This preview has intentionally blurred parts. Sign up to view the full document

View Full Document

Unformatted Document Excerpt

19 Chapter THE DEVELOPMENT AND DEVELOPERS OF BEHAVIOR THERAPY Unlike many of the theories discussed in this book, behavior therapy is not strongly associated with one or two names. Instead, many people contributed to the evolution of this approach. Some, like Eysenck, Lazarus, Wolpe, Dollard and Miller, Krumboltz, and Bandura, applied behavior therapy and learning theory to people. Others, including Skinner, Harlow, and Pavlov, used principles of behavior change to shape the actions and reactions of animals. All of these contributed to the development of behavior therapy. B. F. Skinner B. F. Skinner, an experimental psychologist, may be the best-known behavioral theorist. Skinner received many awards for his contributions to psychology from the 1950s until his death. He emphasized the orderliness of behavior and sought principles to describe and predict behavioral patterns as well as ways to modify behavior. His ideas, known as operant reinforcement theory (Skinner, 1969), postulate that how often a behavior will be emitted is largely determined by the events that follow that behavior. Drawing on the principles of operant conditioning in one of his studies, Skinner used rewards to gradually shape pigeons naturally emitted behaviors until the pigeons learned to peck at a red disc. Similarly, childrens behavior can be shaped through parental reinforcement; for example, parents who attend primarily to childrens misbehavior inadvertently reinforce that behavior. Ivan Pavlov In the early 1900s, Ivan Pavlov (1927), a Russian physiologist, identified and described a type of learning that now is known as classical conditioning. His study of conditioning dogs responses is well known. Pavlov demonstrated that, by simultaneously presenting an unconditioned stimulus (meat paste) and a conditioned stimulus (the sound of a tuning fork), researchers could elicit the dogs salivation using only the conditioned stimulus (the sound) because the dogs learned to associate the sound with the meat. Pavlov also studied the process of extinction. For a while, the dogs in his study salivated to the sound of the tuning fork, even when the sound was no longer accompanied by the meat. However, over time, the salivating response diminished and eventually disappeared in response to the tuning fork alone. John W. Watson John W. Watson, an American psychologist, used Pavlovs principles of classical conditioning and stimulus generalization, along with concepts of learning theory, to change human behavior. Rejecting psychoanalysis, then the prevailing treatment approach, Watson (1925) proposed what he called behaviorism. Watson demonstrated that an unconditioned stimulus (a loud bell), paired with a conditioned stimulus (a white rat), could lead a child to emit a conditioned response (startle) in reaction not only to a white rat but also to white cotton and Watsons white hair. John Dollard and Neal Miller Subsequent work by John Dollard and Neal Miller (1950) contributed greatly to understanding of learning theory and paved the way for behaviorists to move into the arena of psychotherapy Dollard and Miller identified four important elements in behavior: drive, cue, response, and reinforcement. In Social Learning and Imitation (Miller & Dollard, 1941), they wrote: What, then, is learning theory? In its simplest form, it is the study of the circumstances under which a response and a cue stimulus become connected. After learning has been completed, response and cue are bound together in such a way that the appearance of the cue evokes the response The connection between a cue and a response can be strengthened under certain conditions. The learner must be driven to make the response and rewarded for having responded in the presence of the cue. (p. 1) The more frequently a stimulus and a response coincide, with the response being rewarded, the stronger is the tendency to emit the response when that stimulus occurs, leading to the development of a habit or habitual response. This is the essence of the stimulus-response (S-R) concept, which, according to behavior theorists, determines the behaviors that people learn. For example, Jamila was the third child in a family of seven children. Both parents worked outside of the home and had little time for positive interactions with their children. Whenever one of the children was sick, however, the parents gave them extra time and attention. Jamila learned that illness was the best way to elicit her parents attention and so exaggerated even minor physical symptoms for the nurturance that would bring her. She continued this behavior into adulthood, even though it had a deleterious effect on her relationships, her employment, and eventually on her marriage. Dollard and Miller found that counterconditioning could reverse habits. This involves pairing the behavior to be changed with a strong incompatible response to the same cue. For example, Jamilas behavior gradually changed as her employer, friends, and partner became annoyed with her frequent complaints of physical discomfort and withdrew from her when she reported feeling ill. Joseph Wolpe Joseph Wolpe (1969) described a similar process, reciprocal inhibition, in which eliciting a novel response brings about a decrease in the strength of a concurrent habitual response. A parent who makes a silly face to cheer up a child who is crying after a minor fall is a simple example; the silly face elicits amusement, which automatically reduces the sad emotions associated with the fall. Wolpes ideas led to the development of systematic desensitization, a powerful tool that pairs relaxation with controlled exposure to a feared stimulus such as heights or dogs. This technique still is widely used, especially in treatment of phobias, and is discussed in detail later in this chapter. Wolpe also developed strategies to promote assertive behavior. Wolpes work reflects the concept of stimulus generalization. When people learn to respond in a particular way to one stimulus, they often behave in that same way when presented with similar cues. For example, a child who is taught to be respectful of teachers is likely to behave respectfully toward other authority figures. Sometimes behavior is overgeneralized and becomes inappropriate or unhealthy. Then people need to learn stimulus discriminationthe ability to distinguish among similar cues. For example, most of us have learned to confide in a small number of close friends but recognize that it is inappropriate to share many details of our personal lives at work (stimulus discrimination). However, some people share intimate details of their lives not only with close friends but with casual associates, perhaps reflecting inappropriate stimulus generalization. Albert Bandura Albert Bandura (1969) played an important role in the development of behavior therapy through his application of principles of both classical and operant conditioning to social learning. He found that learning and subsequent behavior change could occur vicariously through observation of other peoples behaviors. This process, which Bandura called modeling, can elicit both positive and negative behaviors. Modeling often has a beneficial impact. Observing someone we admire undertake a challenging task can reduce our fears and facilitate our efforts to perform the task. On the other hand, Banduras experiments suggested that children who observed adults acting aggressively were more likely to manifest aggressive behavior than children who had not been exposed to such models. These findings have implications for understanding the apparent increase in violent behaviors in young people. Current Development By the 1980s, behavior therapy had established its place in psychotherapy, and its effectiveness was well substantiated by research. However, many clinicians were dissatisfied with traditional behavior therapy which de-emphasized the therapeutic alliance, viewed the clinician as the authority, and sometimes seemed dehumanizing. As a result, the shape of behavior therapy has evolved over the past 25 years. A positive and collaborative treatment alliance is now an essential element of treatment. The move to integrate behavior therapy and cognitive therapy (reflected in the work of Meichenbaum, Lazarus, Ellis, Beck, and others) has broadened the application of this approach and made it less mechanical and more sensitive to individual needs. IMPORTANT THEORETICAL CONCEPTS The application of behavior therapy varies, depending on clinician, client, concern, and setting. Most approaches to behavior therapy can be described by one or more of the following five models (Wilson, 1995): 1.Applied behavioral analysis. Derived from Skinners theory of operant conditioning, this approach looks at the impact of environmental events on behavior. It takes a scientific approach and focuses on observable, measurable behavior. 2.Neo-behaviorism. Drawing on Pavlovs classical conditioning as well as stimulus-response theories, this focuses on the process of conditioning or learning responses. 3.Social learning theory. Based on the research of Bandura, this approach seeks to understand the interaction of cognitive, behavioral, and environmental factors in shaping behavior. Many strategies that clinicians use to enhance self-efficacy and reduce learned helplessness reflect understanding of social learning (Seligman, 1990). 4.Cognitive-behavioral therapy. Reflected in the work of Meichenbaum, Ellis, and Beck, this approach looks at how cognitions shape behaviors and emotions. This treatment system makes use of both cognitive and behavioral strategies to effect change. 