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Philosophical Differences
Among Cognitive Behavioral
Therapists: Rationalism,
Constructivism, or Both ?
Raymond DiGiuseppe
St. John's University
and Institute for Rational-Emotive Therapy
Jean Linscott
St. John's University
Cognitive behavioral therapy has evolved into a very diverse field, representing
numerous theories, which can no longer be considered a unitary or monolithic
METHOD
Subjects
Subjects were selected from two populations. The first sample, called the general
CBT sample, consisted of authors who published articles on cognitive behavioral
therapy (or related topics) between and including the years 1986-1988. The
journals sampled were: Cognitive Therapy and Research, Journal of Consulting
and Clinical Psychology, and Journal of Cognitive Psychotherapy: an Interna-
tional Quarterly. Also included in this sample were speakers scheduled to appear
at the 1989 World Congress for Cognitive Therapy. If authors from the journal
publication list were also on the referral list for the Institute for Rational Emotive
Therapy, or if the article concerned RET, they were excluded from this group.
The second sample consisted of clinicians from the referral list of the Institute
for Rational-Emotive Therapy. Only those persons on the list who had completed
the Institute for Rational-Emotive Therapy's fellowship or associate fellowship
training programs were included. Those persons who were known to the author to
no longer practice RET were eliminated.
In total, 416 questionnaires were mailed out, 161 to the general CBT sample, and
255 to the RET sample. Of the 416 questionnaires mailed, 39 were returned
unopened due to incorrect addresses, 178 were completed and returned, and the
remaining 199 questionnaires were not returned. The final sample consisted of 178
subjects, including 59 from the general CBT sample, and 119 from the RET sample.
Demographic information obtained from the general CBT sample revealed an
age range of 33-69 years, with an average age of 47 years; 83% of respondents
were male, and 15% female. The highest degree subjects obtained was a Ph.D.,
92%; M.A., 3%; ED.D., 3%; and MD, 2%. Primary employment settings in-
cluded: university academic department, 51%; private practice, 20%; hospital 0.
P. D., 9%; research setting, 5%; university service delivery department, 3%;
mental health center, 3%; hospital inpatient setting, 2%; and other, 7%. Subjects
identified themselves as either scientist/practitioners (70%), practitioners (18%),
or scientists (12%). Subjects were also asked to identify "which theoretical
position within cognitive behavior therapy would be most closely related" to their
own theoretical views. Beck's cognitive therapy (1976) was named by the
majority of the journal publication sample (49%), with the second largest
percentage of respondents naming Ellis' (1962) Rational-Emotive therapy (14%).
The RET sample consisted of respondents with an age range of 26-77, with an
average age of 45, including 72% males and 26% females. The highest degree
subjects obtained was a Ph. D., 66 %; MA, 11%; MSW, 6%; EDD, 5%; MS, 4%;
PsyD, 3%; and MD, 2%; while the year the degree was (or was to be) received
ranged from 1944-1990, with 1976 being the modal year. Primary employment
settings included: private practice, 43%; university academic department, 22%;
Cognitive Behavioral Philosophies 121
mental health center, 8%; hospital inpatient setting, 6%; university service
delivery department, hospital O.P.D., and public school, 4%, respectively, re-
search setting, 1%; and, 7% other. Subjects identified themselves as either
practitioners 55%, or scientist/practitioners 45%. In the RET sample, Ellis' RET
was named as the theoretical preference by 84% of the respondents.
Materials
The "Therapist Attitudes Questionnaire" was constructed to assess the validity of
Mahoney's bipolar categorization of CB therapists. Items were designed to
represent one pole of each of the philosophical, theoretical, and technical bipolar
dimensions derived by Mahoney to represent the rationalist and constructivist
positions, as described (see Table 1). The items were constructed by the authors
from the polarity descriptions of rationalist and constructivist philosophies from
the Mahoney and Gabriel 1987 article. Each of the 32 items represented one end
of Mahoney's descriptions of the philosophical positions. Sixteen items were
designed to represent the rationalist philosophy, and 16 items represented the
constructivist philosophy.
Six additional items of the questionnaire were included to assess differences on
their preferences for target thoughts in the initial stages of therapy. Three items
represented the therapist's choice in disputing automatic thoughts before under-
lying schema/irrational beliefs, spending more time disputing automatic thoughts
than underlying schema irrational beliefs, and the importance of helping patients
adopt new philosophies to cope with negative realities. Three items represented
the reverse order of preference.
Subjects were asked "the degree to which you endorse the following statements"
on a scale 5 point Likert scale. The questionnaire is reproduced in Table 1.
The items were sent to Mahoney asking him to verify whether or not they
accurately represented his descriptions of the rationalist and constructivist posi-
tions. He responded affirmatively.
Procedure
After Mahoney's confirmation, the questionnaires were mailed to the journal
publication and referral list samples. In addition to the questionnaire, a cover letter
describing the intent of the study was enclosed, along with a stamped, addressed
return envelope, and a post card to request the results of the study. The purpose
of the study was described as an interest in "seeing if CB therapists actually have
similar philosophical attitudes, theoretical assumptions, and clinical interven-
tions." Subjects were requested to "fill out the questionnaire, put it in the
envelope, and return the post card separately with your name and address if you
would like us to send you the results of the study."
