PowerPoint -CONTEMPORARY THEORY PRESENTATION

Read: Seligman, Kress & Reichenberg: Chapter 5

Chapter 5

Learning Outcomes 

      

     When you have finished this chapter, you should be able to: 

     • Understand the context and development of Behavior Therapy. 

      • Communicate the key concepts associated with Behavior Therapy and understand how they relate to therapeutic processes. 

      • Describe the therapeutic goals of Behavior Therapy. 

      • Identify the common techniques used in Behavior Therapy. 

      • Understand how Behavior Therapy relates to counseling diverse populations. 

      • Identify the limitations and strengths of Behavior Therapy. 

      

     

     

     We are the only ones who can be aware of our feelings and thoughts; they can be kept private, and any given thought or emotion will not have an impact on our lives if we choose not to act on them. That is not the case with behaviors. Once we take action—choose which road to travel—we make an irreversible move in a certain direction. In addition, the potentially public and observable nature of behaviors intensifies their impact. The actions we take are most likely to determine the direction of our lives as well as our relationships with others and their perceptions of us. Even a small act such as leaving for work early has a profound impact if it enables us to avoid a car accident, make a new friend at the coffee shop, or make a positive impression on a supervisor. 

     Sometimes people feel overwhelmed and immobilized when they consider the possible impact of their behaviors, so they avoid making choices and taking action. However, inaction is an action in itself and does have consequences. Behaviors and behavior therapy will be the focus of this chapter. 

     We will start off with a discussion of the second force in theories of counseling and psychotherapy, theories that focus on client behaviors and cognitions. The rest of the chapter will then discuss behavior therapy, or theories that target client behavior change.

Introduction to the Second Force in Counseling and Psychotherapy: Behavior and Cognitive Behavioral TherapiesThe second force of counseling began with behaviorism, and many factors influenced the development of this force. During the early 1900s, interest in animal intelligence was growing, and this interest led people to study learning principles and how animals, and then humans, learn (Schultz & Schultz, 2011). 150As an example, Clever Hans, a horse who displayed intelligence by answering questions accurately with the tapping of his hoof and the nodding of his head, was of interest to many. There was growing fascination with Clever Hans and his supposed intelligence, but his supposed intelligence also had some detractors. People discovered that Clever Hans was conditioned to tap his foot the correct number of times when people knew the right answer because they would unknowingly make a movement signifying that he was right. This was a process of operant conditioning, an important concept in behavior therapy, in which Hans was reinforced for answering correctly. These types of popular examples intrigued many and led to further examination of learning principles and their applications. Animal psychology linked humans and animals together in such a way to show that they share similar processes.

Another influencer on the development of the second force in psychotherapy was the increased focus on functionalism, William James’ ideas; instead of relying on mental processes, people's behaviors. People rarely seek treatment because they worry they have dysfunctional thoughts, although they do frequently seek help for negative emotions such as depression and anxiety. Often, though, what leads clients to seek help is an upsetting behavior, either their own or someone else’s. Common behavioral concerns include overeating, unhealthy drug or alcohol use, poor impulse control, difficulty finding a rewarding job, problems managing school expectations, and challenges in developing rewarding relationships. Because behaviors often prompt people to seek counseling, people are more likely to feel heard and to believe that therapy will be helpful if, at least initially, it addresses those expressed concerns.

Many times, too, clients are forced to seek help for their behavior. For example, people who are fulfilling court-mandated treatment requirements, those who have been encour aged to meet with an employee-assistance counselor at work, or those who have been brought for help by a concerned parent or dissatisfied partner are usually in counseling because their behaviors have violated the law or have been unsatisfactory or troubling to others. 

    Discussion of behaviors is likely to be less threatening to clients than discussion of their early childhood experiences or their troubling emotions and somewhat less uncomfortable than discussion of their cognitions. People are accustomed to talking about their activities with others but are less likely to talk about their thoughts and emotions. Therefore, behavioral approaches may feel more comfortable to people from certain demographics or cultures who experience discomfort with discussions of feelings. 

    Many clients may be better able to present accurate information about their behaviors than about their emotions or even their cognitions. Having clear and valid information, especially at the beginning of counseling, can help direct the focus of counseling. 

    

    Measurement, Evaluation, and Research

All behavior and cognitive behavioral therapy theories have some focus on measurement and evaluation of client thoughts and/or behaviors. These approaches all center on developing measurable counseling goals that target changing specific behaviors and replacing them with more adaptive behaviors. Because behavior can be readily measured, clients can determine the baseline frequency or occurrence of a behavior and then assess change in such variables as how many beers they drink each day, how often they exercise, how many hours they devote to work, and how much time they spend with friends. Because even small changes can readily be identified, clients trying to modify their actions often have rapid evidence of improvement. This can be empowering and promote motivation, optimism, and further change. Similarly, if a client is struggling to make behavior changes being targeted in counseling, it can indicate to the therapist that a revised counseling approach is needed. 

    Not surprisingly, these approaches also all lend themselves well to research and external validation of their effectiveness. An extensive body of literature describes and affirms the effectiveness of behavior and cognitive behavioral therapy in addressing a variety of client-presented struggles (e.g., depression, anxiety, youth behavior problems). These approaches have generally received more research support than other approaches, not necessarily because behavior and cognitive behavioral therapies are superior, but because of the extensive research conducted on these approaches. Those who practice from these theoretical approaches place a premium on the use of counseling techniques that are based on research-demonstrated effectiveness.

Behavior Therapy: The Three Waves 

    

   Behavior therapy is generally presented as occurring in three waves: 

    

    First-wave behaviorism (i.e., behavior therapy), which focused on the use of traditional behaviorism principles in helping people change152 

    Second-wave behaviorism (i.e., cognitive behavior therapy, reality therapy), which focused on integrating cognitive principles with behavior therapy principles into therapy 

    Third-wave behavior therapy (e.g., dialectical behavior therapy), which focused on integrating mindfulness-based concepts with the more traditional behavior and cognitive therapy principles. 

    

   The first wave of behaviorism that arose in the 1950s and 1960s throughout the United States, South Africa, and Great Britain was developed, in large part, as a response to psychoanalysis. At that time, behavior therapy was intended to show that behavioral techniques were effective and could be used instead of psychoanalysis. In the 1970s, behavior therapy principles increasingly had a significant impact on education, psychology, counseling, psychiatry, social work, businesses, and child-rearing problems. Techniques that evolved from behavior therapy were considered the treatment of choice at the time. 

   In the 1980s, emotions and biological factors were increasingly taken into consideration, and this influenced the second wave of behaviorism, cognitive behavioral therapy (CBT). Bandura’s research and the development of social learning theory, which will be discussed later in the chapter, demonstrated that cognition is an important focus for behavior therapy and his views contributed to the development of CBT. During this time, CBT emerged and behavioral techniques were increasingly applied to physical health and mental health problems. 

   The third-wave CBTs arose in the early 2000s. Research and practice grew to incorporate mindfulness and acceptance of the individual’s thoughts, concepts central to many third-wave CBT theories. Due to the increasing prominence of these third-wave approaches, they will be discussed in Chapter 8.

Table 5.1 provides an overview of the first, second, and third “waves” or generations of behavior therapy from which CBT approaches evolved (Hayes, 2004).

Table 5.1 Development and Progression of the Three Generations of Behavior Therapy

In most real-world practice and application, approaches and techniques associated with the second-force counseling theories focus on both thoughts and behaviors; they are believed to be inseparable. The second-force counseling theories, including all three waves of behavior therapy, have become some of the most dominant theories in modern counseling practice. In this chapter, we will discuss the first wave of behaviorism, behavior therapy.

The first wave of behaviorism provided a basis on which behavioral counseling theories were built. Behavior therapy will be discussed in depth in the remainder of this chapter. 

   Chapter 6 will address the second wave of behaviorism, which focused on the integration of thoughts into behavioral approaches (i.e., CBT approaches). Because of their significance and popularity, Ellis’ rational emotive behavior therapy and Beck’s cognitive therapy are the two CBT approaches that will be discussed in Chapter 6. In CBT, clients learn, through the process of cognitive restructuring, to replace their faulty thinking with healthy, positive, and constructive thoughts that help them to also change their behavior. In Chapter 6, many useful strategies will be discussed. 

   In Chapter 7, reality therapy will be discussed, which is a type of cognitive behavior therapy. Because of its applications to school counseling and school psychology, and because it has a number of theoretical tenets that make it stand apart from some of the other CBT approaches, reality therapy has its own chapter.

Finally, the third wave of behavior therapies, which include the more modern approaches which incorporate mindfulness and acceptance, will be discussed in Chapter_8. These third-wave CBT approaches are, at present, very popular. A quick search of continuing education programs for mental health professionals highlights the popularity of these third-wave counseling approaches. Their focus on the complexities of human behavior and the change process, their emphasis on a variety of dynamic interventions and techniques, and the integration of evidence-based, mindfulness principles make them attractive to many helpers.

Readers should keep in mind that the differences among the various behavioral and cognitive behavioral counseling approaches are primarily those of emphasis. To greater or lesser extents, the theories focus on changing thoughts and/or behaviors.

      

     One of the most influential social learning theorists, Albert Bandura was born in Canada and received his PhD from the University of Iowa. He later moved to Stanford University, where he is now a distinguished professor emeritus. Bandura applied the principles of both classical and operant conditioning to social learning (1969, 1977, 1986). Bandura (1973) has written extensively on aggression, violence, and adolescence and has testified repeatedly before Congress about the causes and possible solutions to aggressive behavior. One of Bandura’s most well-known experiments is the Bobo doll experiment, which demonstrated observational learning. As a result of his theories, most behavior therapies 154(including exposure therapy and social skills training) now include a modeling component (Antony & Roemer, 2011). Albert Bandura has been honored by the American Psychological Association with a lifetime achievement award. He has written seven books and published innumerable articles in scholarly journals. Now in his 80s, he continues to conduct research and teach at Stanford University, where he has worked since 1953.

