topic 4 dq 1
Topic 4: Behavioral Therapy And Rational Emotive Behavior Therapy (REBT)
Objectives:
1. Analyze behavioral and rational emotive behavior therapies in terms of the role of client and counselor, goals of counseling, and types of counseling techniques employed.
2. Describe counseling populations for which behavioral and rational emotive behavior therapies have empirical evidence of their effectiveness.
3. Analyze concepts reflected in behavioral and rational emotive behavior therapies that are important in the development of a counselor.
Topic 4 DQ 1 (Obj. 4.1, 4.2, and 4.3)
Assessment Description
Joseph is a client of yours doing outpatient counseling, one on one at least once a week for social phobia. He presents with intense anxiety, fear of being judged by others, intense negative self-judgments, and has dropped out of college because of these fears.
Using behavioral therapy techniques, describe your approach to helping Joseph overcome his social phobia.
· What is the behavior you would like to change?
· Using concepts of behavioral reinforcement, how can this be achieved?
· How long do you think this would take to make this change?
https://www.samhsa.gov/ebp-resource-center
Box 8.1
John B. Watson on Behavior and the Concept of Mental Disease
For some years I have been attempting to understand the physician’s concept of mental disease. Not long ago I had the pleasure of attending a medical meeting and of listening to a physician who has been very successful in his treatment of neurasthenia. Several cases of neurasthenia were described. Since none of the patients showed general organic disturbances of a serious kind and since all of the neurological tests showed normal functioning of the reflexes of the central nervous system, the physician concluded that the disease was “purely mental.” He then began to describe the condition of such a patient’s ego—the general content of consciousness, the inward reference of attention, and the peculiarities of the field of attention. At the end of his discourse two or three eminent physicians stated their satisfaction that the speaker had been willing to come out clearly and say that the disease was “mental.” In other words, they expressed their approval of the fact that the speaker did not, in functional nervous cases, deem it necessary to find lesions in the central nervous system or even a toxic condition of the nervous system before admitting that the patient had a disease.
Being the only psychologist present, I did not like to admit that I did not understand the physician’s use of the term “mental.” (I do not wish by this assertion to stir up strife or bitter argument, but rather to confess ignorance on my own part and to seek for some common ground of discussion.) As a sequel to this meeting I began to attempt to formulate my own ideas as to the terminology I should use in describing a mental disease. I think that at the outset I should admit that I know a good deal more about terminology than I know about diseases of any kind. I am strengthened in this attempt to give my concept of mental diseases by the difficulty I have had in understanding the terminology (involving throughout and often transcending the current concept of consciousness) of the psychoanalytic movement.
I have been for some years an earnest student of Freud (and other psychoanalysts), but the further I go into their terminology [p. 590] the more sure I am that there is a simpler and a more common-sense way (and at the same time a more scientific way) of describing the essential factors in their theory. I am convinced of the truth of Freud’s work, but as I teach the Freudian movement to my classes I drop out the crude vitalistic and psychological terminology, and stick to what I believe to be the biological factors involved in his theories (Freud himself admits the possibility of this). The central truth that I think Freud has given us is that youthful, outgrown, and partially discarded habit and instinctive systems of reaction can and possibly always do influence the functioning of our adult systems of reactions, and influence to a certain extent even the possibility of our forming the new habit systems which we must reasonably be expected to form.
… I think the chief difficulty in completing the description in terms of the every-day language of habit formation lies in our failure to look upon language (the patient’s here) as being only a system of motor habits. As a short cut—a system of economy—the human animal has formed a system of language habits (spoken words, inner speech, etc.). These language habits are built up from and always correspond more or less closely to the general system of bodily habits (I contrast here for convenience of expression language habits and bodily habits) such as the eye-hand, ear-hand, etc., systems of coordination and their complex integrations. This general correspondence between language and bodily habits is shown clearly in the football field, where we see the player making a complex series of movements and later hear him stating in words what systems of plays he employed; and in the case where we hear a man tell us what acts he is going to perform on a horizontal bar and later see him executing these acts. Words have grown up around motor acts and have no functional significance apart from their connection with motor acts. I have come recently to the view that speech should be looked upon as a vast system of conditioned reflexes … Words as words are learned largely by imitation, but words receive their standing as functional units in integrated habit systems by virtue of the fact that they become substitutable for the stimulus which originally initiated an act. A simple illustration will possibly serve to make clear my point. The cold air from an open window leads a child who has gone to bed to draw up the covers. The words of the nurse “cover up, dear” will lead to the same act. Of course in habit systems as complex as those in speech, words get further and further divorced from the original stimuli for which they were substituted (i.e., from the original integrations in which they first played a part). The final test of all words, however, is the question whether they can stand adequately (be substituted) for acts. We often see an instructor despair of telling a student in words how to conduct an experiment. He then resorts to acts and goes through the experiment for the student. Our words thus stand as a kind of shorthand sketch of our repertoire of acts and motor attitudes.
Source: Watson, J. B. (1916). Behavior and the concept of mental disease. Journal of Philosophy, Psychology, and Scientific Methods, 13, 589–597.
Watson and his graduate student (and later, second wife) Rosalie Rayner applied Pavlov’s ideas about conditioning to create conditioned fear in their famous report about Little Albert (see Box 8.2; J. B. Watson & Rayner, 1920/2000). Later, Watson’s student Mary Cover Jones (1924/1960a) used these ideas to eliminate fear in a 3-year-old boy, Peter (see Box 8.5). It is also interesting that Jones (1924/1960b) acknowledged the usefulness of observational learning (see the brief description in the following paragraphs) in her discussion of eliminating children’s fears.
Box 8.2
Shirley is a 79-year-old single White female. She has been married twice; both husbands are deceased. Shirley has no children and no surviving relatives. She does not work; she lives on Social Security and income from pensions.
Shirley was ordered to come to counseling by the municipal court because she has been caught shoplifting on multiple occasions. Mandated counseling was assigned as an alternative to traditional sentencing after she was recently arrested. Based on her description of the incident that brought her to counseling, it appears that Shirley was an ineffective thief. She did not check to see if she was watched; instead, she just grabbed some items and headed out the door of a department store.
Shirley was a last-born child, raised in Chicago. She describes a very unhappy relationship with her mother, whom she characterizes as unloving, harsh, and domineering. She describes a good relationship with her father, although she resented that he never stepped in to protect her from her mother. Shirley graduated from college with a degree in finance and was one of the few women working in business in the 1940s. She describes herself as very successful at her job managing investments, despite being in a male-dominated career. Her first husband was a military officer. After they married, Shirley left her job and moved with her husband through a number of assignments across the United States and Southeast Asia. Shirley’s second husband owned an auto parts store. During this marriage, Shirley focused on her role as a homemaker and was involved in volunteer work in her community. Shirley portrays both of her marriages as very happy and rewarding.
Currently, Shirley reports being involved in community service with older adults, helping out at a senior citizens’ center about once a week. She no longer drives a car, instead relying on the bus for transportation. Shirley lives alone in an apartment and reports that she has few social contacts outside of her volunteer work.
As she reluctantly discusses her shoplifting, Shirley says that she has recurrent obsessive thoughts about stealing when she is in a store. She describes a feeling of anxiety that does not subside until she has stolen something and left the store. Shirley immediately feels guilty about her actions. She says that she never steals anything particular; it does not matter what she takes. Shirley reports that she first began to steal things when she was in her 40s, after the death of her mother. Her first husband knew about the shoplifting, but she was better able to control it back then. Her second husband apparently never knew about it. Shirley has not experienced legal difficulties as a result of her stealing until recently.
Shirley is unhappy about being referred to counseling. She believes that she is the only one who can prevent her “compulsive stealing” as she terms it, and that therapy can do little to help her. Shirley is extremely embarrassed to see a counselor and expresses a good deal of shame about her behavior.
The Story of Little Albert
John B. Watson was a famous behaviorist. In 1920, he and his graduate student Rosalie Rayner decided to see if they could create human fear through conditioning principles that Watson had outlined in an earlier article (J. B. Watson & Morgan, 1917). They chose as their subject of study Little Albert, an 11-month-old infant whom they described as “stolid and unemotional” (J. B. Watson & Rayner, 1920/2000, p. 313).
Watson and Rayner presented a white rat to Albert. When Albert touched the rat, a loud noise was made by banging a steel bar with a hammer. Albert immediately showed signs of distress and on the second pairing began to cry. Seven subsequent pairings were conducted, and it was clear that the presentation of the rat produced a strong reaction because on the last trial Albert “raised himself on all fours and began to crawl away so rapidly that he was caught with difficulty before reaching the edge of the table” (J. B. Watson & Rayner, 1920/2000, p. 314; emphasis in original).
Watson and Rayner also tested whether the conditioned emotional response would transfer to other stimuli. They presented Albert with a rabbit, dog, sealskin coat, cotton wool, and Santa Claus mask. All of these presentations evoked responses from Albert, as did Watson’s hair. Albert’s reactions were similar 5 days later. Finally, the researchers looked at the effect of time on the conditioning, finding that 31 days later the fear reactions still persisted, without any further pairing of the noise and stimuli.
Unfortunately for Albert, he was mysteriously removed from the hospital a day after the tests of persistence were made. Watson and Rayner never had the chance to decondition him, although they speculated that either pairing feared objects with food or sexual stimulation or simply repeatedly presenting the feared stimuli until habituation occurred would cause the “fatigue” of the reflex.
True to his behaviorist ideology, Watson (and Rayner) took on the Freudian perspective in the report’s discussion. “The Freudians twenty years from now, unless their hypotheses change, when they come to analyze Albert’s fear of a sealskin coat—assuming that he comes to analysis at that age—will probably tease from him the recital of a dream which upon their analysis will show that Albert at three years of age attempted to play with the pubic hair of the mother and was scolded violently for it” (J. B. Watson & Rayner, 1920/2000, p. 317).
The second model of learning, the operant model, originated with the work of E. L. Thorndike, who studied the behavior of cats. He would put cats in a puzzle box and entice them to figure out how to get out of the box by placing food outside. Thorndike noticed that in repeated trials the cats became faster and faster at getting out of the box. From his observations, he formulated the law of effect, which proposed that behavior is learned through its consequences.
B. F. Skinner is probably the most famous name associated with the operant approach, which is sometimes called radical behaviorism. The focus of this approach is on the consequences of behavior. Skinner, who performed most of his research with laboratory animals (rats and pigeons), was aware of the potential applications of his science of behavior to developing intervention techniques for people, but he did not pursue this (Spiegler, 2016). In fact, Skinner and his colleagues were credited with the first use of the term behavior therapy in a report on using conditioning principles with hospitalized schizophrenics (Fishman et al., 2011). However, Skinner was more interested in broad applications of his work, such as in his novel Walden Two (1976), in which he describes a community based on behavioral principles. Others went on to apply the principles outlined by Skinner to working with psychological dysfunction, as was the case with Ayllon and Azrin, who developed the notion of token economies (Glass & Arnkoff, 1992). Token economies are systems of behavior change based on the awarding of a token, such as a coin, for performing desired behavior. Tokens can then be exchanged for other things desired by the participant, such as coveted food, toys, or recreational time.
A third force in BT came from the work of Albert Bandura, who recognized the power of observation in learning (Spiegler, 2016). Bandura (1969, 1974) developed social learning theory, which emphasizes the role of social events such as the observation of others in learning. The individual who demonstrates a behavior is called the model, and hence this approach is sometimes referred to as modeling theory.
Recognizing the power of observation was a revolution because it turned our attention to cognitive processes in learning. Bandura discovered that his participants could learn a behavior through observation and then, placed in the same situation, refuse to perform it. This finding led to the assumption that the learning is stored cognitively in some way (Kazdin, 2012). In current applications, modeling is typically combined with other behavioral techniques, such as when a counselor models a desired social skill as a prelude to teaching it to the client (Antony et al., 2020). The label social-cognitive theory is often used to describe the current version of social learning theory (Antony, 2019).
It is difficult to discuss the history of BT without pointing to the influence of Hans Eysenck and his controversial study of psychotherapy, which I reviewed in Chapter 1. Psychotherapy was the term that Eysenck, a classical conditioning behaviorist, used to refer to approaches other than behavioral, and he expended a great deal of energy attempting to discredit the former and promote the latter. A particularly rabble-rousing quote from Eysenck (1960) is the following: “Learning theory does not postulate any such causes, but regards neurotic symptoms as simple learned habits; there is no neurosis underlying the symptom, but merely the symptom itself. Get rid of the symptom and you have eliminated the neurosis” (p. 9; emphasis in original).
BT is currently a vital approach, and the prominent professional association of these counselors is the Association for Behavioral and Cognitive Therapies (ABCT; www.abct.org). It was formed in 1966, and until 2005 was known as the Association for Advancement of Behavioral Therapies (the name change should tell you something). The Behavior Therapist is the official journal of the ABCT.
A subcategory of BT is applied behavior analysis, or ABA. ABA is the term generally used for an approach to working with individuals diagnosed with autism that is grounded in the principles of operant learning (although to be fair, its proponents argue that ABA is useful in many more contexts than just with those who have autism). You might often hear this approach called the Lovaas method, named for the psychologist who published groundbreaking research on intensive behavioral therapy with kids. Lovaas (1987) claimed that half of the children in his study achieved average intelligence assessments after the very intensive treatment (40 hours per week for over 2 years). Although there are criticisms of this method, it is still widely used and is considered very effective (Sadavoy & Zube, 2022). An organization for the applied behavior analysts is the Association for Behavior Analysis International (www.abainternational.org).
The first journal exclusively devoted to BT was Behavior Research and Therapy, originated by Eysenck and Rachman, and the first to promote operant principles was the Journal of Applied Behavior Analysis, which debuted in 1968 (Fishman et al., 2011). There are many journals devoted to BT, including Behavior Research and Therapy and Behavior Modification. Division 25 of the American Psychological Association is the Division of Behavior Analysis (www.apadivisions.org/division-25). In testimony to its historical roots, Division 25 sponsors a B. F. Skinner award for innovative research on a yearly basis.
S. C. Hayes et al., (2006) identified a third wave of BT approaches that are cognitively oriented, but focus more on the context and function of thought than the specific content of it (as does, for example, classic cognitive therapy; see Chapter 10). That is, these approaches, particularly acceptance and commitment therapy (ACT), look at the situation in which thoughts occur and the effects of the thoughts in terms of behavior and beyond to life satisfaction. Chapter 16, “Mindfulness Approaches,” reviews two of these: ACT and dialectical behavior therapy.
Historically, BT theorists engaged in very little discussion of diversity, broadly defined. However, one technique that is seldom used today, aversive conditioning, was at the center of a controversy regarding sexual orientation. One “problem” to which this type of technique was applied was homosexuality. In the 1960s, there was a flurry of interest in changing sexual orientation, and many times this was approached by showing clients same-sex erotic stimuli (e.g., photographs) while administering shock. The shock was terminated when heterosexual erotic materials were presented (Haldeman, 1994). Of course, the ethics of such treatment were eventually questioned, even when used with men who voluntarily sought such treatment. The ethical issues, arguments about whether these techniques really produced aversion, and lack of support for their effectiveness resulted in their abandonment in the 1970s (Haldeman, 1994; LoPiccolo, 1990).
Contemporary BT advocates are vocal about their attention to diversity. Antony et al., (2020) commented on cultural sensitivity in BT, describing ways in which it can be adapted for individuals of diverse backgrounds. As you will see in the sections on diversity and research, there currently is much interest in adapting behavioral techniques (mainly referenced as CBT) for a wide range of client presentations and identities.
Basic Philosophy
Because contemporary BT is more of a general orientation than a specific theoretical approach, the assumptions behind the orientation are helpful in understanding how it is currently practiced. Martell (2007) outlined eight basic principles of BT; these are listed in Box 8.3. I will present here a general overview of the philosophy of the approach, which will touch on these principles.
Box 8.3
The Principles of Behavioral Therapy
Behavior, whether public or private, is strengthened or weakened by its consequences.
Behaviors that are rewarded are increased; those that are punished will decrease.
The approach is functional rather than structural.
Neutral stimuli, paired with positive or negative environmental stimuli, can take on the properties of the environment in which they are presented and be conditioned to be positive or negative.
Behaviorism is antimentalist.
Behavior therapy is data driven and empirically based.
Changes clients make in therapy must generalize to their day-to-day lives.
Insight alone is not beneficial to a client.
Source: From Martell, C. R. (2007). Behavioral Therapy. In Rochlen, A. (Ed.), Applying Counseling Theories: An Online, Case-Based Approach, pp. 143–156. Prentice Hall. Used with permission.
Behaviorists tend to take a neutral view of human nature. Although they recognize genetic influences, ultimately they believe behavior is determined by the environment, so to rate humans as inherently “good” or “bad” is useless (B. F. Skinner, 1971).
Behavior therapists tend to emphasize, as you might expect, behavioral descriptions of people rather than trait descriptions (Spiegler, 2016). They are more likely to describe how someone talks (e.g., they speak very quickly) than to characterize someone using trait descriptions (they are snotty). At the extremes, behavioral therapists would rather discuss behavior disorders or problems in living than traditional diagnostic categories because the latter are imprecise and involve trait language. However, a review of BT resources will demonstrate that traditional diagnostic categories are often used for organizational purposes.