122 DiGiuseppe and Linscott
TABLE 1. (continued)
21. Mental representations are tacit constructs that order our experience and
constrain perceptions but do not specify the particulars of perception:
22. Cognition, behavior and affect are interdependent expressions of holistic
systemic processes. The three are functionally and structurally inseparable:
23. The body and the mind (brain) are inseparable and interdependent:
24. Intense emotions have a disorganizing effect on behavior. This disorganiza-
tion may be functional in that it initiates a reorganization so that more viable
adaptive constructions can be formed to meet the environmental demands:
25. It is not best for psychotherapy to have a fixed goal, rather it is best to follow
the path that the client's development takes:
26. Psychotherapists should encourage emotional experience, expression, and
exploration:
27. Clinical problems are current or recurrent discrepancies between our ex-
ternal environmental challenges and internal adaptive capacities. Problems
can become powerful opportunities for learning:
28. Awareness or insight is one of many strategies for improvement, however,
emotional and/or behavioral enactments are also very important:
29. Resistance to change reflects a healthy, natural, self protecting process that
guards against changing too quickly. Therefore, resistance is adaptive and
should be worked "with" rather than "against":
30. Relapse, recidivism, and regression are natural aspects of human nature.
Change may be of nonpsychological, linear development. Regressions, and
relapse, are natural and virtually inevitable aspects:
31. Therapists' relationship with clients is best conceptualized as a professional
helping relationship which entails the service and delivery of technical,
instructional information or guidance:
32. Psychotherapists' relationship with clients can best be conceptualized as a
unique social exchange which provides the clients a safe supportive context
to explore and develop relationships with themselves and the world:
33. It is best for psychotherapists to change clients' automatic thoughts before
attempting to change core underlying schema:
34. The main task of the psychotherapist is to ferret out and change core
underlying schema as soon as possible to help the client change:
35. It is more appropriate for psychotherapists to ascertain clients' underlying
assumptions in the beginning of therapy (first sessions) than to challenge
automatic thoughts:
36. While it is important to uncover clients core schema, it is best for psy-
chotherapists to spend the first 10 to 15 sessions dealing with automatic
thoughts so that the client can become aware of their underlying schema:
37. The most important element in cognitive therapy is getting clients to empir-
ically test their notions about reality:
38. The most important aspect of psychotherapy is to help clients adopt new
viable philosophies to cope with negative realities.
124 DiGiuseppe and Linscott
RESULTS
(total item responses/number of items) producing a mean score for each subject
on the rationalist, constructivist, and primacy of disputing scales.
The means and standard deviations of the General CB and RE therapists
attitudes are presented below in Table 3, followed by the summary of the ANOVA
results in Table 4.
A conservative alpha level of .01 was set for both the main effects and simple
effects analyses. Results of the ANOVA indicate that both main effects, thera-
126 DiGiuseppe and Linscott
pists' group [F(l 145) = 6.06, p =.015], and scale type [F(2,290) = 35.72, p
<.0001] demonstrate significance as well as significant interaction of group by
scale [F(2,290) = 6.48, p- .002]. Since the groups were not randomly assigned
and the independence of the error term could not be guaranteed, the epsilon-
corrected degrees of freedom was used. This did not change the significance of the
main effects, or of the interaction effect.
Simple effects analysis on the between-group factor showed subjects in the
RET sample scored significantly higher on the rationalist scale than did subjects
in the General CB sample, F(.9225,133) = 16.24, p< .01. No significant group
differences were seen on the constructivist and primacy scales. Analysis of the
within group factor (scale type) showed significant differences for both the
General CB andRET groups within scales, F(1.845,267) 25.61,p < .01; F(I.845,267)
= 14.26, p <.01, respectively (see Table 5).
Post-hoc comparisons on the within-groups factor using the Tukey Kramer
modification for unequal Ns showed the General CB sample's mean scale scores
were significantly higher on the constructivist scale than on both the rationalist
and primacy scales (HSD = .224). The RET sample's mean scale scores were
significantly higher on the constructivist scale than on the primacy scale (HSD =
.224). There were no significant differences between the rationalist vs. constructivist
scores, or the rationalist vs. primacy scores.
Scales for:
CB Ther. 9 1.845 4.878 25.67 < .01
RET Ther. 5 1.845 2.71 14.26 < .01
Error term:
MS scalesxSSwgps 51.75 267 .19 — —
Discussion
The results from the present study suggest that Mahoney is correct in hypothesiz-
ing two broad philosophical positions in CB therapy. The categories of rational-
ism and constructivism, as based upon the high alpha coefficients for both scales,
the non-significant correlation between scales, and on the interpretation of the
factor analysis were shown to represent consistent positions on philosophical,
theoretical, and practical interventions among CB therapists. In addition, thera-
pists scores on the Therapist Attitudes Questionnaire were shown to correctly
discriminate group membership for a large majority of cases in both the General
CB and RE therapist groups (83% and 84% respectively).
The results do not, however, support Mahoney's hypothesis that the rationalist
vs. constructivist philosophies are bipolar opposites which serve to distinguish
between cognitive behavioral therapists. If Mahoney's hypothesis that these
philosophies are bipolar opposites were correct, a high negative correlation would
have resulted between the rationalist and constructivist scales. The result of a
nonsignificant positive correlation obtained in this study shows, however, that
this was not the case.
128 DiGiuseppe and Linscott
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