CHAPTER 2
BEHAVIOR THERAPY
The central defining feature of behavior therapy is that it involves the application of the laws of learning theory to the modification of problematic behavior. At the time that behavior therapy was first beginning to gain momentum, another aspect that distinguished it from the prevailing Freudian school of therapy was the recognition of the need to distinguish etiological factors from maintaining ones. This distinction no longer can be claimed as being unique to behavior therapy because it is also central to cognitive therapy; however, this distinction still lies at the heart of behavior therapy. We wish to emphasize from the outset that behavior therapy has (not surprisingly) evolved significantly since its inception. Perhaps one of the two most fundamental ways in which behavior therapy has changed is its integration with cognitive therapy such that these days there are probably many more therapists who identify themselves as cognitive-behaviorists (as we do) than behaviorists. The other most fundamental change is that there is more recognition now of the importance of the therapeutic relationship than there was in the beginning.
Whereas contemporary cognitive-behavioral therapy (CBT) almost always combines the behavioral and cognitive traditions, this chapter focuses on the behavioral tradition. Chapter 3 by Scott Kellogg and Jeffrey Young provides an overview of the cognitive tradition. Similarly, Arnold Lazarus, one of the pioneers of the integration of the behavioral and cognitive traditions, writes about multimodal therapy, his approach to CBT, in Chapter 13.
THEORETICAL CONCEPTS OF BEHAVIOR THERAPY
Key theoretical concepts in behavior therapy are classical conditioning, instrumental conditioning, generalization, extinction, and functional assessment. Behavior therapy also gave rise to a key methodological concept: the single case design in psychotherapy.
Classical conditioning is the learning that occurs when two stimuli are presented in close temporal proximity and with some degree of contingency or correlation between them. A form of classical conditioning that is particularly important for behavior therapy occurs when the first of these stimuli (the conditioned stimulus) is affectively neutral prior to being paired with the second (the unconditioned stimulus), whereas the second already has some emotional valence for the individual and elicits some form of response (the unconditioned response) indicative of this valence. In this case, the contingency between the conditioned stimulus and the unconditioned stimulus typically leads to the conditional stimulus acquiring at least some of the emotional valence of the unconditioned stimulus and the capacity to elicit a response (the conditioned emotional response). The conditioned emotional response sometimes resembles the unconditioned response, but does not necessarily need to do so and often does not. As discussed in more detail later, Pavlov (1927) is often credited with being the father of the modern study of classical conditioning, and Watson (1994/1913) and his student Mary Cover Jones (1924) are usually credited for pioneering the application of classical conditioning to the understanding and remediation of problem behaviors in humans.
Instrumental conditioning is the learning that occurs when a response (the instrumental response) is consistently followed by either a positive or a negative consequence (the reinforcer). As stated in Thorndike’s (1927) law of effect, the tendency to emit a behavior that is followed by positive consequences will strengthen a response, whereas the tendency to emit a behavior that is followed by negative consequences will typically weaken a response. Often, the very same behavior that is rewarded in one situation will not be rewarded in a different situation. The cues that help to signal when the different contingencies involving a given response are in effect are called discriminative stimuli because they help the individual discriminate when the different contingencies are in effect. Thus, discriminative stimuli that signal that a given response will be rewarded are called reward cues and elicit hope; those that signal a response will be punished are called passive avoidance cues and elicit anxiety; those that signal that a response will lead to the omission of an otherwise expected reward are called omission cues and elicit frustration; and those that signal that a response will lead to the omission of an otherwise expected punishment are called active avoidance cues and are thought to elicit anxiety (on early learning trials) and relief (on later learning trials).
Generalization refers to the notion that when one conditioned or discriminative stimulus comes to elicit an emotional response, other stimuli that resemble the conditioned or discriminative stimulus will also elicit some of this same emotional response. It is thought that there is a gradient of generalization such that the more similar stimuli are to the conditioned or discriminative stimulus, the stronger the generalized responding will be to them.
Extinction involves the associative changes that occur when the unconditioned stimulus or reinforcer is no longer contingent on the conditioned stimulus, instrumental response, or discriminative stimulus. In the case of a conditioned stimulus, presenting it in the absence of an unconditioned stimulus leads to a decrement in the strength of the conditioned response. An instrumental response that previously had been rewarded will similarly experience a decrement in strength when no longer followed by reward. Similarly, the emotions conditioned to a discriminative stimulus will weaken when the discriminative stimulus no longer signals that a reinforcer is contingent on responding.
Functional assessment involves the attempt to determine the contingencies maintaining problematic behavior and the discriminative stimuli that signal when those contingencies are in effect and thus serve to elicit the problem behaviors. Early behavior therapists favored functional assessment and eschewed diagnosis and diagnostic labels. Contemporary behavior therapists still emphasize the importance of functional assessment but are more open to diagnoses and diagnostic labels.
Single case designs involve the systematic assessment of problem behaviors or treatment targets across both baseline conditions and conditions in which an intervention or therapeutic contingency is actively implemented. The most simple design is one in which a baseline phase (A) is followed by treatment (B), usually referred to as an A/B design. This is the minimal design necessary to determine that meaningful change in the problem behavior has indeed occurred while also being able to rule out at least some threats to internal validity such as testing, instrumentation, and regression to the mean (Kazdin, 1981). If the intervention is one that does not produce permanent change, then the phase change can be repeated like an A/B/A design that begins with a baseline phase (A) followed by treatment (B) that is followed by a second baseline (A) in which treatment is withdrawn (or an A/B/A/B design that adds a second treatment phase to the A/B/A design). If the problem behavior tracks the phase changes, our confidence increases that the treatment is accounting for the changes. Another common design that is more powerful than the simple A/B design for ruling out threats to internal validity is the multiple baseline design. In a multiple baseline design across behaviors, a researcher measures several behaviors targeted for change and applies treatment to them sequentially while continuing baseline measurement on the behaviors not yet targeted. If four behaviors are targeted for change, the design begins with collecting baseline data on all four, and then the treatment is applied to the first behavior while the baseline is continued for the other three behaviors. Subsequently, the treatment is applied to the second behavior while the baseline is continued for the other two behaviors and so on. If each behavior remains relatively stable throughout its baseline and does not begin to show improvement until sometime shortly after the treatment is applied to it, we can rule out additional threats to internal validity and increase our confidence that the treatment caused the observed changes. (For an excellent discussion of multiple baseline designs across behaviors as well as across individuals, see Barlow & Hersen, 1984.)
HISTORY OF BEHAVIOR THERAPY
The history of behavior therapy is closely linked to the history of learning theory in psychology and the rise of behaviorism that took place in the early twentieth century. Thus, an understanding of the history of behavior therapy requires some understanding of the history of learning theory and the role of key historical figures. Indeed, one strength of behavior therapy is its close relationship to basic behavioral science in human and nonhuman animals. The historical connection between the development of learning theories and behavior therapy is evident in a historical time line published by The Behavior Therapist (vol. 29, 2006). Some important people in the history of learning theory are Ivan P. Pavlov, James B. Watson, B. F. Skinner, and Orval H. Mowrer. Their roles in the development of learning theory are discussed in the following sections, as well as how their work relates to contemporary behavior therapy.
Ivan Petrovich Pavlov (1849–1936)
Pavlov was a Russian physiologist who made important contributions to medicine with his work in digestive physiology. He was awarded a Nobel Prize for his digestion research. By serendipity, Pavlov observed a conditioned reflex in one of his animal subjects and, at the age of 50, began to study elementary learning processes. It is difficult to overstate Pavlov’s contribution to science, and specifically psychology. His classic work, Conditioned Reflexes (1927), delineated many observations of important learning phenomena, including the acquisition of conditioned responses, extinction, spontaneous recovery from extinction, and overshadowing.* The many learning phenomena studied by Pavlov all continue to be studied in great detail today. Pavlov is known for his work on classical conditioning, in which a previously novel stimulus (the conditioned stimulus) is presented before an unconditioned stimulus (e.g., food or electrical shock). Unconditional stimuli are often described as biologically significant because they elicit responses without prior training. For example, in Pavlov’s experiments, food was an unconditioned stimulus that elicited salivation. The response to the unconditioned stimulus is referred to as the unconditioned response. With repeated pairings of the conditioned stimulus with the unconditioned stimulus, the conditioned stimulus acquires the ability to elicit a conditioned response, which is often similar to the unconditioned response (but see Siegel & Allan, 1998; Solomon, 1980, for discussions of compensatory conditioned responses). In Pavlov’s initial research, food powder (unconditioned stimulus) elicited salivation (unconditioned response). When an audible sound of a metronome (conditioned stimulus) was repeatedly paired with food (unconditioned stimulus), the tone acquired the ability to elicit salivation (conditioned response).
Although all of Pavlov’s discoveries would have a profound impact on psychology, the discovery of extinction was particularly important for behavior therapy. After a conditioned stimulus has acquired the ability to elicit a conditioned response, the conditioned response can be extinguished by repeatedly presenting the conditioned stimulus without the unconditioned stimulus. After repeated presentations of the conditioned stimulus without the unconditioned stimulus, the conditioned response reduces in magnitude and eventually is no longer observed. The notion that learned responses can be extinguished underlies many exposure-based psychotherapy treatments. The mechanism that underlies extinction is unclear still today and continues to stimulate much learning research (for review, see Rescorla, 2001).
