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Towards the Integration of Behavior Therapy and Cognitive Therapy
by, Dr. Brian Campbell

 

Many of the theories you have studied thus far have incorporated cognitive therapy concepts that involve the basic notion of helping identify and change irrational thinking, self-talk, toxic parenting “tapes,” or “misbeliefs.”  The term Cognitive-Behavioral Therapy (CBT) therapy has been utilized or implied in this context.  Unfortunately, little, if any, specific information has been provided regarding the “behavioral” technology that forms the second half of the “Cognitive-Behavioral” treatment paradigm. 

 

The absence of detailed training in behavior modification techniques is underscored by the fact that a graduate level course in behavior modification is not required in the counseling program at Liberty University.  Fortunately, an overview of behavior modification is provided in the “Theories of Counseling” course.  However, despite this introduction to behaviorism, it is my impression that the link between these two treatment modalities has not been made explicit.  In an attempt to address this “disconnect,” I want to take a few moments to describe how I view the integration of “behavior therapy” and “cognitive therapy.”  I will begin by telling a story.

 

At one point in my career, the main treatment modality I utilized was behavior modification.  I learned this technology under the instruction of my mentor in my postdoctoral fellowship--Dr. James Mulick.  Dr Mulick was a “purist” in terms of his whole-hearted adoption of behavior modification technology (utilizing operant conditioning and applied behavior analysis) as the only valid and objectively scientific approach to treating psychological problems and disorders.  Under Dr. Mulick’s watchful eye, I developed a behavior modification treatment program in a local state hospital for “mentally handicapped” individuals. 

 

The program that Dr. Mulick and I developed focused on treating extremely violent and aggressive clients utilizing behavior modification technology.  To my surprise, we were highly successful in reducing even the most extreme and long-standing maladaptive behaviors, while at the same time significantly increasing adaptive behaviors.  Later on, I would take what I had learned from Dr. Mulick to Nova University, where I was hired as an Assistant Professor of Clinical Psychology.

 

Not long after arriving at Nova, I decided to utilize my new-found knowledge and therapeutic skills to open up a behavior training program in South Florida State Hospital.  Once again, this program focused on treating extremely violent and aggressive clients.  Most of these individuals were “dual-diagnosed” (mentally handicapped and psychotic).  Our program was extremely successful, but not without its “hic ups.”  This brings my story to a client named Martha (pseudonym).

 

Martha was a very large woman (250 pounds) who was extremely strong.  For many, many years, she had been tied down in a chair in one of the back wards of the hospital.  She was restrained because if she was released from the restraints, she would bite people.  When my staff and I started treating her, she had already bitten off someone’s finger, another client’s nose, and the nipple of one of the female nurses.  Because Martha was physically restrained most of her life, she had, in effect, been doing isometrics—as she struggled to get out of her restraints.  This accounts for her fourteen-inch biceps.

 

As our team worked with Martha, it was clear that she had “good days” and “bad days.”  At one point, when we initially confronted her in the behavior training unit, we ended up having to hold her down on a mat for twelve hours because of her extremely “out-of-control” behavior.  It took six strong men to accomplish this.  I was the “little guy,” and at one point while we were holding her in a prone position on a mat (with her arms pinned to her sides), she lifted me entirely off the ground—backwards-- with one arm. 

 

Needless to say, it was to everyone’s advantage to get Martha under control quickly.  In subsequent weeks, she continued to have numerous extremely violent and aggressive episodes.  However, her behavior was not always or consistently problematic.  In fact, on many occasions her behavior was perfectly fine as she worked the entire day sorting bolts and screws in our “workshop.”  This was surprising, since “nothing changed” in the workshop setting.  From an experimental perspective, all the stimuli in the environment were “held constant.” 

 

So, the obvious question for me was, “Why was her behavior perfectly ok on some occasions, but outrageous on other days?”  Remember, almost nothing changed in our “Clockwork Orange” type environment.  Clearly, the answer to this question could not be discerned strictly by an analysis of her environment or a “functional analysis” of her overt behavior.  Then one day, I had an epiphany! 

 

While we were holding Martha down on a mat, I heard her mumble, under her breath, “My mother is going to whup you.”  She’s going to get you.”   Then it dawned on me.  Perhaps what was determining whether or not Martha was going to have a good day or a bad day, was not related to factors immediately observable in her environment.  Perhaps what was causing the changes in her behavior (from good to bad) was the presence of her aggressive thoughts.  

 

This incident marks the point in my career that I switched my focus from strict behavior modification to a combination of behavior modification and cognitive therapy.  In subsequent days and weeks when we were treating Martha, I started focusing on punishing her thoughts (such as, “My mother is going to whup you”).  I did this by challenging her irrational thoughts while she was being physically restrained by the staff.  For example, I might say, “Well, Martha…If your mother is going to come and “Whup” us, where is she?”  “Why hasn’t she come to rescue you?”  This might sound harsh treatment to the uninitiated, but I was trying to save this woman’s life.  I was delighted when this strategy (punishing her aggressive thoughts) worked, and her behavior improved significantly. 

 

In fact, Martha improved to the point that she was eventually able to be free of restraints when she returned to her ward after a day at the behavior-training unit.  Over the next several weeks, she kept improving and she eventually entered a group home located on the hospital grounds where she lived with others (without restraints).  Not only that, the last time I asked about her, she had graduated from the hospital setting and was living in the community in a group home for mentally handicapped individuals.

 

With the remarkable success of my newfound “cognitive-behavioral therapy” of Martha “under-my-belt,” I proceeded in earnest to study everything I could about the topic of cognitive therapy.  As I progressed in my knowledge, I had another epiphany.  I realized that I could utilize all of my behavior modification techniques (that I had learned under Dr. Mulick) and apply the very same technology to the “covert” behavior of thinking.  Let me attempt to explain…

 

Most people fail to understand that behavior modification concepts such as punishment and reward can be directly “applied” to thinking (“cognitions”).  That is, when I am providing Christian counseling, in my mind, I am conceptualizing how I can punish irrational beliefs and reward appropriate beliefs. 

 

For example, I might punish a pastor’s faulty belief (which leads to faulty thinking) that he should be allowed to have affairs with other women.  I might punish this belief (and associated faulty thinking) by: gently questioning the validity of his belief; challenging the Biblical accuracy of his belief; silently listening to him, but not affirming his belief (the behavioral term here is called “extinction”); or, directly and vigorously confronting him regarding his irrational belief.  At the same time, I would reward any more “rational” and “logical” thinking, by:  verbally praising him, or nodding (nonverbally) in agreement when his statements started to reflect that he was changing his irrational thinking to a closer approximation of the “truth,” etc.

 

If you are following this line of reasoning, you will perhaps see that the logical “extension” of my argument is that literally all of the science of behavior modification is directly applicable to the science of cognitive therapy.  It is safe to say that most people are not aware of the potential benefits that result from the “marriage” of the two disciplines.  As for myself, I could not function as a Christian counselor without my knowledge of the science of behavior modification.  For example, I don’t simply flounder around and hope that an individual will change his or her beliefs or associated faulty thinking.  I have a proven arsenal of “tools” to effect change and shape progress in the “cognitive” life of my clients.

 

To be sure, I use scriptures in counseling and I pray a lot.  I ask the Holy Spirit to guide and direct me and give me words when I don’t know what to say.  However, in addition to integrating theology and spirituality into my counseling, I also use the time-honored tools of behavior modification to help my clients.  These tools come in handy when I am attempting to help my client: “demolish arguments and every pretension that sets itself up against the knowledge of God, and…take captive every thought to make it obedient to Christ” (2 Corinthians 10:5).