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9Behavior Therapy

1. Identify the key figures associated with the development of behavior therapy.

2. Differentiate the four developmental areas of behavior therapy: classical conditioning, operant conditioning, social cognitive theory, and cognitive behavior therapy.

3. Evaluate the central characteristics and assumptions that unite the diverse field of behavior therapy.

4. Understand how the function and role of the therapist affects the therapy process.

5. Describe the role of the client– therapist relationship in the behavioral approaches.

6. Identify the diverse array of behavioral techniques and procedures and how they fit within the evidence-based practice movement.

7. Describe the key concepts of EMDR, its main applications, and the effectiveness of this approach.

8. Describe the basic elements of social skills training.

9. Understand and explain the main steps involved in self-management programs.

10. Identify the key concepts of the four major approaches of the mindfulness and acceptance- based behavior therapies.

11. Examine the application of behavioral principles and techniques to brief interventions and to group counseling.

12. Understand the advantages and shortcomings of behavior therapy in working with culturally diverse clients.

13. Discuss the evaluation of contemporary behavior therapy.

L e a r n i n g O b j e c t i v e s

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B. F. SKINNER (1904–1990) reported that he was brought up in a warm, stable family environment.* As he was grow- ing up, Skinner was greatly interested in building all sorts of things, an inter- est that followed him throughout his professional life. He received his PhD in psychology from Harvard University in 1931 and eventually returned to Harvard after teaching in several universities. He had two daughters, one of whom is an educational psychologist and the other an artist.

Skinner was a prominent spokesperson for behaviorism and can be considered the father of the behavioral approach to psychology. Skinner cham- pioned radical behaviorism, which places primary emphasis on the effects of environment on behavior. Skinner was also a determinist; he did not believe that humans had free choice. He acknowledged that feel- ings and thoughts exist, but he denied that they caused our actions. Instead, he stressed the cause-and-effect links between objective, observable environmental conditions and behavior. Skinner maintained that too much attention had been given to internal states of mind and motives, which cannot be observed and changed directly, and that too little focus had been

given to environmental factors that can be directly observed and changed. He was extremely interested in the concept of reinforcement, which he applied to his own life. For example, after working for many hours, he would go into his constructed cocoon (like a tent), put on headphones, and listen to classical music (Frank Dattilio, personal communica- tion, September 24, 2010).

Most of Skinner’s work was of an experimental nature in the laboratory, but others have applied his ideas to teach-

ing, managing human problems, and social plan- ning. Science and Human Behavior (Skinner, 1953) best illustrates how Skinner thought behavioral concepts could be applied to every domain of human behav- ior. In Walden II (1948) Skinner describes a utopian community in which his ideas, derived from the lab- oratory, are applied to social issues. His 1971 book, Beyond Freedom and Dignity, addressed the need for drastic changes if our society was to survive. Skinner believed that science and technology held the promise for a better future.

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*This biography is based largely on Nye’s (2000) discussion of B. F. Skinner’s radical behaviorism.

ALBERT BANDURA (b. 1925) was born in a small town in northern Alberta, Canada; he was the youngest of six chil- dren in a family of Eastern European descent.* Bandura spent his elemen- tary and high school years in the one school in town, which was short of teachers and resources. These meager educational resources proved to be an asset rather than a liability as Bandura early on learned the skills of self-direct- edness, which would later become one of his research themes. He earned his PhD in clinical psychology from the University of Iowa in 1952, and a year later he joined the faculty at Stanford University. Bandura and his colleagues did pioneering work in the area of social model- ing and demonstrated that modeling is a powerful process that explains diverse forms of learning (see

Bandura 1971a, 1971b; Bandura & Wal- ters, 1963). In his research programs at Stanford University, Bandura and his colleagues explored social learning the- ory and the prominent role of observa- tional learning and social modeling in human motivation, thought, and action. By the mid-1980s Bandura had renamed his theoretical approach social cogni- tive theory, which shed light on how we function as self-organizing, proactive, self-reflective, and self-regulating beings (see Bandura, 1986). This notion that we

are not simply reactive organisms shaped by environ- mental forces or driven by inner impulses represented a dramatic shift in the development of behavior ther- apy. Bandura broadened the scope of behavior ther- apy by exploring the inner cognitive-affective forces that motivate human behavior.

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Introduction behavior therapy practitioners focus on directly observable behavior, current determinants of behavior, learning experiences that promote change, tailoring treatment strategies to individual clients, and rigorous assessment and evalua- tion. Behavior therapy has been used to treat a wide range of psychological disor- ders with specific client populations. Anxiety disorders, depression, posttraumatic stress disorder, substance abuse, eating and weight disorders, sexual problems, pain management, and hypertension have all been successfully treated using this approach (Wilson, 2011). Behavioral procedures are used in the fields of develop- mental disabilities, mental illness, education and special education, community psychology, clinical psychology, rehabilitation, business, self-management, sports psychology, health-related behaviors, medicine, and gerontology (Miltenberger, 2012; Wilson, 2011).

Historical Background The behavioral approach had its origin in the 1950s and early 1960s, and it was a radical departure from the dominant psychoanalytic perspective. The behav- ior therapy movement differed from other therapeutic approaches in its application of principles of classical and operant conditioning (which will be explained shortly) to the treatment of a variety of problem behaviors. Today, it is difficult to find a con- sensus on the definition of behavior therapy because the field has grown, become more complex, and is marked by a diversity of views. Contemporary behavior ther- apy is no longer limited to treatments based on traditional learning theory (Antony & Roemer, 2011b), and it increasingly overlaps with other theoretical approaches (Antony, 2014). Behavior therapists now use a variety of evidence-based techniques in their practices, including cognitive therapy, social skills training, relaxation

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There are some existential qualities inherent in Bandura’s social cognitive theory. Bandura has pro- duced a wealth of empirical evidence that demon- strates the life choices we have in all aspects of our lives. In Self-Efficacy: The Exercise of Control (Bandura, 1997), Bandura shows the comprehensive applica- tions of his theory of self-efficacy to areas such as human development, psychology, psychiatry, educa- tion, medicine and health, athletics, business, social and political change, and international affairs.

Bandura has concentrated on four areas of research: (1) the power of psychological modeling in shaping thought, emotion, and action; (2) the mechanisms of human agency, or the ways peo- ple influence their own motivation and behavior through choice; (3) people’s perceptions of their efficacy to exercise influence over the events that

affect their lives; and (4) how stress reactions and depressions are caused. Bandura has created one of the few mega-theories that still thrive in the 21st century. He has shown that people need a sense of self-efficacy and resilience to create a successful life and to meet the inevitable obstacles and adversities they encounter.

Bandura has written nine books, many of which have been translated into various languages. In 2004 he received the Outstanding Lifetime Contribution to Psychology Award from the American Psychologi- cal Association. He still makes time for hiking, opera, being with his family, and wine tasting in the Napa and Sonoma valleys.

*This biography is based largely on Panjares’s (2004) discussion of Bandura’s life and work.

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training, and mindfulness strategies—all discussed in this chapter. The following historical sketch of behavior therapy is largely based on Spiegler (2016).

Traditional behavior therapy arose simultaneously in the United States, South Africa, and Great Britain in the 1950s. In spite of harsh criticism and resistance from psychoanalytic psychotherapists, the approach has survived. Its focus was on dem- onstrating that behavioral conditioning techniques were effective and were a viable alternative to psychoanalytic therapy.

In the 1960s Albert Bandura developed social learning theory, which combined classical and operant conditioning with observational learning. Bandura made cognition a legitimate focus for behavior therapy. During the 1960s a number of cognitive behavioral approaches sprang up, which focus on cognitive representations of the environment rather than on characteristics of the objective environment.

Contemporary behavior therapy emerged as a major force in psychology during the 1970s, and it had a significant impact on education, psychology, psychotherapy, psychiatry, and social work. Behavioral techniques were expanded to provide solu- tions for business, industry, and child-rearing problems as well. Behavior therapy techniques were viewed as the treatment of choice for many psychological problems.

The 1980s were characterized by a search for new horizons in concepts and methods that went beyond traditional learning theory. Behavior therapists continued to subject their methods to empirical scrutiny and to consider the impact of the practice of therapy on both their clients and the larger society. Increased attention was given to the role of emotions in therapeutic change, as well as to the role of biological factors in psychologi- cal disorders. Two of the most significant developments in the field were (1) the contin- ued emergence of cognitive behavior therapy as a major force and (2) the application of behavioral techniques to the prevention and treatment of health-related disorders.

By the late 1990s the Association for Behavioral and Cognitive Therapies (ABCT) (formerly known as the Association for Advancement of Behavior Therapy) claimed a membership of about 4,500. Currently, ABCT includes approximately 6,000 men- tal health professionals and students who are interested in empirically based behav- ior therapy or cognitive behavior therapy. This name change and description reveals the current thinking of integrating behavioral and cognitive therapies.

By the early 2000s, the behavioral tradition had broadened considerably, which involved enlarging the scope of research and practice. This newest development, sometimes known as the “third generation” or “third wave” of behavior therapy, includes dialectical behavior therapy (DBT), mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and acceptance and com- mitment therapy (ACT). Behavior therapies are among the most widely used treat- ment interventions for psychological and behavioral problems today (Antony, 2014).

visit CengageBrain.com or watch the DvD for the video program on Chapter 9, Theory and Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the brief lecture for each chapter prior to reading the chapter.

Four Areas of Development Contemporary behavior therapy can be understood by considering four major areas of development: (1) classical conditioning, (2) operant conditioning, (3) social-cognitive theory, and (4) cognitive behavior therapy.

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classical conditioning (respondent conditioning) refers to what happens prior to learning that creates a response through pairing. A key figure in this area is Ivan Pavlov who illustrated classical conditioning through experiments with dogs. Plac- ing food in a dog’s mouth leads to salivation, which is respondent behavior. When food is repeatedly presented with some originally neutral stimulus (something that does not elicit a particular response), such as the sound of a bell, the dog will eventu- ally salivate to the sound of the bell alone. However, if a bell is sounded repeatedly but not paired again with food, the salivation response will eventually diminish and become extinct. An example of a procedure that is based on the classical condition- ing model is Joseph Wolpe’s systematic desensitization, which is described later in this chapter. This technique illustrates how principles of learning derived from the experimental laboratory can be applied clinically. Desensitization can be applied to people who, through classical conditioning, developed an intense fear of flying after having a frightening experience while flying.

Technically one can develop an intense fear of flying without having a frighten- ing experience personally. For example, someone may see visual images of a plane crashing off the coast of Brazil and develop a fear of flying even though that person has never flown anywhere. Some researchers hold a different view and believe that fear of flying may be due primarily to claustrophobia (Frank Dattilio, personal com- munication, September 24, 2010).

Most of the significant responses we make in everyday life are examples of oper- ant behaviors, such as reading, writing, driving a car, and eating with utensils. Oper- ant conditioning involves a type of learning in which behaviors are influenced mainly by the consequences that follow them. If the environmental changes brought about by the behavior are reinforcing—that is, if they provide some reward to the organism or eliminate aversive stimuli—the chances are increased that the behavior will occur again. If the environmental changes produce no reinforcement or pro- duce aversive stimuli, the chances are lessened that the behavior will recur. Posi- tive and negative reinforcement, punishment, and extinction techniques, described later in this chapter, illustrate how operant conditioning in applied settings can be instrumental in developing prosocial and adaptive behaviors. Operant techniques are used by behavioral practitioners in parent education programs and with weight management programs.