5.Multimodal therapy. Multimodal therapy (discussed in part 6), developed by Arnold Lazarus, is based on principles of behavior therapy. More a holistic approach to assessment and treatment planning than a type of behavior therapy, it systematically integrates strategies from a wide range of approaches. Principles of Behavior Therapy Regardless of their specific approach to behavior therapy, behavior therapists generally subscribe to the following principles (Myers & Thyer, 1994; Stuart, 1998): Although genetics play a role, individual differences are derived primarily from different experiences. Behavior is learned and acquired largely through modeling, conditioning, and reinforcement. Behavior has a purpose. Behavior is the major determinant of habits, thoughts, emotions, and other aspects of personality. Behavior therapy seeks to understand and change behavior. Therapy should be based on the scientific method and be systematic, empirical, and experimental. Goals should be stated in behavioral, specific, and measurable terms, with progress assessed regularly. The focus of treatment should generally be on the present. Even if behaviors are longstanding, they are maintained by factors in the current environment. However, behaviors must be viewed in context, and some exploration of the past is appropriate to provide that context and help people feel understood. Education, promoting new learning and transfer of learning, is an important aspect of behavior therapy. Strategies of behavior therapy need to be individualized to the particular person and problem. People need to take an active part in their treatment to successfully change their behaviors. Clients have primary responsibility for defining their goals and completing homework tasks. The treatment plan is formulated collaboratively, with both client and clinician participating actively in that process. Some people think of behavior therapy as narrow, directive, and deterministic. However, Myers and Thyer (1994) and Stuart (1998) dispute those misconceptions, asserting that modern behavior therapy has both depth and breadth as reflected in the following concepts and practices: Although behavior therapists may focus on observable behavior, they interpret behavior broadly as anything an organism does, including thinking and feeling, and are interested in the total person. Behavior therapists recognize the importance of a collaborative and positive therapeutic relationship and the communication of encouragement as important in promoting learning and motivation. Although objectivity and the scientific method are valued, behavior therapists also recognize the importance of understanding and respecting individual differences. The Development of Personality According to behaviorists, when children are born, they have three basic building blocks of personality: 1.Primary drives, such as those toward food and warmth 2.Specific reflexes, such as sucking and blinking 3.Innate responses to particular stimuli, such as escape or crying in reaction to pain Many behavior therapists also acknowledge that some temperaments have a hereditary basis. Beyond that, behavior therapists believe that personality is shaped primarily through learning and maturation. New behaviors may be emitted accidentally, acquired after observation of others, or be the product of thought. Whether these new behaviors continue to be emitted frequently and become a habit or are rarely if ever produced depends largely on the conditions accompanying or following the behavior. Both maladaptive and healthy behaviors are learned because they have yielded positive reinforcement or led to a decrease in an aversive stimulus. In other words, both internal reinforcements, such as good or bad feelings, and external reinforcements, such as praise or punishment, are the primary determinants of the development of a behavior. UNDERSTANDING TERMINOLOGY Terminology of behavior therapy can be confusing. However, becoming familiar with terminology facilitates understanding of this approach as well as of personality development. Following is a review of important terms, illustrated by the experiences of Theresa, a 33-year-old woman receiving chemotherapy for breast cancer. Although we discussed some of these terms previously, we review them here for clarification. Theresa presented many issues related to her diagnosis of cancer. She had always been fearful of injections and found blood tests and intravenous chemotherapy difficult. She had anticipatory nausea associated with her chemotherapy, becoming queasy when driving into the parking lot of the clinic where she received treatment, whether or not she was scheduled for chemotherapy. In addition, although her prognosis was encouraging, Theresa constantly ruminated about the likelihood of her death. Theresas anticipatory nausea can be explained by classical conditioning. The unconditioned stimulus, the chemotherapy, elicited the response of nausea. Because that stimulus was paired with the conditioned stimulus of driving to the clinic, entering the parking lot became a stimulus that also elicited the response of nausea whether or not the chemotherapy also was present. Theresa, like all of us, had an innate drive to avoid pain. When she received inoculations as a child, her parents reinforced her fears by paying special attention to her when she became fearful. As a result of this operant conditioning, her fear of injections became habitual and evolved into a phobia. In fact, through the process of stimulus generalization, Theresa experienced inordinate anxiety in reaction to any medical appointment, whether or not it necessitated an injection. Her learned behavior reflected a stimulus-response model; because her fearful behavior was rewarded in child-hood, Theresa demonstrated fear and avoidance (response) to the stimulus of any medical visit. Her therapist used several behavioral approaches to modify Theresas responses. Systematic desensitization was used in the hope of extinguishing Theresas excessive fear of medical visits and inoculations. An anxiety hierarchy was created, listing her fears in ascending order from the mildest fear (a visit to a dermatologist that would not involve any physical discomfort) to the most frightening (a visit to the oncologist for chemotherapy). Beginning with the mildest fear, the therapist helped Theresa to relax and feel empowered while visualizing the frightening stimulus. This process of reciprocal inhibition paired relaxation and positive feelings with an aversive stimulus (a frightening image) to decrease the strength of the fear response. Theresa also learned to use both relaxation and stimulus discrimination to reduce her fears; she learned to relax when approaching medical visits and driving into the parking lot at the oncology clinic and reminded herself that not all medical appointments involved discomfort. Counterconditioning was used to help Theresa further reduce her fears; when she began to ruminate or felt anxious, she visualized herself triumphantly completing her chemotherapy and setting off on a trip to Bali that she was planning. The feelings of pride and optimism elicited by that image counteracted and reduced her apprehension. To make sure she could readily access this positive image, the therapist led Theresa through a process of covert modeling in which she mentally rehearsed dealing effectively with her fears about chemotherapy. Joining a support group of other women diagnosed with breast cancer also provided Theresa with an experience in social learning and reinforcement and gave her additional role models. STEPS IN TREATMENT Chapter 18 discussed the steps in a plan to effect behavior change. Although we review them here, readers will find more detailed information in that chapter. Once behavior therapists believe they have obtained enough information to have at least a basic understanding of their clients and to put their concerns in context, clinicians and clients collaborate to develop a plan, generally characterized by the following eight steps: 1.Describe the problem. Review the nature of the problem and its history. Explore the context of the target (unwanted) behaviors. 2.Establish a baseline, reflecting the current frequency, duration, and severity of the target behaviors. 3.Determine goals. Make sure that goals are realistic, clear, specific, and measurable. Make sure that goals are meaningful to the client. State goals positively. Arrive at work on time at least twice this week is a more appealing goal than Avoid being late to work at least twice this week. 4.Develop strategies to facilitate change. Change precipitating conditions that trigger undesirable behaviors. Teach skills and provide information that contribute to the desired change. Review and enhance impulse-control strategies. Use additional strategies such as modeling, rehearsal, and systematic desensitization to facilitate positive change. Formulate appropriate reinforcement contingencies and, if indicated, meaningful consequences. Carefully plan implementation of the change process as well as ways to monitor and record the outcomes of that process. Client and clinician make a written contract; clinician encourages the client to share the commitment to change with others. 5.Implement the plan. 6.Assess progress and evaluate the success of the plan. Monitor and review the results of the implementation. Emphasize successes. Identify and address any obstacles to change. If necessary, revise the plan. 7.Reinforce successes to promote empowerment, continue progress and positive changes. 8.Continue the process by making plans to promote maintenance of gains and prevent relapse. COGNITIVE-BEHAVIORAL THERAPY Behavior therapy is often integrated with cognitive therapy to create a powerful treatment approach known as cognitive-behavioral therapy (CBT). (This is also referred to as cognitive behavior therapy.) The National Association of Cognitive-Behavioral Therapists (NACBT) views Elliss rational emotive behavior therapy and Becks cognitive therapy (discussed in part 4 of this book) as examples of CBT, along with Meichenbaums and Linehans treatment approaches, discussed later in this chapter. In effect, any treatment approach that emphasizes thoughts as well as behaviors, and pays only secondary attention to background and emotions, can be viewed as CBT. CBT evolved from cognitive therapy through incorporation of components of behavior therapy (Parker, Roy, & Eyers, 2003). Descriptions of CBT emphasize cognitions over behaviors, but do integrate guidelines and strategies for the two approaches in a synergistic way. According to NACBT, cognitivebehavioral therapy is based on the principle that thoughts, rather than external circumstances, cause feelings and behaviors. Treatment generally focuses most on a cognitive event, in which a stimulus activates a dysfunctional thought process, leading to an erroneous and harmful thought which, in turn, promotes dysfunctional behaviors. This pattern usually is linked to underlying or core cognitions, discussed in part 4. NACBT further describes CBT as a brief and time-limited approach that recognizes the importance of a sound and collaborative therapeutic alliance. CBT is structured and directive, relying heavily on education, questions, and the inductive method. These strategies are not intended to tell people how to think, act, or feel, but rather to help them test their hypotheses and think, act, and feel in ways that are helpful to them and consistent with reality. Homework is an essential ingredient of CBT, and is used to help people make progress between sessions and apply what they have learned. Meichenbaums Cognitive Behavior Modification Probably the best-known treatment approach that bills itself as a form of CBT is Donald Meichenbaums cognitive behavior modification. That approach is discussed here to illustrate CBT. Meichenbaum (1993) developed cognitive behavior modification (CBM) in an effort to integrate psychodynamic and cognitive treatment systems with the technology of behavior therapists (p. 202). He believed that no one of these treatment systems alone was sufficient to explain psychopathology and promote behavior change but that the combination could accomplish both goals. Three assumptions of CBM clarify how Meichenbaum (1993) integrates cognitive and behavior theory: 1.Constructive narrative. People actively construct their own reality; reality is a product of personal meanings (p. 203). 