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Donald Meichenbaum on Cognitive-Behavioral Therapy

Donald Meichenbaum on Cognitive-Behavioral Therapy

by Victor Yalom

Renowned expert Donald Meichenbaum discusses Cognitive-Behavioral Therapy (CBT), treatment for trauma, and the search for expert psychotherapists.
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The Interview

Victor Yalom: Dr. Meichenbaum thanks for meeting with me today.
Donald Meichenbaum: I welcome the opportunity to be part of your interview series.
VY: I am interested in knowing what got you into the field of clinical psychology.
DM: I started my undergraduate career at City College of New York and from there I went to the University of Illinois in Champaign where I obtained my Ph.D. in Clinical Psychology. I started out in graduate school as an industrial psychologist and I was hired as a research assistant to conduct group observations at a local veteran's psychiatric hospital. I became fascinated with the patients and decided to switch to clinical.
VY: Why did you go into psychology?
DM: I grew up in New York City where one naturally becomes a "people watcher." I was always fascinated by the process of trying to understand human behavior. As a youth, I was interested in how people come to engage in destructive aggressive acts like the Holocaust. On the other side, I grew up in a home where caring for others was important. These two influences led me to choose psychology.

... Continue Reading Interview >>
VY: How did you end up at the University of Waterloo in Ontario Canada?
DM: From Illinois I went to Waterloo, in part because they offered me a job. Waterloo was a new University and it had much promise. Also, the Chairman of the Psychology Department was Richard Walters of Bandura and Walters fame. He was a brilliant psychologist and I had an opportunity to work with him. Unfortunately, he died soon after I arrived, but Waterloo turned out to be a wonderful setting and I have stayed for 33 years until I took early retirement a few years ago.
VY: What are you doing now?
DM: If you live in Ontario, Canada, and you retire, one of the things you do is go to Florida for the winter (with a large percentage of the Canadian population). Besides the weather, the main activity that brings me to Florida is that I have become the Research Director of The Melissa Institute for Violence Prevention and the Treatment of Victims of Violence, in Miami, Florida.
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Trauma and Hope: The Melissa Institute

VY: Can you tell us about The Melissa Institute? How did it emerge? What does it do? Why Melissa?
DM: Melissa was a young lady who grew up in Miami and she was going to Washington University in St. Louis. A tragic thing occurred. She was car jacked and murdered. Now when such a tragedy befalls a family, their relatives, friends and neighbors, one of the ways people try and "cope" is to transform their pain.
There is no way to allay the emotional pain of such trauma, but rather they try and find some meaning in the tragedy.
There is no way to allay the emotional pain of such trauma, but rather they try and find some meaning in the tragedy. Hopefully, some good can come out of such a profound loss.

As you know, one of my areas of specialization is studying the impact of trauma (as I discuss in myClinical Handbook on Treating Adults with PTSD). A friend of Melissa's parents read the handbook and attended one of my workshops. She put me in touch with Melissa's parents and one thing led to another and with the friend, Dr. Suzanne Keeley, we established an Institute in Melissa's name.

VY: What does The Melissa Institute do?
DM: The Melissa Institute is designed to bridge the gap between scientific findings and public policies, clinical and educational practices. The Melissa Institute is designed to "give psychology away" in an effort to reduce violence and to treat victims of violence. It is not a direct service Institute. Instead, it provides services in three areas. First, it provides graduate student scholarships in support of doctoral dissertation work in the areas of violence prevention and treatment of victims. Second, it provides training and education in the form of workshops and conferences. We hold an annual May conference, (next year will be a conference in New York on the aftermath of September 11), and conduct other trainings for various members of the community, as well as school children (e.g., on bullying). Third, and most importantly, The Institute provides consultation to various public agencies in the area of violence prevention.

On a personal note, it has been fascinating for me to consult to the Mayor's office, the Public Defender's Office, the District Attorney, the Juvenile Assessment Center and to other agencies. After some 30 years of research and clinical practice, I have been struggling with how I can have a larger impact. How could I use all that I have experienced and learned to make the world less violent for my new grandchildren? (For more information on The Melissa Institute activities, please visit the website www.melissainstitute.org).