The behaviorists of both the classical and operant conditioning models excluded any reference to mediational concepts, such as the role of thinking pro- cesses, attitudes, and values. This focus is perhaps due to a reaction against the insight-oriented psychodynamic approaches. The social learning approach (or the social-cognitive approach) developed by Albert Bandura and Richard Walters (1963) is interactional, interdisciplinary, and multimodal (Bandura, 1977, 1982). Social-cognitive theory involves a triadic reciprocal interaction among the environment, personal fac- tors (beliefs, preferences, expectations, self-perceptions, and interpretations), and individual behavior. In the social-cognitive approach, the environmental events on behavior are mainly determined by cognitive processes governing how environmen- tal influences are perceived by an individual and how these events are interpreted. A basic assumption is that people are capable of self-directed behavior change and that the person is the agent of change. For Bandura (1982, 1997), self-efficacy is the indi- vidual’s belief or expectation that he or she can master a situation and bring about

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desired change. An example of social learning is ways people can develop effective social skills after they are in contact with other people who effectively model inter- personal skills.

cognitive behavior therapy (cbt) represents the mainstream of contempo- rary behavior therapy and is a popular theoretical orientation among psychologists. Cognitive behavioral therapy operates on the assumption that what people believe influences how they act and feel. Since the early 1970s, the behavioral movement has conceded a legitimate place to thinking, even to the extent of giving cognitive factors a central role in understanding and treating emotional and behavioral prob- lems. By the mid-1970s, cognitive behavior therapy had replaced behavior therapy as the accepted designation, and the field began emphasizing the interaction among affec- tive, behavioral, and cognitive dimensions.

Contemporary behavior therapy has much in common with cognitive behavior therapy in which the mechanism of change is both cognitive (modifying thoughts to change behaviors) and behavioral (altering external factors that lead to behavior change; Follette & Callaghan, 2011). Social skills training, cognitive therapy, stress management training, mindfulness, and acceptance-based practices all represent the cognitive behavioral tradition. This chapter goes beyond the traditional behav- ioral perspective and deals mainly with applied aspects of this model. Chapter 10 is devoted to the cognitive behavioral approaches, which focus on changing clients’ cognitions (thoughts and beliefs) that maintain psychological problems.

Key Concepts Current Trend in Behavior Therapy

Contemporary behavior therapy is grounded on a scientific view of human behavior that accommodates a systematic and structured approach to counseling. The cur- rent trend in behavior therapy is toward developing procedures that give control to clients and thus increase their range of freedom. Behavior therapy aims to increase people’s skills so that they have more options for responding. By overcoming debili- tating behaviors that restrict choices, people are freer to select from possibilities that were not available to them earlier, which increases individual freedom.

Basic Characteristics and Assumptions Seven key characteristics define behavior therapy and its assumptions. One defining characteristic is that behavior therapy is based on the principles and pro- cedures of the scientific method. Experimentally derived principles of learning are systematically applied to help people change their maladaptive behaviors. The distinguishing characteristic of behavioral practitioners is their systematic adher- ence to precision and to empirical evaluation. Behavior therapists state treatment goals in concrete objective terms to make replication of their interventions possible. Treatment goals are agreed upon by the client and the therapist. Throughout the course of therapy, the therapist assesses problem behaviors and the conditions that are maintaining them. Evaluation methods are used to discern the effectiveness

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of both assessment and treatment procedures. Therapeutic techniques employed must have demonstrated effectiveness. In short, behavioral concepts and proce- dures are stated explicitly, tested empirically within a conceptual framework, and revised continually.

Behavior is not limited to overt actions a person engages in that we can observe, however; behavior also includes internal processes such as cognitions, images, beliefs, and emotions. The key characteristic of a behavior is that it is something that can be operationally defined.

Behavior therapy deals with the client’s current problems and the factors influ- encing them today rather than analyzing possible historical determinants. Empha- sis is on specific factors that influence present functioning and what factors can be used to modify performance. Behavior therapists look to the current environmental events that maintain problem behaviors and help clients produce behavior change by changing environmental events, through a process called functional assessment, or what Wolpe (1990) referred to as a “behavioral analysis.” Behavior therapy recog- nizes the importance of the individual, the individual’s environment, and the inter- action between the person and the environment in facilitating change.

Clients involved in behavior therapy are expected to assume an active role by engaging in specific actions to deal with their problems. Rather than simply talking about their condition, clients are required to do something to bring about change. Clients monitor their behaviors both during and outside the therapy sessions, learn and practice coping skills, and role-play new behavior. Therapeutic tasks that clients carry out in daily life, or homework assignments, are a basic part of this approach. Behavior therapy is an action-oriented and an educational approach, and learning is viewed as being at the core of therapy. Clients learn new and adaptive behaviors to replace old and maladaptive behaviors.

This approach assumes that change can take place without insight into under- lying dynamics and without understanding the origins of a psychological problem. Behavior therapists operate on the premise that changes in behavior can occur prior to or simultaneously with understanding of oneself, and that behavioral changes may well lead to an increased level of self-understanding. Although it is true that insight and understanding about the contingencies that exacerbate one’s problems can supply motivation to change, knowing that one has a problem and knowing how to change it are two different things (Martell, 2007).

Assessment is an ongoing process of observation and self-monitoring that focuses on the current determinants of behavior, including identifying the prob- lem and evaluating the change. Assessment informs the treatment process and involves attending to the culture of clients as part of their social environments, including social support networks relating to target behaviors. Critical to behav- ioral approaches is the careful assessment and evaluation of the interventions used to determine whether the behavior change resulted from the procedure.

Behavioral treatment interventions are individually tailored to specific prob- lems experienced by the client. Several therapy techniques may be used to treat an individual client’s problems. An important question that serves as a guide for this choice is, “What treatment, by whom, is the most effective for this individual with that specific problem and under which set of circumstances?” (Paul, 1967, p. 111).

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The Therapeutic Process Therapeutic Goals

Goals occupy a place of central importance in behavior therapy. The general goals of behavior therapy are to increase personal choice and to create new conditions for learning. The client, with the help of the therapist, defines specific treatment goals at the outset of the therapeutic process. Although assessment and treatment occur together, a formal assessment takes place prior to treatment to determine behaviors that are targets of change. Continual assessment throughout therapy determines the degree to which identified goals are being met. It is important to devise a way to measure progress toward goals based on empirical validation.

Contemporary behavior therapy stresses clients’ active role in formulating spe- cific measurable goals. Goals must be clear, concrete, understood, and agreed on by the client and the counselor. The counselor and client discuss the behaviors associ- ated with the goals, the circumstances required for change, the nature of subgoals, and a plan of action to work toward these goals. This process of determining thera- peutic goals entails a negotiation between client and counselor that results in a con- tract that guides the course of therapy. Behavior therapists and clients alter goals throughout the therapeutic process as needed.

Therapist’s Function and Role Behavior therapists conduct a thorough functional assessment (or behav- ioral analysis) to identify the maintaining conditions by systematically gather- ing information about situational antecedents (A), the dimensions of the problem behavior (B), and the consequences (C) of the problem. This is known as the abc model, and the goal of a functional assessment of a client’s behavior is to under- stand the ABC sequence. This model of behavior suggests that behavior (B) is influ- enced by some particular events that precede it, called antecedents (A), and by certain events that follow it, called consequences (C). antecedent events cue or elicit a cer- tain behavior. For example, with a client who has trouble going to sleep, listening to a relaxation tape may serve as a cue for sleep induction. Turning off the lights and removing the television from the bedroom may elicit sleep behaviors as well. consequences are events that maintain a behavior in some way, either by increas- ing or decreasing it. For example, a client may be more likely to return to counseling after the counselor offers verbal praise or encouragement for having come in or for having completed some homework. A client may be less likely to return if the coun- selor is consistently late to sessions. In doing a behavioral assessment interview, the therapist’s task is to identify the particular antecedent and consequent events that influence, or are functionally related to, an individual’s behavior (Cormier, Nurius, & Osborn, 2013).

Behaviorally oriented practitioners tend to be active and directive and to func- tion as consultants and problem solvers. They rely heavily on empirical evidence about the efficacy of the techniques they apply to particular problems. Behavioral practitioners must have skills in selecting and applying treatment methods. They pay close attention to the clues given by clients, and they are willing to follow their clini- cal hunches. Behavior therapists use some techniques common to other approaches,

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such as summarizing, reflection, clarification, and open-ended questioning. Behav- ior therapists are directive and often offer suggestions (Antony, 2014), but they may perform these other functions as well (Miltenberger, 2012; Speigler, 2016):

�� The therapist strives to understand the function of client behaviors, including how certain behaviors originated and how they are sustained. With this understanding, the therapist formulates initial treatment goals and designs and implements a treatment plan to accomplish these goals.

�� The behavioral clinician uses strategies that have research support for use with a particular kind of problem. These evidence-based strategies promote generalization and maintenance of behavior change. A num- ber of these strategies are described later in this chapter.

�� The clinician evaluates the success of the change plan by measuring progress toward the goals throughout the duration of treatment. Out- come measures are given to the client at the beginning of treatment (called a baseline) and collected again periodically during and after treatment to determine whether the strategy and treatment plan are working. If not, adjustments are made in the strategies being used.

�� Follow-up assessments are conducted to evaluate whether the changes are durable over time. Clients learn how to identify and cope with potential setbacks and acquire behavioral and cognitive coping skills to maintain changes and to prevent relapses.

Let’s examine how a behavior therapist might perform these functions. A cli- ent comes to therapy to reduce her anxiety, which is preventing her from leaving the house. The therapist is likely to begin with a specific analysis of the nature of her anxiety. The therapist will ask how she experiences the anxiety of leaving her house, including what she actually does in these situations. Systematically, the therapist gath- ers information about this anxiety. When did the problem begin? In what situations does it arise? What does she do at these times? What are her feelings and thoughts in these situations? Who is present when she experiences anxiety? What does she do to reduce the anxiety? How do her present fears interfere with living effectively? After this assessment, specific behavioral goals are developed, and strategies such as relaxation training, systematic desensitization, and exposure therapy are designed to help the client reduce her anxiety to a manageable level. The therapist will get a commitment from the client to work toward the specified goals, and the two of them will evaluate the client’s progress toward meeting these goals throughout the duration of therapy.

For a description of applying a behavioral approach to the assessment and treat- ment of an individual client, see Dr. Sherry Cormier’s behavioral interventions with Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 7).

Client’s Experience in Therapy One of the unique contributions of behavior therapy is that it provides the therapist with a well-defined system of procedures to employ. Both therapist and client have clearly defined roles, and the importance of client awareness and participation in the therapeutic process is stressed. Behavior therapy is characterized by an active

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role for both therapist and client. A large part of the therapist’s role is to teach concrete skills through the provision of instructions, modeling, and performance feedback. The client engages in behavioral rehearsal with feedback until skills are well learned and generally receives active homework assignments (such as self- monitoring of problem behaviors) to complete between therapy sessions. Behavior clinicians emphasize that changes clients make in therapy need to be translated into their daily lives.

It is important for clients to be motivated to change, and they are expected to cooperate in carrying out therapeutic activities, both during therapy sessions and in everyday life. If clients are not involved in this way, the chances are slim that therapy will be successful. Motivational interviewing (see Chapter 7), which honors the cli- ent’s resistance in such a way that his or her motivation to change is increased over time, is a behavioral strategy that has considerable empirical support (Miller & Roll- nick, 2013).

Clients are encouraged to experiment for the purpose of enlarging their reper- toire of adaptive behaviors. Counseling is not complete unless actions follow verbal- izations. Behavioral practitioners make the assumption that it is only when the transfer of changes is made from the sessions to everyday life that the effects of therapy can be considered successful. Clients are as aware as the therapist is regard- ing when the goals have been accomplished and when it is appropriate to terminate treatment. It is clear that clients are expected to do more than merely gather insights; they need to be willing to make changes and to continue implementing new behav- ior once formal treatment has ended.

Relationship Between Therapist and Client Behavioral practitioners have increasingly recognized the role of the thera- peutic relationship and therapist behavior as critical factors related to the process and outcome of treatment. As you will recall, the experiential therapies (existential therapy, person-centered therapy, and Gestalt therapy) place primary emphasis on the nature of the engagement between counselor and client. Today most behavioral practitioners stress the value of establishing a collaborative working relationship with clients but contend that warmth, empathy, authenticity, permissiveness, and acceptance are necessary, but not sufficient, for behavior change to occur. The client– therapist relationship is a foundation on which behavioral strategies are built to help clients change in the direction they wish.

Application: Therapeutic Techniques and Procedures A strength of the behavioral approaches is the development of specific thera- peutic procedures that must be shown to be effective through objective means. The results of behavioral interventions become clear because therapists receive continual direct feedback from their clients. A hallmark of the behavioral approaches is that the therapeutic techniques are empirically supported and evidence-based practice is highly valued. Behavior therapy has been shown to be effective with many different populations and for a wide array of disorders. Behavioral techniques can easily be incorporated in other approaches as well.