B. F. Skinner was born in Pennsylvania in 1904. Skinner received a PhD from Harvard in 1931 and stayed there as a researcher for several years. Skinner taught at University of Minnesota and then became chair of the psychology department at Indiana University. In 1948, he returned to Harvard as a tenured professor and stayed there until his death. Skinner was a strict behaviorist who believed that the only scientific approach to psychology was one that studied behaviors, not internal (subjective) mental processes. Building on the work of Ivan Pavlov and John W. Watson, B. F. Skinner developed a theory of behavior, operant conditioning, that has become the foundation on which behavior modification is based (Martin & Pear, 2007). He believed that who we are and everything we do is shaped by our experiences of punishment and reward. The results of Skinner’s early studies in operant conditioning were published in his first book, The Behavior of Organisms (1938).

The best summary of his theories is contained in his book About Behaviorism (1974). Skinner continued to write (Walden II, 1948/2005; Beyond Freedom and Dignity, 1971; and a three-part autobiography), lecture, and receive numerous awards for his contributions to psychology until his death from leukemia in 1990. His principles are still incorporated into treatments of phobias and addictive behaviors, and are used to enhance classroom performance (as well as computer-based self-instruction).

Introduction/Development of Behavior Therapy 

    

   Behavior therapy, which developed during the 1950s and 1960s, presented a powerful challenge to the principles of psychoanalysis. Behavior therapy’s focus on observable behaviors rather than the unconscious; on the present rather than the past; and on short-term treatment, clear goals, and rapid change had considerable appeal. 

   As its name implies, behavior therapy centers on specific behaviors, with the goal of changing or modifying that behavior. Behaviorism conceptualizes people’s problems as occurring secondary to maladaptive learning. From a behaviorist’s perspective, children are essentially born a blank slate, neither good nor bad; they are simply the products of their environment. As people go through their lives, they have experiences that shape and mold their reactions, feelings, thoughts, and behaviors. The premise is that all behavior is learned; faulty learning (i.e., conditioning) is the cause of problems. Since behaviorists believe that everything people struggle with is a result of learning, then learning new behaviors is how people make meaningful changes. Therefore, therapy concentrates on learning new behaviors. An important feature of behavior therapy is its focus on current problems, not the past, and on attempts to remove behaviors the client finds to be a challenge. Behavior therapies, sometimes referred to as behavior modification, are based on the theories of classical and operant conditioning, which will be further discussed later in this chapter. 

   In recent years, health-related behaviors such as opioid abuse, smoking, obesity, and a sedentary lifestyle have received increased attention in the United States because these unhealthy behaviors 155have been linked to illness and preventable deaths. Similarly, childhood behaviors such as bullying, tantrums, or academic difficulties may be effectively targeted by behavior therapy. Moreover, behavior therapy can address commonly presented counseling issues like anxiety, depression, and phobias. In fact, behavior therapy can work with almost any human behavior. 

   Many people have contributed to the evolution of this approach. Some, like B. F. Skinner and Ivan Pavlov, used principles of behavior change to shape the actions and reactions of animals. Others, including Hans Eysenck, Arnold Lazarus, Joseph Wolpe, and Albert Bandura, applied behavior therapy and learning theory to people.

Behavior therapy sometimes has a reputation for being mechanical and rigid, but it should be noted that over the past few decades the application of behavior therapy has broadened and it has become increasingly flexible and sensitive to individual needs. A positive and collaborative therapeutic alliance is now considered an essential element of behavior therapy, and the incorporation of mindfulness and other concepts has provided this approach with an entirely new focus. Therapists who use behavior therapy principles are likely to integrate other evidence-based interventions and place some emphasis on factors beyond just learning principles.

Key Concepts 

    

   Behavior therapy sees people as both producers and products of their environments. Therefore, clients are taught the skills they can use to best meet their goals. When people overcome their difficulties, they have more options to choose from, such as how they will respond to their environment. Behavior therapy upholds the scientific view of behavior and is a structured, systematic approach. All behavior therapies generally subscribe to the following ideas (Antony & Roemer, 2011): 

    

    Although genetics plays a role, individual differences are derived primarily from different experiences. 

    Behavior is learned and acquired largely through modeling, conditioning, and reinforcement. 

    All behavior has a purpose or function (e.g., nail biting causes one to feel more relaxed). 

    Therapy should focus on understanding and changing behavior. 

    Therapy should be based on the scientific method and be systematic, empirical, and experimental. 

    Therapy goals should be stated in behavioral, specific, and measurable terms, with regular assessment of progress toward goal attainment. 

    Counseling should generally focus on the present. Even if behaviors are long-standing, they are maintained by factors in the current environment. 

    Behaviors must be viewed and understood in the context in which they occur. 

    A client’s environment can be manipulated to increase appropriate behaviors and decrease harmful behaviors (e.g., reinforcing a child for positive, prosocial behaviors will decrease temper tantrums). 

    Education and teaching, or promoting new learning and the transfer of learning, is an important aspect of therapy. 

    Clients need to take an active role in their counseling experience to successfully change their behaviors. Clients have the primary responsibility for defining their goals and completing homework tasks. The treatment plan is formulated collaboratively, with both the client and therapist participating actively in that process. 

    

   In the following sections, classical conditioning, operant conditioning, and social learning—concepts foundational to understanding behavior therapy—will be discussed. Because understanding these concepts can present a challenge, a short case application of some of these concepts appears in Table 5.2 at the end of this section. Readers are encouraged to be patient as they learn these concepts. While behavior therapy can be difficult to understand and technical, the concepts are valuable, have broad applicability, and should not be dismissed. 

    

     

     Table 5.2 Case Application of Basic Behavior Therapy Concepts 

     

     

     Following is a review of important terms, illustrated by the experiences of Theresa, a 33-year-old woman receiving chemotherapy for breast cancer.  

     Theresa presented many issues and struggles related to her diagnosis of cancer. She had always been fearful of injections and found blood tests and intravenous chemotherapy difficult. She had anticipatory nausea associated with her chemotherapy, becoming queasy when driving into the parking lot of the clinic where she received treatment, whether or not she was scheduled for chemotherapy. In addition, although her prognosis was encouraging, Theresa constantly ruminated about the likelihood of her death.  

     Theresa’s anticipatory nausea can be explained by classical conditioning. The unconditioned stimulus, the chemotherapy, elicited the response of nausea. Because that stimulus was paired with the conditioned stimulus of driving to the clinic, entering the parking lot became a stimulus that also elicited the response of nausea whether or not the chemotherapy was also present.  

     Theresa, like all of us, had an innate drive to avoid pain. When she received vaccinations as a child, her parents reinforced her fears by paying special attention to her when she became fearful. As a result of this operant conditioning, her fear of injections became habitual and evolved into a phobia. In fact, through the process of stimulus generalization, Theresa experienced a great deal of anxiety in reaction to any medical appointment, whether or not it necessitated an injection. Her learned behavior reflected a stimulus-response pairing process; because her fearful behavior was rewarded in childhood, Theresa demonstrated fear and avoidance in response to the stimulus of any medical visit.  

     Her therapist used several behavioral approaches to modify Theresa’s responses. Systematic desensitization was used in the hope of extinguishing Theresa’s excessive fear of medical visits and vaccinations. An anxiety hierarchy was created, listing her fears in ascending order from the mildest fear (a visit to a dermatologist that would not involve any physical discomfort) to the most frightening (a visit to the oncologist for chemotherapy). Beginning with the mildest fear, the therapist helped Theresa to relax and feel empowered while visualizing the frightening stimulus. This process of reciprocal inhibition paired relaxation and positive feelings with an aversive stimulus (a frightening image) to decrease the strength of the fear response. Theresa also learned to use both relaxation and stimulus discrimination to reduce her fears; she learned to relax when approaching medical visits and driving into the parking lot at the oncology clinic and reminded herself that not all medical appointments involved discomfort.  

     Counterconditioning was used to help Theresa further reduce her fears; when she began to ruminate or felt anxious, she visualized herself triumphantly completing her chemotherapy and setting off on a trip to Bali that she was planning. The feelings of pride and optimism elicited by that image counteracted and reduced her apprehension. To make sure she could readily access this positive image, the therapist led Theresa through a process of covert modeling in which she mentally rehearsed dealing effectively with her fears about chemotherapy. Joining a support group of other women diagnosed with breast cancer also provided Theresa with an experience in social learning and positive reinforcement and gave her an opportunity to model herself after others.  

Table 5.2 Case Application of Basic Behavior Therapy Concepts, Full Alternative Text 

    

Classical Conditioning 

     

    In the early 1900s, Ivan Pavlov (1927), a Russian physiologist, identified and described a type of learning that is now known as classical conditioning. Classical conditioning involves the repeated presentation of a certain stimulus that, over time, causes a given response when paired with something else. This is referred to as stimulus-response pairing. Thus, the stimulus and response become associated with one another, or paired, and every time the stimulus is presented, the associated response occurs. Pavlov’s classic study of conditioning responses of dogs demonstrated that, by simultaneously presenting an unconditioned stimulus (food) and a conditioned stimulus (the sound of a bell), researchers could elicit the dogs’ salivation using only the conditioned stimulus (the sound) because the dogs learned to associate the sound with the food. 

    Extinction is another important behavior therapy concept. Extinction involves the conditioned response decreasing over time after the presentation of the conditioned stimulus is removed. Using the Pavlov’s dogs example, for a while, the dogs salivated to the sound of the bell, even when the sound was no longer accompanied by the food. However, over time, the salivating response diminished and eventually disappeared in response to the bell alone. 

