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Tan, S-Y (2022). Counseling and Psychotherapy: A Christian Perspective (2nd ed.). Baker Academic: GrandRapids, MI. ISBN: 9781540962904.
Chapters 11
Behavior Therapy
Behavior therapy first appeared as a systematic approach to counseling and psychotherapy in the treatment of psychological disorders in the late 1950s and 1960s. It was initially defined as “the application of modern learning theory to the treatment of clinical problems” (Wilson 2008, 223), with an emphasis on classical and operant conditioning. However, behavior therapy has developed in significant ways over the past several decades, with greater sophistication and complexity. Contemporary behavior therapy applies principles of learning as well as experimental findings from scientific psychology to the treatment of specific behavioral disorders. It is an empirically based approach to therapy that in theory is broadly oriented to social learning. By the 1970s, behavior therapy had become a major approach to counseling and therapy (Spiegler 2016, 26).
Behavior therapy does not have a single founder. Instead, it has several key figures, including Joseph Wolpe, Hans Eysenck, B. F. Skinner, Arnold Lazarus, Albert Bandura, and Donald Meichenbaum (see Corey 2021, 232–233; Day 2004, 244–245; Fishman & Franks 1992, 161–169; Glass & Arnkoff 1992, 587–599; Parrott 2003, 267–269; Prochaska & Norcross 2018, 200–201, 470–471; Sharf 2016, 290–293; Wilson 2008, 230–232). Behavior therapy can be characterized as consisting of three major thrusts, the three Cs, according to James Prochaska and John Norcross (2018): (1) counterconditioning (Wolpe), (2) contingency management (Skinner), and (3) cognitive behavior modification (Meichenbaum). Behavior therapists view human beings as products of their environments and unique learning histories. Human nature is therefore seen as neither positive nor negative.
The behavior therapist plays an active and directive role in therapy, often acting as coach or teacher. Some examples of well-known behavior therapy techniques or interventions include positive reinforcement (reward for desirable behavior), assertiveness training (role-playing with clients to help them learn how to express their thoughts and feelings more freely and appropriately), systematic desensitization (pairing of a neutral or pleasant stimulus with one that has been conditioned to elicit fear or anxiety), and flooding (exposing the client to stimuli that elicit maximal anxiety for the purpose of eventually extinguishing the anxiety) (see Parrott 2003).
Biographical Sketches of Key Figures in Behavior Therapy
Joseph Wolpe (1915–1997) was born in Johannesburg, South Africa, on April 20, 1915. Although he had a religious Jewish upbringing, Wolpe also read philosophers such as Immanuel Kant, David Hume, and the atheist Bertrand Russell; he eventually ended up embracing physical monism instead of his earlier Jewish faith. He grew up in South Africa and earned his medical degree from the University of Witwatersrand in Johannesburg.
Wolpe had some psychoanalytic influence earlier in his training in psychiatry but eventually gravitated to the conditioning theories of Ivan Pavlov and his work on classical conditioning (or respondent conditioning) in Russia, and especially to the theoretical work of Clark Hull on conditioning as explicated in his book Principles of Behavior (1943).
Wolpe did his MD thesis research on animal neuroses and discovered counterconditioning processes and procedures when he found that the eating response in cats could be used to inhibit, to countercondition, a classical conditioned anxiety response to a buzzer that was initially paired with electric shock. In 1958 he wrote a groundbreaking book, Psychotherapy by Reciprocal Inhibition, in which he described a learning-based approach to therapy based on counterconditioning. More specifically, he used deep relaxation to countercondition anxiety and hence developed systematic desensitization as a unique behavioral intervention for treating phobias and anxiety problems. He also used assertive responses to inhibit social anxiety, leading to the development of assertiveness training. Wolpe reviewed more than two hundred cases of patients with different behavioral problems that had been treated through his counterconditioning procedures with about 90 percent success rates (see Prochaska & Norcross 2018, 200–201). He influenced a group of students and colleagues who often met with him at the University of Witwatersrand. Arnold Lazarus and Stanley Rachman participated in this group, and they eventually helped bring Wolpe’s systematic desensitization to the United States and Great Britain. Wolpe himself moved to the United States in 1963 (Glass & Arnkoff 1992).
Wolpe taught at the University of Virginia and Temple University Medical School in Philadelphia, where he was a professor of psychiatry from 1965 until his retirement in 1988. He then went to Pepperdine University in California, where he spent nine more years as a distinguished professor of psychiatry, until his death on December 4, 1997, due to lung cancer. Wolpe also directed the behavior therapy unit at the Eastern Pennsylvania Psychiatric Institute when he was teaching at Temple University.
Wolpe was a leading figure in behavior therapy and wrote a well-known text, The Practice of Behavior Therapy (1990), that went through four editions. He also helped found the Association for Advancement of Behavior Therapy (AABT), now called the Association for Behavioral and Cognitive Therapies (ABCT), as well as the Journal of Behavior Therapy and Experimental Psychiatry. He coauthored one of the first books on techniques of behavior therapy with Arnold Lazarus, Behavior Therapy Techniques (1966). Wolpe was always an advocate for a purer and less diluted version of behavior therapy that preserved its foundations in learning theory (Wolpe 1989). He therefore did not support expanding the boundaries of behavior therapy to make it more cognitive-behavioral, eclectic, or multimodal as Arnold Lazarus and others have done (see Glass & Arnkoff 1992, 608).
Hans Jürgen Eysenck (1916–1997) was born in Berlin, Germany, on March 4, 1916, but moved to England in the 1930s because of the Nazi movement in Germany. He obtained his PhD in psychology from the Department of Psychology at University College London, with Sir Cyril Burt as his mentor and dissertation supervisor. Eysenck taught at the Institute of Psychiatry, Maudsley Hospital, University of London, as professor of psychology from 1955 to 1983. He was one of England’s best-known psychologists, having made significant contributions to several areas of psychology, including personality and individual differences, intelligence and the role of genetics in IQ differences, and behavior therapy.
Eysenck was a strong advocate for a scientific psychology. In 1952 he published a scathing critique of psychotherapy as practiced in the 1950s with mainly psychoanalytic and client-centered approaches. Based on the studies he had reviewed, he asserted that there was no empirical support for the effectiveness of psychotherapy for patients with neurotic disorders. He drew the shocking conclusion that psychotherapy was not more effective than spontaneous remission rates found in no-treatment control patients (i.e., that around two-thirds of neurotic patients will recover or significantly improve over a two-year period without therapy). More-recent research has contradicted Eysenck’s earlier sweeping conclusions (Eysenck 1952); this research indicates that spontaneous remission rates are actually closer to 43 percent and finds psychotherapy to be effective (Bergin & Lambert 1978). However, his 1952 critique of traditional psychotherapy as being ineffective prepared the field of counseling and psychotherapy to be more open to behavior therapy as a systematic approach for treating psychological disorders.
Eysenck played a quite significant role in helping to establish behavior therapy worldwide. He met weekly with colleagues and students at his home to further discuss and develop this new approach to therapy, based on the learning theories and conditioning views of Hull and Pavlov, which he eventually labeled behavior therapy. He defined it as the application of modern learning theory to the understanding and treatment of behavioral or behaviorally related disorders (Eysenck 1959). Arnold Lazarus (1958) in South Africa also used this term, “behavior therapy,” to describe Wolpe’s approach to treating neurotic patients with reciprocal inhibition techniques. Interestingly enough, B. F. Skinner, H. C. Solomon, and O. R. Lindsley (1953) in the United States initially used the term “behavior therapy” in an unpublished status report, referring to their use of operant conditioning techniques to increase social interactions among psychotic inpatients (see Fishman & Franks 1992, 172).
In the 1960s, Eysenck also published two significant books that helped advance behavior therapy and its practice: Behavior Therapy and the Neuroses (1960), and, with Rachman, The Causes and Cures of Neurosis (1965). In 1963 he also launched the first journal devoted solely to behavior therapy, Behaviour Research and Therapy, and it is still being published today. Eysenck himself did not treat patients, but he was instrumental in supporting the development of behavior therapy techniques at the Maudsley Hospital in the late 1950s and 1960s, when other well-known behavior therapists such as Cyril Franks and Rachman were there. Eysenck was given much support and encouragement by M. B. Shapiro, the head of the clinical section at the Maudsley Hospital, who therefore also played a significant role in the birthing of the behavior therapy movement in England (see Glass & Arnkoff 1992, 594).
Eysenck died on September 4, 1997, in London, England, having achieved the special status around the time of his death of being the most frequently cited living psychologist in scientific journals (Haggbloom et al. 2002). Further details on Eysenck’s life and the development of behavior therapy can be found in his autobiography, Rebel with a Cause (1990).
B. F. Skinner (1904–1990), whose full name was Burrhus Frederick Skinner, has been listed as the most influential psychologist of the twentieth century (Haggbloom et al. 2002). He was born in Susquehanna, Pennsylvania, in 1904. He had a younger brother, Edward, who died when Skinner was visiting home from college in 1923. After Edward’s death, Skinner, who was then known as Fred, drew closer to his parents and became more actively involved with the family. He graduated from Hamilton College in Clinton, New York, in 1926 with a BA in English literature.
Skinner had aspired to be a writer, but after pursuing a writing career for a year, he abandoned the notion (see Day 2004, 244–245). He had always been a bright student, with a special interest in building things, such as gadgets and machines. Eventually he made several significant inventions in experimental psychology that helped researchers to monitor and record behaviors in an unobtrusive way. Skinner earned a PhD in psychology from Harvard University in 1931, after which he continued his work in laboratory research until 1936, when he left Harvard for a time to teach and do research at other universities. In 1936, he wed Yvonne Blue, and they had two daughters, one of whom became an artist and the other an educational psychologist (Corey 2021, 232).
Skinner was a radical behaviorist and did not believe in human free will. He is often viewed as the father of behavioral psychology. Skinner believed that behavior is determined by environmental events, and especially that behavior is governed by its consequences. Rewards, or positive consequences, reinforce or maintain specific behaviors, whereas punishment, or aversive consequences, decrease or eliminate specific behaviors. Skinner therefore developed operant conditioning techniques, the use of reinforcement contingencies to modify behavior; hence the term “behavior modification” is often used for his approach. The label “behavior therapy” was initially used by Skinner and his colleagues in an unpublished status report at the Metropolitan State Hospital in Waltham, Massachusetts (Skinner, Solomon, & Lindsley 1953). Skinner, like Wolpe, did not favor introducing more cognitive concepts and techniques into the field of behavior therapy because he felt that they are unnecessary and would weaken the behavioral approach (Skinner 1990).
