44

T h e S h a r i n g o f B e h a v i o r Therapy: From S c i e n t i s t s a n d Prac t i t i oners to C o m m u n i t i e s a n d C o n s u m e r s

A r t h u r F r e e m a n , Philadelphia College of Osteopathic Medicine

Cognitive behavior therapists should interact with community agencies and the media in order to make cognitive behavior therapy more widely understood and appreciated. These efforts will promote the mental health weU-being of society as a whole.

T HE FOCUS of the 1996 AABT conference was the shar- ing of behavior therapy. The issue addressed in

many of the papers and posters of that conference was how information, change strategies, and t reatment con- ceptualizations move from scientists to practitioners to the public or to consumers. This is by no means a l inear

communica t ion . In some instances the public asks a ques-

Deciding on the topic for my presidential address was extraordinarily difficult. I decided to tell a story.

tion that the scientists are called u p o n to answer. In other cases, the point of ori- gin of a quest ion or issue is

the clinical community. In tile words of Walt Kelly's

cartoon character of another era, Pogo, too often "We have met the enemy, and they is us." Often, the scientists and the practit ioners are the same persons. While there is peace over the land, there are no

fireworks. Other times there appears to be conflict over whether what we do as behavior therapists is more scien- tific or more clinical. Are we scientist /practi t ioners or practi t ioner/scholars? Should we be in the laboratory or in the public eye? Should we be talking to the public or should we only talk to each other?

What I would like to address in this paper are some of these questions. In my survey of several former AABT

presidents, I asked them how they came up with the ideas for their presidential addresses. One said, "Cite some re- search." Another said, "Show some charts and tables." Another said, "Quote the literature." And another said, "Tell a story." While I would like to do all of these, I thought I could make my point best with a story. But then

I d idn ' t know what story to tell. So I went down to the

Cognitive and Behavioral Practice 6, 4 4 - 4 9 , 1999 1077-7229/99/44-4951.00/0 Copyright © 1999 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

deepest, darkest room in the basement archives of the AABT skyscraper in New York. I searched through dusty boxes and shelves, and in my search, I came across a manuscript , written in a language that I d idn ' t know. At great expense and with great effort I had it translated and I want to share with you the contents of that manuscript

as it contains a parable fitting for our time. It starts off as many stories do: "Once u p o n a t i m e . . . "

ONCE UPON A TIME there was, in a land long ago and far away, a generally happy people. The fields were green and the skies were blue and, overall, people lived fairly happy and fulfilled lives. One of the most beautiful build- ings in the entire country was set on a moun ta in top near the largest town in the land. This bui ld ing had been built by a very rich merchan t from the profits of his many en- t repreneuria l and business enterprises. It, a nd the exten- sive su r round ing lands, outbuildings, suppor t structures, and endowment had been donated to a group of scholars many, many years before. The exact name of this bui lding had been lost over the years, and it was now simply called

"The Academy." As the merchan t had been quite wealthy, it was built of

the finest marble and granite, strong and sturdy and made to last for many years. It had lush gardens, a well- stocked wine cellai, and an ample larder. The interior was furnished with the finest artwork and h u n g with beautiful tapestries. A n u m b e r of individuals lived a nd worked in The Academy. They were called, by virtue of their place- men t and setting, "academics." Each of them focused on their specific area of interest, concern, and study. Toward the end of their spending their time in academic pur- suits, each was given by The Academy a work space, funds

for their support, and a place to live. Many of the inhabi- tants of The Academy lived in towers buil t of the finest ivory, and with the rising and the setting of the sun, the ivory towers shone golden for all to see. The merchant had stocked The Academy library with thousands of scrolls from around the k ingdom and the known world so

that all of the available knowledge of this p lanet existed in The Academy to be studied.