2.Information processing. As previously described, an activating event taps into a persons core cognitions, leading to an unhelpful, inaccurate, and distorted thought. People experience negative emotions and engage in unwise and harmful behaviors because they distort reality as a result of cognitive errors and misperceptions. 3.Conditioning. Cognitions are viewed as covert behaviors that have been conditioned. Correspondingly, they can be deconditioned and modified through both external and internal contingencies (rewards or negative consequences), thereby strengthening new and healthier cognitions. Modeling, mental rehearsal, and other strategies are important in effecting cognitive change. The Role of the Clinician According to Meichenbaum (1993), the role of a cognitive-behavioral therapist is that of coconstructivist: helping people alter their stories and cognitions so they can build new assumptive worlds (p. 203). To accomplish this, treatment via CBM entails the use of cognitive interventions, such as Socratic dialog (questions designed to promote clearer perceptions and thoughts) and reframing (changing terminology in an effort to change perceptions). To illustrate these strategies, lets consider Telly who believed that, following an argument, his daughter was enraged with him because she had not returned his telephone calls. The clinician might ask the following Socratic questions, of course pausing for responses between questions, What leads you to assume that her silence reflects rage? Is she prone to react with rage? Is it possible that she is hurt or needs time to sort out her reactions to the argument? How can you determine what she is really feeling? Using reframing, the clinician might refer to the daughters decision to take a break or take some time to cool off, rather than using Tellys language that describes her as ending their relationship. Although clinicians practicing CBM draw on a broad range of treatment strategies, they generally believe that treatment should be demystified and techniques de-emphasized. Learning and self-help are encouraged, and feedback from the client is welcomed. Clients become active, knowledgeable, and responsible partners in their own treatment. Stress Inoculation Training Meichenbaum (1985) developed stress inoculation training (SIT), a useful and effective cognitivebehavioral treatment procedure. People typically experience stress because of a perception that their life circumstances exceed their capacity to cope, to effectively use behavioral and cognitive efforts to master, reduce, or tolerate the internal and/or external demands that are created by stressful transactions (p. 3). SIT is an approach to reducing stress. It assumes that if people can successfully cope with relatively mild stressors, they will be able to tolerate and successfully cope with more severe ones. In other words, as its name implies, SIT seeks to immunize people against the adverse impact of stress by helping them successfully handle increasing levels of stress. SIT usually consists of 1215 weekly sessions plus additional follow-up sessions over 612 months. SIT has three phases (Meichenbaum, 1985): 1.Conceptualization. Clients and clinicians develop a collaborative relationship. People are taught about stress; the relationship between stress and coping; and the roles that thoughts, actions, and emotions play in engendering and maintaining stress. Once people have an understanding of stress and factors that promote it, their stressful thoughts and experiences (as well as the antecedents and consequences of those thoughts and experiences) are explored. Particular attention is paid to stress-inducing and stress-reducing self-statements and self-talk. Initial goals of treatment include translating stress into specific fears and problems that are amenable to solution and helping people achieve some control over their lives. 2.Skills acquisition and rehearsal phase. Treatment during this phase teaches people to cope effectively with mild stressors by gathering information, using coping self-statements, learning relaxation strategies, changing their behaviors, or using other strategies to reduce those fears. In addition, people learn to apply problem solving to their fears according to the following five steps: Problem identification Goal selection, focusing on small manageable units of stress Development of alternatives Evaluation of each possible solution and its probable consequences Decision making and rehearsal of coping strategies 3.Application and follow-through. In phase 3, people implement their plans to solve problems and reduce stress. Increasingly distressing stressors are tackled as people become able to modify their dysfunctional thoughts, effectively use coping skills, and apply what they learned in phase 2. For example, a person might initially use self-talk to address a minor stressor such as being kept waiting for an appointment and gradually work up to addressing major stressors such as a verbally abusive partner. Like Becks cognitive therapy, SIT uses the 0100 subjective units of distress (SUDS) scale to identify the impact of stressors and then track clients progress in coping with them. Treatment includes continuous reinforcement and assessment of peoples efforts and accomplishments. Strategies such as coping imagery and cognitive rehearsal are used to solidify gains, generalize learning to more significant fears, and help people to prevent or cope with relapses. Learning ways to reduce their fears, along with increased confidence from initial successes in managing stress, facilitates peoples efforts to address other fears and problems successfully. Taking one step at a time and building on successes can make challenging situations manageable and foster self-esteem and more desirable cognitions and behaviors. In addition, encouraging people to have a sense of responsibility for their futures rather than their pasts during this phase of treatment can be very empowering. TREATMENT USING BEHAVIOR THERAPY AND COGNITIVE-BEHAVIORAL THERAPY Behavior therapy and CBT make substantial use of specific strategies and interventions. Although these are important treatment ingredients, they should not overshadow the broad goals of treatment and the importance of the therapeutic alliance. Goals Behavior therapy, as its name implies, seeks to extinguish maladaptive behaviors and help people learn new adaptive ones. The following is a partial list of goals that can be achieved through behavior therapy: Reduction in use, or abstinence, from drugs and alcohol Reduction of undesirable habits such as nail biting and pulling out ones own hair Improvement in social skills such as assertiveness and conversation Amelioration of fears and phobias such as fear of flying, apprehension about public speaking, and excessive fear of snakes Improvement in concentration and organization Reduction in undesirable behaviors in children such as tantrums, disobedience, acting out, aggressiveness, and difficulty going to bed Improvement in health and fitness habits such as more nutritious eating, increased exercise, and more regular sleep patterns In addition to specific goals such as these, behavior therapists also have the general goal of teaching people skills that will help them improve their lives. Skills such as decision-making, problem analysis and resolution, time management, assertiveness, and relaxation often are incorporated into behavior therapy. CBT encompasses similar goals, but also entails additional goals related to modification of thoughts. These might include enabling people to recognize, assess, and modify their dysfunctional cognitions; changing persistent underlying cognitions such as I must be perfect and I am unlovable; and helping people make positive changes in their self-talk and sense of empowerment. In CBT, cognitive goals and behavioral goals are usually complimentary and often intertwined. For example, Megan has been unable to locate employment because of a combination of her self-defeating thoughts (e.g., I cant do anything right; no one would want to hire me) and impairment in her skills (e.g., writing a resume, presenting herself well in an interview, initiating conversations, time management). Although Megans primary goal is to locate rewarding employment, many small goals along the way would focus on changing both thoughts and behaviors to help her achieve that goal. Therapeutic Alliance Modern behavior and cognitive-behavioral therapists believe that establishment of a positive and collaborative therapeutic alliance is essential. In fact, some studies have found that cognitivebehavioral and behavior therapists outperformed psychodynamic/interpersonal therapists in terms of their ability to establish highly effective working alliances with their clients (Myers & Thyer, 1994; Raue, Goldfried, & Barkham, 1997). Clinicians practicing CBT assume many roles: teacher, consultant, advisor, devils advocate, supporter, role model, encourager, and facilitator. Active listening, understanding, caring, respect, and concern all are part of the therapists repertoire as is helping clients to understand and make use of the principles of CBT. Although therapists encourage and reinforce positive