As you can see, I have not fully retired. I do not just spend my time on the beach.
VY: What do you miss about the academic setting, if indeed you do?
DM: I do spend the summer months in Waterloo, so I have maintained contact with the University. I miss my colleagues and the daily research activities with my graduate students. I also cut back on my clinical practice and I now spend my time engaged in consultations with a wide array of clinical populations in various settings including psychiatric facilities, residential programs, centers for treating individuals with brain injury and individuals with developmental delays. I am still a "people watcher."
VY: You mentioned that you also are involved with trauma patients.
DM: Yes, I was involved in consultations on an array of traumatic events including the Oklahoma City bombing, the Columbine school shootings, and now the aftermath of the September 11 events. These various forms of violence have led me to write a Clinical Handbook on Treating Individuals with Anger-control Problems and Aggressive Behaviors. This practical therapist manual fits well with my efforts as Research Director of The Melissa Institute.
VY: Your work sounds both gratifying and intellectually stimulating, but it doesn't sound like you're retired.
DM: It is rewarding. I cannot think of a more important problem to focus my attention on than the reduction of violence.
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The Desire to Help and a Story about Mom

VY: Getting back to your desire to help people. Therapists often go about helping people in ways that are based on their own experiences in life. Do you have a sense of how personal experiences in your life have affected your clinical work?
DM: A couple of years ago, I wrote a chapter entitled "A Personal Journey of a Psychotherapist and His Mother". In it, I began with an anecdote that may answer your question. My mother, who lived in New York, came to visit me in Canada soon after I took early retirement. I had to tell her the news about my early retirement. My mother looked a bit puzzled upon hearing of my retirement and then paused and asked, "What am I supposed to tell my friends? I'm still working and my son, the Professor, is retired!"

Now when my mom visits she comes with stories. She is a big "story teller". But, she has a special way of telling stories. She not only tells you about an incident in her life, but she also tells you about the feelings and thoughts she had before, during, and after the incident. Moreover, she provides editorial commentary on what were useful thoughts and what were stress-engendering thoughts and moreover, what she could have done differently. On one recent visit, it dawned on me that I ate dinner with my mother each day of my formative years and listened to such stories. For example, my mother would say:

"I said to myself, Flo, so you moved the heavy box? I knew I shouldn't have done that. Then, I got down on myself for making such a foolish decision. 'What will I tell Donny?' But, then I thought why get down on yourself, because all you were doing was trying to help."  And so the story continued.
VY: What did you learn for this story with your mother?
DM: I came to realize that the form of cognitive-behavioral therapy that I have been working on for my entire career was in some sense a way to validate my socialization process.
As my mom would say what you do is "New York Therapy". You try and teach people (schizophrenics, hyperactive children, aggressive individuals, traumatized individuals) to talk to themselves differently, to change the stories they tell themselves and others. "For this you get paid?"
As my mom would say what you do is "New York Therapy". You try and teach people (schizophrenics, hyperactive children, aggressive individuals, traumatized individuals) to talk to themselves differently, to change the stories they tell themselves and others. "For this you get paid?"
VY: I didn't realize your mom was one of the originators of Cognitive-Behavior Therapy (CBT).
DM: I think she would be willing to share credit with others. I could give a scholarly answer about the origins of CBT ranging from Immanual Kant to Freud to Dubois to Adler to Kelly to Ellis and to Beck. But, I like to give credit to my mom who recently died of cancer. You can trace the scholarly lineage in my Handbooks.
VY: I know the intellectual roots of your inspiration also run deep, but it is particularity refreshing to hear you speak outside of the traditional academic jargon and learn of your personal connection to your work. That is what we expect of our clients, namely, their ability to learn from their lives, so why not therapists. Back to Top