Skinner did most of his work in experimental studies in the laboratory, focusing on the behaviors of pigeons and rats, but he ultimately applied his principles and procedures to human beings as well, especially in areas such as education, behavior modification as a therapeutic approach for the treatment of psychological disorders, and social planning. He wrote several important books, including Walden Two (1948), about a utopian community; Science and Human Behavior (1953), about the application of behavioral principles to all areas of human behavior; and Beyond Freedom and Dignity (1971), about the need for drastic changes in using science and technology for the survival of our society (Corey 2021, 232). Skinner kept up his active schedule as a lecturer and writer until his death in 1990 from leukemia, at the age of eighty-six.
Arnold Allan Lazarus (1932–2013) was born in 1932 in South Africa, where he grew up and received his education (see Prochaska & Norcross 2018, 401). He obtained his PhD in 1960 from the University of Witwatersrand in Johannesburg. His mentor was Joseph Wolpe, one of the pioneers of behavior therapy. Lazarus wrote his dissertation on the effectiveness of group systematic desensitization in the treatment of phobic conditions.
Lazarus received his early training in behavior therapy and initially conducted his clinical practice through using mainly behavioral interventions. He is credited with being one of the first authors to use the term “behavior therapy” in a published article (A. A. Lazarus 1958), and he coauthored an early text on behavior therapy techniques with Wolpe (Wolpe & Lazarus 1966). However, Lazarus found that the behavioral interventions he used with his clients often produced significant therapeutic outcomes that did not last at follow-up. Although he is often considered a pioneer in behavior therapy, he was also one of the first to advocate broad-spectrum behavior therapy that incorporated cognitive interventions rather than narrow-band purist behavior therapy (A. A. Lazarus 1966, 1971).
Lazarus eventually became dissatisfied even with broad-spectrum behavior therapy and went on to develop a more distinctive approach to therapy that he called multimodal behavior therapy; in this, he added to behavior and cognition several other domains such as imagery, affect, sensation, interpersonal, and biological: the BASIC ID (see later in this chapter; A. A. Lazarus 1973, 1976). He refined his approach even more, advocating technical eclecticism but not theoretical eclecticism, finally calling his new approach to therapy multimodal therapy (A. A. Lazarus 1981, 1985, 1989, 1997, 2008). Lazarus added new therapeutic techniques to the repertoire of multimodal therapy interventions, while emphasizing the need to match the therapist’s approach and techniques to the specific needs of the individual client.
Lazarus taught at Stanford, Temple, and Yale universities, but he eventually settled at the Graduate School of Applied and Professional Psychology at Rutgers University in Piscataway, New Jersey. He was a distinguished professor emeritus but continued to present workshops and training seminars on multimodal therapy. Also, he directed the Lazarus Institute in Princeton, New Jersey. He died in 2013. Lazarus was highly regarded and often cited as one of the most influential psychotherapists, being a particularly significant voice for technical eclecticism (Prochaska & Norcross 2018, 401).
Albert Bandura (1925–2021) was born in 1925 in Mundare, Alberta, Canada, the youngest of six children from an Eastern European family background. He obtained his BA from the University of British Columbia in Vancouver, and then went to the University of Iowa for graduate school, where he earned a PhD in clinical psychology in 1952. After a year of clinical internship, he accepted a faculty position at Stanford University, where he remained.
Bandura made significant contributions to several areas of psychology, including authoring an early key text on behavior therapy and behavior modification, Principles of Behavior Modification (1969). He is well known for his research on observational learning (modeling) and his development of social learning theory (1977b), a social cognitive theory, which has had a tremendous influence on counseling and psychotherapy. He also published a groundbreaking article in 1977 on self-efficacy as a unifying theory of behavioral change (1977a). After this Bandura further developed his theory of self-efficacy (1986, 1997), which has been the subject of numerous doctoral dissertations in diverse areas.
Perceived self-efficacy, a self-efficacy expectation, is the belief that one can successfully perform the behavior required to produce a specific outcome, and such perceived self-efficacy will determine one’s persistence and ultimate success in coping with threats (Bandura 1977a). Perceived self-efficacy can therefore be simply defined as one’s belief that one can succeed at a task (Spiegler 2016, 287). Bandura (1997) more recently described the wide-ranging applications of his self-efficacy theory to many areas, including psychology, psychiatry, education, health, medicine, human development, business, athletics, as well as international affairs and political and social change (see Corey 2021, 233). His self-efficacy theory of behavioral change greatly influenced the further development of behavior therapy into broader-spectrum cognitive-behavioral therapy. Bandura advocated a more open reciprocal determinism that allows for some degree of self-reflection and self-regulation, and some choice (1986, 1997).
Bandura served as president of the American Psychological Association in 1974 and received many honors, including the Outstanding Lifetime Contribution to Psychology Award from the American Psychological Association in 2004. In a survey conducted in 2002, he was found to be the fourth most frequently cited psychologist of all time (Haggbloom et al. 2002).
Donald Meichenbaum (1940–) was born in 1940 and raised in New York City. He completed his undergraduate studies at the City College of New York and obtained a PhD in clinical psychology from the University of Illinois, Urbana-Champaign. Shortly thereafter, in 1966, he joined the faculty at the University of Waterloo in Waterloo, Ontario, and continued his teaching and research there for thirty-three years, until he retired in 1998. He is now a distinguished professor emeritus at the University of Waterloo, and a distinguished visiting professor at the School of Education at the University of Miami in Florida. He is also the research director of the Melissa Institute for Violence Prevention and Treatment of Victims in Miami, Florida.
Meichenbaum has helped to further develop behavior therapy into a broader-based cognitive-behavioral approach by emphasizing the crucial role of self-instruction, self-talk, in the regulation of one’s emotions and behaviors. He conducted important research on self-instructional training as a cognitive-behavioral intervention to help people instruct themselves to cope better with different types of problems such as impulsive behavior in children and bizarre speech and thoughts in schizophrenic patients (see Spiegler 2016, 360–361). He also expanded self-instructional training into a more comprehensive intervention called stress inoculation training, to help clients cope more effectively with stressful situations and problems such as anxiety, anger, and pain (see Meichenbaum 1977, 1985, 2003, 2007). His book Cognitive-Behavior Modification, first published in 1977, has become a classic in the field of cognitive behavior therapy, and he is considered one of the founders of cognitive behavior therapy.
Meichenbaum has also done significant work in the areas of posttraumatic stress disorder (1994); anger-control problems and aggressive behaviors (2002); treatment adherence (Meichenbaum & Turk 1987); stress prevention and management (Meichenbaum & Jaremko 1982); suicide (2005); resilience (2012); and addictive disorders (2020). He also documented his own personal and professional journey in the evolution of cognitive behavior therapy (2017). He was one of the founders of the journal Cognitive Therapy and Research.
Meichenbaum has received many honors and awards, including the prestigious Izaak Killam Fellowship Award from the Canada Council. He is also a fellow of the Royal Society of Canada. Clinicians voted him to be one of the ten most influential therapists of the twentieth century; he was also found to be the most frequently cited psychology researcher at Canadian universities during his academic career. He has lectured and conducted workshops as well as consulted widely, both nationally and internationally. Meichenbaum continues to make contributions in the areas of education, violence prevention, trauma, suicide, resilience, and addictive behaviors.
In addition to Wolpe, Eysenck, Skinner, Lazarus, Bandura, and Meichenbaum, other important figures associated with the development of behavior therapy include Franks and Rachman, mentioned earlier, Hobart Mowrer, and Willie Mowrer. Early experimental work that provided the initial learning and conditioning foundations for behavior therapy was done by well-known researchers such as Ivan Pavlov, John B. Watson, Mary Cover Jones, and Edward Thorndike in the 1920s and 1930s (see Spiegler 2016, 16–25). A key figure who significantly contributed to the development of behavior therapy in Canada in the 1960s and later was Ernest G. Poser, a professor of psychology at McGill University and founder and director of the behavior therapy unit at the Douglas Hospital Centre in Montreal, one of the first clinical treatment and teaching facilities of its kind (see Poser 1977). He retired in Vancouver, British Columbia, where he died in 2012. He was my mentor at McGill University when I was a student for both my undergraduate (1973–1976) and graduate studies (PhD in clinical psychology, 1976–1980).
Major Theoretical Ideas of Behavior Therapy
Perspective on Human Nature
The history of the development of behavior therapy consists of three major generations or waves (Hayes et al. 2006). The first wave was traditional behavior therapy, which emerged in the late 1950s and developed further in the 1960s and early 1970s; it emphasized what Prochaska and Norcross (2018) have described as counterconditioning (Wolpe) and contingency management (Skinner) thrusts. So-called modern learning theories, especially classical conditioning following the work of Pavlov and operant conditioning based on Skinner’s work, dominated the field of behavior therapy in the first wave. Conditioning theories of learning viewed human beings as controlled by classical or operant conditioning; therefore, early behavior therapy tended to have a deterministic view of human nature, with little or no freedom to choose. Human nature was also seen as primarily neutral, neither positive nor negative.
The second wave of behavior therapy began in the late 1970s and involved the development of a broader-based cognitive behavior therapy that incorporated the thinking dimension of individuals, rather than only focusing narrowly on environmental factors. Cognitive behavior therapy, however, is more than forty years old (Hayes et al. 2006). It is the predominant approach today in behavior therapy but has expanded to include newer treatment approaches that incorporate mindfulness and acceptance (see Hayes, Follette, & Linehan 2004).
The third wave of behavior therapy that developed in the 1990s and the early twenty-first century involves relatively contextualistic approaches that are based to some extent on concepts such as mindfulness and acceptance (Hayes et al. 2006). The major approaches in this third wave of behavior therapy include dialectical behavior therapy (DBT) (Linehan 1993a, 1993b, 2015a, 2015b); mindfulness-based cognitive therapy (MBCT) (Segal, Williams, & Teasdale 2013); and acceptance and commitment therapy (ACT) (Hayes, Strosahl, & Wilson 2012).
Sidebar 11.1: Features of Development in Behavior Therapy
1. Classical conditioning
2. Operant conditioning
3. Social learning theory
4. Cognitive behavior therapy
The approaches to behavior therapy in its second and third waves have moved beyond the earlier mechanistic and radically behavioristic views of human nature espoused by traditional behaviorists such as Skinner. Contemporary behavior therapy and cognitive behavior therapy tend to view human beings as having some capacity for choice, self-reflection, and self-control (Kazdin 2013; D. Watson & Tharp 2014). Bandura’s social learning or social cognitive theory and especially his concepts of self-efficacy and reciprocal determinism (Bandura 1977a, 1977b, 1986, 1997) have resulted in a more complex view of human nature as having a greater capacity for self-regulation and choice and therefore some free will. Human beings are still seen as neutral, however, neither inherently good nor inherently evil.
Basic Theoretical Principles of Behavior Therapy
Contemporary behavior therapy can no longer be easily defined. Marvin Goldfried and Gerald Davison have broadly described behavior therapy as “reflecting a general orientation to clinical work that aligns itself philosophically with an experimental approach to the study of human behavior” (1994, 3). The four major features of development in behavior therapy are classical conditioning, operant conditioning, social learning theory, and cognitive behavior therapy (see Corey 2021, 234–236).