Early resources, such as Ullmann and Krasner’s (1965) classic Case Studies in Behavior Modification, pointed out that traditional approaches to behavior change were based on what they called the “medical model” (p. 2). In this approach, also called the disease model, a person experiencing psychological difficulties is viewed as sick or diseased, and the sickness results from some underlying causal factor or mechanism inside the individual (such as repressed conflicts). What needs to be changed, then, is the underlying cause, not the symptom. If you don’t treat the cause, you get more symptoms—perhaps different ones, but symptoms just the same; this process is called symptom substitution. Taking a medical approach to psychological dysfunction leads to a “doctor knows best” attitude because the real causes of behavior can’t be seen. Diagnosis becomes central in the medical model, which should then guide treatment.
In stark contrast to the medical model, BT adopts the psychological or learning model of dysfunctional behavior, which focuses on overt behavior—and in the case of CBT, cognition, too. In this model, the symptom is the focus of attention rather than the assumed underlying causal factor(s). Behavior is seen as simply behavior, which gets defined as pathological because it deviates from social norms (Bandura, 1969). BT counselors see themselves as scientists who rely on the results of experimental studies of learning to help their clients. They do not search for deep, hidden causes of behavior; it is not necessary to know the origins of a problem to solve it (Spiegler, 2016).
Historically, a controversy within the ranks of behavior therapists has centered on the roles of cognition and emotion in human behavior. These arguments allow the identification of several varieties of BT, ranging from radical behaviorism to cognitive-behavior modification. Radical behaviorism, rooted in the ideas of Watson and Skinner, would totally exclude cognitive or otherwise inferred processes from causal explanations of behavior (Goldfried & Davison, 1994). That is, although these theorists recognize that thoughts and feelings exist, they can be controlled or modified using the same manipulation of antecedents and consequences as any other behavior (Rummel et al., 2012). A more moderate position is the one that was presented by Martell (2007): “behaviorists do not accept that there is a mind apart from the body” (p. 147). At the extreme, these theorists adhere to an “outer model of psychopathology” and accused cognitively oriented behavior therapists of adopting the medical model because they pay attention to events inside people that cannot be observed directly (Reitman, 1997, p. 342).
At the other end of the spectrum fall the cognitive-behavior therapists and social learning theorists, who allow for the influence of internal events such as cognition and imagery in understanding and changing behavior. Most behavior therapists today probably fall into the cognitive-behavioral camp; in fact, as early as 1982 a study of the members of ABCT showed that a majority of them used cognitive techniques (Gochman et al., 1982), and Craighead (1990) reported that 69% of respondents to an ABCT membership survey characterized themselves as cognitive-behavioral in orientation. To clearly describe behavioral principles, my presentation of BT will rely mostly on classic discussions of the theory; readers should keep in mind that current practices are pragmatic and integrative (Antony et al., 2020). Cognitive techniques will be covered more extensively in Chapters 9, 10, and 17.
JaNelle is the behavior therapist who accepts Shirley as her client. She is a moderate behavior therapist who, at times, attends to cognitive processes. Approaching Shirley with a neutral attitude, JaNelle assumes that Shirley’s behavior is mostly environmentally determined. She is aware that some therapists (and indeed some behavior therapists) would associate Shirley’s behavior with a Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2022a; Fifth Edition-TR; DSM-5) diagnosis of obsessive-compulsive disorder. JaNelle prefers to simply describe the behavior and look for the elements that support it. JaNelle is also interested in the cognitions that Shirley has at the times when the problem behavior occurs.
Human Motivation
Behaviorists see humans as motivated to adapt to the environment. Adaptation in this view means survival; thus, our behavior serves to obtain things that help us survive—things that then become valuable to us, or reinforcing—and to move us away from behaviors or experiences that don’t promote survival—experiences that then become aversive. According to Skinner (1971), “The process of operant conditioning presumably evolved when those organisms which were more sensitively affected by the consequences of their behavior were better able to adjust to the environment and survive” (p. 114). On a more general level, Wolpe (1990) defined adaptive behavior as that which “actually results in satisfying the individual’s needs, brings them relief from pain, discomfort, or danger, or avoids undue expenditure of energy” (p. 8).
JaNelle sees Shirley’s behavior simply as the most recent way she has adapted to the environment. Shirley seeks positive stimulation and avoids aversive situations. In this way, Shirley is seeking the resources she needs to survive and moving away from experiences that might be harmful. Unfortunately, Shirley’s behavior has become maladaptive for her because it places her in opposition to society. Getting resources (i.e., items from the store) is adaptive in some ways, but social rules have determined that Shirley’s behavior is dysfunctional.
Central Constructs
To understand contemporary BT, it is helpful to know the three major models of learning: classical, or Pavlovian; operant, or Skinnerian; and observational, or modeling. The first two approaches generate a distinct set of techniques, whereas the theory of observational learning is generally applied as a way to enhance operant and classical interventions through adding attention to cognitive and social influences on behavior (Bandura, 1969). Although the distinctions among the models can be fuzzy, and the connections between the models and techniques are not as simple as one would like, I present the models because a basic understanding of learning principles is useful in many situations.
Classical Conditioning
Classical conditioning is thought to be an involuntary, reflexive process (Ullmann & Krasner, 1965). In this model, a relation between a stimulus and response that is presumably “wired in” for evolutionary reasons gets associated with a new stimulus, which can then elicit the response. For Pavlov, this sequence had to do with a bell, food, and dog saliva. We could diagram this relation in humans as follows:
8.4-1 Full Alternative Text
This classical conditioning model is the basis of Wolpe’s approach to changing dysfunctional behavior, which he called reciprocal inhibition (Wolpe, 1960, 1990). Wolpe reasoned that anxiety is a dysfunctional behavior when it occurs in circumstances in which there is no objective threat to the person (Wolpe, 1960). The idea is that anxiety (the unconditioned stimulus, or UCS) gets conditioned to some stimulus that is normally not anxiety provoking (the conditioned stimulus, or CS). In other instances, anxiety is a natural and adaptive response, or the “autonomic response pattern or patterns that are characteristically part of the given organism’s response to noxious stimulation” (Wolpe, 1960, p. 88).
A little green garden snake, for example, is not really an occasion for a major anxiety attack because it is not harmful to me (provided that I have correctly identified it). So why do I jump and scream when I see one of these little critters? Using a classical conditioning model, we would see the snake as a CS, having been paired with some other natural event that was indeed threatening or noxious, the UCS. That other event (and we often don’t know what it is) is what originally evoked the anxiety. The snake now evokes anxiety because of its earlier association with the UCS.
The association between a conditioned stimulus and a conditioned response can be weakened or eliminated by repeated presentation of the CS in the absence of the UCS, a process called extinction (Wolpe, 1990). For example, Pavlov could repeatedly ring his bell and never present food to the dog. Eventually, the dog will stop responding with salivation when the bell rings because it hasn’t gotten any food in a long time—the salivation response is extinguished. Some BT techniques are based on the principle of extinction, such as when an individual (maybe your author?) is made to sit in a room with a garden snake until their anxiety goes away, a procedure called exposure therapy. You will learn more about exposure interventions later in the chapter.
Because Shirley’s problem behavior involves anxiety, JaNelle considers the possibility that classical conditioning is involved. Somehow, anxiety has been associated with being in a store for Shirley, and it disappears when she steals something and leaves the store. JaNelle wonders if Shirley has somehow associated being in a store with a truly threatening situation that would logically lead to anxiety. Perhaps she experienced a life-threatening event in a store in the distant past. In terms of intervention, it does not matter how or when the original conditioning occurred, except that JaNelle needs to be sure that the anxiety is conditioned to the store, not something else. For example, the problem could be more general. Shirley might experience anxiety every time she leaves her home. JaNelle knows that she needs to explore this issue with Shirley as well as the abrupt cessation of the anxiety that she experiences upon leaving the store.
Operant Conditioning
Developed most elegantly by B. F. Skinner, the operant learning model starts with the idea that behavior is maintained by its consequences. The term operant is used because it emphasizes that behavior operates on the environment to produce consequences that, ideally, contribute to the person’s adaptation (Nye, 2000; Skinner, 1953); it contrasts with respondent (classically conditioned) learning, in which the behavior considered is seen as sort of automatic.
In the operant model, behavior is said to be contingent upon its consequences (Skinner, 1971). Reinforcement is the formal term for consequences that maintain a given behavior. That is, reinforcers are consequences that increase the probability that a behavior will occur. Whether a particular event is reinforcing is a function of an “individual’s biological endowment, learning history, and current situation” (Milan, 1990, p. 71). To take a simple example, some people like salty foods, and others like sweet foods. The reinforcement value of potato chips is higher for me compared to that of chocolate.
Two kinds of reinforcers can be distinguished—positive and negative (Skinner, 1953). Positive reinforcers increase the likelihood of a behavior occurring because something good is presented following the appearance of the desired behavior. Negative reinforcers increase the probability of behavior through the removal of aversive stimuli. Keep in mind here that the terms positive and negative are not used in the ways we typically use them. In BT language, positive refers to the addition of something that causes behavior to increase, whereas negative refers to the removal of something, resulting in an increase in behavior (Nye, 2000). In other words, do not confuse negative reinforcement with punishment. When Mom pats little Johnny on the head after he does a cartwheel, she has employed positive reinforcement; you are likely to observe more cartwheels. When Dad gives Laura a cookie to stop her tantrum, Dad’s cookie-giving behavior is negatively reinforced; it terminated an aversive stimulus (the tantrum). You will likely see Dad give cookies when future tantrums appear. Note that Laura’s tantrum behavior is positively reinforced, assuming that she likes cookies and has not just eaten a truckload of them. Box 8.4 gives another example of positive and negative reinforcement.
Box 8.4
Behavior Modification in Humans and Felines
I have a cat. His name is Skat, but he is also known as the Cat from Hell. Skat the Cat is, like most cats, used to going where he wants to when he wants to. Skat is equally comfortable roaming the neighborhood or sleeping on my feet.
Sometimes Skat the Cat wants inside when he is, in fact, outside. He is not very patient, and one way of demonstrating this is through screen-scratching behavior. Clearly, someone at some point must have let him in the house following screen-scratching behavior, thereby positively reinforcing his screen-scratching behavior (it was not me, of course). As a good student of behavior modification, I would never positively reinforce screen-scratching behavior, yet because some visitor(s) have, this behavior is on an intermittent schedule of reinforcement with a very long interval. The intermittent schedule thus accounts for Skat’s persistence in the behavior—he has been known to keep it up for hours … despite it being 3 a.m.
What is my response to Skat’s behavior? I consider screen-scratching behavior an aversive stimulus, so my first impulse is to yell at him. This behavior on my part, as you might guess, is extinguished very quickly because it produces no change in the noxious stimulus. I could opt for an extinction approach (i.e., never opening the door), but because he is apparently on a long-interval intermittent schedule, it would take a very long time and many screen replacements to extinguish his behavior. Chasing him away is even more aversive to me because I must get out of bed in the middle of the night to do so. Also, Skat might just find my chasing him a positive reinforcer! “Hey look! I got Mom out of bed and all upset! This is fun! Maybe I can get her to do it again!”
One night I had a glass of water at hand and, perhaps vaguely remembering some observed relationship between Skat’s behavior and the experience of getting wet, decided to throw the water thorough the screen. Bingo! Skat was gone … and my water-throwing behavior was negatively reinforced. The noxious stimulus of screen scratching was terminated as a result of my water-throwing behavior. The next time he appeared at the screen, guess what I did? (I threw the water, of course.)
But what of Skat’s behavior? Because screen scratching was immediately followed by a consequence that decreased the probability of that behavior, we conclude that he experienced punishment. Now we know that punishment merely suppresses behavior and could have some other problematic consequences, such as avoidance, but Skat likes inside and food too much to avoid me altogether. Instead, he substituted another behavior for screen scratching, a very loud meow. Choosing the lesser of two evils, I now immediately let him inside when he yowls (thus positively reinforcing the yowling behavior). Every now and then he delicately puts a few claws on the screen to show me that he has not forgotten his power and then yowls. Mostly, though, we are satisfied with the contingencies we have established.
Reinforcers come in all shapes and forms. The most basic reinforcers are food and sex because they relate to the evolutionary goals of survival and reproduction (Nye, 2000). Skinner (1953) called these primary reinforcers. Many things are reinforcers because they have been historically linked with survival. Skinner (1971) gave the example of a person moving out of the hot sun into the shade. The behavior of moving is reinforced by the reduction in temperature that follows, which is presumably good for the organism’s survival.
Unfortunately for neophyte behavior modifiers, though, what is reinforcing to one person may not be to another. The power of a given reinforcer can also vary across time. Many things affect whether a given consequence is reinforcing; for example, food is not reinforcing just after a big gourmet meal. Too much of a good thing is called satiation; the power of a reinforcer is decreased in these circumstances (Skinner, 1953).
Many things become positively reinforcing because they are associated with gaining desired outcomes; they are not the desired consequence itself. These conditioned reinforcers become reinforcing because they tend to occur at about the same time that reinforcement occurs (almost in a classical conditioning sense; Skinner, 1953). Some stimuli occur in the presence of many kinds of reinforcers, and these stimuli become generalized reinforcers. Money is a good example of a generalized conditioned reinforcer. The paper or metal substance is not in itself positively reinforcing, but it becomes so because it is associated with getting reinforcing things (food, clothes, or other things that support survival). Attention from others is a conditioned reinforcement, presumably because babies have to get someone’s attention to get things that meet survival needs, such as food or clothing (Ullmann & Krasner, 1965). Manipulating the environment is a generalized reinforcement because many kinds of reinforcers occur only following such behavior (Skinner, 1953).
Sometimes a stimulus in the environment signals that a given contingency is operative. This is called a discriminative stimulus, and you can think of it as a traffic light of sorts. When the light is green, a behavior such as walking across the street will result in reinforcement (getting to where one wants to go, a conditioned reinforcer). When the light is red, it is a signal that behavior will not be reinforced (i.e., you could get hit by a car and smushed, which would be considered punishment, I think). As we all know, however, a traffic light is not truly a discriminative stimulus because, if you are careful, you can still walk across the street on a red light and receive the reinforcer of getting to the other side. Perhaps a better example would be a light on a drawbridge. If you go against the red light, you will not be reinforced; instead, you will probably be punished unless you are a very good swimmer!
When behavior becomes controlled by discriminative stimuli, it is said to be under stimulus control. Discriminative stimuli can become conditioned reinforcers, as in the case of money. The acquisition of money becomes reinforcing because it signals that the behavior of giving money to others gets us desired things (food, swimming pools, shoes; Ullmann & Krasner, 1965).
Once a discriminative stimulus is established, generalization can occur, and the reinforced behavior will appear in situations in which a stimulus similar to the discriminative stimulus is present. For example, if Laura receives cookies from Dad when she throws a temper tantrum, Dad becomes a discriminative stimulus for tantrum behavior. Generalization is seen when Laura also shows tantrum behavior in the presence of other male adults or in the presence of adults in general.
Extinction is said to occur when the reinforcement maintaining behavior is removed and a response becomes less frequent and finally disappears (Skinner, 1953). The behavior is extinguished because the contingencies supporting it are no longer in effect. An important thing to know about extinction, however, is that early in the process “emotional behaviors,” such as anger or frustration, may occur (Skinner, 1953, p. 69). Also, the target behavior may intensify (i.e., increase in frequency or strength) under extinction conditions (Spiegler, 2016). For example, Sam exhibits loving behavior toward Sally, calling her daily on the phone and visiting her in the evenings. She reinforces him by cooking his dinner and allowing sexual contact. However, Sally suddenly decides that she no longer desires relationship behaviors with Sam and discontinues reinforcing his loving behaviors. At first, his phone-calling behavior intensifies; he calls her hourly and drives by her house every night. He probably displays some emotional behavior, such as anger or sadness. If Sally continues to ignore Sam, his behaviors of calling and driving by will eventually decrease and then disappear.
Reinforcements can be given after every response (called continuous reinforcement) or after some responses and not others (intermittent reinforcement). Resistance of the target behavior to extinction varies depending on the schedule of reinforcement (Skinner, 1953). Behavior reinforced intermittently is extremely resistant to extinction, whereas continuous schedules produce much less resistance. In the laboratory, behavior can be maintained in pigeons on a 1-in-10,000 response schedule (Skinner, 1953). My cat’s screen-scratching behavior is clearly on an intermittent schedule, with long intervals between reinforcements (see Box 8.4).
Punishment is the opposite of reinforcement; a punisher is anything that reduces the probability of a behavior occurring. For example, if I lock myself out of my house in the middle of January, I am strongly punished for this behavior because it results in (for me) an extremely aversive event (exposure to cold weather). It is unlikely that I will repeat this behavior, for sure.