change, they also value genuineness and professionalism. According to Jacobson (1989), The therapist who offers unsolicited reassurance, arbitrary reinforcement, or deceptive acceptance will be acting in a self-defeating manner (p. 93). Clinicians practicing CBT are cautious about giving advice and praise. They want clients to take credit for their positive changes rather than attribute them to the therapists. Symbolic of the caring that behavior therapists have toward their clients was the American Humanist Associations 1972 selection of B. F. Skinner as Humanist of the Year. Clients are expected to participate fully in the process of behavior or cognitive-behavioral therapy and take responsibility for presenting their concerns, identifying their goals, and implementing plans for change. Clinicians typically encourage clients to try out new behaviors, complete tasks between sessions, self-monitor, and provide feedback to the clinicians. CBT and behavior therapy today are shared endeavors. Strategies and Interventions Behavior and cognitive-behavioral therapists use a broad range of specific change strategies. These strategies also can be useful to clinicians using other treatment approaches. Cognitive techniques have been discussed in earlier chapters of this book. However, to facilitate their integration into behavior therapy and CBT, they are listed here followed by the chapter number in which they are described in more detail. Behavior change strategies are also listed here, with an accompanying description. Cognitive Strategies Strategies to improve thinking Elliss ABCDEF model (16) Self-talk (15) Development and assessment of alternatives (15) Relabeling and reframing (15) Projecting into the future/distancing (15) Systematic decision making (16) Problem solving (16) Distraction (16) Thought stopping (16) Writing out thoughts, letter writing (16, 17) Flooding (17) Cognitive and covert modeling (16) Visual imagery (14, 16) Graded task assignments (16) Bibliotherapy (16) Role playing (16) Strategies to curtail ruminating and repetitive self-destructive thoughts Strategies to improve coping skills Strategies to reinforce positive change Affirmations (16) Focusing on the positive (17) Cueing, anchoring (18) Behavioral Strategies Acting as if. This strategy was first developed by Alfred Adler (discussed in chapter 5), whose ideas can be viewed as an early version of CBT. When confronting a challenging situation, people act as if they are someone whom they view as capable of handling the situation effectively Children undergoing medical treatments, for example, have coped more successfully when they pretended to be their favorite superhero. Adults, too, can benefit from this empowering approach by acting as if they are an admired friend or colleague. Activity scheduling. Planning activities that are rewarding and provide a sense of accomplishment can help people in many ways. Having a schedule provides focus and direction, which can counteract inertia, confusion, and problems in decision making. It can limit excessive sleeping or television watching and prevent isolation. It increases optimism and reduces depression by helping people realize that they can enjoy their lives and have successes. Activities designed to accomplish treatment goals are particularly valuable. For example, the person who is overwhelmed by a recent job loss can benefit from preparing a realistic schedule of activities to find another job. The schedule should list the activities, when they will be performed, and how much time will be spent on each task. Exercise and other forms of physical activity also can be very helpful. Research has shown that physical exercise can reduce depression and increase the secretion of endorphins that improve feelings of well-being (Locke & Colligan, 1987). Aversion therapy. Rewards rather than punishments or negative consequences are usually favored in therapy because they enhance self-esteem, optimism, and relationships. However, sometimes linking undesirable behaviors with negative experiences motivates change. Readers should bear in mind that aversion therapy is a risky intervention. Care must be exercised in planning and implementing aversion therapy to be sure it does not have a negative emotional or physical impact and is respectful of peoples rights and choices. Done poorly, aversion therapy can cause people to leave therapy prematurely, to feel exploited and traumatized, and to develop even more severe symptoms. Antabuse, an emetic used to discourage people from consuming alcohol, is an example of aversion therapy. Time-outs, used to modify childrens behavior, are another form of aversion therapy, although their primary purpose is to give a child an opportunity to calm down and reflect. Visual imagery sometimes entails aversion therapy. For example, a woman who wants to stop smoking might imagine herself having severe difficulty breathing or coping with a smoking-related disease. A young man who is contemplating suicide so that his girlfriend will feel guilty about ending their relationship may change his mind after imagining himself lying in his grave while she goes on to have a full and rewarding life. Satiationgiving people excessive exposure to a negative stimulus or behavioris a type of aversion therapy (see chapter 16). For example, the woman who wants to stop smoking might smoke a large number of cigarettes in rapid succession until she feels ill. Behavioral rehearsal. This strategy gives people an opportunity to practice a challenging task. The rehearsal might involve a role play with the clinician or a practice session with a friend. Tape-recording the rehearsal or observing oneself in the mirror while practicing the desired behavior offers opportunities for feedback and improvement. Behavioral rehearsal can be used for a wide variety of experiences. Making or refusing requests and sharing positive and negative feelings with others lend themselves particularly well to behavioral rehearsal. Behavioral rehearsal also can help people improve their social skillsfor example, by practicing ways to initiate and maintain conversations or invite other people to join them in social activities. Biofeedback. Biofeedback involves the use of instruments that monitor bodily functions such as heart rate, sweat gland activity, skin temperature, and pulse rate and give people feedback on those functions via a tone or light. Biofeedback can promote reductions in tension and anxiety and increased relaxation. It also can have physical and medical benefits such as lowering blood pressure and improving pain control. Contracting. Establishing a clear agreement between client and clinician about the goals of treatment and the roles of both participants is an important component of CBT and behavior therapy. Contracting is usually done early in the treatment process. However, each time a new problem area is targeted for change, client and clinician can expand their contract to include additional objectives and procedures. This provides direction and motivation and can increase client cooperation with the treatment process. Diaphragmatic breathing. Taking slow, deep breaths and focusing on breathing can be calming and even induce sleep. This sort of breathing supplies the body with more oxygen, focuses concentration, and increases self-control and mindfulness. Abdominal, or diaphragmatic, breathing is particularly helpful; people breath in through the nose, expanding the diaphragm, and then expel the air through the mouth. Counting to eight with each breath creates a slow and relaxed pace (Golden, Gersh, & Robbins, 1992). Expressive and creative activities. Although art therapy, dance therapy, and music therapy are professions in their own right, clinicians with other areas of specialization sometimes incorporate these and other forms of creative self-expression into their work. This can enable people to become more aware of and give form to their emotions. Expressive techniques can be particularly successful with people who have difficulty verbalizing their feelings and concerns or who may feel stuck or blocked. These approaches can be freeing and empowering and are useful with both adults and children. Of course, they should be used cautiously by clinicians who do not have specialized training in therapeutic use of the arts. Extinction. Extinction involves withdrawing the payoff of an undesirable behavior in hopes of reducing or eliminating it. For example, parents who give their children extra attention whenever they misbehave may be inadvertently reinforcing the undesirable behavior. Coaching the parents to pay attention to positive behavior and ignore misbehavior as much as possible is likely to reduce negative behavior. Flooding. Flooding, like aversion therapy, is a high-risk intervention that must be used with caution, and only by clinicians who are well versed in the appropriate use of this strategy In flooding, people are exposed to high doses of a feared stimulus in the expectation that this will desensitize them to the feared stimulus. An example is putting a person with a fear of balloons in a room full of balloons. The person must remain in the feared situation long enough for the fear to peak and then diminish. If the person leaves the situation prematurely, the fear may worsen and the person may learn to fear those who staged the flooding. In addition, the fear may lead the person to act in unsafe ways. Some people believe that pushing a child into a swimming pool is a way to cure a fear of water. This misguided belief can endanger the childs life, create a traumatic experience, and impair the childs trust in others. Flooding should rarely be used, and then only after the client is fully informed about the procedure and consents to the procedure. Modeling. By observing models and identifying the ingredients that make their behaviors successful, people can expand their repertoire of positive behaviors. People are most likely to be influenced by models who are similar to them in terms of gender, age, race, and beliefs; perceived as attractive and admirable in realistic ways; and viewed as competent and warm (Bandura, 1969). Clients can observe others engaged in behaviors or activities that they would like to emulate, such as public speaking, conversing at social gatherings, or offering suggestions at a meeting. Clinicians can serve as models, demonstrating target behaviors. Clients also can serve as their own models by making audio or