    John Watson, an American psychologist, used Pavlov’s principles of classical conditioning, concepts of learning theory (discussed in the next section), and stimulus generalization (responding the same way to similar stimuli) to change human behavior. When people learn to respond in a particular way to one stimulus, they often behave or respond in that same way when presented with similar cues or similar stimuli. As an example of stimulus generalization, an unconditioned stimulus (a loud bell), paired with a conditioned stimulus (a white rat), could lead a child to emit a conditioned response (startle) in reaction not only to a white rat but also to white cotton, Watson’s white hair, and other similar stimuli. Behaviorism is the theory that behavior can be explained by conditioning, without emphasis on thoughts or feelings, and that behavioral problems are best addressed and altered by changing behavior (Watson, 1925). 

    Joseph Wolpe (1969) described a similar process, reciprocal inhibition, in which eliciting a novel response brings about a decrease in the strength of a concurrent habitual response. A parent who makes a silly face to cheer up a child who is crying after a minor fall is a simple example; the silly face elicits amusement, which automatically reduces the sad emotions associated with the fall. These concepts led to the development of systematic desensitization, a powerful therapy technique that pairs relaxation with controlled exposure to a feared stimulus, such as heights or dogs. This technique is widely used, especially in the treatment of phobias. 

    Wolpe’s work reflects the concept of stimulus generalization. For example, a child who is taught to be respectful of teachers is likely to behave respectfully toward other authority figures. Sometimes behavior is overgeneralized and becomes inappropriate or unhealthy. Because of this, people then need to learn stimulus discrimination—the ability to distinguish among similar cues. For example, most people have learned to confide in a small number of close friends but recognize that it is inappropriate to share many details of their personal lives at work (stimulus discrimination). However, some people share intimate details of their lives not only with close friends but also with casual associates, perhaps reflecting inappropriate stimulus generalization. 

    

Operant Conditioning 

     

    Operant conditioning is also applicable to counseling clients, as many behavioral treatment interventions pull on operant conditioning principles. Operant conditioning is a type of learning based on consequences, in which behavior is influenced by the positive or negative association of the consequence that follows a behavior. Therapists frequently use behavior modification interventions 157such as positive reinforcement, negative reinforcement, punishment, and extinction techniques to increase the frequency of client’s positive behavior, and decrease or eliminate undesired behaviors. These terms will be discussed further in the techniques section of this chapter. 

    The more frequently a stimulus and a response coincide, with the response being rewarded, the stronger is the tendency to emit the response when that stimulus occurs, leading to the development of a habit or habitual response. This is the essence of the stimulus-response (S-R) concept, which, according to behavior theorists, determines the behaviors that people learn. 

    For example, Jamila was the third child in a family of seven children. Both parents worked outside the home and had little time for positive interactions with their children. Whenever one of the children was sick, however, the parents gave them extra time and attention. Jamila learned that illness was the best way to elicit her parents’ attention and so exaggerated even minor physical symptoms for the nurturance that she would receive. She continued this behavior into adulthood, even though it had a harmful effect on her relationships, her employment, and eventually on her marriage. 

    John Dollard and Neal Miller found that counterconditioning could reverse habits. This involves pairing the behavior with a strong incompatible response to the same cue to change the behavior. For example, Jamila’s behavior gradually changed as her employer, friends, and partner became annoyed with her frequent complaints of physical discomfort and withdrew from her when she reported feeling ill. 

    

Social Learning Theory 

     

    While not an approach to therapy, social learning theory principles are, like operant and classical conditioning, foundational to behavior therapy. Social learning theory (Bandura, 1986) differs slightly from the aforementioned classical and operant conditioning methods that solely focus on behavior and the environment. It differs by including an additional focus on people’s worldview, beliefs, perspectives, and other cognitive processes, as internal appraisals or interpretations of events are assumed to significantly influence one’s behavior. Social learning theory emphasizes how individuals learn by observing and modeling others (Bandura, 2006). Modeling has to do with learning by imitating others’ behavior. Bandura found that in addition to direct experience, learning and subsequent behavior change could occur vicariously through observation of other people’s behavior. 

    Modeling can elicit both positive and negative behaviors. On the one hand, modeling often has a beneficial impact, as when a parent models appropriate behavior. On the other hand, as Bandura’s famous Bobo doll experiments suggests, children who observed an adult acting aggressively and hitting the Bobo doll were more likely to manifest aggressive behavior than children who had not been exposed to the aggressive behavior. Thus, modeling can also elicit negative behavior. 

    Modeling has more than just an impact on behavior (Bandura, 1969). Modeling can actually change our cognitions about our abilities and improve our self-efficacy. Self-efficacy is our belief in our ability to accomplish something and thus be efficacious. Observing someone we admire undertake a challenging task can reduce our fears and facilitate our own belief in our efforts to perform the task. People with strong beliefs in their own efficacy are more likely to face problems as challenges to be reckoned with rather than threats to be avoided. Bandura found that self-efficacy impacts how people think, feel, motivate themselves, and behave. 

    Self-efficacy theory posits that people will be able to perform a certain task based on their beliefs about how well they will perform (their competencies), as well as the consequences that come from doing it (environmental reinforcement). Over time, people develop a sense of their own competency at a given task. This sense of competency shapes their future attempts (Bandura, 1977). Many behavioral approaches, such as behavior activation therapy and exposure-based therapies, are based on the premise that self-efficacy increases as people spend more time on behaviors at which 158they feel competent. Social learning theory expands on behavior theory and cognitive behavioral theory by recognizing that not only reinforced behaviors or faulty thoughts are responsible for human behavior, but also a complicated cognitive mediational process that includes cognitive, affective, and motivational processes.

The Therapeutic Process 

    

   The therapeutic process of behavior therapy emphasizes: 

    

    The individual assessment and evaluation of objective, operationally defined behaviors 

    Identification of specific target behaviors, or those behaviors most significantly interfering with the current daily functioning of clients (i.e., those that are often the initial focus of counseling)159 

    Identification of the functions of behaviors, or why they occur; the consequences that follow specific behavior; and how clients respond to these consequences 

    Selection of interventions aimed at systematically extinguishing undesirable behaviors while reinforcing desired behaviors, and teaching clients to implement interventions independently 

    Ongoing assessment and monitoring of behavior to determine the effectiveness of interventions, and modifying treatment plans and interventions as needed throughout the counseling process 

    Conducting follow-up assessments after the completion of counseling goals to determine the overall effectiveness of counseling, as evidenced by the maintenance of adaptive behaviors and the elimination of maladaptive behaviors. 

    

   Because of the deliberate, targeted, and methodical nature of behavior therapy, counseling processes are highly structured, active, and, most notably, learning oriented. In the broadest sense, behavior therapy is essentially a process of unlearning maladaptive behaviors and replacing them with new, relearned behaviors or skills that enhance adaptive functioning (Spiegler & Guevremont, 2016). As an example, consider a 4-year-old boy whose father brings him to counseling for hitting his younger brother and children at his daycare. A counselor working from a behavior therapy perspective would focus on carefully defining the problematic behavior (e.g., the boy hits children at school), teaching the boy how to respond when angry or frustrated (e.g., the use of a relaxation exercise such as imagining he has a balloon in his belly that he blows up when he inhales, and then a candle he blows out upon the exhale) while removing the behavioral reinforcers by teaching the adults around him to respond in a manner that will extinguish the negative behaviors (e.g., placing the boy in a time-out when he hits and not reinforcing the behavior with adult contact). 

    

     

     Therapeutic Goals 

     

    Behavior therapy, as its name implies, seeks to extinguish maladaptive behaviors and help people learn new, more adaptive behaviors. The overriding goal of behavior therapy is to help clients become more flexible and sensitive in their reactions to changes in their environment and to establish tools that are effective in helping them meet their needs (Antony & Roemer, 2011). Counseling goals must be clear, specific, measurable, and agreed upon. The following are examples of issues behavior therapy techniques can address:

Reduction in use of, or abstinence from, drugs and alcohol 

     Reduction of undesirable habits, such as nail biting or pulling out one’s own hair 

     Improvement in social skills, such as assertiveness and conversation 

     Reduction of fears and phobias, such as fear of flying, apprehension about public speaking, and excessive fear of snakes 

     Improvement in concentration and organization 

     Reduction in undesirable behaviors in children, such as tantrums, disobedience, acting out, aggressiveness, and difficulty going to bed 

     Improvement in health and fitness habits, such as more nutritious eating, increased exercise, and more regular sleep patterns. 

     

    In addition to specific goals like these, behavior therapists also have the general goal of teaching people skills that will help them improve their lives. Skills such as decision making, problem analysis and resolution, time management, assertiveness, and relaxation are often incorporated into behavior therapy. 

    It is important to note, however, that enhancing insight, exploring underlying internal conflicts, or demonstrating unconditional positive regard to foster self-actualization is not of interest to 160behaviorists. Behavior therapy focuses on action; clients are expected to practice and use the new skills and strategies they have learned in counseling to assist them with changing their behavior and achieving their counseling goals (Wagner, 2008). 

    

   Therapist’s Function and Role 

     

    Therapists who use a behavioral approach with clients serve as consultants, teachers, architects, and/or problem solvers. Behavior therapists conduct sessions in a directive, planned, and instructional manner, and they value the systematic, objective, observable, and rigorous elements of research-based therapeutic procedures and practices (Miltenberger, 2012; Spiegler & Guevremont, 2016). 

    Despite this linear, scientific approach, behavior therapists believe that relational factors can influence counseling processes, and therapists who practice contemporary behavior therapy recognize the importance of establishing a strong therapeutic alliance when working with clients. Because learned behaviors can be difficult to change, the process of behavioral change can present challenges. As such, behavior therapists understand that they must assign the same degree of time and effort to the therapeutic relationship as they do to assessment, evaluation, and implementation of behavioral interventions if they are to effectively promote change and help clients achieve their goals. 

    Behaviorists believe that all behavior is learned, and thus problem behaviors can be unlearned and replaced with more desirable ones. Through this lens, the etiology of maladaptive behavior is not attributed to the individual or considered to be a personally held disturbance or impairment. In this way, a behavior therapist assumes an inherently empowering stance. 

