that psychotherapy has for misuse (Damousi and Plotkin, 2012; Müller, 2016; ffytche and Pick, 2016).
To this day, on both sides of the Atlantic, Freudian and psychodynamic approaches based on ideas about transference and unconscious conflicts continue to inform psychotherapeutic training and practice, as well as wider culture and intellectual life, from film studies to literary theory. But from the mid-twentieth century, the psychoanalytic tradition was subject to fierce competition from two other key schools of psychotherapy: cognitive and behavioural therapies, and humanistic therapies.
2 Cognitive and behavioural therapies
Cognitive behavioural therapy (CBT) is classically dated back to the work of Aaron Beck, whose book Cognitive therapy of depression (Beck et al., 1979) among others, is a foundational text for the field. Others fly the flag for Albert Ellis, a contemporary and colleague of Beck’s, who was arguably the first to coin the tripartite term ‘cognitive behavioural therapy’ in 1969, in an article in the International Journal of Psychiatry (Ellis, 1969). Others still, particularly in Britain, make the case that the foundation of CBT also rested on earlier practices of behaviour therapy developed in the 1950s, which included processes such as desensitisation and exposure and – most controversially – aversion. Some proponents of CBT have also looked back to historical antecedents to argue that current methods are part of a much longer tradition in western thought. Examples include the early twentieth-century rational therapy of the Swiss psychotherapist Paul DuBois, and even the classical writings of Stoic philosophers such as Epictetus (Dryden and Still, 2012). This section of the chapter will outline these different trajectories while summarising some of the emerging historiography on CBT.
Cognitive behavioural therapy A collection of therapeutic techniques that has gained prominence since the 1960s. CBT aims to address maladaptive beliefs and behaviours and is based on both behaviour modification and cognitive approaches. There is often overlap between the use of the terms ‘cognitive behavioural therapy’, ‘cognitive behavioural therapies’ and ‘cognitive therapy’.
2.1 The emergence of behaviour therapies
Behaviour therapies emerged in the 1950s, predominantly in the US and Britain. They arose out of a particular approach to human nature that saw it as similar to that of other animals: just as in any other species, behaviours are learnt through a process of conditioning. Animal behaviourists were able to show that behaviours could also be ‘unlearnt’, and therefore, so too could unwanted or maladaptive patterns of behaviour, such as anxieties, phobias and compulsions. Conditioning rested on the premise that it is behaviour (rather than underlying thoughts, feelings and experiences) that should be the target for change. It focused on changing present behaviours rather than on analysing past experiences. This made behaviourism a more immediate approach to mental distress and meant that results were observable.
Conditioning A process of learning by association whereby particular behaviours or beliefs become reinforced through repeated association with a stimulus (classical conditioning) or through reward or punishment (operant conditioning).
There were two main theories of conditioning. The first, classical conditioning, was associated with the Russian physiologist Ivan Pavlov and the American psychologist John Watson (O’Donnell, 1985). It posited that behavioural responses were conditioned by the creation of associations in the brain and nervous system, such as a dog which salivated on hearing a buzzer because it associated this sound with the imminent arrival of food. The second theory, operant conditioning, was associated with B.F. Skinner (1953) and focused on how behaviours could be modified through reward and punishment.
Behaviour therapies emerged from a particular theoretical strain in the human sciences, but their success was also in part due to a number of other factors particular to the mid-twentieth century. This period saw vociferous debates about the philosophical assumptions that undergirded psychoanalysis, as a new generation of psychologists and psychiatrists wanted to ground psychotherapies in (what they saw as) a more scientific and experimental approach. Behaviourism was a particularly alluring world view to those who wanted to explicitly break away from a psychology that rested on human introspection and towards one built on observation and measurement. This was at a time when optimism about the possibilities of applied science was at its height (Marks, 2015). By not addressing the difficult problems of both conscious and unconscious processes and focusing on what could be externally observed, behavioural psychology – and therefore behaviour therapy – was presented as a rigorous, experimentally provable alternative. Its proponents also argued that it could be delivered within a particular timeframe and was therefore more efficient and cost-effective than psychoanalytic approaches. But the fact that many people were still fascinated by the human experience of consciousness – and, indeed, of the unconscious – limited the popularity of behaviourism.
Behaviourism A theory of human and animal psychology, popular in the mid-twentieth century, that focuses on observable behaviours that can be explained and changed through learning and conditioning, rather than through unconscious drives and conflicts.
Pause for reflection
Thinking back to the principles of psychotherapy, can you think of any other reasons why behaviourism may have been less popular than other therapies? How might people have perceived the nature of behaviourist principles, with the prioritisation of rapid behaviour changes over personal introspection?
One reason for behaviour therapy’s limited success was its association with ‘mind control’ and coercion. Hans Eysenck – an outspoken London-based German clinical psychologist, and a strong proponent of behavioural therapies – openly admitted that behavioural therapy shared the same techniques as those used in brainwashing. The difference, he claimed, was that the former was being used for a benevolent purpose (Eysenck, 1964). While it might be difficult to understand the association with brainwashing in relation to, for example, desensitising phobic patients, the use of aversion treatments with homosexual or cross-dressing subjects is a dark passage in the overall history of the CBT tradition. Regardless of whether or not the treatment conformed to the ethical norms of the day, it should not be overlooked as part of the history of psychotherapy and reminds us that the clinical setting is always vulnerable to the possibility of coercion. Although testimonies of these cases have been publicly reported, there is little discussion of them today. This suggests that some level of acknowledgement and reconciliation is needed to move beyond the difficult chapters of the profession’s past (Dickinson, 2014)
2.2 The rise of cognitive behavioural therapy
Figure 3.2 Aaron Beck
CBT emerged in the 1960s, associated most closely with Aaron Beck (shown in Figure 3.2) and Albert Ellis (Beck et al., 1979; Ellis, 1969). There were some important differences in their approaches: Ellis’ rational emotive behaviour therapy took a more confrontational, challenging approach to the client’s irrational beliefs, while Beck’s preferred method enabled clients to see the irrationality for themselves. However, the approaches shared the core theoretical claim that people’s difficulties are produced by strongly held, maladaptive beliefs and automatic thoughts, which were most likely learnt in familial and social environments. The merging of these ‘cognitive’ approaches with behavioural approaches happened gradually over the course of the 1960s and 1970s. Beck and Ellis were also interested in their therapies changing behaviour, as well as thoughts. Despite the apparent theoretical shift away from behaviourism in terms of the focus on internal thoughts and beliefs, some behavioural therapists embraced these new techniques. They saw that the fundamental emphasis of both approaches was still about learning and conditioning.
