WHAT CHANGES IN COGNITIVE THERAPY? THE ROLE OF TACIT KNOWLEDGE STRUCTURES: Theoretical Considerations-New Ideas
Dowd, E. Thomas, Journal of Evidence-Based Psychotherapies
Rarely has knowledge within cognitive psychology influenced the development and practice of cognitive behavior therapy. This article explores the integration of the contributions of the cognitive psychology areas of implicit learning, tacit knowledge structures, and encoding processes with producing or retarding change in cognitive behavior therapy. Differences are discussed between understanding something and knowing something. Implications for the practice of cognitive therapy, indeed all psychotherapy are discussed. A clinical example is provided.
Key words: tacit knowledge, implicit learning, cognitive encoding, cognitive therapy
WHAT CHANGES IN COGNITIVE THERAPY? THE ROLE OF TACIT KNOWLEDGE STRUCTURES
The fact that cognitive psychotherapy results in psychological and behavior change is undeniable - many studies have demonstrated that to be true. On the other hand, cognitive psychotherapy has not been shown to be consistently more effective than alternative therapies. In a recent short revie w of the comparative outcome literature, Dowd (2004a) concluded that the evidence for the greater efficacy of cognitive therapy is mixed, especially when compared with specific alternative treatments rather than with placebo or generic and supportive types of therapy. There is some evidence, however, that cognitive therapy may be especially useful in preventing relapse or with certain specific problems such as panic disorder. Whisman (1999) argued that the evidence is equivocal regarding whether cognitive change precedes or follows symptom change.
Why is this happening? Why, despite our best efforts, can we not develop cognitive therapy procedures that are more effective that other targeted treatments? Why can we not even agree whether cognitive changes cause behavioral changes or results from behavior change (e.g. Whisman, 1993) or whether cognitive change precedes or follows cognitive change (Whisman, 1999)? Why, as Imber and his colleagues (Imber et al, 1990) discovered, did neither cognitive therapy nor other therapies, produce the specific results that were predicted by their theoretical orientations? Is cognitive therapy even necessary at all? Jacobson and his colleagues (1996) argued it is not necessary and that behavioral activation is enough. Likewise, Feeney, Hembree, and Zoellner (2003) argued that the research literature has not demonstrated that adding additional interventions (such as cognitive therapy) to exposure therapy produced better outcomes than exposure alone.
These questions cannot be answered in one article but a partial answer is possible that might account for some of these findings. To do so I suggest that the fundamental conceptual model of cognitive behavior therapy be expanded to include changes in implicit knowledge structures as well as changes in explicit knowledge. More specifically I propose an integration of certain features of tacit or implicit learning in cognitive psychology with the theory of cognitive change. As David and Szentagotai (2005) have pointed out, cognitive psychology and cognitive behavioral psychotherapy developed independently and rarely has the former influenced the latter. This article is an attempt to do that in a limited area of knowledge.
Years ago, Hobbs (1962) suggested - contrary to the wisdom of that day - that cognitive change (insight) is the result of behavior change, not the cause of it. Clients, he said, changed their behavior and then reflected cognitively about what that new behavior meant and its implications. Later, and in the same vein, Bandura (1977) said, "On one hand the mechanisms by which human behavior is acquired and regulated are increasingly formulated in terms of cognitive processes. On the other hand, it is performance-based procedures that are proving to be the most powerful for effecting psychological changes" (p. 191). Or, in more popular terms, "It is easier to act your way into a new way of thinking than to think your way into a new way of acting. …