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The therapeutic procedures used by behavior therapists are specifically designed for a particular client rather than being randomly selected from a “bag of techniques.” Therapists are often quite creative in their interventions. In the following sections I describe a range of behavioral techniques available to the practitioner: applied behav- ioral analysis, relaxation training, systematic desensitization, exposure therapies, eye movement desensitization and reprocessing, social skills training, self-management programs, multimodal therapy, and mindfulness and acceptance-based approaches. These techniques do not encompass the full spectrum of behavioral procedures, but they do represent a sample of the approaches used in the practice of contemporary behavior therapy.

Applied Behavioral Analysis: Operant Conditioning Techniques This section describes a few key principles of operant conditioning: positive rein- forcement, negative reinforcement, extinction, positive punishment, and negative punishment. For a detailed treatment of the wide range of operant conditioning methods that are part of contemporary behavior modification, I recommend Milt- enberger (2012) and Speigler (2016).

The most important contribution of applied behavior analysis is that it offers a functional approach to understanding clients’ problems and addresses these prob- lems by changing antecedents and consequences (the ABC model). Behaviorists believe we respond in predictable ways because of the gains we experience (positive reinforcement) or because of the need to escape or avoid unpleasant consequences (negative reinforcement). Once clients’ goals have been assessed, specific behaviors are targeted. The goal of reinforcement, whether positive or negative, is to increase the target behavior. Positive reinforcement involves the addition of something of value to the individual (such as praise, attention, money, or food) as a consequence of certain behavior. The stimulus that follows the behavior is the positive reinforcer. For example, a child earns excellent grades and is praised for studying by her parents. If she values this praise, it is likely that she will have an investment in studying in the future. When the goal of a program is to decrease or eliminate undesirable behav- iors, positive reinforcement is often used to increase the frequency of more desirable behaviors, which replace undesirable behaviors. In the above example, the parental praise functions as the positive reinforcer and makes it more likely that the child will maintain or even increase the frequency of studying and earning good grades. Note that if a child did not value parental praise, this would not serve as a reinforcer. The reinforcer is not defined by the form or substance that it takes but rather by the function it serves: namely, to maintain or increase the frequency of a desired behavior.

negative reinforcement involves the escape from or the avoidance of aversive (unpleasant) stimuli. The individual is motivated to exhibit a desired behavior to avoid the unpleasant condition. For example, a friend of mine does not appreciate waking up to the shrill sound of an alarm clock. She has trained herself to wake up a few minutes before the alarm sounds to avoid the aversive stimulus of the alarm buzzer.

Another operant method of changing behavior is extinction, which refers to withholding reinforcement from a previously reinforced response. In applied set- tings, extinction can be used for behaviors that have been maintained by positive

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reinforcement or negative reinforcement. For example, in the case of children who display temper tantrums, parents often reinforce this behavior by the attention they give to it. An approach to dealing with problematic behavior is to eliminate the con- nection between a certain behavior (tantrums) and positive reinforcement (atten- tion). In this example, if the parent ignores the child’s tantrum-related behaviors, these behaviors will decrease or be eliminated through the extinction process. It should be noted that extinction might well have negative side effects, such as anger and aggression. Also note that during the extinction process unwanted behaviors may increase temporarily before they begin to decrease. Extinction can reduce or elimi- nate certain behaviors, but extinction does not replace those responses that have been extinguished.

Another way behavior is controlled is through punishment, sometimes referred to as aversive control, in which the consequences of a certain behavior result in a decrease of that behavior. The goal of reinforcement is to increase target behavior, but the goal of punishment is to decrease target behavior. Miltenberger (2012) describes two kinds of punishment that may occur as a consequence of behavior: positive punishment and negative punishment. In positive punishment an aversive stimu- lus is added after the behavior to decrease the frequency of a behavior (such as a time- out procedure with a child who is displaying misbehavior).

In negative punishment a reinforcing stimulus is removed following the behav- ior to decrease the frequency of a target behavior (such as deducting money from a worker’s salary for missing time at work, or taking television time away from a child for misbehavior). In both kinds of punishment, the behavior is less likely to occur in the future. These four operant procedures form the basis of behavior therapy pro- grams for parent skills training and are also used in the self-management proce- dures that are discussed later in this chapter.

Some behavioral practitioners are opposed to using aversive control or punish- ment and recommended substituting positive reinforcement. The key principle in the applied behavior analysis approach is to use the least aversive means possible to change behavior, and positive reinforcement is known to be the most powerful change agent. It is essential that reinforcement be used as a way to develop appropri- ate behaviors that replace the behaviors that are suppressed.

Progressive Muscle Relaxation Progressive muscle relaxation has become increasingly popular as a method of teaching people to cope with the stresses produced by daily living. It is aimed at achieving muscle and mental relaxation and is easily learned. After clients learn the basics of relaxation procedures, it is essential that they practice these exercises daily to obtain maximum results.

Jacobson (1938) is credited with initially developing the progressive muscle relax- ation procedure. It has since been refined and modified, and relaxation procedures are frequently used in combination with a number of other behavioral techniques. Progressive muscle relaxation involves several components. Clients are given a set of instructions that teaches them to relax. They assume a passive and relaxed position in a quiet environment while alternately contracting and relaxing muscles. This pro- gressive muscle relaxation is explicitly taught to the client by the therapist. Deep and

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regular breathing also is associated with producing relaxation. At the same time cli- ents learn to mentally “let go,” perhaps by focusing on pleasant thoughts or images. Clients are instructed to actually feel and experience the tension building up, to notice their muscles getting tighter and study this tension, and to hold and fully experience the tension. It is useful for clients to experience the difference between a tense and a relaxed state. The client is then taught how to relax all the muscles while visualizing the various parts of the body, with emphasis on the facial muscles. The arm muscles are relaxed first, followed by the head, the neck and shoulders, the back, abdomen, and thorax, and then the lower limbs. Relaxation becomes a well-learned response, which can become a habitual pattern if practiced daily for about 25 minutes each day.

Relaxation procedures have been applied to a variety of clinical problems, either as a separate technique or in conjunction with related methods. The most common use has been with problems related to stress and anxiety, which are often mani- fested in psychosomatic symptoms. Relaxation training has benefits in areas such as preparing patients for surgery, teaching clients how to cope with chronic pain, and reducing the frequency of migraine attacks (Ferguson & Sgambati, 2008). Some other ailments for which progressive muscle relaxation is helpful include asthma, headache, hypertension, insomnia, irritable bowel syndrome, and panic disorder (Cormier et al., 2013).

For an exercise of the phases of the progressive muscle relaxation procedure that you can apply to yourself, see Student Manual for Theory and Practice of Counseling and Psychotherapy (Corey, 2017). For a more detailed discussion of progressive muscle relaxation, see Ferguson and Sgambati (2008).

Systematic Desensitization systematic desensitization, which is based on the principle of classical condition- ing, is a basic behavioral procedure developed by Joseph Wolpe, one of the pioneers of behavior therapy. Clients imagine successively more anxiety-arousing situations at the same time that they engage in a behavior that competes with anxiety. Grad- ually, or systematically, clients become less sensitive (desensitized) to the anxiety- arousing situation. This procedure can be considered a form of exposure therapy because clients are required to expose themselves to anxiety-arousing images as a way to reduce anxiety.

Systematic desensitization is an empirically researched behavior therapy pro- cedure that is time consuming, yet it is clearly effective and efficient in reducing maladaptive anxiety and treating anxiety-related disorders, particularly in the area of specific phobias (Cormier et al., 2013; Spiegler, 2016). Before implementing the desensitization procedure, the therapist conducts an initial interview to identify spe- cific information about the anxiety and to gather relevant background information about the client. This interview, which may last several sessions, gives the therapist a good understanding of who the client is. The therapist questions the client about the particular circumstances that elicit the conditioned fears. For instance, under what circumstances does the client feel anxious? If the client is anxious in social situations, does the anxiety vary with the number of people present? Is the client more anxious with women or men? The client is asked to begin a self-monitoring process consisting of observing and recording situations during the week that elicit

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anxiety responses. Some therapists also administer a questionnaire to gather addi- tional data about situations leading to anxiety.

If the decision is made to use the desensitization procedure, the therapist gives the client a rationale for the procedure and briefly describes what is involved. A three- step process is carried out in the desensitization process: (1) relaxation training, (2) development of a graduated anxiety hierarchy, and (3) systematic desensitization through presentation of hierarchy items while the client is in a deeply relaxed state (Head & Gross, 2008).

The first step is progressive muscle relaxation, which were described earlier. The therapist uses a quiet, soft, and pleasant voice to teach progressive muscular relax- ation. The client is asked to create imagery of previously relaxing situations, such as sitting by a lake or wandering through a beautiful field. It is important that the client reach a state of calm and peacefulness. The client is instructed to practice relaxation both as a part of the desensitization procedure and also outside the ses- sion on a daily basis.

The therapist then works with the client to develop an anxiety hierarchy for each of the identified areas. Stimuli that elicit anxiety in a particular area are analyzed, such as rejection, jealousy, criticism, disapproval, or any phobia. The therapist con- structs a ranked list of situations that elicit increasing degrees of anxiety or avoid- ance. The hierarchy is arranged in order from the most anxiety-provoking situation the client can imagine down to the situation that evokes the least anxiety. If it has been determined that the client has anxiety related to fear of rejection, for exam- ple, the highest anxiety-producing situation might be rejection by the spouse, next, rejection by a close friend, and then rejection by a coworker. The least disturbing situation might be a stranger’s indifference toward the client at a party.

Desensitization does not begin until several sessions after the initial interview has been completed. Enough time is allowed for clients to learn relaxation in therapy sessions, to practice it at home, and to construct their anxiety hierarchy. The desen- sitization process begins with the client reaching complete relaxation with eyes closed. A neutral scene is presented, and the client is asked to imagine it. If the client remains relaxed, he or she is asked to imagine the least anxiety-arousing scene on the hierarchy of situations that has been developed. The therapist moves progres- sively up the hierarchy until the client signals that he or she is experiencing anxiety, at which time the scene is terminated. Relaxation is then induced again, and the scene is reintroduced again until little anxiety is experienced to it. Treatment ends when the client is able to remain in a relaxed state while imagining the scene that was formerly the most disturbing and anxiety-producing. The core of systematic desensitization is repeated exposure in the imagination to anxiety-evoking situa- tions without experiencing any negative consequences.

Homework and follow-up are essential components of successful desensiti- zation. Clients are encouraged to practice selected relaxation procedures daily, at which time they visualize scenes completed in the previous session. Gradually, they can expose themselves to daily-life situations as a further way to manage their anxi- eties. Clients tend to benefit the most when they have a variety of ways to cope with anxiety-arousing situations that they can continue to use once therapy has ended (Head & Gross, 2008).

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Systematic desensitization is among the most empirically supported therapy methods available, especially for the treatment of anxiety. Not only does systematic desensitization have a good track record in dealing with fears, it also has been used to treat a variety of conditions including anger, asthmatic attacks, insomnia, motion sickness, nightmares, and sleepwalking (Spiegler, 2016). Systematic desensitization is often acceptable to clients because they are gradually and symbolically exposed to anxiety-evoking situations. For a more detailed discussion of systematic desensitiza- tion, see Head and Gross (2008), Speigler (2016), and Cormier et al. (2013).

In Vivo Exposure and Flooding exposure therapies are designed to treat fears and other negative emotional responses by introducing clients, under carefully controlled conditions, to the situations that contributed to such problems. Exposure is a key process in treating a wide range of problems associated with fear and anxiety. Exposure therapy involves systematic confrontation with a feared stimulus, either through imagination or in vivo (live). Imaginal exposure can be used prior to implementing in vivo exposure when a client’s fears are so severe that the client is unable to participate in live exposure (Hazlett-Stevens & Craske, 2008). Whatever route is used, exposure involves con- tact by clients with what they find fearful. Desensitization is one type of exposure therapy, but there are others. Two variations of traditional systematic desensitiza- tion are in vivo exposure and flooding.

