CULTURAL TRENDS ON COGNITIVE THERAPY
di Isabel Caro
Invited address to the World Congress of Behavioral and Cognitive Therapies Vancouver, july, 2001
1 - Foreword and Introduction
Dear colleagues, thanks a lot for your invitation to this invited address, and for being here this morning. After coping with the first panic moment, and blaming myself (see figure 1 for accepting this invitation, I came out with a few beliefs I would like to share with you on cultural trends on cognitive therapy.
Introduction What are we as psychologists, therapists or cognitive psychotherapists? What are the determinants of our current interests in our field? These two main questions guide my talk. And the general answer to them goes along the concept of culture. What I'd like to assume as an starting point is that psychology and obviously cognitive therapy, is a changing scientific discipline, which pertains to an specific cultural and historical time. So, each historical and cultural moment is characterized by different attitudes, values, worries and needs, which are behind an specific epistemology and ontology. We are, as human beings a social and cultural product. Each therapeutic approach is a direct consequence of a cultural context. As psychotherapists, we inherit, and equally construe, a particular point of view about the human beings we work with. At the same time, this reflects how we behave as active participants, in therapy. Its combination produces or develops into an specific therapeutic context. This my starting point, but what is my focus?
2 - The cognitive label
Let me assume, and sure that we all agree, that cognitive psychotherapy is one of the main therapeutic approaches, nowadays.
PCognitive psychotherapy has become today a wide and open label. Three main orientations in cognitive psychotherapy are important for my discussion.
- Reestructuring models.
- Cognitive-behavioral models.
- Constructionist, narrative models.
Differences and definitions could be got from different authors, and I am sure you are familiar with them. Also, we can establish three main phases in cognitive psychotherapy. Cognitive therapy is in the air: mid 50-60/80 I would like to call the first phase of evolution as “cognitive therapy is in the air”. It ranges from the mid of 50's and the beginning of the 60's, with the first cognitive therapy works of Ellis and Beck, includes the first big study on efficacy from Beck et al (Rush et al, 1977) and ends with the first criticisms to cognitive therapy, within the model, the ones from Mahoney (1980). Also, at that time we saw the development of cognitive-behavioral models, such as the work in problem solving by D'Zurilla and Goldfried (1971) and the first works from Meichenbaum (1977) in the stress inoculation training. Cognitive establishment: 1980-1990 The second phase of evolution of cognitive therapy, from 1981-1990, is the phase of cognitive establishment. Reestructuring and cognitive-behavioral models increase their relevance and applicability. This is the decade of spread and popularization because it has seen the application of cognitive therapy to almost all kind of psychopathologies, and the profusion of handbooks and self-help books (i.e., Burns, 1980; Emery, 1981). But this is the phase where a change on paradigm and the opening to other models in cognitive therapy is defended by authors such as, Mahoney (1988), Guidano (1987) and Liotti (Guidano and Liotti, 1983), or Safran and Segal (1990). It ends with the publication of Human change processes, from Mahoney (1991) and The self in process from Guidano (1991). A happy cognitive world: 1991-till now I like to call the third phase as “a happy cognitive world”, from 1991, till nowThis phase sees a deeply contribution to the cognitive field of constructivist, linguistic and narrative approaches, and an increase or exarcebation of previous phases characteristics such as: wide range of application, its wide recognition, etc. However, which is more relevant for my discussion is the establishment and the happy coexistence of two different cognitive paradigms. Now, that we know my starting point, let's see the idea I would like to explore. I think that cognitive therapy “debts” its evolution to a certain post-modernization of therapy, which is more obvious in this third phase. But, please, let me remind you that I have said “a certain”. That is, some present characteristics of cognitive therapy are quite post-modern. While in some others it retains a modernist attitude. Although all classifications are problematic, what is more relevant, at this moment, for my intention of connecting cognitive psychotherapy with culture is to distinguish, in epistemological terms, between two main ways of practicing cognitive therapy. So we can relate (Caro, 1995, 1997) reestructuring and cognitive-behavioral models with a modernist epistemology, while constructionist models, I prefer to use the term constructionist instead of constructivist, are related to a postmodern epistemology.