The Sharing of Behavior Therapy 45

Living in one of the towers was a mem- ber of the Academy known, as near as I can make out in the translation, as Kvetchel. Kvetchel's area of concern was answering the question, "Why do people do what peo- ple do?" This area of study and concern was known, even at that far distant time, as "behavior." He studied, hypothesized, ex- amined, experimented, analyzed, wrote, revised, reformulated, theorized, and gen- erally did all that was expected of a m e m b e r in good standing of The Academy. After much practice, he learned to write accord- ing to the rules and style of The Academy.

This involved an arcane code that was no t easily unders tood by those not properly ini- tiated, and, the truth be known, even by some who were. It was, however, no t good form to let on that one disagreed with the required format or did no t unders tand and

subscribe to its usage. While Kvetchel was thoroughly absorbed with his work,

there were many times that he did no t believe that others

thought that his work was very important . There were times that he quest ioned the value of his work, and as- sumed that others did too. One day, Kvetchel was sitting

at the work table in his tower feeling very down. His head was in his hands and overall he was not a very happy per- son. He thought aloud, "If only there was a way for me to do more of what I want to do to unders tand more about

what motivates people to act as they do and to help peo- ple gain greater control over what they do. Alas, for me there isn't; therefore; I am a failure and I feel so sad." As

Kvetchel sat with his head in his hands, he was startled and fr ightened to see a brill iant glow in a corner of his room. It glowed more and more brightly unt i l it near b l inded him. Kvetchel's fright increased when from the glow stepped a person. The specter was wearing a white robe and had flowing white hair and, s t r a n g e l y . . , a red bow tie.

Kvetchel was startled. "Who--who are you?" he gasped.

The appari t ion responded, "I am one of your fairy godparents and I came in response to your call."

Kvetchel was frightened. "What call?" he asked.

"You called and said that you wished you could do more," said the fairy godparent.

"Who are you? What - -what is your name?" s tammered Kvetchel.

His fairy godparent smiled and said,

"My name is too difficult for mortals to p ronounce , so you may call me Timbeck."

"What do you want, Timbeck?" asked Kvetchel.

"I want to help you with this feeling of be ing sad and down. Why indeed do you feel so down?"

"Well," said Kvetchel, "There's so much I want to do, bu t I can ' t do it. There are things that need to be done but I don ' t think they can be done. The system that I live in is unyielding and always will be. Therefore I am a failure."

Timbeck n o d d e d and said, "It sounds as if you ' re more than feeling down, that you may indeed be depressed."

"Depressed," said Kvetchel, "how can you tell?" With that, Timbeck reached into his gown and pul led

out a scroll and said, "Let's see." Timbeck unro l led the scroll, and there, before Kvetchel's unbel ieving eyes, was

the Godparen t Depression Inventory, the fabled GDI. Timbeck h a n d e d the scroll and a quill to Kvetchel and said, "Here, Kvetchel, please fill this out." Kvetchel did as he was asked. W h e n he finished answering the 21 questions on the scroll, Timbeck spent a m o m e n t re- viewing the scroll and said, "Based on your responses, I can see that you are mildly to moderately depressed. You have a GDI score of 23. Let's talk about why this is so. Specifically, let us look at some of your thoughts about yourself, your work, and your thoughts about the future."

Kvetchel and Timbeck spent the next hour discussing Kvetchel's thoughts,

46 Freeman

feelings, and actions. They spoke of Kvetchel's thoughts o f be ing unable to do anything. They spoke of his bel ief that he was a failure.

With Timbeck 's he lp Kvetchel began to identify things that he thought , where those thoughts came from, the beliefs that under lay the thoughts , and what Kvetchel migh t i ndeed do. They ident i f ied that the major p rob l em for Kvetchel was that he wanted the people in the com- muni ty to know more of what he did. But, alas and alack, they d idn ' t seem to know what he did.

"Why is this so?" asked Timbeck. "Don ' t the peop le

3 . - - - - - - - - -

. . . . t ~ . . . .

j

/ . . . . . .

in town know what you and your colleagues do here at The Academy?" Kvetchel shook his head and said, "No, Timbeck. Yet we do many studies and ex- pe r iments and we write them up on the p rope r scrolls in the p r o p e r academic fashion."

