Putting psychotherapy in its place: The regionalization of behavior therapy in France, Switzerland, and Belgium, 1960s-1990s.

This article traces the history of the behavior therapy movement in French-speaking Europe between the 1960s and the 1990s, focusing on its geographically located development, whether on a national, sub- or supra-national scale. By examining the trajectories of the three main behavioral therapy associations in France, Switzerland, and Belgium, we show that it is not possible to subsume them under a common intellectual history. Despite the importance of theoretical debates in the emergence of this brand of psychotherapy in English-speaking countries, adherence to this type of explanation falls short of accounting for the differential reception of behavioral therapies in these countries. We argue that the later development of behavioral therapy in France, Belgium, and Switzerland was shaped more by professional agendas, local definitions, and regulations of psychotherapy than by "pure" theoretical commitments and conflicts between schools of thought. From a historiographical perspective, exploring the regionalization of psychotherapeutic styles thus involves contesting the idea that different therapies are mainly characterized by adherence to psychological theories and embedded ontologies of the self that are radically opposed (i.e., humanism vs. naturalism, psychoanalysis vs. behavior therapy). Localizing psychotherapies and paying attention to the varying circumstances and traditions in which they have evolved allows us to go beyond this dichotomous vision and to access a multiplicity of nondogmatic and intermediate positions that would otherwise be invisible.

INTRODUCTION

The history of psychotherapy written by practitioners has often been framed in theoretical terms, as a confrontation between a rather understanding tradition (psychoanalysis or humanism) and a naturalistic tradition (cognitive–behavioral therapy, or CBT). Psychotherapists themselves have been pointing out the limits of this polarized perspective at least since the 1980s. For instance, according to Goldfried (1980, p. 991): “In reviewing the history of various approaches to therapy, it becomes apparent that therapists have typically operated from within a given theoretical framework, often to the point of being completely blind to alternative conceptualizations […].” This critic of orthodox schoolism is notably mobilized by those who favor an integrative perspective. They necessarily take a dim view of these “therapy wars” (Saltzman & Norcross, 1990) and, more broadly, of Manichean conceptions, where “dogma eats dogma” (Larson, 1980, p. 19). All this has contributed to a history of psychotherapies open to nuances (Meichenbaum, 2003; O'Donohue, 2001) where the opposition between CBT and psychoanalysis is no longer the main narrative arc.

In the francophone context, where school wars are lively, the available narratives are still polarized. This is especially the case in France, where the publication of a report on the effectiveness of psychotherapies in 2004 (INSERM, 2004) led to an intense public and professional debate. In particular, we can mention the publication of two radically opposed books that embody this controversy in an almost caricatural way: The black book of psychoanalysis (Meyer, 2005) and The anti‐black book of psychoanalysis (Miller, 2006). The idea of a “French cultural exceptionalism” in psychotherapeutic practice played an essential role in this debate. The pro‐psychoanalysis school proposed a historical narrative centered around the idea of a struggle between French humanism and American scientism, while the pro‐CBT group framed France's psy‐scene as lagging behind the rest of the world and entangled in ideological debates from another time (Amouroux, 2017).

In contrast to this perspective favored in practitioner's histories, Sarah Marks (2017, 2018), Rachel Rosner (2018), and Sonu Shamdasani (2018) have recently called for a cultural and social history of psychotherapies. In this approach, emphasis is placed on the cultural, social, and political formations that have shaped the emergence and development of psychotherapies in specific locales and time periods, as well as on the networks involved in their dissemination. These scholars have brought a much‐needed comparative and transnational perspective on the history of psychotherapy. By putting psychotherapy in its place, they have highlighted the plurality of approaches subsumed under this general term, as well as the diversity of professions that have laid claim to its practice in the 20th century. At the same time, they have stressed the importance of paying attention to similarities and their drivers, starting with the growing internationalization of scientific exchanges. This is especially crucial for psychotherapies “imported” from abroad, whose reception may have oscillated between alignment with global trends and selective local appropriations. The point here is that combining a comparative with a transnational approach may help historians to understand the interplay between different spatial scales in shaping the trajectories of psychotherapies.

In this article, we contribute to this growing field of research that studies psychotherapy in context. We trace the history of the behavior therapy movement in French‐speaking Europe between the 1960s and the 1990s. More specifically, we explore how behavioral therapies have simultaneously developed in France, Belgium, and Switzerland. In doing so, we would like to follow the lead of Marks and Rosner by taking into consideration both the transnational networks and the local factors at play in their transit and contextualized appropriation by practitioners. At the same time, our approach is immediately comparative. In keeping with a historical geography of science, as mapped out by David Livingstone (1995, 2003) we focus on the regionalization of the behavioral therapy movement in three bordering French‐speaking territories. We thus seek to document its regionally differentiated development, describe its specificities in terms of spatial scales, as well as of the theoretical, methodological and socio‐political commitments of its promoters, and identify factors that may account for them. Beyond documenting behavioral subcultures through the use of original source material, the historiographical purpose of this article is to foreground the relevance of regionalism for the study of the history of psychotherapy.

The three main behavioral associations in France, Belgium, and Switzerland are our point of entry into the history of the movement in these three countries. We trace their historical trajectories using primary and published sources, such as minutes of general assembly meetings, presidents' correspondence and newsletters, as well as oral testimonies. This material—hitherto little explored by historians—provides access not only to the careers and thinking of their individual founding members in their diversity, but also to the shared aspects, circumstances, and concerns that interest us here.

We will show that it is not possible to subsume the French, the Belgian, and the Swiss groups under a common intellectual history. We argue that the development of behavioral therapies in France, Belgium, and Switzerland was shaped more by the professional affiliation of their members and different agendas between psychiatrists, experimental and clinical psychologists, their training in particular scientific traditions (e.g., Pavlovian psychophysiology, radical behaviorism, integrative psychotherapy research), and local understandings and regulations of psychotherapies, than by “pure” theoretical commitments, and conflicts between schools of thoughts. As a result, there was a regionalization of psychotherapeutic styles, ranging from the assumed filiation of the Belgian to B. F. Skinner's radical behaviorism to the cautious pragmatism of the French to the Swiss' claimed “critical eclecticism.” Moreover, we highlight that, in the three cases, it was less the external opposition between psychoanalysis and behavioral therapy, as frequently claimed by practitioners, than internal debates on the integration of the cognitive current that underpinned self‐definition and identity negotiations among behavior therapists. Lastly, we have also found a point of convergence between these three associations in a certain form of criticism of dogmatism, which is difficult to reconcile with the “school wars narrative arc.” Regionalizing behavior therapies and paying attention to the varying circumstances and traditions in which they have evolved thus allows us to go beyond a dichotomous vision and to access a multiplicity of intermediate positions that would otherwise remain invisible.