Although Pavlov was not a behavior therapist, he was clearly interested in applying behavioral sciences to problems of the human condition. Early on, he described experimental neuroses in which his canine subjects would exhibit signs of aggression when presented with difficult discrimination tasks. Pavlov’s work has contributed greatly to our understanding of many clinically relevant phenomena including avoidance behavior (see the following review of Mowrer’s work), drug addiction (e.g., Siegel & Allan, 1998), anxiety (Wolpe, 1995), and chemotherapy side effects (Carey & Burish, 1988). Pavlov’s accomplishments as a behavioral scientist were impressive. He discovered many fundamental learning phenomena firsthand, and his discoveries are still important to the work of behavior therapists today (for reviews, see Plaud, 2003; Wolpe & Plaud, 1997). The work of Pavlov was popularized with the rise of behaviorism. The behaviorist movement in psychology started with J. B. Watson, who we turn to next.
John Broadus Watson (1878–1958)
Watson did his doctoral work at the University of Chicago where he studied animal learning in white rats. While studying at the University of Chicago, Watson was strongly influenced by several of his professors, including the physiologist Jacques Loeb. Loeb believed that behavior could be explained by tropisms that, in Loeb’s terminology, were instinctual chains of responses that involved the whole organism responding to environmental stimuli. In essence, Loeb believed that behavior could be explained in mechanistic terms by observing how organisms responded to environmental input (Loeb, 1964/1912). In fact, the second chapter of Loeb’s classic book was entitled “The Significance of Tropisms for Psychology” in which Loeb argued that behavior could be understood in purely “physico-chemical” terms. Watson also thought that psychology could be understood mechanistically—solely in stimulus-response terms, without reference to mental constructs or introspection. Watson later moved to John Hopkins University where he became editor of Psychological Review and eventually published “Psychology as the Behaviorist Views It” in 1913 (Watson, 1994/1913). Some historians regard the publication of this paper as the founding of behaviorism (Hergenhahn, 2001). In that paper and subsequent writings, Watson consistently endorsed the idea that psychology should be the study of stimulus-response relationships and rejected the use of mental constructs.
Watson was explicitly interested in applying behavioral science to human problems. Watson and Rayner (2000/1920) examined the acquisition of fear in a case study of Little Albert. In this study, they showed that a fear response could be evoked by a previously neutral stimulus (a white rat) by pairing it with an aversive outcome (striking a bar, which resulted in a loud noise). The study of Albert showed how a phobia might develop, but not how it might be treated.
Shortly after his work with Albert, Watson showed how behavioral principles could help to treat phobias. Under Watson’s supervision, Mary Cover Jones (1924) showed, in her study of Peter, that graduated exposure to a feared stimulus could help to reduce the fear response. Peter was a young boy who feared furry animals, and Jones presented a rabbit to Peter while he ate in a cafeteria. Over time, the rabbit was moved closer and closer until it was in Peter’s presence. By the time the rabbit was close to Peter, he showed no signs of fear. This is one of the earliest examples of behavior therapy for phobias. Specifically, Jones’s work with Peter is an example of in vivo exposure therapy in which the patient is presented with feared objects or situations. Later work in exposure therapy would employ the use of imaginal exposure in which the patient imagines feared situations for exposure (e.g., Wolpe, 1990).
Watson’s behaviorism also helped to emphasize the importance of understanding overt behavior. Watson insisted that behavior be objectively measured. Contemporary behavior therapy still focuses on objective measurements of behavior. The patient often records behavior between sessions to aid the therapist in assessing the effectiveness of the various strategies employed. Thus, progress in behavior therapy is evaluated by directly observing changes in behavior.
Watson’s radical behaviorism was eventually disfavored in mainstream psychology. For example, contemporary behavior therapists often make use of many cognitive techniques and refer to internal processes that Watson eschewed. Over time, many psychologists and even many behaviorists found Watson’s radical behaviorism to be too restrictive. Behaviorists embraced logical positivism—which accepted the use of internal constructs, provided that they are linked to objective measurements (Hergenhahn, 2001). These post-Watson behaviorists were known as neobehaviorists. Contemporary psychologists, including behavior therapists, often make use of internal processes such as physiology and/or cognition. Watson has also been criticized as advocating extreme nurture-ism. Although the environment obviously influences behavior, the denial of other factors has fallen into some disfavor in light of increased research on genetic influences on behavior (e.g., James D. Waston, 2003). Although Watson’s brand of behaviorism lost popularity over time, his thinking did much to advance psychology in that he emphasized focusing on empirical and verifiable data.
Although many neobehaviorists made extensive use of internal processes, the most influential post-Watson behaviorist was B. F. Skinner who shared Watson’s aversion to mental constructs, as well as his insistence on empiricism in psychology. Skinner had a profound influence on psychology, perhaps more so than any other psychologist, and we turn to his influence on behavior therapy next.
Burrhus Frederic Skinner (1905–1990)
Skinner has been classified as a neobehaviorist by some historians (e.g., Hergenhahn, 2001) because of his use of operationalism, which posits that concepts should be defined in terms of objective measurements. Although Skinner recognized the need to make assumptions in science, Skinner’s approach to psychology was largely atheoretical because he believed psychology should avoid seeking internal explanations of behavior (Skinner, 1950). Rather, he believed psychology should focus on describing the relationships between environmental consequences and emitted responses (Skinner, 1974). Skinner’s work focused on the relationship between response and outcome that he referred to as operant behavior. Learning relationships between responses and outcomes is sometimes referred to as instrumental learning. Skinner was also interested in the behavior of individual organisms and eschewed the use of statistical analysis. He founded the Journal of the Experimental Analysis of Behavior, which encouraged the presentation of data on individual subjects. To this day, this journal encourages authors to demonstrate that experimental effects hold for individual organisms. The focus on the individual is quite consistent with how behavior therapy is conducted. Assessments in behavior therapy often strive to understand how an individual’s environment is controlling his or her behavior.
A corollary of Skinner’s perspective, as it relates to psychotherapy, is that problematic behavior should be treated by making changes to environmental contingencies. Events in the environment that lead to an increase in the probability of a response are said to have reinforced the response, and many contemporary treatments involve manipulating contingencies of reinforcement. Indeed, contemporary treatments that involve changes in environmental contingencies exist for a diverse array of problems including attention-deficit/hyperactivity disorder (Abramowitz & O’Leary, 1991), mental retardation (Handen, 1998), and clinical depression (Jacobson et al., 1996; Jacobson, Martell, & Dimidjian, 2001).
Skinnerian principles are also the basis for token economies that are used in various settings to increase the frequency of desirable behaviors (Allyon & Azrin, 1968). Token economies have been widely used to help manage behavior in homes, classrooms, and institutions. In a token economy, desirable behaviors are reinforced with tokens. The tokens may have symbolic value or they can be exchanged for tangible rewards.
Instrumental learning has also helped to advance our understanding of several disorders in which problematic behaviors have rewarding consequences. Part of behavioral assessment involves conducting a functional analysis in which reinforcers are identified for various behaviors, especially problematic behaviors. By identifying variables that control certain behaviors, treatment can be tailored to change these behaviors. For example, Wulfert, Greenway, and Dougher (1996) present a functional analysis of alcoholism. In their analysis, alcoholism can be conceptualized as drinking being reinforced by its physiological aftereffects (i.e., a feeling of being “buzzed” or drunk), as well as by its depressive effects on the nervous system that help to palliate feelings of anxiety and depression in the short term. Although drinking alcohol can be reinforced by its immediate aftereffects, in the long term alcoholism can cause health problems, absenteeism from work and school, and social and marital problems. By understanding situations that create risk for drinking, the therapist and patient can create coping strategies to use alternative behaviors in those high-risk situations.
Like Watson, Skinner strove to understand behavior without reference to cognitive constructs. His emphasis on measuring observable behavior of individuals greatly influenced how behavior therapists assess patients and formulate a case conceptualization. Pavlov and Watson focused primarily on stimulus-response relationships, whereas Skinner focused primarily on response-outcome relationships. Modern learning theorists often seek to understand how a three-part contingency (i.e., stimulus-response-outcome) controls behavior (e.g., Foree & Lolordo, 1973). This three-part contingency is often discussed in behavior therapy as an ABC conceptualization of behavior: antecedents, behaviors, and consequences (e.g., Goldfried & Davidson, 1994). Skinner greatly emphasized the importance of behaviors and their consequences, and thus helped to create the foundation for functional analyses of behavior, as well as behavior therapy that seeks to manipulate contingencies of reinforcement.
Orval Hobart Mowrer (1907–1982)
Mowrer was an early behaviorist who studied avoidance behavior. His work was influential to behavior therapists of his day, and his work also influences contemporary behavior therapy. The reason for his influence is that many psychological problems can be conceptualized as avoidance. For example, public speaking might be avoided in people with social phobia, friends and activities might be avoided in people with depression, and reminders of past trauma might be avoided in people with posttraumatic stress disorder. Avoidance behavior was of theoretical interest because it was tempting to explain avoidance behavior in terms of expectancies (e.g., responses were emitted to prevent expected negative outcomes). Mowrer sought to explain avoidance behavior without reference to mental constructs, such as expectancies, and formulated a two-factor theory of avoidance behavior (Levis & Brewer, 2001; Mowrer, 1947). For Mowrer, animals learned relationships between stimuli and fear responses (a stimulus-response relationship). Responses that lead to the removal of the eliciting stimulus were reinforced by the reduction of fear (a response-outcome relationship). Thus, Mowrer combined classical condition and instrumental learning in his two-factor theory. Some stimuli became conditioned stimuli for fear responding, and operant behavior was reinforced by the removal of the conditioned stimulus.