Operant behavior is behavior that the organism freely emits. However, a desired behavior can be created by a process called shaping, in which responses that gradually more closely resemble the desired behavior are reinforced in a progression.
JaNelle wonders if operant learning could account for Shirley’s stealing behavior. From that perspective, stealing behavior would be reinforced by something. Normally, JaNelle might guess that the stealing behavior is reinforced by what Shirley acquires as a result. However, Shirley has indicated that she does not steal any particular object, which suggests that the objects themselves are not reinforcing. JaNelle guesses that the cessation of anxiety is highly negatively reinforcing to Shirley, so that leaving the store becomes a highly reinforced behavior. It is possible that on an earlier occasion Shirley experienced anxiety while in a store and resorted to a previously learned behavior of picking something up in a wild, almost random attempt to decrease her anxiety. She then fled the store. In a chaining process, the anxiety reduction reinforced the behavior of leaving the store, which then became a conditioned reinforcer that reinforced the stealing behavior.
Observational Learning
The idea that people can learn by viewing the behavior of others was developed by Bandura (1969, 1974). Also called social learning theory (Bandura, 1969), this approach incorporates the cognitive aspects of learning because what is learned through observation and later performed must be retained somehow, presumably in the brain. Observational learning plays a large part in the acquisition of new behaviors; it is much more efficient to learn a behavior vicariously than to randomly emit behaviors to be shaped by the environment (Bandura, 1969).
Consider learning to bowl. You’ve never bowled before, and your buddies drag you to the bowling alley. Trying to be a good sport, you put on your bowling shoes and take to the lanes. Almost automatically the first thing you do is watch someone else bowl. If one of your buddies is a teacher-type, they may take you through the process of a turn by showing you step by step how to wind up, move forward, and release the ball. Your buddy is the model. You learn the fundamentals without ever picking up the ball. Of course, you may need some practice to bowl a perfect game. Bandura (1969) pointed out that role-playing interventions often involve modeling because the client first observes the behavior on the part of the counselor before performing it.
Both dysfunctional and functional behavior can be learned through modeling. For example, a phobia can be acquired by watching someone else experience an anxiety-provoking event (Bandura, 1969; Wolpe, 1990). This phenomenon is called vicarious conditioning.
Modeling theory combines readily with operant theory because the consequences of the modeled behavior for the model influence the observer’s behavior as well (Bandura, 1969). If, for example, Marco sees other children praised for speaking up in class, he will be more likely to speak himself (if he values the teacher’s positive reinforcement). Likewise, punished behavior can be learned observationally and displayed when the punishment contingencies are not known to be in effect.
JaNelle wonders if modeling plays a role in Shirley’s behavior. Certainly, aspects of the stealing behavior could have been learned through modeling, but the observation that Shirley is not a successful thief would suggest otherwise. Had Shirley observed a good thief, she might have learned to be inconspicuous in her behavior and to hide the stolen object!
Theory of the Person and Development of the Individual
Traditional behaviorists are not interested in personality theory or developmental stages, although they do allow that personality is an abstract term that describes consistency in behavior across situations (Antony et al., 2020). They generally don’t see the term as very useful and prefer to discuss the individual’s learning history. Antony et al., (2020) acknowledge the role of all three identified models of learning (classical, operant, and social learning) in the development of what we like to see as personality, otherwise known as our learning histories.
JaNelle is not very interested in Shirley’s childhood. She is, however, interested in the history of the stealing behavior and asks Shirley to recount how it first started. Shirley remembers being in a store shortly after her mother’s death and getting panicky. She grabbed the first thing she saw (a really nice fountain pen) and left the store immediately. Afterward, she felt very guilty and ashamed, as well as fearful of returning to the store because they might catch her.
Health and Dysfunction
In the behavioral tradition, psychological health is seen as adaptive behavior, taking social and cultural context into consideration (Antony et al., 2020). Adaptive behavior is that which promotes the survival of the person. Although BT advocates acknowledge that genetics and biology have roles in behavior, they would assert that almost all behavior has learned components (Craske, 2017).
Psychological dysfunction is maladaptive behavior, and it arises from the same processes as adaptive behavior—namely, it is learned. In addition, maladaptive behavior can result from not learning—that is, deficits in skills (Spiegler, 2016). Whether a behavior is considered dysfunctional is dependent on whether it is adaptive or maladaptive for a given situation. Maladaptive behavior is not considered to be equivalent to mental illness or psychopathology, as it is in the medical model.
A classical conditioning perspective portrays psychological dysfunction as resulting from faulty conditioning of anxiety (or fear; the terms are used interchangeably) to behaviors (Wolpe, 1990). Essentially, fear is an unconditioned response that gets associated with a previously neutral conditioned stimulus. Although he did acknowledge that some behavior (e.g., nail biting, extreme stinginess, and nocturnal enuresis) is unrelated to anxiety (1990, p. 9), for Wolpe the majority of neurotic behavior is, in essence, simply habit learned in anxiety-provoking settings. Wolpe (1990) saw schizophrenia, antisocial personality disorder, and drug addictions as primarily biological in nature, although conditioning procedures could be used to alter some behavior patterns in these presentations.
Wolpe defined neuroses as “persistent maladaptive learned habits in which the foremost feature is anxiety” (1990, p. 23). These habits can be established in a variety of ways. First, neurosis can be based on simple classical conditioning, in which anxiety is aroused by a threatening situation and some stimulus in the situation is associated with the anxiety. This association can be established in one trial if the situation is traumatic enough. For example, the anxiety in a battle situation can become conditioned to the sound of gunfire or sirens. The individual knows that the sounds of gunfire or sirens are not immediately threatening but becomes anxious nonetheless when they hear them in a nonbattle situation.
Fear can also be vicariously conditioned, according to Wolpe (1990). Observing someone else’s extreme fear response to a stimulus might result in the observer acquiring a classically conditioned fear of that stimulus. If Damon, as a child, observed his mother reacting very fearfully to the sight of a Doberman Pinscher, he might develop the same fear of Dobermans, and maybe other large dogs, too.
In a similar process, neurotic fears can be brought about by misinformation (Wolpe, 1990). The old fear of masturbation causing blindness is a good example of this neurotic mechanism.
Although the classical conditioning approach appears to focus heavily on anxiety and the maladaptive behavior associated with it, Wolpe (1992) maintained that many forms of depression are based in anxiety as well. In fact, he estimated that 60% of depressions are neurotic, which in his view meant that they are based in anxiety.
JaNelle considers the possibility that Shirley’s anxiety in stores is classically conditioned somehow. When she asks Shirley about the history of her anxiety in stores, Shirley relates that she doesn’t remember anything in particular triggering the anxiety. She just started to get panicky while in a store one day. Although it is interesting that Shirley mentions that the attacks started shortly after the death of her mother, JaNelle does not consider this information particularly useful.
From an operant perspective, dysfunctional behavior is maintained by contingencies of reinforcement. Spiegler (2016) suggested two broad classifications of maladaptive behavior: behavioral excesses and deficits. Excesses are behaviors that are performed too strongly or too often (p. 55); I’d add to this group behaviors that are inappropriate or ineffective for a given situation. Behavioral deficits refer to situations in which individuals have failed to learn behaviors called for by the situation. From this perspective, excess behaviors are viewed as maladaptive responses maintained by existing environmental reinforcers. Deficit problems involve a lack of desirable behaviors—the individual just never learned them. A deficit in behavior can also result when the contingencies in a situation punish or simply do not reinforce the behavior.
A social learning perspective fits with the operant perspective because dysfunctional behavior can be learned, maintained, and suppressed by observations of models. If the individual is not exposed to the right models, they will not learn certain behaviors deemed important to a given cultural group, for example. If a child is never exposed to a dinner in which multiple forks are used, for instance, they will not know what to do when faced with a formal place setting.
Even though BT advocates don’t like formal diagnosis, they will still theorize about general diagnostic presentations. For example, some early operant theorists viewed depression as stemming from problems in the person’s range of actions, or what is called the behavioral repertory. Ferster (1973) conceptualized depression as resulting from an overuse of passive behaviors and a decreased incidence of adaptive, active behavior. Consequently, the depressed person receives little positive reinforcement from their environment (Ferster, 1983). Escape behavior is reinforced when the individual avoids the stress and anxiety of uncomfortable situations, such as when the passive, depressed individual avoids unpleasant events at work by staying home in bed. This conception of depression has led to the treatment strategy known as behavioral activation (BA; Dimidjian et al., 2011). The idea behind BA is to get the client moving so that positive reinforcement is obtained while blocking attempts to escape aversive experiences.
The cognitive behavior theorists have a lot to say about the role of cognition in psychological dysfunction; you will read more about these ideas in Chapters 9 and 10. Still other behaviorists point out that depression can result when an individual perceives no control over the world or, more accurately, when she perceives that there are no contingencies between her behaviors and outcomes. This “helplessness” view of depression suggests that the critical factor in affective states is “the person’s perception of his ability to control the world” (Goldfried & Davison, 1994, p. 234).
Social skills deficits, from an operant perspective, could be the result of faulty learning (i.e., the individual was reinforced for behaviors deemed socially inappropriate) or a simple lack of behaviors (i.e., the individual never learned social behaviors). Some social behaviors might have been punished.
JaNelle thinks that Shirley’s stealing behavior may be reinforced by the cessation of anxiety; that is, the stealing is negatively reinforced. When she enters a store, Shirley becomes anxious and then steals something so that she has to exit the store, thereby escaping the anxiety.
Nature of Therapy
Assessment
Assessment is very important in BT. Both formal and informal assessments are used, but behaviorists are most emphatic that they are not doing personality assessment or looking for underlying causes of symptoms. Multiple methods of assessment are recommended, from different sources (e.g., the client, their family, teachers). Assessment can be done with standardized instruments or just through simple observation. Spiegler (2016) recommended a multimodal assessment, covering overt behavior, cognition, emotions and physiological responses. The goal of assessment is to establish one or more target behaviors, which are to be modified in some way.
Traditionally, formal diagnosis (e.g., from the DSM-V) is not consistent with the BT model because it is based on the trait-oriented medical model and is thus far from a functional analysis of an individual’s behavior. However, Antony et al., (2020) wrote that many contemporary BT counselors have shifted toward a more symptom-oriented approach because recent research has been organized according to diagnoses, thereby creating treatment approaches to fit certain client presentations (e.g., panic disorder, phobia). BT therapists may also use formal diagnoses for pragmatic reasons, such as when required by third-party payers or specific treatment settings (Spiegler, 2016).
In BT, assessment is closely linked to intervention, and it focuses on the individual’s current behavior, with specific attention paid to antecedents and consequences, broadly speaking. A baseline, or frequency count of the target behavior over time, is typically established so that change in behavior can be clearly documented.
Assessment in BT can be seen as a functional analysis, and the acronym SORC tells us the elements of the analysis, which are stimulus, organism, response, and consequences (Antony et al., 2020). I think you know what S, R, and C are about at this point. The O for organism is there to account for individual differences, such as learning history and cultural factors. Another way to look at assessment is through the ABC model. A stands for antecedents, B for behavior, and C for consequences. From a BT perspective, assessment should cover all of these letters, and interventions can be made anywhere in the progression.
The most theoretically pure form of assessment is direct observation of the client by independent, trained raters across various life situations (Goldfried & Davison, 1994). Clearly, this is an expensive and cumbersome form of assessment, and it is rarely used except perhaps in institutional settings. Even in institutional settings, samples are used (e.g., a 10-minute observation taken eight times per day). Instead, BT counselors more often use their own observations (e.g., in-session role play or imagery techniques), those of the client’s significant others, or simply the client’s self-report.
Behavior therapists often ask clients to log the frequency of a behavior between counseling sessions, a technique called self-monitoring. There are three potential problems with self-monitoring. First, there is the question of whether the client can accurately and honestly monitor their behavior. Second, monitoring may disrupt normal routines, causing the client to become aggravated. Third, behavior has been known to change when monitored—most notably, unwanted behavior tends to decrease (Spiegler, 2016).
Formal assessment in BT involves the use of standardized instruments or symptom checklists. Wolpe (1990), for instance, was adamant that the use of the Willoughby Neuroticism Questionnaire and the Fear Survey Schedule is essential in BT. He said, “Failure to use these instruments is a serious deprivation of data, parallel to a physician’s nonuse of the electrocardiogram in suspected heart disease” (1990, p. xi).
Behavioral checklists and surveys are often used in cognitive-behavioral forms of BT (Spiegler, 2016). Clients might be asked to complete the Beck Depression Inventory (A. T. Beck et al., 1961), the Reinforcement Survey Schedule (Cautela & Kastenbaum, 1967), or the Test Anxiety Behavior Scale (Suinn, 1969). Many other such inventories exist.
JaNelle begins with a simple interview approach with Shirley. She asks a lot of questions about Shirley’s current situation, including her living situation, social activities, and financial supports. Shirley reports that, although she enjoys her community service, she wishes she had more friends with whom to spend off-hours. JaNelle thinks that an assessment of Shirley’s social skills, is warranted. To start, JaNelle closely observes as she and Shirley interact. She notices that Shirley seems a little shy at times, avoiding eye contact and speaking very softly.
Gently, JaNelle asks Shirley about the incident that got her to counseling. Initially reluctant, Shirley responds to JaNelle’s approach and tells JaNelle about the recent incident. She admits that this behavior happens about on a weekly basis. JaNelle asks many specific questions about these incidents, attempting to gain a step-by-step picture of Shirley’s behavior. She considers a live observation of Shirley’s stealing behavior, but then decides to have her role play the behavior in the counseling session.
Overview of the Therapeutic Atmosphere
Behavior therapists assume that behavior is predictable from antecedents, organismic variables, and consequences, so “clinical interaction constitutes a form of experiment” (Goldfried & Davison, 1994, p. 4). This emphasis on the scientific approach in BT has led, at times, to significant disagreement about the nature of, or necessity for, the counseling relationship in BT. At one extreme, Eysenck (1960) dismissed the transference-based relationship of psychoanalysis, saying, “Behavior therapy has no need of this adjunct, nor does it admit that the evidence for its existence is remotely adequate at the present time… . In certain cases, of course, personal relationships may be required in order to provide a necessary step on the generalization gradient; but this is not always true” (p. 19).
In contrast, others emphasize that the therapeutic relationship is essential to BT. Early on, Wolpe (1985) maintained that “trust, positive regard, and serious acceptance of the patient are part and parcel of behavior therapy practice” (p. 127). Contemporary behavior therapists are clear that the relationship is essential, well aware of the research documenting the consistent positive association between the therapeutic relationship and counseling outcomes (Antony, 2019).
Because Shirley does not really believe that she belongs in counseling, JaNelle knows that it is essential that she establish a solid relationship with her. JaNelle tries to be supportive, genuine, and caring in her interactions with Shirley.
Roles of Client and Counselor
The counseling relationship in BT is collaborative, and the client is seen as a co-therapist (Spiegler, 2016). The counselor is a model for the client (Goldfried & Davison, 1994) and takes the role of a consultant who is teaching the client the skills necessary to be their own behavior therapist. As you might guess, the therapist is very active and directive, and may do quite a bit of teaching.
The client is expected to contribute actively to the BT assessment and goal setting and to complete their homework faithfully because BT practitioners assume that most change in BT is a result of this practice (Antony, 2019). The client is a learner of the knowledge presented by the BT teacher/counselor.
JaNelle approaches Shirley as a collaborator, acknowledging that Shirley has not voluntarily come to counseling. She offers herself as a consultant to Shirley, suggesting that she has some ideas that might help Shirley better her life conditions. If Shirley accepts this offer, JaNelle will expect Shirley to be a partner in BT counseling, participating in goal setting and homework assignments.
Goals
The goal in BT is simple: reduce or eliminate maladaptive behavior and teach or increase the incidence of adaptive responses. Picking behaviors to modify sounds easier than it really is. Traditionally, BT has targeted very specific behaviors such as smoking, weight gain or loss, and specific phobias. These behaviors are easily observable and quantifiable. However, clients often present much more complicated pictures and often do not present their concerns in terms of specific, observable behaviors. For example, many clients come to counseling saying that they want to get rid of their depression or that they are unhappy with their relationships.
Spiegler (2016, p. 57) presented the “dead person rule: never ask a client to do something a dead person can do.” Only dead people can avoid behaving altogether, so it is generally better to prescribe behavior than to try to delete it. For example, it would be better for Robert to ask Steve to pick up his clothes after his shower than to admonish “Don’t leave your clothes on the bathroom floor.”
The process of setting goals is a critical part of BT (Antony et al., 2020). Clients and counselors generally work together to establish them, and it is the BT therapist’s job to make sure that they are specific and attainable.
Shirley and JaNelle set two goals for counseling: decrease the anxiety that seems to be connected to Shirley’s stealing behavior and increase her social skills in the interest of helping her find more friends. They also agree that some problem solving around Shirley’s desire to have more social contact in her life would be helpful.
The specific goals they establish are as follows: (a) Shirley will be able to enter a department store and purchase an item (or just browse) without stealing anything, (b) Shirley will learn new social behaviors, including increased eye contact and voice volume, and (c) Shirley will increase her social contacts (outside of her volunteer work) to at least three times per week.