T imbeck asked, "What do you do with these scholarly scrolls?"

"Well," said Kvetchel, "we follow t radi t ion and we post t hem prominen t ly in the cour tyard at The Academy, But the peop le from town or the su r round ing countryside d o n ' t come to the courtyard to read our scrolls. Somet imes we even make several copies of

a scroll and send it to o the r academies in o the r lands to be pos ted in thei r courtyards, but we have found that the pos ted scrolls r ema in un read in those places too."

T imbeck ran his hand th rough his flowing white hair and asked, "What stops you f rom going into town, maybe r ight to the marketplace , to share your work with the peo- ple? Wha t stops you from pos t ing your work p rominen t ly in the marketplace?"

"Oh," said Kvetchel with a shudder, "we could never do that. That ' s no t the way we've ever done things. We are, af ter all, The Academy. We should not have to have congress with those in the marketplace . They are, you should excuse the expression, benea th us. Also, the idea of going r ight to the marke tp lace is personal ly discom- forting. I must admi t I ' m r e l u c t a n t - - T h e truth be known, I have a fear of the marketplace ."

"All," said Timbeck, "the fear of the marketp lace can be deal t with too." And as he said this, Timbeck 's figure began to fade.

"Timbeck, where are you going?" cr ied Kvetchel. "My t ime with you is over, bu t do no t fear, you ' l l soon

be visited by another . With him, you can speak of the fear of the marke tp lace ." As Timbeck ' s f igure faded

away, a glow emerged in the opposi te co rner of Kvetchel's room.

From this glow too s tepped a white-haired, white- r o b e d individual. Braver now, Kvetchel asked, " W h o - - who are you?"

The specter repl ied, "I am one of your fairy god- parents. My name is too difficult for mortals to " ~ .... p ronounce , so you may call me Joewolpe. I un- ders tand you have a fear of the marketplace. That we can deal with." With that, Joewolpe took a scroll from benea th his gown and laid it ou t on the table. It was a system- atic p rogram that would quickly, easily, and effec- tively help Kvetchel over- come his fear of the marketplace. He asked Kvetchel to evaluate jus t how distressed he was with the image of going to the mar- ketplace. With that, the work began. He was with Kvetchel for an hour imaging the marke tp lace and learn ing how to be calmer and more re laxed while doing it.

At the end o f that time, Kvetchel said, '~(es, I can see it. This series of small steps can clearly he lp me deal with my fear. Just p ic tur ing it now, bu t do ing it later. But what if I d o n ' t do it?"

"Ah," said Joewolpe, "my time with you is nearly over, and that ques- t ion is for yet another."

As Joewolpe 's figure faded, a l ight began shin- ing in yet ano the r par t of Kvetchel's room. From that glow stepped a white- haired, white-gowned spec- ter. Kvetchel was no longer afraid and said, "And who are you, specter?" The specter repl ied, "I am one of your fairy godparen t s and have come to he lp you. My name is too diffi- cult for mortals to pro- nounce , so you may call me Alellis."

"Tell me, Alellis, how can you he lp me?" "I have come to he lp you deal with your i r rat ional fear

and possible re luc tance to try to cope with what you have l ea rned thus far."

The Sharing of Behavior Therapy 47

"How would you do this?" asked Kvetchel. "I would give every e/merI own to be able to go freely into the mar- ketplace. (The e/m~ you should know, was the uni t of cur- rency for the k ingdom. It was of great value and though there were those who a t t empted f rom t ime to t ime to de- value it, it was the strength of the eimer that he lped to keep the k ingdom solid and strong for many years.)