    Following the completion of assessment processes, therapists analyze obtained data and shift their role toward: 

     

     Developing initial individualized counseling goals and objectives that target specific, observable behaviors 

     Identifying evidence-based behavioral interventions, and teaching clients how they can be utilized, generalized across settings, and independently maintained 

     Continually monitoring behavior, assessing the effectiveness of interventions, and modifying counseling goals and objectives as needed throughout counseling 

     Completing follow-up assessments to determine counseling effectiveness and the maintenance of positive behavioral change. 

     

    Therapists also strive to establish a clear agreement with the client about the goals of counseling and the roles of both participants. A contingency contract, a type of behavior contract between the therapist and the client that specifies the behaviors to be addressed in counseling, is often developed. 

    

    

     

     Relationship Between Therapist and Client 

     

    Behavior therapists are more directive and focused than the therapists who use the other approaches discussed in this book. Behavior therapists are likely to develop and concentrate on formalized treatment plans, set goals and objectives, and monitor homework assignments in their efforts to help clients effect behavioral change. Behavior therapists recognize the importance of a collaborative and positive therapeutic relationship and the communication of encouragement as vital in promoting learning and motivation. Therapists can foster a positive therapeutic relationship by learning about the strengths, interests, and unique personal qualities of clients and integrate such themes into their individually tailored interventions. They tend to take a holistic approach—interpreting behavior broadly as anything an organism does, including thinking and feeling—and are interested in the total person. Although objectivity and the scientific method are valued, behavior therapists also recognize the importance of understanding and respecting individual differences. 

    161Behavior therapy inherently emphasizes individualized counseling practices that consider specific settings, environmental circumstances, people, and other factors associated with a client’s behavior. Therapists aim to individually tailor assessment processes and intervention techniques in a manner that is developmentally, intellectually, and contextually sensitive to the needs of each client.

Therapeutic Techniques and Procedures 

    

   Behavior therapists emphasize that counselors should individually tailor assessment processes and intervention techniques in a manner that is developmentally, intellectually, and contextually sensitive to the needs of each client. For example, counselors working with children can design treatment plans that look similar to coloring books or children’s stories, create rating scales with smiley faces as opposed to numbers to track self-report data, or use role playing as a creative avenue for children to verbally express the new competencies they have learned throughout counseling or to demonstrate before and after examples of the behavioral changes they have made. 

   Behavior therapists pull on a variety of interventions and techniques to help clients make changes. Some of the more commonly used behavior therapy interventions follow, but many more are available that could not be included in this text due to space limitations. 

    

     

     Assessment 

     

    Behavioral counselors gather initial information related to a client’s presenting concerns through a variety of different assessment approaches (Flynn & Lo, 2016). To understand a client’s behavior, a counselor might ask the client to thoroughly explain a typical instance of the problem behavior. It is important for the client to offer detailed accounts, as it is within these details that the counselor can identify what may be maintaining the problem. 

    Generally speaking, counselors working from a behavioral approach are interested in three questions: 

     

      

      What does the problem look like in concrete, specific, behavioral terms? 

      What happens before the problem occurs? 

      What happens after the problem occurs? 

These three questions provide answers to behavioral change.

Understanding and gaining awareness of reasons for certain behaviors and ways to change behavior are important. Functional behavior assessments (FBAs) involve identifying a specific target behavior, the purpose of the behavior, and what factors maintain the behavior. Even maladaptive behaviors serve a purpose; therefore, it is helpful to understand the dynamics that go into creating and sustaining the behaviors. The function of maladaptive behaviors can be met through more adaptive and beneficial ways of behaving. In addition, understanding what happens before the behavior (the antecedents or triggers) and what happens after the behavior occurs (the consequences) gives a better picture of the relationships between the stimuli and responses.

FBAs have become one of the most frequently used assessment methods among behavioral counselors. FBAs are intended to objectively identify clients’ problem behaviors, and determine the individual and environmental determinants that trigger and maintain behavior (Leaf et al., 2016; Oliver, Pratt, & Normand, 2015). The systematic procedures of FBAs are recognized as a particularly advantageous behavioral assessment, as they enable helping professionals to obtain a comprehensive and precise understanding of the cause-effect correlations between specific behaviors and environmental circumstances that help determine the underlying function of clients’ behavior (Shriver et al., 2001). That is, by making connections between the behavior and factors that include the setting, time, around whom, and what happens before and after, FBAs allow counselors to identify what purpose behaviors serve and what clients are getting from engaging in a certain behavior.

FBAs are conducted using the Antecedent-Behavior-Consequence (ABC) Model, in which counselors observe and gather data on Antecedents, observed Behaviors, and the Consequences of behavior. Counselors first seek to identify the antecedent events or cues that occur before a certain behavior is displayed or, in other words, identify what factors or aspects of a client’s environment are responsible for eliciting the behavioral response. These responses in turn serve as the target behaviors counselors focus on. For example, while observing a child in the classroom to determine antecedents of target behaviors, counselors aim to answer questions about target behaviors similar to the following: In what setting do they occur? What are the physical characteristics of the setting, or how is the setting uniquely arranged? What time of day do behaviors occur? What is typically occurring in the environment before behaviors are displayed? Is the child experiencing academic difficulties? Who is around? Are there peer influences? Antecedents provide counselors with an understanding of the beforehand factors that prompt youth to demonstrate a certain behavioral response. Other people’s responses or events that follow a behavior are known as consequences; and not only do they keep clients’ behaviors maintained, but they also explain the function of behavior. 

    Once antecedents, behaviors, and consequences have been identified, counselors form hypotheses about the function of behavior based on their conceptualization of how environmental determinants are influencing the expression and maintenance of target behaviors. Counselors then test their hypotheses by staging brief experiments in which clients are systematically presented with a series of events or situations that are expected to elicit target behavior responses. That is, counselors intentionally introduce previously identified antecedents to determine if clients exhibit target behaviors. Alternatively, counselors may also stage different events specifically related to certain functional behavior domains and track which set of circumstances most frequently elicit target behavior responses. Maladaptive functional relationships—those in which environmental determinants lead to a client’s engagement in undesired target behaviors—serve as a foundation to establish treatment goals and objectives aimed to extinguish such relationships, and assist clients in developing more adaptive behaviors. 

    While functional behavior assessments take some effort to complete, they are very pragmatic and hold great utility for counselors, especially counselors working with children or those who have autism spectrum disorders or intellectual disabilities (Kress et al., 2019). As functional behavior assessments reduce complex behaviors into isolated components or smaller parts, counselors can provide clients with concrete, logical interpretations of problems. Reducing behaviors into smaller specific components can help in formulating realistic and attainable goals. Such behavioral approaches are particularly applicable in the school environment, as many youth who experience behavioral problems in the classroom also encounter academic difficulties. Establishing small goals that clients are able to accomplish in a prompt time period can engender an advantageous sense of success and self-efficacy. Fostering clients’ personal agency can increase therapeutic momentum, as goal achievement naturally serves as reinforcement.

Operant Conditioning Techniques 

    

   As previously mentioned, operant conditioning is a type of learning based on consequences and reinforcement, in which behavior is influenced by the positive or negative association of the consequence that follows a behavior (Miltenberger, 2012). Subsequent to the completion of an individualized functional behavior assessment and the establishment of clear, measurable, and observable goals, counselors identify empirically validated interventions that support the desired counseling outcomes. 163A number of behavior therapy techniques and interventions are based on operant conditioning principles (Table 5.3). Some of the foundations and principles that support operant conditioning techniques will be discussed in the following sections.

Table 5.3 Operant Conditioning Interventions

 The use of the words “positive” and “negative” can be confusing at first. For example, negative reinforcement is often mistaken for punishment, when in fact the two are separate, and important, concepts in behavioral theory. Negative does not necessarily mean “bad”; it means removing something from the environment. The opposite of negative is positive, which means adding something to the environment, 164which does not necessarily mean “good,” as we will see when we discuss positive punishment. Punishment intends to decrease undesirable behavior, and reinforcement intends to increase desirable behavior. These terms combined make up the four contingencies of operant conditioning: positive reinforcement, negative reinforcement, positive punishment, and negative punishment, which will be discussed below. 

    

     

     Reinforcement 

     

    Reinforcements and rewards encourage behavior change, enhance learning, and solidify gains. Reinforcements are used to increase desirable behavior. Reinforcements should be carefully selected and planned; should be meaningful and worthwhile to the individual so that they are motivating; and should be realistic and reasonable. For example, giving a child a video game for cleaning his room once is not realistic, but setting aside $3 toward the purchase of a video game each week the child cleans his room 5 out of 7 days probably is. Reinforcement is of two types: 

     

     Positive reinforcement: A behavior followed by a positive reinforcement has an increased probability of being repeated. Positive reinforcement involves providing a “reward” to a client upon completion of a desired behavior (at the schedule of reinforcement that has been determined). Positive reinforcement encourages a behavior to be repeated, much as a parent’s smiles and excitement reinforce a baby to smile. 

     Negative reinforcement: The removal of an already active aversive stimulus (e.g., turning off the electricity when the mouse stands on its hind legs will result in the mouse standing more) is known as negative reinforcement. Therefore, behavior followed by the removal of an aversive stimulus results in an increased probability of that behavior occurring in the future. 

     

    Adults can create their own reinforcement plans. One woman who had difficulty paying bills on time set aside 1 hour twice a week for organizing her finances. Each time she completed the hour of financial planning, she rewarded herself by going to the bookstore to buy a new mystery and spending the rest of the evening reading her book. 

    Rewards do not need to be material. Social reinforcement, such as parental approval, a positive rating at work, and admiration from friends, can be as powerful or even more powerful. In addition, clients can reward themselves through positive affirmations and reminders of their success, such as the declining balance on their credit card bill and their improved grades. Reinforcements usually are most powerful if they are provided shortly after the success and are clearly linked to the accomplishment. Such reinforcers are particularly likely to solidify the desired change in behavior and contribute to either further change or maintenance of goal achievement. 