video recordings of themselves in engaged positive and desired behaviors. Reasonable (natural) consequences. Discussed further in chapter 20, reasonable consequences are the logical, and usually unpleasant, outcomes of undesirable behavior. For example, the child who does not pick up her toys before dinner is required to clean her room after dinner instead of watching her favorite television program. Getting fired for repeatedly coming to work late is another example of such a consequence. Although reasonable consequences can be viewed as punishment, they are preferable to arbitrary and contrived punishments because they have a logical connection to the undesirable behavior and give people a strong message about the implications of their behavior. Reinforcements. Reinforcements and rewards encourage behavior change, enhance learning, and solidify gains. Reinforcements should be carefully selected and planned; they should be meaningful and worthwhile to the person so that they are motivating and should be realistic and reasonable. For example, giving a child a video game for cleaning his room once is not realistic, but setting aside $3 toward the purchase of a video game each week the child cleans his room five out of seven days probably is. Adults can create their own reinforcement plans. One woman who had difficulty paying bills on time set aside 1 hour twice a week for organizing her finances. Each time she completed the hour of financial planning, she rewarded herself by going to the bookstore to buy a new mystery and spending the rest of the evening reading her book. Rewards need not be material. Social reinforcement, such as parental approval, a positive rating at work, and admiration from friends can be at least as powerful. In addition, clients can reward themselves through positive affirmations and reminders of their success such as the declining balance on their credit bill and their improved grades. Reinforcements usually are most powerful if they are provided shortly after the success and are clearly linked to the accomplishment. Such reinforcers are particularly likely to solidify the desired change in behavior and contribute to either further change or maintenance of goal achievement. Relaxation. Relaxation is often combined with other techniques such as systematic desensitization, abdominal breathing, hypnosis, and visual imagery Teaching relaxation strategies in a treatment session and encouraging practice between sessions can facilitate peoples efforts to reduce stress and anxiety and make behavioral changes. Several well-established relaxation strategies are available, including progressive muscle relaxation (sequentially tensing and relaxing each muscle group in the body); a body scan (each part of the body is systematically assessed and relaxed); and simple exercises such as head rolls, shoulder shrugs, and shaking ones body until it feels loose and relaxed. Shaping. This technique is used to effect a gradual change in behaviors. People make successive approximations of desired behaviors, eventually leading to new patterns of behavior. For example, the following steps might help people with social anxiety to improve their interactions with others: Spend 510 minutes at a social gathering. Do not initiate any conversations. Spend 510 minutes at a social gathering and greet at least two people. Spend 1520 minutes at a social gathering, greet at least two people, introduce yourself to at least one person, and ask a question of one other person. Follow the previous step and, in addition, have a brief conversation about the weather and compliment the host on the food. Skill training. An important component of promoting positive change is teaching people the skills they need to effect that change. Clinicians can teach clients both general skills (e.g., assertiveness training, decision making, problem solving, communication skills) and those serving the needs of a particular person (e.g., interviewing, anger management). Parents often benefit from learning to use behavior change strategies with their children. Bibliotherapy or relevant readings, can supplement clinicians efforts to teach new skills. Many books are available, for example, on assertiveness, time management, parenting, and other positive behaviors. Systematic desensitization. Systematic desensitization, a powerful behavior change strategy, is useful in reducing fears, phobias, obsessions and compulsions, and anxiety. Systematic desensitization can be conducted in the imagination (imaginal desensitization) or in context (in vivo desensitization). Initial fears often are worsened when the person avoids the feared stimulus and the avoidance is reinforced by the good feelings that ensue. For example, Dwanna feared interacting with strangers. As a result, she remained in her home, venturing out only with her husband. She was relieved not to struggle with her fear of people, but her avoidance kept her a prisoner and contributed to her dissatisfaction with herself and her life. Systematic desensitization is designed to reverse this process by gradually exposing a person to the disturbing stimulus in ways that reduce rather than increase fear. The first step is the construction of an anxiety hierarchy: a list of frightening or disturbing stimuli ranked from the mildest to the most severe. Clients then learn relaxation and cognitive coping strategies to help them handle exposure to the disturbing stimuli and counteract any fears that might arise. Desensitization begins when the clinician suggests that the person focus on the mildest fear (for Dwanna, this might be standing alone in front of her open front door), pairing exposure to the stimulus with relaxation. This is repeated until the person develops comfort with a given stimulus. Then the clinician moves onto the next troubling stimulus on the list until even the greatest fears have been reduced to manageable levels. Continuing desensitization until a fear has subsided is imperative; stopping the process while a fear still is great can be iatrogenic, increasing rather than decreasing apprehension. Practicing desensitization between sessions enhances progress. Token economies. Particularly useful in group settings such as schools, day treatment programs, hospitals, prisons, and even families, token economies are an effective and efficient way to change a broad range of behaviors in a group of people. Behavioral rules or guidelines first must be established and then understood and learned by all participants. These guidelines are generally written out and posted to maintain awareness. Then a system of rapidly identifying and recording each persons performance of the desired behaviors is developed. Staff members in a group home, for example, might place stars or marks on a chart or distribute a poker chip as soon as possible after a desired behavior is emitted. Finally, a system of rewards is developed. The rewards should be clear, realistic, and meaningful to the participants and be given in ways that are fair and consistent. In a typical token economy, the stars, points, or poker chips are used like trading stamps to earn privileges. For example, 2 points might be exchanged for television time or a telephone call, 5 points might merit a trip to the movies, and 15 points might be exchanged for a new CD. Opportunities should be provided for frequent redemption of rewards to provide reinforcement. In addition, social reinforcement (praise, appropriate physical affection) should be paired with the material rewards to develop intrinsic motivation and internalization of the desired behaviors. Generalization of the behaviors outside of the therapeutic setting promotes their establishment. APPLICATION OF BEHAVIOR THERAPY AND COGNITIVE-BEHAVIORAL THERAPY Behavior therapy and cognitive-behavioral therapy have a broad range of applications. Used either alone or in combination with other treatment systems, their principles and strategies can be applied in almost any treatment setting and with almost any client or problem. Application to Diagnostic Groups Many empirical studies support the use of CBT with the most prevalent mental disorders. These include mood disorders, anxiety disorders, some personality disorders, eating disorders, substance use disorders, and others. In addition, CBT can relieve both emotional and physical symptoms associated with medical conditions. Mood Disorders Cognitive-behavioral therapy has demonstrated strong effectiveness in the treatment of mood disorders (Sexton, 1995a). Cognitive interventions can modify dysfunctional thoughts that maintain depression, hopelessness, and low self-esteem. Similarly, behavior change strategies such as activity scheduling and systematic decision making can reduce the severity of depression, counteract the inertia and confusion often associated with depression, and promote feelings of mastery and competence. The collaborative nature of CBT, as well as its clear rationale and its use of structure and achievable goals, also enhances its effect in treating depression. Parker, Roy and Eyers (2003) conducted a meta-analysis of the efficacy of CBT in treating depression. They concluded that this approach was most effective with mild or moderate depression and that the combination of CBT and medication was more effective in treating depression than either alone. Anxiety Disorders Behavior therapy and CBT also are effective in treating many types of anxiety disorders. Systematic desensitization is a powerful tool in the treatment of agoraphobia and specific phobias such as fear of flying, fear of heights, and fear of snakes. People diagnosed with social phobia often benefit from training in social skills involving instruction in assertiveness and communication, modeling, role playing, and practice. Reduction in level of self-criticism via CBT also can enhance treatment of people with social phobias. Thought stopping, distraction, and substitution of positive activities for negative ones can help people cope with obsessive-compulsive disorder (OCD). In addition, aversion therapy, satiation, and flooding, used with great care, also can be useful in treatment of OCD. Trauma-based concerns, including acute stress disorder and posttraumatic stress disorder, also respond well to CBT. Jaycox, Zoellner, and Foa (2002), for example, studied the use of CBT with women who had been sexually assaulted. They concluded that strategies such as education about PTSD, cognitive restructuring, breathing retraining, imaginal desensitization, and confrontation of feared situations gave people a greater sense of control and alleviated symptoms. Although exposure-based treatments such as systematic desensitization must be used cautiously with people who have experienced traumas, the authors found that few of those in their study experienced symptom exacerbation. Borderline Personality Disorders Borderline personality disorder is reflected in six behavioral patterns: emotional vulnerability, selfinvalidation, constant crises, restricted emotions, learned helplessness, and impaired competence (Smith & Peck, 2004, pp. 2930). Many people with this disorder have multiple symptoms (e.g., depression, substance misuse, impulsivity), are chronically suicidal, and have impaired functioning. Marcia Linehan (1993) and her colleagues developed Dialectical Behavior Therapy (DBT), a form of CBT, primarily to treat people with borderline personality disorders. DBT is guided by seven assumptions (Smith & Peck, 2004, pp. 3031): 1.Clients are doing the best they can. 2.They want to improve. 