Journal of Consulting and Clinical Psychology
1993. Vol. 61. No. 2. 202-204
Changing Conceptions of Cognitive Behavior Modification:
Retrospect and Prospect
Donald Meichenbaum
A retrospective analysis of cognitive behavior modification reveals that 3 major metaphors have
been offered to explain the role that cognitions play in behavior change. These metaphors include
cognition as a form of conditioning, information processing, and, currently, narrative construction.
The implications of using each of these metaphors are discussed.
Since its inception, cognitive behavior modification (CBM)
has attempted to integrate the clinical concerns of psychody-
namic and systems-oriented psychotherapists with the technol-
ogy of behavior therapists. CBM has contributed to current
integrative efforts in the field of psychotherapy. As in most
forms of psychotherapy, CBM was the result of an evolutionary
process and was part of a Zeitgeist of what Dember (1974) called
a "cognitive revolution."
Cognitive-behavioral therapies derived from a long tradition
of semantic therapists ranging from Dubois to Kelly, and along
the way were influenced by the social learning theories of Rot-
ter, Bandura, Mischel, Kanfer, and others. The influential writ-
ings of Albert Ellis, Aaron Beck, and both Arnold and Richard
Lazarus highlighted the role of cognitive and affective pro-
cesses in psychopathology and in the behavior change process.
One major catalyst for the development of cognitive-behav-
ioral therapy was the growing dissatisfaction with both the em-
pirical and the theoretical bases of a strictly behavioral thera-
peutic approach. A number of authors, such as Breger and
McGaugh (1965), Brewer (1974), McKeachie(1974), Mahoney
(1974), and Meichenbaum (1977), were questioning the ade-
quacy of learning theory explanations of both psychopathology
and behavioral change. A second major catalyst was the initial
results of cognitive therapists such as Aaron Beck (1970) and
Albert Ellis (1962) who demonstrated the promise of their in-
terventions.
This interest in cognitive factors in psychotherapy was often
not well received by "behavioral types," who called for the ex-
clusion of "cognitive types" from such organizations as the Asso-
ciation for the Advancement of Behavior Therapy. Such mal-
contents were supposedly diluting, if not undermining, the "pu-
rity" of behavior therapy. But Pandora's box, with all of its
difficulties and challenges, had been opened as cognitive-be-
havioral practitioners struggled with questions as how best to
conceptualize their clients' cognitions and how to fit such cog-
nitive processes into the complex reciprocal interrelationships
with clients' feelings, behavior, and resultant consequences, as
well as with physiological and social-cultural processes. The
answers to these research questions have been strongly in-
Correspondence concerning this article should be addressed to
Donald Meichenbaum, Department of Psychology, University of Wa-
terloo, Waterloo, Ontario, Canada N2L 3G1.
202
Copyright 1993 b> the American Psvchological Association, inc.
0022-006X/93/$3JK)
fluenced by the specific conceptualizations and metaphors
used to explain clients' thought processes. I will consider three
of these guiding metaphors, namely, conditioning, information
processing, and constructing narratives.
Conditioning as a Metaphor
Initially, cognitive-behavioral therapists proposed that an in-
dividual's cognitions could be viewed as covert behaviors, sub-
ject to the same "laws of learning" as are overt behaviors. In the
tradition of Skinner and conditioning theorists, cognition was
viewed as covert operants, or what Homme (1965) called "co-
verants," supposedly responsive to both external and internal
contingencies and altered by contiguous pairings, as in the case
of covert sensitization (Cautela, 1973). Clients' self-statements
and images were viewed as discriminative stimuli and as condi-
tioned responses that come to guide and control overt behavior.
The focus of treatment was to "decondition" and to strengthen
new connections, bolster and rehearse adaptive coping skills,
and the like. The technology of behavior therapy, such as model-
ing, mental rehearsal, and contingency manipulations, was
used to alter not only clients' overt behaviors, but also their
thoughts and feelings.