Paradigm Shifts in Psychotherapy

DM: I have become fascinated with the nature of story telling that patients offer themselves and others and how their stories change over the course of therapy.
VY: It sounds like this relates a lot to the ideas of narrative constructions.
DM: If you look at the evolution of cognitive behavior therapy you can find a shift in the models employed to explain the nature and role of cognitions. In 1960's and early 1970's, I (and others) was viewing cognitions within the framework of learning theory. Cognitions were viewed as "covert behaviors" subject to the same so-called "laws of learning", as are overt behaviors. Now, I don't believe that there are laws of learning" that explain overt behavior, let alone cognitions. In the 1970's and 1980's, the computer metaphor became prominent and cognitions were viewed within the framework of social information processing. Concepts of decoding, mental heuristics, attributional biases, self-fulfilling prophecies, and the like were used to explain the role of thoughts and feelings played in overt behavior.

These first two conceptual stages were heuristically useful, as they yielded the development of self-instructional training, stress inoculation training, and various cognitive restructuring procedures. (See Meichenbaum's Cognitive-Behavior Modification : An Integrative Approach for a discussion of these origins.) More recently, as the role of meaning, with all of its developmental and contextual-cultural influences, has come to the fore, I (and others) have begun to explore the usefulness of a constructive narrative perspective. I have written about the importance of this theoretical shift in various places, including the two Clinical Handbooks.
VY: In terms of theoretical shifts, you are one of the few writers to directly confront how to treat co-existing anxiety and depression, which is so common in clinical practice. Indeed, in the video training film you demonstrated how CBT can be applied when these clinical conditions co-occur. What were you attempting to illustrate in this video?
DM: This teaching film was an interesting exercise because the producers wanted me to demonstrate short-term CBT intervention (12 sessions) with a patient who experienced both anxiety and depression. Not only that, they wanted me to reduce all 12 sessions into a one hour film. If you had to make such a one-hour film, what would you put in it? What exactly would an "expert" therapist demonstrate? What does the research literature suggest as being critical to include?

I should note, parenthetically, that the area of "expertise" interests me a great deal. With a colleague, Andy Biemiller, we wrote a book called Nurturing Independent Learners (Brookline Books Publishers) in which we reviewed the literature on expertise in various areas such as athletes, musicians, teachers, students and clinicians.
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People Have Stories to Tell

VY: Can you speak more about nature of stories and change in therapy?
DM: If you work with people who have been victimized as a result of having been raped or sexually abused, or exposed to intimate partner violence, or some other form of violence, you soon come to see that the nature of their "stories" changes over the course of therapy.
VY: How so?
DM: One of the things that becomes apparent when you work with people who've been victimized is they have a story to tell. One of the things we know is that people who have been victimized and have shared that story do better than those who have not. Moreover, if you work with those clients over a period of time, as I have, one of things you come to realize is that the nature of their story changes.

At the outset of therapy, they may view themselves as "victims", as "prisoners of the past", as "soiled goods". This is more likely if the individual has been repeatedly victimized. At the outset of therapy, they may see themselves as "unlovable and "worthless" and view the world as being unsafe and their situation as being "helpless" and "hopeless". As one patient observed, "My life is a glob of misery, a total personal tragedy." The patients' beliefs in themselves and others have been "shattered".
VY: That reminds me of a song by Sting to this effect: "I've been shattered, I've been scattered I've been knocked out of the race, but I'll get better." As you describe patients' feelings as expressed in their stories, it becomes clear how important the therapeutic alliance is to this change process.
DM: Very much so. In the safety of the therapeutic alliance, the therapist listens compassionately, emphatically, and in a nonjudgmental manner to the patient's accounts. One of the things that becomes very interesting is that collaboratively, in the safety of the therapeutic relationship, you start to see the story of the trauma change.

But more is involved as the therapist can help the patients attend to features of their "stories" that are often overlooked. What did the patients do to endure and survive the abuse? In short, the therapist helps the patients tell the "rest of the story" and to consider the implications of such survival skills for coping in the future.