In Vivo Exposure In vivo exposure involves client exposure to the actual anxiety- evoking events rather than simply imagining these situations. Live exposure has been a cornerstone of behavior therapy for decades. Hazlett-Stevens and Craske (2008) describe the key elements of the process of in vivo exposure. Typically, treatment begins with a functional analysis of objects or situations a person avoids or fears. Together, the therapist and the client generate a hierarchy of situations for the client to encounter in ascending order of difficulty. In vivo exposure involves repeated systematic exposure to fear items, beginning from the bottom of the hierarchy. Clients engage in a brief, graduated series of exposures to feared events. As is the case with systematic desensitization, clients learn responses incompatible with anxiety, such as responses involving muscle relaxation. Clients are encouraged eventually to experience their full fear response during exposure without engaging in avoidance. Between therapy sessions, clients carry out self-directed exposure exercises. Clients’ progress with home practice is reviewed, and the therapist provides feedback on how the client could deal with any difficulties encountered.

In some cases the therapist may accompany clients as they encounter feared sit- uations. For example, a therapist could go with clients in an elevator if they had pho- bias of using elevators. Of course, when this kind of out-of-office procedure is used, matters of safety and appropriate ethical boundaries are always considered. People who have extreme fears of certain animals could be exposed to these animals in real life in a safe setting with a therapist. Self-managed in vivo exposure—a procedure in which clients expose themselves to anxiety-evoking events on their own—is an alter- native when it is not practical for a therapist to be with clients in real-life situations.

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Flooding Another form of exposure therapy is flooding, which refers to either in vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of time. As is characteristic of all exposure therapies, even though the client experiences anxiety during the exposure, the feared consequences do not occur.

in vivo flooding consists of intense and prolonged exposure to the actual anx- iety-producing stimuli. Remaining exposed to feared stimuli for a prolonged period without engaging in any anxiety-reducing behaviors allows the anxiety to decrease on its own. Generally, highly fearful clients tend to curb their anxiety through the use of maladaptive behaviors. In flooding, clients are prevented from engaging in their usual maladaptive responses to anxiety-arousing situations. In vivo flooding tends to reduce anxiety rapidly.

Imaginal flooding is based on similar principles and follows the same proce- dures except the exposure occurs in the client’s imagination instead of in daily life. An advantage of using imaginal flooding over in vivo flooding is that there are no restrictions on the nature of the anxiety-arousing situations that can be treated. In vivo exposure to actual traumatic events (airplane crash, rape, fire, flood) is often not possible nor is it appropriate for both ethical and practical reasons. Imagi- nal flooding can re-create the circumstances of the trauma in a way that does not bring about adverse consequences to the client. Survivors of an airplane crash, for example, may suffer from a range of debilitating symptoms. They are likely to have nightmares and flashbacks to the disaster; they may avoid travel by air or have anxiety about travel by any means; and they probably have a variety of distressing symptoms such as guilt, anxiety, and depression. In vivo and imaginal exposure, as well as flooding, are frequently used in the behavioral treatment for anxiety- related disorders, specific phobia, social phobia, panic disorder, obsessive-compul- sive disorder, posttraumatic stress disorder, and agoraphobia (Hazlett-Stevens & Craske, 2008).

Because of the discomfort associated with prolonged and intense exposure, some clients may not elect these exposure treatments. It is important for the behavior therapist to work with the client to create motivation and readiness for exposure. From an ethical perspective, clients should have adequate information about prolonged and intense exposure therapy before agreeing to participate. It is important that they understand that anxiety will be induced as a way to reduce it. Clients need to make informed decisions after considering the pros and cons of subjecting themselves to temporarily stressful aspects of treatment. Clients should be informed that they can terminate exposure if they experience a high level of anxiety.

The repeated success of exposure therapy in treating various disorders has resulted in exposure being used as a part of most behavioral treatments for anxiety disorders. Spiegler (2016) notes that exposure therapies are among the most potent behavioral procedures available for anxiety-related disorders, and they can have long-lasting effects. However, he adds, using exposure as a single treatment proce- dure is not always sufficient. In cases involving severe and multifaceted disorders, more than one behavioral intervention is often required. This is especially true with posttraumatic stress disorders. Increasingly, imaginal and in vivo exposure are being used in combination, which fits with the trend in behavior therapy to use treatment packages as a way to enhance the effectiveness of therapy.

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Eye Movement Desensitization and Reprocessing eye movement desensitization and reprocessing (EMDR) is a form of exposure therapy that entails assessment and preparation, imaginal flooding, and cognitive restructuring in the treatment of individuals with traumatic memories. According to Shapiro and Solomon (2015), “EMDR is an integrative psychothera- peutic approach that conceptualizes current mental health problems as emanating from past experiences that have been maladaptively stored neurophysiologically as unprocessed memories” (p. 303). The treatment involves the use of rapid, rhythmic eye movements and other bilateral stimulation to treat clients who have experienced traumatic stress. “EMDR comprises eight phases and a three-pronged methodology to identify and process (1) memories of past adverse life experiences that underlie present problems, (2) current situations that elicit disturbance, and (3) needed skills that will provide positive memory templates to guide the client’s future behavior” (p. 389). Developed by Francine Shapiro (2001), this therapeutic procedure draws from a wide range of behavioral interventions. Designed to assist clients in dealing with posttraumatic stress disorders, EMDR has been applied to a variety of popula- tions including children, couples, sexual abuse victims, combat veterans, victims of crime, rape survivors, accident victims, and individuals dealing with anxiety, panic, depression, grief, addictions, and phobias.

Shapiro (2001) emphasizes the importance of the safety and welfare of the cli- ent when using this approach. EMDR may appear simple to some, but the ethical use of the procedure demands training and clinical supervision, as is true of using exposure therapies in general. Because of the powerful reactions from clients, it is essential that practitioners know how to safely and effectively manage these occur- rences. Therapists should not use this procedure unless they receive proper training and supervision from an authorized EMDR instructor. A more complete discussion of this behavioral procedure can be found in Shapiro (2001, 2002a).

There is some controversy over whether the eye movements themselves create change or whether cognitive techniques paired with eye movements act as change agents. The role of lateral eye movements has yet to be clearly demonstrated, and some evidence indicates that the eye movement component may not be integral to the treatment (Prochaska & Norcross, 2014; Speigler, 2016). In a review of con- trolled studies of EMDR in the treatment of trauma, Shapiro (2002b) reports that EMDR clearly outperforms no treatment and achieves similar or superior results to other methods of treating trauma. Shapiro and Solomon (2015) state that extensive research has validated EMDR and randomized trials have confirmed that EMDR is both effective and efficient. Twelve sessions with combat veterans resulted in the elimination of PTSD diagnosis in more than 77% of the cases. When it comes to the overall effectiveness of EMDR, Prochaska and Norcross (2014) note that “in its 25-year history, EMDR has garnered more controlled research than any other method used to treat trauma” (p. 210). In writing about the future of EMDR, Pro- chaska and Norcross make several predictions: increasing numbers of practitioners will receive training in EMDR; outcome research will shed light on EMDR’s effec- tiveness compared to other current therapies for trauma; and further research and practice will provide a sense of its effectiveness with disorders beyond posttraumatic stress disorder.

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Social Skills Training social skills training is a broad category that deals with an individual’s abil- ity to interact effectively with others in various social situations; it is used to help clients develop and achieve skills in interpersonal competence. Social skills involve being able to communicate with others in a way that is both appropriate and effec- tive. Individuals who experience psychosocial problems that are partly caused by interpersonal difficulties are good candidates for social skills training. Typically, social skills training involves various behavioral techniques such as psychoeduca- tion, modeling, behavior rehearsal, and feedback (Antony & Roemer, 2011b). Social skills training is effective in treating psychosocial problems by increasing clients’ interpersonal skills (Kress & Henry, 2015; Segrin, 2008). Some of the desirable aspects of social skills training are that it has a very broad base of applicability and that it can easily be tailored to suit the particular needs of individual clients.

Key elements of social skills training include assessment, direct instruction and coaching, modeling, role playing, and homework assignments (Segrin 2008). Clients learn information that they can apply to various interpersonal situations, and skills are modeled for them so they can actually see how skills can be used. A key step involves clients putting into action the information they are acquiring. Individu- als actively practice desired behaviors through role playing. Feedback and reinforce- ment assist clients in conceptualizing and using a new set of social skills that enables them to communicate more effectively. If clients are able to correct their problem- atic behaviors in practice situations, they can then apply these new skills in daily life (Kress & Henry, 2015). A follow-up phase is critical for clients in establishing a range of effective behaviors that can be applied to many social situations.

A few examples of evidence-based applications of social skills training include alcohol/substance abuse, attention-deficit/hyperactivity disorder, bullying, social anxiety, emotional and behavioral problems in children, behavioral treatment for couples, and depression (Antony & Roemer, 2011b; Segrin, 2008). A popular varia- tion of social skills training is anger management training, which is designed for indi- viduals who have trouble with aggressive behavior.

Self-Management Programs and Self-Directed Behavior For some time there has been a trend toward “giving psychology away.” This involves psychologists being willing to share their knowledge so that “consumers” can increasingly lead self-directed lives and not be dependent on experts to deal with their problems. Psychologists who share this perspective are primarily concerned with teaching people the skills they will need to manage their own lives effectively. An advantage of self-management techniques is that treatment can be extended to consumers in ways that cannot be done with traditional approaches to therapy. Another advantage is that costs are minimal. Because clients have a direct role in their own treatment, techniques aimed at self-change tend to increase involvement and commitment to their treatment.

The basic idea of self-management assessments and interventions is that change can be brought about by teaching people to use coping skills in problematic situa- tions. self-management strategies include teaching clients how to select realistic goals, how to translate these goals into target behaviors, how to create an action

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plan for change, and ways to self-monitor and evaluate their actions (Kress & Henry 2015). Generalization and maintenance of the outcomes are enhanced by encourag- ing clients to accept the responsibility for carrying out these strategies in daily life.

In self-management programs people make decisions concerning specific behav- iors they want to control or change. People frequently discover that a major reason they do not attain their goals is the lack of certain skills or unrealistic expectations of change. Hope can be a therapeutic factor that leads to change, but unrealistic hope can pave the way for a pattern of failures in a self-change program. A self- directed approach can provide the guidelines for change and a realistic plan that will lead to change.

If you want to succeed in such a program, a careful analysis of the context of the behavior pattern is essential, and you must be willing to follow some basic steps such as these provided by Watson and Tharp (2014):

1. Selecting goals. Goals should be established one at a time, and they should be measurable, attainable, positive, and significant for you. It is essential that expectations be realistic.

2. Translating goals into target behaviors. Identify behaviors targeted for change. Once targets for change are selected, anticipate obstacles and think of ways to negotiate them.

3. Self-monitoring. Deliberately and systematically observe your own behavior, and keep a behavioral diary in which you record your actions, thoughts, and feelings along with comments about the relevant ante- cedent cues and consequences. This diary can help you identify what you need to change.

4. Working out a plan for change. A good plan involves substituting new thoughts and behaviors for ineffective thoughts and behaviors. Devise an action program to bring about actual changes that are in line with your goals. Various plans for the same goal can be designed, each of which can be effective. Some type of self-reinforcement system is necessary in this plan because reinforcement is the cornerstone of modern behavior therapy. Discover and select reinforcers to use until the new behaviors have been implemented in everyday life. Practice the new behaviors you want to acquire or refine, and take steps to ensure that the gains made will be maintained.

5. Evaluating an action plan. Evaluate the plan for change to determine whether goals are being achieved, and adjust and revise the plan as other ways to meet goals are learned. Be willing to adjust your plan as conditions change. Evaluation is an ongoing process rather than a one- time occurrence, and self-change is a lifelong practice.

Self-management strategies have been successfully applied to many popula- tions and problems, a few of which include coping with panic attacks, reducing perfectionism, helping children to cope with fear of the dark, increasing creative productivity, managing anxiety in social situations, encouraging speaking in front of a class, increasing exercise, reducing conflict with coworkers, improving study habits, control of smoking, and dealing with depression (Watson & Tharp, 2014). Research on self-management has been conducted in a wide variety of health

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problems, a few of which include arthritis, asthma, cancer, cardiac disease, sub- stance abuse, diabetes, headaches, vision loss, depression, nutrition, and self-health care (Cormier et al., 2013).