Process of Therapy
BT practitioners see therapy as composed of two distinct phases: assessment and intervention. After the therapist has performed a functional analysis of the client’s behavior and goals have been set, it is time to intervene. At an early point in this process, the client is oriented to BT, which usually consists of giving them a brief explanation of how the BT counselor views problems and interventions (Spiegler, 2016). Goldfried and Davison (1994) were very clear that the client’s expectations about therapy are important to assess and address because misconceptions can get in the way of treatment. Clients may expect detailed explorations of childhood events, dream analysis, or free association. The BT counselor should be empathic about the client’s reasons for these assumptions, but should not necessarily accede to them (Goldfried & Davison, 1994). The counselor can listen to client history empathically, while also inserting comments to help the client redefine the problem in behavioral terms. In essence, the behavior therapist teaches the client the behavioral model.
BT counselors see the first session of counseling as critical. It has four goals: “(1) establishing rapport with the client, (2) understanding the client’s problem and selecting a target behavior, (3) gathering data about maintaining conditions, and (4) educating the client about the behavioral approach to treatment and issues of confidentiality” (Spiegler & Guevremont, 2003, p. 83). At the end of this session, the client and counselor may create a written therapeutic contract (Goldfried & Davison, 1994). The contract typically contains information about fees, cancellations, frequency of sessions, and other procedural details. It also outlines the expectations for the client’s and counselor’s behavior both within and outside of the counseling sessions (such as the expectation that the client will complete homework between sessions).
When clients behave in ways that suggest resistance to BT, the fault is laid squarely at the feet of the BT counselor. In discussing this issue, Goldfried and Davison (1994) maintained that “the client is never wrong. If one truly accepts the assumption that behavior is lawful—whether it be deviant or nondeviant—then any difficulties occurring during the course of therapy should more appropriately be traced to the therapist’s inadequate or incomplete evaluation of the case” (p. 17; emphasis in original). What other therapists (particularly of a psychoanalytic persuasion) would call transference and countertransference, the behavior therapist calls stimulus generalization (Beach, 2005). In the case of “transference,” for example, the person of the therapist is similar to a stimulus person in another realm or time of the client’s life, and the client responds to the therapist in the same way that they responded to the previous person.
JaNelle works to establish a good working relationship with Shirley. She describes the basics of BT to Shirley and explains that Shirley’s anxiety and stealing behavior are learned and can be unlearned if Shirley is willing to work on it. Shirley, the reluctant client, is not very happy about the ordeal of therapy, but she grudgingly agrees that getting rid of her stealing behavior might be a good thing. JaNelle empathizes with Shirley’s unhappiness about being compelled to undergo therapy. After Shirley and JaNelle agree on goals for counseling, JaNelle gives Shirley a written contract that states these goals, the duties of both parties, and the expected outcomes of counseling.
Therapeutic Techniques
A variety of techniques are used in BT counseling. The majority of these techniques focus on overt behavior, but others focus on internal events such as cognition (you will read more about these in Chapters 9, 10 and 16). Some of these techniques are implemented by the counselor, and others are taught to the client so that they can use them on their own. Many of the techniques presented have cognitive aspects.
Relaxation Training
In addition to being the basis for several other techniques in BT (e.g., systematic desensitization), progressive relaxation training is thought to be therapeutic by itself (K. E. Ferguson & Sgambati, 2009; Goldfried & Davison, 1994). Most commonly, clients are taught progressive muscle relaxation, in which they are taught to alternate between tensing and relaxing specific groups of muscles (Antony et al., 2020). For example, the counselor might begin by having the client tense their right hand, then relax it, and then study the difference. After several repetitions of this sequence, the therapist might direct the client to tense their arm, and so forth, progressing through all of the various major muscle groups in the body. It is important that clients practice their relaxation training, so various types of recordings are used at home between sessions. (You can bet there’s an app for that!).
JaNelle teaches Shirley progressive relaxation training, beginning by giving her an introduction to the process and why it is helpful. She then guides Shirley through a complete relaxation session. Shirley records the session on her phone so that she can practice at home.
Exposure Therapy
Used widely for phobias and other fears and for compulsive behavior, exposure therapy, also sometimes called flooding, requires that the client encounter the anxiety-provoking stimulus and not respond as they typically do (e.g., with escape or compulsive behaviors; Hazlett-Stevens & Craske, 2009; Levis, 2009). Mary Cover Jones’s work with Peter, described in Box 8.5, is an example of this technique. Exposure can be done imaginally or in vivo, and sometimes the therapist even accompanies the client in these situations to make sure the response is prevented. In other instances, a significant other is recruited to help with the procedure. For these reasons, the technique may be referred to as exposure with response prevention and is often used with individuals diagnosed with obsessive-compulsive disorder (Antony et al., 2020). For example, I once had a client who had a light switch compulsion. On his own, he discovered the technique of “just not doing it.” Even though he was anxious, he would refrain from touching the light switches in his home. He was doing self-directed exposure and response prevention. This technique was very successful for him; his light-switching behavior was virtually eliminated.
Box 8.5
Mary Cover Jones: A Pioneer in Eliminating Fear in Children
Mary Cover Jones was a graduate student who worked with John B. Watson, the American founder of BT. In two articles, she described her work, which was based on Watson and Rayner’s (1920/2000) study of fear in infants (the Little Albert study; see Box 8.2). In an article published in the Journal of Experimental Psychology, Jones (1924/1960a) related her efforts to eliminate fear in children, fear that had presumably been classically conditioned.
Jones selected 70 children from a group in an institution that we might call day care. These children were in this institution temporarily because they could not be cared for in their homes (e.g., a parent was ill, a mother worked). Jones (1924/1960a) selected kids who showed “a marked degree of fear under conditions normally evoking positive (pleasant) or mildly negative (unpleasant) responses” (p. 39). The children’s fears included such things as being left alone, loud sounds, and the sudden presentation of animals (rats, rabbits, snakes).
Jones tested a number of techniques in a case study format. For example, she found that “verbal appeal,” which consisted of talking about the feared object in a pleasant way, did not work. “Social repression,” in which the feared object was presented to a child in the presence of other children, was equally ineffective. Presaging Bandura’s (1969) ideas, Jones did find that social imitation showed promise as an intervention for fear. However, Jones maintained that the best method of eliminating fear was direct conditioning, which she detailed in a separate article, “A Laboratory Study of Fear: The Case of Peter” (1924/1960b).
Peter was a 2-year-old boy who demonstrated fears very similar to Little Albert’s—of a rat, fur coat, rabbit, cotton wool, and other white furry objects. After presenting a white rat to Peter (whereupon he screamed and fell over), Jones (1924/1960b, p. 46) observed the following reactions in a subsequent testing period:
Playroom and crib Selected toys, got into crib without protest
White ball rolled in Picked it up and held it
Fur rug hung over crib Cried until it was removed
Fur coat hung over crib Cried until it was removed
Cotton Whimpered, withdrew, cried
Hat with feathers Cried
Blue woolly sweater Looked, turned away, no fear
White toy rabbit of rough cloth No interest, no fear
Wooden doll No interest, no fear
Jones used two kinds of conditioning with Peter and reported that his fear was completely eliminated and that he even showed signs of affection toward a rabbit at the end of the study. In the first stage of conditioning, Peter was exposed to the rabbit in the presence of other children who were not afraid of it. Gradually, situations were introduced that required Peter to be closer to the rabbit. In a second stage of the procedure, a rabbit in a cage was brought as close as possible to Peter while he was eating, without disturbing his eating. Presumably, the rabbit was brought closer and closer every day.
Jones reported extinction of the fear behavior not only toward the rabbit, but also in response to the white cotton, fur coat, and the other objects to which he initially reacted. Peter also seemed to be less fearful of new animals or unfamiliar situations. Although his fears appeared to be gone, Jones reported that Peter returned to a rather diminished and discouraging home environment, in which his mother used fear to control his behavior (“Come inside Peter, someone might steal you!” M. C. Jones, 1924/1960b, p. 51). Unfortunately, we have no further information about the fate of Peter.
A variety of theoretical conceptualizations have been offered for the underlying mechanisms supporting this technique. Although theoretically based in extinction, Massad and Hulsey (2006) warned that the prudent behavior therapist should know that exposure does not eliminate underlying conditioning in associations established by trauma; it merely weakens them. Other theorists argue that exposure builds new associations alongside the old, which inhibit the expression of the anxiety-ridden ones (Zalta & Foa, 2012). Recent conceptualizations also emphasize that learning to tolerate anxiety during exposure is more important than reducing it (Law & Boisseau, 2019).
Exposure is a tricky technique to use. Several critical considerations in the success of it are (a) an accurate assessment and conceptualization by the therapist, (b) proper client preparation, and (c) a strong therapeutic relationship (Zoellner et al., 2009). The counselor must also be ready to deal with the real distress experienced by the client because, theoretically, terminating the exposure too soon may result in the failure of the technique or even an increase in the anxiety (Marshall & Gauthier, 1983). Flooding involves exposure to the client’s worst fear for extended periods of time, and Zalta and Foa (2012) reported that it is not often used currently because clients prefer gradual exposure. In addition, flooding has been found to be no more effective than gradual exposure. For gradual exposure, a fear hierarchy, described in the following section on systematic desensitization, is developed to guide the exposure (Antony et al., 2020).
JaNelle thinks that in vivo exposure and response prevention is a potentially useful technique for Shirley. Shirley will have to enter a store, experience her anxiety, and refrain from stealing anything. JaNelle begins by taking a “field trip” with Shirley. She and Shirley enter numerous stores, and JaNelle makes sure that Shirley does not take anything.
Systematic Desensitization
This technique evolved from Wolpe’s (1990) idea that, if a response that is incompatible with anxiety (or other undesirable behavior) can be produced in the presence of a stimulus classically conditioned to fear, the fear will become disassociated with the stimulus. He called this process reciprocal inhibition because one response (anxiety) is inhibited by a presumably opposite one. Nowadays systematic desensitization is seen as simply another form of exposure therapy. Most commonly, step-by-step graduated exposure to the feared stimulus is paired with deep muscle relaxation (Spiegler, 2016). However, other responses, such as pleasant imagery, humor, and sexual arousal, have been used in this procedure, along with drugs (tranquilizers) and carbon dioxide inhalation.
The first steps in systematic desensitization are (a) teaching the client progressive relaxation procedures and (b) constructing an anxiety hierarchy to be used in the procedure (Head & Gross, 2009). Progressive relaxation, as described earlier, consists of teaching the client to alternatively contract and relax muscle groups in the body, progressing from one part of the body to another.
The anxiety (or fear) hierarchy is a list of situations that evoke fear in the client, ranked from least to most threatening, on a 1-to-100 scale. Goldfried and Davison (1994) recommended that jumps between items be 10 points or less; if a gap is more than 10, at least one additional item should be constructed to bridge the gap. Hierarchies are usually composed of 12 to 24 items.
Once these tasks have been accomplished, the actual desensitization procedure begins. The client is relaxed and is instructed to imagine the item or scene lowest on their fear hierarchy. They are taught to give some kind of a signal, usually by raising one finger, when the image creates anxiety. The image is visualized for 5–7 seconds, after which the counselor helps the client get back to the relaxed state (Head & Gross, 2009). The idea is to keep the level of anxiety relatively low so that it is counteracted by the relaxation. The item is then presented again until the client can visualize the scene without anxiety. When the client is successful, they are asked to visualize the next item on the hierarchy. Antony et al., (2020) reported that the hierarchy can be used in other ways, such as randomly choosing items or starting with very difficult items and progressing quickly if the client is amenable.
JaNelle decides that systematic desensitization would be ideal for Shirley’s anxiety episodes connected with her stealing behavior. She explains the procedure to Shirley, and they work on Shirley’s anxiety hierarchy. As expected, Shirley’s most feared image is of being in a store by herself. This scene she rates as a 100. The remainder of Shirley’s hierarchy is shown in Figure 8.1.
JaNelle begins the procedure in the next session, asking Shirley to relax and taking her through a progressive relaxation sequence. She then asks Shirley to imagine being in her apartment and thinking about going to a store. Immediately, Shirley’s finger shoots up, and JaNelle asks her to again relax and to “wipe the picture out of your mind.” JaNelle presents the image repeatedly until Shirley no longer indicates anxiety, and then they progress to the next item in the hierarchy.
Figure 8.1. Shirley’s Hierarchy of Anxiety.
100 Standing in a store by herself
95 Walking through the door of the store
90 Getting off the bus near the store
80 Riding the bus to the store
75 Getting on the bus to go to the store
65 Walking to the bus stop
55 Leaving her apartment to go to the store
50 Looking at an item she has stolen
40 Telling someone she is going to the store
30 Thinking about going to a store
Shaping
The process of teaching a new behavior is called shaping. First, the BT counselor gets the client to respond in some way, usually by using verbal prompts. Modeling can also be used in this stage. The therapist can demonstrate the behavior, or the client can watch a videotape. After the initial response is established, the therapist will reinforce only responses that move a step closer to the desired response (Antony et al., 2020). Verbal coaching by the therapist can move the process along more quickly.
Shaping could be used to address Shirley’s social skills deficits, JaNelle thinks. She plans to model eye contact and appropriate voice tone for Shirley and then praise her when she attempts these behaviors. At first, Shirley’s attempts will be tentative, but JaNelle will reinforce them and coach Shirley to improve them. She will then reinforce Shirley’s improved behaviors.
Reinforcement
The BT counselor can use positive and negative reinforcement to increase the occurrence of a desired behavior. For instance, praising the client for completing an assigned homework activity would tend to increase the probability of homework getting done. Negative reinforcement is probably used less often because it is difficult to find a situation in which a negative stimulus could be discontinued upon the appearance of a desired behavior. An important source of reinforcement in BT is the counselor’s verbal responses to the client, which Beach (2005) called verbal conditioning. He opined that the therapist must be alert in the counseling situation to the kind of verbal behavior they are reinforcing—for instance, differentially reinforcing verbalizations about problems (by “uh hming” every time the client speaks of these and not responding to nonproblematic or successful behavior) might make the client’s situation worse (Beach, 2005).
Often clients are taught to self-reinforce. If the client, for example, went to the gym and worked out, they would reward themself with a hot bath or a special cookie.
JaNelle thinks that positive reinforcement would be a good technique to use with Shirley. She praises Shirley for coming to counseling and reinforces Shirley’s discussions of her life with attention and head nods. JaNelle will use positive reinforcement to teach Shirley assertive skills and will reinforce her for completing homework assignments. She will also use positive reinforcement when Shirley survives an in vivo experience in a store.
Extinction
Extinction involves removing a reinforcement that is maintaining a behavior. A very common example is when parental attention is reinforcing a child’s tantrum behavior. The parent simply does not respond to the tantrum. When using extinction procedures in isolation, it is important to be sure one can tolerate the possible intensification in the target behavior that might result when the intervention is first implemented. For the parent tolerating a tantrum, this can be a very stressful experience, as you can guess! Extinction also may take some time, so it might be wise to reinforce an alternative, desired, behavior during the extinction process (Antony et al., 2020) Telling clients about time frame is likely to be helpful, lest they be tempted to let up in situations where they are implementing the extinction procedure, such as when parents are addressing temper tantrums or a child having trouble getting to sleep at night.
Time-out from reinforcement is a form of time-limited extinction, in which positive reinforcers are removed for a specified period of time. A familiar example of this procedure is seen in classrooms, when a child displaying disruptive behavior is removed to a time-out room. The critical element is that all sources of reinforcement are unavailable to the child; in practice, this is fairly difficult to achieve, which makes the procedure less effective (Spiegler, 2016). When using time-out, there are some good guidelines to remember: (a) always explain what is happening, why, and how long the time-out will last; (b) time-out should only be ended if the undesired behavior has stopped and the specified time period is up; and (c) time-out should not be used if it allows a child to escape situations they don’t like (Spiegler, 2016). Usually, the access to reinforcers is removed only for a short period of time (e.g., a minute or two) because longer intervals do not increase the effectiveness of the time-out intervention. Spiegler (2016) recommended 5 minutes or less, and for children up to age 5, one minute per each year of age.
For Shirley, applying extinction to her stealing behavior would mean virtually the same thing as in vivo exposure because JaNelle thinks that the stealing is partly maintained by the anxiety reduction Shirley experiences. However, operant extinction might require that Shirley perform a very difficult behavior—picking up an item in the store and not leaving the store. JaNelle could then praise Shirley, which would be differential reinforcement of another behavior.
Punishment
Punishment, remember, is when the consequences of an event are linked to a decrease in or disappearance of the behavior. For the purposes of intervention, two kinds of punishment can be identified (Milan, 1990; Skinner, 1953). First, and most familiar to us, an aversive event can be applied following the undesirable behavior, which is sometimes called punishment by contingent stimulation (Milan, 1990). Spanking a child falls under this category. I will pause here to note that physical discipline has been found to be ineffective and potentially harmful in addressing misbehavior in children (Glicksman, 2019).