3.They must learn their new behaviors in each and all relevant contexts. 4.Clients cannot fail in DBT; any effort is progress. 5.Clients may not have caused all of their problems, but they have to solve them anyway. 6.Clients need to do better, try harder, or be more motivated to change. 7.Their lives are currently unbearable as they are being lived. Although based on CBT, DBT also incorporates insight-oriented therapy and considerable support into the treatment package. Clients receive at least 1 year of 1-hour weekly individual therapy sessions and 2-hour weekly group therapy, emphasizing skill training and problem solving. Available in a manualized version, DBT is characterized by four stages: 1.Clinicians help people make a commitment to treatment and facilitate their attainment of basic competencies such as keeping themselves safe, reducing self-destructive behaviors (e.g., drug and alcohol use, unwise sexual activity, self-injury), and teaching relevant skills such as interpersonal effectiveness, self-care, and emotional regulation. 2.Desensitization and other strategies help people deal with traumatic experiences and the impact of past messages and events. 3.Self-respect, problems of living, and individual goals are the focus of this stage, as clients begin to look to the future and apply what they are learning. 4.This stage promotes synthesis and generalization of gains; integration of past, present, and future; development of spirituality; acceptance of self and reality; increased self-respect; achievement of individual goals; better coping skills; and a greater capacity for happiness. Empirical research, focused primarily on the first stage of DBT, yielded positive results. People treated with at least one year of DBT achieved considerable reductions in suicidal ideation, hospitalization, anxiety, and anger and increases in occupational and social adjustment (Linehan & Kehrer, 1993). Treatment of suicidal adolescents via DBT for one year led to significant reductions in behavioral problems, suicidal ideation, and depression (Katz, Cox, Gunasekara, & Miller, 2004). These and other studies also indicated that common symptoms accompanying borderline personality disorder, including substance misuse and dysfunctional eating, were alleviated. Other Mental Disorders Cognitive-behavioral therapy and behavior therapy also have demonstrated effectiveness with many other mental disorders and problems. Token economies and reasonable consequences have been used successfully to treat children and adolescents diagnosed with conduct disorders. Relaxation, activity scheduling, and time management all can be helpful to people with attention-deficit disorders. Behavior therapy has demonstrated effectiveness in helping people diagnosed with mental retardation, impulsecontrol disorders, sexual dysfunctions, sleep disorders, and paraphilias. Behavior therapy plays a major role in the treatment of eating disorders, including bulimia nervosa and anorexia nervosa (Pike, Walsh, Vitousek, Wilson, & Bauer 2003), as well as disorders that involve unhealthy use of drugs or alcohol. Research also supports the use of behavior therapy and CBT in the treatment of people with suicidal ideation (Carney & Hazler, 1998) and assaultive behavior (Lanza et al., 2002). CBT has facilitated improved grade-point averages, attendance, and self-concepts in academically at-risk students (Sapp, 1994). Application to Multicultural Groups Although research is limited on the use of behavior therapy and CBT with people from diverse backgrounds, these approaches seem well suited to treatment of a multicultural population. Behavior therapy and CBT have wide appeal. These approaches are easily understood and logical, respect individual differences, and can be adapted to a broad range of people and problems. Behavior therapy and CBT offer a large repertoire of interventions to address almost any concern. These approaches are not intrusive; they do not emphasize the unconscious, the early years of development, or the covert meanings of dreams and body language. Behavior therapy and CBT encourage people to play an active and informed role in their treatment, promote learning and competence, and can produce rapid and positive results that are reinforcing. These approaches are particularly appropriate for people from cultures that do not emphasize personal growth, insight, and self-expression. As Stuart (1998) stated of behavior therapy, Individual differences must be understood and respected. People want to be accepted for who they are, not only for who they could be (p. 8). Several studies affirm the use of CBT with multicultural clients. Miranda et al. (2003), for example, found that CBT, along with medication, reduced depression in low-income young African American and Latina women. Treatment was enhanced by being combined with encouragement, intensive outreach, and direct services such as child care and transportation. Butcher and Manning (2001/2002) illustrated the application of Skinners behavioral approaches, as well as those of other theorists, to classroom management in middle schools. Use of CBT also has shown benefits for people with medical conditions, including those experiencing chronic pain, chronic fatigue, or depression following a heart attack. In addition, CBT, along with medication, effectively reduced symptoms in Cambodian refugees experiencing posttraumatic stress disorder. Current Use Behavior therapy and CBT have been used in a wide variety of settings (Kazdin, 1994) and with a wide variety of people. Their use extends far beyond treatment of individuals with mental disorders. Relaxation, hypnosis, and visual imagery have been used in behavioral medicine to reduce pain and help people cope with cancer, heart disease, and other chronic and life-threatening illnesses. Schools and correctional institutions, as well as day treatment and inpatient treatment programs, rely heavily on behavior therapy to teach and establish positive behaviors. In addition, behavior therapy and CBT can be used in family and group counseling, as well as individual therapy. The reinforcement and modeling provided by the other group members make the group setting especially well suited for CBT. Cognitive-behavioral group counseling enables people to learn and experiment with new behaviors, while receiving information and feedback from multiple sources. Hearing other peoples thoughts also can help people to broaden their perspectives, identify and modify their own dysfunctional thoughts, and solidify their valid and reasonable thoughts and feelings. Parents can benefit from learning behavior change strategies and using those to shape their childrens behavior. Such common parental interventions as time-outs, rewards, consequences, and limit setting reflect behavior therapy. Most of us use behavior change strategies in our everyday lives. When we reward ourselves with a snack after finishing a difficult chore, give a chronically late friend a message by deciding not to wait more than five minutes, buy a kitten for a child who is afraid of animals, or embark on a plan to improve our nutrition and exercise, we are using behavior change strategies. These approaches, then, have a great deal to offer a broad and diverse range of people. Behavior therapy, as well as CBT, generally are combined with a broad range of other approaches, including psychodynamic therapy, Gestalt therapy, and person-centered counseling. Such combinations can deepen the impact of treatment and ensure that resulting changes are meaningful and enduring. EVALUATION OF BEHAVIOR THERAPY AND COGNITIVE-BEHAVIORAL THERAPY Extensive research has been conducted on behavior therapy and CBT. The literature suggests that treatment focused on cognitions and behavior can be very powerful and effective. Of course, it also has limitations. Limitations Most of the criticisms of behavior therapy and CBT focus on the possibility that they will accomplish only superficial and temporary gains. Emotions and insight may not receive the attention they merit in treatment. Clinicians may hone in too quickly on behaviors, without sufficiently exploring their underlying antecedents and dynamics. For example, a clinician may emphasize development of social skills in a woman who is fearful of dating and neglect her history of abuse. In addition, clinicians may become so caught up in the power of CBT that they fail to help clients take adequate responsibility for their treatment and progress. As a result, people may feel manipulated and powerless rather than experience the growth in self-worth and competence that should result from treatment. These potential limitations usually can be avoided by skilled clinicians who take a holistic view of their clients, understand behavior in context, and remember the importance of empowering people. At the same time, treatment limited to CBT is not the ideal approach for all clients. An initial focus on cognitions and behavior can promote change and enhance motivation. However, for people with longstanding and deep-seated problems, perhaps stemming from an early history of abuse and inadequate parenting, psychodynamic and other approaches should probably be combined with behavior therapy and CBT. This combination can help clients develop insight and allow them to work through past concerns, while also helping them make cognitive and behavioral changes. In