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How and Why Cognitive Behavior Therapy Works
I described how and why cognitive behavior therapy works on pages 540 – 542 of my book, Cognitive Neuroscience and Psychotherapy: Network Principles for a Unified Theory. Here I summarize much of this material with some additional discussion and citations. Clinicians have developed effective treatments through trial and error in their clinical practice but cannot explain how they work.
Tryon (2005, 2014 pp 381, 385, 534-540) reviewed and discredited several classic explanations for how systematic desensitization works that I do not have space to review here. Suffice it to say that exposure with response prevention (ERP) has been confirmed to be the active ingredient in the treatment known as systematic desensitization but no satisfactory natural science explanation of how and why ERP works has been provided.
Izard (1971) noted that changing responses to emotions is an effective means of modifying emotional reactions but no natural science explanation of how and why such treatments work has been provided. Allen, McHugh, and Barlow (2008) and Barlow et al. (2011) based their unified protocol for treating various emotional disorders on Izard’s observation but did not offer any natural science explanation for why they included this method. Effective means of modifying emotions does not constitute a natural science explanation of the responsible causal mechanisms.
Lynch, Chapman, Rosenthal, Kuo, and Linehan (2006) described Linehan’s opposite action method as a variant of exposure with response prevention. They characterized the components of opposite action as follows:
One of the most central emotion regulation skills is opposite action, which essentially involves (1) determining that an emotion either is not warranted by the situation (i.e., “unjustified”) or interferes with effective behavior, (2) being exposed to emotionally evocative cue or stimuli, (3) blocking the behavior prompted by the emotion’s action urge, and (4) substituting a behavior that is inconsistent with the action tendency compelled by the emotion. Given that emotion dysregulation occurs across multiple emotions (both positive and negative) in BPD, opposite action in DBT targets a broad range of emotions (e.g., shame, guilt, unjustified love, sadness, fear, anger) (p. 471).
This list of four components defines what opposite action entails but is not a natural science explanation of how and why it works. The title of the Lynch et al. (2006) article is “Mechanisms of Change in Dialectical Behavior Therapy: Theoretical and Empirical Observations”. The first portion of their “Mechanisms of Change in Opposite Action” section on page 471 is entitled “Exposure and Response Prevention” where they describe the similarity between opposite action and ERP. They claimed that ERP and opposite action work for the same reason; namely, that they both weaken a conditioned association between cues and the emotional reactions that they elicit. While it is true that both ERP and opposite action weaken the association between cues and the emotional reactions that they elicit, this observation is not a natural science explanation of how and why this weakening occurs because no mechanism information is provided regarding the causal sequence by which such weakening should, must, and does occur.
Classical conditioning, like operant conditioning, is a method for modifying behavior. Methods are not explanations. Psychologists have readily, and unfortunately, accepted classical and operant conditioning as natural science explanations because the ability to explain how they work lies outside of psychological science. The relevant mechanisms are biological. All conditioning effects work because experience-dependent plasticity mechanisms modify synaptic connections that enable associated neural networks to function differently.
Natural science explanations require detailing one or more mechanisms that can account for how and why things work as they do. Natural science explanations compel their effects. Psychologists cannot provide such mechanisms because they lie outside psychological science with neuroscience. My book, presents four core and eight, now nine, corollary network principles that implement neuroscience mechanisms and have extensive empirical support in psychological research. Network Principle 7 concerns consonance and dissonance. Heider (1958), Festinger (1957, 1964), Abelson et al. (1968) and Thagard (1989, 2000) have clearly demonstrated that people prefer consonance to dissonance. Network Principle 8 formulates how artificial neural networks can be trained and how both real and artificial neural networks can be retrained. Cognitive behavior therapy retrains neural networks consistent with Network Principle 8. I now briefly summarize how this works.
Imagine a simple three layered neural network. The top layer represents sensory neurons, the bottom layer represents motor neurons responsible for behavior. The middle layer represents processing neurons that mediate stimulus-response relationships. This middle layer makes this network model a cognitive model because it transforms stimulus input into response output. Also imagine that each of the simulated sensory neurons in the top layer is connected to each of the simulated neurons in the middle processing layer by synapses and that each of the simulated neurons in the middle layer is connected to each of the simulated motor neurons.