By emphasizing the relationship between stimuli and fear responses, Mowrer influenced early behavior therapists to develop exposure therapy. The goal of exposure therapy is, in part, to extinguish the relationship between certain stimuli and fear responses. Many forms of psychopathology involve fear and avoidance of specific stimuli including phobias, posttraumatic stress disorder, and obsessive-compulsive disorder (e.g., Foa & Franklin, 2001; Resick & Calhoun, 2001; Stampfl & Levis, 1967). The emphasis of avoidance in Mowrer’s theorizing has influenced how modern behavior therapists conceptualize of psychopathology, and his theorizing helped to provide an early conceptual framework for exposure-based therapies.
CONTEMPORARY VARIATIONS OF BEHAVIOR THERAPY
Although both Watson and Skinner addressed some questions of treating psychopathology in their work, it was not until later that others began to focus their careers on theories and techniques in behavior therapy. The term behavior therapy often refers to a perspective on how assessment and therapy are done, as opposed to specific techniques (Goldfried & Davidson, 1994). Nonetheless, several specific techniques exist that are widely used. Next, we review some specific techniques in behavior therapy, along with some key figures that helped to develop and popularize them. Interested readers may wish to consult other, more comprehensive texts on behavior therapy (e.g., Goldfried & Davidson, 1994; Spiegler & Guevremont, 2003).
Systematic Desensitization
Joseph Wolpe was a psychiatrist who is considered by many to be the founder of behavior therapy. Wolpe showed that anxiety could be treated by pairing previously anxiety-eliciting stimuli with a state of relaxation. Wolpe’s techniques, which are in wide use today, included the use of relaxation and systematic desensitization (Wolpe, 1990). The theoretical basis for systematic desensitization is reciprocal inhibition— the notion that opposite emotional states cannot be experienced simultaneously (Wolpe, 1995). In learning theory, reciprocal inhibition is sometimes referred to counterconditioning because it involves changing the valence of an unconditioned stimulus (e.g., training with food, and then switching to shock).
According to the Wolpe’s theory of reciprocal inhibition, if the patient can learn to relax in particular situations, then the state of relaxation will supersede feelings of anxiety. Other mechanisms, such as extinction and habituation, are also involved in systematic desensitization. As noted by Foa and Kozak (1986), the distinction between extinction and habituation can be difficult to make with regard to their role in exposure therapy. Wolpe’s theory suggests that patients can be treated by relaxing in the presence of feared stimuli. This is similar to the in vivo exposure therapy of Jones (1924). However, systematic desensitization is often done by having a person imagine his or her feared stimuli because this overcomes many practical difficulties (e.g., it would not be easy to conduct in vivo exposure to sharks).
Goldfried and Davidson (1994) describe the basic steps of systematic desensitization. Before beginning systematic desensitization, the patient is trained to relax using behavioral and imagery techniques. Relaxation training involves contracting and relaxing muscles while imagining calming scenes. A patient can learn to induce a state of relaxation with repeated practice. The patient is often asked to report on his or her level of relaxation and anxiety using a quantitative scale of 0–100. This is referred to as a subjective units of discomfort (SUD) scale. This scale is helpful to measure how effectively a person can relax, as well as the amount of fear associated with certain stimuli.
If a course of imaginal exposure is planned, the patient is further trained in the use of imagery so that anxiety-evoking scenes can be vividly imagined. The therapist and patient work to create a fear hierarchy—a list of situations that evoke anxiety. The hierarchy is organized from least to most anxiety provoking. The SUD scale is used to help organize the hierarchy of feared situations in ascending order of difficulty.
The exposure component of systematic desensitization begins with exposure to the first item in the hierarchy. The patient is first asked to relax. Then, the first item in the hierarchy is imagined or presented in vivo (e.g., exposing the patient to feared stimuli such as dogs, crowds, or heights). According to Wolpe, relaxation will inhibit anxiety. Therefore, anxiety associated with a feared stimulus will decrease with repeated pairings of relaxation and the feared stimulus. While exposed to items in the fear hierarchy, the patient signals to the therapist when he or she begins to feel anxious. The therapist then terminates the exposure and the patient enters a state of relaxation using imagery and muscle relaxation. According to Wolpe, this procedure prevents the feared stimulus from being paired with anxiety. This process of alternating exposure and relaxing imagery is repeated until the patient is able to feel relaxed in that particular item in the hierarchy. After one item in the fear hierarchy is compete, the next item in the hierarchy is attempted. Therapy progresses until the patient is able to maintain a state of relaxation for each item in the hierarchy. Like many behavior therapy techniques, systematic desensitization is a flexible technique. Goldfried and Davidson (1994) described how it could be adapted for use in groups, with in vivo stimuli, and with the use of recorded sessions.
Systematic desensitization is an effective treatment for several forms of psychopathology and has a coherent theoretical basis. Many patients prefer systematic desensitization to other forms of exposure, such as flooding, because fearful situations are approached gradually. Nonetheless, other forms of exposure can also be useful to the behavior therapist. We turn next to prolonged exposure, or flooding, which shares some similarities to systematic desensitization but is distinct in its theoretical basis and implementation.
Prolonged Exposure Therapy or Flooding
Prolonged exposure therapy or flooding is a widely used form of behavior therapy which involves repeated presentations of feared stimuli to facilitate habituation both within a psychotherapy session and across sessions. Prolonged exposure differs from systematic desensitization in that treatment sometimes begins with intensely feared stimuli. One of the first exposure therapies, implosive therapy (Stampfl & Levis, 1967), is similar to the prolonged exposure therapy (flooding) that is widely used today.
Edna Foa is well known for her work on prolonged exposure for posttraumatic stress disorder and obsessive-compulsive disorder (e.g., Foa, Feske, Murdock, Kozak, & McCarthy, 1991; Foa & Franklin, 2001; Foa, Rothbaum, Riggs, & Murdoch, 1991). Foa and Kozak (1986) posited that traumatic experiences could be described as containing many stimulus elements. These stimulus elements are stored in memory as a fear network. Foa and Kozak posited that exposing the patient to as many elements of the fear network as possible should result in habituation to these elements. In this context, they define habituation as a response decrement that occurs with repeated exposure to a stimulus. Thus, with repeated exposure to feared stimuli, the fear response should decrease. Although Foa and her collaborators discuss habituation as the primary mechanism in flooding, it is possible to frame flooding as an extinction-based treatment (e.g., Zinbarg, 1993). For example, sexual assault could be associated with intense pain (unconditioned stimulus), but also many conditioned stimuli (the smell of an alley, the face of the attacker). To extinguish conditioned responses to these stimuli, the patient is exposed to elements of the fear network (conditioned stimuli) without the unconditioned stimulus (i.e., the stimulus elements of the actual assault).
The execution of prolonged exposure differs from systematic desensitization in that whole therapy sessions are often devoted to exposure. Sometimes extended sessions of 90 minutes or more are used. Each session is dedicated to exposing the patient to feared situations to create habituation. Because prolonged exposure requires the patient to confront highly upsetting memories or in vivo situations, extra time is often needed to allow the patient to gain his or her composure before leaving the therapist’s office. A fear hierarchy might be used in flooding, but it is less crucial because exposure often begins with intensely frightening situations. This is in contrast to systematic desensitization, in which the hierarchy is confronted in order of least to most anxiety provoking.
Because habituation is viewed as a key mechanism of change, it is critical that the patient not be able to escape or avoid the feared situation in therapy. Mowrer’s two-factor theory would suggest that avoidance maintains problematic behaviors because the avoidance behaviors are reinforced by the termination of fear. To overcome this issue, one aspect of Foa’s treatment for anxiety is response prevention to prevent maladaptive avoidance behaviors from being reinforced. Prolonged exposure with response prevention is often used in the treatment of obsessive-compulsive disorder. In prolonged exposure with response prevention, feared situations are presented to the patient, but typical responses to anxiety (e.g., rituals) are prevented. For example, a person with obsessive-compulsive disorder who fears contamination might be asked to put his or her hands in dirty water without an opportunity to wash his or her hands. The exposure to dirty water should activate the fear network to promote habituation, and response prevention will prevent the ritualistic washing behavior from being reinforced.
Several studies of prolonged exposure with response prevention have shown it to be effective for not only obsessive-compulsive disorder, but also for other problems such as bulimia nervosa (Leitenberg, Rosen, Gross, Nudelman, & Vara, 1988), posttraumatic stress disorder, hypochondriasis (Visser & Bouman, 2001), and alcohol use disorders (Rankin, Hodgson, & Stockwell, 1983). Prolonged exposure and systematic desensitization are both treatments that focus on presenting patients with feared stimuli, either in vivo or with imagery, to attain fear reduction. Behavioral rehearsal (see the following section) also involves patients confronting feared stimuli, but exposure per se is not the primary mechanism of change. Rather, patients learn about new behaviors through observation and enact more effective behaviors through practice.
Behavioral Rehearsal
Behavioral rehearsal refers to a family of techniques in which the patient and therapist act out various situations that are problematic for the patient. Behavioral rehearsal is sometimes referred to as modeling, assertiveness training, social skills training, or role-playing. The situations that are addressed in behavioral rehearsal could include such things as giving a speech, asking for a raise, starting a conversation, or asking someone on a date. Behavioral rehearsal is often done with scenes arranged in a fear hierarchy, similar to systematic desensitization.