Punishment 

       The opposite of reinforcement is punishment, or reasonable consequences, which are the logical, and usually unpleasant, outcomes of undesirable behavior. Punishment is used to decrease undesirable behavior. Getting fired for repeatedly coming to work late is an example of such a consequence. Punishment consists of two main types: 

     

     Positive punishment: A behavior followed by positive punishment has a decreased probability of being repeated. Positive punishment involves adding something aversive to the environment upon completion of an undesirable behavior. For example, the child who does not pick up her toys before dinner must clean her room after dinner instead of watching her favorite television program. 

     Negative punishment: The removal of an already active favorable stimulus (e.g., toys) is known as negative punishment or response cost. Therefore, behavior followed by the removal of a favorable stimulus results in a decreased probability of that behavior occurring in the future. An example of negative punishment is giving children a time-out or taking away their toy after they misbehave. 

     

    165Although reasonable consequences can be viewed as punishment, they are preferable to arbitrary and contrived punishments because they have a logical connection to the undesirable behavior and give people a strong message about the implications of their behavior. Reasonable (or natural) consequences avoid some of the potentially harmful consequences of other types of punishment while still giving a powerful message. Reasonable consequences are designed to grow logically out of an undesirable behavior; for example, a boy who neglects his homework is required to keep a notebook in which his teachers write down daily homework assignments for parent follow-up. The girl who uses six towels each time she bathes is made responsible for doing the laundry. 

    Although penalties or punishments are sometimes used instead of rewards to shape behavior, rewards are generally more effective. They make the process of change a positive and empowering experience and promote motivation. In addition, if other people are giving the consequences, those people are likely to be perceived positively if they are giving rewards but viewed negatively if they are providing punishments. However, punishments can provide a powerful and immediate message and do have a place in behavior change. Arrest of people guilty of domestic abuse, for example, can break through their denial, leading them to enter counseling and make positive changes. 

    Despite the fact that punishment is not generally an effective strategy for modifying behavior, people from the United States generally approve of using corporal punishment (e.g., washing children’s mouths out with soap, spanking or hitting children with some type of an instrument; Aronson-Fontes, 2005), and counselors in all settings will frequently find themselves needing to advise adults on effective discipline strategies. Many mental health associations have made public statements condemning the use of spanking and corporal punishment, and research demonstrates that it is not an effective way to modify children’s behavior. In fact, the more children are spanked, the more likely they are to defy their parents, experience increased aggressive behavior, and struggle with mental health problems (Gershoff & Grogan-Kaylor, 2016). Armed with research and knowledge on effective and ineffective discipline and parenting strategies, therapists can play an important role in applying behavior principles and assisting parents to help their children. 

Extinction 

Extinction involves withdrawing the payoff or reinforcement of an undesirable behavior in hopes of reducing or eliminating it. For example, parents who give their children extra attention whenever they misbehave may be inadvertently reinforcing the undesirable behavior. Coaching the parents to pay attention to positive behavior and ignore misbehavior as much as possible is likely to reduce undesirable behavior. 

    

    

     

     Shaping 

     

    Skinner first introduced shaping, which refers to the process of gradually reinforcing particular target behaviors to approximate the desired behavior. In other words, this technique is used to effect a gradual change in behaviors. Shaping can help people make successive approximations of desired behaviors, eventually leading to new patterns of behavior. Drawing on the principles of operant conditioning in one of his studies, Skinner was able to reinforce a pigeon to turn in a circle and peck at a red disk by reinforcing small successive approximations of the desired behavior until the pigeon was able to complete an entire turn with only one reinforcement. Shaping can also reinforce undesirable behavior. For example, children’s behavior can be shaped through parental reinforcement; parents who give attention primarily to children’s misbehavior inadvertently reinforce that behavior. Another example of shaping is the way children learn to talk—they are rewarded for making a sound that is similar to a word until they can say the word. The following steps might help people with social anxiety improve their interactions with others: 

     

     Spend 5 to 10 minutes at a social gathering. Do not initiate any conversations. 

     Spend 5 to 10 minutes at a social gathering and greet at least two people.166 

     Spend 15 to 20 minutes at a social gathering, greet at least two people, introduce yourself to at least one person, and ask a question of one other person. 

     Follow the previous step and, in addition, have a brief conversation about the weather and compliment the host on the food. 

     

     Contingency Management and Token Economies 

     

    Contingency management is the theoretical foundation of token economies. Contingency management is based on the behavioral principle that if a behavior is reinforced or rewarded, it is more likely to occur in the future. In more formal terms, contingency management is the systematic delivery of reinforcing or punishing consequences contingent on the occurrence of a target response, and the withholding of those consequences in the absence of a target response. As an example, a client receiving methadone treatment for heroin addiction is provided with take-home methadone privileges for maintaining a long period of abstinence. The client is reinforced for positive behavior by not having to come into a clinic to dose each morning. 

    Token economy systems, an applied form of contingency management, are operant reinforcement programs that are particularly useful in group settings such as schools, day treatment programs, hospitals, prisons, and within families. Token economies effectively and efficiently change a broad range of behaviors in a group of people. As with all behavioral counseling processes, a target behavior or set of behaviors must initially be identified and defined. Behavioral rules, guidelines, or goals must first be established and then understood and learned by all participants in the token economy system. These guidelines are generally written out and posted to maintain awareness. Clients earn something that is reinforcing for them based on their age, developmental level, and current needs (e.g., tokens, points, tickets) for demonstrating desired target behaviors. Tokens are provided each time the behavior occurs. With children, it can be helpful to store the tokens in a visible jar or container as a reminder of success. Once a predetermined number of tokens are earned, they can be traded in for a reward. The rewards should be clear, realistic, and meaningful to the participants and be given in ways that are fair and consistent. For example, consider a child who is staying in a residential treatment facility: 2 points might be exchanged for television time, 5 points might merit a trip to the movies, and 15 points might be exchanged for a telephone call to a friend. To provide reinforcement, opportunities should be offered for frequent redemption of rewards. In addition, social reinforcement (praise, appropriate physical affection) should be paired with the material rewards to develop intrinsic motivation and internalization of the desired behaviors. Generalization of the behaviors outside the therapeutic setting promotes their establishment. 

    Behavior contracts can document the terms or conditions of the token economy system, including specific behavioral expectations and schedules of reinforcement. Then a system of rapidly identifying and recording each individual’s performance of the desired behaviors is developed. Creating behavior contracts and using other visual aids help to make token economies more concrete and understandable when working with children or people who have developmental or intellectual delays.

Application of Operant Conditioning Principles: Applied Behavior Anlaysis 

     

    One of the most powerful applications of behavior therapy principles in recent years has been the development of applied behavior analysis (ABA), a gold standard treatment for those who have autism spectrum disorder (Boutot & Hume, 2012; Matson et al., 2012). ABA is often delivered one-on-one in a school, home, or clinical setting. ABA can also be delivered in social skills group settings that sometimes incorporate siblings or peers who do not have autism to serve as models for appropriate behavior and social communication. ABA uses Skinner’s behavioral principles of operant conditioning to elicit 167positive behavior change. ABA can be used to teach age-appropriate communication skills, social skills, adaptive behavior skills, and academic content to adults and children with autism, while simultaneously decreasing negative behaviors such as tantrums and outbursts. ABA also involves functional behavior assessment procedures or a functional assessment. Counselors use functional behavior assessment to systematically identify the contributing and maintaining factors of problem behaviors, and the function or purpose these behaviors serve (Harvey, Luiselli, & Wong, 2009). Following the completion of assessment processes, counselors analyze obtained data and shift their role toward (1) developing initial individualized treatment goals and objectives that target specific, observable behaviors; (2) identifying evidence-based behavioral interventions and teaching youth how they can be utilized, generalized across settings, and independently maintained; (3) continually monitoring behavior, assessing the effectiveness of interventions, and modifying treatment goals and objectives as needed throughout counseling; and (4) completing follow-up assessments to determine treatment effectiveness and the maintenance of positive behavioral change. To bring to life some of the behavior therapy concepts we have been discussing, a summary of several ABA techniques, with examples of their application, is provided in Table 5.4. 

Table 5.4 Applied Behavior Analysis (ABA): An Application of Operant Conditioning Techniques

Classical Conditioning Techniques 

    

   Interventions founded on the principles of classical conditioning are most applicable to clients who experience distress related to anxiety, panic, fear, or trauma—all of which share common features of heightened body responses, such as increased heart rate, rapid breathing, or shaking, along with upsetting thoughts about the feared object, event, or situation. Accordingly, classical conditioning interventions not only use behavioral learning principles to target the physiological responses characteristic of stress-related presenting concerns (e.g., separation anxiety, specific phobia disorder, social anxiety disorder, agoraphobia, panic disorder, posttraumatic stress disorder [PTSD]) but also include supplemental cognitive-oriented exercises to address thought-based symptoms (e.g., worrying about getting lost; being embarrassed in front of others; anticipation that harm, injury, or death will occur). Interventions including progressive muscle relaxation, systematic desensitization, and exposure-based strategies are all commonly used with clients and are all backed by empirical evidence. 

    

     Exposure-Based Interventions 

     

    Exposure is one of the most important components of behavior therapy for anxiety disorders. Through the use of exposure, people learn to identify their fear responses; recognize maladaptive cognitions; confront or “sit with” the uncomfortable feelings without avoiding, running away, or otherwise modifying the experience; and achieve a certain amount of self-efficacy or control over the feelings of distress. As a result, people learn new methods of coping and handling emotions, rather than giving in to fear (Bandura, 1977). Research has found that repeated contact with a feared or avoided stimulus will result in adaptation. In other words, the more exposure individuals have to a feared object (e.g., a snake, tarantula, or tall building), the less fear they will experience. In contrast, avoidance of the feared object reinforces the fear and actually increases the resulting anxiety. Most exposure-based therapies and interventions also include a cognitive component, usually cognitive restructuring, to help increase the client’s positive coping statements and reduce thought distortions, self-blame, and anxiety. 