F rom u n d e r his gown, Alellis took a scroll and un- rol led it on the table. On the scroll were the let ters A-B-C. Alellis taught Kvetchel about the activating events that were f i l tered by his beliefs and had emot iona l and behav- ioral consequences. And in an hour, Kvetchel unde r s tood that he had to be able to u n d e r s t a n d the Bs that led to

the Cs. All he cou ld say to the wise specter was thank you.

"Now, what would stop you f rom using the tech- niques that you have ac- quired from the fairy god- parents that p r e c e d e d me? Wha t would stop you f rom going into the mar- ketplace and making your work known to the peo- ple in town?"

Kvetchel though t and repl ied, "That 's no t the way it's done. We have no t typically gone r ight

to the marketplace. It would be a very dif ferent experi- ence for us here in The Academy. In fact, The Academi- cian's Protective Association, the APA, has many strict rules abou t how scholars might advertise and demon- strate what they do in the marketplace."

'Tou have l ea rned tonight that you can change the way that you th ink and the ways that you feel and behave. Maybe they can be he lped to also change," said Alellis.

Kvetchel thought about that and concluded , "That might be one possibility."

With that, Alellis's l ight began to fade, bu t as it was al- most gone it b r igh tened again and Alellis spoke once more: ' Jus t remember , don ' t jus t talk abou t it, get off your ass and do it."

After that, Kvetchel, exhausted, quickly fell into a deep s leep and awoke hours la ter as the br igh t m o r n i n g sun p o u r e d into his tower room. He awoke first th inking that he had had a dream, a d ream both scary and wonder- ful. It was only when he looked on his worktable and saw the three scrolls that he real ized this had not been a d ream at all. Kvetchel smiled broadly.

That very morn ing he called a mee t ing of The Acad- emy and in fo rmed the members of what he had experi- enced. Some thought Kvetchel had gone off the deep

end and become very strange, a state known in academic circles as " terminal appo in tment . " Others though t the ideas that he shared with them were somewhat interest- ing, bu t unworkable or impossible. But one energet ic g roup though t that these ideas were very interes t ing and were i ndeed possible. Some main ta ined that the ideas were heretical and that Kvetchel should be sent out of The Academy immediately.

"But how," they all asked, "are we to go into town? The people in town don ' t know who we are and, in fact, are not used to seeing us."

One group had the idea that they should send some- one into town u n d e r cover o f darkness and post an invita- t ion for the peop le in town

" H o w can y o u help

me?" ! asked.

"I have c o m e to

he lp y o u deal wi th

your irrational fear

and reluctance to

teach w h a t y o u

have learned

thus far."

and the su r round ing countryside to come to the court- yard of The Academy at specif ied times to read and slowly translate the l ea rned manuscr ip ts f rom the origi- nal Academese . But others said, "No, the manuscr ip ts have to be writ ten in a way that peop le in town and in the marke tp lace can read and easily unde r s t and them. The re has to be a way of t ranslat ing what we do in The Academy so peop le in the marke tp lace can easily read them."

"There must be some way of t ranslat ing what we do in The Academy to peop le in the marketplace ," said Kvetchel.

A brave few of the academi- cians came up with the idea of going into town that very day and ren t ing a stall in the mar- ketplace to tell peop le in the town and the countryside abou t the wonderfu l work, the impor- tant work, the essential work, the scientific work, that was be- ing done in The Academy. But there was still a g roup who ma in t a ined that there should no t be a need to en te r the mar- ketplace. Somehow, the market- place was not for them, even though The Academy was started as a function of the marketplace. This g roup bel ieved that if the peop le in the marke tp lace were

B C

truly in teres ted in thei r work, they would (and should) come to The Academy cour tyard and read the pos ted manuscripts . The argu- ments went on well into the night. For and against, they argued. The groups polar ized and they came close to

48 Freeman

blows. Harsh words were exchanged , and the fabric of the academic communi ty was sorely tested.