Classical conditioning, respondent conditioning, refers to the way behavior is controlled by its antecedents, what has happened before the behavior. For example, in his early experimental work, Pavlov found that putting food into a dog’s mouth will lead the dog to salivate. This salivation is called the “respondent behavior,” the unconditioned response (UCR) to the food, which is the unconditioned stimulus (UCS). However, if the UCS of food is then repeatedly paired with the sound of a bell as a conditioned stimulus (CS), presented just before the food, eventually the sound of the bell itself (CS), presented without the food (UCS), will elicit salivation as the conditioned response (CR) of the dog to the CS. However, if this process is done repeatedly, presenting the CS without the UCS, the CR of salivation will eventually decrease and be eliminated. In this way, through the process of classical (or respondent) conditioning, neutral stimuli, such as a sound, can elicit conditioned responses. Fear responses can be conditioned through classical conditioning processes. Wolpe’s systematic desensitization technique, a reciprocal inhibition approach to treating phobias and anxiety disorders, is based on classical conditioning and counterconditioning processes.
Operant conditioning involves learning processes in which one’s behavior is controlled by the consequences that follow the behavior. Skinner’s work helped to explicate the principles and schedules of operant conditioning. If a behavior is followed by pleasant or rewarding consequences (positive reinforcement) or the elimination of negative and aversive stimuli (negative reinforcement), then it is more likely to increase or be maintained. On the other hand, if a behavior is followed by aversive or negative consequences (punishment) or no reinforcement at all, then it is likely to decrease or be eliminated. Reinforcement contingencies, that is, the techniques of positive and negative reinforcement, punishment, and extinction, are powerful interventions used in behavior therapy for the modification of behavior, based on operant conditioning principles and processes.
Earlier views of classical and operant conditioning did not refer to more-cognitive processes that could mediate such conditioning. Bandura’s social learning theory, a social-cognitive approach, paid much more attention to symbolic processes such as observational learning or modeling, and his subsequent development of self-efficacy theory greatly influenced behavior therapy to move beyond simplistic notions of classical and operant conditioning. Behavior therapy today has incorporated mediational concepts such as an individual’s cognitions and perceptions, including self-efficacy expectations, which can significantly affect one’s emotions and behavior. The interpretation of environmental events, as opposed to only the tangible influence of environmental events, is therefore viewed as a crucial determinant of human behavior.
Contemporary behavior therapy has therefore developed predominantly into cognitive behavior therapy, influenced by social learning theory and self-efficacy. Cognitive behavior therapy has been simply defined as “a more purposeful attempt to preserve the demonstrated efficiencies of behavior modification within a less doctrinaire context, and to incorporate the cognitive activities of the client in the efforts to produce therapeutic change” (Kendall & Hollon 1979, 1). Contemporary behavior therapy has accepted the importance of an individual’s self-talk, attitudes, expectations, beliefs, and values—one’s cognitions or thoughts in influencing one’s feelings and behavior—and has incorporated techniques to modify maladaptive cognitions or thinking in bringing about behavioral change.
Development of Psychopathology
Behavior therapists often view maladaptive behavior, psychopathology, as attributable to an individual’s specific learning history. Such behavior is either detrimental or dangerous to oneself and/or to others (see Parrott 2003, 273). More specifically, early behavior therapists such as Wolpe (1990) defined psychopathology, neurosis, as consisting of maladaptive habits that have been acquired through conditioning. For example, fear and anxiety have been considered conditioned responses to certain stimuli and can thus be deconditioned or counterconditioned. Maladaptive habits that an individual has learned through past experiences can therefore be unlearned, and more adaptive habits or behaviors can then be relearned or learned anew.
Similarly, Skinner and the behavior modification practitioners who followed him viewed maladaptive behavior as attributable to operant conditioning processes. For example, a young boy’s temper tantrums may be due to the profuse attention his parents give him when he acts out, even if they are scolding him. They are reinforcing his negative behavior of whining, crying, and yelling by attending to him, thus strengthening such maladaptive behavior. Behavior therapists, following Skinner, will use operant conditioning procedures, that is, rearrange the reinforcement contingencies in deliberate, purposeful ways to decrease the temper tantrums by teaching the parents to ignore them and to provide social reinforcement, positive praise and attention, to the boy when he is behaving himself.
Contemporary behavior therapists, however, do not view psychopathology simply as learned maladaptive habits. They tend to be more cognitive-behavioral in orientation and consider maladaptive behavior and feelings as resulting from internal dialogues, the self-talk of the individual, focusing more on the person’s thoughts and images. Negative, irrational, extreme, unreasonable, and illogical thinking is often seen as underlying problematic feelings and behaviors. Such thinking must be identified, challenged, and modified with more rational, reasonable, and logical thinking that can then lead to better adaptive behavior and emotional experiencing. Self-criticism or self-contempt in one’s thinking can especially cause much emotional pain and problem behavior (see Bandura 1977b, 1986). Behavior therapists today pay more attention to how observational learning or modeling can contribute to maladaptive behavior, and to how such modeling can be used to promote more prosocial and appropriate behavior.
Therapeutic Process and Relationship
The behavior therapist is active and directive in conducting therapy with clients, functioning as a problem solver as well as a coping model for and with the client (Wilson 2008, 238; see also Antony 2019; Antony & Roemer 2011). Although the therapeutic relationship is important in behavior therapy, and the behavior therapist does show genuine concern and respect for the client, the therapeutic alliance itself is not sufficient for effective therapy to occur (see DeRubeis, Brotman, & Gibbons 2005). In accounting for the efficacy of behavior therapy, therapeutic interventions have been found to be more significant than the therapeutic alliance (Loeb et al. 2005). Nevertheless, a strong, positive therapeutic alliance—warm, empathic, genuine, and collaborative—is still essential for the effectiveness of behavior therapy (see, e.g., J. S. Beck 2005; A. T. Beck, Rush, et al. 1979; P. Gilbert & Leahy 2007), even in manual-based versions of behavior therapy (Wilson 2008, 238).
The process of behavior therapy is relatively more structured and systematic than many other approaches to therapy (see Miltenberger 2016; Spiegler 2016; Wilson 2008). It consists of several steps or stages. First, the behavior therapist conducts a functional assessment, behavioral analysis (Wolpe 1990), of the major complaints, the target behaviors, that the client wants to deal with and change. This involves a concrete definition of the client’s expressed problem behaviors and clarification of the antecedents as well as the consequences of the target behaviors. The therapist usually asks specific questions such as how, when, where, and what rather than why regarding the problem behavior being discussed. The behavior therapist may also use other methods of assessment (see Wilson 2008, 239–240), such as guided imagery (in which the client imagines a specific situation and shares the thoughts and feelings it may trigger); role-playing; physiological recording (e.g., heart rate); self-monitoring (which involves the client keeping careful daily records of specific behaviors such as frequency of handwashing); behavioral observation (in which the client observes their own behavior or others observe the client’s behavior and record it with rating scales); and sometimes psychological tests and questionnaires (e.g., the Beck Depression Inventory [see A. T. Beck, Rush, et al. 1979] as a self-report measure of depression).
Second, the behavior therapist obtains a developmental history of the client and the problem behaviors being presented, to further assess the client’s past learning or conditioning experiences as well as possible organic or biological bases for the problems (see Parrott 2003, 274).
Third, the behavior therapist helps the client set specific goals for therapy in a collaborative way. It is ethically important for the behavior therapist to empower the client to ultimately choose their own goals, with the therapist functioning as the expert or coach in helping the client achieve them. As G. T. Wilson has emphasized: “The client controls what; the therapist controls how” (2008, 238).
Fourth, and finally, the behavior therapist helps the client choose the most effective therapeutic interventions to best enable the client to change the identified problem behaviors and to achieve the goals the client has set. The behavior therapist then administers these therapeutic techniques to help the client in direct and systematic ways, while monitoring the client’s progress. The therapist is sensitive and flexible enough to use other techniques if the current interventions are not working effectively for the client.
Major Therapeutic Techniques and Interventions
Behavior therapy is a unique approach to therapy that focuses on solving problems and overcoming symptoms presented by the client. It therefore emphasizes the use of specific techniques that have received empirical support (see Antony 2019). Behavior therapy (see Emmelkamp 2013) and cognitive behavior therapy (see Hofmann, Asnaani, et al. 2012; Hollon & Beck 2013) are among the most empirically supported treatments for a wide range of psychological disorders (Chambless & Ollendick 2001; Nathan & Gorman 2015; Roth & Fonagy 2005; see also Fonagy et al. 2015; Weisz & Kazdin 2017).
The number of behavior therapy techniques has dramatically increased since the late 1950s and 1960s, when behavior therapy first emerged as a systematic therapeutic approach. Published in 1987, the Dictionary of Behavior Therapy Techniques (Bellack & Hersen) already listed and described over 150 behavior therapy techniques. Today, with broader-spectrum behavior therapy and cognitive behavior therapy as well as even more-comprehensive multimodal therapy as developed by Arnold Lazarus (1971, 1976, 1981, 1997), behavior therapy interventions have increased exponentially. It is thus impossible to describe most of them in this chapter. However, the major behavior therapy techniques will now be briefly described. They include behavioral assessment; operant conditioning techniques (e.g., positive reinforcement, negative reinforcement, extinction, and punishment); token economies; social skills training and assertiveness training; modeling; relaxation training; systematic desensitization; flooding and in vivo exposure; eye movement desensitization and reprocessing (EMDR); self-modification programs and self-directed behavior; multimodal therapy; and mindfulness and acceptance-based cognitive behavior therapy (see Corey 2021, 240–256; Parrott 2003, 277–286; also Miltenberger 2016; Spiegler 2016).
Sidebar 11.2: Behavior Therapy Techniques
(see Corey 2021, 240–256; Parrott 2003, 277–286)
1. Behavioral assessment
2. Operant conditioning techniques
3. Token economies
4. Social skills training and assertiveness training
5. Modeling
6. Relaxation training
7. Systematic desensitization
8. Flooding and in vivo exposure
9. Eye movement desensitization and reprocessing
10. Self-management programs and self-directed behavior
11. Multimodal therapy
12. Mindfulness and acceptance-based cognitive behavior therapy
Behavioral Assessment
The first stage of behavior therapy involves conducting a comprehensive behavioral assessment of the client, identifying the target problems and symptoms (e.g., anxiety, anger, or depression). This process has also been described as performing a functional assessment or behavioral analysis (Wolpe 1990); some details of functional or behavioral assessment have already been provided in the previous section of this chapter on the therapeutic process of behavior therapy.
Operant Conditioning Techniques
Operant conditioning techniques include positive reinforcement, negative reinforcement, extinction, positive punishment, and negative punishment (see Kazdin 2013; Miltenberger 2016).