    Virtual reality therapy uses technology to provide another delivery method for exposure-based therapies. By creating a human–computer interaction that imitates in vivo exposure, virtual reality can be particularly helpful for anxiety disorders, including social anxiety, phobias, obsessive-compulsive disorder [OCD], PTSD, and the fear of public speaking (Powers & Emmelkamp, 2008; Wallach, Safir, & Bar-Zvi, 2009). Interactions can occur via video or three-dimensional (3D) technology and may include use of a joystick, glove, or similar device to provide interactive feedback between the individual and the computer. A distinct advantage of virtual reality over other approaches is the ability to adjust the level of stimuli the individual receives. Virtual reality therapy has also helped individuals who have snake phobias or fear of heights (Klinger et al., 2005). Sensitivity and clinical judgement must be used when incorporating virtual reality into counseling, and the technique should never be used as a substitute for therapy (Rothbaum, 2005). 

    Pacing is another important consideration in exposure-based therapies. Some therapies are designed to take place within one session. Flooding, for example, usually provides intensive exposure over 30 minutes to 8 hours to the individual’s most feared stimulus (see below). Because of the intense emotions, flooding can be overwhelming and is not appropriate for treating phobias for which it might pose danger, such as phobias of driving over bridges or on highways. Implosion is another type of prolonged, intense exposure therapy in which the client imagines anxiety-producing situations or events in order to develop a more appropriate response for the future.

Graduated exposure involves having the individual confront the fear for a short period, and then gradually increasing the length of exposure with each session. Systematic desensitization is a type of graduated exposure. An example of graduated exposure for an elevator phobia would involve taking the elevator to more floors with each successive therapy session. Flooding, systematic 170desensitization, and interoceptive exposure are the most common exposure-based therapies and are discussed below. 

    Flooding involves exposing an individual to high doses of a feared stimulus, with the expectation that this will desensitize them to the feared stimulus. The person must remain in the feared situation long enough for the fear to peak and then diminish. If the person leaves the situation prematurely, the fear may worsen and the person may learn to fear those who staged the flooding. In addition, the fear may lead the person to act in unsafe ways. Flooding is a high-risk intervention that must be used with caution, and only by therapists who are well versed in its appropriate use. 

    Some people believe that pushing a child into a swimming pool is a way to cure a fear of water. This misguided belief can endanger the child’s life, create a traumatic experience, and impair the child’s trust in others. Flooding should rarely be used, and then only after the client is fully informed about the risks associated with the procedure and consents to participate in the procedure. 

    Systematic desensitization, as created by Wolpe, is a powerful exposure intervention for reducing fears, phobias, obsessions, compulsions, and anxiety. Initial fears are generally worsened when the individual avoids the feared stimulus and the avoidance is reinforced by the relief that follows. Systematic desensitization is designed to reverse this process by gradually exposing an individual to the disturbing stimulus in ways that reduce rather than increase fear.

Counselors who use systematic desensitization generally begin counseling with one or two sessions focused on relaxation techniques, followed by the creation of an anxiety hierarchy. The least frightening presentation of the feared object (a picture of a spider, for example) is shown as clients engage in relaxation techniques. As clients become more comfortable with the spider picture, they might be shown a picture of multiple spiders, gradually moving up the hierarchy to watching a video of spiders, watching a spider in a terrarium, and eventually handling a spider. Systematic desensitization can be conducted in the imagination (imaginal), in vivo (in real life contexts), or as a combination of both. 

    Another type of exposure, interoceptive exposure, is a structured approach that encourages people to experience feared bodily sensations (such as shortness of breath or heart flutters) in the safe environment of a therapy session without engaging in avoidance or escape strategies. Counseling continues until adaptation occurs and the feelings are no longer frightening. An example of interoceptive exposure is spinning in a chair to achieve dizziness. Interoceptive exposure is used most frequently in the treatment of panic disorder (Forsyth, Fuse, & Acheson, 2009). 

    Other elements that add to the effectiveness of exposure-based therapies include behavioral strategies such as relaxation training, deep-breathing instruction, paradoxical intention, rehearsal, hypnosis, role playing, and modeling. Many different types of exposure-based therapies are available, and they can be individualized for each client’s needs. Box 5.1, Prolonged Exposure Therapy, discusses an exposure-based behavioral treatment approach. 

     

      

      Box 5.1 Prolonged Exposure Therapy: An Application of Behavior Therapy Exposure Techniques 

      

     Building on the exposure therapy techniques historically used to treat anxiety disorders, prolonged exposure therapy (PET) was specifically designed to treat PTSD (Foa & Yadin, 2011). The purpose of PET is to help clients recall trauma and associated fears, develop new information about the trauma and their responses, and learn new ways of reframing and coping with pathological fear associated with the trauma. Among people who have experienced recent traumatic events, exposure therapy has contributed to decreased PTSD symptoms, when compared to cognitive interventions. In fact, exposure therapy is recommended as an early intervention for people who experience a traumatic event and who are thus at high risk of developing subsequent PTSD (Bryant et al., 2008). Furthermore, exposure therapy has been well studied and empirically supported as a treatment for PTSD and has emerged as the most effective approach for addressing trauma (Foa et al., 2009; Foa & Yadin, 2011). 

     PET is typically offered over 8 to 15 sessions, each session lasting between 60 and 90 minutes. Different formats may be used, such as meeting once or twice per week, using guided imagery, incorporating in vivo exposure, or using recordings. The most effective method is combining imaginal exposure of the trauma memory with in vivo exposure to people, places, and situations associated with the trauma that do not pose a realistic risk of harm (Foa et al., 2009).

     Regardless of variations in how this approach is conducted, the critical aspect is facilitating client exposure to the part of a specific traumatic event that elicits the greatest fear in order to gradually reduce the fear and anxiety. Using visual imagery, virtual reality, or a combination, clients emotionally engage with the recollection. In doing so, they confront the feared event, identify and acknowledge their fears, and learn that expected disasters do not occur when they encounter the feared stimuli. 

     Revisiting trauma as part of therapy helps clients organize their memories of the traumatic event(s); re-evaluate negative cognitions about their involvement with the trauma; develop new perceptions about themselves and others; differentiate between recalling the trauma and re-experiencing the trauma; develop skills that will allow them to recall the trauma without experiencing undue anxiety; and understand that memories of the trauma will not harm them (Foa & Yadin, 2011).

Relaxation Techniques 

     

    Relaxation is often combined with other techniques such as systematic desensitization, abdominal breathing, hypnosis, and visual imagery. Teaching relaxation strategies in a counseling session and encouraging practice between sessions can facilitate people’s efforts to reduce stress and anxiety and make behavioral changes. Several well-established relaxation strategies are available, including progressive muscle relaxation (sequentially tensing and relaxing each muscle group in the body); a body scan (each part of the body is systematically assessed and relaxed); and simple exercises such as head rolls, shoulder shrugs, and shaking one’s body until it feels loose and relaxed. 

     

      Progressive Muscle Relaxation 

      

     Anxiety or other stress-related presenting concerns involve a wide variety of physical symptoms, including muscle tension, heart palpitations, dizziness, fatigue, or sleep disturbance. Progressive muscle relaxation (Jacobson, 1938; Lopata, 2003) is one intervention behavior therapists use to assist clients with calming their bodies and relaxing when they are feeling anxious or worried. Clients are encouraged to breathe deeply as they find a comfortable seated or lying position with their eyes closed. Therapists systematically guide clients to tense the muscles of a certain body area for approximately 5 seconds, release or let go of the muscle tension, and notice the state of relaxation that ensues. A progression through the major muscle area of the body from head to toe is typically done. The most critical component of progressive muscle relaxation involves clients’ discrimination between sensations of tension and relaxation. Clients begin to recognize how their bodies respond to anxiety, and with continued practice, they learn to relax their muscles on cue when presented with an anxiety-provoking stimulus. However, as with all conditioning interventions, repetition is imperative to yield the desired effect. Later in this chapter, the Skill Development section provides an example of how progressive muscle relaxation can be applied. 

     

      Breathing Techniques 

      

     Breathing techniques are typically used to help manage stress, anxiety, sleep problems, and anger. One type of breathing technique is diaphragmatic breathing, which involves taking slow, deep breaths and focusing on the breath. People breathe in through the nose, expand the diaphragm, and then expel the air through the mouth. This sort of breathing supplies the body with more oxygen, focuses concentration, and has been associated with increased self-control 172and mindfulness. Breath focus can also be used, which involves picturing a calming image in the mind and repeating a word or phrase. It is especially helpful to imagine breathing in peace and calmness and breathing out stress and anxiety. People can also breathe in and breathe out for equal periods of time and eventually increase the length of breathing in and out. 

    

      Biofeedback 

      

     Biofeedback involves the use of instruments that monitor bodily functions such as heart rate, sweat gland activity, skin temperature, and pulse rate and give people feedback on those functions via a tone or light. Biofeedback can promote reductions in tension and anxiety and increased relaxation. It also can have physical and medical benefits, such as lowering blood pressure and improving pain control. It has been used to treat brain injuries, sleep disorders, attention-deficit hyperactivity disorder (ADHD), and depression (Myers & Young, 2012). Neurofeedback, a subset of biofeedback, allows people to monitor and regulate brain wave patterns and change behavior as a result.