We start by outlining the early history of the French, the Belgian, and the Swiss behavior therapy associations, paying attention to similarities and differences in terms of professional composition and issues. Then we will explore the flexible boundaries of behavior therapies, by examining the comparative geographical reception of cognitive therapies and more generally the engagement with other types of psychotherapies. Finally, we will explore the diversity of positions of these three groups concerning the relationship between psychotherapies and society.

A HISTORY OF BEHAVIORAL THERAPY IN THE FRENCH‐SPEAKING WORLD

Lost in translation

The expression “behavior therapy” emerged in the late 1950s in the English‐speaking world (O'Donohue, 2001), but its translation into French was far from self‐evident. Although “thérapie comportementale” was eventually chosen in France, Switzerland, and Belgium, other expressions have preceded it. What these alternatives had in common was that they were strongly linked to the locally prevailing scientific tradition.

In France, it was the psychiatrist Jacques Rognant who first used these methods in the early 1960s (Rognant, 1961), which he then referred to as “deconditioning therapy” because the term seemed to him “more scientific” and less likely to offend his psychoanalyst colleagues than “behavioral therapy” (Interview with J. Rognant, 05/15/2015). This first translation resonated with the Pavlovian‐inspired psycho‐physiology existing at that time in France, and in which other early figures of the French movement, such as Mélinée Agathon, had been trained (Agathon, 1982a; Barbara, 2011). Eventually, on October 3, 1971, Rognant, Agathon, and the other founding members created the Association Francaise de Thérapie Comportementale (AFTC) (French Association of Behavior Therapy). According to Agathon's testimony 20 years later: “From the outset, we had refused the label of behaviorism by translating the Anglo‐Saxon term ‘Behavior therapy’ by ‘thérapie comportementale’” (Agathon, 1991, p. 3). Indeed, at the time, there was already a French‐speaking behavioral therapy association in Canada. They initially chose the expression “thérapie béhaviorale” [behavior therapy] to stick as closely as possible to the original English expression and affirm their adherence to radical behaviorism (Malcuit et al., 1972, pp. 1–4). Conversely, in Belgium, the pioneers of behavioral therapies initially chose not to translate this expression and thus founded “L'Association Belge de Behavior Therapy” (Belgian Behavior Therapy Association) on August 16, 1973. The name of the association would be francized 2 years later as the “Association pour l'Etude, la Modification et la Thérapie du Comportement” (AEMTC) (Association for the Study, Modification and Therapy of Behavior). The two versions specifically emphasized the legacy of radical behaviorism by using the Skinnerian term of “behavior modification” (Seron et al., 1977, pp. 8–12). As to the Swiss association, it was founded much later—on April 7, 1978—and was primarily a German‐speaking association. The “Schweizerische Gesellschaft für Verhaltenstherapie” (SGVT) (Swiss Society for Behavioral Therapy) opted for the term which had already been stabilized by the German group—the Deutsche Gesellschaft für Verhaltenstherapie (DGVT) (German Society for Behavioral Therapy) founded in 1968—which seems not to have caused the same translation problems (Daiminger, 2007).

In the 1980s, with the advent of cognitive therapies, most European societies began discussing a name change so they could claim to be both behavioral and cognitive. The French group was amongst the first to ratify this change in 1991. However, at that time, neither the Franco‐Belgian nor the Swiss‐German groups changed their names, following the German model where behavior therapists never appended the qualifier “cognitive” to their official designation. Interestingly, in the 1990s, only the Swiss francophone group wished for such a change, which led to a lively discussion within the bulletin of the SGVT. Better still, in 1994, the Swiss psychologist Lucio Bizzini created the Association Suisse de Psychothérapie Cognitive (ASPCo) (the Swiss Association of Cognitive Psychotherapy) (Interview L. Bizzini, 11/09/2020), a competing Swiss association resolutely in favor of the renewal of behavioral therapies, illustrating the geographical and linguistic differences toward behavioral and cognitive therapy even within the same country. These differences were not limited to the French‐speaking area: the British Association of Behavioural Psychotherapies inserted “Cognitive” into its name in 1992, whereas the American‐based Association for the Advancement of Behavioral Therapies (AABT) did not do so until 2004.

The diversity of French translations of the English expression “Behavior Therapy” we have just pointed out reflected local traditions of psychological knowledge and practice, leading to different positions toward radical behaviorist theories and epistemology. To better understand these disparities, we will now look at who the promoters of these three groups were.

Who were the first behavior therapists in French‐speaking Europe?

In the country of Jacques Lacan, the “psy” circles have been strongly marked by psychoanalysis (Turkle, 1992). This was particularly the case among psychologists who saw it as a means of emancipation from medical control for the practice of psychotherapy (Soulez‐Larivière, 1990). As for psychiatry, it has also been durably and structurally influenced by psychoanalysis while adopting a more pragmatic strategy with regard to new offers in psychotherapy (Amouroux, 2017). It is therefore hardly surprising that, in the early 1970s, the French group of behavior therapist was mainly composed of psychiatrists and academics. It included professors of psychiatry, like Daniel Widlöcher and Pierre Pichot, who wished to promote a plurality of approaches in their field and perhaps especially not to miss potentially interesting therapeutic innovations. These academics, who held leading positions in the “psy” field, never practiced behavioral therapies. Some of them were even “classic” psychoanalysts. Widlöcher, for instance, held both the position of President of AFTC and of the International Association of Psychoanalysis, which is the main Freudian international association. Like Pichot, who would preside over both the AFTC in 1971 and the World Psychiatric Association in 1977, these academics played an important legitimizing role in the early years of the association. But the real pioneers of the movement were obviously practitioners. In Brest, the psychiatrist Rognant started working in this field more or less alone. He was followed by psychologist Agathon. In the 50s, she had worked with Nicolas and Catherine Popov, students of Pavlov, on electroencephalographic conditioning at the Salpêtrière Hospital, Paris. She then moved to Sainte‐Anne Hospital, also in Paris, where she established a conditioning laboratory and conducted the first French experimental studies of behavioral treatment (Agathon & Roussel, 1968). Thereafter, the membership of the French group remained predominantly medical, unlike most behavioral therapy associations. Thus, in 1991, noting that 70% of the AFTC was composed of psychiatrists, Patrick Légeron, then president of the association and himself a psychiatrist, asked: “But where are the psychologists?” (Légeron, 1991). The French situation was indeed unique. For example, at that time, there were 85% of psychologists in the American Association (AABT) and 60% in the British Association for Behavioural Psychotherapy (Poinsart, 1990). As a result, without ever becoming a dominant approach in psychiatry, we can say that behavioral therapies have penetrated the French psychiatric culture much more widely than psychological ones.