Positive reinforcement involves the addition of something that rewards an individual following a target behavior that is to be strengthened or increased. For example, to increase the target behavior of writing, a person is reinforced with verbal praise from a close friend after completing several pages of writing. The positive reinforcement can be anything that the person finds rewarding, such as verbal praise, food, money, or attention.
Negative reinforcement involves the removal of unpleasant or aversive stimuli following the occurrence of a target behavior that is to be increased or strengthened. For example, a person’s writing can be negatively reinforced when, after writing a few pages, a close friend stops nagging that person about writing. The removal of the nagging, which is an aversive or unpleasant stimulus, negatively reinforces the person’s writing so that the writing behavior is strengthened. Both positive and negative reinforcement are meant to increase or strengthen the target behavior that is seen as desirable.
Extinction refers to removing reinforcement from a target behavior or response that has been previously reinforced. For example, a child’s temper tantrums that have been previously reinforced by the attention his parents provided can be extinguished as the parents withhold their attention when that child is acting out with temper tantrums. Extinction is usually combined with positive reinforcement of other, more desirable behaviors (Kazdin 2013). In the example just described, the parents will now positively reward their child with attention and praise when the child is behaving well and ignore the child’s temper tantrums.
Punishment, also called aversive control, is another operant conditioning technique aimed at decreasing an undesirable target behavior. There are two main kinds of punishment: positive punishment and negative punishment (Miltenberger 2016). Positive punishment involves the addition of an aversive stimulus after a specific target behavior has occurred, to decrease or weaken that behavior and make it less likely to occur in the future. For example, when a child engages in aggressive behavior in class by hitting someone else, that child then must do twenty push-ups as a form of unpleasant positive punishment, which should lead to less frequent aggressive behavior.
Negative punishment involves the removal of a pleasant or positively reinforcing stimulus following the occurrence of a target behavior in order to decrease or weaken it, that is, make it less likely to occur in the future. For example, when a child misbehaves, the parents take away television-watching time, thus negatively punishing the misbehavior, making the child less likely to misbehave again in the future.
Extinction and punishment can lead to certain side effects, such as aggression and anger. In applied behavior analysis or operant conditioning, positive reinforcement is the major intervention, with the use of punishment or aversive control only when necessary (Kazdin 2013; Miltenberger 2016). Skinner (1948) himself advocated the use of positive reinforcement for modifying behavior and believed that punishment should rarely be used because it was undesirable and had limited utility in changing behavior.
More recently, behavioral activation has been found to be especially effective as a treatment for more severely depressed clients and for prevention of relapse (Dimidjian, Hollon, et al. 2016; K. Dobson et al. 2008; see also Coffman et al. 2007). Richard Zinbarg and James Griffith (2008) have described behavioral activation as a specific behavior therapy technique based primarily on positive reinforcement of healthy behaviors and activity in depressed clients (see also Lewinsohn 1974; Martell, Addis, & Jacobson 2001; Martell, Dimidjian, & Herman-Dunn 2022). Behavioral activation has been defined as “the therapeutic scheduling of specific activities for the client to complete in daily life that function to increase contact with diverse, stable, and personally meaningful sources of positive reinforcement” (Kanter & Puspitasari 2012, 217). A randomized controlled trial of behavioral activation for moderately depressed university students using only a structured single-session intervention, with a no-treatment control group, yielded strong effect sizes, reflecting significant decreases in depression and increased environmental reward (Gawrysiak, Nicholas, & Hopko 2009). More recent research on the effectiveness of behavioral activation and other behavior therapy interventions is covered in the later section on research in this chapter.
Token Economies
“Token economies” refers to a specific application of operant conditioning in which tokens are given to clients when they engage in appropriate behaviors, so that these behaviors are reinforced by the tokens earned. Tokens can also be lost because of inappropriate or undesirable client behaviors. Clients can then choose specific reinforcers for which they can exchange their tokens, such as food, candy, toys, or the privilege to watch a movie. Token economies have been effectively used to shape and reinforce appropriate social behaviors in institutionalized patients and clients in residential homes, but also in the classroom and for individuals (Spiegler 2016, 194–209).
Social Skills Training and Assertiveness Training
Social skills training is a behavioral intervention that comprehensively covers helping clients with interpersonal difficulties or deficits in social skills when interacting with other people. The behavior therapist coaches and teaches the client how to interact more effectively and appropriately with others, especially in social situations. Several specific techniques are used in social skills training, including providing information about appropriate ways of interacting with others, modeling of such social skills for the client, reinforcing the client with verbal praise for trying more effective ways of social interaction through behavioral rehearsal, role-playing, and providing feedback and further instruction and coaching to the client. Social skills training can also be used as a significant intervention in anger management training for clients who have difficulty controlling their tempers or those with aggressive behavior. Social skills training has been used with children and adolescents as well as with adults, including adults with schizophrenia (Spiegler 2016, 294–297).
Assertiveness training, or assertion training, is a type of social skills training (Spiegler 2016, 297–308) used to help clients who have trouble expressing themselves freely, whether in making requests of others, saying “no” to others, stating positive or negative sentiments (e.g., affection or anger), or otherwise interacting with people in social situations. Clients are taught to differentiate between passive, aggressive, and appropriately assertive behaviors or responses. The behavior therapist then uses instruction, modeling of assertive responses, practice of such responses by the client, role-playing with the client, and further feedback and coaching to help the client improve assertiveness responses; the therapist provides appropriate positive reinforcement by verbally praising the client for effectively performing assertive responses. Clients therefore learn that it is their right to stand up, speak out, and be heard where and when appropriate (see Alberti & Emmons 2008).
Modeling
The behavioral techniques of modeling are based mainly on Albert Bandura’s significant work on observational learning (1969, 1971, 1977b, 1986, 1997). Modeling involves a client observing another person’s behavior and its consequences and then imitating that behavior.
Modeling has five major functions when it is used in behavior therapy to help clients: teaching, prompting, motivating, reducing anxiety, and discouraging (Spiegler 2016, 278). Teaching through modeling occurs when the client learns a new behavior by observing a model. For example, a child learns language by watching and hearing an adult model speak. Prompting through modeling occurs when the client is reminded or cued to do a certain behavior after watching a model perform that behavior. For example, a client watches a model take a slow, deep breath to relax and then does likewise, being reminded to relax in a stressful situation. Motivating through modeling occurs when the client sees a model receiving positive reinforcement or some reward for performing a specific behavior and then is motivated also to engage in that behavior due to the vicarious reinforcement that the client has experienced. For example, a student volunteers to answer a question in class because of observing other students doing so and being praised by the teacher. Reducing anxiety through modeling occurs when the client watches a model performing an anxiety-provoking behavior safely and with little or no anxiety, with anxiety reduction vicariously experienced by the client. For example, a client with aquaphobia, a fear of water and swimming, overcomes this fear by watching a model enjoy going into the pool and swimming. Finally, discouraging the client through modeling occurs when the client watches a model’s behavior that is followed by negative or unpleasant consequences, which discourages the client from engaging in such behavior. For example, a child observes a classmate being punished by the teacher for hitting others, and the child is then discouraged from engaging in hitting behavior too. These five functions of modeling are not always independent, and several of them can occur at once.
Modeling can be used in various ways: live modeling, in which the client observes an actual person or the therapist; symbolic modeling, in which the client is exposed to models indirectly, for example, through DVDs, plays, photographs, and books; covert modeling, in which the client imagines successfully performing a certain desirable behavior such as making an effective sales presentation or speech; self-modeling, in which the client is recorded doing a specific desired behavior well, and then watching the recording later to observe this self-modeling; and participant modeling, in which the therapist first models a specific behavior for the client by executing it well, and then guides the client to engage in that behavior. For example, the therapist will pet a well-trained dog and then guide the client, who has a fear of dogs, to gradually pet the dog too, so that the client becomes a participant in the modeling by the therapist (see Sharf 2016, 307–309).
Relaxation Training
Relaxation training is an important or core behavior therapy technique. It is used to help clients suffering from several different clinical disorders such as anxiety disorders, stress, insomnia, headaches and other chronic pain conditions, asthma, hypertension, eczema (skin inflammation), irritable bowel syndrome, side effects of chemotherapy, postsurgical distress, and panic disorder (see Cormier, Nurius, & Osborn 2017; Spiegler 2016). Yet relaxation training for some panic-prone clients can be harmful rather than helpful (Lilienfeld 2007). Relaxation training should therefore be conducted in a clinically sensitive way, adapted and tailor-made for each client. Relaxation training targets tension and its alleviation as critical for the management and reduction of emotionally intense states such as anxiety and anger. There are various techniques for relaxation training, but an important one is progressive muscle relaxation, based on the earlier work of Edmund Jacobson (1938). It involves the alternate tensing and relaxing or letting go of major muscle groups. Jacobson’s original version of progressive muscle relaxation was very elaborate and time-consuming to follow, with almost two hundred hours of training required. Behavior therapists have shortened progressive muscle relaxation to around sixteen muscle groups (see Goldfried & Davison 1994; Wolpe 1990), and sometimes even to four major muscle groups (Tan 1996a). Frank Dattilio (2006) has made available an excellent recorded demonstration of progressive muscle relaxation.
Here is an example of progressive muscle relaxation training, using four major muscle groups, which can be done by a client at home:
This relaxation technique involves the alternate tensing and then relaxing or letting go of various muscle parts of your body. . . . First, sit in a comfortable chair or recliner, in a room and at a time when you will not be disturbed. Give yourself at least 15–20 minutes of uninterrupted “relaxation time” to practice the relaxation exercises, beginning with the leg muscles and ending with the arm muscles.
Leg muscles. You can tense your thigh and calf muscles by pointing your toes toward your face and tensing these muscles hard. Hold the tension for 7–10 seconds by counting slowly up to 5. Then let go and allow the muscles to go limp. Now use self-talk: tell yourself to “just relax, let go of all the tension, . . . allow the muscles to smooth out, . . . take it easy, . . . just unwind and relax more and more . . .” Continue with this relaxation patter for 20 seconds or so before proceeding to repeat this exercise. Do this exercise a total of 4 times. Then proceed to the next one.
Upper-body muscles. After completing the exercise for the leg muscles, focus your attention on the muscles of your upper body—your chest, stomach, shoulders, and back. Tense them by taking in a slow, deep breath, holding it for a count up to 5 (about 7–10 seconds), pulling your stomach in, and arching your back (unless you have a back injury or back pain, in which case you should not arch your back). When you reach a count of 5, slowly exhale and let go of all the muscle tension, again telling yourself mentally to relax and take it easy, using the relaxation patter or self-talk for about 20 seconds or so before repeating the exercise. Do it a total of 4 times. . . .