Multimodal Therapy: Clinical Behavior Therapy Multimodal therapy is a comprehensive, systematic, holistic approach to behav- ior therapy developed by the late Arnold Lazarus (1989,1997, 2005, 2008a), a key pioneer in clinical behavior therapy. Multimodal therapy is grounded in social cog- nitive learning theory. The assessment process is multimodal, yet the treatment is cognitive behavioral and draws upon empirically supported methods. It is an open system that encourages technical eclecticism in that it applies diverse behavioral tech- niques from a variety of theories to a wide range of problems. Whenever possible, multimodal therapists strive to incorporate empirically supported and evidence- based treatments in their practice (Lazarus & Lazarus, 2015). This approach serves as a major link between some behavioral principles and the cognitive behavioral approach that has largely replaced traditional behavioral therapy.

Multimodal therapists borrow techniques from many other therapy systems, but Lazarus and Lazarus (2015) point out that these techniques are never used in a shotgun manner: “a rag-tag combination of techniques without a sound ratio- nale will likely result only in syncretistic confusion” (p. 682). Multimodal therapists take great pains to determine precisely what relationship and what treatment strate- gies will work best with each client and under which particular circumstances. The underlying assumption of this approach is that because individuals are troubled by a variety of specific problems it is appropriate that a multitude of treatment strategies be used in bringing about change. Therapeutic flexibility and versatility, along with breadth over depth, are highly valued, and multimodal therapists are constantly adjusting their procedures to achieve the client’s goals. Therapists need to decide when and how to be challenging or supportive and how to adapt their rela- tionship style to the needs of the client. The therapeutic relationship is the soil that enables techniques to take root, and multimodal therapists recognize that a good working alliance is a cornerstone in the foundation of effective therapeutic prac- tice (Lazarus & Lazarus, 2015). Multimodal therapists tend to be very active during therapist sessions, functioning as trainers, educators, consultants, coaches, and role models. They provide information, instruction, and feedback as well as modeling assertive behaviors. They offer suggestions, positive reinforcements, and are appro- priately self-disclosing.

For an illustration of how Dr. Lazarus applies the BASIC I.D. assessment model to the case of Ruth, along with examples of various techniques he uses, see Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 7).

Mindfulness and Acceptance-Based Approaches The third generation (or “third wave”) of behavior therapy emphasizes con- siderations that were considered off limits for behavior therapists until recently, including mindfulness, acceptance, the therapeutic relationship, spirituality, val- ues, meditation, being in the present moment, and emotional expression (Hayes, Follette, & Linehan, 2004; Herbert & Forman, 2011). Third-generation behavior

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therapies center around five interrelated core themes: (1) an expanded view of psy- chological health, (2) a broad view of acceptable outcomes in therapy, (3) accep- tance, (4) mindfulness, and (5) creating a life worth living (Speigler, 2016).

Mindfulness is “the awareness that emerges through having attention on pur- pose, in the present moment, and nonjudgmentally, to the unfolding of experience moment by moment” (Kabat-Zinn, 2003, p. 145). In mindfulness practice, clients train themselves to intentionally focus on their “present experience with accep- tance” (Siegel, 2010, p. 27) and develop an attitude of curiosity and compassion toward present experience.

Mindfulness shows promise across a broad range of clinical problems, includ- ing the treatment of depression, anxiety disorders, relationship problems, substance abuse, and psychophysiological disorders (Germer, Siegel, & Fulton, 2013). It is useful in treating posttraumatic stress disorder among military veterans. Through mindfulness exercises, veterans may be better able to observe repetitive negative thinking and prevent extensive engagement with maladaptive ruminative pro- cesses (Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2011). Many therapeutic approaches are incorporating mindfulness and meditation, as well as other contem- plative practices, in the counseling process, and this trend seems likely to continue (Worthington, 2011).

acceptance is a process involving receiving one’s present experience without judgment or preference, but with curiosity and kindness, and striving for full aware- ness of the present moment (Germer, 2013). Acceptance is an alternative way of responding to our internal experience. By replacing judgment, criticism, and avoid- ance with acceptance, the likely result is increased adaptive functioning (Antony & Roemer, 2011b). Mindfulness and acceptance approaches are also good avenues for the integration of spirituality in the counseling process.

For an extensive discussion of mindfulness and acceptance, see Acceptance and Mindfulness in Cognitive Behavior Therapy: Understanding and Applying the New Therapies (Herbert & Forman, 2011).

Recent developments in the cognitive behavioral tradition include four major approaches: (1) dialectical behavior therapy, which has become a recognized treatment for borderline personality disorder (Linehan, 1993a, 1993b, 2015); (2) mindfulness- based stress reduction, an 8- to 10-week group program that applies mindfulness techniques to coping with stress and promoting physical and psychological health (Kabat-Zinn, 1990, 2003); (3) mindfulness-based cognitive therapy, aimed primarily at treating depression (Segal, Williams, & Teasdale, 2013); and (4) acceptance and commit- ment therapy, which encourages clients to accept unpleasant sensations rather than attempting to control or change them (Hayes, Strosahl, & Houts, 2005; Hayes, Stro- sahl, & Wilson, 2011). All four of these approaches use mindfulness strategies that have been subjected to empirical scrutiny, a hallmark of the behavioral tradition.

Dialectical Behavior Therapy (DBT) Dialectical behavior therapy was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD), and it is now recognized as a major psychological treatment for this population. Formulated by Linehan (1993a, 1993b, 2015), who was motivated to alleviate emotional suffering for those miserable enough to consider suicide, DBT has been proven effective in treating a wide range of disorders,

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including substance dependence, depression, posttraumatic stress disorder (PTSD), eating disorders, suicidal behavior, and nonsuicidal self-injury (Linehan, 2015).

DBT is a promising blend of behavioral and psychoanalytic techniques for treat- ing borderline personality disorders. Like analytic therapy, DBT emphasizes the importance of the psychotherapeutic relationship, validation of the client, the etio- logic importance of the client having experienced an “invalidating environment” as a child, and confrontation of resistance. DBT treatment includes both acceptance- and change-oriented strategies. Mindfulness procedures are taught to develop an attitude of acceptance (Fishman, Rego, & Muller, 2011; Kuo & Fitzpatrick, 2015). The treatment program is geared toward helping clients make changes in their behavior and environment while communicating acceptance of their current state (Kuo & Fitzpatrick, 2015; Robins & Rosenthal, 2011). To help clients who have par- ticular problems with emotional regulation, DBT teaches clients to recognize and accept the existence of simultaneous, opposing forces. By acknowledging this fun- damental dialectic relationship—such as not wanting to engage in a certain behav- ior, yet knowing they have to engage in the behavior if they want to achieve a desired goal—clients can learn to integrate the opposing notions of acceptance and change, and the therapist can teach clients how to regulate their emotions and behaviors.

DBT skills training is not a “quick fix” approach. It generally involves a mini- mum of one year of treatment and includes both individual therapy and skills train- ing done in a group. DBT is an empirically supported intervention that employs behavioral and cognitive behavioral techniques, including a form of exposure ther- apy in which the client learns to tolerate painful emotions without enacting self- destructive behaviors. DBT draws upon Zen teachings and practices to integrate mindfulness and acceptance-based techniques in therapy (Kuo & Fitzpatrick, 2015). Some of the Zen Buddhist principles and practices include being aware of the pres- ent moment, seeing reality without distortion, accepting reality without judgment, letting go of attachments that result in suffering, developing a greater degree of acceptance of self and others, and entering fully into present activities without sepa- rating oneself from ongoing events and interactions (Robins & Rosenthal, 2011).

DBT promotes a structured, predictable therapeutic environment. The goals are tailored to each individual. Therapists assist clients in using whatever skills they possess or are learning to navigate crises more effectively and to address problem behaviors (Robins & Rosenthal, 2011). Skills are taught in four modules: mindful- ness, interpersonal effectiveness, emotional regulation, and distress tolerance (Kuo & Fitzpatrick, 2015).

Mindfulness is a fundamental skill in DBT that teaches individuals to be aware of and accept the world as it is and to respond to each moment effectively. Through mindfulness, clients learn to embrace and tolerate the intense emotions they experi- ence when facing distressing situations. Interpersonal effectiveness teaches clients to ask for what they need and how to say “no” while maintaining self-respect and relation- ships with others. This skill entails increasing the chances that a client’s goals will be met, while at the same time not damaging the relationship. Emotional regulation includes identifying emotions, identifying obstacles to changing emotions, reduc- ing vulnerability, and increasing positive emotions. Clients learn the benefits of regulating emotions such as anger, depression, and anxiety. Distress tolerance is aimed at helping individuals to calmly recognizing emotions associated with negative

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situations without becoming overwhelmed by these situations. Clients learn how to tolerate pain or discomfort skillfully.

DBT helps individuals acquire, strengthen, and generalize the skills they learn in therapy to their daily environments (Kuo & Fitzpatrick, 2015). Because DBT places heavy emphasis on didactic instruction and teaching mindfulness skills, therapists must obtain training to become competent in applying these skills and be able to model specific strategies and attitudes for clients. Therapists who want to employ mindfulness strategies must also have personal understanding of these interven- tions to be able to effectively use them with clients.

For a more detailed review of DBT, see DBT Skills Training Manual (Linehan, 2015), which includes instructions for orienting clients to DBT and explains how to use many skills in DBT. Another useful resource for a more detailed discussion of DBT is Robins and Rosenthal (2011).

Mindfulness-Based Stress Reduction (MBSR) Jon Kabat-Zinn, at the University of Massachusetts, developed MBSR in 1979 to see if it was possible to create a training program to relieve medical patients of stress, pain, illness, and other forms of suffering. The eight-week structured group program involves training people in mindfulness meditation, and today instructors are often not mental health clinicians. Originally designed to help people increase their responsibility for their own well-being and to actively develop inner resources for treating their physical health concerns (Kabat-Zinn, 2003), MBSR is not a form of psychotherapy per se, but it can be an adjunct to therapy.

The essence of mindfulness-based stress reduction (MBSR) consists of the notion that much of our distress and suffering results from continually wanting things to be different from how they actually are (Salmon, Sephton, & Dreeben, 2011). MBSR assists people in learning how to live more fully in the present rather than ruminating about the past or being overly concerned about the future. MBSR does not actively teach cognitive modification techniques, nor does it label certain cognitions as “dysfunctional,” because this is not consistent with the nonjudgmen- tal attitude one strives to cultivate in mindfulness practice.

The approach adopted in the MBSR program is to develop the capacity for sus- tained directed attention through formal and informal meditation practice. There is a heavy emphasis on experiential learning and the process of client self-discovery (Dimidjian & Linehan, 2008). In formal practice, skills taught include sitting medi- tation and mindful yoga, which are aimed at cultivating mindfulness. The program includes a body scan meditation, which helps clients to observe all the sensations in their body. Clients are encouraged to bring mindfulness into all of their daily activi- ties, and this informal practice includes being mindful when standing, walking, eat- ing, and doing chores. Those who are involved in the program are encouraged to practice formal mindfulness meditation for 45 minutes daily.

The MBSR program is designed to teach participants to relate to external and internal sources of stress in constructive ways, and an ongoing commitment to culti- vate and practice its principles in each moment is required. Acquiring a mindful way of being is not a simple behavioral technique but is more like an art form that individu- als develop over time as they deepen their focus through disciplined practice. Kabat- Zinn (2003) makes it clear that mindfulness is not about getting anywhere or fixing

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anything: “It is an invitation to allow oneself to be where one already is and to know the inner and outer landscape of the direct experience in each moment” (p. 148).

MBSR programs are offered in hospitals, clinics, schools, workplaces, corporate offices, law schools, prisons, and inner-city health centers (Kabat-Zinn, 2003). MBSR has many clinical applications, and it is expected that the approach will evolve to address a range of negative psychological states, such as anxiety, stress, and depres- sion. This approach has many applications in the area of health and wellness and in promoting healthy lifestyle changes. Numerous research reviews and meta-analyses indicate that mindfulness, acceptance, and compassion-based treatments are effec- tive in promoting physical and psychological health (Germer, 2013). One of these studies suggests that MBSR training may lead to changes in the brain that result in people being able to better cope with negative emotional reactions under stress (as cited in Kabat-Zinn, 2003).

Kabat-Zinn’s (1990, 1994) books offer a comprehensive treatment of MBSR, and they did a great deal to popularize the program he developed. An excellent resource for a more detailed treatment of MBSR is Salmon, Sephton, and Dreeben (2011).