In Belgium, the situation was quite different. The development of behavioral therapies in the French‐speaking part of the country was strongly linked to the Faculty of Psychology at the University of Liège where Marc Richelle, a rather isolated translator and ambassador of Skinner's work in the French‐speaking world, was working. In 1958, Richelle, who had been trained in both Piaget's genetic psychology and cultural anthropology, spent 1 year at Harvard with Skinner (Interview with M. Richelle, 05/01/2019). Back in Belgium, he became professor on a new chair created in Liege to teach experimental psychology. Resolutely turned toward research, he nevertheless trained the first generation of Belgian French‐speaking behavior therapists. We can mention in particular psychologists such as Michel Ylieff, Jean‐Luc Lambert, Xavier Seron, and the psychiatrist Ovide Fontaine. All of them received a solid training in experimental psychology, especially experimental psychopharmacology, and mastered the Skinnerian paradigm of operant conditioning. Initially the Belgian group membership was composed of “two‐thirds psychologists and one‐third psychiatrists” (Interview with M. Ylieff, 05/02/2019). Early on, their professional orientation and intellectual proximity with Skinner's work manifested in the emphasis put on methodology (Eelen & Fontaine, 1986; Fontaine, 1978). For instance, in 1981, far from the French pragmatic and quite ambivalent approach towards behaviorism, Fontaine and Ylieff claimed the founding role of the experimental paradigm and regretted the loss of this scientific culture among clinicians:

Whatever some may say, the first behaviorists were trained in experimental psychology laboratories and most often first worked on animals. Later, as the movement grew, with the number of techniques increasing, the theoretical and practical problems of specific clinical training arose, which gradually became independent of basic research laboratories. […]. Today, it must be said that few clinicians do research. (Fontaine & Ylieff, 1981, p. 119)

The superiority of the Belgians over the French in terms of theoretical understanding and mastery was frequently mentioned in the newsletter of the Canadian Francophone Behavioural Therapy Association. On the other hand, some commentators did not fail to point out the limits of this approach:

Let's say that at the University of Liège, there is a core of people originally gathered around Richelle, who work but confine themselves mainly to the laboratory level, doing research in experimental psychology. And I would almost personally tend to qualify this as experimental psychology rather than the clinical application of experimental psychology. So I would characterize it more as experimental psychology than behavioral therapy or behavior modification. (Harvey, 1979, p. 93)

Contrary to what happened in Belgium, the Swiss group originally created a single association despite the presence of different language regions. It is the German model of the DGVT, which, because of its success—already several thousand members in 1979—inspired the founders of the Swiss SGVT group. Thus, even if the association presented itself as multilingual, its members were essentially German speaking. Moreover, it was primarily an association of psychologists. In 1978, there were no physicians and, almost 20 years later, they represented less than 5% of members (SGVT, 1996). The first president was Hansruedi Ambühl, with the following board members: Hanspeter Dauwalder, Hugo Blickensdorfer, Beat Brauchli, Viktor Hobi, Jo Kramis, and Ernst Winter. All were young psychologists who were either clinicians or at the beginning of their academic careers. In Switzerland, since the mid 1970s, the status of psychotherapy and its coverage by health insurance has been a major concern. In confederal Switzerland, health is a cantonal prerogative. In fact, the history of the Swiss group is difficult to separate from that of the recognition of the practice of psychotherapy in the country's different cantons. In 1975, 3 years before the creation of the SGVT, the canton of Basel proposed the first of a series of regulations for the profession of psychotherapist. This has led to a series of debates and lawsuits for the recognition of the practice of psychotherapy by psychologists. The pioneers of the Swiss group of behavior therapy were especially involved (Hobi, 1978). Winter even initiated a Federal Court decision recognizing the right of psychologists to practice psychotherapy in the canton of Ticino, set to make jurisprudence in the rest of the country. It was in direct extension of these initiatives that the Swiss Association of Psychotherapists (ASP), created in 1979, and then the Swiss Federation of Psychologists (FSP), created in 1987, proposed that the various associations of psychotherapists participate in the elaboration of a common standard (Fussinger, 2006; Fussinger & Ohayon, 2010). What characterizes the Swiss group is also the underrepresentation of francophones, which was little more than 5% at the beginning of the 1980s. This led to difficulties, particularly with regard to the training program, not available in French for French‐speaking trainees before the mid 1990s. As a result, the latter were essentially trained in France. The Swiss group was therefore subject to multiple influences, which explains the creation of Bizzini's dissident French‐speaking ASPCo group in 1994, and the debates surrounding the addition of the term cognitive in the name of the association. As a German‐speaking member of the SGVT pointed out:

The change of name appears secondary, but at the end of the day linguistic borders are more cumbersome than state borders. It is no coincidence that cognitive therapy has become more popular in French‐speaking regions than in German‐speaking regions. There is a similar development in psychoanalysis: Here too there is a linguistic direction […] which comes from France. (Kundig, 1994, p. 7)

The history of these different groups testifies to a regionalization of the reception of behavioral therapies, characterized less by an adherence to behaviorist theses than by a crucial influence of local factors such as the legal, professional, linguistic and intellectual context.