Face and neck muscles. Focus your attention on the muscles of your face and neck regions. Tense these muscles by closing your eyes tightly, biting your teeth, smiling back, pushing your chin down as if to touch your chest but not allowing it to touch your chest. Hold the tension for a count up to 5 (7–10 seconds), and then relax and let go of these muscles, again using the relaxation patter or self-talk for up to 20 seconds or so. Repeat this exercise for a total of 4 times before proceeding to the final exercise.
Arm muscles. Now focus your attention on the muscles of your arms. Tense them by clenching your fists and flexing your biceps. . . . Hold the tension for a count up to 5 (7–10 seconds), and then relax and let your arms flop down limp by your sides. Again, engage in the relaxation patter or self-talk for 20 seconds or so before repeating the exercise, doing it a total of 4 times. . . .
At the end you should give yourself a couple more minutes to just sit quietly and enjoy the feelings of deeper and more complete muscle relaxation that you are experiencing by this time. Then, count from 1 to 5 as you slowly move your muscles, and eventually open your eyes at the count of 5, feeling very relaxed and refreshed. (Tan 1996a, 59–61)
This version of progressive muscle relaxation training can also be conducted in the reverse order, starting with the arm muscles, next the face and neck muscles, then the upper body muscles, and ending with the leg muscles.
Another form of relaxation training often used by behavior therapists today is an even more abbreviated version based on the work of Donald Meichenbaum (1977, 1985) on stress inoculation training. In this stress management, or stress inoculation approach to relaxation training, the following three major relaxation techniques are used: (1) slow, deep breathing: the client is instructed to take in a slow, deep breath, hold it for a few seconds, and then exhale the tension slowly; this is repeated a few times; (2) calming self-talk: the therapist instructs the client to say several calming and relaxing statements, that is, to use self-talk such as this: “Just relax, take it easy, let go of all the tension, allow the muscles to smooth out”; (3) pleasant imagery: the therapist instructs the client to imagine or visualize as clearly and as vividly as possible a very pleasant, relaxing, enjoyable, and peaceful scene, such as lying on the beach in Hawaii, watching a beautiful sunset or sunrise, or taking a walk in the woods.
Finally, another well-known relaxation technique that can be used to help clients alleviate tension and anxiety is a passive, quiet meditative exercise developed by Herbert Benson for activating what he has called “the relaxation response” (1975). It involves a few simple steps: (1) sit quietly in a comfortable position with your eyes closed; (2) deeply relax all your muscles from your feet up to your face; (3) breathe through your nose and then say a word such as “one” or “peace” when exhaling or breathing out; and (4) maintain a quiet and passive attitude throughout for a total time of about twenty minutes, even if you have distracting thoughts at times.
Systematic Desensitization
Systematic desensitization is another core behavior therapy technique that has received much empirical support for its effectiveness as a behavioral treatment for anxiety disorders and specific phobias (Cormier, Nurius, & Osborn 2017; Spiegler 2016). It has also been used to treat other problems such as anger, insomnia, asthma, motion sickness, nightmares, and sleepwalking (Spiegler 2008). Originally it was developed by Wolpe over fifty years ago when he used classical conditioning principles and processes to conduct psychotherapy by reciprocal inhibition (1958) in the treatment of neurotic disorders, such as anxiety problems and phobias. Systematic desensitization was therefore the first major behavior therapy intervention (Spiegler 2016, 221). It involves pairing an anxiety-provoking stimulus that usually elicits an anxiety response (as the conditioned response) with a competing response, usually relaxation. This process is done repeatedly until eventually that specific anxiety-provoking stimulus no longer elicits anxiety because it is now associated more with relaxation as a competing response that has replaced fear. This is the usual process and explanation for traditional systematic desensitization, which consists of three steps: (1) The behavior therapist teaches the client a response that competes with anxiety, usually relaxation. (2) The specific stimuli or events that provoke anxiety in the client are listed from the least anxiety provoking to the most anxiety provoking, thus constructing an anxiety hierarchy. A simple Subjective Units of Discomfort scale (SUDs) is used to rate the anxiety level that the client experiences on a 0 (no anxiety) to 100 (maximum, extreme anxiety) for each of the anxiety-provoking items on the anxiety hierarchy. (3) The behavior therapist then guides the client to repeatedly visualize the anxiety-provoking items (for usually about fifteen seconds at a time), in order of increasing anxiety, while engaging in the competing response, usually relaxation (see Spiegler 2016, 221–230).
Sidebar 11.3: Systematic Desensitization Procedure Using an Anxiety Hierarchy
An example of an anxiety hierarchy for a client with a phobia or fear of spiders might include the following items in order of increasing anxiety, with SUDs ratings in parentheses:
1. Reading the word “spider” in a book (10).
2. Seeing a picture/drawing of a small spider in a book (20).
3. Seeing a picture/drawing of a large spider in a book (30).
4. Seeing a small dead spider (40).
5. Seeing a large dead spider (50).
6. Seeing a small live spider (60).
7. Seeing a large live spider (70).
8. Touching a small dead spider with a pen (80).
9. Touching a large dead spider with a pen (85).
10. Touching a small live spider with a pen (90).
11. Touching a large live spider with a pen (95).
12. Touching a small or large live spider with a finger (100).
Goldfried and Davison (1994, 124–126) describe Wolpe’s traditional systematic desensitization as consisting of conducting deep relaxation, constructing an anxiety hierarchy (usually with one to two dozen items), and presenting an item from it (in order of increasing anxiety) for five, ten, or fifteen seconds to the client in imagination while the client is in a deeply relaxed state. If the client signals anxiety while visualizing the item or scene, the client is asked to remove the scene from imagination and return to a deeply relaxed state, at which point the item will be presented again. This process is repeated until the client’s SUDs rating of anxiety for that specific item goes down to about zero. Then the next item from the client’s anxiety hierarchy is presented in this manner repeatedly until the client rates it also with a SUDs rating of zero. Then another item is presented. Usually, two to five items from a hierarchy are presented in each session of traditional systematic desensitization. It is therefore a tedious and time-consuming behavior therapy technique; it may take between ten and thirty sessions to successfully help a client overcome a specific phobia or anxiety problem. It is, however, an effective intervention. Clients usually find traditional systematic desensitization acceptable because they are exposed to anxiety-provoking scenes only in a gradual way and at their own pace and have control of when they want to end the exposure to such scenes (Spiegler 2016).
Wolpe originally explained the effectiveness of traditional systematic desensitization by the process of counterconditioning, a reciprocal inhibition of the anxiety response with the competing response of relaxation. He emphasized the need for a thorough anxiety hierarchy consisting of one to two dozen items in order of gradually increasing anxiety, and for the client’s complete relaxation with virtually no anxiety, a SUDs rating of about zero, before proceeding to the next item in the anxiety hierarchy. Research, however, has shown that Wolpe’s approach and explanations are not necessarily valid for the effective treatment of anxiety disorders. The essential element in systematic desensitization and its effectiveness has been found instead to be “repeated exposure to anxiety-evoking situations without the client experiencing any negative consequences” (Spiegler 2016, 230, emphasis in original). Items on the anxiety hierarchy can therefore be presented out of order, and relaxation training can be omitted in effective systematic desensitization. In fact, emotive imagery involving the use of pleasant images and thoughts as well as humor and laughter have been found to be alternative, effective, competing responses to anxiety (see Spiegler 2016, 230).
There are also variations in systematic desensitization that go beyond Wolpe’s traditional version, such as coping desensitization developed by Goldfried (1971), which focuses more on the bodily sensations of anxiety and using coping responses (such as muscle relaxation but also calming self-talk and other techniques); anxiety management training, developed by Richard Suinn and Frank Richardson (1971), which is similar to coping desensitization but does not use an anxiety hierarchy; and interoceptive exposure and cognitive behavior therapy, developed by David Barlow and his colleagues (Barlow 1988, 2002; Craske & Barlow 2008), for treating panic attacks, which includes artificially inducing the somatic symptoms (e.g., increased heart rate and dizziness) of panic attacks while the client imagines panic-provoking events, cognitive restructuring or use of coping self-talk, and breathing retraining, especially slow, deep, and steady diaphragmatic breathing (see Spiegler 2016, 233–234).
Flooding and In Vivo Exposure
Flooding, like systematic desensitization, is another form of exposure therapy in which the client with a phobia or anxiety disorder is exposed to the anxiety-provoking stimulus or event without the feared consequences occurring. However, unlike systematic desensitization, flooding is a behavior therapy technique that exposes the client to maximal anxiety from the start (rather than to minimal anxiety initially). While being exposed to the anxiety-provoking event, the client is encouraged to tolerate the high anxiety levels until the anxiety subsides. Flooding can be conducted in real life, in which case it is called flooding in vivo, or in imagination, in which case it is called imaginal flooding. Likewise, systematic desensitization can be conducted in imagination, which is usually the case, but it can also be conducted in vivo. An example of flooding in vivo is when a client with a balloon phobia is exposed to dozens of balloons at one time in the treatment room, with no recourse to leaving the room as an escape response, until the high anxiety level experienced by the client is significantly reduced before the session is terminated. Such flooding in vivo is also called in vivo exposure with response prevention because the client is prevented from engaging in any maladaptive responses for anxiety reduction (e.g., avoiding the anxiety-provoking situation, or performing ritualistic or obsessive-compulsive behaviors such as checking and rechecking something or handwashing) during the exposure therapy. An example of imaginal flooding would be asking a client with a balloon phobia to visualize facing dozens of balloons without being able to leave or avoid the situation. This imaginal flooding session is continued until the client’s high anxiety level has substantially subsided. Thomas Stampfl and Donald Levis (1967, 1973) developed an earlier variant of imaginal flooding called implosive therapy, in which the prolonged or intense exposure included therapist-hypothesized cues and exaggerated imaginary scenes, often with psychodynamic themes that went far beyond the client-reported scenes. Implosive therapy is practiced less frequently today.
Sidebar 11.4: Eye Movement Desensitization and Reprocessing
Eye movement desensitization and reprocessing (EMDR) is now a well-known exposure-based therapy that has received some empirical support for its effectiveness, especially in treating posttraumatic stress disorder (PTSD) (see Prochaska & Norcross, 2018, 191–192; Spiegler 2016, 263–264; J. Sommers-Flanagan & Sommers-Flanagan 2018, 377–378). It was originally developed by Francine Shapiro (1948–2019) to treat emotionally disturbing thoughts and memories of traumatic events, such as combat-related trauma, sexual assault, and robbery at gunpoint (see F. Shapiro 2002, 2018). EMDR involves imaginal flooding, during which the client is instructed to watch and visually track the index finger of the therapist as it moves back and forth (from left to right about twice per second, for a dozen to two dozen times) in a rapid and rhythmic fashion within the client’s visual field. Such eye movements, according to Shapiro, result in a neurological effect, similar to rapid eye movements seen in intense dreaming, that helps the client to better process intense and stressful experiences and memories. EMDR also involves cognitive restructuring of the client’s thinking, focusing on adaptive beliefs associated with the traumatic images presented to the client in imaginal flooding.
