The dominant approach to behavior change in 2020 was still "cognitive-behavioral therapy" (CBT). If you pick a therapist at random from the phone book, chances are that they will offer this brand of treatment. Furthermore, the majority of behavior-focused grants funded by the National Institutes of Health use either cognitive-behavioral methods, or the related social-cognitive model, to explain and influence people's health choices. Although CBT is the dominant model of behavior change (having replaced older psychodynamic approaches in the 1980s and 1990s), it has a checkered history that shows its combined and sometimes competing roots in both the Intuitive and Narrative systems. In fact, today's CBT is an amalgam of two earlier schools of thought that were once in fierce opposition.
Behaviorism was the earlier approach, developed by laboratory-based American psychologists starting around the turn of the 20th century. This school of thought attempted to change people's behavior using methods that target the Intuitive mind. Johns Hopkins University psychologist John Watson advocated an approach called "methodological behaviorism" starting in 1913. Watson rejected the idea of studying conscious experiences, and instead focused his science on observable stimuli and people's observable responses to them. Watson's most infamous experiment (and perhaps the most infamous study in all of psychology) involved using loud noises to train a young child that he called "Little Albert" to be afraid whenever he saw a white rat. Despite the study's questionable ethics, it strongly demonstrated the role of reinforcement-based learning in humans. Watson had to resign his university position when his wife left him over an affair with his graduate student, Rosalie Rayner, along with unsubstantiated rumors that the two were conducting sex research in their lab. In later life Watson turned his expertise to advertising, coining the term "coffee break" for Maxwell House. With time and marriage to Rayner, the scandal around Watson gradually faded, and he received a medal from the American Psychological Association honoring his scientific contributions before his death in 1958.
In 1937, Harvard psychologist B. F. Skinner coined the term "operant conditioning" and initiated the next wave of behaviorist research. Skinner's work with pigeons and rats showed that even complex behaviors could be shaped gradually using a series of small steps and rewards. His approach is epitomized by the "Skinner box" in which an animal is provided with rewards or punishments (e.g., electric shocks) based on its behavior. Skinner was generally a well-respected academic figure, but his ideas were still strange or frightening to some people because they showed how behavior could be shaped without appealing to reason and outside of people's conscious awareness. Fear of behaviorism's implications led to rumors that Skinner had raised his own daughter in a Skinner box (false, although Skinner did invent an "air crib" to provide her with climate control). Skinner's ideas also led to wild concepts like a "pigeon-guided missile" explored by the U.S. military. In general, however, Skinner's operant conditioning has achieved a stable place in modern psychotherapy and psychological science.
The greatest weakness of Skinner's ideas was in the area of language, where an argument with philosopher Alfred North Whitehead led to the book Verbal Behavior in 1957. Sitting at dinner with the 30-year-old Skinner in 1937, Whitehead challenged him to explain using only behaviorist principles why the great philosopher might utter the sentence "no black scorpion is falling upon this table." Skinner spent the next 20 years trying to answer this challenge. (The radical behaviorist group in my grad school at Temple University accordingly called themselves the "Black Scorpion Society"). Skinner's core contention was that language was also under the direct control of reinforcers and rewards, just like any other behavior, and that it did not reflect innate capabilities of will or reason that were separate from the person's history of reinforcement. Skinner ultimately concluded that Whitehead had selected a "black scorpion" for his example because the idea of that insect generated a fear response similar to Whitehead's intuitive reaction to behaviorism, which he would have seen as a threat to his own cherished beliefs in human rationality. This might seem like an oddly meaning-focused explanation from a researcher focused on observable behavior, but Skinner argued that Whitehead's choice of words came from his history of learning that some insects and some theories were similarly to be feared.
Parallel to Skinner's work in the 1950s and 1960s, a school of thought emerged in psychology that was focused only on language and meaning, the cognitive therapy approaches of Albert Ellis and Aaron Beck. Ellis published his work first, under the label "rational-emotive therapy" or later "rational-emotive behavioral therapy" (REBT). Ellis argued for an approach to living based on the work of stoic philosophers like Epictetus and emperor Marcus Aurelius, in which "virtue is sufficient for happiness." The right way of thinking supports right actions in the world; through right action one can be happy regardless of results, and one is additionally more likely to get the desired result. Ellis gave a famous example of his experience asking out 100 women in Central Park in order to cure his own shyness. (It worked, but one wonders what the women thought). Beck's work added the idea of mental "filters" or schema through which people see the world. Beck argued that most mental health concerns come down to three basic negative beliefs, about the self ("I'm no good"), the world ("life isn't fair"), or the future ("nothing will ever get better"). Attempts to modify people's beliefs in this "negative cognitive triad" are the core of Beck's cognitive therapy approach. Both Ellis and Beck used a combination of rational argument and structured experiments to change people's beliefs; the experiments are a bit behavioral, but both theorists argued that changes in thinking (i.e., the Narrative mind) was the ultimate goal of treatment. Although it once mattered whether you were a "Beck cognitive therapist" or an "Ellis cognitive therapist," the two approaches have essentially merged under the idea that one's thoughts control one's feelings and behaviors, and that modifying or challenging thoughts is the key to achieving different results in living. A strong version of this view is found in the so-called "law of attraction."