Skills Training 

    

   An important component of promoting positive change is teaching people the skills they need to effect that change. Skills training can be used in individual counseling or in group counseling. For example, social skills training can work well in a group setting. Therapists can teach clients both general skills (e.g., assertiveness training, decision making, problem solving, communication skills) and those serving the needs of particular individuals (e.g., interviewing, anger management, work-related skills). Assertiveness training is often used to teach clients to empower themselves and effectively express positive and negative feelings to others. Parents often benefit from learning these skills to use behavior change strategies with their children. Bibliotherapy, or relevant readings, can supplement therapists’ efforts to teach new skills. Many books are available, for example, on assertiveness, time management, parenting, and other positive behaviors. 

   Modeling is a type of observational learning in which people are influenced by observing the behaviors of another. Modeling can figure importantly in skills training and development, and it is an adjunct to approaches such as assertiveness training; relationship training; social skills for children, adolescents, or adults; or any other situations in which people would like to develop certain behaviors. People are most likely influenced by models who are similar to them in terms of gender, age, race, and beliefs; perceived as attractive and admirable in realistic ways; and viewed as competent and warm (Bandura, 1969). Modeling can occur in different ways: 

    

    Therapists can serve as models, demonstrating target behaviors, including social skills training or negotiation skills. 

    Clients can observe others engaged in behaviors or activities they would like to emulate, such as public speaking, conversing at social gatherings, or offering suggestions at a meeting with their clients. 

    Covert or imaginal modeling involves the therapist describing a situation for the client to visualize. An example of covert modeling would be asking a 14-year-old boy to imagine saying “no” to a friend who was trying to get him to drink a beer. 

    Symbolic modeling via movies or books is a common approach to teaching children and young adults appropriate behavior. 

    Self-modeling is also an option. Clients can serve as their own models by making audio or video recordings of themselves engaged in positive and desired behaviors (Bandura, 1969). 

    

   Related to modeling, behavioral rehearsal, or practicing a behavior clients wish to develop, gives them an opportunity to practice new behaviors they have perhaps witnessed or want to engage in. The rehearsal might involve a role play with the therapist or a practice session with a friend. 173Video-recording the rehearsal or observing themselves in the mirror while practicing the desired behavior offers opportunities for feedback and improvement. 

   Behavioral rehearsal can be used for a wide variety of experiences. Making or refusing requests to promote assertiveness and sharing positive and negative feelings with others lend themselves particularly well to behavioral rehearsal. Behavioral rehearsal also can help people improve their social skills—for example, by practicing ways to initiate and maintain conversations or invite other people to join them in social activities.

Application and Current Use of Behavior Therapy 

    

   Behavior therapies have a broad range of applications. Used either alone or in combination with other approaches, their principles and strategies can be applied in almost any setting and with almost any client or problem. Behavior therapy has more applications than could ever be addressed in this text. 

    

     

     Counseling Applications 

     

    Many empirical studies support the use of behavior therapy with populations and presenting issues. Behavior therapy is helpful in treating people who have autism spectrum disorder, depressive/bipolar disorders, anxiety and traumatic stress disorders, some personality disorders, eating disorders, and substance use disorders. 

    Behavior therapy is particularly effective with those who are struggling with depression. Behavior change strategies such as activity scheduling and systematic decision making can reduce the severity of depression, counteract the inertia and confusion often associated with depression, and promote feelings of mastery and competence (Kress & Paylo, 2019). 

    Exposure-based therapies have shown value in addressing a wide range of anxiety disorders, including specific phobias (e.g., animals, thunderstorms, public speaking, and flying), PTSD and trauma, and panic disorder. Behavior therapy can also be adapted for use with children to help them overcome a variety of fears (e.g., fear of the dark or other frightening situations; Kress, Paylo, & Stargell, 2019). 

    People who have a social phobia (i.e., a fear of social situations) often benefit from behavioral techniques such as training in social skills involving instruction in assertiveness and communication, modeling, roleplaying, and practice (Beidel et al., 2014). Substitution of positive activities for negative ones and distraction can help people cope with obsessive-compulsive disorder (Olatunji, Davis, Powers, & Smits, 2013). 

    Behavioral interventions, including contingency management , shaping, stimulus fading, and exposure, have shown effectiveness in addressing selective mutism (i.e., a childhood anxiety disorder in which a child does not speak; Busse & Downey, 2011; Hung et al., 2012; Zakszeski & DuPaul, 2017). Meta-analyses have reported that behavior therapy (i.e., habit reversal training) has demonstrated efficacy in treating trichotillomania (i.e., hair pulling; McGuire et al., 2014; Slikboer, Nedeljkovic, Bowe, & Moulding, 2015). 

    Behavior therapy has been used successfully when working with children and adolescents diagnosed with oppositional defiant disorder, conduct disorder, and ADHD (Miller et al., 2014). Relaxation, activity scheduling, and time management can be helpful when working with people who have ADHD. Behavior therapy has demonstrated effectiveness in helping people diagnosed with intellectual disabilities, impulse-control disorders, sexual dysfunctions, sleep disorders, paraphilias (i.e., sexual disorders), and aggressive behavior (Hofmann, 2012; Lanza et al., 2002). 

    The use of behavior therapy extends far beyond work with people who struggle with various mental disorders. Relaxation, hypnosis, and visual imagery have been used in behavioral medicine 174to reduce pain and help people cope with cancer, heart disease, and other chronic and life-threatening illnesses. Schools and correctional institutions, as well as day treatment and inpatient treatment programs, rely heavily on behavior therapy to teach and establish positive behaviors. 

    Family and group counseling can use behavior therapy, as well. Parents can benefit from learning behavior change strategies and using those to shape their children’s behavior. Such common parental interventions as time-out, rewards, consequences, and limit setting reflect behavior therapy. 

Application to Multicultural Groups 

     

    Behavior therapy has wide appeal and is easily integrated into counseling with people from a variety of backgrounds and situations. These approaches are easily understood and logical, respect individual differences, and offer a large repertoire of interventions to address almost any concern. Behavior therapy encourages people to play an active and informed role in their counseling process, promotes learning and competence, and can produce rapid and positive results that are reinforcing. 

    The focus on behaviors rather than feelings may fit well with certain cultures. Behavior therapy does not typically emphasize catharsis or expression of emotion. Of particular importance, a focus on behavior can make the counseling process more acceptable to people who are not used to sharing their emotions, including some men, many older people, and some people from Asian and other cultural backgrounds who may view expression of emotions to a stranger as inappropriate, weak, or in conflict with their upbringing and self-images (Sue, Sue, Neville, & Smith, 2019). The specificity, objectivity, present-focus, and problem-solving components are possible strengths of behavior therapy for certain cultures. Clients who are seeking action and specific plans will likely benefit from this approach. 

    Therapy that is active, directive, and short term is compatible with many people’s cultural expectations regarding therapy (Sue et al., 2019). People who are highly motivated, fairly resilient, pragmatic, logical, and tough minded are most likely to enjoy this energetic and interactive approach and appreciate the directness of the behavior therapist. However, just as therapists vary in their comfort with the active and directive stance of behavior therapy, clients vary in their reactions to this approach. Of course, behavior therapists must use culturally competent skills and communication styles, and not make assumptions about what is in the individual’s best interest.

Evaluation of Behavior Therapy 

    

    

     

     Limitations 

     

    Behavior therapy, like many other therapies, has drawn several criticisms. For example, behavior therapy has been criticized for changing behavior but failing to change feelings. Behavior therapy may not spend enough time focusing on feelings or allowing clients to experience their feelings. In addition, some believe that to change behavior, emotions must be changed first. Another criticism is that behavior therapy does not help clients acquire insight. Some believe that insight and awareness about problems and how change is occurring are necessary components for change and growth. However, a change in behavior may lead to gaining insight. Therefore, instead of focusing on insight first, behavior therapy may initially concentrate on changing behavior, which will then help clients reach an understanding of their problems and how change occurred. It may be helpful to create open communication with clients regarding any insights they may have noticed after making the behavior change. A further criticism is that behavior therapy strategies are superficial and likely to worsen or shift symptoms from one problem area to another (symptom substitution). Therefore, symptoms may change, but underlying causes stay the same, which prevents true change from occurring. Finally, some therapists believe that the role of the behavior therapist is controlling and has too much social influence. However, behavior therapists aim to include clients in the counseling process, 175to be explicit about the roles of both therapists and clients, and to take more of a psychoeducational approach. That said, the following three criticisms of behavior therapy are the most common: 

     

     The possibility exists that therapy will accomplish only superficial and temporary gains. 

     Emotions and insight may not receive the attention they merit. 

     Therapists may focus too quickly on behaviors, without sufficiently exploring their underlying antecedents and dynamics. For example, a therapist may emphasize development of social skills in a woman who is fearful of dating and neglect her history of abuse. 

Strengths and Contributions 

     

    Most of us use behavior change strategies in our everyday lives. When we reward ourselves with a snack after finishing a difficult chore, give a chronically late friend a message by deciding not to wait more than 15 minutes, or embark on a plan to improve our diet and exercise, we are using behavior change strategies. These approaches have been around for decades, and have a great deal to offer. They are also easily integrated with a broad range of other approaches, including psychodynamic therapy, Gestalt therapy, and person-centered counseling. Such combinations can deepen the impact of counseling and ensure that resulting changes are meaningful and enduring. 

    Behavior therapy has made important contributions to counseling and psychotherapy. It has emphasized the importance of research on counseling effectiveness. The emphasis on goal setting, accountability, and outcome is very much in keeping with the requirements of managed care for treatment plans and progress reports, as well as clients’ demands for efficient and effective counseling. Behavior therapy has also provided a foundation for the development of numerous other approaches—for example, reality therapy and multimodal therapy. 

    Behavior therapy is specific and concrete, which helps clients move from unclear goals toward plans and action. Behavior therapy emphasizes doing rather than insight gathering, so clients and therapists collaborate on a plan to enhance change. While behavior therapists instruct clients on how to change behavior, clients choose what behaviors they want to change, which follows the ethical principle of autonomy. A wide variety of behavioral strategies are also available, which helps therapists choose the strategies most beneficial for their clients. 