Information Processing as a Metaphor
A different metaphor soon began to influence the develop-
ment of CBM, namely, that of the mind as a computer, with the
accompanying language of information processing and social
learning theory. It was proposed that clients' cognitions could
be conceptualized as consisting of a number of processes, in-
cluding decoding, encoding, retrieval, preattention and atten-
tion, attributional biases, and distortion mechanisms, the last
in the form of cognitive errors. Moreover, these cognitive errors
were viewed as being a consequence of the cognitive structures
or beliefs, schemata, current concerns, and tacit assumptions
that clients brought to situations. It was proposed that such
beliefs were strengthened by the manner in which clients be-
haved. The operable terms to depict this sequence were transac-
tional, interactional, and bidirectional, as described by Lazarus
and Folkman, Bandura, Wachtel, Kiesler, and Patterson. Indi-
viduals were viewed as "architects" of their experiences, in-
fluencing the data they were creating and collecting. Rather
than being passive, the information-processing perspective
 SPECIAL SECTION: COGNITIVE BEHAVIOR MODIFICATION
proposed that individuals may inadvertently, if not unwittingly
and even unknowingly, behave in ways that elicited the very
reactions in others (a form of data) that they could take as evi-
dence to confirm their views of themselves and of the world.
A number of investigators (e.g., Beck, 1970, and Hollon, 1990,
who studied depression; Barlow, 1988, and Clark, 1986, who
studied anxiety disorders; Dodge & Coie, 1987, and Novaco,
1979, who studied aggression in children and in adults, respec-
tively; and Marlatt & Gordon, 1985, who studied clients with
addiction problems) have used an information-processing per-
spective to explain their clients' difficulties and to formulate an
intervention plan.
From an information-processing perspective, clients are seen
to be depressed because they distort reality as a result of a
number of cognitive errors (e.g., dichotomous thinking, magni-
fication, and personalization) and because they hold so-called
irrational beliefs. They also hold negative views of themselves,
of the past, and of the future, emitting characterological attri-
butions of self-blame when they encounter failures and frustra-
tions. Anxious clients who have panic attacks are seen as misin-
terpreting bodily cues and viewing them as personal threats
given their preoccupation with physical well-being and the
need to maintain a sense of personal control. Such misinterpre-
tations or appraisals lead to "catastrophic" anxiety-engender-
ing ideation with accompanying physiological arousal, as a
vicious self-perpetuating cycle is established and maintained.
Those clients who have problems with anger and who are ag-
gressive, especially if that aggressive behavior is reactive as op-
posed to instrumental in nature, have been found to hold hos-
tile attributional styles; to interpret ambiguous interpersonal
cues as provocations, retrieving from memory other aggressive
events; and to fail to generate and implement socially accept-
able alternatives. Moreover, aggressive clients, both children
and adults, behave in ways that elicit the coercive and reciprocal
reactions that confirm their aggressive outlooks. Thus, their
expectations and self-statements become self-fulfilling
prophecies.
Cognitive-behavioral therapists have developed intervention
programs that are designed to help clients become aware of
these processes and teach them how to notice, catch, monitor,
and interrupt the cognitive-affective-behavioral chains and to
produce more adaptive incompatible coping responses. More-
over, cognitive-behavioral therapists help clients to identify
high-risk situations that they are likely to encounter and to
consider ways to prepare, handle, and deal with failures if they
should occur (namely, a form of relapse prevention). When posi-
tive results occur, clients are encouraged to make self-attribu-
tions for the changes that they have been able to bring about.
Often, clients will require specific skills training, and treatment
frequently involves significant others (spouse, family members,
teachers, and peers) to increase the likelihood of generalization
and maintenance.
Constructive Narrative as a Metaphor
The notion that clients are architects and constructors of
their environments has given rise to a third metaphor that is
guiding the present development of cognitive-behavioral thera-
pies. The constructivist perspective is founded on the idea that
203
humans actively construct their personal realities and create
their own representational models of the world. This construc-
tivist perspective finds root in the philosophical writings of
Immanuel Kant, Ernst Cassirer, and Nelson Goodman and in
the psychological writings of Willhelm Wundt, Alfred Adler,
George Kelly, Jean Piaget, Viktor Frankl, and Jerome Frank.
More recently, the constructivist perspective has been advo-
cated by Epstein and Erskine (1983), Mahoney and Lyddon
(1988), McCann and Perlman (1990), Neimeyer and Feixas
(1990), Meichenbaum (1990), and White and Epston (1990).
