory self-statements (i.e., “relax” and/or “be cool”). Third, the client should be told that learning to use relaxation training and breathing control procedures are skills that require practice. Finally, the client obtains data to support that such controlled breathing can have a direct physiological effect (Meichenbaum, 1994). This may be accomplished by directing the client to record his/her heart rate before and after relaxation to confirm that the client has accomplished the task of achieving relaxation. In systematic desensitization (developed by Joseph Wolpe) the fearful client, while deeply mentally relaxed, is asked to imagine a series of progressively more fearsome situations that fall along a continuum (Meichenbaum, 1977). The responses of relaxation and fear are incompatible and as a result, fear is dispelled. Phase three involves restructuring the client’s story. This includes restructuring the meaning of the story and perhaps changing the meaning of the story for the client. As the therapist begins to understand the significance of the meaning behind the story and discovers how the stressful occasion was experienced, he/she accomplishes the first task of altering the meaning (Meichenbaum, 1994). The therapist maintains a here-and-now focus to restructure what happened by taking the client back to the location through imagination and allowing the client to respond to the stress. The client is asked to report any feelings and thoughts that preceded, accompanied, and that followed the incident. This process enables clients to recognize how they behave, appraise situations, think, and feel, which may inadvertently contribute to their problems. As the client to come to terms with the traumatic experience, the therapist teaches the client how to develop supportive relationships (perhaps through getting the family involved with therapy), and shows the client how crucial their own coping techniques were in enabling him/her to cope with the traumatic event. The goal of these phases of therapy for PTSD clientele is to have them address what life would be like if a miracle occurred and the traumatic ordeal was over (Meichenbaum 1994). In doing this, the therapist shifts the perspective of the client from victim to survivor. As one of Meichenbaum’s clients stated, “I was victimized, I was in a fight that was not a fair fight. I have reached the stage of survivor and am no longer a slave of victim status. I look back with sadness rather than hate. I look forward with hope rather than despair. I was a victim, I am a survivor” (Meichenbaum, 1994). The shifts in language that the clients use and the metaphors they employ from victim to survivor have important implications for how they appraise traumatic events and how they construct narratives (Meichenbaum, 1994). Termination of therapy involves discussing with the client what the future holds for him/her. During the termination of therapy, the therapist educates the client ways to look out for triggers (i.e., anniversary relapse) and they collaboratively discuss what kind of recovery work needs to be done in terms of relapse prevention, such as having a booster session if the client finds him/herself in a troublesome situation and need assistance. Behavior change occurs through the sequence of intertwined processes involving the interaction of self-instruction, cognitive structures, and behavior and their resultant outcomes. Prior to CBT, a client’s internal dialogue about his/her maladaptive behaviors is likely to be repetitive and unproductive, contributing to a sense of helplessness and despair. The client must attend to his/her maladaptive behaviors and begin to notice opportunities for adaptive behavioral alternatives if he/she is to produce behavioral-cognitive-affective changes (Meichenbaum, 1977). CBT provides clear structure and focus to treatment; the therapist continues with the steps and changes course only when there are sound reasons for doing so. When combined into CBT, behavior therapy and cognitive therapy provide clients with very powerful tools for stopping their symptoms and getting their life on a more satisfying track. As the philosopher Epictetus said almost 2,000 years ago: "The thing that upsets people is not what happens but what they think it means." Bongar, B., & Buetler, L.E. (1995). Comprehensive Textbook of Psychotherapy. Oxford University Press, New York. Bowers, K.S., & Meichenbaum, D. (1984). The Unconscious Reconsidered. John Wiley & Sons, Inc. Canada. Kazdin, A. E. (1994). Behavior Modification in Applied Settings. Brooks/Cole Publishing Company, Pacific Grove, CA. Mahoney, M. J. (1995). Cognitive and Constructive Psychotherapies. Springer Publishing Company, New York, NY. Martin, G., & Pear, J. (1999). Behavior Modification: What it is and How to do it. Prentice Hall, Upper Saddle River, New Jersey. Meichenbaum, D., & Cameron, R. (1974). The clinical potential of modifying what clients say to themselves. Psychotherapy: Theory, Research, and Practice, 11 (2), 103-117. Meichenbaum, D., & Goodman, J. (1971). Training impulsive children to talk to themselves: A means of developing self-control. Journal of Abnormal Psychology, 77, 115-126. Meichenbaum, D. (1977). Cognitive-Behavior Modification: An Integrative Approach. Plenum Press Publishing Corporation, New York, NY. Bibliography: Word Count: 2762
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