A second kind of punishment results when a desirable set of conditions is terminated when an unwanted behavior occurs. For instance, Dad can turn off Liza’s favorite television show if she is slapping her little brother. Because this kind of punishment can be seen as the termination of a positive reinforcer, it is referred to as punishment by contingent withdrawal (Milan, 1990). A similar procedure is response cost, in which an individual is required to surrender something reinforcing, such as when you pay a fine at the bank for bouncing a check.
Punishment as a behavior change technique has drawbacks. First, because punishment only suppresses behavior, such behavior is likely to reappear when the contingencies are no longer in effect (Skinner, 1971). Also, humans are motivated to escape or avoid aversive conditions, so punishment can create these behaviors—the best way to avoid punishment is to avoid the punisher. Punishment can also result in aversive emotional states, such as shame, anger, frustration, anxiety, or depression (Spiegler, 2016). Individuals may resort to dysfunctional behaviors to avoid these aversive states, such as refusing to think about the punished behaviors or engaging in risky behaviors such as drinking alcohol or doing drugs to blunt these feelings. Finally, these negative feelings may become associated with the agents of punishment, such as parents, school, or law enforcement officials (Kazdin, 2012). Consider also that using punishment models the use of aggressive behavior. For these reasons, punishment should be a last resort and used very carefully (Antony et al., 2020).
If punishment must be used, it should be immediate to the undesired behavior (Spiegler, 2016). A consistent, continuous schedule is more effective than intermittent punishment.
JaNelle doubts that punishment would work for Shirley’s stealing behavior unless Shirley would agree to self-punish. In a sense, she already does that by making herself feel guilty and ashamed after she steals, and this has not been effective in deterring her behavior. Getting arrested can be seen as a punishment, but not one that is likely to happen every time, making it an ineffective punisher.
Social and Communication Skills Training
Social skills training involves just that—teaching clients how to interact with others. Specific skills can be identified, such as eye contact, body orientation, or paraphrasing what another is saying, modeled, and then positively reinforced.
Historically, much attention was focused on a special form of social skills recently, assertiveness training (AT). Much less attention is focused on this type of intervention recently, prompting Speed et al., (2018) to call it “a forgotten evidence-based treatment” (p. 1). Originally, Wolpe conceptualized AT as a treatment for social anxiety, defining it as “socially appropriate verbal and motor expression of any emotion other than anxiety” (Wolpe, 1990, p. 135). Wolpe thought that anxiety got (classically) conditioned to social responding, and through reciprocal inhibition, assertive responding should compete with the anxiety and weaken the conditioning.
Other BT theorists acknowledge an operant (i.e., skills deficit) view in using this technique (Duckworth, 2009; Speed et al., 2018). After assertive behavior is defined for the client, the assertive behavior is modeled for the client, or they could be verbally prompted to perform the behavior. The behavior therapist then shapes the client’s behavior, reinforcing better and better assertiveness responses. Primarily, the behavior therapist could use praise as the reinforcer unless they are working with a child, in which case other kinds of reinforcers might work (such as food).
Assertiveness training is perfect for Shirley. JaNelle will teach her to make eye contact, speak with more volume, and ask for things she wants. For example, JaNelle will help Shirley practice asking a fellow volunteer to go out to a movie or dinner with her.
Stimulus Control
Stimulus control can be used to produce or eliminate behaviors. First, many behaviors are under the control of one or more stimuli. As noted earlier, these stimuli are termed discriminative stimuli. The most commonly used examples of these types of behavior are sleep management, cigarette smoking, and eating. People who smoke tend to have specific triggers for smoking behavior, such as finishing a big meal. If you eat popcorn in bed at night, just getting in bed may cause you to feel an urge to eat. The idea is to identify the triggering event and either eliminate or modify it (Spiegler, 2016). In other cases, the client might need to associate a behavior with one or more stimuli to get it under control. For example, if Julie has a problem with eating too much too often, it might be helpful for her to limit eating to full meals at a set table. She would not be allowed to eat while watching television or in any other location.
A second form of stimulus control is a prompt. Prompts are stimuli that remind us to do a behavior, such as when Anton reminds little Amy to pick up her toys (Spiegler, 2016). It’s important to reinforce the behavior when it appears after the prompt, and I daresay that not enforcing a prompt will be ineffective. Too many unsuccessful prompts becomes nagging, right?
JaNelle decides that Shirley’s stealing behavior is cued by the stimulus of a department store. Shirley reports that she rarely steals at the grocery store or in other kinds of stores. JaNelle decides that to extinguish the association between the store and stealing, Shirley will avoid the department store for a while. She is assigned the task of going to the grocery store once a day for a week. The first day she is to walk into the store and immediately walk out. The second day she is to walk down one aisle and then out of the store. After each of these forays, she is to positively reinforce herself in some way. A gradual progression in the amount of time she spends in the grocery store is prescribed until she reports no anxiety or impulses to steal. JaNelle then transfers this program to the department store.
Modeling
Modeling is a flexible technique that often is combined with other kinds of interventions. The most basic form of modeling is simple observation, in which the client watches a model perform a target behavior. The model will typically progress through harder and harder tasks. For example, if a client is afraid of heights, they might observe a model standing on a step stool and so on until the model is looking over the balcony rail of a 20-story hotel.
Another version of modeling is participant modeling, also known as guided participation (Spiegler, 2016). In this approach, the client actually practices the target behavior after the model (usually the therapist) has demonstrated it. The model coaches the client through successively more difficult behaviors.
JaNelle uses modeling to help Shirley learn new social skills. She demonstrates appropriate vocal tone and eye contact and then asks Shirley to practice these in the counseling session. Together, JaNelle and Shirley identify situations in which Shirley might have behavioral deficits and then generate new responses for Shirley. JaNelle first models these behaviors, and then Shirley tries them out for herself.
JaNelle considers using modeling as an initial step in desensitizing Shirley to department stores. She could video a model entering a store, choosing an item to buy, purchasing it, and then leaving the store. Shirley could watch the video between counseling sessions until she could do so without experiencing anxiety.
Evaluation of the Theory
BT has evoked a great deal of controversy over the years, comparable to that associated with psychoanalytic theory. Historically, behavior therapists have been accused of being cold-hearted because of their scientific approach and language (Goldfried & Davison, 1994). The emphasis on prediction and control of behavior led to accusations that BT denied the rights and freedom of clients (Franks & Barbrack, 1990) and that it ignores the importance of emotion in human behavior. As Sweet (1984) put it, “Behavior Therapy is viewed as the cold and mechanical application of techniques, previously tested on sub-human species, and often delivered in a dangerous and impersonal fashion” (p. 254).
Behavioral approaches are seen as simplistic and most applicable to discrete and narrowly defined problems, such as phobias. The first applications of BT were with extremely dysfunctional clients (e.g., mentally challenged or psychotic clients), so its utility for a wider range of clients was questioned (Franks & Barbrack, 1990).
BT has been criticized for its emphasis on observable behavior at the expense of thought and feeling. However, as we have seen, most behavior therapists today attend to cognition and other inferred events as important aspects of human behavior. Neglect of the client’s past is also cited as a weakness of behavioral approaches, to which the behaviorists would retort that reinforcement (learning) histories are very important in understanding the client’s current presentation.
Behavior therapists are also said to ignore the role of interpersonal relationships in the generation and maintenance of psychological dysfunction (Marshall & Gauthier, 1983). For example, Marshall and Gauthier (1983) suggested that failures in BT procedures could result when improvement results in decreased dependence of the client on family members or other significant others.
Currently, BT, or probably more accurately cognitive-behavior therapy, is considered a mainstream, evidence-based form of therapy. Because its techniques are so structured and easy to understand, it lends itself to easily manualized and disseminated forms of treatment, even interactive, computer-based treatment (see www.stoppulling.com for an example of a treatment for trichotillomania, or hair pulling).
Qualities of the Theory
Precision and Testability
BT theorists maintain that theirs is the most scientific approach because it is rooted in “established principles and paradigms of learning” (Wolpe, 1997, p. 633). Certainly, it is very precise to count behaviors following the institution of a reinforcer and observe changes from baseline rates of behavior. If one is studying nodding behavior, clearly this behavior can be operationalized fairly easily. The complex behaviors involved in client presentations and in the counseling process, however, are not as easily specified and targeted.
Arguments abound about the exact definition of some BT terms, such as reinforcement. Some critics assert that the definition of reinforcement is circular: What is a reinforcement? Something that makes behavior increase. Why did that behavior increase? Because it was reinforced. The classical conditioning model has also been criticized, particularly by advocates of social learning theory (Bandura, 1969). They maintained that the effects of classical conditioning procedures are simply that the person builds a mental image that affects their behaviors rather than establishing a relatively permanent conditioned reflex. Still other authors noted that attempts to tie BT techniques to the principles of learning from experimental laboratory study are fruitless and that these very principles (e.g., reinforcement) are questionable as explanations for learning even though they can at times predict performance (Breger & McGaugh, 1965/1973; Jacobson, 1997).
Empirical Support
Overall, BT has received support from outcome research. It is important to note, though, that many studies test cognitive-behavior therapy (in a multitude of forms) rather than pure BT (if such a thing really exists). As indicated earlier, the validity of the theoretical bases of BT is much less clear.
Research Support
Outcome Research
In some ways it is easy to approach the effectiveness question regarding BT, but in other ways, it is difficult. Why? The answer is because there are very few recent studies of BT that test a purely behavioral approach. Most studies with adult samples offer some form of cognitive-behavioral therapy (CBT), making it possible to say that there is overwhelming research support for this approach. For example, in what is considered an authoritative source on psychotherapy effectiveness (Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change; Barkham et al., 2021), the relevant chapter reviews outcome research under the heading CBT, defining it “broadly to include behavioral therapy, cognitive therapy, and cognitive behavior therapy to denote initial (so-called “first and second wave”) therapies that have evolved from Skinnerian (Skinner, 1963), Pavlovian (Pavlov, 1994), and social learning (Bandura, 1974) theories, and functional analyses (Ferster, 1983)” (Newman et al., 2021, pp. 469–470, quotes in original). Hundreds of studies are included in this review, and it is no surprise that Newman et al. concluded that CBT is effective for most client presentations, including depression, anxiety-related disorders, eating disorders, some personality disorders, and psychosis. However, we should note, as do the authors, that CBT does not routinely prove to be more effective than other treatments. For example, in addressing depression, Newman et al. stated that “CBT reduces symptoms at least as much as antidepressant medication, interpersonal psychotherapy, dynamic psychotherapy, and supportive psychotherapy” (p. 493).
Newman et al.’s (2021) findings are consistent with a long history of outcome research, beginning with M. L. Smith and Glass (1977), who suggested a slight superiority for behavioral and cognitive-behavioral approaches over the other approaches in the analyses. However, these effects tend to disappear when methodological variables are controlled (M. L. Smith et al., 1980). These methodological issues involve the reactivity of the measures used—how responsive the outcome measures are to the demands of the experimental situation (Lambert & Ogles, 2004). Behaviorally oriented studies generally use measures that are more susceptible to these influences. Also, when allegiance effects (i.e., the theoretical allegiance of the study’s authors) are controlled, differences between approaches tend to disappear (Wampold & Imel, 2015). Overall, then, we can be pretty certain that BT is effective, but probably not superior to other therapeutic approaches (which of course is the typical conclusion for all of the major approaches to counseling, as you read in Chapter 1). Because the research is so voluminous, I am only going to review selected literature and leave further investigation to interested readers.
One area in which BT based interventions don’t do so well is with substance abuse. Let’s start with an extinction-based model, in which cues for substance use are presented while preventing the behavior, which according to the BT model should extinguish the substance use behavior. Newman et al., (2021) report a long history of ineffectiveness for these types of interventions, culminating in a fairly recent meta-analysis that found that that cue exposure was only effective when compared to relaxation alone or assessment only (no treatment) conditions (Mellentin et al., 2017). Even these differences were suspect due to methodological issues and potential for investigator bias. Studies of cognitive therapy and relapse prevention produced similar results, with treatments showing equal but not superior effects compared to other approaches, such as 12-step programs. Interestingly, the BT folks adopt motivational interviewing (MI) as their own (Rollnick et al., 2023; see Chapter 5 for a brief description), although it is not based in a behavioral model. Some studies show some, typically small, effects of MI over no treatment for alcohol use and smoking cessation, but MI does not appear to do better than other active treatments (Newman et al., 2021). On the flip side, behavioral couples therapy appears to have small effects in addressing alcohol use and increasing relationship satisfaction. Schmit et al., (2022) meta-analyzed 17 RCTs of BCT, finding small effects, but also cautioned that publication bias (in favor of publishing studies that find differences in favor of BCT) could be influencing their results. They cautioned that counselors should probably not consider BCT to be superior to other approaches.
You might find it interesting and useful to know that CBT is generally considered to be effective for clients who are diagnosed with psychosis (Newman et al., 2021). In fact, some evidence indicates that CBT is an acceptable alternative (combined with treatment as usual) for individuals who do not want to take antipsychotic medication (Morrison et al., 2014). Also, CBT appeared to be equivalent to antipsychotic treatment in one large trial that compared CBT, antipsychotic medication, and CBT plus antipsychotic medication, and the participants in the two CBT groups had fewer side effects (Morrison et al., 2018).
Theory-Testing Research
Discussing the role of theory in BT is difficult because BT is not a theory per se; it is more a collection of techniques said to be based on theories of learning. BT scientists had little use for the “hows” of their technologies, prompting Tryon (2005) to opine “the cognitive revolution in psychology occurred partly because functional statements made by behaviorists lacked causal mediating explanatory mechanisms. The search for causal mediators and moderators is evidence that behavioral scientists value explanation in addition to novel prediction” (p. 69). Still, most investigations of BT have focused on the effects of a given technique on the incidence of a target behavior (or symptoms). There is currently some interest in assessing the predictions of behavior theory, and in general, I would say that the support for behavior theory is not terribly strong.
For example, several causal models for the effects of systematic desensitization and other forms of exposure have been proposed. However, none has gained strong empirical support. Here is an example: Wolpe (1990) thought that pairing an incompatible state (e.g., relaxation) with the undesirable one (e.g., anxiety) would cause deconditioning (i.e., reciprocal inhibition). Because research seems to show that relaxation is not necessary, Wolpe’s causal scheme is undermined (Emmelkamp, 1990). However, a meta-analysis of relaxation treatment (Manzoni et al., 2008) found that relaxation was effective with a wide range of presentations in which anxiety was central. Regardless, exposure to the feared object or situation is currently considered to be the curative factor for anxiety disorders, but there is little agreement about how it actually works (Abramowitz, 2013; Emmelkamp, 2013; Tryon, 2005). Still, the fact that exposure and response prevention seem to help when fear avoidance responses are present would seem to support a hypothesis that these behaviors are maintained by avoidance conditioning. At the same time, you probably recall that behavioral and cognitive interventions are equally effective in treating depression and anxiety, and the two treatments, said to have different underlying mechanisms, produce similar changes in both cognitive and behavioral indicators (Emmelkamp, 2013; Goetter et al., 2021; Podina et al., 2019). If the underlying explanation for how anxiety and depression are learned are different (e.g., exposure vs. lack of positive reinforcement), then it would seem that exposure and pure cognitive intervention would be differentially effective for these syndromes. Crits-Christoph and Gibbons (2021) also surveyed the research on two other (cognitive-behavioral) models of change thought to underlie the effectiveness of exposure therapy, finding less than impressive support.
Crits-Christoph and Gibbons (2021) also reviewed the evidence testing the underlying causal assumptions in behavioral activation (BA) for depression. The assumption, as indicated earlier, is that depression is the result of reduced levels of response-contingent positive reinforcement, and BA leads to increases in positive reinforcement, thereby decreasing depressive symptoms. “Response-contingent” here just means that the positive reinforcement is linked to specific client behaviors rather than being random. This explanation would seem to be a purely behavioral one—no cognitions need apply. Of the studies reviewed, only one found strong evidence for specific links between higher levels of activity and reward and decreases in depression (Dimidjian et al., 2017), prompting Crits-Cristoph and Gibbons to call for more research in this area before any strong conclusions could be drawn. Fernández-Rodríguez et al., (2023) did just that—they compared outcomes for BA, acceptance and commitment therapy (ACT), and CBT, looking at the role of theory-specific variables in the change process. This study will be discussed further in Chapter 10, which includes ACT, but here, I will note that BA seemed to play a role in all three approaches (which did not differ in effectiveness according to most outcome measures)—when behavior was activated, anxiety and depression symptoms decreased. However, it should be noted that theory-specific variables associated with ACT and CBT also changed in expected directions over the course of treatment—Fernandez-Rodríguez argued that the changes in BA were stronger and longer lasting than those associated with the other variables (fusion and emotional regulation; see Chapter 16).