But at the end, a brave, forward- looking group agreed to try thei r h a n d in the marketplace . They agreed and ar- r anged to ren t a stall r ight in the midst of the market- place. An a r g u m e n t then ensued as to what to call their stall. Each group had a powerful rat ionale for their choice of a name. The genera l a g r e e m e n t was to speak of focus- ing on actions, so the te rm "Behavioral Things" seemed reasonable . This was the only th ing that was clear and to which all agreed. Hencefor th , the letters BT would be a major par t of the name of thei r stall. So they e n d e d up pu t t ing up a sign that advert ised "All Abou t Behavioral Things." (This was, by the way, the first use of the logo AABT.)

The group in the marke tp lace p r o d u c e d a large num- be r of mul t i co lo red fact scrolls. Each of these fact scrolls descr ibed the behavioral t r ea tment of a c o m m o n prob- lem that might afflict any m e m b e r of the community.

The marke tp lace group made mater ia l and informa- t ion directly available to peop le in the marketplace. They

i

1

/

1 ~,ABT Fees/services" =onsultation 6 eimers[hour Fact Scrolls I eirner each Behavioral Analysis to be discussed Lectures i0 eimers Research 8 eimers/hour Tuna on rye 2 eimers Bagel 1 eimer

met with various merchants and professionals in town to talk about ways that the peop le in The Academy could he lp the peop le in town and the countryside under s t and behavioral things and live even be t t e r lives.

Some members of The Academy stayed in the castle and worked at do ing the research n e e d e d to demons t ra te the empirical basis o f successful interventions. Others took the research and translated it for the people in the marketplace.

They met with the pedagogue to talk about how they could enhance the educa t ion of the children.

They met with the constable to talk about the cr iminal jus t ice system in the k ingdom.

They met with the b a r b e r / s u r g e o n to talk about the effects of feelings on people ' s heal th.

They were called into the palace and spoke with the king on more effective techniques of governing.

They met with farmers to discuss how to improve the behavior of the animals.

They talked to the captain of the town's rock-throwing team to talk abou t how to increase distance among rock throwers.

Soon people came from far and wide to the AABT boo th in the marke tp lace because it was clear that what was being done had relevance for all.

Then some of the members of The Academy wrote books translat ing the scientific work of The Academy into s impler terms and, in fact, worked to recrui t townspeople to come to The Academy to learn more of what The Academy had to offer.

Needless to say, Kvetchel was no longer depressed. He was happy, busy, and involved in giving classes for others in the marketplace. It was clear that the marketp lace was an impor tan t pa r t of the academic work, jus t as the aca- demic work was impor t an t to the marketplace. But it was also clear that no t everyone had to be in the marketplace. There were those who had to stay in The Academy to do the work that was impor t an t and essential. And others n e e d e d to be in the marke tp lace to share that work, to translate it for all to use.

The courtyard o f The Academy became a meet ing and learn ing place for all people . The Academy became the source of the studies of ideas for effective change while the marketplace suggested many ideas for The Academy to study. What e me rge d was an effective col laborat ion and par tnersh ip for change.

As that pa r tne rsh ip grew between the members of The Academy, the peop le of the k ingdom, and those in the marketplace, everyone was happier . There was clearly room for all, and they all lived happi ly ever after.

AS WE REVIEW many of the meet ings at AABT and at o ther conferences, consider the discussions in the profes- sional l i terature, and think about the casual meetings over

The Sharing of Behavior Therapy 49

It w a s clear that

the marketplace

w a s an important

part of the

academic work.

coffee and Cokes, many of the issues confront ing Kvetchel are still with us as a discipline and as an organizat ion.

One only has to look in our conference p rog ra m to see the collaborative work of the scientists, the practi t io- ners, the scholars, and the clinicians of AABT to see how our work is be ing shared with a b r o a d range of clinical popula t ions and with all possible clinical syndromes.

Alber t Ellis en te red the marketp lace with his RT over 40 years ago. For those of us a r o u n d long enough, we know the negative react ions of many in The Academy to this marke tp lace focus (i.e., going out to the publ ic with his work).