addition, although CBT can help people with psychotic and other severe disorders, medication and other interventions also are needed. Behavior therapy and CBT are useful with almost all clients but often need to be combined with other treatment modalities to maximize their effectiveness. Strengths and Contributions Behavior therapy and CBT have many strengths. They offer a straightforward approach to treatment that has both face and empirical validity. They are flexible and broad treatment modalities, encompassing many useful interventions that facilitate their application to a wide range of people and problems. These approaches emphasize goal setting, accountability, and results. They are respectful and collaborative, encouraging people to take responsibility for themselves. Although improved behaviors and thinking are the targets, treatment also seeks to improve emotional health. Early versions of behavior therapy and CBT downplayed the importance of background, individual differences, and the therapeutic alliance, and sometimes seemed too directive and contrived. However, modern versions address these shortcomings. Today, clinicians practicing behavior therapy and CBT recognize that problems must be viewed in context. Clinicians explore the historical roots and antecedents of peoples concerns, are sensitive to individual differences, develop positive and collaborative therapeutic alliances, and seek to know and understand their clients as individuals. Clinicians practicing behavior therapy and CBT help to empower clients so that they can not only deal with immediate presenting concerns but also develop skills and strategies they can use in the future to lead healthier and more rewarding lives. Some clinicians dismissed behavior therapy, and even CBT, when they were first developed, viewing them as superficial and likely to worsen or shift symptoms from one problem area to another (symptom substitution). However, extensive research has dispelled these concerns. The positive outcomes of behavior therapy and CBT tend to be enduring. Rather than leading to symptom substitution, these approaches often lead to a generalization of positive change in which people spontaneously apply the skills they have learned to many areas of concern. As Jacobson (1989) concluded of CBT, there is no doubt that the treatment is a powerful one (p. 87). Behavior therapy and CBT have made important contributions to counseling and psychotherapy. Behavior therapy, more than any other treatment system, has emphasized the importance of research on treatment effectiveness. Through research, behavior and cognitive-behavioral therapists have demonstrated the success of their work. Their emphasis on goal setting, accountability, and outcome is very much in keeping with modern conceptions of counseling and psychotherapy. The requirements of managed care for treatment plans and progress reports, as well as clients demands for efficient and effective treatment, can readily be met through behavior therapy and CBT. In addition, these approaches paved the way for other treatment systems to research their effectiveness, establish clear goals and interventions, and assess their impact. Behavior therapy and CBT also have provided a foundation for the development of several other approachesfor example, reality therapy and solution-focused brief therapy (discussed in chapters 20 and 21) as well as multimodal therapy (discussed in part 6). The practice of behavior and cognitivebehavioral therapy is widespread, and articles on these approaches to treatment appear regularly in most psychotherapy and counseling journals. CBT is well positioned to provide the basis for new treatment approaches that incorporate emerging learning on cognitive processes and to remain a leading and innovative treatment approach. Research on brain functioning has expanded greatly in recent years. CBT already has focused attention on thinking processes in determining emotions and actions and should continue to lead the way in incorporating this research into approaches to counseling and psychotherapy. SKILL DEVELOPMENT: SYSTEMATIC DESENSITIZATION Systematic desensitization is one of the most powerful interventions in behavior therapy and CBT. It is particularly important in the treatment of phobias and excessive fears of certain situations such as socializing, flying, and public speaking. It also is useful in addressing other apprehensions and anxieties. For example, it can reduce fear of surgery and chemotherapy in people who have been diagnosed with cancer. Systematic desensitization involves gradually exposing people to the object of their fears while helping them relax. Relaxation and fear are incompatible responses; as a result, fear of a stimulus typically diminishes if relaxation can be achieved and maintained during exposure to that stimulus. However, this treatment can have a reverse effect if not well planned; premature exposure to frightening stimuli or exposure that is aborted while the fear is still high can increase terror of the stimulus. Consequently, careful pacing is essential to successful treatment using systematic desensitization. Exposure to the frightening stimulus may occur in the imagination (imaginal desensitization) or the real world (in vivo desensitization). One is not clearly more effective than the other. The choice of whether to use imaginal desensitization, in vivo desensitization, or a combination of the two is determined primarily by the nature of the feared stimulus and the ease of creating a situation of controlled exposure to that stimulus. For example, imaginal desensitization, perhaps enhanced by pictures and films, would be used to treat someone with a fear of hurricanes, while in vivo desensitization could help someone overcome an inordinate fear of dogs or balloons. A combination of imaginal and in vivo desensitization would probably work best for someone coping with a fear of flying or of heights. Systematic desensitization typically follows a series of steps, after one or more sessions have been spent on developing the therapeutic alliance, exploring the antecedents and symptoms of the fear, and discussing the persons history and present life situation so that the symptoms can be viewed in context. These steps are illustrated by the case of Makita, a young girl who was frightened by balloons bursting at a party and has since developed a phobia of balloons that prevents her from attending any parties or social gatherings where balloons might be present. 1.Teach an effective relaxation strategy. Makita was taught to relax by shifting her breathing to a pattern of slow diaphragmatic breaths while focusing on her breathing. She also was taught to progressively relax her body, gradually moving her attention down from her head to her toes, until her entire body felt relaxed. 2.Establish an anxiety hierarchy. A list of fear-provoking stimuli is developed and ranked according to the amount of fear each elicits. A 0100 SUDS (subjective units of distress) scale is used to obtain an initial rating of the fear associated with each item on the list and to facilitate ordering the list. Here is Makitas list: Stimulus Picture of a balloon One small deflated balloon A bunch of larger deflated balloons One small inflated balloon SUDS Rating 55 60 67 74 Several medium-sized inflated balloons 80 Several large inflated balloons Gradually deflating a balloon Bursting one small balloon Bursting a group of large balloons 3.Provide controlled exposure. Makitas counselor used in vivo desensitization to help Makita overcome her fear because the object of her fears, balloons, could easily be brought into the treatment room. After helping Makita relax as fully as possible, her counselor brought out a picture of a balloon as she and Makita had agreed. With guidance from Makita, the picture was gradually moved closer to her and finally handed to her. The counselor encouraged Makita to hold the picture and look at it until she felt her fear subside significantly. The SUDS scale was used to track the fear level. This experience was repeated as often as necessary, perhaps over several sessions, until Makita and her counselor decided she was ready to move to the next item on the list. The exposure and desensitization process must be carefully planned so that it does not raise anxiety but promotes feelings of self-confidence, optimism, and control. Continuing the desensitization between sessions, with the help of a friend or a family member who has been coached by the clinician, can accelerate progress. Makitas parents helped her continue her treatment at home, never exposing her to more than she had successfully handled in her counseling sessions. Approximately five sessions were required to complete the desensitization process and reduce Makitas fears to a manageable level. Although she was able to deal with some of the fears on her list rapidly, several sessions were necessary to help Makita feel comfortable with the actual bursting of a balloon. 84 88 95 99 However, Makita and her family were able to celebrate her success by having a family party, complete with balloons. CASE ILLUSTRATION As treatment of Edie, Roberto, and Ava Diaz progressed, the clinician realized that Edies selfconsciousness, her apprehensions about socialization, and her weak interpersonal skills had an impact not only on Edie but on the rest of the family. Because of her social discomfort, Edie avoided talking to Avas teachers and the parents of Avas friends and was reluctant to accompany Roberto to office parties or on business trips. Her avoidance of these and similar situations had relieved Edie of considerable stress and anxiety; however, negative reinforcement had occurred. The rewards she experienced from social avoidance had further entrenched this behavior, so that Edies apprehension about and avoidance of interpersonal contact had worsened over the years. Edie and her therapist decided to use Meichenbaums (1985) stress inoculation training (SIT) to address her social difficulties. This approach integrates both cognitive and behavior change strategies. The process of using SIT with Edie had three phases. 