Some BT researchers would point to single-subject intensive case studies as providing evidence for the theoretical underpinnings of BT. A baseline is established on a target behavior, an intervention is made (e.g., instituting reinforcement or extinction), and then the intervention is withdrawn. Changes in behavior with the presentation and withdrawal of the intervention are thought to be evidence of the validity of behavioral techniques. Often, the intervention is reinstituted to further strengthen confidence that the treatment resulted in any observed behavior change (Heppner et al., 2016). Again, these types of studies can demonstrate relationships between interventions and performance of a given behavior, but they provide little evidence for the theoretical foundations of BT.
Issues of Diversity
It is probably no surprise that there are abundant discussions of the applicability of behavioral approaches with clients of diverse backgrounds and identities. Most reviews focus on cognitive-behavioral therapy (CBT) rather than classic BT, which makes sense given that many, if not most, BT practitioners include cognitive techniques in their work. In the review following, I will sample sources on BT, where available, and some addressing CBT, selectively. I will include brief summaries of older literature, because it contains arguments relevant today.
Newman et al., (2021) concluded there is strong evidence indicating that CBT must be culturally adapted to be fully effective. Fong et al., (2017) called for increasing diversity understanding in ABA, writing that “cultural competency is no longer an option but a necessity for serving an increasingly multicultural background of consumers” (p. 103).
Historically, BT was looked upon with suspicion by people of color and other oppressed groups; BT was viewed as a technology used to control those in less powerful positions. The BT aversive interventions to change sexual orientation used in the 60s (discussed earlier) are just one example of how disempowered folks could have a negative view of BT. Other groups who have historically experienced oppression and marginalization, such as individuals who are of Black, American Indian, or Alaska Native heritage, and those of diverse sexual orientations and identities, may also be reluctant to engage in an enterprise that changes them rather than the problems they perceive around them. However, many theorists and therapists point to strengths inherent in a BT approach that make it an excellent way to help a wide range of people. However, I will pause to agree with Spiegler (2016) that many of the observations in the following summary are based on cultural stereotypes, and it is critical for counselors to recognize this issue and remember that diversity within a given cultural or identity group is likely to be as great as differences between groups. It’s important for the therapist to carefully assess a client’s sense of identity and maintain a sense of cultural humility (see Chapter 1), while continuously striving for greater cultural competence and awareness.
Spiegler (2016) maintained that BT’s emphasis on the role of the environment in problematic behavior is particularly suitable to clients who are of diverse backgrounds because cultural differences are part of the context considered by BT therapists. Some specific features of BT are thought to be consistent or ill-fitting for certain groups, however. The structure inherent in BT, as well as the therapist’s directiveness, might appeal to clients from Asian backgrounds, as would the relative de-emphasis on expression of emotion (Shen et al.,2006; Sue et al., 2022). The concrete and immediate nature of the BT approach might fit well for American Indians and Alaskan Natives because they tend to be present-oriented. However, Spiegler specifically called out assessment procedures, warning that the direct questioning in behavioral interviews may be insulting to individuals from some cultural backgrounds (e.g., Native Americans, Japanese). Other cultural factors in assessment include how dysfunction is manifested; for example, clients from Asian cultures may evidence depression via somatic symptoms rather than sad mood.
Although the collaborative approach emphasized in BT can be a good fit for clients of some identities, it could be problematic for others. Individuals of Asian or Hispanic/Latinx backgrounds may expect a more formal approach from the counselor because of the emphasis on hierarchy found in these cultures (Frew, 2016). In addition, cultures that are high context (i.e., more reliant on nonverbal than verbal communication) might be less than comfortable with the structured, direct nature of BT intervention. Many clients from non-White cultures adopt a more collectivistic view of life, so the emphasis on individual assessment and goal setting in BT might be problematic. However, there is no inherent reason why important others in the client’s life can’t be brought into the BT process, if the client desires it.
Early critics charged that practitioners used BT to control and subjugate Black children (Neal-Barnett & Smith, 1996). Both historical and current discrimination play into how Black families parent, and similar concerns should be recognized with other groups that have experienced various forms of oppression (Crouch & Andrew, 2022). Forehand and Kotchick (1996) discussed the cultural embeddedness of parenting, providing a summary of parenting values and practices in a number of different cultural groups, but these should be viewed with caution and with respect to intersectionality and within group variability. Some BT advocates have found ways to adapt BT parenting programs to make them accessible and relevant to Black families. Neal-Barnett and Smith described some of these adaptations, which include integrating the Seven Principles of Kwanza into parent training, following the work of M. Hill (1992). Neal-Barnett and Smith found that in establishing parenting workshops for women who identified as African American it was essential that the therapists be perceived as part of the community.
The future orientation implicit in the BT emphasis on goal setting could create discomfort for clients who value a present-centered orientation, such those of American Indian and Alaska Native (AI/NA) heritage. Historically, individuals from these backgrounds have not exactly trusted health professionals due to the trauma experienced by their ancestors and by discrimination and oppression experienced currently. Similarly, Crouch and Andrew (2022) reinforced the need to recognize the historical and current oppression experienced by AI/NA people, but at the same time, they summarized research that demonstrated that culturally adapted variants of BT (e.g., dialectical behavior therapy, cognitive processing therapy) were effective with these groups. Graziosi et al., (2021) encouraged BT professionals to understand and integrate spirituality into treatment for clients from AI/NA backgrounds where appropriate. All of these writers pointed out that, when possible, it is wise to partner with the community involved, as well as its leaders and traditional healers, in designing and implementing interventions.
Some aspects of BT are compatible with feminist values. Historically, feminists reacted positively to the behavioral principle that learning is a function of environmental factors, seeing this as a departure from traditional approaches that blame the individual for their problems (Kantrowitz & Ballou, 1992; Worell & Remer, 2003). BT emphasizes self-help and encourages client self-direction, values that are consistent with feminist philosophy (Hunter & Kelso, 1985). BT’s emphasis on skills development and goal of giving the client more control over the environment are also consistent with feminist ideology.
At the same time, the behaviorists have, in the past, been criticized for ignoring the sociopolitical context of their clients’ lives. Kantrowitz and Ballou (1992) argued that defining health as behavior that is adaptive is problematic. Who decides what is adaptive? They maintained that the norms of the dominant social group (i.e., White males) defined adaptiveness, which is an unfair, biased standard, particularly for women and other historically oppressed groups. Further, BT’s emphasis on a rational, scientific approach to human behavior is a reflection of White, male, European values, which may be very different than those of women and members of other ethnic or cultural groups (Kantrowitz & Ballou, 1992). One thing to keep in mind is that any counseling with clients who are members of groups that have experienced oppression and discrimination should provide a safe and supportive space to process experiences of racism, sexism, and other forms of prejudice and discrimination (Carvalho et al., 2022; Ching, 2022; Scheer et al., 2022). Scheer et al., (2022) supported a feminist framework in working with sexual minority woman, as well as appreciation for intersectionality. Ching (2022) added that it is also important to assist Asian American clients to address the effects of the model minority myth (i.e., the belief in Western, particularly U.S., culture that individuals of Asian descent are smart, hardworking, and so on). However, most writers in this area allow that adaptations of this sort do not preclude the use of many BT and CBT procedures.
Balsam et al., (2019) wrote about the use of CBT with sexual and gender minority people (SGM). The term SGM refers to individuals who are marginalized based on sexual identity/behavior (lesbian, gay, or bisexual) and those marginalized on the basis of gender identity/expression (transgender or gender nonconforming). Noting that SGM adults are more likely to undertake therapy compared to heterosexual individuals, Balsam et al. found a number of strengths in a CBT approach for these clients. These strengths include CBT’s empirical basis, attention to environment and social context, collaborative approach, a skills training focus, a view of behavior as functional or not functional (as compared to good or bad), and the inclusion of cognitive techniques that can combat internalized trans- or homophobia. Weaknesses of CBT for SGM clients include distrust among some clients who are aware of the attempts to “cure” homosexuals in the 1960s and a relative lack of empirical studies of CBT for these clients. Carvalho et al., (2022) echoed these same strengths of CBT with SGM, and reminded therapists that in CBT, affirmation “does not imply a preferred outcome, i.e., a push towards a certain gender identity (transgender, cisgender, or otherwise) or presentation, especially when working with children who identify” (p. 6). They specifically referenced the ESTEEM program (see the research summarized below) which includes consciousness raising, self-affirmation, emotional awareness and acceptance, modification of automatic thoughts related to minority stress, decreasing avoidance, and assertiveness training
An area of diversity receiving attention of late is neurodiversity, which is concerned with individuals who are diagnosed with autism spectrum disorder (Leaf et al., 2022). Neurodiversity advocates have criticized the use of applied behavior analysis (ABA) with individuals so diagnosed. Critics point to the use of punishment or extinction procedures, contending that the implementation of ABA is abusive and leads to trauma. In this view, ABA is dedicated to creating individuals who conform to societal expectation rather than honoring the diversity among those diagnosed as autistic/on the autism spectrum. Leaf et al. reviewed these contentions and provided detailed responses. The issues are complex and often historical (i.e. some criticisms are based on procedures that are now very rarely used, such as aversive conditioning), so it is difficult to provide a succinct summary here. Advocates of ABA point to the positive effects of behavior modification but also advocate for investigation into claims of negative outcomes. If you are interested in learning more about ABA and the controversy, Leaf et al.’s article should be required reading.
Currently, advocates for culturally sensitive BT and CBT are all over the place. Several resources interested readers could peruse are Multiculturalism and Diversity in Applied Behavior Analysis (Conners & Capell, 2021), and Culturally Responsive Cognitive Behavior Therapy (Iwamasa & Hays, 2019). Also, research has been accumulating on adaptations of BT and CBT with diverse clients. Although again, most are focused on CBT, I will review several recent studies here; others will be found in Chapters 9, 10, and 16.
Sivaraman and Fahmie (2020) reviewed telehealth ABA treatments for individuals diagnosed with autism outside of the United States. They reviewed 9 studies, finding adaptations that addressed the structure and process of service delivery, and importantly, the involvement of community members in the process of adaptation.
Gregory (2016) meta-analyzed 12 studies of CBT for individuals of African descent. Most of the clients in the studies included in the analyses were persons diagnosed with anxiety disorders. Only 4 of the studies were RCTs; the remaining 8 were pre- and post-test investigations with no control groups, which weakens causal conclusions that can be drawn from them and thus, the meta-analysis as a whole. Across both groups of studies, Gregory documented large effect sizes that indicated that CBT was effective for individuals of African descent. To their credit, Gregory noted that although it could be that CBT is effective regardless of the background of clients, it is also possible that the effectiveness of CBT was a result of common factors (e.g., the therapeutic relationship, and counselor empathy). Without specific tests of the mechanisms of change in studies, there is no way to differentiate between these explanations.
Pachankis et al., (2022) described a randomly controlled trial featuring a program called ESTEEM (Effective Skills to Empower Effective Men), an adaptation of CBT to work with sexual minority men. They compared the ESTEEM intervention to what they considered to be the most common services available in the community, LGBQ-affirmative counseling and one session of HIV testing and counseling. They were interested in risky sexual behavior (in terms of HIV transmission), but also assessed other outcomes (e.g., depression, anxiety, general psychological distress). Results showed that although the direction of changes over follow-up assessments (4, 8, and 12 months) favored ESTEEM, the differences among the three groups were generally not statistically significant. Pachankis et al. wanted to attribute the lack of statistical significance to several factors, including the robust effects of the comparison conditions and low statistical power. Earlier, a version of the ESTEEM program developed for sexual minority women, EQuIP (Empowering Queer Identities in Psychotherapy) was compared to the outcomes of individuals on a waitlist (Pachankis et al., 2020). Participants in the EQuIP program showed significantly decreased depression and anxiety over treatment and follow up, and smaller, marginally significant differences in alcohol use problems. I will pause to note that waitlist participants in this study were assigned to receive treatment at 3 months after the study began. Also, stratified random assignment was used to equalize the number of White and racial/ethnic minority participants in each condition. Interestingly, the control group showed greater increases in social support compared to the treatment group. Pachankis et al. speculated that the participants in the waitlist group had taken advantage of referral resources given to them (24% did) or that being placed on the waitlist motivated them to seek support from important others around them over the waiting period.
Noting that most adaptations of CBT for sexual minority young people (SMYP) are designed and tested in Western cultures, Y. Huang et al., (2021) conducted a qualitative study of participants in a culturally adapted CBT in Taiwan and Hong Kong. Huang et al. asserted that beyond the factors that typically contribute to adverse mental health outcomes for SMYP (social exclusion, interpersonal victimization), Chinese sexual minorities also experience culture-specific stressors such as norms promoting obedience to parents and pressure to marry. They adapted an eight-session manualized intervention with the goals of improving coping skills and reducing psychological distress, that had shown good outcomes in Canada and the United States, for Chinese SMYP. To facilitate this adaptation, they gathered input from practitioners and potential users regarding important considerations in adapting the program in Hong Kong and Taiwan. A sample of 15 sexual minority youth and 18 frontline practitioners who worked with SMYP participated in a focus group where they were provided with information about the intervention and discussed potential adaptations. The participants pointed to issues with translation of terms and the need to promote the intervention in ways that avoided emphasizing that it was for individuals seeking psychological treatment because of the cultural norms around the acceptability of therapy in Chinese culture. They further noted the need to assist SMYP with self-differentiation in relation to parents and families specific to Chinese cultural norms. Finally, participants strongly emphasized that the program should help SMYP develop pragmatic, safe, plans for coming out to parents and families.
The Case Study
The story of Shirley is, in many ways, an ideal fit for the BT approach. Her primary problem behavior, the shoplifting, is fairly specific, and BT approaches are easily applied. It is less clear that BT approaches will directly affect Shirley’s loneliness, although it does seem to make some sense that increasing Shirley’s social contacts would help to some degree with this problem. However, if Shirley’s loneliness is associated with feelings that are not addressed by increased social contacts, such as mourning, this approach might be less useful. Shirley is a White, heterosexual, and presumably a cisgender woman so the applicability of a BT approach may be appropriate from a diversity standpoint because it was largely developed with White clients of Western-European backgrounds and appears to be consistent with many features of this cultural worldview.
Summary
Behavior therapy rests on a psychological model that emphasizes the learned nature of behaviors, whether they are adaptive or maladaptive. Three general models of learning are identified (classical, operant, and social learning), although the validity of these models and their direct connections to some techniques can be questioned. A variety of techniques is associated with BT, and most have been found to be effective.
BT has been the target of criticism and controversy. The traditional approach to BT emphasizes behaviors and their environmental rather than personal determinants. This emphasis, less common today, may lead to less attention to emotional and cognitive factors in behavior.
In some ways, BT seems to be an approach that is applicable to a range of clients—if carefully applied. Some client groups may respond favorably to the problem-focused, direct techniques used in BT. However, BT’s lack of attention to societal norms that influence behavior in ways that discriminate against some groups is a potential pitfall associated with this approach.
Chapter 9Rational Emotive Behavior Therapy
Alan is a 27-year-old White male. He works in a warehouse managing workers who move stock. Alan is married to Teresa, a woman of Asian descent, who is 30 years old. The only child of devout Catholic parents, Alan is a committed Catholic, as is Teresa. Teresa and Alan are active in their church, and most of their social activity is church related. Alan’s parents live in another city two hours away, and Teresa’s live on the West Coast. The couple has no children.
Alan comes to counseling because he is anxiety ridden and showing some repetitive, anxiety-driven behavior. He reports that when he leaves a room in his home, he has to return several times to be certain that he has turned off the lights. Sometimes he flips the light switch; other times he just looks at it. Alan is also troubled by the worry that he has run over someone with his car on his way home from work and frequently gets back in his car and retraces his route to make sure he has not. Most troubling to Alan is disturbing mental imagery of a religious nature that he believes he cannot control. Alan is hesitant to describe these images, but he says they involve the Virgin Mary and sexual content.
Alan reports that he has had variants of these symptoms for at least 5 years. He recalls being almost immobilized by his fears shortly before he and Teresa married. Alan went to counseling at that time and found some relief from his symptoms, but says that his anxiety was still bothersome. Since that time, Alan has experienced brief periods of compulsive behavior, but of the least disturbing kind, such as checking the light switches. He became more concerned when the religious images began about a month ago, along with the worries about hitting someone with his car.
When he comes to counseling, Alan appears uncomfortable and nervous. He speaks quickly and softly and seems motivated, but is at a loss about what to do about his symptoms.
Box 9.1
Rational Emotive Behavior Therapist, Heal Thyself!
Young Al Ellis had a fear of girls. When he was 19, he decided to do something about it. He had already conquered his fear of public speaking—in his own words, “Shit, I said to myself. If in vivo desensitization is good enough for little children, it’s good enough for me. I’ll try it with my terror of public speaking. If I fail, I fail. If I die of discomfort, I die! Too damned bad!” (Ellis, 1997a, p. 71). With this experiment, the technique now known as shame attacking was born—and was found to be successful.