    Today, therapists practicing behavior therapy recognize that problems must be viewed in context. Therapists explore the historical roots and antecedents of people’s concerns, are sensitive to individual differences, develop positive and collaborative therapeutic alliances, and seek to know and understand their clients as individuals. Therapists help to empower clients so that they not only can deal with immediate presenting concerns but also can develop skills and strategies to use in the future for healthier and more rewarding lives. 

    The positive outcomes of behavior therapy tend to be enduring. Rather than leading to symptom substitution, these approaches often lead to a generalization of positive change in which people spontaneously apply the skills they have learned to many areas of concern.

Skill Development: Progressive Muscle Relaxation 

    

   As previously discussed, progressive muscle relaxation is a technique that can be used with almost all clients. What follows is a relaxation script for teaching children how to use progressive muscle relaxation as a way to relax and manage anxiety. 

   “Today we are going to do an exercise to help you see how good it feels to be relaxed, and to teach you how you can help your body become more relaxed. We are going to focus on different parts of the body, and when I tell you, you are going to tense that body part as much as you can. If you feel like you’re ready and comfortable, please close your eyes and listen to the sound of my voice. We will start at the top, so let’s start with your face. Pretend you just ate something really sour—like a piece of lemon. Scrunch your eyes and lips as much as you can because that lemon was SOUR! Now relax your lips and eyes. Relax your lips so much that your mouth may even open a bit. 

   Now scrunch your nose and your forehead. See how tense you can make them. Picture your eyebrows getting so high that they almost touch your hair. Now relax the muscles in your forehead, letting your muscles slide back into place. Doesn’t it feel good to relax your face? 

   Next we will move to relaxing the lower part of your face. Pretend you have a big jawbreaker candy in your mouth and the jawbreaker has a piece of bubble gum in its center. You really want to get to that bubble gum, but you are going to have to bite down hard to break it open. Now gently bite down and try to crack the jawbreaker open. It is really tough! Take a break and let your muscles relax. Give me one more good bite and the jawbreaker will break. Ready? Go! Fantastic! You did it! Now relax your neck and jaw muscles, letting your chin roll down to your chest. Maybe even let your mouth hang open a little bit. It sure feels good to relax after biting down so hard, doesn’t it? 

   Next, bring your attention to your neck and shoulders. You already used your neck muscles a little bit to break the jawbreaker, and we are going to use them again. Tense your back and shoulders up so much that your shoulders are close to your ears. Maybe try to make your shoulders like earrings. Squeeze your muscles and make them as tight as you can. See if you can get your shoulders just a little bit higher. Tuck your chin to your chest and keep pushing your shoulders higher. Now let go. Pay attention to how good it feels to let your muscles relax and go back to their natural places. Doesn’t it feel much better to relax? 

   Let’s move to your belly. Pretend you are trying to suck your belly button in so hard that it is going to touch your back. Good. Now hold it in even tighter, like you are going to squeeze sideways through a tiny door. Make yourself as tiny as you can be. Now let your muscles relax, and take a deep breath to fill up your tummy. That feels good, doesn’t it? 

   Bring your attention to your legs and feet. Stand up, and pretend you are on a sandy beach and you are pushing your feet into wet sand. Spread your toes down into the sand as the waves from the ocean are rolling by your waist. The waves are big and you need to really make your legs strong and spread your toes into the sand so you don’t get swept onto shore. You have to stand really strong. Flex your leg muscles as strongly as you can, a really big wave is coming! You don’t want to get washed ashore! Good job. Now relax your muscles again. 

   Think of how good it feels to relax your muscles after they have been tightened up. It feels much better to relax than to be tense, doesn’t it? You can practice this exercise anytime to help you relax. Maybe you would like to practice this at bedtime to help you to relax before sleep. You can do these exercises anywhere, anytime you feel stressed or your muscles feel tense. You did a great job today! Keep practicing, and you will be an expert relaxer!” 

   This script can be modified to fit the client’s developmental level. For example, when working with an adolescent or an adult the counselor might be more literal and talk about scrunching the mouth instead of suggesting the client imagine tasting a sour lemon. 

    

Case Application 

Roberto has recently been isolating after having arguments with Edie. This is disrupting his connections with Ava, Edie, and his friends. His isolating behavior is leading to feelings of depression, as well. Using functional behavior assessment, the therapist works with Roberto to identify causes of isolating, consequences of isolating, and the function the behavior serves. 

T herapist: 

Roberto, how have things been going for you lately? 

R oberto: 

Well, Edie and I are still arguing pretty frequently. She thinks I don’t spend enough time with her or Ava. 

T herapist: 

So it sounds like there have been some misunderstandings lately. Walk me through what normally happens while you and Edie argue. 

R oberto: 

We both tend to hold things in until we explode. She seems to get mad at me all of a sudden and it makes me get defensive. 

T herapist: 

Okay. How do you normally respond to Edie? 

R oberto: 

I get upset that she thinks I don’t spend enough time with her or Ava. I normally try to end the argument as soon as possible. I start ignoring her. 

T herapist: 

So what do you normally do after you argue? 

R oberto: 

  I isolate myself. I don’t want to talk to anyone. Edie, Ava, my friends, no one. 

     T herapist: 

You tend to withdraw from people after arguments with Edie. What else is going through your mind before you withdraw? 

R oberto: 

I’m stressed with work. I can’t seem to get a break. 

T herapist: 

So work is another stressor that may lead to some isolation. When you isolate, what is that experience like for you? 

My anxiety decreases. I get time to myself. I don’t really have to worry about anything. It’s my escape. 

T herapist: 

I’m noticing that after arguments you isolate yourself, which makes you worry less. How else does isolating affect you? 

R oberto: 

Well sometimes I feel sad if I isolate too long. Edie gets even more mad at me because I spend less time with her and Ava. My social life gets worse and my friends stop inviting me to things because I always say no. 

T herapist: 

So on one hand, isolating initially helps you feel better in the moment. On the other hand, it is also causing some problems in your relationship and your social life. It also seems to be contributing to feelings of depression. 

R oberto: 

I’d say so, yeah. 

T herapist: 

Is there anything other than isolating that makes you feel better? 

R oberto: 

I like reading and going for walks. Those things tend to calm me down a bit, too. 

       

T herapist: 

Okay, great. So it sounds like doing things you enjoy also seems to help. Anything else? 

R oberto: 

I don’t know. I typically choose isolating over anything. I’m just not sure how to stop. 

T herapist: 

How often would you say you isolate after arguments? 

R oberto: 

Almost every time. But it never actually makes me feel better. In the moment it helps but it makes things worse overall. 

T herapist: 

I’m sensing a desire to change the isolating behavior. Maybe we can start with implementing some coping skills like the relaxation techniques we’ve talked about. 

R oberto: 

Yes. That is a good idea. 

This case analysis shows that the problem behavior is isolating. The common antecedents (causes) of isolating are arguments with Edie and stress related to work. The function the behavior serves is an immediate reduction of anxiety; however, increased depression and increased fights occur due to isolating, which are the consequences.

Reflect and Respond 

Identify a fear or source of apprehension in your life. Develop a plan to use exposure therapy to help yourself reduce this fear. Write down the plan in your journal and then try to implement it. 

Consider a behavior that you would like to increase, decrease, or change. Develop a written plan to help yourself make that change. The plan should include, but not necessarily be limited to, determining how to establish a baseline, setting specific goals, identifying counseling strategies, establishing rewards or reinforcements, and specifying ways to track progress. Continue your learning by actually implementing the plan you have developed. Write in your journal about the successes and challenges you experience as you try to implement this plan.

Summary 

Behavior therapy evolved during the 20th century from the research of B. F. Skinner, Ivan Pavlov, John W. Watson, Joseph Wolpe, Albert Bandura, and others. This counseling approach takes the stance that behavior is learned and consequently can be unlearned. Behavior therapists are concerned about results; so they take the time to establish a baseline, develop interventions that facilitate behavioral change, use reinforcements to solidify gains, carefully plan implementation, and monitor progress. 

   Behavior therapy uses the key principles of classical conditioning, operant conditioning, and social learning theory. Classical conditioning is a type of learning that involves a stimulus-response pairing process. Behavioral interventions such as systematic desensitization and progressive muscle relaxation developed from classical conditioning. Operant conditioning involves learning in which a behavior is either increased through reinforcement or decreased through punishment. The goal is for desirable behavior to increase and undesirable behavior to decrease or stop entirely. Operant conditioning techniques include token economies and shaping. Social learning theory involves learning through observing and modeling others. 

   Behavior therapy is present focused, active, and educational. The main goal of behavior therapy is to extinguish maladaptive behaviors and help people learn new adaptive ones. Goals specific to each client are also important to consider. Behavior therapists are directive and serve as consultants, teachers, and problem solvers. Behavior therapists implement a wide variety of techniques such as exposure, exposure and response prevention, and habit reversal training. 

   Behavior therapy is applicable to a wide variety of populations with a wide variety of presenting concerns. People with mood disorders and anxiety disorders may particularly benefit from behavior therapy. People with OCD, conduct disorders, and issues with substance use may also benefit. Certain diverse groups may particularly enjoy behavior therapy due to its focus on the present, its objectivity, and its concentration on behavior rather than emotions. Behavior therapy has many strengths and contributions as well, such as the development of behavioral parent training. 

Recommended Readings 

    

    Martin, G., & Pear, J. (2007). Behavior modification: What it is and how to do it (8th ed.). Upper Saddle River, NJ: Pearson/Prentice Hall. 

    Spiegler, M. D., & Guevremont, D. C. (2010). Contemporary behavior therapy (5th ed.). Belmont, CA: Wadsworth.

     Numerous journals focus on CBT and behavior therapy, including Behavior Therapy, Cognitive and Behavioral Practice, Advances in Behaviour Research and Therapy, Child and Family Behavior Therapy, Cognitive Therapy and Research, and Journal of Behavior Therapy and Experimental Psychiatry.