EMDR was initially touted as an effective breakthrough exposure treatment that produces rapid and significant therapeutic results with clients who have trauma-based anxiety disorders. However, the controlled outcome studies conducted so far have not generally supported the effectiveness of EMDR beyond that of its imaginal flooding component, and the eye movements have not been consistently found to be necessary for its effectiveness (see Spiegler 2016, 263–264), but a couple of more recent systematic reviews have provided some evidence for the eye movements making a distinct contribution to the effectiveness of EMDR (Christopher Lee & Cuijpers 2013; Jeffries & Davis 2013).
EMDR is now listed as an empirically supported or well-established treatment for PTSD by several organizations (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 377). A recent meta-analysis, with eleven direct comparison-controlled studies for adult trauma, found EMDR to be slightly more effective than cognitive behavior therapy (including exposure), but the differences were small, and there are methodological problems with some of the studies (L. Chen et al. 2015). EMDR may also be effective for chronic pain, according to two recent systematic reviews (Tefft & Jordan 2016; Tesarz et al. 2014), but additional controlled outcome studies are needed. EMDR has therefore become a major therapy, especially for trauma-related disorders, with a strong empirical support base.
Systematic desensitization in vivo involves gradually exposing the client in real life to an increasing number of anxiety-provoking items from the client’s anxiety hierarchy.
Effective exposure treatments can be conducted in gradual or intense ways, in vivo or in imagination, and with individual clients or in groups. Effective exposure treatments are usually prolonged in duration, frequent, and comprehensive (see Persons 1989, 94–95). They are typically conducted by therapists, in which case they are called therapist-directed exposure. Clients can also perform their own exposure treatments in what is called self-managed exposure. Some types of phobias, such as fears of natural disasters (e.g., fires, floods, earthquakes), cannot be practically treated with in vivo exposure; hence, imaginal exposure is more appropriate and feasible in treating these kinds of phobias. Since the 1980s and 1990s, exposure therapy has also been conducted using computer-based virtual reality technology in exposing clients to specific anxiety-provoking scenes. Such virtual reality exposure therapy was pioneered by Barbara Rothbaum and Larry Hodges (1999). It has been used to treat panic disorder, agoraphobia, obsessive-compulsive disorder, social phobia, posttraumatic stress disorder, and specific phobias such as fears of flying, public speaking, driving, spiders, heights, enclosed spaces, and several medical procedures (Wiederhold & Wiederhold 2005). It is a promising approach to exposure treatment that warrants further research and evaluation of its effectiveness (Spiegler 2016; see also Galea 2013). Meta-analyses have, in fact, shown substantial decreases in symptoms of anxiety after virtual reality exposure therapy (T. D. Parsons & Rizzo 2008) and large average effect sizes (M. B. Powers & Emmelkamp 2008; see also Meyerbroker & Emmelkamp 2010).
Self-Management Programs and Self-Directed Behavior
Self-management or self-modification programs in behavior therapy focus on developing clients’ self-directed behavior, empowering them to choose their own goals with specific target behaviors they want to modify, with some guidance from the behavior therapist, who coaches the clients with specific behavioral change techniques (see Corey 2021, 248–250).
David Watson and Roland Tharp (2014) have described the following steps that a client needs to take in order to successfully implement a self-management or self-modification program: (1) select goals that are realistic, attainable, measurable, and meaningful to the client; (2) translate goals into target behaviors that are clear and concrete; (3) engage in self-monitoring, in which the client keeps a daily behavioral diary of systematic observations of their own target behaviors and those behaviors’ antecedents and consequences; (4) develop a specific plan for behavioral change and use self-reinforcement when desirable target behaviors occur; and (5) evaluate each action plan, making adjustments or revisions to it where necessary, to keep it realistic and attainable.
Self-management or self-modification programs have been used to help clients struggling with depression, panic attacks, fear of the dark, social anxiety, and public-speaking anxiety as well as for increasing creativity and productivity, enhancing study habits, decreasing perfectionism, reducing coworker conflicts, controlling smoking, and increasing exercise (D. Watson & Tharp 2014). Self-management has also been evaluated with clients suffering from health problems such as asthma, arthritis, cardiac disease, cancer, diabetes, headaches, substance abuse, depression, and vision loss (Cormier, Nurius, & Osborn 2017).
Multimodal Therapy
Arnold Lazarus was a key figure in the development of behavior therapy and especially in expanding it to broad-spectrum behavior therapy (A. A. Lazarus 1966, 1971), then to multimodal behavior therapy (A. A. Lazarus 1973, 1976), and eventually to multimodal therapy (A. A. Lazarus 1981, 1985, 1989, 1997, 2008; see also C. N. Lazarus & A. A. Lazarus 2019). Multimodal therapy as developed by Arnold Lazarus is a comprehensive and systematic approach to therapy that has gone beyond clinical broad-spectrum behavior therapy, although it is still largely based in social learning theory and social cognitive theory and uses many cognitive and behavioral techniques in treating a broad range of clinical problems. Lazarus also used other techniques, such as the empty chair from Gestalt therapy, and listed thirty-nine techniques that can be employed in multimodal therapy (A. A. Lazarus 1989).
Arnold Lazarus strongly advocated technical eclecticism, using whatever therapeutic techniques have been found to be effective. However, he did not advocate theoretical eclecticism, which can be confusing, inconsistent, and incoherent. Multimodal therapists, like behavior therapists and cognitive behavior therapists, are quite active and directive in conducting therapy, comfortably functioning as coaches, consultants, educators, trainers, and role models for their clients. They also engage in appropriate levels of self-disclosure and openly provide instructions, suggestions, and constructive feedback as well as offer positive reinforcement or verbal praise to their clients (Corey 2021, 250).
The multimodal approach to therapy is based on a view of human personality as consisting of seven major dimensions of functioning that can be summarized as one’s BASIC ID (or basic identity). BASIC ID stands for the following: B = Behavior; A = Affect; S = Sensations; I = Images; C = Cognitions; I = Interpersonal Relationships; and D = Drugs/Biology (A. A. Lazarus 1981, 1989, 1997, 2008). All seven modalities or areas of human functioning can interact among themselves, but they can also be seen as separate dimensions. The seventh modality, drugs and biology, also includes nutrition and exercise.
Multimodal therapy emphasizes the need for a comprehensive assessment of the client across the BASIC ID, covering each modality or dimension, which yields a BASIC ID profile unique to the client. A multimodal life history inventory (A. A. Lazarus & Lazarus 1991) is often used by multimodal therapists in exploring a client’s history. Arnold Lazarus (2008) believed that effective therapy should be comprehensive, covering all the modalities of a client’s BASIC ID, using as many therapeutic interventions as needed to help the client learn as broad a repertoire of coping skills as possible to deal with personal problems and to prevent relapse.
Mindfulness and Acceptance-Based Cognitive Behavior Therapy
The third wave of behavior therapy has expanded the behavioral and cognitive-behavioral approach to therapy to include relatively contextualistic mindfulness and acceptance-based therapies (Hayes, Follette, & Linehan 2004; Herbert & Forman 2011; Roemer & Orsillo 2009, 2020). Such therapies emphasize mindfulness, focusing attention on one’s immediate experience in the present moment, with acceptance in an open, curious, and receptive orientation, and not with a judgmental or evaluative attitude.
There are four major approaches to third-wave behavior therapy (see Corey 2021, 250–256). They are also mindfulness and acceptance-based cognitive-behavioral therapies and are covered in more detail in chapter 13 of this book (see also Prochaska & Norcross 2018, 270–288; J. Sommers-Flanagan & Sommers-Flanagan 2018, 382–387).
Dialectical Behavior Therapy (DBT). DBT was developed by Marsha Linehan (1993a, 1993b, 2015a, 2015b) initially for the treatment of borderline personality disorder. It emphasizes acceptance and mindfulness in helping clients to regulate their intense emotions. DBT’s major components are regulating emotions, tolerating distress, improving interpersonal relationships, and training in mindfulness that is based on Zen practice (Corey 2021, 252–253). Clients need enough time to learn such skills in DBT, and therapy therefore usually lasts for at least a year, involving individual therapy as well as group skills training. DBT has now been applied across different disorders and settings (Dimeff & Koerner 2007), including in private practice (Marra 2005), and received much empirical support for its effectiveness not only for borderline personality disorder but also for other problems such as suicidal behavior and non-suicidal self-injury, depression, PTSD, substance dependence, and eating disorders (Linehan 2015b).
Mindfulness-Based Stress Reduction (MBSR). MBSR was developed by Jon Kabat-Zinn (2003, 2013). It is a group intervention that usually lasts for eight to ten weeks; clients are taught sitting meditation and mindful yoga as well as a body-scan meditation to help them observe and experience all their bodily sensations. Clients practice about forty-five minutes of daily mindfulness meditation, learn to attend to their immediate experience in coping more effectively with stress, and thus improve their health. MBSR has been applied in inner-city health centers, hospitals, clinics, workplaces, offices, schools, prisons, and law schools (J. Kabat-Zinn 2013), especially in promoting health and wellness, including lifestyle changes that are healthy. There is empirical evidence for the effectiveness of mindfulness and acceptance as well as compassion-based interventions for enhancing health, both physically and psychologically (L. Germer 2013).
Mindfulness-Based Cognitive Therapy (MBCT). MBCT was developed by Zindel Segal, J. Mark Williams, and John Teasdale (2013), based on Kabat-Zinn’s MBSR. It combines mindfulness training with cognitive-behavioral therapy in an eight-week program for the treatment of depression and its recurrence. It has been found effective in preventing relapse in depression, especially for clients who have had three or more previous episodes of depression (Kuyken et al. 2016; see also Chiesa & Serretti 2009; Galante, Iribarren, & Pearce 2013; Piet & Hougaard 2011). It also shows some promise for effectively treating other problems such as anxiety, stress in medical patients, relapse prevention for substance abuse, and insomnia (Abbott et al. 2014; Larouche et al. 2015).
Acceptance and Commitment Therapy (ACT). ACT was developed by Steven C. Hayes and his colleagues (Hayes & Strosahl 2004; Hayes, Strosahl, & Wilson 2012; see also R. Harris 2019; Hayes & Smith 2005; Luoma, Hayes, & Walser 2017). This approach to therapy helps clients accept painful experiences rather than fight to modify or control unpleasant feelings. It emphasizes acceptance as well as commitment to one’s own values and taking action to live according to one’s values. ACT has six major components: acceptance, cognitive defusion (emphasizing flexibility in place of rigidity), being present, self as context in focusing on a transcendent sense of self, values, and committed action. It is a well-known approach to third-wave behavior therapy that has now received empirical support for its effectiveness in treating several clinical problems (Hayes, Pistorello, & Levin 2012), but especially depression, chronic pain, tinnitus, and, to a lesser extent, anxiety and work stress (Öst 2014; see also Bluett et al. 2014).