Andrew Salter wrote about assertiveness in his early text Condition Reflex Therapy (1949). In his book, he discusses inhibition as the root cause of psychopathology, and thus prescribes excitation as the treatment. His terminology was clearly influenced by Pavlov, who used these same terms to describe changes that occurred in the nervous system as a result of conditioning. Salter discussed several patients is his book that he treated for shyness, anxiety, and addictions. In his chapter on “conditioning excitatory reflexes,” Salter discusses several techniques that are similar to those used in behavioral rehearsal today, including contradict and attack and deliberate. The contradict-and-attack technique was intended to reduce acquiescence in unassertive people. Salter wrote of this technique, “When you differ with someone, do not simulate agreeability.” Deliberation referred to the use of the word I to focus on your own needs and feelings (e.g., “I need to talk to you.”). Both of these techniques can be effective for increasing assertive behavior.
The work of Albert Bandura also influenced the development of behavior therapy by highlighting the role of observational learning. Early on, he referred to his theory as social learning theory (Bandura, 1977), although he later integrated many cognitive processes (e.g., self-appraisal, expectation) into his theories (e.g., Bandura, 1999). Bandura argued that potentially problematic behavior could be learned via observation (e.g., He found that children learned aggressive behavior by watching others attack bobo dolls), and people could also learn adaptive behaviors through observation and practice. Bandura (1969) suggested that therapy should involve opportunities for patients to practice important behaviors in-session to enact the same behavior in naturalistic settings. This technique is the essence of behavioral rehearsal. In addition, Bandura’s research suggested that fear could be reduced through vicarious extinction— observing others interact with a feared object. In his research, having people observe a therapist handle a snake, and gradually handling the snake themselves, was highly effective for reducing fear (Bandura, 1969). In sum, Bandura highlighted how effective models (e.g., therapists) could help individuals master situations that were anxiety provoking.
The efficacy of behavioral rehearsal was evaluated early on by Lazarus (1966) and was shown to be superior to direct advice and reflective listening. Contemporary behavioral rehearsal often consists of four steps (Goldfried & Davidson, 1994):
Cognitive aspects of behavioral rehearsal are also important. Some patients may not do well in social situations because of unrealistic expectations. In preparing the patient, it is often helpful to discuss appropriate expectations for some interactions. For example, a boss may be reluctant to give a large raise in pay. Cognitive change often occurs after rehearsal begins. After exhibiting some behavior effectiveness in role-plays or in vivo experience, the patient’s belief about his or her own efficacy may increase.
Behavioral Activation
Systematic desensitization and prolonged exposure are based on the notion that exposing patients to feared stimuli reduces their distress associated with these stimuli. The mechanisms that underlie systematic desensitization and prolonged exposure are reciprocal inhibition, extinction, and habituation. Behavioral activation is a treatment used for depression that has a strong emphasis on a different mechanism: positive reinforcement. The theory is based on the notion that reinforcement of healthy behaviors is lacking in the life of depressed people. In addition, unhealthy or depressive behaviors may be excessively reinforced. For example, a person without much opportunity for social reinforcement might develop feelings of loneliness and isolation. This low social functioning might be maintained through reinforcement of unhealthy behaviors (e.g., a spouse might or friend might reinforce depression behavior by increased positive attention). Peter Lewinsohn did much research on this particular model of depression (e.g., Lewinsohn, 1974; Lewinsohn & Graf, 1973). The work of Lewinsohn and his colleagues showed that one effective treatment for depression was to increase the frequency of positive events and to engage in self-monitoring so that patients could learn what activities were related to various mood states.
Although cognitive therapy techniques have been popular over the past few decades (e.g., Beck, 1976), there is now renewed interest in behavioral activation techniques. Part of the renewed interest in behavioral activation comes from a dismantling study of CBT that showed that behavioral activation was the most active ingredient in reducing depressive symptoms (Jacobson et al., 1996). Martell, Addis, and Jacobson (2001) have a protocol for treating depression that is based on behavioral activation. This treatment incorporates Lewinsohn’s (1974) notion that reinforcement contingencies contribute to depression. This protocol emphasizes the monitoring of healthy behaviors and the scheduling of pleasant activities. However, this treatment also stresses that a functional analysis of behavior is crucial to assess what outcomes reinforce healthy and depressive behaviors for a particular individual. It is not sufficient to increase the frequency of positive events in a person’s life without knowing which events will reinforce more active behaviors for a particular individual.
Interoceptive Exposure in Panic Control Treatment
One highly effective treatment for panic disorder and agoraphobia has been developed by David Barlow and his collaborators and is referred to as panic control treatment (PCT; Craske & Barlow, 2001). Panic control treatment is an excellent example of how behavior therapy can be integrated with other techniques because the treatment is a multimodal package of exposure-based techniques coupled with cognitive restructuring. Panic control treatment is based on the notion that certain individuals may be more sensitive to their own internal physiology and prone to making negative, catastrophic inferences about bodily sensations (Barlow, 2002). One component of this treatment is interoceptive exposure, or the procedure in which the patient is exposed to bodily sensations associated with panic; that is, the patient engages in activities that induce symptoms of panic. Exposure to physical sensations helps to extinguish the relationship between bodily sensations and full panic attacks. Interoceptive exposure procedures include hyperventilation, chair spinning, and physical exercise to simulate physical symptoms that occur in panic attacks. Through exposure to these physical sensations, patients learn that the sensations are not dangerous. Like other cognitive-behavioral interventions, cognitive changes are also emphasized in treatment. Patients may shift from believing that panic attacks are catastrophic, to believing that anxiety is a normal reaction and may even be helpful in some situations. Patients practice changing cognitions associated with panic attacks to help prevent physical symptoms from escalating (“I feel my heart rate increasing, but that is normal” rather than “I’m having a heart attack!”).
Panic control treatment also involves exposure to feared situations to help reduce agoraphobic avoidance. To plan in vivo exposure sessions, a functional analysis is conducted to assess what situations the patient associates with anxiety and panic. Some individuals may associate panic with driving across bridges, whereas other people may associate panic with going to the grocery store. A functional analysis of behavior is a core feature of behavior therapy. Behavioral case formulation has been described as “[the] search for idiographic relations between environment and behavior” (Wolpe & Turkat, 1985, p. 6). Barlow’s PCT adopts idiographic behavior assessment, but integrates it with a set of procedures that can be generally applied to reduce agoraphobic avoidance. Barlow himself was instrumental in emphasizing the application of scientific principles to the assessment of single individuals (Barlow & Hersen, 1984). The application of scientific principles to individuals, along with general knowledge about learning processes, is part of what defines behavior therapy.
Panic control treatment is an excellent example of how behavior therapy can be used in conjunction with cognitive techniques. It integrates several core features of behavior therapy including functional analysis and exposure to feared stimuli. However, the use of interoceptive exposure was an important development in the treatment of panic. Many treatments focus on reducing anxiety, but PCT goes a step further by educating the patient about how anxiety itself is not necessarily dangerous and exposing the patient to panic sensations in an effort to reduce the “fear of fear.”
THEORIES OF PERSONALITY AND DEVELOPMENT OF PSYCHOPATHOLOGY
Personality can be defined as behavioral consistency across situations (or, by some, as that which gives rise to such consistency). To the behaviorist, personality is an abstraction that summarizes this behavioral consistency. For Skinner and the radical behaviorists, behavior is a function of environmental inputs. A person’s personality is nothing more than the sum of his or her individual behaviors. Thus, personality to the radical behaviorist is a descriptive concept, as opposed to an explanatory concept. To the radical behaviorist, the organism is a “black box.” What occurs in the organism is unimportant if it cannot be measured directly. Rather, the relationship between environmental input and observed behavior is paramount. The aversion to internal processes has been unsatisfying to mainstream psychology. Thus, there is currently great interest in cognitive and physiological processes that may affect the development and treatment of psychopathology. In addition, there is great interest in how an understanding of personality and individual differences can be used in conjunction with behavioral techniques.
Pavlov recognized that individual differences were important to understanding learning. He noted that different forms of training may “lead to different forms of disturbance, depending on the type of nervous system of the animal” (Pavlov, 1927, p. 397). Pavlov speculated about how his work could be applied to humans and reasoned that mental illness might be due to sensitivity to excitatory and inhibitory process. Salter (1949) attempted to further Pavlov’s speculations about how people who were too inhibited might be treated. As shown later, modern conceptions of personality embrace the idea that individual differences may affect learning. Subsequently, some attempts have been made to integrate personality theories with behavior therapy.
Hans Eysenck and Jeffrey Gray have attempted to integrate personality and individual differences with behavior therapy. They both have posited physiological systems that underlie certain personality traits. Moreover, they have linked these personality traits to the degree of sensitivity an individual has to rewarding and aversive stimuli. For Eysenck (1967), the reticulo-cortical and reticulo-limbic systems underlie the traits of extraversion and neuroticism, respectively. For Gray (1970), anxiety and impulsivity are the two main dimensions of personality. Anxiety is thought to be related to a behavior inhibition system that is sensitive to punishment and nonreward, whereas impulsivity is related to a behavioral activation system that is sensitive to reward and avoidance of punishment. Both of their theories attempt to understand how the organism might intervene between stimuli, response, and outcome. A detailed review of their theories can be found in Matthews and Gilliland (1999).