Common to each of these proponents is the tenet that the hu-
man mind is a product of constructive symbolic activity, and
that reality is a product of personal meanings that individuals
create. It is not as if there is one reality and clients distort that
reality, thus contributing to their problems; rather, there are
multiple realities, and the task for the therapist is to help clients
become aware of how they create these realities and of the
consequences of such constructions. Bruner (1990), writing
from a narrative psychology perspective, described how individ-
uals make meaning or construct stories to explain their symp-
toms and situations. For instance, clients may use metaphors to
describe their emotional experience. One client recently re-
ported that she "always stuffed her feelings down" and then she
would explode; another patient described "how he built walls
between himself and others." The therapist helped these clients
to appreciate the nature and impact of using such metaphors.
What is the impact, what is the emotional toll, what is the price
they pay for behaving in accord with such a metaphor of "stuff-
ing feelings" and "building walls"? At this point, the therapist
explored collaboratively and experientially the "price" they
paid. "If this is not the way they would like things to be, then
what could they do?" It is not a big step for clients to suggest that
perhaps they should "not stuff feelings" and "not build walls."
The therapist then says, "Not stuff feelings, not build walls,
that is interesting. What did you have in mind?" In this manner
the therapist enlists the client as a collaborator in engaging in
what Shafer (1981) called "narrative repair."
The metaphor of a constructive narrative to explain clients'
problems has a number of important theoretical and practical
implications for the further development of CBM.
1. The therapist is viewed as a co-constructivist helping
clients to alter their stories, as Spence (1984) proposed. The
therapist must first listen empathically and reflectively to the
initial story line of the patient and then collaboratively help the
client to transform his or her story. A nurturant, compassion-
ate, nonjudgmental set of conditions is required for distressed
clients to tell their story at their own pace. A number of clinical
techniques, including reflective listening, Socratic dialogue,
sensitive probes, imagery reconstruction of stressful experi-
ences, and client self-monitoring, are used to help clients relate
what happened and why. Thus, the role of relationship variables
is critical, as is the role of affect in the therapeutic process.
2. The therapist helps clients to cognitively reframe stress-
ful events and to "normalize" their reactions. From this per-
spective, it is not the symptoms of depression, anxiety, and
anger per se that interfere with functioning; rather, what clients
say to themselves and others about these reactions, the stories
they construct, are important to the adaptive process. The ther-
apist not only helps to validate clients' reactions but indicates
204 DONALD MEICHENBAUM
that such symptoms are normal. In fact, their emotional dis-
tress is viewed as a normal spontaneous reconstructive and
natural rehabilitative adaptive process. This reconceptualiza-
tion process is an attempt to formulate a "healing theory" of
what happened and why (see Meichenbaum & Fitzpatrick, in
press, for a fuller discussion). The therapist also helps clients
relate examples of their strengths, resources, and coping abili-
ties to convey "the rest of the story" (to use a popular meta-
phor). The therapist avoids holding a pathology bias, instead
looking for and building on those exceptional occasions when
clients coped effectively.
3. From a narrative perspective, the therapist not only helps
clients to break down global stressors into behaviorally pre-
scriptive events so they can use problem-solving and emotion-
ally palliative coping techniques, but also helps them build new
assumptive worlds and new ways to view themselves and the
world (Meichenbaum, in press).
The cognitive therapist helps clients to construct narratives
that fit their particular present circumstances, that are coher-
ent, and that are adequate in capturing and explaining their
difficulties. As Shafer (1981) indicated, therapy allows clients
to retell their tale "in a way that allows them to understand the
origins, meanings and significance of present difficulties, and
moreover, to do so in a way that makes change conceivable and
attainable" (p. 38). What matters most about this story telling
or narrative construction is not its "historical truthfulness," as
Spence (1984) observed, but its "narrative truthfulness."
4. One of the implications of adapting the constructive
narrative metaphor is that it suggests that one look at therapeu-
tic interventions in a different fashion. Perhaps, one can even
find therapeutic suggestions from the way that teachers teach
narrative writing. It also suggests different types of dependent
measures that individuals can use (e.g., indicators of narrative
transformations).
The field of CBM has come a long way since its inception.