BEHAVIOR THERAPY BEYOND BEHAVIORISM

Behavior therapy has been commonly understood as an outgrowth of the modern learning psychology laboratory. Controversies over its merits and demerits have thus tended to mimic those raised by objectivist psychology, especially its American variant. In particular, the link established between behavior therapy and behaviorism has underpinned its frequent opposition to other varieties of psychotherapy, first and foremost psychoanalysis. As it was explicitly stated by the French psychologist Françoise Parot‐Locatelli in 1978: “[o]ne can conceive of behavior therapy as the armed arm of behaviorism in the field of therapy and then ask ourselves who this arm threatens…” (Parot‐Locatelli, 1978, p. 72). From this point of view emerged a series of oppositions, of an epistemological, clinical and political kind, which contrasted behavior therapy's alignment on the positivism of the natural sciences with the specificity of the human sciences, the deliberately superficial approach to mental health suffering with the search for its underlying causes, and the normalizing uses of conditioning principles with the subversive potential of Freudian theory.

The tendency to conflate behavior therapy and behaviorism, whether at the level of theory, as operating within “the conditioning framework,” or at the more general level of methodology, as a practice abiding to the strict requirements and ethos of modern experimental sciences, is not without historical foundations (Eelen & Fontaine, 1986, pp. 7–8). However, it tends to freeze the history of behavior therapy in its beginnings, obscuring its later diversification. An analysis of the reception of behavior therapy in French‐speaking countries in the 1970s and 1980s must take into account that this type of psychotherapy was then in a state of flux. The behavioral psychology of reference was then remolded by Albert Bandura's social learning theory, and, above all, by the “cognitive revolution.” As outlined in 1986 by the Belgian psychologist Paul Eelen and Fontaine: “the modern learning theory of the 1950s is no longer modern, to say the least” (p. 8). Likewise, Albert Ellis' rational emotive therapy and Aaron T. Beck's cognitive therapy of depression were representing the new psychotherapeutic avant‐garde. Furthermore, these innovations, as analyzed by Karen Baistow, supported a broader shift in the “social project” of American behavioral psychology from expertise claims to provide means of external social control to that of helping people to help themselves (Baistow, 2001).

In France, Switzerland, and Belgium, the question of what behavior therapy ought to be emerged in relation to the transnational dissemination of these theoretical and practical renewals through study trips abroad, attendance to international conferences, translations of texts, and training courses. The questioning around the identity and boundaries of behavior therapy was also shaped by regional factors, including the professional composition of associations and the locally prevailing psychotherapeutic culture. This section looks at how the members of the French, the Swiss and the Belgian groups have, with different accents, negotiated the cognitive turn in psychotherapy, and more broadly engaged with other types of psychotherapies.

Psychotherapeutic mobilities: The French case

As already mentioned, in France, pioneers of behavior therapy were not of Skinnerian obedience. When the AFTC was founded, its few practitioners rather followed the Wolpean approach and focused on the treatment of phobias, exhibitionism or sexual disorders (Cottraux, 1990). Some of its younger members soon raised the question of opening up learning theory informed behavior therapy to other conceptions of psychology and techniques. Many of those who were to “spread the new Gospel” (Cottraux, 1990, p. 189), like the psychiatrists Légeron, Bernard Rivière or Jean Cottraux and the psychologist Huguette Viala, had gone to the United States and the United Kingdom in the 1970s to further their training. Under the supervision of the American psychiatrist Robert P. Liberman at the University of California, Los Angeles (UCLA) and the British psychiatrist of South African origin Isaac Marks at the Maudsley Hospital in London, they had been immersed in a hotbed of psychotherapeutic innovations, both within and outside behavior therapy.

The role played by these psychotherapeutic mobilities in the diversification and extension of behavior therapy in France can be illustrated through the professional trajectories of Rivière and Viala. In the early 1970s, Rivière went to medical school to pursue a career in psychiatry, aspiring to become a psychoanalyst (Interview with B. Rivière and H. Viala, 03/11/2019). At the beginning of his internship, he went to the Sainte‐Anne Hospital, where he was trained by Rognant, who had introduced Wolpe's work in France, and came from Brest to give courses on behavior therapy. There, Rivière also met Viala, then a clinical psychologist in training at the Paris X Nanterre University. In 1975, he obtained a study grant from the French Ministry of Foreign Affairs. Following the advice of Agathon, the two left Paris for California to work with Liberman, who was then adapting behavior therapy to psychiatric rehabilitation, family therapy, and community psychiatry. The psychiatrist had given a conference at Sainte‐Anne as early as 1971, the year of the foundation of the AFTC, and became a privileged contact person of the French movement.

For 1 year, Rivière and Viala attended courses in behavior therapy at UCLA, in which prominent figures of psychological cognitivism, such as Beck and Martin Seligman, were intervening. They also worked at the Clinical Research Unit at the Camarillo State Hospital with psychotic patients, participated in assertiveness training with women suffering from anxiety and depression at the Oxnard Community Mental Health Center, and were more generally immersed in an eclectic psychotherapeutic hotbed (Rivière, 1977a; Viala & Rivière, 1976). As vividly remembered by Viala:

When you arrived in California in the mid‐1970s, […] it was the explosion of Gestalt, transactional analysis, bioenergy, the whole school of Paolo Alto came out at that time. […] And that was called humanistic therapies. We [the behaviorists] we were seen as killjoys, with our serious, scientific measures. You had to see the others: getting naked, holding hands, singing…. And these therapies, an enthusiasm, an exaltation! We were in an extremely creative, generous, and open environment that carried us. We were invited for free in all the trainings. […] So we were not only trained in behavior therapy, but we saw everything. (Interview with H. Viala, 03/11/2019).