Although behaviorism long eschewed theorizing about internal concepts, assessing individual sensitivity to reward and punishment may help to frame a functional analysis and alternative contingency structures in a person’s life. Corr, Pickering, and Gray (1995) and Zinbarg and Mohlman (1998) showed that personality traits differently influenced learning about aversive and rewarding unconditioned stimuli. Thus, a person who scores high on measures of extraversion might be well suited to behavioral activation that focuses on managing positive reinforcement of health behaviors. In contrast, a person who is high on neuroticism or trait anxiety is sensitive to cues for punishment and is therefore thought to be at greater risk for developing anxiety disorders and/or major depression (Zinbarg & Yoon, in press).
Behavior therapists are sometimes characterized as ignoring the role of early experience in the role of mental health problems. Although it is true that behavior therapists focus on present environmental contingencies, there have been attempts to understand the role of early experience from a behavioral perspective. Miller and Dollard (1941) attempted to integrate knowledge about classical and operant conditioning with social learning. In their perspective, imitation was an important form of learning, and they argued that maladaptive behaviors might be learned by observing others. Miller and Dollard argued imitation behavior might be reinforced, which in turn would facilitate more imitation. Thus, imitation could be explained though the principles of operant conditioning. However, maladaptive behavior might develop if a person was exposed to other maladaptive behavior in early life. A child might learn anxious behaviors by imitating anxious parents. For example, a child might observe his parents express concern about being robbed and repeatedly check the home’s locks. Over time, the child might imitate these checking behaviors and this checking behavior might be reinforced (perhaps by parental praise) and thus increase over time. After the behavior is manifest, other mechanisms could help to maintain it (e.g., fear reduction could reinforce checking). The role of observational learning may be helpful for the clinician. If a patient is particularly prone to imitation, other people in her environment may be reinforcing maladaptive behaviors (e.g., drug use among peers). In such cases, treatment may focus on helping the patient deal with peers or exploring more adaptive behaviors with alternative sources of reinforcement.
Maladaptive behavior may also arise when a behavior is adaptive in one context, but maladaptive in another. For example, aggression is highly adaptive for soldiers in war, but maladaptive in a romantic relationship. Unfortunately, it is often the case that a behavior learned in one context persists in another. The phenomenon of vicious circle behavior (e.g., Campbell, Smith, & Misanin, 1966) refers to avoidance responses being resistant to extinction after environmental contingencies change. For example, a person might escape from meetings because of social fears related to a problematic coworker. After this escape behavior is reinforced, it can prove difficult to extinguish. The escape behavior might persist even after the problematic coworker no longer works in the same department. In other cases, maladaptive behavior can be reinforced by short-term consequences, despite deleterious long-term consequences. This pattern can explain why drugs are abused despite serious long-term consequences. Despite the complexity with which maladaptive behavior can develop, the behavior therapist can intervene by doing an individualized functional analysis of the maladaptive behavior and can help the patient alter the reinforcement contingencies that support those behaviors.
THEORY OF PSYCHOTHERAPY
Goals of Psychotherapy
Specific goals are typically determined by the client in behavior therapy with shaping and feedback from the therapist. There are exceptions to every rule, and there are applications of behavior therapy in which the goals are imposed on the client by the therapist and/or other interested parties. One example of such an exception would be token economies for acting-out children. In a token economy, the child earns and loses tokens or points redeemable for rewards with tokens being earned for engaging in prosocial behaviors and lost for engaging in antisocial or problem behaviors. Typically in a token economy, the parents (or unit staff) decide which behaviors are deemed as desirable and unacceptable, targeting them to be strengthened or reduced.
Though some contend that the goal of behavior therapy (and cognitive therapy) is to lower levels of emotional experiencing (e.g., Samoilov & Goldfried, 2000), we believe that, although this may be a goal of some behavior therapists, this is not true of all behavior therapists (Zinbarg, 2000). Behavioral activation or pleasant event scheduling represents an orthodox behavior therapy technique that is designed to increase the experience of one form of emotion—positive emotion. We believe that it is not even the case that behavior therapy aims to reduce any and all forms of negative emotion. Any behavior therapy intervention (e.g., interoceptive exposure) aimed at reducing anxiety sensitivity could be construed as trying to help patients be more open to and less avoidant of the experience of anxiety. Furthermore, if a behavior therapist determines that some experience of negative emotion is going to help motivate a patient to avoid a realistic threat, we believe the therapist should not work to reduce that emotion. Thus, we believe that it is most accurate to say the key goals that a behavior therapist holds at an abstract level are the reduction of problematic behavior and/or emotions and the increase or maintenance of more adaptive behaviors and/or emotions.
Assessment
Formal assessment is critical to most behavior therapists not only in identifying contingencies and patterns to alter but also in clinical decision making. Thus, the early phase of behavior therapy is typically marked by the conduct of a functional assessment in which the therapist and patient collaboratively seek to identify the contingencies, classically conditioned stimuli, and discriminative stimuli-controlling problem behaviors. Early in the treatment of anxiety disorders, the behavior therapist typically inquires about the presence of avoidance behaviors and their consequences. When avoidance behaviors are present and produce some immediate relief (as they almost always do), it is important to help the patient understand both how the immediate relief reinforces avoidant tendencies and prevents extinction of the anxiety response. As another example, early in the treatment of sleep disorders, the behavior therapist typically inquires about sleep hygiene habits. When many other activities other than sleep take place in bed (e.g., reading, watching television, crossword puzzles), it is important to help the patient understand that doing so turns the bed into a conditioned stimulus for wakefulness rather than drowsiness. Formal assessment typically continues on an ongoing basis in the context of a single case design to assist in clinical decision making, including which interventions are effective for a particular case and when to terminate treatment.
In behavior therapy, the special assessment phase typically involves a baseline assessment phase and a functional analysis at the beginning of therapy, followed by ongoing assessment throughout treatment, as mentioned earlier. The purpose of the baseline assessment phase is so that the behavior therapist can subsequently draw stronger inferences regarding whether treatment was effective for the patient (e.g., Barlow & Hersen, 1984; Kazdin, 1981). Baseline assessment typically consists of some form of monitoring the frequency of problematic behaviors and feelings targeted for reduction as well as desirable behaviors and feelings targeted for strengthening. In theory, the baseline phase will continue until a stable baseline has been achieved. In practice, ethical concerns regarding withholding of treatment often dictate that the intervention phase begin before the baseline has stabilized (unless, the baseline shows an improving trend in which case the intervention may not be necessary).
In terms of the temporal foci of assessment, one of the hallmarks of behavior therapy is the focus on current maintaining factors or contingencies. In many cases, there is little to no assessment focused on the distant past. One exception to this, at least in our practice of behavior therapy, occurs when a patient not only has little understanding of how his or her problem behavior patterns developed but also is particularly self-critical for having developed these patterns. In such cases, we find that it can often be very helpful for the patient to review his or her learning history to appreciate how the currently problematic behaviors were a natural and understandable, if not inevitable, consequence of the contingencies and learning environment of the past.
Regarding the issue of the levels of self addressed explicitly in some of the other schools of therapy covered in this book, the issue is largely irrelevant to most behavior therapists or is conceptualized radically different in behavior therapy in comparison with other schools such as psychodynamic therapy. Thus, the modern behavior therapist accepts the notion of automaticity of some responses and for many this includes not only the notion of uncontrollability but also of being outside of conscious awareness. However, behavior therapy does not incorporate the notion of repression motivated by unconscious psychosexual conflict.
In terms of the methods of interviewing and tests used, the method of assessment most associated with behavior therapy is a functional assessment, which can consist of either an interview component and/or monitoring of behavior. After noting the problem behavior, the next steps in a functional assessment consist of identifying (a) the stimuli or situations that reliably predict the problem behavior and (b) the consequences of the behavior that may be reinforcing it.
Contemporary behavior therapists also make frequent use of objective questionnaires—typically self-report (e.g., the Beck Depression Inventory, though sometimes supplemented by collateral report) and patient self-monitoring completed repeatedly throughout the course of therapy. The resulting data often forms the basis of the single case design used to evaluate the effectiveness of intervention for an individual case. Early behaviorists tended to eschew diagnostic labels because such labels were said to imply that the causes of problem behavior are to be found within the individual, whereas behaviorism is predicated on the notion that the causes of behavior are to be found in environmental contingencies. As a result, early behaviorists were less vulnerable to labeling bias than psychodynamic therapists. Langer and Abelson (1974) found psychodynamic therapists would be more likely to judge a given behavior as pathological if told that the behavior was performed by a psychotherapy patient as compared with a job applicant, whereas the judgments of behavior therapists were less influenced by information about who performed the behavior. Many contemporary behaviorists, however, do make use of diagnoses and those who do tend to base them on semi-structured diagnostic interviews such as the Anxiety Disorders Interview Schedule (Brown, Di Nardo, & Barlow, 1994).
Process of Psychotherapy
As regards the role of the therapist in behavior therapy, the therapist is typically quite active and directive. Typically, there is much active psychoeducation about the factors maintaining the problematic behaviors, active instruction regarding the principles of intervention and how to implement them, and negotiation of homework or self-help exercises to be conducted between sessions. Two behavior therapists can be equally active and directive but differ markedly in their style. Our training and experience leads us to prefer adopting a Socratic style, as opposed to a lecturing style, whenever possible to help minimize patient resistance and noncompliance. Similarly, we were careful to choose the word negotiation rather than assignment when discussing the previous self-help activities because we find that adopting such a collaborative stance goes a long way toward minimizing patient resistance and noncompliance.