Mindfulness-Based Cognitive Therapy (MBCT) This program is a comprehensive integration of the principles and skills of mindfulness applied to the treatment of depression (Segal et al., 2013). MBCT is an eight-week group treatment program of two-hour weekly sessions adapted from Kabat-Zinn’s (1990, 2003) mindfulness-based stress reduction program. The program integrates techniques from MBSR with teaching cognitive behavioral skills to clients. The primary aim is to change clients’ awareness of and relation to their negative thoughts. Participants are taught how to respond in skillful and intentional ways to their automatic negative thought patterns (Hammond, 2015).

Segal, Williams, and Teasdale (2013) describe kindness and self-compassion as essential components of MBCT. Mindfulness is a way of developing self-compassion, which is a form of self-care when facing difficult situations. Mindfulness practices focus on moment-to-moment experiencing and assist clients in developing an atti- tude of open awareness and acceptance of what is rather than being self-critical. When we acknowledge our shortcomings without critical judgment, we can begin to treat ourselves with kindness. We can intentionally activate goodwill toward ourselves and others while experiencing emotions such as anger, anxiety, and depression. Research has shown that self-compassion is positively associated with emotional well-being and decreased levels of anxiety and depression (Morgan, Morgan, & Germer, 2013; Neff, 2012). Other research findings on the association between self-compassion and emo- tional well-being have been reported by Neff (2012):

�� Self-compassionate people recognize when they are suffering, yet they are kind toward themselves in these moments.

�� Self-compassion is associated with greater wisdom and emotional intelligence.

�� Self-compassion is associated with feelings of life satisfaction and con- nection to others.

�� Self-compassionate individuals tend to experience increased happiness, optimism, curiosity, and positive emotions.

�� Self-compassion engenders compassion toward others.

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Morgan, Morgan, and Germer (2013) report that there is ample evidence that mindfulness meditation enhances the ability to pay attention in a concentrated and sustained manner. Being able to attend to present experiencing is a route to devel- oping compassion toward oneself and expressing compassion toward others. Mind- fulness is something that is caught more than something that is taught. The attitude and behavior of the instructor/facilitator of the MBCT group are critical in helping participants acquire an accepting way of being and discarding self-critical and judg- mental habits.

Segal, Williams, and Teasdale (2013) describe the essence of eight sessions in the MBCT program:

�� Therapy begins by identifying negative automatic thinking of people experiencing depression and by introducing some basic mindfulness practices.

�� In the second session, participants learn about the reactions they have to life experiences and learn more about mindfulness practices. Clients learn the importance of kindness and self-compassion, both to self and to others.

�� The third session is focused on gathering the scattered mind; partici- pants learn breathing techniques and focus their attention on their present experiencing. Clients learn how to anchor thoughts with a focus on the breath while allowing experience to unfold.

�� In session four, the emphasis is on learning to experience the moment without becoming attached to outcomes; participants practice sitting meditation and mindful walking.

�� The fifth session teaches participants how to accept their experiencing without holding on; participants learn the value of allowing and letting be.

�� Session six is used to describe thoughts as “merely thoughts”; clients learn that they do not have to act on their thoughts. They can tell them- selves, “I am not my thoughts” and “Thoughts are not facts.”

�� In session seven, participants learn how to take care of themselves and to develop an action plan to deal with the threat of relapse.

�� Session eight focuses on maintaining and extending new learning; clients learn how to generalize their mindfulness practices to daily life.

MBCT emphasizes experiential learning, in-session practice, learning from feed- back, completing homework assignments, and applying what is learned in the pro- gram to challenging situations encountered outside of the sessions. The brevity of MBCT makes this approach an efficient and cost-effective treatment. For a more detailed review of MBCT, see Mindfulness-Based Cognitive Therapy for Depression (Segal et al., 2013).

Acceptance and Commitment Therapy (ACT) Another mindfulness-based approach is acceptance and commitment therapy (Hayes et al., 2005, 2011). ACT is a unique empirically based psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase psychological flexibility. ACT involves fully accepting present experience and mindfully letting go of obstacles. In this approach “acceptance is not merely

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tolerance—rather it is the active nonjudgmental embracing of experience in the here and now” (Hayes, 2004, p. 32). Acceptance is a stance or posture from which to conduct therapy and from which a client can conduct life that provides an alternative to contemporary forms of cognitive behavioral therapy. In contrast to the cognitive behavioral approaches discussed in Chapter 10, in which dysfunctional thoughts are identified and challenged, in ACT there is little emphasis on changing the content of a client’s thoughts. Hayes has found that confronting maladaptive cognitions strengthens rather than reduces these cognitions. Instead, the emphasis is on acceptance (nonjudgmental awareness) of cognitions. The goal is for individuals to become aware of and examine their thoughts. Clients learn how to change their relationship to their thoughts. They learn how to accept yet not identify with thoughts and feelings they may have been trying to deny.

Values are a basic part of the therapeutic process, and the work of ACT depends on what an individual wants and values. Client and therapist work together to identify personal values in areas such as work, relationships, spirituality, and well-being (Bat- ten & Cairrochi, 2015). ACT practitioners might ask clients, “What do you want your life to stand for?” Therapy involves assisting clients to choose values they want to live by, designing specific goals, and taking steps to achieve their goals (Speigler, 2016).

A commitment to action is essential, and clients are asked to make mindful decisions about what they are willing to do to live a valued and meaningful life. Con- crete homework and behavioral exercises as two ways clients can commit to action. For example, one form of homework asks clients to write down life goals or things they value in various aspects of their lives. Clients learn to allow experience to come and go while they pursue a meaningful life.

ACT is an effective form of therapy that continues to influence the practice of behavior therapy. Germer (2013) suggests “mindfulness appears to be drawing clinical theory, research, and practice closer together, and helping to integrate the private and professional lives of therapists” (p. 13). ACT emphasizes common pro- cesses across clinical disorders, which makes it easier to learn basic treatment skills. Practitioners can then implement basic principles in diverse and creative ways. ACT has been empirically shown to be effective in the treatment of a variety of disorders, including substance abuse, depression, anxiety, phobias, posttraumatic stress disor- der, and chronic pain (Batten & Cairrochi, 2015).

For an in-depth discussion of the role of mindfulness in psychotherapeutic practice, four highly recommended books are Acceptance and Mindfulness in Cognitive Behavior Therapy: Understanding and Applying the New Therapies (Herbert & Forman, 2011), Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition (Hayes et al., 2004), Mindfulness and Psychotherapy (Germer et al., 2013), and Wisdom and Compas- sion in Psychotherapy: Deepening Mindfulness in Clinical Practice, (Germer & Siegel, 2012).

Application to Group Counseling Behavioral group therapy incorporates classical behavior therapy treatment principles rooted in classical conditioning, operant conditioning, and social learn- ing theory. The focus of a behavioral group is on teaching, modeling, and applying scientific principles to target specific behaviors for change (Kress & Henry, 2015).

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Group-based behavioral approaches emphasize teaching clients self-management skills and a range of new coping behaviors, as well as how to restructure their thoughts. Clients can learn to use these techniques to control their lives, deal effec- tively with present and future problems, and function well after they complete their group experience. Many groups are designed primarily to increase the client’s degree of control and freedom in specific aspects of daily life.

Group leaders who function within a behavioral framework may develop tech- niques from various theoretical viewpoints. Behavioral practitioners make use of a brief, active, directive, structured, collaborative, psychoeducational model of therapy that relies on empirical validation of its concepts and techniques. The leader follows the progress of group members through the ongoing collection of data before, dur- ing, and after all interventions. Such an approach provides both the group leader and the members with continuous feedback about therapeutic progress. Today, many groups in community agencies demand this kind of accountability.

Behavioral group therapy has some unique characteristics that set it apart from most of the other group approaches. A distinguishing characteristic of behavioral practitioners is their systematic adherence to specification and mea- surement. The specific unique characteristics of behavioral group therapy include (1) conducting a behavioral assessment, (2) precisely spelling out collaborative treatment goals, (3) formulating a specific treatment procedure appropriate to a particular problem, and (4) objectively evaluating the outcomes of therapy. Behavior therapists tend to utilize short-term, time-limited interventions aimed at efficiently and effectively solving problems and assisting members in develop- ing new skills.

Behavioral group leaders assume the role of teacher and encourage members to learn and practice skills in the group that they can apply to everyday living. Group leaders typically assume an active, directive, and supportive role in the group and apply their knowledge of behavioral principles and skills to the resolution of prob- lems. They model active participation and collaboration by their involvement with members in creating an agenda, designing homework, and teaching skills and new behaviors. Leaders carefully observe and assess behavior to determine the conditions that are related to certain problems and the conditions that will facilitate change. Members in behavioral groups identify specific skills that they lack or would like to enhance. Assertiveness and social skills training fit well into a group format. Relax- ation procedures, behavioral rehearsal, modeling, coaching, meditation, and mind- fulness techniques are often incorporated in behavioral groups. The experience of being mindful is expanded in the group setting where people meditate and are still in the presence of others. Most of the other techniques described earlier in this chap- ter can be applied to group work.

Today, most behavior therapy groups blend cognitive and behavioral concepts and techniques, with few having a strictly behavioral focus (Kress & Henry, 2015). There are many different types of groups with a behavioral twist, or groups that blend both behavioral and cognitive methods for specific populations. Structured groups, with a psychoeducational focus, are especially popular in various settings today. At least four general approaches can be applied to the practice of behavioral groups: (1) social skills training groups, (2) psychoeducational groups with specific

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themes, (3) stress management groups, and (4) mindfulness and acceptance-based behavior therapy in groups.

For a more detailed discussion of cognitive behavioral approaches to groups, see Corey (2016, chap. 13).

Behavior Therapy From a Multicultural Perspective Strengths From a Diversity Perspective

Behavior therapy has some clear advantages over many other theories in counseling culturally diverse clients. Because of their cultural and ethnic back- grounds, some clients hold values that are contrary to the free expression of feelings and the sharing of personal concerns. Behavioral counseling does not generally place emphasis on experiencing catharsis. Rather, it stresses changing specific behaviors and developing problem-solving skills. Some potential strengths of the behavioral approaches in working with diverse client populations include its specificity, task orientation, focus on objectivity, focus on cognition and behavior, action orienta- tion, dealing with the present more than the past, emphasis on brief interventions, teaching coping strategies, and problem-solving orientation. The attention given to transfer of learning and the principles and strategies for maintaining new behavior in daily life are crucial. Clients who are looking for action plans and specific behav- ioral change are likely to cooperate with this approach because they can see that it offers them concrete methods for dealing with their problems of living.

Behavior therapy focuses on environmental conditions that contribute to a cli- ent’s problems. Social and political influences can play a significant role in the lives of people of color through discriminatory practices and economic problems, and the behavioral approach takes into consideration the social and cultural dimensions of the client’s life. Behavior therapy is based on an experimental analysis of behavior in the client’s own social environment and gives special attention to a number of specific conditions: the client’s cultural conception of problem behaviors, establish- ing specific therapeutic goals, arranging conditions to increase the client’s expecta- tion of successful therapeutic outcomes, and employing appropriate social influence agents (Tanaka-Matsumi, Higginbotham, & Chang, 2002). The foundation of ethi- cal practice involves a therapist’s familiarity with the client’s culture, as well as the competent application of this knowledge in formulating assessment, diagnostic, and treatment strategies.

The behavioral approach has moved beyond treating clients for a specific symp- tom or behavioral problem. Instead, it stresses a thorough assessment of the person’s life circumstances to ascertain not only what conditions give rise to the client’s prob- lems but also whether the target behavior is amenable to change and whether such a change is likely to lead to a significant improvement in the client’s total life situation.

In designing a change program for clients from diverse backgrounds, effective behavioral practitioners conduct a functional analysis of the problem situation. This assessment includes the cultural context in which the problem behavior occurs, the con- sequences both to the client and to the client’s sociocultural environment, the resources within the environment that can promote change, and the impact that change is likely to have on others in the client’s social surroundings. Assessment methods should be

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chosen with the client’s cultural background in mind (Spiegler, 2016; Tanaka-Matsumi et al., 2002). Counselors must be knowledgeable as well as open and sensitive to issues such as these: What is considered normal and abnormal behavior in the client’s culture? What are the client’s culturally based conceptions of his or her problems? What is the potential role of spirituality or religion in the client’s life? What kind of information about the client is essential in making an accurate assessment?