Upon their return to France in 1976, they simultaneously cultivated a mistrust of the then prevailing psychoanalysis and an ecumenical attitude toward new developments in psychotherapy. In the report he wrote for the AFTC newsletter on the first Days of Behavioral Therapy, which were held in Brest in 1978, Rivière appealed to the openness of its members. Summarizing the interventions of Viala on assertiveness training, of Fontaine on the reciprocal insights of psychoanalysis and learning theory, or of the Swiss Dauwalder on the use of the Skinner‐informed token economy in the socio‐professional readaptation of institutionalized patients, he thought he was witnessing:

[…] a dialectical balancing movement from the subjectivist pole to the scientific pole of psychiatry, in a sense of progress. These days […] showed, in a spirit of tolerance, how enriching it was to build bridges between hitherto competing models, and that new avenues of development in the understanding and treatment of mental pathology were opening up. The cognitive, affective, experimental and humanistic aspects of this workshop gave behavior therapy a very new flavor in opposition to the stereotypes that usually halo it. (Rivière, 1978, p. 18)

In practice, Rivière and Viala's commitment to a comprehensive understanding of behavior therapy initially translated into the introduction in France of assertiveness training (Rivière, 1977b; Viala, 1976; Viala & Rivière, 1976) as well as in the organization of training courses in public institutions, private businesses, and, from the 1980s onwards, in AFTC's own training program. Known as the Institut de thérapie comportementale, its aim was to offer training in behavior therapies outside and in addition to academia to “doctors, psychiatrists, psychologists, workers and students in the fields of health and mental health” (La Commission de formation de l'A.F.T.C, 1980, p. 19). The teaching initially took place at the Pitié‐Salpêtrière, and consisted of twenty‐five 2‐h seminars. With the participation in international conferences, it has been a major channel for the transmission of an enlarged understanding of behavior therapies. For instance, the teaching program for the year 1982–1983 comprised courses in conditioning theory, systematic desensitization and relaxation, but also on social learning, assertiveness training, cognitive learning and treatment of depression, as well as a course on “behavior therapies and other psycho therapies” given by the institutional host and psychoanalyst Widlöcher (La Commission de formation de l'A.F.T.C, 1982, p. 8‐9).

These innovations were met with varying degrees of enthusiasm by the members of the French behavior therapy association, including by some of those most responsible for their introduction. We can contrast the ecumenical outlook of Rivière with the more critical and skeptical stance of Légeron. As the editor and contributor of the association's newsletter, he witnessed and commented on the rise of cognitivism in behavior therapy throughout the 1980s. He consistently shared the reservations of some American behaviorists who “fear[ed] that the rigor of the pure behavioral approach will be lost in subjectivism” (Légeron, 1980, p. 11). For instance, in his report on the 12th congress of the European Association of Behavioral Therapy, held in Rome in September 1982, Légeron expressed his disappointment at the interventions of “American ‘stars’.” In particular, he regretted that Beck's “masterful presentation of his conceptions” was not backed up with “experimental elements.” He added that “[n]o one would be surprised or regret [the cognitivist push] if one did not have the (perhaps erroneous) impression that it sometimes comes at the cost of certain renunciations” (Légeron, 1982, pp. 13–14).

In any case, the enthusiasm for cognitive therapies in France continued to grow. A good indicator of this was the almost unanimous vote to integrate the cognitive approach in the name of the association. At the Extraordinary General Meeting of September 13, 1990, 101 members voted in favor of an amendment to the statutes of the association along these lines, four against, and one null (Anonymous, 1990, p. 2). To Légeron, by then president of the AFTC, this change in name was a means to “reaffirm that cognitive therapies belong to the domain of behavior therapies, and that cognition is behavior” (Légeron, 1990, p. 1). The physician Gérard Apfeldorfer also saw it as a means to stay positioned in the changing psychotherapeutic market by revamping the public image of behavior therapists. Not without humor, he noted that “the silly and mean behaviorist has given way to the cognitivist‐behaviorist, whose archetypical image is that of a freshly shaved technician with a stainless steel smile, wonderfully efficient but human nevertheless. This is a good example of how to straighten out a faulty brand image, which many marketing managers could learn from.” (Apfeldorfer, 1992, p. 3)

Psychotherapy in an experimental spirit: The Belgian case

Some French behavior therapists treated the irruption of the cognitive movement as a radical rupture with its behaviorist past. In 1983, for instance, Cottraux cracked a mocking bill in the AFTC's newsletter about his encounter with Skinner at the first European Conference of Experimental Analysis of Behavior, held that year in Liège. He was among the happy few who had been invited to the cocktail given by the organizer of the conference, Richelle, in the honor of the psychologist. Reporting about the informal chat they had with him, Cottraux painted the portrait a scholar mired in his system of thought, impervious to novelty:

I […] had the perverse idea of asking him what he thought about cognition and the cognitive movement. This led to the […] answer […] that not much could be expected from the development of this movement in terms of behavior therapy, experimental analysis of behavior and psychology. On this Skinner stood up to continue the discussion in other small groups. Some bad spirits in the group pointed out that “cognition” had probably served as a discriminating stimulus for his motor behavior. Others suggested that we had shaped his behavior to respond according to our expectations. Yet others pointed out that the cocktail party was held in a former Templar commandery, which did not predispose to an ecumenical attitude […]. (Cottraux, 1983, p. 15)

The Belgian hosts, who had come to behavior therapy through the practice of radical behaviorism in the experimental psychology laboratory, met the ascending paradigm of cognitivism with more nuance. As recalled by Fontaine and Ylieff: “[…] we followed the cognitive models with curiosity and hope […] but without denying our first loves” (Fontaine et al., 2009, p. 4). Here, the confrontation with novelty took place first and foremost on the level of ideas and epistemology. Deviations from the narrow path traced by Skinner were tolerated and even embraced, provided that psychologists and therapists maintained an experimental spirit. Appreciative of the theoretical prowess of the cognitive movement, the Belgian behavior therapists also cautioned that few of its explanatory models had been subjected to empirical validation. Still, they did not question the necessity of using inferences about internal structures and processes to investigate psychological phenomena in their wide range and complexity, only the “quality” of the control methods implemented to keep it scientific (Fontaine, 1978, p. 92).