Joseph Wolpe, Andrew Salter, Aaron T. Beck, and Al- ber t Ellis have seen their work i nco rpo ra t ed and inte- gra ted into many different t r ea tment models, of ten with-

out p r o p e r reference. They have, in many cases, become the " common knowledge" o f the marketplace. Volumes and programs on stress manage- men t all speak of the relax- at ion response. Hardly a mon th goes by when a na- tional magazine doesn ' t carry some article on the impor-

tance of re laxat ion or even of reciprocal inhibi t ion, though not in those words, not quot ing the behavioral work of so many researchers that have empir ical ly dem- ons t ra ted the efficacy of the techniques.

We have been discussing the marketplace , whether di- rectly del ivering services to the consumers , or working with managed heal th care organizations. Behavioral and cognitive behavioral therapy has been app l i ed to every pat ient popu la t ion and clinical p rob lem.

We must cont inue to move beyond the deba te of whether behavior therapy is the province of scientists or practi t ioners. It must cont inue to be both. It is essential that the work of The Academy be suppo r t ed and encour- aged. I t is essential that we cont inue to develop empir i- cally val idated therapies. It is essential that these models reach the marketplace. It is essential that we must develop therapy models that have the effect, as Ellis says, " . . . o f not jus t he lp ing peop le feel better, but of he lp ing them get better."

Similarly, we need behavior therapists who are com- fortable with the marketp lace because that is where the suppor t for our work will be in the future. We need to be able to market , to inform, to tell, and even to sell the em- pirically val idated therapy techniques that have been de- veloped over the years, mainly by member s of AABT.

Following Kvetchel's lead, we can b r ing our work to the marketplace. Some marke tp lace activities that you can do would include the following:

1. Contact your local schools and ask about the pos- sibility of speaking to t eacher groups abou t behav- ioral approaches in school settings.

2. Contact the local p a r e n t / t e a c h e r or h o m e / s c h o o l groups about address ing their pe r iod ic mee t ing regard ing behavioral work with ch i ld ren and adolescents.

3. Contact local churches and synagogues abou t be ing a speaker at meet ings of thei r men 's club, women 's club, or seniors club regard ing re levant topics in behavior and cognitive behavior therapy.

4. Contact the local senior citizen's cen te r abou t speaking with some of the groups abou t behav- ioral issues in aging.

5. Contact your local cable channe l r egard ing be ing a speaker or r e sponde n t to local news and issues.

6. Part icipate in hea l th fairs. Take a table, dis t r ibute material , answer questions.

7. Contac t your local newspaper abou t the possi- bility of your con t r ibu t ing articles on a weekly o r month ly basis or in per iod ic hea l th supplements .

8. Make in format ion (such as fact sheets) available in heal th food stores and in wellness centers. (Don ' t forget to at tach your business card.)

9. Contact the YMCA or YWCA abou t p resen t ing a p rog ra m on behavioral app roaches to your a rea o f specialty.

10. Contact the local C h a m b e r of C o m m e r c e andJCs abou t having you speak at one of their breakfast meetings.

These suggestions will pu t you r ight in the midd le o f the marketplace . I f we are consis tent with ou r mode l of ther- apy, we need to have an active, directive, and educa t iona l focus. This will make behavioral and cognitive behaviora l therapy more widely known, more general ly sought, and more broadly accepted.

Much of Kvetchel 's work and the work of the o thers of that first AABT may have been lost. But for many years, especially the last 30, Kvetchel 's spiri t has moved our work. May it con t inue to do so in the future. In Kvetchel 's name and in his spirit, I wish you good luck.

This article was adapted from the Presidential Address to the Asso- ciation for Advancement of Behavior Therapy Annual Convention, New York, November 1996.

Address correspondence to Arthur Freeman, Department of Psy- chology, Philadelphia College of Osteopathic Medicine, 4190 City Avenue, Philadelphia, PA 19131-1693.

Received: September 30, 1998 Accepted: November 1, 1998