Shortcomings From a Diversity Perspective Although behavior therapy is sensitive to differences among clients in a broad sense, behavior therapists need to become more responsive to specific issues pertaining to all forms of diversity. Because race, gender, ethnicity, and sexual orientation are crit- ical variables that influence the process and outcome of therapy, it is essential that behavior therapists pay careful attention to these factors and address social justice issues as they arise in a client’s therapy.

Some behavioral counselors may focus on using a variety of techniques in narrowly treating specific behavioral problems. Instead of viewing clients in the context of their sociocultural environment, these practitioners concentrate too much on problems within the individual. In doing so they may overlook significant issues in the lives of cli- ents. Such practitioners are not likely to bring about beneficial changes for their clients.

The fact that behavioral interventions often work well raises an interesting issue in multicultural counseling. When clients make significant personal changes, it is very likely that others in their environment will react to them differently. Before deciding too quickly on goals for therapy, the counselor and client need to discuss the complexity inherent in change. It is essential for therapists to conduct a thor- ough assessment of the interpersonal and cultural dimensions of the problem. Cli- ents should be helped in assessing the possible consequences of some of their newly acquired social skills. Once goals are determined and therapy is under way, clients should have opportunities to talk about the problems they encounter as they bring new skills and behaviors into their home and work settings.

I n Stan’s case many specific and interrelated prob-lems can be identified through an assessment pro- cess. Behaviorally, he is defensive, avoids eye contact, speaks hesitantly, uses alcohol excessively, has a poor sleep pattern, and displays various avoidance behaviors in social and interpersonal situations. In the emotional area, Stan has a number of specific problems, some of which include anxiety, panic attacks, depression, fear of criticism and rejection, feeling worthless and stu- pid, and feeling isolated and alienated. He experiences a range of physiological complaints such as dizziness, heart palpitations, and headaches. Cognitively, he wor- ries about death and dying, has many self-defeating

thoughts and beliefs, is governed by categorical imper- atives (“shoulds,” “oughts,” “musts”), engages in fatal- istic thinking, and compares himself negatively with others. In the interpersonal area, Stan is unassertive, has an unsatisfactory relationship with his parents, has few friends, is afraid of contact with women and fears intimacy, and feels socially inferior.

After completing this assessment, I focus on help- ing Stan define the specific areas where he would like to make changes. Before developing a treatment plan, I assist Stan in understanding the purposes of his behavior. I then educate Stan about how the therapy sessions (and his work outside of the sessions) can

Behavior Therapy Applied to the Case of Stan

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help him reach his goals. Early during treatment I help Stan translate some of his general goals into concrete and measurable ones. When Stan says, “I want to feel better about myself,” I help him define more specific goals. When he says, “I want to get rid of my inferior- ity complex,” I reply: “What exactly do you mean by this? What are some situations in which you feel infe- rior? What do you actually do that leads to feelings of inferiority?” Stan’s concrete aims include his desire to function without drugs or alcohol. I suggest that he keep a record of when he drinks and what events lead to drinking. My hope is that Stan will establish goals that are based on positive markers, not negative goals. Instead of focusing on what Stan would like to get rid of, I am more interested in what he would like to acquire and develop.

Stan indicates that he does not want to feel apolo- getic for his existence. I introduce behavioral skills training because he has trouble talking with his boss and coworkers. I demonstrate specific skills that he can use in approaching them more directly and confi- dently. This procedure includes modeling, role playing, and behavior rehearsal. He then tries more effective behaviors with me as I play the role of the boss. I give him feedback on how strong or apologetic he seemed.

Imaginal exposure and systematic desensitization are appropriate in working with Stan’s fear of failing. Before using these procedures, I explain the procedure to Stan and get his informed consent. Stan first learns relaxation procedures during the sessions and then practices them daily at home. Next, he lists his specific fears relating to failure, and he then generates a hierar- chy of fear items. Stan identifies his greatest fear as fear of dating and interacting with women. The least fear- ful situation he identifies is being with a female stu- dent for whom he does not feel an attraction. I first do some systematic desensitization on Stan’s hierarchy.

Stan begins repeated, systematic exposure to items that he finds frightening, beginning at the bottom of the fear hierarchy. He continues with repeated expo- sure to the next fear hierarchy item when exposure to the previous item generates only mild fear. Part of the process involves exposure exercises for practice in vari- ous situations away from the therapy office.

The goal of therapy is to help Stan modify the behavior that results in his feelings of guilt and anxi- ety. By learning more appropriate coping behaviors, eliminating unrealistic anxiety and guilt, and acquiring more adaptive responses, Stan’s presenting symptoms decrease, and he reports a greater degree of satisfaction.

Questions for Reflection �� How would you collaboratively work with Stan in

identifying specific behavioral goals to give a direc- tion to your therapy?

�� What behavioral techniques might be most appro- priate in helping Stan with his problems?

�� Stan indicates that he does not want to feel apolo- getic for his existence. How might you help him translate this wish into a specific behavioral goal? What behavioral techniques might you draw on in helping him in this area?

�� What homework assignments are you likely to suggest for Stan?

I n daily life, Gwen has a tendency to try to get every-thing done without enlisting the support of others. In our previous session, she decided on a goal of ask- ing for support from others both at home and at work.

We engaged in behavioral rehearsals in which Gwen practiced asking someone for support. Gwen found this difficult, but she hesitantly said she was willing to try out these new behaviors. Her homework was to

Behavior Therapy Applied to the Case of Gwen*

visit CengageBrain.com or watch the DvD for the video program Theory and Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes, Session 7 (behavior therapy), for a demonstration of my approach to counseling Stan from this perspective. This session involves collaboratively working on homework and behavior rehearsals to experiment with assertive behavior.

*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a behavior therapy perspective and applying this model to Gwen.

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ask for help both at work and at home. Gwen is late for our session, and when she arrives she looks tired and defeated.

Gwen: Sorry I am late. I left work early to take my mother to the doctor, and the appointment ran longer than I expected.

Therapist: I am pleased you were able to make it, but our session will be shorter. Last week you talked about feeling disconnected from your husband. We agreed that asking him for assis- tance and sharing your daily life with him might help you communicate with each other. What have you done this week to get support and share more at home?

Gwen: I expressed to colleagues that I needed help when completing some tasks at work, but I fell back into the same pattern of silence when at home with Ron.

Therapist: Tell me more about falling back into the same pattern of silence.

Gwen: I wanted to ask Ron to help with my mom, but ultimately I feel like she is my mom and my responsibility. He sees what I am doing and could offer to pitch in.

Therapist: You seemed eager to express your need for support to Ron, but then something stopped you. What do you think caused you to stop? [Using the A-B-C model]

Gwen: I hate to ask. It is my responsibility. I think I am the only one who can do it. I would feel like I was putting a burden on Ron’s shoulders if I asked for help.

Therapist: You must feel an overwhelming amount of pressure being solely responsible for so much.

Gwen: Yes, it is hard to make sense of it all.

Therapist: Let me see if I understand. It sounds as though taking care of your mom is your sole responsibility and not Ron’s [antecedent]. You do not want to feel like a burden to Ron, so you stop yourself from asking for support [behavior].

Gwen: Yes, when I get home I want to talk, but I do not want to become a burden on someone I love. So I just withdraw into myself [consequence].

Assessment is a large part of behavioral therapy, and reviewing homework assignments helps us to see if our approach is effective. Although Gwen was aware of her pattern of silence at home, she was not able to modify her behavior and express her feelings to her husband.

I decide to introduce Gwen to the concept of mindfulness to help her stop the automatic behaviors that have kept her feeling stressed and overwhelmed. Gwen has difficulty being in the present moment, and she could profit from slowing down and engaging in self-care activities. Mindfulness practice can bring increased peace and calm into her life and quiet the constant chatter in her mind. I want to give Gwen some simple tools she can use and practice at home.

Therapist: Gwen, take a moment to sit quietly. Let your thoughts flow away and concentrate your attention on the present moment. How are you feeling? [She begins to notice bodily sensations] Gwen please bring your awareness to the top of your head and slowly begin to scan your entire body for any sensations of tension or tightness. What are you noticing?

Gwen: I am aware of tightness in my chest. It feels like a ball of stress.

Therapist: Focus all of your attention on the sensa- tion in your chest. As you consciously tell yourself to relax, simply notice the sensations without judg- ing them. How are you feeling?

Gwen: It’s a little strange, but I feel more at ease than when I first walked in the door.

Therapist: Do you think you can practice this mind- fulness at home this week and focus on what you want to bring into your life?

Gwen: I do want to communicate better with my husband and be able to ask him for support. I feel much more relaxed here now, and I would like to try to feel that at home too. Calming myself and staying in the moment is a new experience for me.

Therapist: You have a good start on learning how mindfulness feels; let’s see how much progress you can make at home as you practice this week.

Gwen: OK, I feel less stressed when I slow down and try to relax in the moment. I am going to practice this every day during the week. [Goal-setting is an important part of behavior therapy]

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Summary and Evaluation Summary

Behavior therapy is diverse with respect not only to basic concepts but also to techniques that can be applied in coping with specific problems with a wide range of clients. The behavioral movement includes four major areas of development: classical conditioning, operant conditioning, social-cognitive theory, and increas- ing attention to the cognitive factors influencing behavior (see Chapter 10). Third- generation behavior therapies are recent developments in the field, and they include mindfulness and acceptance-based behavior therapies. A unique characteristic of all forms of behavior therapy is its strict reliance on the principles of the scientific method. Concepts and procedures are stated explicitly, tested empirically, and revised continually. Treatment and assessment are interrelated and occur simulta- neously. Research is considered to be a basic aspect of the approach, and therapeutic techniques are continually refined.

A cornerstone of behavior therapy is identifying specific goals at the outset of the therapeutic process. In helping clients achieve their goals, behavior therapists typically assume an active and directive role. Although the client generally deter- mines what behavior will be changed, the therapist typically determines how this behavior can best be modified. In designing a treatment plan, behavior therapists employ techniques and procedures from a wide variety of therapeutic systems and apply them to the unique needs of each client.

Contemporary behavior therapy places emphasis on the interplay between the individual and the environment. Behavioral strategies can be used to attain both individual goals and societal goals. Because cognitive factors have a place in the practice of behavior therapy, techniques from this approach can be used to attain humanistic ends. It is clear that bridges can connect humanistic and behavioral therapies, especially with the current focus of attention on self-management and the incorporation of mindfulness and acceptance-based approaches into behav- ioral practice. Mindfulness practices rely on experiential learning and client dis- covery rather than on didactic instruction. Mindfulness is a way of being that takes ongoing effort to develop and refine (Kabat-Zinn, 2003). Self-compassion is a foun- dational part of the new wave of behavior therapies and is linked to an increased

I encourage Gwen to practice paying attention to her behaviors and to consider using mindfulness practice as a way of refocusing on what she wants to bring into her life. It is my hope that her mind- fulness practice will lead to an overall reduction in stress and increased presence and connection in her life.

Questions for Reflection �� What could be the consequence(s) if Gwen does

not change her behavior? �� What kind of homework might you suggest to

Gwen? �� What kind of mindfulness practices would you

like to incorporate into your daily life?

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sense of well-being. These newer approaches represent a blend of Eastern practices and Western methodology. Contemporary behavior therapy has broadened from a narrow focus on dealing with simple problems to addressing complex aspects of personal functioning.

Contributions of Behavior Therapy Behavior therapy challenges us to reconsider our global approach to counseling. Some may assume they know what a client means by the statement, “I feel unloved; life has no meaning.” A humanist might nod in acceptance to such a statement, but the behaviorist may respond with: “Who specifically do you feel is not loving you?” “What is going on in your life to make you think it has no meaning?” “What are some specific things you might be doing that contribute to the state you are in?” “What would you most like to change?” A key strength of behavior therapy is its precision in specifying goals, target behaviors, and procedures. The specificity of the behavioral approaches helps clients translate unclear goals into concrete plans of action, and it helps both the counselor and the client to keep these plans clearly in focus. Ledley, Marx, and Heimberg (2010) state that therapists can help clients learn about the contingencies that maintain their problematic thoughts and behaviors and then teach them ways to make the changes they want. Techniques such as role playing, relaxation proce- dures, behavioral rehearsal, coaching, guided practice, modeling, feedback, learning by successive approximations, mindfulness skills, and homework assignments can be included in any therapist’s repertoire, regardless of theoretical orientation.