3 - Modernist antecedents of cognitive psychotherapy
The first great inheritance of modernity is the individual. Modernism gave us a culture of personality, about the self (Lipovetsky) which is reflected in the literary works of Joyce (fig.3), Proust (fig.4), Faulkner or Baudelaire, and in paintings from Picasso (fig.5), van Gogh (fig.6) or Matisse. They were examples of and art that mirror the inner world of the artist (fig.7). The writers challenged and sought to subvert a society that had gained the world but was losing its soul in the process. They portrayed their inner torment and uncertainty, expressed symbolically, methaphorically, and, (Joyce and Proust) minutely (Parry, 1993, p. 431) (fig.8). The modernists were critical with what they considered (fig.9) to be the spiritual emptiness of the society's material conquest of the world, but they were very optimistics. They share their utopian faith in the coming of a better world (Parry, 1993, 431, 432) (fig.10). In the center of the modernist perspective lies the heady and optimistic romance with foundation and essence (Gergen, 1992, p. 19)(fig.11). However, modernity was a time with a deep gap between lay and elite culture (fig.12). The penetrating diagnoses of the modern psyche and its times by the artists and writers of modernism have remained impenetrable to the general population, which prefers the shorter, sharper, kick of the arts of popular culture (Parry, p. 434). Modernism add to the artists and writers accomplishments the development of psychology, understood as the internalization of the grand narratives (Parry, 1993, p. 432). Psychology is a project of modernity. As points Kvale (1992, p. 40), the science of psychology was founded on a conception of individual subjects, with internal souls and later internal psychic apparatuses. The concept of madness and the main psychotherapeutic systems are a consequence of modernity (Ibáñez, 1993) (fig.13).
4 - Going into post-modernity
The postmodern culture certifies the death of the subject. The individual is no longer at the center of the universe, but it is decentered (fig.14). The modernist self died (Jameson, 1984). Instead we have saturated (fig.15), fragmented (fig.16), or narcissistic selves (fig.17). Postmodernity is very well represented in the arts, the arquitecture and the movies. Lyon (1994) described it using the film Blade Runner as an example (fig.18). The film pictures an scenary of urban decadency, abandoned buildings, crowded streets, market streets, trash all around, and an ongoing drizzle. Here we have a society made of replicants, non-humans, that want to become humans, that dream about a mother from one photograph. Blade Runner is postmodern as reality itself is questioned. The replicants want to be real persons, but Rachel, a replicant, construes her identity from a construction itself: a photograph. Also, buildings and streets show treads of modernity. As postmodernity enlarges or exagerates some of the modernists characteristics, while criticizes some others. The film shows a new organizational order which goes around knowledge instead of work and capital (fig.19). A knowledge which increases mind power, instead of being based on muscles. Knowledge has become a business. The genetic engineering makes human simulacrum possible. The replicants exist in a world which has conquered time and space constraints, through the new information and communication technologies of the global village. In the city pictured in the movie, Los Angeles, co-exist different cultures (fig.20),specially Third World persons which are part of the postindustrial proletariat and where woman and some minories are no longer the Other (fig.21). This cultural mixture, intensified by the new media gives postmodernity its societal referents. Postmodern individuals live in an incredible (fig.22) consumer society, where everything is a show, being public image the only important thing (fig.23). We are what we consum (fig.24). Dysneyland is more real than we could think (fig.25). Two further characteristics need to be emphasized: From the elitist modernist culture(fig.26) we have changed toward an eclectic attitude, where “everything goes”(fig.27).From the essential and basic lines, from the efficient, pragmatics layout of mass and space, as the Guggenheim in New York shows (fig.28) postmodern art emphasizes the aesthetic over the functional (Rosenau, 1992, p. 7) as the Guggenheim in Bilbao shows (fig.29). From the critical, anti-middleclass and innovative modernist vanguard we are facing an art where everything goes (fig.30), being more important to be oneself, and where art objects are not the objects themselves, but their commercial facsimiles, as Warhol works showed (fig.31). After this cultural introduction, let's come back again to the three main phases of cognitive therapy looking, now, to the modern and postmodern traits.