The therapist helps the patients move from viewing themselves as a "victim", to becoming a "survivor", and even to the point of becoming a "thriver", as patients come to help others and transform their pain into something good that may come from their experiences. The therapist can use a number of clinical skills and the "art of questioning" to help nurture the patient's sense of personal agency in this transformation process. The "thriver" is someone who still remembers, but can use that pain more effectively. Patients learn to develop their own voice and not repeat the "stories" that were conveyed by victimizers.
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Change in Trauma Clients

VY: Can you give an example of this change process?
DM: Take Melissa's parents as an example. Their daughter was victim of a senseless brutal murder. The emotional pain and loss that surviving members experience do not go away as attested to by the survivors of the events of September 11. The question for patients is how to muster the courage and to transform their emotional pain into something good that will come of it. As I discuss in some detail in the PTSD Handbook, the adage that "thou shalt not forget", becomes a personal directive; for forgetting would dishonor the memory of the lost one. Instead,
how individuals use the memory of the loss to make changes is a task of therapy.
how individuals use the memory of the loss to make changes is a task of therapy. In Melissa's case, her parents helped establish an Institute in her name. If they could prevent one more Melissa from dying, then maybe she did not die in vain. Patients do not need to create an Institute to heal. Their Institute may be a small personal way to "find meaning". This constructive narrative perspective that I am advocating is not unique to cognitive-behavior therapy. A number of psychodynamic therapists such as Schafer and Spence have been strong advocates of a narrative perspective, as has the developmental psychologist Jerome Bruner.
VY: How does your concept of narrative construction fit in with the narrative therapies of Michael White and David Epston?
DM: I think there is some overlap theoretically, but there are also differences in terms of specific interventions. My commitment to cognitive-behavioral interventions highlight the role of behavioral change, namely, the value of helping change the nature of the "stories" patients tell themselves and others as a result of personal behavioral experiments they engage in. As a cognitive-behavioral therapist, there is still a critical role for skills training and relapse prevention in the therapy regimen. So the focus of therapy is not delimited to just trying to have patients change their stories. There is also a need for the therapist to collaboratively address the other clinical needs that patients experience, especially in those instances when comorbid disorders occur. Since PTSD often co-occurs with such additional problems as anxiety, depression, substance abuse and anger, there is a need for therapists to attend to these clinical areas.
VY: You mention anger in passing yet I know you have spent quite a bit of time and study on anger which resulted in your writing new book, Clinical Handbook in Anger Control.
DM: Yes, in a number of settings in which I consult the patients (children, adolescents and adults) have a history of victimization (up to 50%) and they evidence problems with emotional dysregulation, where anger comes into play. I am often called upon to help frontline staff and therapists to deal with potentially violence and aggressive patients. The Anger Handbook provides practical examples of how to assess, and treat such patients.
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The Search for "Expert" Therapists

VY: What did you learn about what works in therapy from you research and study of expert therapists?
DM: In general, three features characterize experts.
Experts know a lot, and moreover, their knowledge is organized in an efficient, retrievable fashion.
Experts know a lot, and moreover, their knowledge is organized in an efficient, retrievable fashion. They have a good deal of knowledge - declarative ("knowing what", strategic ("knowing how") and conditional ("knowing if - then relationships"). Secondly, they use this knowledge in a strategic flexible fashion. Third, expertise develops as a result of deliberate practice - practice that is designed to achieve specific goals. In fact, there is some suggestion that expertise does not develop until you have been at an activity for several years.

One very interesting thing that comes out of the literature on expertise: -whether you study chess players or chefs- you are unlikely to become expert until you're at it for several years. Why should it take so long to become an expert? Or, for some, they might say "so little." So a good, expert therapist has a lot of knowledge about patterns, about strategies. And they hang in there.
VY: So I get a sense of what the qualities of an expert therapist are, but in your view what do they attend to or do differently in the session?
DM: Let me enumerate what my research has shown to be the core tasks of therapy. I have discussed them in detail in the Anger-Control Handbook. First, the "expert" therapist needs to establish and maintain a therapeutic alliance. This is the "glue" or key ingredient for nurturing change. Second, inherent to all forms of therapy is some form of education. I don't mean didactic instruction, but rather Socratic interactions. I spell out the innumerable ways that therapist can engage in the educational process over the course of treatment. These include the "art of questioning", the use of patients' self-monitoring, modeling films, the use of "teaching stories", and the like.