Cognitive Behavior Modification
Prochaska and Norcross have described three major thrusts or categories of behavior therapy techniques: (1) counterconditioning (Wolpe), including systematic desensitization, assertiveness training, sexual arousal, behavioral activation, and stimulus control (Prochaska & Norcross 2018, 200–207); (2) contingency management (Skinner), including institutional control, self-control, mutual control, therapist control, and aversive control (Prochaska & Norcross 2018, 201–214); and (3) cognitive behavior modification (Meichenbaum) including Meichenbaum’s self-instructional training (1977) and stress inoculation training (1985) as well as biofeedback and problem-solving therapy (Prochaska & Norcross 2018, 214–218).
Cognitive behavior modification (CBM), as developed by Meichenbaum, is a broad-spectrum behavior therapy that includes both behavioral coping skills such as relaxation techniques as well as cognitive strategies such as calming and coping self-talk or self-instructional training. It can also be considered a major approach to cognitive behavior therapy. Prochaska and Norcross (2018) have chosen to categorize CBM as part of the contemporary behavior therapies. CBM will be discussed only briefly here, in the form of stress inoculation training, because it will receive more detailed coverage in the next chapter of this book, which covers cognitive behavior therapy and rational emotive behavior therapy.
Meichenbaum went beyond self-talk or self-instructional training in developing a more comprehensive approach to therapy that he called stress inoculation training (SIT), which is a substantial part of CBM (see Meichenbaum 1985, 1993, 2003, 2007, 2017). It consists of three phases: a conceptual educational phase; a skills acquisition, consolidation, and rehearsal phase; and an application phase with follow-through. In the conceptual educational phase, clients are provided with a meaningful rationale for stress inoculation training aimed at helping them cope more effectively with stressful situations in their lives by anticipating stress and practicing coping skills for stress management. In the second phase of skills acquisition, consolidation, and rehearsal, various coping skills are reviewed with clients, and they choose and practice the ones most relevant and helpful to them (e.g., problem-solving, assertiveness training, cognitive reframing, relaxation techniques, calming self-talk, pleasant imagery). In the final phase of application and follow-through, the client uses the coping skills to manage experimental or actual stressors, or works through role-playing and imagery rehearsal (Meichenbaum 1985, 2003).
SIT has been successfully used in helping clients cope with a wide range of stressful situations, including acute stressors such as medical procedures and surgery; traumatic events; chronic intermittent stressors such as athletic competitions and evaluations; and chronic stressors such as chronic pain, anxiety and anger problems, and persistent exposure to occupational challenges such as those in police work, nursing, teaching, and combat (Meichenbaum 2003). Meichenbaum has also more recently written on resilience (2012) and treating people with addictive disorders (2020).
Behavior Therapy in Practice
This hypothetical transcript of a small part of a behavior therapy session demonstrates the therapist’s use of several behavioral techniques. They include brief relaxation and coping-skills training and assertiveness training with coaching, modeling, role-playing, providing constructive feedback, and giving positive reinforcement in the form of verbal praise and encouragement. The behavior therapist uses these techniques to help the client overcome nervousness and anxiety about possibly getting angry and provides the client with tools to learn how to respond in an appropriately assertive way. The behavior therapist also interacts with the client in a warm and empathic manner.
Client: I was at the grocery store the other day, waiting in line to pay the cashier for a couple of things. Another customer then cut right in front of me. I felt really angry but couldn’t bring myself to say anything to him. He paid for his stuff and then walked away as if nothing had happened. I was fuming mad inside but kept it all to myself. . . . I wish I could be bolder and had told him off for cutting in front of me!
Behavior Therapist: Sounds like you really felt upset at this guy for cutting in front of you, but you have trouble speaking up though you want to do so. What do you think holds you back? What’s getting in the way of you saying what you want to say to this guy?
Client: Well . . . I have trouble asserting myself or speaking up when I want to. . . . I get nervous, and I’m not sure what to say. . . . I also am afraid of losing my temper and getting really mad and shouting at the guy.
Behavior Therapist: So you have some feelings of nervousness as well as fear of blowing up in anger at the guy.
Client: Yeah . . . I’m not sure how to control my feelings, except to stuff them. . . . I’m also not sure what to say to express myself appropriately to the guy, to let him know that what he did wasn’t right.
Behavior Therapist: OK, let’s see if we can help you first to manage your feelings of nervousness and fear of blowing up. Some simple relaxation and coping techniques for calming ourselves down may be helpful. For example, you can take a slow, deep breath, hold it for a few moments, and then breathe out slowly and relax. You can then tell yourself quietly, “Just relax, take it easy, I can handle this without blowing up.” You can also briefly visualize or imagine yourself lying on the beach in Hawaii to relax yourself more. What do you think?
Client: Yeah, that sounds good!
Behavior Therapist: Let’s try practicing these three simple but powerful stress control techniques of slow, deep breathing, calming self-talk, and pleasant imagery. I want you to take in a slow, deep breath now; hold it for a few moments as you notice the tension rising, . . . and now just relax and breathe out slowly; . . . quietly tell yourself, “Just relax, take it easy, . . . I can handle this . . .” and then briefly picture or imagine yourself lying on the beach in Hawaii. . . . Just relax more and more deeply. . . . How are you feeling?
Client: I’m feeling much more relaxed. . . . These techniques are really helpful!
Behavior Therapist: Good! Now do you think it would also be helpful to you if we practice in a role-play several times what you could actually say to this guy in an appropriate and bold or assertive way without losing your cool?
Client: Yeah . . . I need some suggestions and coaching from you!
Behavior Therapist: OK . . . let’s do a brief role-play with you being yourself and with me playing the role of the guy cutting in front of you. So here goes: . . . I’ve just cut in front of you, . . . and you go ahead and try saying what you want to say, to me . . .
Client: Well, . . . excuse me, do you mind waiting in line like the rest of us instead of cutting in like this?
Behavior Therapist: That’s not bad at all for a first try. How do you feel about what you said? How might we improve on it?
Client: I’m not sure, . . . but maybe I don’t have to say the last part about cutting in like this, especially since I’m raising my voice too.
Behavior Therapist: That’s a good observation! Let me play the role of you now, and you take the role of the guy so that I can provide you an example of what to say. . . . “Excuse me, but I would appreciate it if you wait in line like the rest of us. . . . Thanks!”
Client: Yeah, that sounds much better and like what I really want to say!
Behavior Therapist: OK . . . Let’s practice it again, but now you play the role of yourself, and I’ll play the role of the guy again; . . . go ahead . . .
Client: “Excuse me, . . . I would appreciate it if you wait in line like the rest of us; . . . there’s a line here. . . . Thanks!”
Behavior Therapist: That’s great! Well done! How do you feel now?
Critique of Behavior Therapy: Strengths and Weaknesses
Behavior therapy has several strengths (see Corey 2021, 258–264; Parrott 2003, 289–291; Prochaska & Norcross 2018, 231–235), many of which are similar to the strengths of reality therapy, covered in the preceding chapter of this book. First, behavior therapy is a versatile and comprehensive approach to therapy that has been applied to diverse populations, including children, adolescents, adults, and older adults; in various settings, such as schools, hospitals, rehabilitation centers, residential homes, clinics, private practice offices, prisons, and private homes; and for a wide range of clinical problems (see Kazdin 2013; Miltenberger 2016; Spiegler 2016; Wilson 2008). Behavior therapy is usually relatively short-term and is therefore also consistent with managed care’s emphasis on effective short-term treatments and brief therapy.
Second, behavior therapy is a concrete and specific approach to therapy that focuses on specific behavioral goals set by the client and how to achieve them, using the most empirically supported or effective behavioral and cognitive-behavioral interventions. Behavior therapists engage in regular monitoring and measurement of client progress toward desirable therapeutic or behavioral change. Its approach to therapy is accountable and focused on achieving the goals of the client in a clear and measurable way.
Third, behavior therapy primarily addresses the current environmental situation and the problems or symptoms of the client, with emphasis on making specific behavioral changes according to the goals and needs of the client. It is therefore a good corrective to other approaches to therapy that may focus too much on the past or on exploration of feelings and achievement of insight, without sufficient attention to present environmental conditions affecting the client and actual behavioral change.
Fourth, behavior therapy emphasizes client choice in setting the goals for therapy, although it is not an existential approach to therapy, like reality therapy or existential therapy, which makes one’s freedom to choose, in an authentic and responsible way, an all-pervasive capacity and necessity for every human being. Although behavior therapy does not overemphasize choice as reality therapy tends to do, it does empower clients to choose their own goals for therapy.
Fifth, behavior therapy is open to the use of psychiatric medications for certain severe psychological disorders such as major depressive disorder, bipolar disorder, and schizophrenia, unlike William Glasser’s extreme and radical stance against the use of psychiatric medications in treating such disorders due to his overemphasis on client choice, even asserting that people choose their symptoms and misery and suffering (W. Glasser 2003). Behavior therapists have explored the use of combined treatments for certain clinical problems, such as antidepressants with behavior therapy, including exposure therapy for helping clients with obsessive-compulsive disorder (OCD) (see Prochaska & Norcross 2018, 227).
Sixth, behavior therapy is a unique approach that offers a wide array, an armamentarium, of therapeutic interventions and techniques to help clients with many diverse types of psychological and behavioral disorders, with empirical support for the effectiveness of the majority of the techniques. Clients who want specific and effective help to overcome certain identified problems or symptoms, including somatic symptoms (e.g., hypertension, migraine headaches, irritable bowel syndrome) and psychological symptoms (e.g., anxiety disorders, depression, eating disorders), can get it from behavior therapists who have developed effective therapeutic interventions and techniques for treating such problems (Prochaska & Norcross 2018, 230).
Seventh, behavior therapy takes empirical research very seriously and subjects its techniques and therapeutic interventions to controlled outcome studies as much as possible. It therefore is, together with cognitive behavior therapy, the most empirically supported approach to therapy today.
Finally, behavior therapy can be easily used with clients from different cultures and countries in a multicultural counseling context because it focuses on treating symptoms and problems that cut across cultures. It also gives clients the freedom to choose their own goals in a culturally sensitive way. It is a problem-solving approach to therapy that is direct, systematic, and relatively short-term, without the need for much introspection and exploration of the past. Behavior therapy and cognitive behavior therapy, with some modification and adaptation, can be especially helpful with ethnic minority clients (see Hays 2009; Iwamasa & Hays 2018; see also D. W. Sue, Sue, et al. 2019, 194, 205–206, 341–342), including Chinese American clients (S. W.-H. Chen & Davenport 2005). There is now some accumulating research evidence supporting the effectiveness of cognitive-behavioral therapy with adult ethnic minority clients (Horrell 2008; see also Miranda et al. 2005).