Self-disclosure is certainly not prohibited in behavior therapy like it would be among orthodox psychoanalysts who believe it is important for the therapist to remain a blank screen as it were for the patient to project transferences onto. Certainly, we see therapist self-disclosure as appropriate if done explicitly for the benefit of the patient. Thus, self-disclosure may be appropriate in the service of normalization of a patient’s feelings. In addition, the work of social learning theorists on the effectiveness of different types of models also suggests that therapist self-disclosure can serve a useful function in therapy. These social learning theorists studied the effects of mastery models versus coping models on the reduction of fears and avoidance. A mastery model displays approach behavior in the absence of any distress from the outset. In contrast, a coping model initially communicates that he or she has some discomfort about engaging in approach behavior and yet engages in the approach behavior anyway and gradually gains confidence. At least three studies have demonstrated that observing a coping model leads to significantly greater benefits among fearful individuals (e.g., Kornhaber & Schroeder, 1975; Schunk, Hanson, & Cox, 1987; Vernon, 1974). Thus, a therapist who discloses some discomfort about holding a snake, for example, when doing exposure therapy with a snake phobic patient (or who discloses that he or she used to experience anxiety about being assertive or public speaking but his or her anxiety diminished with repeated exposures) may be a more effective model than a therapist who never self-discloses.
Behavior therapy is typically short term, often involving 12 to 16 sessions. If a patient has shown signs of improvement and has mastered the skills, a behavior therapist often initiates a discussion of termination rather than waiting for complete symptom remission. Prior to termination, it is also common in behavior therapy to begin to “thin” the sessions (i.e., reducing their frequency) to give the patient more practice at applying skills on his or her own and to prepare him or her for termination.
Views regarding the role of the therapeutic alliance have changed over time in the behavior therapy community. Early behavior therapy was often described as a technology that could be automated (e.g., Lang, Melamed, & Hart, 1970). More contemporary views have acknowledged the importance of the therapeutic alliance (e.g., Raue, Goldfried, & Barkham, 1997; Williams & Chambless, 1990). The way we express this latter view to our supervisees (using a bit more colorful language) is that a therapist could know everything there is to know about the behavioral formulation of a particular problem and how to apply behavioral principles toward its remediation, but if the therapist is rude and uncaring, his or her patients are unlikely to pay any attention to him or her.
Strategies and Interventions
Extinction is the first major behavior therapy strategy we consider. Extinction-based techniques include the presentation of a trigger for an emotional response in the absence of a strong, affectively valenced consequence. They can also include the prevention of an avoidance response that has previously been associated with the reinforcement of anxiety reduction and that likely served to block extinction from occurring spontaneously. Extinction-based techniques also involve the withholding of reinforcement for responses that have been reinforced in the past. Certainly, exposure therapy in which the patient is encouraged to come into contact with his or her anxiety triggers (conditioned stimuli) in a manner that will either not result in a negative consequence or at least a consequence that is not as negative as the patient fears can be construed as an application of extinction (Zinbarg, 1993; see Watts, 1979, for the view that exposure therapy does not represent an application of extinction but rather of habituation). For anxiety disorders in which patients engage in active avoidance responses or safety rituals, exposure needs to be combined with response prevention. It is often not enough to expose someone with contamination fears and cleaning rituals to dirt, but rather the therapist must also instruct the patient to refrain from “undoing” the exposure by engaging in his or her washing ritual. An example of extinction applied in a purely instrumental learning framework is a technique that is a component of many parent training packages (e.g., Forehand & McMahon, 1981) involving instructing a parent to ignore low-level problem behaviors that may have been reinforced in the past in the form of attention (bad attention being better than no attention). This latter strategy is most effective if the parent is giving the child attention at times when he or she is behaving appropriately. A closely related application of extinction is a time-out (or time-out from reward) in which the parent is instructed to respond to a more serious inappropriate behavior (e.g., hitting or biting someone) not by yelling at or hitting the child, but rather by removing the child for a brief period (one rule of thumb is one minute for each year of age) from toys, television, and other children and ignoring the child for the duration of the time-out period (an empty playpen or a chair in a corner make good time-out locations).
Stimulus control is a second behavior therapy strategy. One example of the use of stimulus control comes from insomnia treatment (e.g., Bootzin, 1972). An individual with poor sleep hygiene habits is encouraged to do all the things he does in bed other than sleep (e.g., read, watch television) somewhere other than in bed. He is encouraged to get into bed only when he feels very drowsy. In this way, the bed can become a discriminative stimulus for sleepiness. Another example of stimulus control is when an individual with excessive worries is encouraged to designate a worry period at the same time and place each day (Borkovec, Wilkinson, Folensbee, & Lerman, 1983). If she begins to worry at other times, the notion is that she postpone this worrying until the worry period (perhaps even writing down the worry topic so she will remember it during the worry period). In this way, the time of day associated with the worry period can become a discriminative stimulus for worry, whereas all the other times of day become discriminative stimuli for nonworrisome cognition.
Third, contingency management is a behavior therapy strategy often used with children or residents of inpatient facilities. A behavioral contract is a technique based on contingency management. In a behavioral contract, parents clearly articulate which behaviors will be rewarded and which ones will lead to time-out from reward or loss of rewards and negotiate with the child regarding what the rewards for good behavior will be. It is important that the negotiation over rewards be collaborative because if the consequences designated as rewards are not reinforcing to the child, the technique will not work. A token economy is another contingency management technique practiced in some residential settings (and prisons). Similar to a behavioral contract, the staff clearly articulate which behaviors will be rewarded and by how many tokens or points, which ones will lead to loss of privileges/tokens/points, and what the choice of rewards for various levels of tokens or points earned will be.
Fourth, skill acquisition is a behavior therapy strategy applied in cases of skills deficits. Assertiveness training, social skills training, and parent training are examples of skill-acquisition techniques. In each of these techniques, the therapist teaches the patient a skill, encourages the patient to practice the skill often through role-plays in session, and provides positive reinforcement for correct implementation and corrective feedback when necessary. In assertiveness training, the therapist begins by teaching the patient the difference between assertive and aggressive, rude responses. The therapist might next model an assertive response and then engage in role-plays with the patient in which the therapist plays the role of someone who the patient needs to be assertive with to give the patient practice at being assertive, followed by positive reinforcement and corrective feedback.
The final behavior therapy strategy, shaping involves rewarding successive approximations to the target behavior the person is ultimately working toward. Shaping is often used in behavioral contracts in which the behavioral requirements for earning a particular reward might be increased over time. Some behavior therapists even implement a reward-sampling phase at the outset of a behavioral contract in which the child receives the rewards regardless of his or her behavior while the parent monitors the target behaviors. Such a reward-sampling phase serves two purposes: (1) It can allow for collection of baseline data regarding the frequency of target behaviors, and (2) it also ensures the child has enough experience with the rewards to be motivated by them once they start to become contingent on compliance with the behavioral expectations of the contract.
In terms of typical sequences in intervention, a new behavior therapy technique tends to be introduced in session with some psychoeducation and/or demonstrations to ensure that the patient understands the underlying principles. Next, the therapist and patient would apply the technique in session. At the end of a session, when the therapist and patient negotiate self-help exercises for the patient to complete between sessions, they typically agree on some degree of practice and application of the technique. Thus, when introducing exposure therapy, we would typically begin with a Socratic discussion of the underlying principles (“If you had a young relative who was afraid of dogs, what would you do to help him or her overcome that fear?”). We would then conduct therapist-assisted exposure in session and negotiate further exposure practices for the patient to complete between sessions. Finally, we end every session by asking the patient to share anything that troubled them about the session and to summarize anything from the session that might be useful.
As noted earlier, the typical clinical decision process is data driven whenever possible in behavior therapy. Many behavior therapists continue baseline assessment and wait to commence the intervention until the baseline has stabilized. Assessment then continues through the intervention phase to be able to ascertain whether improvement relative to baseline has occurred. If no or minimal improvement is observed within a reasonable time period (ranging from 2 or 3 weeks for interventions that are expected to produce some immediate effects to 12 weeks for other interventions), the decision is typically made to try a new intervention or refer to another treatment modality.
Homework is viewed as critical in behavior therapy. If we were to rate schools of therapy on a continuum ranging from action oriented to insight oriented, behavior therapy would most probably define the action-oriented pole of this dimension. A therapist can talk until he or she is blue in the face about extinction or contingency management or any other behavioral strategy, but if the patient does not apply the strategy in his or her life, we believe it is extremely unlikely that progress will be made. There is evidence showing that homework compliance correlates with treatment outcomes in behavior therapy trials for the treatment of anxiety (e.g., Huppert, Roth Ledley, & Foa, 2006) and from cognitive-behavior therapy trials for depression (e.g., Addis & Jacobson, 2000; Burns & Spangler, 2000), schizophrenia (Bailer, Takats, & Schmitt, 2002), and substance dependence (e.g., Gonzalez, Schmitz, & DeLaune, 2006). In keeping with our earlier statements about minimizing patient noncompliance, however, we find it preferable to speak of self-help exercises rather than of homework given that many patients have negative conditioned emotional responses to the term homework stemming back to their attitudes toward schoolwork as children.