Ellis then decided to apply this technique to his girl phobia. He lived, at the time, near the Bronx Botanical Gardens and frequented this beautiful park often, but flirted with girls only in fantasy. Telling himself “do, don’t stew” (1997a, p. 72), Ellis gave himself the homework assignment to go to the gardens every day in July, find women sitting alone on benches, sit down beside them, and talk—for 1 whole minute! Ellis carried out his assignment with 130 women that month, and to his great surprise, not one screamed, threw up, or called the police. Ever the scientist, Ellis reported that “30 of them waltzed away. They rejected me before I even got going! But, I said to myself, strongly, ‘that’s okay. That leaves me a sample of an even hundred—good for research purposes!’” (1997a, p. 72).
Of the first hundred, Ellis managed to make one date, but then she didn’t show up. Ellis persisted and reported that of the second hundred women he talked to, he got three dates. He claimed that this first expedition into REBT was entirely successful, so that forevermore he could talk to women any place, any time.
REBT was first known as rational therapy, but in 1961 Ellis renamed his theory rational emotive therapy to emphasize the emotional elements of the approach (Ellis, 1994b). The B was added in 1991 to acknowledge the behavioral element that Ellis maintained had always been crucial to rational emotive therapy but had not been widely recognized. Using the term rational, Ellis said, was a mistake because rational implies an absolute criterion, and no such criterion exists (Ellis, 1999c). He opined that a better name would be cognitive-emotive behavior therapy, except that cognitive therapy and cognitive-behavioral therapy got there first.
Albert Ellis was born in Pittsburgh, Pennsylvania, in 1913, the oldest of three children. He was raised in New York City. Ellis experienced a number of physical maladies in his early years that required periods of hospitalization and reduced activity during convalescent periods at home (Yankura & Dryden, 1994). At age 12 Ellis launched his writing career, and around age 16 he began devouring books and articles about philosophy and psychology, which set the stage for the development of his theory.
As a child and young adult, Ellis was shy and socially avoidant. Ellis’s voracious reading habits served him well when at the age of 19 he decided to overcome his fear of public speaking (Ellis, 1997a). He had read the early works of several behaviorists who advocated in vivo desensitization (Mary Cover Jones and John Watson; see Chapter 8) and assigned himself the task of giving many public speeches. Ellis found, to his surprise, that he actually began to enjoy public speaking. Subsequently, he applied this desensitization technique to his anxiety about relating to women (D. J. Ellis, 2021; see Box 9.1).
After receiving his bachelor’s degree in business administration, Ellis worked at a succession of jobs, planning to support himself with these while becoming a professional writer. He wrote voluminously during this time, but had little success getting published. At the same time, he was extensively reading and studying many resources on sex to produce his manuscript The Case for Sexual Promiscuity (Yankura & Dryden, 1994). He became somewhat of an authority on sex among his friends and associates and even started a small consulting practice (Blau, 1998). At the age of 28, Ellis entered Columbia University, training as a marriage, family, and sex therapist and eventually earning his master’s and Ph.D. degrees in clinical psychology.
Working in his first job, Ellis increasingly became aware of the weaknesses of the authoritative, advice-giving approach he was taught in graduate school. Ellis embarked on a course of traditional psychoanalytic study, complete with a training analysis and supervised practice. He learned to use the psychoanalytic couch, dream analysis, and transference neurosis in his work. Anticipating that this “depth” therapy would create more profound change in his clients, Ellis was disappointed to find that the results did not meet his expectations. His clients simply did not change in the profound ways promised by psychoanalytic theory. Becoming skeptical about the efficacy of traditional psychoanalysis, Ellis began experimenting with variants of psychoanalytic theory, such as those proposed by Harry Stack Sullivan, Karen Horney, and Otto Rank. Ellis found these approaches much more to his liking because, although they used psychoanalytic theory, they dispensed with the slow, laborious methods such as free association and dream analysis.
Although these variants of psychoanalysis seemed to create client change more quickly than standard psychoanalysis, Ellis still found himself dissatisfied with the results of his therapy. He began to experiment with a fusion of psychoanalysis and behavior therapy and became convinced that insight alone was not enough to “cure” his clients—behavioral change was needed, too (Ellis, 1994b). In 1954, Ellis began to integrate his knowledge of behaviorism, philosophy, and psychology, and by January 1955 he began practicing rational therapy (RT; Ellis, 1992a). He presented his first paper on RT at the American Psychological Association (APA) annual convention in 1956. In 1959 he founded the Institute for Rational-Emotive Therapy, which later became the Albert Ellis Institute. In 1962, Ellis published his landmark book, Reason and Emotion in Psychotherapy (revised in 1994; Ellis, 1994b). It is considered a major source on REBT, which is why you will see it referenced often in this chapter.
These events marked the beginning of Ellis’s long and controversial career. He was known for his no-nonsense style and his free use of profanity in professional contexts. His early career took place in a psychological community largely dominated by psychoanalysis and conservative attitudes about sex; Ellis’s ideas ran counter to both of these cultures. In fact, Ellis’s first idea for his doctoral dissertation about love among college women was not approved because the faculty thought it was too controversial (Yankura & Dryden, 1994). The profession of psychology was not very accepting of his rational emotive therapy either; Ellis reported that “its strong cognitive component horrified almost everyone except the Adlerians” (1992a, p. 9). Eventually, however, Ellis’s persistence paid off, and his contributions have been recognized by several professional organizations (American Counseling Association, American Humanist Association). In 1985, he was given the APA’s award for distinguished professional contribution to knowledge. Today REBT is international in its influence and is generally considered one of the major approaches to psychotherapy.
A close study of REBT theory will reveal similarities to the ideas of the intellectual descendants of Sigmund Freud. Ellis acknowledged the influence of Alfred Adler, Karen Horney, Harry Stack Sullivan, and Otto Rank on his work, along with the existential philosophers (Heidegger, Kierkegaard, Buber, Sartre, and others). He also recognized the contributions of Will Schutz and Fritz Perls and the 1960s encounter movement (Ellis, 1994b). Ellis (1997a) was also unflinchingly critical of other theorists, writing, “I could fairly easily see that Socrates was something of a sophist. That Plato was often a silly idealist. That Kant courageously threw out God and then cravenly brought him in the back door. That Freud was an arrant overgeneralizer. That Jung was a brilliant but sloppily mystical thinker. That Wilhelm Reich was pretty psychotic. That Carl Rogers was a nice fellow, but an FFB—a fearful fucking baby” (p. 70).
Ellis was one of the most prolific psychologists of the twentieth century. He published over 800 articles and more than 70 books. You can read Ellis’s response to an early critique of his theory in Box 9.2.
Box 9.2
An Early Defense of Rational Emotive Therapy from Albert Ellis
Dr. Robert J. Smith (1964), in a recent article, has raised some interesting objections to rational-emotive psychotherapy. The kind of thoughtful presentation that Dr. Smith has made in his article is quite valuable, in that it vigorously challenges the originator of a theoretical view to face certain difficulties inherent in his system and to present experimental data that would validate his views. Let me now, thanks to Dr. Smith, put on my own thinking cap and see if rational-emotive therapy (R-E T) cannot meet and benefit from some of the points he makes.
Dr. Smith first notes that R-E T in severing itself from historical rationalism raises the question: how is a criterion for rationality determined (e.g., the therapist as being rational when the client or patient is not).
The answer seems to be—if we are perfectly honest—that practically all contemporary systems of psychotherapy contend that the patient is “irrational” (that is, “neurotic,” “sick,” “disturbed”) and that this contention is largely a definitional value system, since a nontherapist (a Nietzschean, for example) could counter that either (a) the patient is not irrational, because he should be anxious or hostile and “enjoy” these feelings, or that (b) he is truly irrational, but that it is good for him to be so (since certain human values are enhanced by irrationality). Only by somewhat arbitrary definition, therefore, is the patient held to be irrational—by the rational, Freudian, Rogerian, or other type of therapist.
Fortunately enough, however, the patient almost invariably comes to therapy because he thinks he is getting poor results in living and he agrees with the therapist that he is therefore self-defeating, unreasonable, or irrational. He presumably wants to change his ways and become less disturbed and more rational; and this is what the therapist will presumably help him do. In rational-emotive therapy, therefore, rationality is not exactly, as Dr. Smith notes, “what the body of expert RT practitioners jointly accept as such,” but also what the body of most therapists and patients accept as such.
How to have your therapeutic cake and eat it?—or to define emotional disturbance in the patient’s own terms and try to help him actualize himself and still guide him, at least at times, away from a “self” that he largely defines in regard to fairly rigid and too-limiting cultural norms? R-E T solves this problem, not entirely elegantly, with what Smith calls a “naive eclecticism.” While accepting the fact that the patient is largely irrational because he defeats his own ends (e.g., makes himself anxious when he would like to be self-confident and secure), it also points out to him that he is never likely to get the goals he desires until he unconditionally and unqualifiedly accepts himself whether or not he fails at certain achievements and whether or not he is universally approved by others.
R-E T contends, in other words, that once certain goals, such as being unanxious and self-confident are (by somewhat arbitrary definition) assumed to be “good” and “rational,” then a scientific and factually validatable method of reaching these goals can be established and taught to patients; and one of its “findings” is that feelings of security and worth, to be permanent and deep seated, can not be anchored to arbitrary, culture-centered norms, but that, instead, the truly self-accepting individual likes himself when he seeks his own unique satisfactions and is not too concerned (though for practical reasons, he has to be somewhat concerned) about the conformity of pressures of his culture.
Source: Ellis, A. (1965). An answer to some objections to rational-emotive psychotherapy. Psychotherapy: Theory, Research and Practice, 2, 108–111. Copyright © 1965 American Psychological Association. Reproduced with permission.
For many years, on Friday nights Ellis conducted a demonstration of REBT at the Albert Ellis Institute (albertellis.org). Admission was $5, and two lucky audience members were chosen to serve as the demonstration clients for Ellis. Even in his 80s he maintained an 80-hour workweek schedule, conducting individual and group REBT and REBT supervision, lecturing, and, of course, writing.
Albert Ellis passed away in July 2007. His autobiography All Out! was published in 2010. Ellis’s work is continued at the Albert Ellis Institute, and interestingly, the Friday night tradition is currently still held at the institute, with once-a-month demonstrations by various REBT practitioners, both in person and via zoom. The cost of admission is a little higher now, though: $20.
Rational Living, the first REBT journal, was first published by the institute in 1966; in 1988 it became the Journal of Rational-Emotive & Cognitive-Behavior Therapy (Neenan & Dryden, 1996). There are a number of prolific REBT theorists and therapists, many of whom were mentored by Albert Ellis. Among these you will find Raymond DiGiuseppe, Kristene Doyle, Windy Dryden, Catherine MacLaren, and Michael Neenan. Due to a disagreement in philosophy with the Albert Ellis Institute, the REBT Network (www.rebtnetwork.org) was created in 2006 and Ellis REBT in 2012 (www.ellisrebt.co.uk), both largely the product of the energy of Debbie Joffe Ellis, Ellis’s wife, to carry on his vision. Joffe Ellis still writes, teaches, and practices REBT as I write.
REBT is like Gestalt therapy in that the theory is often equated with the creator. Albert Ellis had a very distinctive style, for sure, and many have seen his interview with Gloria in the Three Approaches to Psychotherapy series (Shostrom, 1965) or other videos. His forceful, vehement disputing of beliefs typically prompts the question “Do I have to be like Albert Ellis to do REBT?” The answer is, of course, no. As you read through this chapter, though, you will get a good sense of Albert Ellis’s style because I believe that he is the best communicator of his theory. However, you should keep in mind that there are ways to do REBT counseling in a softer manner. Also, we should remember that this theory was developed largely in the 1950s and 1960s, its major proponent a White male, and many of the contributors along the way are of White Western European descent. As you will read later, the theory has come under fire for its emphasis on logical thinking and neglect of emotion, which can be seen as culturally bound, stereotypically male, qualities. As you will also see, Ellis disagreed with this characterization of REBT.
Basic Philosophy
REBT can be summarized in one sentence by Ellis’s paraphrase of Epictetus, the stoic philosopher: “It’s never the events that happen that make us disturbed, but our view of them” (2005, p. 259). This assumption lies at the heart of REBT theory: that people can control their own thoughts, feelings, and behaviors. When his clients said someone “made” them feel a certain way, Ellis was known to reply, “That’s really impossible. No one can make you feel almost anything—except with a baseball bat” (2002, p. 110).
Ellis saw his theory as constructivist—by this, he emphasized the individual’s creation of their reality and the fact that the individual’s perception of reality, not some externally validated reality, is the deciding factor in determining behavior (Ellis, 1998a). In his later writings, Ellis (Ellis & Ellis, 2019b) was inclined to say that philosophically REBT has much in common with Tibetan Buddhism in its emphasis on the connection between healthy mental processes and happiness.
REBT theory holds that individuals have some choice in their lives, but inherited or innate potentials also exert substantial influence. In fact, Ellis (1979b) once wrote that he thought that about 80% of the variability in human behavior is attributable to biological factors, leaving only 20% to environmental influence (p. 17). If so much of behavior is biologically determined, one might wonder if it makes any sense at all to attempt behavior change. Ellis would reply that innate characteristics can be changed—it is just very difficult, requiring much use of the REBT tactic of PYA (push your ass; Ellis, 1998b).
REBT theory is fairly neutral in terms of human nature. Humans are neither essentially evil nor actualizing; in fact, REBT advocates would probably acknowledge that there is a little of God and the devil in all of us. Ellis (199b) identified two powerful human tendencies: the tendency to take wishes or desires and make them into absolute MUSTS and the tendency to work to achieve a better life (pp. 14–15). Thus, human beings are biologically programmed to be both irrational and rational, self-actualizing and self-defeating (Ellis & Ellis, 2019a).
In REBT, people are seen as responsible for their behavior; they can easily determine if that behavior is “bad” or “good,” self- and society-serving or self- and society-defeating. The standard for good and bad is a consensual one based on community standards (Ellis, 1994b). A centerpiece of REBT theory is that the behavior should never be equated with the person—one’s behavior can be said to be bad, but not the person behaving. Ellis opined that people are always in process, ever changing, so that makes it impossible to evaluate their worth at any one point in time (Ellis, 1994b).
Raphael is Alan’s REBT counselor. He greets Alan and asks him what brings him in. Raphael is thinking that Alan is, like himself, only human, likely to have both strengths and weaknesses. Alan will probably show some signs of irrationality. At other times, Raphael will discern very forward-moving, productive aspects of Alan. What Raphael keeps most in mind is that the world is as Alan currently views it and that because Raphael is of Mexican descent, Alan’s views could be somewhat different than his.
Human Motivation
REBT counselors assume that people have the overall goals of “surviving and being reasonably happy (a) when alone, (b) socially, with other people, (c) intimately relating to a few selected people, (d) gathering information and education, (e) working productively, and (f) having recreational interests, such as art, music, literature, philosophy, entertainment, and sports” (Ellis, 1994b, p. 18). Ellis believed that humans should be long-range hedonists, implying that the basic human motivation is to obtain pleasure and avoid pain but with an eye toward the future in terms of the effects of behavioral choices.
Raphael sees Alan as a person in search of survival and happiness. Raphael notes that Alan is currently involved in behavior directed toward satisfying intrinsic human goals. He seeks (and has established) social and intimate relationships in that he has a partner, Teresa, and friends at work as well as at his church. He and Teresa play on the church softball team. Alan mostly works productively, but lately his anxiety is getting in the way. He also finds that his anxiety leads to socially avoidant behavior, and he has been spending more time at home.
Central Constructs
ABCs
REBT is as simple as ABC. The A stands for the antecedent event or activating experience, or something that happens to us that we find relevant. Sometimes the A refers to adversity (Ellis & Ellis, 2019a). The A, in fact, can be almost anything. As can be thoughts, fantasies, emotions, or other people; it is whatever the person is upset about. Dryden (2019) argued that most often, the A will involve an inference about the activating event, meaning that it is not just that I fell down the stairs at the theater but that I fell down the stairs and everyone was looking at me and thinking “what a klutz.”
The C is the consequence, or what we normally think of as the result of the A. Cs can be emotional events (sadness, happiness, anxiety, depression) or behaviors (persistence at a task, avoidance, compulsive behavior). Cs can take the form of healthy emotions (such as sadness or happiness) or unhealthy emotions (depression, anxiety, or rage; Ellis, 2021).
If you have had the good fortune to be exposed to Ellis, Epictetus, or some other rational emotive behavior therapist, you know that what makes the difference in experiencing healthy or unhealthy emotions is what you think about the A event. A is not directly connected to C, but instead is filtered through B, our belief about A (Ellis & Ellis, 2019b).
An important but conceptually difficult aspect of REBT is that, even though the ABC model seems very straightforward (i.e., A activates B, then B causes C, or
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), Ellis (1994b) was clear that emotions, beliefs, and behaviors interact. That is, feelings usually involve cognitive components and vice versa. Behaviors are intertwined with thinking and feeling. Let’s assume that I believe very strongly that the world must be fair and just. When someone cuts in front of me in line at the grocery store (an A), I am likely to perceive this slight as much more catastrophic than someone who does not hold the same belief. The A becomes much more negatively valenced based on my B system. Another example of the interrelatedness of human experience is that extremely powerful or unusual As (e.g., a hurricane) can cause Cs (Ellis & Dryden, 1997).