5 - First phase: cognitive therapy is in the air (50-80)
The first phase of cognitive therapy is an example of the main modernist characteristics. Although it has been a controversial issue, we can describe reestructuring and cognitive-behavioral models as rationalist models. Rationalism (in Mahoney, 1991, p. 38) bases knowledge and knowing in reason, and formal, logical thought, while senses are illusory and inferior to reason. This rationalist point of view implies an specific conceptualization of human beings, and accordingly an specific definition of the scientific role which, at the same time, is related with a split between the professional and the lay culture. All of this could be exemplified in the kind of therapeutic relationship that is defended and, in the aims science should have. The modernist person Cognitive therapy began developing the carthesian dictum: I think, therefore I exist. (fig.32). The modernist person, shared with other approaches such as the behavioral and the psychodinamic ones, is represented as a mechanism, a mechanism that could have problems and so, needs to be fixed up from time to time (McLeod, 1997) (fig.33). From this mechanicistic point of view a great importance is given to rationality, control and risk cancelling. Modernists portrayed individuals as beings who, by implication, could not have been expected to know their own mind, who were essentially left having to seek out and rely on experts (fig.34) in psychological and mythological interpretation in order to understand themselves, not to mention change (Parry, 1993, p. 433). Let's see the experts. The modern scientist According to Cushman (1992, p. 25), industrialization, urbanization and secularization caused renewed interest in the physical world, the humanities, science, commerce and rationality. The state had to develop ways to control a new kind of subject: more mobile, less constrained by tradition and religion, less confined by role, and less predictable. For Foucault (1975, Surveiller et punir) the self changes from being controlled by absolute monarchies, to be an isolated self, less communal and more individualistic, more confused about what is “good” or “bad”, the “ethical” or “non-ethical”. This new emerging self needs to be guided and therefore the State creates the role of a new kind of expert, the modern philosopher, who, along the time, becomes a social scientist, who develops techniques to:
- Control subjects behavior
Self-conscioussness is the more relevant element of this new self. This implies, individuals who:
- Observe themselves
- Reflect upon their nature
- Thinks about what they hide or manifest
- Speculate about their real being and identity
As a consequence, a discourse emerges which separates:
- body from soul
- subject from object
- reason from emotion
This has been, by the way, one of the core criticisms and debates within cognitive therapy, at this first phase. The methaphorical example offered by Foucault is the Panopticum (fig.35). This was a prison designed by Bentham, in the XVIII century, with the aim the prisoners seem themselves, but never seem the guards. The aims of the Panopticum were:
- Increasing the tolerance to be observed
- Increasing the tendency and capability to observe themselves
- Increasing the pressure for being “normals”
- Increasing the tendency to practice self-observation and conscious behavioral change.
This is the perfect symbol for a new social order. But how could we get access to the private domain?: the answer comes from developing practices which facilitates this access. Practices which fits with the modernist self, that as Cushman said (1992) awaits to be observed. So, when cognitive therapy began it inherited, at the core, a particular kind of human being, who look eagerly to be guided in his/her discovering process, which fits perfectly with the therapist behavior. So, we can understand that classical or modernist cognitive technology is directed to work with this rational and able to get control individual, to use and encourage as far as possible these rational attitudes, teaching the individual to become a scientist who observes, control and self-regulates. We have quite a lot of examples from this cure technology, encouraged by this cultural heritage. To mention a few of them, we have techniques such as:
- Evidence in front of a jury, etc.
- Hypothesis testing
- Rational response
- Analysis of faulty reasoning, etc.
The therapeutic relationship Therefore, with such kind of scientists, persons, and aims, little wonder that cognitive therapists clearly more influenced by the modernist zeitgeist, defended a therapeutic relationship where:
- The therapist should be a scientist who guides
- The patient should become a scientist who analyzes, observes, changes. Please, do remember the Panopticum metaphor.
- Reason over emotion is emphasized
So, at the beginning cognitive therapy:
- Assumed a rationalist point of view upon human beings
- Therapists split, rationalize, and follow the science metaphor in their relationships with clients. From this point of view the modernist gap between lay and professional culture is represented, again, in this therapeutic context.
- Cognitive therapy tried to be a grand therapeutic approach, contributing deeply to psychology as a grand narrative, valid as the other therapeutic narratives, for the understanding of human beings.
This was the backgroound which inherit the first cognitive therapists. However, the developments that our field has had or is having, come, in my opinion, from a post-modern turn. Cognitive therapy has changed toward postmodernity with the constructionist and narrative approaches. Timidly, at this first phase, constructionist models critiziced the primacy of reason over emotion and favored a radical turn. As all of this is clearer in the second phase, let's go into it, now.