Along these lines, in keeping with their dual status of practitioners and scientists, the Belgian behavior therapists explicitly engaged in the theoretical discussion around cognitivism. Far more than their French and Swiss colleagues, they reflected on its continuities and discontinuities with behaviorism, and critically discussed its implications for psychotherapy. An excellent illustration of this can be found in the taxonomy of cognitivism developed by Richelle and Fontaine in the mid‐1980s (Richelle, 1986; Richelle & Fontaine, 1986). It distinguished four varieties of cognitivism in psychological research. The first one extended the investigations initiated in the framework of behaviorism by Edward C. Tolman, and focused on “specifying intervening variables” (Richelle, 1986, p. 14). Here, the emphasis was on continuity: this brand of cognitivism essentially abided by the “same methodological rules” and epistemological norms of behaviorism, “maintain[ing] behavior as part of [its] subject matter, and anyhow, as the necessary source of data” for inferential analysis (Richelle, 1986, p. 15). By contrast, the second variety, dubbed “radical cognitivism,” restricted its subject matter to mental phenomena, exalted representation over action, and, in its hope to dispense with the study of behavior, paved the way for the subjugation of psychology by the brain sciences. The third variant was presented as a reaction to behaviorism with philosophical undertones. Against deterministic accounts of behavior, it strove to “rehabilitat[e] […] the willing subject” (Richelle, 1986, p. 16), as reflected in the emphasis put on the ability of individuals to make choices, have purposeful behaviors, select their environment as much as their behavior is selected by it. In its last variant, cognitivism was a “territory within psychological sciences, rather than […] a general theoretical or epistemological approach to psychology,” which dealt with cognition, “as opposed to emotion, affectivity and motivation” (Richelle, 1986, p. 17).

This taxonomy was linked to an assessment of cognitive therapies. At a general level, their perceived strength was that they had stripped behavior therapies of their original “naiveties,” with the side benefit of offering its practitioners an acceptable alternative to “psychoanalysis” for attending to what the “real subject” had “in his head”, that is his or her “ideas and feelings.” In details, the second variant of cognitivism was found to have resonance in therapies such as Beck's that emphasized errors of reasoning in the genesis of mental disorders, including emotional syndromes. In this perspective, depression or anxiety resulted from misrepresentations or distorted representations of the self and the world. This orientation, while backed by theoretical and experimental arguments, also set potential traps for behavior therapists. In particular, “radical cognitivism” was seen as a backdoor for the return of the medical model in psychotherapy because it “tended to reinstate behaviors as mere symptoms” (Richelle, 1986, p. 20), that is as an “indicator” of some underlying dysfunction, “which could be dispended with.” (Richelle, 1986, p. 11), As to the third variety of cognitivism, it had affinities with the therapies developed by Bandura and Meichenbaum, “wherein the role of self‐instruction [was] emphasized” (Richelle, 1986, p. 11), but also with a burgeoning set of self‐control training practices. Popularized through do‐it‐yourself books, the latter echoed the distrust of traditional vertical authority, the “search for freedom in the unconstrained expression of one's emotional half,” and the rising value of autonomy in Western ethics (Richelle, 1986, p. 18). To Richelle and Fontaine, however, their strong cultural resonance was inversely proportional to their scientific foundation and empirical validation.

The Belgian group also pondered the political, rather than clinical implications of cognitivism. Against the tide of representations of behaviorism as a normalizing movement, providing means for maintaining the existing social order, they emphasized its reformist stance. To Richelle, for instance, what might have been lost “with the rise of cognitivism” was “the subversive side of behavior therapy”:

By pointing to environmental conditions in the analysis of disturbed behavior, the classical behavioral approach inevitably led to a critical appraisal of prevailing contingencies. Cognitivism has brought the problem back in the head of the subject; let him or her be responsible for personal adaptation, and to that purpose let us reinstate in him or her free will and control. The world outside is alright, and need not to be changed (it has no cognition, anyhow). (Richelle, 1986, p. 21)

The Belgian group did not limit itself to a critical evaluation of the latest developments in psychotherapy. They also strove to develop new clinical tools integrating the content of the patient's cognitions in a scientific approach of his or her disorders. This selective appropriation of cognitivism resulted in a new model for functional analysis, the process by which “the behaviorist collects and orders information about the patient's problems in a hypothesis linking […] stimulus to response” (Fontaine & Ylieff, 1981, p. 119). Published in 1981 by Fontaine and Ylieff, this model was dynamic, adopting the cybernetic notion of retroaction in its analysis of causal relations to better adapt to the ever‐changing clinical reality (Fontaine & Ylieff, 1981, p. 122). Furthermore, it explicitly integrated internal variables in the analysis of the determinants and consequence of problem behaviors, including mental representations, though processes and emotions (Fontaine & Ylieff, 1981, pp. 124–125).

Critical psychotherapeutic eclecticism: The Swiss case

As clinical psychologists who had not been trained in behaviorism, the Swiss behavior therapists did not have the same sense of debt toward this tradition and its leading figures as the Belgians. In 1983, the President of the Swiss Behavior Therapy Association, Hans Althaus, stated that the conception of behavior therapy as “an application of behaviorism,” with its narrow learning‐theory and technical focus, now had “mainly a historical significance.” “An important characteristic of behavior therapy, he added, is the absence of a leader personality, which largely eliminates the danger of dogmatic rigidity and allows it to be always open to new developments.” The open‐minded stand taken by the Swiss group was related to the desire for a new, integrative conception of psychotherapy. As such, in the first years after the foundation, which were mainly devoted to training issues, the members of the SGVT tried to deal with the perceived shortcomings of traditional behavior therapy by reflectively incorporating not only newer behavioral and cognitive models, but also models and approaches from other psychotherapeutic schools.

As already mentioned, this “critical eclecticism” can be linked to the need for collaborations between orientations brought by the struggle for the recognition of psychotherapy in Switzerland. Not unlike the French group, the desire for reform can also be harked back to the movement of people, knowledge and practice across national borders. Yet, the decisive psychotherapeutic mobilities were here more regional in scope. The SGVT had close ties with its German counterpart, and some of its early members had been trained in clinical psychology in Germany, where they grew up to exchanges across psychotherapeutic orientations. Franz Caspar, for instance, moved from Zürich to Hamburg in the 1970s to study psychology and political sciences at the university. There, he pursued parallel training in behavior therapy and in client‐centered therapy, got involved in the German Association for Behavior Therapy where he exchanged with members who were also attending workshops in Gestalt therapy, and, most importantly, met the German psychologist Klaus Grawe (Interview with F. Caspar, 10/12/2020). Grawe was then clinical and research associate at the University's psychiatric hospital, where he had cofounded a “multiapproach psychotherapy ward” (Caspar & Grosse Holtforth, 2010, p. 115). This was a decisive encounter for Caspar, leading to a long‐term collaboration with a major psychotherapy researcher who dedicated his career to the development of an empirically grounded psychotherapy that transcended boundaries between schools of therapy. Appointed Professor of Clinical Psychology and Psychotherapy at the University of Bern in 1979, Grawe worked toward that goal by conducting research on topics such as the integration of learning and other approaches in case formulation and treatment planning, outcome and process research, and comparative treatment assessment (Caspar & Znoj, 2011).