1.Conceptualization First, the clinician explained SIT to Edie, reviewing the interventions that would probably be used and describing how SIT was likely to help her. Once Edies questions and concerns were discussed, she felt ready to cooperate with the process and was optimistic that it might alleviate her longstanding social discomfort.Edie and her therapist then clarified the nature of the problem and established realistic goals. Edie believed that people generally found her unappealing and uninteresting. She feared that if she risked exposure to social situations, she would experience painful rejection and humiliation. Using the SUDS scale, the extent of Edies fears were assessed. Specific goals were identified, focused on reducing her fears of rejection and humiliation in social situations and increasing her participation in social conversations and activities. 2.Skills Acquisition and Rehearsal Several techniques were used to help Edie overcome her fears: At work, where Edie felt competent and her professional role was clear, she experienced little social anxiety and interacted well with others. Edie identified communication skills that served her well in her role as librarian and identified ways to transfer them to other interpersonal arenas. The therapist helped Edie dispute her belief that she would certainly be rejected and humiliated in social situations. This had not happened to her since adolescence, and she could report only two instances of ever having seen other people rejected and embarrassed in a social setting. Edie further developed her social skills. Her therapist provided readings and exercises on assertiveness and communication and helped Edie to identify and practice skills that seemed useful to her. She and the therapist paid particular attention to role-playing ways to initiate and develop conversations. Because she enjoyed reading, Edie sought out literature on shyness, as well as biographies of people who viewed themselves as having had social difficulties, so that she could learn more about ways to cope with her social discomfort. Edie identified a co-worker whose social skills she admired. She observed that person in order to identify her social strengths and use her as a role model. In addition, Edie tried to act as if she were that person when she role-played conversations in her treatment sessions. 3.Application and Follow-Through Edie and her clinician generated some small steps for Edie to take in order to apply her developing social skills and increased self-confidence. Edie considered volunteering at Avas school, accompanying Roberto on a business trip, and throwing a small party. Although she anticipated engaging in all these activities eventually, she decided to begin by inviting the mother of one of Avas friends to have tea with her after they dropped their daughters off at ballet class. Edie felt relatively safe with this woman and believed that meeting one person at a time with readily available topics of discussion (tea, the ballet class, their daughters) would provide a successful experience. A role play of social conversation over tea helped Edie feel well prepared for this venture.After the tea, Edie processed the experience with her therapist, focusing on what she did well and identifying a few ways in which she might have improved on the experience. For example, she had gotten flustered when it was time to pay the check and saw that she needed to develop more comfortable strategies for dealing with that. Edie rewarded herself for her efforts, as well as for her success, and began to plan the next steps to improve her social skills. EXERCISES Large-Group Exercises 1.Although the value of CBT has clearly been substantiated by research, some clinicians view it as less powerful than psychodynamic therapy. Discuss what thoughts and feelings might underlie this perception and then discuss your reactions to and perceptions of CBT. 2.Using your class as the target group, plan implementation of a token economy that might be useful in promoting learning in the class. Identify the behavioral goals, the system for tracking and recording performance, and the rewards for positive behavior. 3.Ava was troubled by fears of the dark and of being alone. Plan her treatment, using behavioral strategies. Be sure to view her presenting problems in the context of what you already know about Ava and her family. The treatment plan should include, but not necessarily be limited to, determining how to establish a baseline, setting specific goals, identifying treatment strategies, establishing rewards or reinforcements, and specifying ways to track progress. In addition, consider whether to integrate other approaches with the behavioral interventions. Small-Group Exercises 1.Divide into your groups of four participants. Identify one person to lead the group in a relaxation exercise, beginning with diaphragmatic breathing, continuing to progressive muscle relaxation, and ending with an anchoring of the feelings of relaxation. (The skill of anchoring was presented in chapter 17.) 2.Following the guidelines presented in Large-Group Exercise 3, plan treatment for the following behavioral difficulties: A 4-year-old refuses to go to bed on time and delays his bedtime by several hours each evening with requests for stories, drinks of water, and other attention. A 33-year-old man reports family conflict as a result of his nightly consumption of 8 10 cans of beer. A 42-year-old man describes himself as addicted to sex. Although he is married and has a sexual relationship with his wife, he has had many extramarital affairs. His wife has warned him that she will end their marriage if this continues. He wants to continue his marriage but feels unable to control his sexual impulses. 3.Divide into your groups of four, composed of two dyads. Each dyad should engage in a 15minute role-played counseling interview in which the person playing the client talks about a behavior he or she would like to change while the person in the clinician role gathers information on the nature of the concern; its context; and its frequency or severity. If you have time, begin to identify realistic goals and procedures to effect behavioral change. Spend 10 minutes processing each role play after it is completed, providing feedback to both client and clinician on strengths and areas needing improvement. Individual Exercises 1.Identify a fear or source of apprehension in your life. Following the guidelines presented in the Skill Development section of this chapter, develop a plan to use systematic desensitization to help yourself reduce this fear. Write down the plan in your journal and then try to implement it. 2.Consider a behavior that you would like to increase, decrease, or change. Develop a written treatment plan to help yourself make that change. The treatment plan should include, but not necessarily be limited to, determining how to establish a baseline, setting specific goals, identifying treatment strategies, establishing rewards or reinforcements, and specifying ways to track progress. Continue your learning by actually implementing the plan you have developed. Write in your journal about the successes and challenges you experience as you try to implement this plan. 3.Most of us automatically use behavior change strategies on ourselves and others without being aware of what we are doing. Monitor yourself for the next 2 days and list in your journal any behavior change strategies you used such as rewarding yourself for completing a difficult task, using a time-out with a child, or applying consequences when you are treated badly. SUMMARY Behavior therapy evolved during the twentieth century from the research of B. F. Skinner, Ivan Pavlov, John W. Watson, Joseph Wolpe, and others. This treatment approach takes the stance that behavior is learned and consequently can be unlearned. Behavior therapists are concerned about results; so they take the time to establish a baseline, develop interventions that facilitate behavioral change, use reinforcements to solidify gains, carefully plan implementation, and monitor progress. Today, behavior therapy and cognitive therapy, are more likely to be combined rather than used alone. Their merger into cognitive-behavioral therapy, promoted by Donald Meichenbaum and others, expanded the application of cognitive and behavioral strategies and created a powerful treatment approach. Although practitioners of CBT focus on improving thoughts and behaviors, they also pay attention to the whole person; recognize the importance of history, background, and context; explore emotions; and take steps to develop a positive and collaborative therapeutic alliance. Behavior therapy and CBT have demonstrated strong effectiveness with a wide range of people and problems; their concepts and interventions should be incorporated into the work of all clinicians. RECOMMENDED READINGS Meichenbaum, D. (1985). Stress inoculation training. Elms-ford, NY: Pergamon. Smith, L. D., & Peck, P. L. (2004). Dialectical behavior therapy: A review and call to research. Journal of Mental Health Counseling, 26, 2539. Stuart, R. B. (1998). Updating behavior therapy with couples. Family Journal, 6(1), 612. Thorpe, G. L., & Olson, S. L. (1997). Behavior therapy. Needham Heights, MA: Allyn & Bacon. Numerous journals focus on CBT and behavior therapy, including Behavior Therapy, Cognitive and Behavioral Practice, Advances in Behaviour Research and Therapy, Child and Family Behavior Therapy, Cognitive Therapy and Research, and Journal of Behavior Therapy and Experimental Psychiatry. ADDITIONAL SOURCES OF INFORMATION http://www.aabt.orgWebsite of The Association for Advancement of Behavior Therapy (AABT) (305 Seventh Avenue, 16th floor, New York, New York 10001, 800685-AABT). AABT focuses its training and publications primarily on analysis and assessment of behavior and the use of behavior therapy and CBT. AABT publishes two journals, Behavior Therapy and Cognitive and Behavioral Practice, as well as directories of internships and training opportunities. It holds an annual convention and offers continuing education and other learning resources. Student, associate, and full memberships are available. www.nacbt.orgWebsite for The National Association of Cognitive-Behavioral Therapists. This association is dedicated to the teaching and practice of CBT. It offers seminars and other educational opportunities, literature on CBT, and certification for practitioners. http://www.cognitivetherapy.comWebsite for the New York Institute for Cognitive and Behavioral Therapies. for the National Institute on Drug Abuse of the National Institutes of Health website, focusing on the use of CBT with people who abuse substances. ... View Full Document

End of Preview

Sign up now to access the rest of the document