6 - Second phase: cognitive establishment
In this phase, modernist cognitive therapies continue their progress and evolution, but postmodern ones were introduced. The postmodern turn in cognitive therapy defends a different point of view about human beings, a constructivist point of view, which implies, equally, changes in the scientist role, neglecting the split between the professional and lay culture, now everybody is an expert. This implies, also, an specific kind of therapeutic relationship and of science aims. Let's explore it, beginning with the kind of human being. The postmodern person In psychology postmodernity questions the conscious, logical and coherent subject (Rosenau, 1992, p. 7). Postmodernity certifies the death of the modernist subject(fig.36) as a rational, unified, self-organized person. They re-theorize “subjectivity” as multiple and contradictor, largely irrational. Our postmodern friends are saturated, fragmented, empty selves. Contrary to the modern person, “boundedness, coherence and consistency are impossible and irrelevant characteristics of the self” (Lyddon and Weill, 1997, p. 77).The dictum is now, as Gergen said (1992, in Lyddon and Weill, 1997, p. 78): “we communicate, therefore I am”. However, I would like to make some reflections (fig.37). PCould we certify the death of the subject in cognitive psychotherapy? The problem for therapy is that the subject, the patient is “real and necessary” as Kristeva said (Rosenau, 1992, p. 58). How can we make therapy without a “subject”? What is the kind of subject behind the postmodern cognitive practice? What cognitive therapy approach could deal better with this fragmented, saturated self? I think that constructionist and narrative cognitive models, which were introduced in this second phase, can work better with this kind of persons. Also, what are we dealing with in therapy? If the problems of patients are texts and they are readers construing multiple meanings, postmodern therapists will assume that the stories a patient tells in therapy are constructed narratives, and inseparable mixture of construction and event. These accounts must be judged in terms of narrative truth rather than historical truth (Burr and Butt, 2000, pp. 201-202.) Although, “the objective is not anymore to substitute thoughts and emotions but to allow the possibility of expanding and actualizing multiple world views, meanings and emotional experiences” (Gonçalves, 1997, p. 106), it is also true, from my point of view, that the postmodern cure technology implies a kind of subject who is able to give sense and coherence to their stories, who makes a more coherent narrative. In some sense, it is, still, a human being who observes, reflects and thinks. Does it mean that both kind of cognitive practices are defending the same kind of human being? The problem is to keep our psychotherapeutic practice alive but making sense at the same time, without clear epistemological and ontological contradictions. But, I think they have some paralells. Both, modernist and postmodern need a human being who is able to observe him/herself. A human being who is able to understand the meaning things have, know a little bit more about him/herself and change what is recommended for a “better” functioning. Nevertheless, two main differences arise:
- Modernist and postmodern practices want to get a different kind of human being. The modernists want through insight and reflection make patients to become masters of their own ships (Burr and Butt, 2000, p. 202). A rational and a foundational self is the aim. A specifically postmodern psychology, can make people more intelligible to themselves -without the search for any foundational self. Rather, they might be enabled to produce self-narratives which allow them to live at peace with themselves.
- Modernist and postmodern practices give a different treatment to patients constructions. The modernist wants patients to make a more perfect, and valid theorization upon reality. A theory which represents reality, and fits nicely with data. Postmodernists treat patients narratives as local, never representing “something out there”. Narratives that are only a little piece in a chain of meanings.
Therefore, the aim of the therapy is different. Modernists therapists were no naive (Hare-Mustin and Marecek, 1988). Modern psychology has long emphasized that what the client in therapy told the therapists was only a narrative, a story, not a real representation of actual experience. Post-modernists agree. But while the modern therapist's role might be to help the client sort things out, get below the surface, and achieve a more adequate understanding of reality, the post-modern therapist has no such intent. There is no true reality out there to discover. Therefore, the post-modern therapist merely “disrupts the frame of reference” and “manipulates meanings” by referring to marginalized subtexts, to alternative interpretations; in doing so the therapist “changes the clients' meanings”. This needs, by the way, a different kind of therapeutic relationship.