Strategies are adapted to specific presenting problems a great deal; behavior therapy is definitely not a one-size-fits-all approach. There is no one principle or strategy akin to transference interpretation that is viewed as being critical for every case. Exposure therapy is used to reduce excessive anxiety, behavioral activation is used to ameliorate depression, behavioral contracts are used to treat externalizing problems in children, and so forth. Moreover, depending on the results of the therapist’s functional analysis and the behavioral case formulation, he or she might even take seemingly diametrically opposed tactics for a superficially identical behavior in two different patients. We have treated individuals with facial tics who have a great deal of social anxiety related to urges to tic in public and the possibility that others will notice their tics and reject them. We have also treated one young man who had obsessions about the essence of other people somehow contaminating him, turning him into them and causing him to be untrue to himself. He would also get urges to tic when interacting with people but he welcomed these tics because he believed that they would close the opening in his soul through which others might contaminate him. With the first group of individuals, we conceptualized the tics as a conditioned stimulus that elicited anxiety and passive avoidance (avoiding going out in public) and so encouraged these individuals to intentionally tic in public for exposure. With the young man who welcomed the tics, we conceptualized his tics as serving the role of a safety ritual and encouraged him to both increase his interactions and to refrain from engaging in the tics while doing so for exposure plus response prevention.
There is no single, monolithic view of medication in behavior therapy. Many contemporary behavior therapists view some medications as potentially useful (e.g., Ritalin for hyperactivity, tricyclic antidepressants and serotonin reuptake inhibitors for depression and anxiety, D-cycloserine to augment the effects of exposure therapy). However, some medications are viewed as potentially blocking therapeutic gains (e.g., benzodiazepines used on an as needed basis concurrently with exposure therapy for anxiety).
Curative Factors
As mentioned earlier when discussing the therapeutic alliance, early behavior therapists minimized the role of the therapeutic relationship if not denying it any role whatsoever in their conceptualizations. Contemporary behavior therapists seem to appreciate that therapy is almost always delivered in the context of a human relationship and that the qualities of this relationship can affect the therapy. In addition, whereas behavior therapists would argue that there are some active ingredients that are specific to behavior therapy, it seems to us that specific factors can coexist with common factors. Moreover, we are not aware of any tenets of behavior therapy that would deny a role for common curative factors. Thus, many contemporary behavior therapists would probably agree that the therapeutic relationship is necessary (for ensuring compliance with behavioral assignments if nothing else) but is not sufficient as a curative factor.
Insight is viewed as potentially helpful because understanding a behavior pattern and its functions and origins helps the patient be more willing to make behavioral changes. Traditionally, however, insight is viewed as being neither necessary nor sufficient in behavior therapy.
In contrast to insight, behavioral assignments are viewed as both necessary and sufficient by most behavior therapists. As noted earlier, behavior therapists believe that there are some active ingredients that are specific to behavior therapy and these are precisely the ingredients that need to be applied in between sessions for the most progress to be made.
Special Issues
Homework or self-help exercise compliance is often critical as mentioned earlier and can be problematic with many cases. Motivational interviewing techniques (e.g., Miller & Rollnick, 1991) can be useful for working with resistance as can cognitive therapy techniques (Newman, 1994). The basic principles of motivational interviewing are fairly simple and center on reframing resistance as ambivalence. The therapist assumes some motivation for therapeutic change that coexists with some motivation to maintain current behavior patterns. Based on this assumption, the therapist uses techniques such as using reflective listening techniques, siding with resistance, and offering choices to try to strengthen the patient’s internal motivation for change and to encourage the patient to articulate reasons for changing rather than engaging in a verbal tug-of-war with the patient. Some basic behavioral principles are important for homework compliance as well. Beginning a session by following up on homework negotiated in previous sessions, giving praise for homework completion, and taking some time in session for completing incomplete homework tasks (e.g., filling out a questionnaire) can be useful for minimizing noncompliance.
Culture and Gender
The major principles of extinction, stimulus control, and contingency management are believed to be universal; however, there can be tremendous differences in how these are applied depending on factors such as culture and gender. What is reinforcing to one individual may not be to another because of cultural factors and gender. Thus, whereas access to playing video games may be very reinforcing to an adolescent boy, this may not be the case with an adolescent girl.
Adaptation to Specific Problem Areas
As noted earlier, behavior therapy is definitely not a one-size-fits-all approach, and there is no one principle or strategy akin to transference interpretation that is viewed as being critical for every case. However, different strategies tend to be seen as being more relevant for different types of specific problem areas. Behavior therapy for anxiety disorders tends to emphasize extinction strategies (i.e., exposure or exposure plus response prevention) and skill acquisition (i.e., relaxation, assertiveness) although a bit of stimulus control has been applied as well (e.g., Borkovec, Wilkinson, Folensbee, & Lerman, 1983). In contrast, behavior therapy for child-externalizing problems tends to emphasize contingency management (e.g., token economies, behavioral contracts, time-out from reward), and stimulus control strategies tend to be applied more in the treatment of insomnia than for anxiety or child-externalizing problems.
Empirical Support
There is a great deal of empirical support for behavior therapy strategies for various specific problems though much of this evidence comes from studies testing cognitive-behavioral treatment packages that combine behavior therapy and cognitive therapy. Behavior therapy and CBT have been subjected to empirical tests more often than any other form of psychotherapy and are the most well-established forms of psychotherapy in terms of their empirical support. In support of this assertion, we note that 20 of the 25 treatments classified by the Clinical Psychology Division of the American Psychological Association Task Force on Promotion and Dissemination of Psychological Procedures as being either well established or probably efficacious were behavioral or cognitive-behavioral (Crits-Christoph, Frank, Chambless, Brody & Karp, 1995). Thus, the evidence supporting behavior therapy and CBT is too voluminous to review in its entirety here, and several of the relevant literatures have been reviewed elsewhere. However, we do offer some selective citations to give a flavor for the depth and breadth of the empirical support for these approaches.
Exposure therapy has been shown to be efficacious for several anxiety disorders, and in many cases the addition of cognitive restructuring has not led to significantly better outcomes (e.g., Barlow, 2002; Feske & Chambless, 1995; Foa, Hembree, et al., 2005; Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998). Applied relaxation (which involves not only teaching the patient progressive muscle relaxation but also deliberately inducing anxiety in session—either via imaginal or in vivo exposure—so that the patient can practice using relaxation to reduce his or her anxiety) has also been supported for generalized anxiety disorder (Ost & Breitholtz, 2000) and panic disorder (Ost & Westling, 1995). Applied tension has been shown to be efficacious for blood-injury-illness phobia even when delivered in a single session (e.g., Hellstrom, Fellenius, & Ost, 1996; Ost & Sterner, 1987). Behavioral activation therapy and social skills training have been shown to be efficacious for major depression (e.g., Dimidjian et al., 2006; Zeiss, Lewinsohn, & Munoz, 1979). Crits-Christoph et al. (1995) also list behavior therapy for headache and for irritable bowel syndrome, behavior therapy for female orgasmic dysfunction and male erectile dysfunction, behavioral marital therapy, parent training programs for children with oppositional behavior, and token economy programs among their list of 18 well-established treatments.
One issue that has been receiving increasing attention in the behavior therapy and CBT literature in recent years is the distinction between statistical and clinical significance (Jacobson & Truax, 1991). Although even the previous brief review demonstrates that there can be no doubt that behavior therapy techniques, either on their own or in combination with cognitive therapy, often produce statistically significant outcomes, the evidence is at least somewhat more sobering with respect to clinical significance. To illustrate this point, we consider the literature on CBT for generalized anxiety disorder. Several meta-analyses in the past decade and a half have shown this approach to be significantly more effective than wait-list and placebo control conditions (Borkovec & Whisman, 1996; Chambless & Gillis, 1993; Gould, Otto, Pollack, & Yap, 1997). Based on the evidence reviewed in these meta-analyses, Crits-Christoph et al. (1995) list CBT for generalized anxiety disorder as a well-established intervention. The most widely used strategy for assessing clinically significant change in this literature has been to classify patients according to whether they have achieved high end state (HES) functioning. Although slightly different definitions were used, the core of HES functioning remained largely the same across all of these studies—the patient’s scores on the outcome measures are tending to be brought back within the nonclinical range of scores on those measures. In one well-conducted study, Borkovec and Costello (1993) reported that, at the posttreatment assessment, only 57.9% of their patients treated with CBT were classified as having achieved HES functioning. In another well-conducted study, Butler, Fennell, Robson, and Gelder (1991) reported that only 32% of their patients treated with CBT were classified as achieving HES functioning at the posttreatment assessment. This range of HES functioning (32% to 57.9%) fits Borkovec & Whisman’s (1996) average HES functioning figure of 50% from their meta-analysis of CBT trials. Results such as these illustrate that whereas many behavioral and cognitive behavioral therapies are efficacious, there is still much work to be done to enhance their efficacy.
Description of a Specific Approach to Treatment in Behavior Therapy
In our description of a specific approach to treatment in the behavioral school of therapy, we focus on the behavioral techniques we are best known for—those for generalized anxiety disorder. However, given that many of the other chapters in this book focus on the treatment of depression and that generalized anxiety disorder is highly comorbid with depression, for our Case Illustration we have chosen to describe a woman who had both generalized anxiety disorder and depression. Thus, the case illustrates not only our somewhat unique application of behavioral strategies to generalized anxiety disorder but also the application of some behavioral strategies for depression.
