Clasificación de las medidas de mitigación

The more popular part of the second wave was the advancement of cognitive therapies. In 1958, Albert Ellis proposed the first cognitive psychotherapy methods, sug- gesting that clinicians help their clients by teaching them to alter their thinking. Ellis’s

theory, currently called rational emotive behavior therapy (REBT), suggests that when a client holds an irrational belief about things that happen in his life, he is more likely to feel negative emotions and to act dysfunctionally. And if he can replace the irratio- nal beliefs with more rational beliefs, then he might behave more appropriately toward desires and experience less negative feelings when presented with adversity. This type of clinical intervention was similarly suggested in the early 1960s by Aaron Beck, who pro- posed that individuals are often emotionally affected by the way they cognitively distort interpretations of their world, their future, and their self (Beck, 1963; Beck, Rush, Shaw, & Emery, 1979).

The cognitive model. Coincidentally, this part of the second wave can also be talked

about with an A-B-C model. Although the different brands of cognitive therapies some- times use different terminology, the general consensus in cognitive therapy is that there are activating events (A; Ellis, 1975) or actual events (A; Beck et al., 1979) that occur in the environment. These events can be public or private. When an A occurs, individu- als then hold certain interpretations or beliefs (B) about the A. When these beliefs (B) about the A are irrational or faulty, this leads to negative and unhealthy consequences (C). Cognitive therapy pioneers suggest that the therapy is founded on rational philoso- phies, and both Beck and Ellis quote Epictetus (AD 55–138) to demonstrate the legacy of the rational approach: “Man is disturbed not by things, but by the views he takes of them.” The philosophical legacy of this approach is also seen in the following quotes that are often used in discussing cognitive therapy:

The universe is transformation; our life is what our thoughts make it. —Marcus Aurelius (AD 121–180)

There is nothing either good or bad but thinking makes it so. —Shakespeare (1564–1616)

The “correction of misconceptions.” Arnold Lazarus (1972), whose work is also found

in the first wave, suggested during the cognitive revolution that “the bulk of psychother- apeutic endeavors may be said to center around the correction of misconceptions” (p. 165). This “correction of misconceptions” makes up the bulk of the interventions from the cognitive revolution. Whether the client’s negative thoughts are verbally disputed or reality tested experientially, the main idea is to replace the faulty or irrational cognition with an alternate cognition that works better.

In the cognitive therapy approach of Beck and others, the therapist describes how thinking influences feeling, and holds that if a person has certain cognitive distortions (such as inaccurate beliefs about the self, others, or the world), he is quite likely to feel negative emotions. This cognitive therapy approach contends that correcting these

Clinical Behavior Analysis and the Three Waves of Behavior Therapy 27

cognitive distortions through reality testing or reattribution techniques will lead to improved clinical outcomes. For instance, in Cognitive Therapy of Depression (Beck et al., 1979), the authors use an example (p. 165) of a clerical worker who has a brief inter- action with a nurse where the female nurse says, “I hate medical records,” and treats the clerical worker curtly. According to the vignette, the clerical worker reports feeling sadness, slight anger, and loneliness. When the clerical worker is asked to write down the cognitions associated with this experience, the worker writes, “She doesn’t like me.” The cognitive therapist takes this cognition and shows the client that he is personalizing and making an arbitrary inference about the interaction. The cognitive therapist then attempts to correct these cognitive distortions through reality testing and reattribution. When therapist and client consider other interpretations, the clerical worker may realize that the nurse is just generally unhappy, or that her hatred of medical records is not equivalent to hating medical record clerks. The clerical worker may correct the distor- tion by recognizing that the nurse is under a lot of pressure or by considering that the nurse is silly for having that attitude because medical records are important to hospital work. Cognitive therapy supposes that changing these types of distorted thoughts by testing their reasonableness or by replacing them with new and more “accurate” (that is, “nondistorted”) thoughts will lead to improved clinical outcomes. And this thera- peutic endeavor is a powerful intervention, as cognitive therapy has been shown in double-blind placebo research to be as effective as psychiatric medication in improving outcomes for individuals with depression (Casacalenda, Perry, & Looper, 2002), as well as showing positive clinical outcomes for several other clinical concerns (see Nathan & Gorman, 2002).

In Ellis’s rational emotive behavior therapy approach, the therapist also describes how thinking influences feelings, and that if a person holds certain irrational beliefs (such as rigid, illogical, unhelpful, or inaccurate beliefs about the self, others, or the world), he is quite likely to feel negative emotions. This cognitive therapy approach con- tends that replacing these irrational beliefs or cognitive distortions through disputation or experiential techniques will lead to improved clinical outcomes. In A Practitioner’s

Guide to Rational Emotive Therapy (Walen, DiGiuseppe, & Dryden, 1992), the authors

use an example (p. 146) of a man who is feeling guilty for having yelled at his daughter in the middle of the night because she woke up and was calling for her mother. The dia- logue between the client and the therapist shows the client saying, “I went in there and started shaking her, and yelled, ‘Stop it, stop it, stop it … I can’t stand it’” [ellipses origi- nal]. The REBT clinician notices that the client said that he “can’t stand” his daughter’s crying and suggests that this is an irrational statement by asking a question.

T[herapist]: Did you stand it?

C[lient]: I got through it. I didn’t like it.

T[herapist]: That’s right, you didn’t like it. But you didn’t die, though, right? C[lient]: (inaudible murmur)

T[herapist]: Alright. See, you made an irrational statement to yourself. I Can’t Stand It. In other words, she must not do this to me. That’s what gave you

irrational anger…

C[lient]: …I’m telling myself that I can’t stand something. I guess what you’re saying is that when I say that, I make myself more angry?

T[herapist]: Absolutely. You got it! You’re the one … you’re the author of your own

feelings. (p. 148)

The REBT therapist goes on to teach the client that the client’s thinking is making him irritate himself about the crying in the middle of the night. The REBT approach would suggest disputing the thought “I can’t stand it,” and then observing and verbal- izing instances where the client “can stand it,” and replacing the irrational belief with “I may not like this, but I can stand it.” According to REBT, this new, more rational cognition would lead to more functional responses.

Both of the aforementioned cognitive approaches also include the first-wave inter- ventions of exposure and skills training, thus the name: cognitive behavioral therapy (CBT). The second-wave pioneers encouraged therapists to maintain structure and have a directive approach to clinical sessions, and also to include doing homework during the week to maintain clinical gains from each session. CBT practitioners also influenced clients to keep daily diaries or thought records to help with reattribution and disputa- tion throughout the 167 hours per week the client wasn’t with the therapist. These therapeutic conventions also have a place in third-wave therapies.

These basic tenets of the cognitive therapies dovetailed nicely with traditional office-based psychotherapy because it could remain a talk therapy. And the second-wave pioneers saw the importance of integrating the first-wave approaches and operant psy- chology with these cognitive therapy methods, and cognitive behavioral therapies began to progress with research that demonstrated their efficacy as treatments for a myriad of clinical concerns. Garnering the empirical support from scholarly investigations and the financial support of managed care, CBT has been established as a powerfully effective force in clinical psychology.