The therapeutic relationship in postmodern cognitive therapies As Rosenau (1992) stated, for the postmodern the reader is an actor-receiver, a participant observer and an observing participant all at once. Using this metaphor, the author'the therapist diminishes his/her importance, and the reader, the client, got, in the constructionist and narrative cognitive approaches a more relevant role. So we have seen in therapy an important change which has been, also, the focus of an important criticism to the modernist cognitive therapies. “Because of his/her assumed superior position, the modern author's role is to educate, instill moral values, or enlighten the reader (who is not held in such high regard)” (Rosenau, 1992, p. 27). Instead, in postmodernity the therapist comes to be an interpreter, that makes no universal truth claims and has no prescription to offer (Rosenau, 1992, p. 31). Postmodern cognitive therapies give primacy to the client-reader, who is helped through therapeutic techniques to become the meaning making of the text. For instance, cognitive-narrative therapy from Gonçalves helps patients to become readers-actors of their problems, and through different phases they are encouraged to give meaning and coherence to their lives converted in a prototype narrative. A similar aim is behind the “moviola technique” from Guidano, where the patient is helped to focus on their problems as being stories that must be construe and reconstrue. So, let's focus now in what is happening in the third phase of cognitive therapy evolution?
7 - Third phase: a happy cognitive world
My interpretation of this third phase is related with the kind of culture we are leaving in: the collage(fig.38). Although it has a modernist origin, in postmodernity the collage has the possibility of becoming a “pastiche”(fig.39). First of all, let's remember that in postmodernity we have big consumers, but consumers well informed. They consume psychology, but our society (Seoane, 1996) imposes an style and an specific type of psychological practice. Authority arguments are “out” and society feels more comfortable being able to chose between diferent little models which do not conflict (T. Ibáñez, 1992). They consum psychology but a psychology which is a micro-narrative, a micro-model, as psychology has developed itself as a social tool ready to be used. So, this third phase exemplifies, that we are living in a psy culture, that for Lipovetsky (1983) means to consume conscioussness. A culture with an extraordinary therapeutic sensibility, where everybody surrenders to self-exploration by the most diverse means: zen, group dynamics, yoga, meditation, energy liberation, etc.Cognitive therapy popularization is contributing, no doubt, to it. Cognitive therapy has become part of the psychological collage in our global village, contributes to the psy culture, and it is, at the same time, another collage. What is the cognitive collage? A modernist and a postmodern one. Any practitioner, is able to chose between different ways of practicing, and even is able to assume postmodern concepts or to postmodernize his/her theory a little bit, mantaining at the same time, clear modernist techniques. Also, it is a scientific collage. Cognitive therapy shows examples of a verificationist, justificationist, and paradigmatic (based on the hypothetical-deductive method) modernist science, and examples of a postmodern scientific attitude: non-verificationist, non-justificationist and narrative (based on hermeneutics). A postmodern science? Are they contradictory terms? What could be the scientific contribution of postmodern therapists to the cognitive field? What kind of methodology should we follow? This is a very important and complicated topic and I'm not going to add further details as it deserves a whole different presentation. Finally, cognitive therapy in its last developments have evolved toward eclecticism, one of the main elements of postmodernity. For instance, many cognitive therapists feel comfortable getting techniques from gestalt, other humanistic approaches, behavioral ones, etc. Does it mean that cognitive therapy is becoming some kind of pastiche?
- Future of cognitive therapy
Well, cognitive therapy is a today's fashion, and the consumers, consum it. The problem, from my point of view is that the subject who consumes lacks any kind of ideology and so, we do not know what is he/she going to demand in a near future. Also, I assume that cognitive therapy will go with the sign of times. Thereafter, in the future cognitive therapy:
- Obviously, it will go along with the new technologies development that are part of our 21rst century lives.
- Cognitive therapy, as other therapies by the way, has the risk of becoming some kind of “fast food”, ready and easy to be consumed in a short moment. This is facilitated by the handbooks, its range of application, popularization, etc. This situation could contribute, I think, to make cognitive therapy some kind of “pastiche”. So, just in case,
I consider important to keep working and selling theoretical reflections on cognitive therapy, although they must be treated in a postmodern way: without any kind of epistemological authority. Do we need this kind of authority? The answer is no, right now. So, let's play with our ideas, interpretations and constructions. To do it with the issue modernism-postmodernism is just one possibility for playing, and I enjoy doing it (fig.40).
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