How Specific Approach Implements or Modifies the Broad Theory
The general behavioral model of anxiety disorders places heavy emphasis on the role of behavioral avoidance in maintaining the anxiety. Accordingly, in vivo exposure plays a prominent role in the general behavioral approach to anxiety disorders. However, one feature that differentiates generalized anxiety disorder from many of the other anxiety disorders is that overt avoidance behaviors are not nearly so prevalent or prominent as they are in other anxiety disorders. Thus, many cognitive-behavioral therapists do not incorporate exposure therapy in their treatment of generalized anxiety disorder. Borkovec and his colleagues have developed a fascinating theory of generalized anxiety disorder, however, that suggests that even though behavioral avoidance is not prominent in generalized anxiety disorder another form of avoidance might be. Borkovec’s model of generalized anxiety disorder ascribes an avoidance function to worry—a central diagnostic feature—by emotionally distancing the individual from negatively valenced (i.e., catastrophic) images that trigger worry (e.g., Borkovec, Alcaine, & Behar, 2004; Borkovec, Shadick, & Hopkins, 1991; Freeston, Dugas, & Ladouceur, 1996). Specifically, not only do those with generalized anxiety disorder generate more negative scenarios for potential problems (Davey & Levy, 1998; Hazlett-Stevens & Craske, 2003; Vasey & Borkovec, 1992), and possibly experience more intense negative emotions (Mennin, Heimberg, Turk, & Fresco, 2005) than controls, but worry in generalized anxiety disorder involves an exaggerated shift from imagistic processing toward verbal/linguistic processing. Worry that accompanies generalized anxiety disorder is more abstract than concrete (Stober, 1998), and Borkovec et al. (2004) found that it tends to be more linguistic (i.e., self-statements) than imagistic (i.e., visual, auditory, or kinesthetic images). Initial findings indicated that individuals with generalized anxiety disorder report more “thoughts” than “images” when instructed to relax, and even more so when instructed to worry, relative to controls (Borkovec & Inz, 1990). These self-report findings were corroborated by laboratory measures in other studies (e.g., Craske & Herrmann, 1993). Rapee (1993) established that, whereas secondary verbal tasks interfered with worry activity (presumably by competing with the same processing resources), secondary visual and spatial tasks did not (presumably by involving different processing resources).
Verbal/linguistic processing of threat is associated with less autonomic reactivity (Borkovec & Hu, 1990; Vrana, Cuthbert, & Lang, 1986) and weaker subjective reports of negative affect (Holmes & Mathews, 2005) than imagistic processing of the same threat. Furthermore, autonomic reactions to imagined scenarios of public speaking in public-speaking-anxious individuals were lessened after an interval of worry in contrast to an interval of imagery (e.g., Borkovec, Lyonfields, Wiser, & Diehl, 1993; Peasley-Miklus & Vrana, 2000), and prior worrying was associated with decreased negative affect in a subsequent trauma recall task (Behar, Quellig, & Borkovec, 2005). Hence, it is hypothesized that worry is negatively reinforced by reductions of fear-based affect and autonomic arousal in the short run. However, by virtue of this dampening effect on emotional responding, worry is presumed to maintain itself and generalized anxiety disorder in the long run because largely unprocessed catastrophic images and associated autonomic arousal continue to emerge periodically and motivate continued avoidance in the form of worry. Partial support for this sequence was provided by Butler, Wells, and Dewick (1995) who found that participants instructed to worry about the content of distressing films had reduced anxiety immediately afterward but increased intrusive images over the next 3 days compared to those instructed to form images or to “settle down” (also see Wells & Papageorgiou, 1995).
Thus, the general behavioral model for anxiety disorders that focuses on behavioral avoidance of external cues or situations has been modified for generalized anxiety disorder because avoidance takes a more cognitive than behavioral form, and it is focused not so much on avoiding actual aversive experiences as on avoiding aversive imagery and emotional arousal. Given that avoidance is thought to play a role in maintaining generalized anxiety disorder, some form of exposure might also have a role to play in treating it. However, the avoidance theory of worry calls for a different form of exposure than in vivo exposure. Next, we describe the form of exposure developed based on the avoidance theory of worry.
Specific Strategies and Interventions
Based on the avoidance theory of worry, the general approach of exposure for anxiety disorders has been adapted to incorporate sustained exposure to negatively valenced imagery, including those aspects of imagery that encode efferent commands to the autonomic system (Craske & Barlow, 2006; Craske, Barlow, & O’Leary, 1992; Zinbarg, 1993; Zinbarg, Craske, & Barlow, 2006; Zinbarg, Lee, & Yoon, 2007). Thus, imagery exposure for generalized anxiety disorder closely resembles imaginal exposure to intrusive images used in CBT for obsessive-compulsive disorder and to traumatic memories used in generalized anxiety disorder for posttraumatic stress disorder. The patient is encouraged to form detailed and sensory-rich images—incorporating imagery of the physiological manifestations of the emotional experience—representing the content of his or her worry. To ensure that the patient is not distracting from the negative content of the worry theme, the therapist periodically asks the patient not only to report SUDs ratings but also to verbalize the content of the imagery. To keep verbal encoding to the minimum necessary to ensure that the patient is not distracting from the negative content, the patient is encouraged to focus silently on the imagery in-between the periodic requests for SUDs ratings and verbal descriptions of the imagery. That is, the patient alternates back and forth between silent periods of relatively pure imagery and periods of describing the imagery aloud. As in imaginal exposure for posttraumatic stress disorder (e.g., Foa & Rothbaum, 1998) and obsessive-compulsive disorder (e.g., Foa & Wilson, 1991), the patient is encouraged to imagine that the events are taking place in the present moment and is then asked to elaborate on the sensory aspects of the imagery including the kinesthetic cues if not spontaneously doing so.
Empirical Support
Though some CBT packages include self-control or coping desensitization that involves first imagining anxiety-provoking situations and then imaginal rehearsal of somatic and cognitive coping with anxiety in those situations and others have made use of imagery to aid in the identification of negative automatic thoughts (e.g., Borkovec & Costello, 1993; Borkovec & Mathews, 1988; Borkovec, Newman, Pincus, & Lytle, 2002), only two packages include prolonged exposure to negatively valenced images: First, the Mastery of Your Anxiety and Worry (MAW) treatment package includes imagery exposure and relaxation as two of its major components with cognitive restructuring as its other major component (Craske & Barlow, 2006; Craske et al., 1992; Zinbarg, 1993; Zinbarg et al., 2007). Second, a package developed by Dugas and colleagues includes imagery exposure, cognitive restructuring (focused on altering positive beliefs about worry and increasing tolerance for uncertainty), and problem solving (Dugas, Gagnon, Ladouceur, & Freeston, 1998; Ladouceur et al., 2000).
Ladouceur et al. (2000) found CBT for generalized anxiety disorder incorporating imagery exposure led to significantly greater improvement than a wait-list condition on all 6 variables they used as outcome measures. These gains were maintained at 6- and 12-month follow-ups, and the percentage of treated patients reaching HES on at least 5 of the 6 measures was 62% at posttreatment and 58% at 12-month follow-up. Dugas et al. (2003) adapted this package for administration in a group therapy format and found significantly greater improvement than in a wait-list condition on all 7 variables they used as outcome measures. Again, these gains were maintained over a 2-year follow-up interval. Finally, 65% of the treated participants reached HES at posttreatment on at least 5 of the 7 measures as did 72% at the 2-year follow-up.
Wetherell, Gatz, and Craske (2003) adapted the MAW program for a late-life sample (mean age 67 years) and compared it to a discussion group pertaining to worry provoking topics, and to a wait-list control. The MAW condition was clearly more effective than the wait-list control (i.e., 5 out of 10 study measures) and marginally more effective than the discussion group (i.e., 1 out of 10 study measures). However, consistent with other evidence for poorer generalized anxiety disorder treatment response in older age groups (e.g., Stanley, Beck, et al., 2003), rates of HES on 3 of the 4 major outcome measures were low, with only 28% of the MAW program condition achieving HES at follow-up.
Zinbarg et al. (2007) studied the major components of the MAW program—relaxation training, cognitive restructuring, and imagery exposure—for generalized anxiety disorder. Eighteen participants completed either a 12-session individual therapy (n = 8) or a wait-list condition (n = 10). Results showed significantly more improvement in the treatment group on 4 of 5 outcome measures. Fifty percent of the treated participants reached HES at posttreatment on at least 4 of the 5 measures. Using a HES cutoff closer to that used by Dugas et al. (2003) and identical to that used by Barlow, Rapee, and Brown (1992), 66.7% reached HES on at least 3 of the 5 measures.
Taken together, the results reported by Ladouceur et al. (2000), Dugas et al. (2003) and Zinbarg et al. (2007) provide strong evidence for the efficacy of CBT packages that include imagery exposure. Wetherell et al. (2003) obtained smaller effect sizes in a late-life sample, although the marginally superior outcomes from CBT incorporating imagery exposure compared to the discussion group are notable because prior research in elderly samples has failed to find differences between standard CBT and discussion control groups (e.g., Stanley, Beck, & Glasco, 1996).
The HES functioning results suggest that these packages might be more efficacious than standard CBT packages for generalized anxiety disorder. Barlow et al. (1992) and Butler et al. (1991) reported posttreatment HES rates of only 36% and 32%, respectively compared to 62% to 66.7% in the three studies incorporating imagery exposure. However, whereas imagery exposure may be accounting for these larger effect sizes, many other differences among these studies could also account for the larger effect sizes and dismantling studies are needed to definitively answer this question.
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