Caspar followed Grawe back to Switzerland as his assistant. In the outpatient clinic they founded in Bern, he met two SGVT representatives, Ambühl and Hans Peter Müller, and soon got involved in its training committee (Interview with F. Caspar, 10/12/2020). Caspar transferred the spirit of his German years to his associative activities. For instance, in 1983, when the Tages Anzeiger, a German‐language Swiss daily newspaper, contacted the SGVT for a planned series on the psychotherapies available in the Zürich area, Caspar frowned at its school‐oriented approach. He was concerned that it “would reinforce the impression that psychotherapy is something that rival schools fight out among each other. Although, unfortunately, this is largely the case on the market […], this view does not correspond at all to the state of scientific assessment of psychotherapy as it is represented at non‐school oriented scientific conferences, in the literature, and at non‐school‐oriented university institutes.” In this perspective, Caspar, who later became a leading member of the Society for the Exploration of Psychotherapy Integration (SEPI), also established links between the SGVT and the Rogerian Schweizerische Gesellschaft für Gesprächspsychotherapie (SGGT).

In particular, this integrative spirit was shown by the close interest taken by the members of the SGVT in the “personal experience of the therapist.” As described in the early 1980s by its Continuing Education and Training Commission, this field could be broken down into three component elements. The “technique‐centered” part focused on the acquisition of an “in‐depth knowledge of individual techniques from one's own experience,” and should be taught with self‐modification training. The “person‐centered” and the “therapeutic interaction‐centered” parts respectively referred to self‐reflection about “one's own effect […] on other people in general,” and on clients in particular. These later training elements defined what the German‐speaking behavior therapy associations called Selbsterfahrung (“self‐directed experience”) (Laireiter, 1998). In addition to self‐awareness about one's attitudes, behavior, and motives, it aimed at instilling in aspiring behavior therapists a “sensitivity to the interpersonal processes in therapy, empathy with the client and a self‐reflective style in practicing psychotherapy” (Laireiter & Willutzki, 2003, p. 28).

Reminiscent of the didactic analysis dear to psychoanalysis and of the emphasis put on personal development in the humanistic tradition, such self‐reflective work was not part of the training tradition in classical behavior therapy. Admittedly, behavior therapy societies had included “self‐modification” in their training concept for many years: “each training candidate had to work on a specific problem to be changed.” However, a less technical understanding of the personal experience of the behavior therapist, focused on self‐knowledge, only emerged in the late 1970s and early 1980s, especially in German‐speaking countries (Lutz, 1982; Ringler, 1982; Zimmer, 1978). To the members of the SGVT's Continuing Education and Training Commission, this change in emphasis was partly due to the extension and diversification of the behavior therapy field. For one thing, they adopted the point of view that the “success rates [had] decreased with the application of behavior therapy methods to a broader range of disorders, unless relationship aspects, and thus the person of the therapist, [were] systematically taken into account in therapy.” Furthermore, the Commission outlined that the new CBTs addressed “‘deeper’ layers of the client, and—precisely for that reason—[were] also dependent on the personality of the therapist in their application.” From the mid‐1980s onwards, the drafting of new cantonal health laws provided additional impetus for the inclusion of Selbsterfahrung in the training of behavior therapists. To be heard by the lawmakers, the Swiss associations of clinical psychologists, including the SGVT, gathered under the umbrella organization of the SPV to develop common training guidelines. These have made self‐directed work a standard requirement, by asking trainee for a minimum of 200–800 h in this domain, depending on the orientation chosen.

Far from being a superficial requirement, Selbsterfahrung training became a fixation point for identity debates in the German‐speaking behavior therapy movements, as well as prompted exchanges with other orientations. From the outset, this discussion was in fact fueled by therapists from other schools, including psychoanalysts who drew attention to a shortcoming in training and advised for the development of self‐directed work endogenous to behavior therapy (Ringler, 1982, 1996). This was also the position of Caspar and his fellow members of the SGVT's Training Commission who in 1981 proposed a mandatory behavior therapy basis for Selbsterfahrung. However, they also recognized that such a training offer was not yet available. Given the original lack of genuinely behavioral training concepts and methods, and the related shortage of qualified trainers in their own orientation, they were ready to—temporarily—loosen their requirements. They have thus suggested that “[…] a training analysis or a conversational psychotherapy‐based Selbsterfahrung could be recognized as equivalent,” provided that it met the association's training guidelines. It is perhaps for the same reasons that the SGVT has looked for possibilities to cooperate with the humanistically oriented SGGT, and considered developing training and continuous education courses together.

SOCIETAL CONTRIBUTION OF BEHAVIORAL THERAPY?

Focusing on the regionalization of behavioral therapies not only brings to light different therapeutic subcultures, but also reveals specificities in the psychotherapy‐society nexus. In France, behavior therapists were confronted with vigorous external critiques from practitioners, especially psychologists and social workers, social scientists as well as journalists (Binder, 1982; Welger et al., 1980). In a context marked by the events of May 1968, where the political ramifications of psychiatry and psychology were debated in public forums, behavior therapy's directiveness, superficiality, and coercive techniques, such as aversive conditioning, were frequently singled out. The issue of the behavior therapists' political positioning was imposed on the members of the AFTC, who were asked to take a position, even though it was not a subject of active reflection among them. The Belgian case more or less mirrored the French one. In Switzerland, by contrast, this issue emanated from within the association and became the subject of an ongoing discussion focused on the contribution of behavior therapy to the improvement of psychosocial care.