The story continues to unfold and to change as new metaphors
are adopted and new narratives constructed.
References
Barlow, D. (1988). Anxiety and its disorders: The nature and treatment of
anxiety and panic. New York: Guilford Press.
Beck, A. (1970). Cognitive therapy: Nature and relation to behavior
therapy. Behavior Therapy, 1. 184-200.
Breger, L., & McGaugh, J. (1965). Critique and reformulation of "learn-
ing theory": Approaches to psychotherapy and neurosis. Psychologi-
cal Bulletin, 63. 338-358.
Brewer, W (1974). There is no convincing evidence for operant or clas-
sical conditioning in adult humans. In W Weimer & D. Palermo
(Eds.), Cognition and the symbolic processes. (Vol. 1,1-42). Hillsdale,
NJ: Erlbaum.
Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard Univer-
sity Press.
Cautela, J. (1973). Covert processes and behavior modification. Jour-
nal of Nervous and Mental Disease, 157, 27-35.
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Re-
search and Therapy. 24, 461 -470.
Dember, W (1974). Motivation and the cognitive revolution. American
Psychologist. 29. 161-168.
Dodge, K. A., & Coie, J. D. (1987). Social information-processing fac-
tors in reactive and proactive aggression in children's peer groups.
Journal of Personality and Social Psychology, 53, 1146-1158.
Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle
Stuart.
Epstein, S., & Erskine, N. (1983). The development of personal theories
of reality. In D. Magnusson & V Allen (Eds.), Human development:
An interactional perspective (pp. 133-147). San Diego, CA: Academic
Press.
Hollon, S. D. (1990). Cognitive therapy and pharmacotherapy for de-
pression. Psychiatric Annals, 20, 249-258.
Homme, L. (1965). Perspectives in psychology: Control of coverants,
the operants of the mind. Psychological Record, 15, 501 -511.
Mahoney, M. (1974). Cognition and behavior modification. Cambridge,
MA: Ballinger.
Mahoney, M. J., & Lyddon, W J. (1988). Recent developments in cogni-
tive approaches to counseling and psychotherapy. The Counseling
Psychologist, 16, 190-234.
Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: Mainte-
nance strategies in the treatment of addictive behaviors. New York:
Guilford Press.
McCann, I. L., & Perlman, L. A. (1990). Psychological trauma and the
adult survivor. New York: Brunner/Mazel.
McKeachie, W (1974). The decline and fall of the laws of learning.
Educational Researcher, 3, 7-11.
Meichenbaum, D. (1977). Cognitive behavior modification: An integra-
tive approach. New York: Plenum Press.
Meichenbaum, D. (1990). Evolution of cognitive behavior therapy: Ori-
gins, tenets and clinical examples. In J. Zeig (Ed.), The evolution of
psychotherapy: //(pp. 96-115). New York: Brunner/Mazel.
Meichenbaum, D. (in press). Stress inoculation training: A twenty year
update. In R. L. Woolfolk & P. M. Lehrer(Eds), Principles and prac-
tices of stress management. New York: Guilford Press.
Meichenbaum, D.. & Fitzpatrick, D. (in press). A constructivist narra-
tive perspective of stress and coping: Stress inoculation applica-
tions. In L. Goldberger & S. Breznitz(Eds.), Handbook of stress. New
York: Free Press.
Neimeyer, R., & Feixas, G. (1990). Constructivist contributions to psy-
chotherapy integration. Journal of Integralive and Eclectic Psycho-
therapy, 9, 4-20.
Novaco, R. (1979). The cognitive regulation of anger and stress. In P. C.
Kendall & S. D. Hollon (Eds.), Cognitive behavioral interventions:
Theory, research and procedures, (pp. 84-101). San Diego, CA: Aca-
demic Press.
Shafer, R. (1981). Narration in the psychoanalytic dialogue. In W 3.
Mitchell (Ed.), On narrative (pp. 212-253). Chicago: University of
Chicago Press.
Spence, D. (1984). Narrative truth and historical truth: Meaning and
interpretation in psychoanalysis. New York: Norton.
White, M., & Epton, D. (1990). Narrative means to therapeutic ends.
New York: Norton.
Received February 13,1992
Revision received June 5,1992
Accepted July 30,1992 •