Now consider what happens when an anxiety provoking “phobic” stimulus is perceived. It activates the thoughts and feelings that are represented in the middle layer that in turn activate avoidance behaviors represented by the bottom layer. Exposure and Response Prevention therapy “clamps” the motor neurons to an incompatible state by requiring the person to continue to attend to the phobic stimulus. This treatment places the person’s neural network into a dissonant state in that the computed avoidance response conflicts with the approach behaviors performed during therapy. This dissonance activates experience-dependent plasticity neuroscience mechanisms that modify synaptic connections among all processing nodes such that the computed result becomes more consonant with the imposed behavior. These synaptic changes modify the thoughts and feelings mediated by the middle processing neurons. Hence, patients think, feel, and behave differently after therapy than they did before therapy.
The brain appears to treat thoughts, ideas, like memories. They are recalled via a gradient descent process that can be visualized as spiraling down into a memory well that Tryon (2014) illustrated as Figure 11.2 on page 515. The brain also appears to treat thoughts in a dialectical fashion in that each one also activates its opposite. For example, thoughts about success also activate thoughts about failure. The cognitive restructuring that is a central part of cognitive-behavior therapy and dialectic behavior therapy exploits this feature. Fears about failure or that something bad will happen if a particular ritual is not performed, as occurs with people suffering from Obsession-Compulsion Disorder (OCD), can be counteracted by priming with a positive conscious thought such “what if the presumed catastrophic event does not occur”, “what if I succeed”, and/or “what if it works”. Priming with positive thoughts is explained by Network Principle 5. The neuroscience basis for priming is as follows. Each processing pathway through a neural network activates experience-dependent plasticity mechanisms that biologically reinforce it. The result is a preferred way of processing similar stimuli. Repeated processing of negative thoughts can predispose the person do chronically doing so. Psychopathology can develop as a consequence of consistent repetitive negative priming. Therapy can treat this condition with positive priming to biologically reinforce more positive processing pathways.
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About the Author
Warren W. Tryon received his undergraduate degree from Ohio Northern University in 1966. He was enrolled in the APA approved Doctoral Program in Clinical Psychology at Kent State University from 1966 – 1970. Upon graduation from Kent State, Dr. Tryon joined the Psychology Department faculty at Fordham University in 1970 as an Assistant Professor. He was promoted to Associate Professor in 1977 and to Full Professor in 1983. Licensed as a psychologist in New York State in 1973, he joined the National Register of Health Service Providers in Psychology in 1976, became a Diplomate in Clinical Psychology from the American Board of Professional Psychology (ABPP) in 1984, was promoted to Fellow of Division 12 (Clinical) of the American Psychological Association in 1994 and a fellow of the American Association of Applied and Preventive Psychology in 1996. Also in 1996 he became a Founder of the Assembly of Behavior Analysis and Therapy.
In 2003 he joined The Academy of Clinical Psychology. He was Director of Clinical Psychology Training from 1997 to 2003, and presently is in the third and final year of phased retirement. He will become Emeritus Professor of Psychology in May 2015 after 45 years of service to Fordham University. Dr. Tryon has published 179 titles, including 3 books, 22 chapters, and 140 articles in peer reviewed journals covering statistics, neuropsychology, and clinical psychology. He has reviewed manuscripts for 45 journals and book publishers and has authored 145 papers/posters that were presented at major scientific meetings. Dr. Tryon has mentored 87 doctoral dissertations to completion. This is a record number of completed dissertations at the Fordham University Graduate School of Arts and Sciences and likely elsewhere.
His academic lineage is as follows. His mentor was V. Edwin Bixenstein who studied with O. Hobart Mowrer at the University of Illinois who studied with Knight Dunlap at Johns Hopkins University who studied with Hugo Munsterberg at Harvard University who studied with Wilhelm Wundt at the University of Leipzig.
Cognitive Neuroscience and Psychotherapy: Network Principles for a Unified Theory is Dr. Tryon’s capstone publication. It is the product of more than a quarter of a century of scholarship. Additional material added after this book was printed is available at www.fordham.edu/psychology/tryon. This includes chapter supplements, a color version of Figure 5.6, and a thirteenth “Final Evaluation” chapter. He is on LinkedIn and Facebook. His email address is email@example.com.
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