To address criticisms, the French and the Belgian groups included discussions on ‘ethical issues’ in their training programs and publications (Fontaine, 1978; Guilbert, 1978; Guilbert & Dorna, 1982). Both built on Wolpe's work, considering the therapist's behavior as a reinforcing agent, and emphasizing a “therapeutic contract” with a patient considered as an active partner in the treatment process (Agathon, 1978; Rognant, 1982). As for the charge of superficiality, they claimed to take a more straightforward attitude to the patient's request than psychoanalysis, focusing on resolving circumscribed concrete problems without changing his or her personality (Apfeldorfer, 1980; Guilbert & Dorna, 1982). Within the AEMTC, Fontaine used the Skinnerian argument that one's acknowledgment and command over reinforcements in one's own daily environment was a means to become autonomous (Fontaine, 1978, p. 269). In 1981, Agathon made a similar claim at the “Psychology and Freedom” Congress held by the Syndicat National des Psychologues, a psychoanalytically‐oriented union. During her talk, entitled “Behaviourism and liberation process,” she emphasized that these therapies' purpose was “to provide people with means to achieve a normality to which they aspire” (Agathon, 1982b, p. 61). The discussion that followed was opened by the progressist experimental psychologist Guy Tiberghien (Tiberghien, 1979, 2007). Ignoring Agathon's pragmatic argument about patients' expectations, Tiberghien steered the discussion towards the political commitment of behavioral therapists in France, by asking her: “Why do behavioral psychologists, who use a number of legitimate theories and methods from a scientific knowledge standpoint, not denounce, in a very public and rigorous way, the ideological extensions of behavioral psychology?” (Anonymous, 1982, p. 73).

Meanwhile, within the SGVT, the interplay between psychology and politics was more openly addressed. The Swiss group, for instance, provided support to “Psychologists for Peace” in the German Federal Republic by organizing antimilitaristic demonstrations in Bern and Lucerne. In addition to such statements on topical societal issues, the political valence of psychology was also addressed through internal discussions on how behavioral psychotherapy should be developed (Interview with J.‐P. Dauwalder, 05/11/2020). Should it be intended to benefit the well‐being of people in good health, or be part of psychosocial care? This was a much‐debated issue, and during Ambühl's time as president the second orientation was favored. Not only were they involved in cantonal surveys on these issues, but they also collaborated in the 1980s with the association Pro Mente Sana, founded in 1970 for the social reinsertion of psychiatric patients. To Ambühl, who looks back on the Swiss group as a “child of the wild 1970s,” behavior therapy, notably due to its length, offered an accessible alternative to more expensive methods. Along similar lines, treatment costs, set by the group members, were not to exceed two percent of patients' income (Interview with H. Ambühl, 01/27/2021).

It was also in an intellectual atmosphere colored by the development of the Marxist‐inspired Critical Psychology in Germany and by its most famous advocate Klaus Holzkamp (Teo, 1998), that Ambühl and other SGVT members condemned any commercial use of behavior therapies. As part of the XIX International Congress of Applied Psychology in 1978, the SGVT received the statutes of the company Brain GmbH, soon to be established in Zürich by the Münich‐based psychologists Johannes C. Brengelmann and Georg M. Sieber to deliver behavior analysis and modification services in industry, trade, and services. Further to such news, the Board of Directors delegated Ambühl to inquire about the company by attending its founding meeting, which resulted in a critical report. The SGVT's collective decision to circulate the latter to other therapists led to legal wrangling between Ambühl, the DGVT and Sieber eventually settled by the Regional Court of Hamburg. Besides an issue of academic integrity, these moments were also, it seems, an additional occasion to affirm a rather psychosocial orientation taken by the Swiss group in its early years of existence. In line with the circulated report, the Hamburg Regional Court ruled in favor of Ambühl's criticism of Brain GmbH's project, and stated that the company's activities “could discredit professional groups working in psychosocial care, and give them an air of quackery and lack of professionalism.”

In the French group, “para‐therapeutic” uses of behavioral therapies did not cause any resistance (Castel, 2011, p. 170). For instance, in 1989, Légeron while president of the AFTC, created the Paris‐based consulting firm Stimulus. As he recalled, the idea took root during his American journey in the late 1970s. While working with Liberman, he met colleagues from Stanford and Berkeley Universities who had been hired as consultants in companies, to examine work environments and their impact on employees' health (Interview with P. Légeron, 08/04/2016). Similar to Brain GmbH, Stimulus was founded on “the core idea of providing the world of work with counselling, assessment and services based on sound scientific knowledge of health psychology” (Légeron, 2018, p. 3). Its creation had neither been advertised in the AFTC's newsletter, nor did it receive any adverse reaction. Still in operation, it has in the meantime become a quite flourishing agency, with approximately 50 full‐time consultants and a diversified portfolio of activities, including stress management, managerial training and work organization. In the first half of the 2000s, the Labour Minister even entrusted Légeron with a mandate to produce a report on psychosocial risks at work (Nass & Légeron, 2008), a telling example of the success of his agency and of regionally contrasted attitudes toward broad applications of behavioral approaches.

CONCLUSION

In this article, we have investigated the comparative regional development of behavioral therapies in France, Switzerland, and Belgium between the 1960s and the 1990S. From the comparison of cases, common points emerge. In the three groups, self‐definition and identity negotiations have not so much revolved around the clash of epistemologies and ontologies between psychoanalysis and CBT. It was more the integration of the “cognitivist turn” that was in the foreground. As Marks (2017) has pointed out, what characterizes the history of psychotherapy during the second part of the 20th century is in fact less dogmatism than dialogue and hybridization between orientations. As such, the three groups tended to take an open‐minded stance toward therapeutic innovations, including those coming from rival schools.

But what is most striking are the differences and even unexpected oppositions between proponents of the same approach. First of all, concerning association membership, for the period under study the overwhelming majority were psychologists in Switzerland and Belgium. Conversely, in France, the majority were psychiatrists. There were also divergent views on the extension of behavioral approaches into the wider social world. In France, one of the founding members created a company to promote their use in the field of work. On the other hand, the first president of the Swiss group strongly criticized the establishment of a company pursuing a similar project. Last but not least, there were major differences in the positions taken with regard to behaviorist theses. Thus, we find in Belgium a group that clearly claims the filiation with Skinner's work and proposes a substantial theoretical reflection. In France, on the other hand, while also claiming a scientific position, several founding members were openly critical of radical behaviorism. As for the Swiss association, it can probably be qualified as integrative because it included founding members who also actively engaged with other theoretical schools, notably humanistic therapy.

Overall, there was a real “political topography” (Livingstone, 1995, p. 19) underlying this regionalization of psychotherapeutic styles. Namely, issues of professional politics, particularly the regulation of the profession of psychotherapist, together with local scientific traditions, all help account for the differential development of behavior therapy in French‐speaking Europe.