By 1958, behaviorist psychotherapy developed a new tool based on the work of South African psychiatrist Joseph Wolpe -- systematic desensitization. This approach relies on the physiological principle of habituation, another Intuitive-system process in which people get used to things over time. Specifically in the case of things that make us afraid, the body can't sustain a fear response indefinitely when no actual harm has occurred. Wolpe therefore designed a procedure in which people would voluntarily expose themselves to things that made them afraid (like spiders), and then sit with the anxiety until it started to go down naturally on its own. After that, they would have a lower anxiety reaction to spiders in the future. By doing this multiple times, Wolpe was able to eliminate the fear almost entirely. In order to get people to participate he also used a "hierarchy" or ladder in which people would start with things that made them less nervous (e.g., thinking about spiders), and move up gradually to things that made them more nervous (e.g., seeing a spider, or touching a spider). Like the other Intuitive-level tools in the behaviorist toolbox, Wolpe's method worked very well. Wolpe taught at my alma mater, Temple University, from 1965 onward.
Another South African who taught at Temple in the late 1960s was psychologist Arnold Lazarus (later at Yale and then at Rutgers), who advocated for a much more cognitive approach to problems. His motto "Think Well - Act Well - Feel Well - Be Well" summarizes the proposed sequence of events from Narratives to behaviors, which in turn influence emotions and then overall health. Lazarus was known for his use of purely mental stimuli like imagery to modify behavior, something that Skinner and the earlier behaviorists would have seen as an inappropriate subject for study because it was unobservable. In prioritizing people's mental experiences and narratives, Lazarus exemplified the cognitive thread in cognitive-behavioral therapy even though he also utilized behaviorist techniques. His colleague Wolpe strongly emphasized the behavioral thread. The conflict between these two experts was well-known among the faculty, and apparently led to public altercations. In print, Wolpe reviewed Lazarus's 1972 book Behavior Therapy and Beyond as "stilted," "pontifical" and "totally incorrect," and stated that "in sum, the book does not make any substantive contribution to the literature of psychotherapy." The "beyond behavior therapy" techniques that Wolpe hated were those focused on the Narrative mind.
Meanwhile, Aaron Beck was also working in Philadelphia and continuing to develop "Beck's Cognitive Therapy." Although Beck's methods readily borrowed behaviorist methods like desensitization, the core of the method remained the A-B-C model in which a belief (the "B" between "activating event" and "consequences") played the central role in determining behaviors and emotions. In 1972, psychologist Donald Meichenbaum proposed a set of mixed cognitive and behavioral techniques that became known as Stress Inoculation Training; it involved a mix of coping statements (a Narrative strategy) and the practice of specific relaxation skills (an Intuitive approach). Other behaviorist strategies like structuring one's environment or scheduling reinforcers were gradually added to the combined cognitive-behavioral toolbox, but the dominant theory espoused by Meichenbaum and his colleagues was Beck's. By the 1990s, Beck's daughter Dr. Judith Beck wrote a book called Cognitive Therapy: Basics and Beyond that formalized a broader mixture of Narrative- and Intuitive-focused strategies under the umbrella of Beck's cognitive theory. J. Beck argued for the central role of enduring cognitive structures called schemas that generate everyday thoughts and feelings, which in turn produce behaviors and life problems. The schema is a sort of master Narrative that arises from early experiences including childhood trauma. In some ways this focus on unconscious Narratives is an idea worthy of Sigmund Freud, and a far cry from Wolpe's or Skinner's insistence on studying nothing that could not be observed in the lab.
As cognitive theory's influence grew, behaviorist techniques were increasingly seen as just a means to an end -- get people to practice new skills, and their beliefs will change. The other factor in the late 1980s and early 1990s that helped to end previously contentious disputes between cognitivists and behaviorists was the ascendancy of managed care. With a ruthless focus on cutting costs and a demand that all psychotherapy procedures have empirical support, managed care organizations helped to unite CBT practitioners against a common enemy. Therapists became more willing to embrace any technique with empirical support in order to smooth the way for insurance reimbursement, and both the cognitive and behavioral threads of CBT had stronger empirical support than any other form of therapy at the time. Ironically, those sources of evidence arose mainly out of an earlier generation of scientists' attempts to contradict one another.
What, then, do we get when we sign up for a course of "cognitive-behavioral therapy" (CBT) in 2020? The answer is that we are probably getting two things -- a behaviorist approach focused on the Intuitive system plus a cognitive one focused on the Narrative system. Studies have confirmed independent benefits of both the cognitive component and the behavioral component of CBT, which might not be surprising given that the Intuitive and Narrative systems provide two different but potentially efficacious pathways to behavior change. The major problem for recipients of CBT might be that the approach itself is somewhat confusing, presenting a hodge-podge of hardheaded empirical behavior modification strategies that emphasize action, alongside aphorisms from Stoic philosophy and a cognitive theory that emphasizes Narratives above all else. It can be easy for patients to get mixed up in this melange, perhaps experiencing misplaced guilt over their lack of "adaptive" thinking or focusing unnecessary energy on trying to change their thinking. (Always a challenging task: Take just a moment and don't think about a white bear). Although both the cognitive and the behavioral threads of CBT have potential benefits, what they lack is a clear integrative approach that acknowledges both the Intuitive and Narrative systems' effects on people's behavior.
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