Raphael begins to identify some of the As, Bs, and Cs of Alan’s presentation. The Cs are what brings him to counseling, so Raphael starts by looking at them: anxiety, unwanted repetitive checking behavior (of light switches and his path home from work), and disturbing imagery or possibly the emotions experienced as a result of the imagery. The As of Alan’s situation seem less clear. Alan reports that prior to his repetitive behavior, he has thoughts and images associated with danger that seem to trigger it—simple sentences like “Something bad might happen if I leave the lights on” or “I might have run someone over.” The C of experiencing religious imagery is also an A event because it is connected to the Cs of anxiety, shame, and guilt.
Beliefs
Beliefs are simple, declarative sentences we say to ourselves or images and symbols that have special meaning to us. Collectively, our beliefs form our life philosophies, which then “run—and ruin! most of our lives” (Ellis, 1994b, p. 46).
There are two kinds of beliefs, according to REBT theory: rational beliefs (rBs) and irrational beliefs (iBs). On a descriptive level, rational beliefs are “logical and/or have empirical support, and/or are pragmatic” (Ellis et al., 2010, p. 3). As you can see from the “and/ors” in the previous sentence, to be rational beliefs must meet one of the three criteria. They generally lead to mild to moderate emotions (DiGiuseppe et al., 2014). Dryden (2021) identified four kinds of rational beliefs: “nondogmatic preferences . . . non-awfulizing, bearability, and unconditional acceptance” (p. 4). These will make much more sense to you after you read the following information on irrational beliefs. I would also note that Dryden prefers the term attitude to beliefs, but for this chapter, I am sticking with Ellis’s tradition.
Irrational beliefs are rigid, demanding musts or shoulds (Ellis & Ellis, 2019b). They are usually illogical and unrealistic, but not always. Early versions of the theory listed various specific irrational beliefs (e.g., “It is absolutely necessary that I be loved and approved of by everybody around me”), but generally Ellis said that the core irrational belief was demandingness, which leads us to musterbate (yes; this is Ellis’s term; Ellis, 1994b): the world must be fair, I must be perfect, others must be nice and love me.
When people rely on irrational thinking a lot, they can fall into other kinds of irrational thinking that are thought to be derivatives of the musts—that is, one doesn’t engage in these unless there is a demand in play. These irrational beliefs beyond demandingness are awfulizing, low frustration tolerance (LFT), and self- and other downing. Other writers substitute frustration intolerance for LFT and self-condemnation, or other condemnation for the downings (DiGiuseppe & Doyle, 2021).
We are not always aware of our iBs because they can operate on both conscious and unconscious levels (Ellis et al., 2010). Humans are in the habit of hanging onto their iBs, repeating them again and again to themselves. Eventually, they are transformed into basic (irrational) philosophies that feel like the truth sent from on high (Ellis, 1994b). These dysfunctional basic philosophies are then reinforced in a number of ways. They lead to strong negative emotions, which makes them feel true. They use circular reasoning (If I fail, I am bad. I failed, therefore I’m bad).
Raphael thinks that Alan’s iBs are fairly easy to guess, although Alan might not consciously think about them. Raphael thinks that Alan seems to have some kind of extreme belief around the light switches: “If I don’t turn off all light switches, some disaster will happen and that would be awful!” Similarly, he might be thinking, “I absolutely must not ever hit anyone with my car. If I did that, it would be terrible and I would be an absolutely rotten person!” Although Raphael is wondering what the imagery is about, he suspects that Alan is also telling himself that he should never have images such as these, and the fact that he does makes him an unworthy worm, a definite no-goodnik! Underlying these specific beliefs is Alan’s adoption of the three musts, and most particularly the first: I must be perfect. Because he has such difficult symptoms that sometimes seem to cause other people to treat him badly, Alan probably harbors the other two musts as well: others must treat me well, and the world must be an easy place to live or I just can’t stand it. Clearly, Alan is awfulizing, is rating himself as worthless, and is beset by low frustration tolerance. He sees himself as all bad because of the symptoms he experiences.
Goals
According to REBT, people have goals that they carry with them, and the most important As happen when those goals are thwarted. We all have the general goals to survive and be happy, but these are translated into more-specific subgoals that we share with other people (e.g., the desire for a successful career) or that may be idiosyncratic. One common goal is to be loved (Ellis, 1995a). When we receive information that indicates that someone important is unhappy with us, the goal of being loved is blocked and we experience an antecedent event. Other specific goals mentioned by Ellis are to be comfortable and successful (Ellis, 1995a). “We naturally want love, power, freedom and fun—for they often add to our enjoying of life and help us survive” (Ellis, 1999c, p. 8).
Alan’s goal of being reasonably happy is threatened by his compulsive behavior. He has to interrupt his normal life rhythms to check the light switches, and he can never relax at home because he must go back and check to see if he has hit anyone with his car. The anxiety and depression he experiences also interfere with his goal to be comfortable and successful. He is having difficulty at work because of his anxious, compulsive behavior, Raphael discovers. His coworkers sometimes react to his apparent discomfort and anxiety, and he sometimes checks and rechecks small details of their work. Raphael suspects that Alan’s goals to be accepted by others and loved by his wife are also frustrated to some extent because his sometimes odd, anxious behavior puts others off, and Teresa is getting quite frustrated with his “checking” behavior (the light switches and his route home from work). He is most concerned about the strife in his relationship with Teresa. (Raphael wonders, as an aside, if Teresa is experiencing some I-can’t-stand-it-itis about Alan’s behaviors.) Raphael also knows that Alan’s religion is very important to him and guesses that the imagery Alan reports creates a perception that Alan can’t possibly achieve his goal of being worthwhile in the eyes of God and his church.
Human Worth Ratings and USA
In REBT, global human worth ratings—that is, seeing yourself or someone else as an all-good or all-bad person—are a no-no. The person and the behavior must be separated—one can behave badly, but that does not make one a bad person (a rotten person or a worm; Ellis, 1999a). Ellis (2005) opined, “So you accurately tell yourself, ‘I did that desirable or undesirable act. It certainly did not do itself! I did it with my little hatchet; and I will—because of my talents and fallibilities—do many more desirable and undesirable behaviors. But I am not my acts—just a person who behaves well and badly’” (p. 15; emphasis in original).
Instead of making global judgments of worth, individuals should work toward unconditional self-acceptance, or USA (Ellis & Ellis, 2019b). USA can be achieved in one of two ways. One option is to fight your natural tendencies to self-evaluate and instead choose to see yourself as a good person just because you are alive and human (Ellis, 1999b). The problem with viewing yourself as inherently good is that just anyone could come along and disagree with your definition of yourself and say that you are a worm. You have no way of proving that your assertion is right. Also, “you, alas, are a fallible and often screwed-up human” (Ellis, 1999b, p. 54), so you would be constantly confronted with your own imperfection. The better option to global goodness is to refuse to make such evaluations of the self at all. Simply evaluate your behavior, thoughts, and feelings as good or bad according to the standard of rationality (i.e., whether they help you achieve your goals; Ellis, 1999a).
This REBT rule applies to our self-ratings as well as to our appraisals of others. Ellis maintained that it is best to practice UOA, or unconditional other-acceptance, too (D. J. Ellis, 2021). Because others are human, they will also most certainly treat you badly and may even believe that you deserve to be treated that way! UOA, then, involves applying the same standards to others that you apply to yourself—hate the behavior, not the person. Similarly, Ellis argued that unconditional life-acceptance (ULA) is necessary to achieve a state of minimal disturbance (Ellis & Ellis, 2019b).
Alan is rating himself as a worthless human being, particularly because of the uncomfortable religious images he experiences that he feels he cannot control. He does not unconditionally accept himself. Because he has experienced the anxiety and repetitive behavior for a long time, he tells Raphael that he believes that there is something wrong with him—he is a 100% bad person. He also sees most other people as uncaring and mean because they do not accept him and sometimes appear uncomfortable with his anxious behavior.
Secondary Disturbances
It’s bad enough that we create our own unwanted negative feelings and behaviors (Cs). What’s worse is that, according to REBT, we go even further and believe that we “must not think crookedly, must not have disturbed feelings, must not have dysfunctional behaviors” (Ellis, 1999a, p. 81). When we have an upsetting ABC experience, we treat the Cs as activating experiences themselves (A2s) and then get all wound up with Bs about them. Ellis called these kinds of upsets secondary disturbances because they come in response to the first ABC sequence, which we have mishandled by relying on an iB in response to A1. Then we create more trouble by adding an iB in response to A2 (or the original C). When we tell ourselves that we must not have lousy thinking, or get anxious, or whatever, we are creating a secondary disturbance or symptom stress (DiGiuseppe et al., 2014).
For example, if my mother yells at me (A1), I can respond with the rB “Well, I’d rather she didn’t do that, but it does not make me or her a rotten person.” This sequence might result in some annoyance or mild discomfort on my part, a healthy negative emotion. Alternately, I might respond with the iB “She must not yell at me—I can’t stand it and she is a rotten person!” In this second case, the C would probably be anger, and even some angry behavior (such as shouting back at Mom). If I shout, then I have created an A2 because I immediately respond with the iB “I must be perfect at all times, absolutely never lose my cool or be mean to anyone or I am a worm!” I have then constructed the secondary disturbance, C2—that is, shame, guilt, or depression.
Ellis (1999a) noted that clients can even create tertiary disturbances that have to do with musting about doing well in therapy and expecting that the counselor will help perfectly, significantly, and quickly! These tertiary disturbances need to be discovered and disputed while, or even before, the counseling addresses the primary or secondary ones.
Raphael thinks that Alan is evidencing significant secondary disturbances. When he gets anxious and performs his compulsive behavior (C1 and also A2), he tells himself that he must not be like this (iB2) and that he absolutely should not ever act in such silly, immature ways (iB2). Further, life should not be so difficult—he just can’t stand how hard it is to live (iB2). These Bs are likely creating feelings of rage and depression (C2s).
Theory of the Person and Development of the Individual
REBT does not present a personality theory or offer a detailed developmental discussion. As noted earlier, REBT postulates that humans are a product of both inherited influences and environmental teaching, but constitutional factors are considered the more powerful ones (Neenan & Dryden, 2021). Ellis did not discuss any developmental progression; at one point, he called Freud’s psychosexual stages figments of his (Freud’s) obsessive need for perfection.
Biological influences include things such as individual differences in the tendency to think irrationally or react emotionally and, conversely, to grow and actualize. Tendencies toward behavior (such as compulsive behaviors) can also be innately determined (Ellis, 1997b).
The most important environmental influences are other people. We absorb rules, standards of behavior, and goals from those around us, including parents, siblings, teachers, peers, and religious or political groups. “You, like almost all people, are a born ‘musturbator’ and will almost inevitably take parental, societal and personal rules and foolishly make them into imperatives. So most—not all—of your profound musturbation is self-constructed, self-repeated, self-learned” (Ellis, 1995a, p. 4; quotes in original). Of course, we don’t have to internalize these rules, but it is our human nature to do so.
When her parents, for example, tell Julie that she should be getting better grades, they really mean, according to Ellis (1995a), that it would be preferable if she got all As. Like most parents, they then proceed with business as usual and still love Julie even if she gets all Cs. Because she is born with a twisted little human mind, Julie takes the preferential “you should” and turns it into an absolute demand that runs something like this: “I absolutely must get all As and be perfect. It will be positively horrible if I don’t, and I will be a worthless, rotten worm.”
Much of this construction of musts and shoulds happens when we are children and have immature (bad, rigid, crooked) thinking processes (Ellis, 1995a). We then carry these irrational ideas into adulthood, constantly reindoctrinating ourselves without really realizing what we are doing.
Raphael and Alan don’t spend a lot of time discussing Alan’s childhood or how he got to be how he is today. Raphael knows that, although some of Alan’s behaviors and beliefs probably originated early in his life, some things about Alan may be the result of biological influences.
Health and Dysfunction
In the REBT view, healthy people are those who rely mostly on rational beliefs in their daily lives. Healthy folks tend to use flexible, preferential thinking rather than absolutistic musts and shoulds (Dryden, 2021). Unconditional self-acceptance is characteristic of healthy individuals because they take responsibility for their psychological functioning and choose to accept that they are imperfect beings. They will still have the inclination to awfulize, should, musturbate, and do all of those other things associated with the human tendency to be irrational, but mostly they will defeat these tendencies (Ellis, 1995a). High frustration tolerance (HFT) is an important aspect of psychological health, but it must not be confused with always accepting situations we don’t like. Instead, HFT means that one often tolerates disliked situations in the short term, while working to change them, if possible (Ellis & Ellis, 2019a).
Healthy people have healthy basic philosophies that value flexibility and open-mindedness and oppose bigotry (Ellis, 1994b). Relativistic thinking and desiring (as opposed to absolutely needing) is a core characteristic of psychological health. Self-interest is a primary value because healthy people realize that “if they do not primarily take care of themselves, who else will?” (Ellis, 1985, p. 108). However, they balance self-interest with social interest because most of them also want to live happily in a social group. If they act in ways counter to the group’s good, they are not likely to create an environment in which they can live happily. REBT advocates call this enlightened self-interest (Matweychuk, 2022).
Acceptance (USA, UOA, ULA) is an important characteristic of the healthy person, in the sense of accepting one’s and others’ human fallibility, given that life is complicated and sometimes influenced by factors outside of one’s control. However, acceptance does not mean resignation; healthy people actively change their worlds when they can (Dryden, 2011). In fact, Ellis (1999c) argued that the REBT counselor’s job is not only to help clients deal with iBs around social injustice, but also to encourage them to work to change these unhealthy As.
Healthy people endorse the philosophy of REBT. The values in the REBT philosophy include long-range hedonism, self-interest, social interest, self-direction, tolerance of others, acceptance of life’s ambiguity and uncertainty, flexibility and openness to change, and the value of scientific thinking (Ellis, 2005). Commitment to something outside of one’s self is important, whether that commitment is to people, things, or ideas. REBT also emphasizes risk taking, nonperfectionism, and nonutopianism (Ellis, 1985, p. 110).
Dysfunction from an REBT perspective is, most simply, operating in the world on the basis of irrational beliefs or, more globally, on the basis of an irrational philosophical system. Ellis (2003) wrote, “I have stubbornly insisted that human disturbance is contributed to by environmental pressures, including our childhood upbringing, but that its most important and vital source originates in our innate tendency to indulge in crooked thinking” (p. 205).
People who experience life difficulties have taken their preferences and elevated them to absolute demands. “Anxious, depressed, and enraged people have many dysfunctional ideas or irrational beliefs by which they largely create their neurotic disturbances; and as the theory of REBT holds, these beliefs almost always seem to consist of or be derived from unrealistically, illogically, and rigidly raising their nondisturbing wishes and preferences into godlike absolutist musts, shoulds, demands, and commands” (Ellis, 1999b, p. 477). They awfulize, engage in damnation, and have textbook cases of I-can’t-stand-it-itis.
Demandingness is the core of psychological dysfunction, from which all other problems flow (DiGiuseppe & Doyle, 2019). Awfulizing, frustration intolerance, and global condemnation of human worth flow from the original must: it is badder than bad that my demand isn’t met, I just can’t stand it, and I am a worm/you are a worm/the world is one big worm.
Ellis acknowledged that severe psychological dysfunction, such as personality disorders, profound depression, obsessive-compulsive disorder, or psychosis, likely stems from the joint influence of traumatizing early experience and innate, organic deficits (Ellis, 2002). Individuals who display these syndromes are probably inherently more emotionally reactive and behaviorally disorganized than “nice normal neurotics” (Ellis, 1997b, p. 198). They may experience more frustration and criticism in life because of their sometimes odd behavior (Ellis, 1994a). Even worse, individuals with severe dysfunction tend to create severe secondary disturbances about their very real deficits. They easily develop severe LFT, insisting that “my symptoms must not be so upsetting and handicapping.” They self-down about having such deficits (Ellis, 1994a). These problems tend to make individuals with these kinds of dysfunction VDCs (very difficult customers; Ellis, 1994a, 1994b).
Raphael thinks that some of Alan’s thoughts and behaviors stem from biological tendencies, such as the propensity toward anxiety and compulsive behaviors. Alan might even be diagnosed as having obsessive-compulsive disorder. Raphael has identified the irrational beliefs that Alan connects with light switches, running people over with his car, and the scary sexual religious imagery. Raphael can also see how Alan responds to events in his life with thought processes that are self-defeating. He is self-downing and has low frustration tolerance. With the recent resurgence of his compulsive behavior, Alan seems to be holding beliefs such as “I must not be flawed like this! I can’t stand it that I am not perfect in every way! Further, when I am like this, everyone disapproves of me. I’ll never be loved and accepted by everyone, and that is really intolerable! I can’t stand this anxiety or the rejection of others! I am a rotten, flawed human, and I will never lose these symptoms, and therefore I can never have a happy life or the love of those important to me. This is just too hard!” Clearly, Alan demands that his life not be this difficult; he downs himself for his anxiety, compulsive behavior, and images. He believes that he can’t stand the pain and trouble in his life.