An advantage behavior therapists have is the wide variety of specific behavioral techniques at their disposal. Because behavior therapy stresses doing, as opposed to merely talking about problems and gathering insights, practitioners use many behavioral strategies to assist clients in formulating a plan of action for changing behavior. The basic therapeutic conditions stressed by person-centered therapists— active listening, accurate empathy, positive regard, genuineness, respect, acceptance, and immediacy—need to be integrated in a behavioral framework.

A major contribution of behavior therapy is its emphasis on research into and assessment of treatment outcomes. It is up to practitioners to demonstrate that therapy is working. If progress is not being made, therapists look carefully at the original analysis and treatment plan. Of all the therapies presented in this book, this approach and its techniques have been subjected to the most empirical research. Behavioral practitioners are put to the test of identifying specific interventions that have been demonstrated to be effective.

Evidence-based therapies (EBT) are a hallmark of both behavior therapy and cognitive behavior therapy. To their credit, behavior therapists are willing to exam- ine the effectiveness of their procedures in terms of the generalizability, meaningful- ness, and durability of change. Most studies show that behavior therapy methods are more effective than no treatment. Moreover, a number of behavioral and cogni- tive behavioral procedures are currently the best treatment strategies available for depression, obsessive-compulsive disorder, panic disorder, social phobia, hypochon- driasis, generalized anxiety disorder, posttraumatic stress disorder, eating disorders,

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borderline personality disorder, bipolar disorder, and childhood disorders (Hollon & DiGiuseppe, 2011).

The new generation of mindfulness and acceptance-based therapies has shifted behavior therapy from treating simple and discrete problems to a more complex and complete psychotherapy that is based in behavioral principles (Prochaska & Nor- cross, 2014). Prochaska and Norcross confidently predict an increase and expansion of the third-wave therapies in the next decade and state that these approaches will likely “become firmly established within the ever-expanding, evidence-based context of cognitive-behavioral therapy” (p. 314).

A strength of the behavioral approaches is the emphasis on ethical accountabil- ity. Behavior therapy is ethically neutral in that it does not dictate whose behavior or what behavior should be changed. At least in cases of voluntary counseling, the behavioral practitioner only specifies how to change those behaviors the client tar- gets for change. Clients have a good deal of control and freedom in deciding what the goals of therapy will be. A collaborative therapist–client relationship is an essen- tial aspect of behavior therapy. Because clients are active in selecting goals and pro- cedures in the therapy process and are applying what they are learning in therapy to daily life, the chance that they will become the target of unethical behavior is decreased (Speigler, 2016).

Limitations and Criticisms of Behavior Therapy Behavior therapy has been criticized for a variety of reasons. Let’s examine four common criticisms and misconceptions people often have about behavior therapy, together with my reactions.

Behavior therapy may change behaviors, but it does not change feelings. Some critics argue that feelings must change before behavior can change. Behavioral practitioners hold that empirical evidence has not shown that feelings must be changed first, and behavioral clinicians do in actual practice deal with feelings as an overall part of the treatment process. A general criticism of both the behavioral and the cognitive approaches is that clients are not encouraged to experience their emotions. In concentrating on how clients are behaving or thinking, some behavior therapists tend to play down the working through of emotional issues. Generally, I favor initially focusing on what clients are feeling and then working with the behavioral and cognitive dimensions. When clients’ feelings are engaged, this seems to me to be a good point of departure. I can still tie a discussion of what clients are feeling with how this is affecting their behavior, and I can later inquire about their cognitions.

Behavior therapy does not provide insight. If this assertion is indeed true, behavior therapists would probably respond that insight is not a necessary requisite for behavior change. Follette and Callaghan (2011) state that contemporary behavior therapists tend to be leery of the role of insight in favor of alterable, controllable, causal variables. It is possible for therapy to proceed without a client knowing how change is taking place. Although change may be taking place, clients often cannot explain precisely why. Furthermore, insights may result after clients make a change

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in behavior. Behavioral shifts often lead to a change in understanding or to insight, which may lead to emotional changes as well.

Behavior therapy treats symptoms rather than causes. The psychoanalytic assumption is that early traumatic events are at the root of present dysfunction. Behavior therapists may acknowledge that deviant responses have historical origins, but they contend that history is less important in the maintenance of current problems than environmental events such as antecedents and consequences. However, behavior therapists emphasize changing current environmental circumstances to change behavior.

Related to this criticism is the notion that unless historical causes of present behavior are therapeutically explored new symptoms will soon take the place of those that were “cured.” Behaviorists rebut this assertion on both theoretical and empirical grounds. They contend that behavior therapy directly changes the main- taining conditions of problem behaviors (symptoms), thereby indirectly changing the problem behaviors. Furthermore, they assert that there is no empirical evidence that symptom substitution occurs after behavior therapy has successfully elimi- nated unwanted behavior because they have changed the conditions that give rise to those behaviors (Spiegler, 2016).

Behavior therapy involves control and social influence by the therapist. All therapists have a power relationship with the client and thus therapy involves social influence; the ethical issue relates to the therapist’s degree of awareness of this influence and how it is addressed in therapy. Behavior therapy recognizes the importance of making the social influence process explicit, and it emphasizes client- oriented behavioral goals. Therapy progress is continually assessed and treatment is modified to ensure that the client’s goals are being met.

Behavior therapists address ethical issues by stating that therapy is basically a psychoeducational process. At the outset of behavior therapy, clients learn about the nature of counseling, the procedures that may be employed, and the benefits and risks. Clients are given information about the specific therapy procedures appropri- ate for their particular problems. To some extent, they also participate in the choice of techniques that will be used in dealing with their problems. With this informa- tion clients become informed, genuine partners in the therapeutic venture.

The literature in the field of behavior therapy is so extensive and diverse that it is not possible in one brief survey chapter to present a comprehensive, in-depth discus- sion of behavioral concepts and techniques. Examining some of the suggested read- ings at the end of this chapter will further your knowledge of this complex approach.

Self-Reflection and Discussion Questions

1. Behavior therapists use a brief, active, directive, collaborative, present- focused, didactic, psychoeducational model of therapy that relies on empirical validation of its concepts and techniques. What do you see as the main strengths and limitations of this focus?

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2. What are some unique characteristics common to all of the behavioral therapies? How do you see these therapies as being able to apply to a setting in which you might work?

3. The third-generation behavioral approaches involve mindfulness and acceptance-based concepts. What aspects of these concepts would you most want to incorporate in your work with clients?

4. How can you apply mindfulness techniques in your daily life? What value do you place on becoming more mindful?

5. What are some of the behavioral interventions that you can see yourself applying to your personal life? What specific behavioral techniques do you most want to incorporate into your counseling practice?

Where to Go From Here Visit CengageBrain,com or watch the DVD program Integrative Counseling: The Case of Ruth and Lecturettes, Session 8 (“Behavioral Focus in Counseling”), in which I dem- onstrate a behavioral way to assist Ruth in developing an exercise program. It is crucial that Ruth makes her own decisions about specific behavioral goals she wants to pursue. This applies to my attempts to work with her in developing methods of relaxation, increasing her self-efficacy, and designing an exercise plan.

Other Resources DVDs offered by the American Psychological Association that are relevant to this chapter include the following:

Antony, M. M. (2009). Behavioral Therapy Over Time (APA Psychotherapy Video Series)

Hayes, S. C. (2011). Acceptance and Commitment Therapy (Systems of Psycho- therapy Video Series)

Psychotherapy.net is a comprehensive resource for students and professionals that offers videos and interviews on behavior therapy. New video and editorial con- tent is made available monthly. DVDs relevant to this chapter are available at www .psychotherapy.net and include the following:

Stuart, R. (1998). Behavioral Couples Therapy (Couples Therapy With the Experts Series)

If you have an interest in further training in behavior therapy, the Association for Behavioral and Cognitive Therapies (ABCT) is an excellent resource. ABCT (for- merly AABT) is a membership organization of more than 4,500 mental health pro- fessionals and students who are interested in behavior therapy, cognitive behavior therapy, behavioral assessment, and applied behavioral analysis. Members receive discounts on all ABCT publications, some of which are:

�� Directory of Graduate Training in Behavior Therapy and Experimental-Clinical Psychology is an excellent source for students and job seekers who want information on programs with an emphasis on behavioral training.

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�� Directory of Psychology Internships: Programs Offering Behavioral Training describes training programs having a behavioral component.

�� Behavior Therapy is an international quarterly journal focusing on origi- nal experimental and clinical research, theory, and practice.

�� Cognitive and Behavioral Practice is a quarterly journal that features clini- cally oriented articles.

Full and associate memberships are $199 and include one journal subscription (to either Behavior Therapy or Cognitive and Behavioral Practice) and a subscription to the Behavior Therapist (a newsletter with feature articles, training updates, and asso- ciation news). Membership also includes reduced registration and continuing edu- cation course fees for ABCT’s annual convention held in November, which features workshops, master clinician programs, symposia, and other educational presenta- tions. Student memberships are $49.

Association for Behavioral and Cognitive Therapies www.abct.org

Mindfulness and Acceptance-Based Approaches If you are interested in finding out more about mindfulness and acceptance-based programs and resources for the newer therapies, explore some of these websites:

Institute for Meditation and Psychotherapy www.meditationandpsychotherapy.org

Mindfulness-Based Stress Reduction www.umassmed.edu/cfm

Dialectical Behavior Therapy www.behavioraltech.com

Acceptance and Commitment Therapy www.acceptanceandcommitmenttherapy.com

Self-Compassion Resources www.self-compassion.org

Recommended Supplementary Readings Behavior Therapy (Antony & Roemer, 2011a) offers a useful and updated overview of behavior therapy.

Contemporary Behavior Therapy (Spiegler, 2016) is a comprehensive discussion of basic principles and applications of the behavior therapies. It is an excel- lent text that is based on research.

Interviewing and Change Strategies for Helpers (Corm- ier, Nurius, & Osborn, 2013) is a comprehensive

and clearly written textbook dealing with training experiences and skill development. This book offers practitioners a wealth of material on a variety of topics, such as assessment procedures, selection of goals, development of appropriate treatment pro- grams, and methods of evaluating outcomes.

Mindfulness and Psychotherapy (Germer, Siegel, & Ful- ton, 2013) is a practical introduction to mindfulness

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and its clinical applications. This edited work addresses the basics of mindfulness meditation, the centrality of the therapeutic relationship, and ways that cultivating mindfulness can enhance accep- tance and empathy.

Wisdom and Compassion in Psychotherapy: Deepening Mindfulness in Clinical Practice (Germer & Siegel, 2012) is an edited book that expands on the mes- sage that we need to treat ourselves as we would want other to treat us. There are some excellent contributed chapters that discuss the meaning of wisdom and demonstrate the clinical applications inherent in blending Western psychotherapy and Buddhist psychology.

Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy (Pollak, Pedulla, & Siegel, 2014) is a very useful resource for introducing mindfulness into the practice of psychotherapy. This clearly writ- ten book features practical meditation exercises that can enhance the therapy process and demonstrates

the power of mindful presence for therapists and their clients.

Mindfulness-Based Cognitive Therapy for Depression (Segal, Williams, & Teasdale, 2013) is an excellent resource for those who are interested in learning about the fundamentals and clinical applications of mindfulness-based cognitive therapy, especially in working with depression.

Acceptance and Mindfulness in Cognitive Behavior Therapy: Understanding and Applying the New Therapies (Herbert & Forman, 2011) is one of the best resources for discussion of new developments in behavior therapy and future trends.

The Mindfulness Solution: Everyday Practices for Everyday Problems (Siegel, 2010) is an outstanding practical guide in applying mindfulness practices to living a meaning- ful life, as well as a guide for practitioners who wish to teach clients how to use mindfulness in meeting life’s challenges. This is a well-written book that highlights applications to personal and professional areas.

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