Other core tasks of therapy include nurturing patient's hope, teaching skills and ensuring the likelihood of generalization. I have included in the Anger-Control Handbook a checklist of how to increase the likelihood of generalization, as well as ways to engage in relapse prevention and self-attribution training (i.e., making sure that patients take credit for change).

The therapist needs to ensure that not only do patients have intra- and interpersonal skills, but also that they apply them in their everyday experience. Patients also need to come to see the connections between their efforts and resultant consequences. Moreover, given the high likelihood of patients re-experiencing their problematic behaviors and given the episodic nature of chronic mental disorders, there is a need to help patients develop relapse prevention skills.
The expert therapist attends to these core tasks in a consistent, creative manner, tailored to each patient's needs.

VY: Are there additional core tasks that need to be considered when working with patients who have been victimized?
DM: If the patient has been traumatized, then there are five additional core tasks that need to be considered. These include addressing the specific needs in terms of safety and the specific PTSD or complex PTSD symptomatology, as well as any comorbid features. There is also a need to help patients share their stories and consider not only what they experienced, but also what are the implications, what are the conclusions they draw about themselves and others as a result of having experienced trauma. What is the nature of the "story" that patients fashion as a result of having been victimized?

It is not just that "bad" things happen to people, but what people tell themselves and others as a result of having been victimized that is critical.
It is not just that "bad" things happen to people, but what people tell themselves and others as a result of having been victimized that is critical. Out of the sharing of these accounts, the therapist helps patients co-construct "meaning" and transform their pain into some activity that permits them to continue functioning. Other core tasks include helping patients develop strategies in order to avoid victimization. Patients also have to be encouraged to associate with and nurture relationships with prosocial non-victimized others. Not delimiting their life to being a "victim".
VY: Can these same core tasks be applied to other clinical populations besides individuals with PTSD?
DM: Yes. For example, in the recent Handbook on Treating Individuals with Anger-Controls Problems, I discuss various ways to establish a therapeutic alliance with aggressive angry individuals who may be persistent perpetrators. There is a need to understand the "mind-set" of individuals who engage in such aggressive behaviors. There is also a need to educate clients about the distinction between anger and aggression. By use of collaborative goal-setting, the therapist can nurture hope. There is a need to teach self-regulating skills and interpersonal skills and to take the steps required to increase the likelihood of generalization or transfer. I enumerate a variety of skills that may be taught including relaxation, self-coping skills, relapse prevention skills, and the like.

In the Handbook, as I noted earlier, I have included a behavioral checklist so therapists can assess how "expert" they are in implementing these core tasks. Moreover, since a percentage of individuals who engage in violent behavior have been victimized themselves, there is a need to address therapeutically the impact of such experiences on the development of their belief system.
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How Meichenbaum's Work Has Grown

VY: Do you think you are a better therapist now than say 20 years ago?
DM: I would like to think so. Remember it takes about seven years to become an "expert" at any activity.
VY: In what ways do you think you are a better therapist?
DM: Before answering, I wish I had hard data that the patients outcomes are better now than when I began. The data on level of therapists' experience and treatment outcomes may give one pause in drawing any conclusions. On the other side of the equation, I believe that the patients I am now seeing are more distressed than those I saw 20 years ago. They also have fewer resources and supports.

