We so easily juggle with emotions, cognitions, and behaviors in our clinical practice that we almost forget that CBT does not result from a marriage of love between the behavioral and cognitive approaches, but rather from a marriage of convenience!
Indeed, it is a bit constrained that the behavioral approach, historically the first to appear, had to make room for the cognitive approach. It has to be said that the latter highlighted the shortcomings of the former, by proposing an alternative… which the former was quick to disqualify! This often occurs between competing models, except that usually one of the two eventually disappears, which has not been the case here.
In the clinical field, when faced with suffering patients, we seek for all useful means to help. The goal is to build a set of the most effective approaches possible, and the more tools that work, the better (at least until a broader definition of the criteria an evidence-based psychotherapy should meet was proposed). What’s more, even the most determined of behaviorists have perceived that they flirted with cognitions as soon as they started talking with their patients. Over time, each has been able to acknowledge the contributions of the other and integrate them into their practice; and if some clinicians today say that they are more of a cognitive approach while others define themselves more having more of a behavioral approach, in reality, the practices are most often comparable.
Among researchers, however, the two schools of thought haven’t ever really collaborated, to say the least. It’s always the same story: as soon as we refer to ourselves by our words in “ism”, positions become almost political, even religious. For the two opposing camps here, the schism is very real. To my left the behaviorists. For them the cause of behavior is to be found in the environment. To my right the cognitivists. For them, the behaviors are caused by cognitions. A small difference of emphasis, you might say. An abyss on the contrary! For from these premises radically different conceptions of therapy are derived. Basically behaviorists will try to achieve changes in the environment, so that problematic behaviors adjust to those changes. Cognitivists, on their end, will favor the transformation of cognitions (notably via the famous “cognitive restructuring”) while in return aiming at the transformation of behaviors linked to these cognitions.
In clinical psychology, this period of theoretical confrontations is possibly on its way to being a thing of the past, as the publication of the collective work “Process-Based CBT”, edited by one of the big names of each “camp”, and to which I had the fortune of contributing, proves it.
Indeed, in the game of causality, although resolutely environmentalist, ACT gives a certain place to cognitions. ACT is part of a so-called “contextual” approach, that is, it considers each behavior as an act in a context, on which it is dependent as much as it contributes to it. The subtlety here is that the context – a synonym of environment – must be defined from the point of view of each behavior. We cannot define the context in absolute terms, in advance, for example by determining that it encompasses everything that is happening outside of us. For each behavior, the context is made up of the physical environment, the social environment, but also what we perceive inside us (proprioception), our history, and also our current cognitions. It is a dynamic whole, in which cognitions play a role.
When we practice defusion in ACT, we do not seek to directly change “problematic” cognitions, but to modify the cognitive context in which these cognitions appear. We are therefore working on cognitions, but on those that constitute the environment of the cognitions at the origin of suffering. The cognitions on which we are working are themselves caused by other elements of the environment (the therapist who leads to defusion, among others) and are themselves also inscribed in a cognitive context (for example the evaluation of the care or effectiveness of the therapist by the patient).
At the heart of this reconciliation is the recognition of a common interest in psychological processes, that is, the emphasis on the lowest common denominator of behaviorists and cognitivists. More than main principles, the processes are directly testable, in their efficiency as in their mode of action. The referee is therefore recognized by all, since it is a question of the scientific method.
We can only rejoice at the start of this peace process, which will perhaps lead to the disappearance of “isms”, in favor of transdiagnostic approach based on evolutionary processes.
See also this article:
The chapter I co-authored with Steven Hayes and David Sloan Wilson, on evolutionary processes:
Hayes, S. C., Monestès, JL., & Wilson, D. S. (2018). Evolutionary Principles for Applied Psychology. In S. C. Hayes & S. Hofmann (Eds). Process based CBT: Core clinical competencies in evidence-based treatment. Oakland, CA: New Harbinger Publications / Context Press., pp. 179-196.
Translated with the help of Chelsea Davis-Laurin
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