In terms of specific changes in my approach, I believe I have become more strengths-based in my therapy approach.
I now focus more on what patients have been able to accomplish in spite of the exposure to multiple stressors and how patients can use such resilience to address present needs.
I now focus more on what patients have been able to accomplish in spite of the exposure to multiple stressors and how patients can use such resilience to address present needs. I have come to appreciate the value of having patients be collaborative, and in fact even one step ahead of me, offering the advice I would otherwise offer. I have written a book (with Dennis Turk) on Facilitating Treatment Adherence that convinced me of the need for the "expert" therapist to anticipate and address issues of noncompliance, resistance, and barriers to generalization throughout therapy. One cannot "train and hope" for transfer, but must build these issues into treatment from the outset.
VY: I can see that many things have changed in your work. What has stayed the same in your work?
DM: I have still maintained my desire to help and to respect my patients. I have always had a commitment to integrate empirically-sound treatment approaches with a clinically sensitive compassionate approach. I have tried to be sensitive to the role of racial and cultural factors and the need for an ecologically sensitive treatment approach. I have always been hopeful about human behavior and the ability of psychology to make a difference. My current involvement with The Melissa Institute provides me with an opportunity to implement that dream. For example, The Melissa Institute recently had a conference on ethnic diversity and the implications for assessment and treatment. I became supersensitive to the issue of culture when I taught at the University of Hawaii on several occasions. The "expert" therapist needs to be sensitive to how culture impacts on the expression, course and treatment receptivity of patients. For example, research indicates that depression looks different cross-culturally - a lesson I learned in Hawaii. Or what constitutes risk and protective factors among delinquent youth in the Miami Juvenile Assessment Center varies by age and gender. I believe it is crucial for the clinician to develop an appreciation of the role of culture and a questioning of what makes someone an "expert" therapist.
VY: I am really struck by the scope of your work. To take a wide angle view of your career paints quite a picture, so please indulge me for a moment. Your studies range far and wide covering varied clinical populations of psychological trauma, head injury, medical and psychiatric patients. You have pushed the field ahead in terms of developing new cognitive behavioral treatment approaches such as stress inoculation training and self-instructional training. And now you are in the midst of refining cognitive therapy from a cognitive narrative perspective. Professionally, you have extended yourself to influencing public policy and clinical and educational practices with The Melissa Institute. You may be "retired", but your curiosity and passion still seem very much alive.
DM:
The sense of inquiry and the desire to help that were there when I began this journey in the 1960's are very much alive in the year 2002.
The sense of inquiry and the desire to help that were there when I began this journey in the 1960's are very much alive in the year 2002. The urgency for social action is even more pressing.
VY: It has been a pleasure speaking with you and thanks for sharing your thoughts with our readers.
DM: Thank you very much.

Copyright © 2002 Psychotherapy.net. All rights reserved. Published April 2002.
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Donald MeichenbaumDonald Meichenbaum, PhD is Professor Emeritus of Clinical Psychology at the University of Waterloo, and founding member of The Melissa Institute for Violence Prevention and Treatment. He holds the dual distinction of having been voted "one of the ten most influential psychotherapists of the century" (reported in the American Psychologist) and being the most cited psychology researcher at a Canadian university.
Victor Yalom, PhD is the founder, president and resident cartoonist of Psychotherapy.net. He also maintains a part-time practice in individual, group and couples therapy in San Francisco and Mill Valley. He has conducted workshops in existential-humanistic and group therapy in the US, Mexico, and China, and also leads ongoing consultation groups for therapists.

It was good to read the article with Don Meichenbaum. As a beginning therapist in the early 1970's Don was a great source of ideas but also a generous contributor to the field. His Cognitive Behavioural Newsletter was a tremendous spur to all of us. He shared articles published and unpublished and was open to new directions. I was interested in the comments on narrative as that was always implicit in his work as was the importance of shared collaboration with clients to create a formulation. It was a direction my own work took (Constructing Stories Telling Tales). Thanks Don for all you contributed. Prof David Lane - London UK
David Lane
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CE credits: 1
Learning objectives: • Consider ways in which Cognitive-Behavioral Therapy developed out of Don Meichenbaum?s personal life experiences.
• Increase awareness of Cognitive-Behavioral approaches to treating traumatized clients.
• Explore common themes in Cognitive-Behavioral and Narrative therapies. 
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