Yet behavior therapy has several limitations and weaknesses. First, it tends to treat symptoms and problems rather than focus holistically on the whole person of the client. It can therefore be conducted in a mechanistic way, without adequate attention to the person and the life context of the client. However, contemporary behavior therapy tends to be more comprehensive in its behavioral assessment of the client and the client’s life context (see, e.g., A. A. Lazarus 1976, 1989, 1997; Wilson 2008).
Second, behavior therapists emphasize their techniques and empirically supported interventions more than the therapeutic relationship with clients, although they do acknowledge the importance of having a warm, empathic, and supportive relationship with the client (see Wilson 2008; see also Antony 2019; Antony & Roemer 2011). Again, the danger exists for behavior therapy to be conducted in a mechanistic way that is not sufficiently sensitive to the intricacies and complexities of the therapeutic relationship between the behavior therapist and the client. However, behavior therapists and cognitive behavior therapists have begun paying more attention to the importance of the therapeutic relationship in the cognitive-behavioral therapies (see P. Gilbert & Leahy 2007; see also Kazantzis, Dattilio, & Dobson 2017; Safran & Segal 1990).
Third, behavior therapy does not adequately focus on the past and its unresolved issues or painful memories; it is a problem-solving approach that mainly treats the presenting problems and current symptoms of the client. Some clients need more time to process and deal with past issues and pain than behavior therapists typically provide.
Fourth, behavior therapy is still based mainly on social learning or social cognitive theory. It tends to ignore unconscious processes such as transference and dreams, which can be rich sources of helpful insights for clients and for facilitating further therapeutic change. Behavior therapists and cognitive behavior therapists, however, have tried to deal with such unconscious processes and dreams but within a cognitive-behavioral framework of understanding rather than from a psychodynamic or psychoanalytic perspective (see, e.g., K. S. Bowers & Meichenbaum 1984; Rosner, Lyddon, & Freeman 2003).
Fifth, behavior therapy does not adequately deal with existential issues, with which some clients may be struggling, such as seeking meaning in life, choosing authentic values, and overcoming the fear of death. Furthermore, traditional secular behavior therapy also does not seriously incorporate spirituality and religion, which may be of crucial importance to religious clients. However, significant attempts and advances have been made in recent years to develop a more spiritually oriented behavior therapy (see, e.g., W. R. Miller & Martin 1988) or cognitive-behavioral therapy (see, e.g., Tan 1987a, 2007b, 2013a; Tan & Johnson 2005; see also Pearce 2016; Propst 1988; Rosmarin 2018; Tirch, Silberstein, & Kolts 2017) that seriously integrates religion and spirituality into therapy. The third wave of behavior therapy also includes approaches such as DBT, MBSR, MBCT, and ACT that are mindfulness based and acceptance based (Hayes, Follette, & Linehan 2004), centered in some form of contemplative or meditative spirituality, usually within a Zen Buddhist framework (but it can also be some other religious framework such as Roman Catholic or Eastern Orthodox).
Sixth, behavior therapy is a directive and systematic approach to therapy in which the behavior therapist functions as a coach, trainer, teacher, consultant, and role model in helping the client to achieve their therapeutic goals. There is a real danger of the behavior therapist acting like an expert and ultimately influencing the client with the therapist’s own values, or even worse, imposing the therapist’s values on the client, a potential ethical problem that also plagues other directive therapies such as reality therapy (see Wubbolding 2011; 2017). Behavior therapists try to avoid this potential danger by encouraging the client to actively participate in therapy and to choose their own treatment goals (Wilson 2008).
Seventh, behavior therapy techniques can be simplistically and easily misused and abused by inadequately trained or inexperienced therapists. Some behavioral interventions such as flooding and in vivo exposure require adequate training and careful clinical supervision before therapists make independent attempts to conduct them. Proper training and supervision in behavior therapy are therefore needed for the competent and ethical use of behavior therapy techniques.
Eighth, although behavior therapy can be adapted for effective use with clients from other cultures and countries, it may still not be sensitive enough to the larger sociopolitical and environmental contexts within which clients live. In other words, behavior therapists may still pay too much and too narrow attention to the client and the identified symptoms and target complaints, without adequately considering factors such as discrimination, oppression, and marginalization in the larger sociopolitical context of the client’s life, which can have a substantial negative impact on the client’s functioning. The client may need to be empowered to deal more directly with factors such as discrimination and oppression (see D. W. Sue et al. 2019).
Finally, behavior therapists may not be sensitive enough to the possibility that successful behavioral change in the client may negatively impact those around that person, even though the client’s own treatment goals may be achieved (e.g., becoming more assertive). Conflicts between the client’s goals and the cultural and social values of significant others in their life will require more attention and sensitivity on the part of the behavior therapist who is working with such clients in a multicultural counseling context or from a diversity perspective (see Corey 2021, 259; see also D. W. Sue et al. 2019).
A Biblical Perspective on Behavior Therapy
Behavior therapy has both strengths and weaknesses from a biblical perspective (Tan 1987a; see also Browning & Cooper 2004, 86–105; S. L. Jones & Butman 1991, 154–170).
First, behavior therapy or behavior modification, in its earlier version, was more deterministic and naturalistic in its basic philosophy, following Skinner and his radical behaviorism, which had no place for human free will. This version also had no place for transcendence and the supernatural since behavioral approaches to therapy tend to be reductionistic in their naturalistic and materialistic assumptions (S. L. Jones & Butman 1991). These earlier philosophical assumptions of behavior therapy are problematic from a biblical perspective, which assumes that human beings have at least some free will and freedom to choose (see Josh. 24:15; Luke 13:3). The Bible also affirms self-transcendence and the reality of God and the supernatural, including eternity. However, more recent versions of behavior therapy are based more on Bandura’s social cognitive theory, which includes reciprocal determinism that allows for some limited degree of free will and choice on the part of the individual person. There have also been serious attempts to integrate religion and spirituality, including transcendence and the supernatural, into behavior therapy (e.g., W. R. Miller & Martin 1988) and cognitive behavior therapy (e.g., Tan 1987a, 2007b, 2013a; Tan & Johnson 2005; see also Pearce 2016; Propst 1988; Rosmarin 2018; Tirch, Silberstein, & Kolts 2017).
Second, behavior therapy’s emphasis on environmental control of human behavior and the importance of conditioning, including operant conditioning and reinforcement contingencies, is a good reminder of how human beings are not totally free, even as creatures made in the image of God the creator (Gen. 1:26–27). Being human means that our nature also has an animal side that is subject to conditioning to a certain extent (see Bufford 1981; Browning & Cooper 2004; S. L. Jones & Butman 1991). The Bible also talks about rewards and incentives, but it has a higher ultimate view of eternal rewards to come in heaven, which transcends immediate gratification or positive reinforcement of specific behaviors now. Paul can therefore talk about enduring and even accepting present suffering and trials in anticipation of future glory and eternal joy in heaven (see Rom. 8:18; 2 Cor. 4:16–18). Although we are creatures with conditioned habits, we are not totally conditioned. We are also created in the image of God (Gen. 1:26–27), with some freedom to choose, although our capacity to choose is not absolute, as existential therapists and reality therapists may want us to believe. Behavior therapists have correctly reminded us of our limited freedom to choose.
Third, behavior therapists’ empowerment of clients to choose their own goals, based on their own values, is a good corrective to the potential danger of imposing the therapist’s values and goals on the client because behavior therapy is such a directive approach to therapy. However, ultimate values from a biblical perspective can come only from God and his inspired Word, the Scriptures (2 Tim. 3:16).
Fourth, behavior therapy’s focus on powerful and effective techniques of behavior change can result in not only self-efficacy but also sinful self-sufficiency and overdependence on one’s skills to cope effectively with the problems in one’s life. A biblical perspective will instead emphasize sufficiency and strength in Christ (Phil. 4:13) and dependence on the filling and power of the Holy Spirit (Zech. 4:6; Eph. 5:18) in bringing about lasting behavioral change.
Fifth, behavior therapy’s emphasis on techniques of behavior change may not focus enough attention on the therapeutic relationship, although recently there have been more deliberate attempts to make the therapeutic relationship more central in behavior therapy and cognitive behavior therapy (see, e.g., P. Gilbert & Leahy 2007; also Kazantzis, Dattilio, & Dobson 2017; Safran & Segal 1990). A biblical perspective will emphasize the primacy of agape love (1 Cor. 13) in the therapeutic relationship and the importance of establishing a warm, empathic, and genuine relationship with the client.
Sixth, behavior therapy tends to focus on current symptoms and the presenting problems of the client, with less attention paid to the past. Although this emphasis is a good corrective to the endless exploring of past issues and experiences, a biblical perspective will nevertheless deal more adequately with the past, especially with unresolved developmental issues and painful memories, and include the judicious use of the healing of memories, inner-healing prayer, when appropriate (see Tan 2003b, 2007b, 2013a).
Seventh, behavior therapy does not pay much attention to unconscious processes, including the darker, fallen side of human nature, which is capable of sin and evil, as well as more complex internal conflicts, in what the Bible calls the inner “heart” of a person (see Jer. 17:9; Rom. 3:23). A biblical perspective will more adequately deal with such complex struggles, including unconscious conflicts.
Eighth, one of behavior therapy’s major techniques is exposure therapy for treating various anxiety disorders. The Bible also emphasizes the need to confront the truth in order to be set free (cf. John 8:32), and exposure therapy is consistent with this teaching, which also underscores the need for cognitive restructuring and renewal of the mind (Rom. 12:1–2), using biblical truth in cognitive behavior therapy (Tan 1987a, 2007b, 2013a).
Ninth, behavior therapy needs to focus more on larger contextual factors such as familial, social, religious, cultural, and even political influences affecting a specific client’s life and functioning. A biblical perspective will emphasize the need to make use of community resources in therapeutic interventions with a client, including the church as a body of believers available for mutual support, help, and ministry to one another (1 Cor. 12; 1 Pet. 2:5, 9).
Finally, behavior therapy’s hallmark of subjecting its techniques to controlled outcome research and using empirically supported therapeutic interventions is a strength that can be appreciated. From a biblical perspective, however, empirical support cannot be accepted as the ultimate criterion for using specific behavioral or other therapeutic techniques. A Christian therapist will not simply use whatever works. The therapeutic interventions chosen for use must ultimately be consistent with biblical truth, morality, and ethics. Furthermore, the amelioration or reduction of symptoms and emotional suffering is not the ultimate goal of therapy from a biblical perspective. The ultimate goal of Christian therapy or counseling is more transcendent and eternal, centered in becoming more Christlike (Rom. 8:29) and therefore in holiness rather than simply in happiness. This perspective means that some temporal suffering has ultimate meaning (cf. Rom. 8:18; 2 Cor. 4:16–18).
Research: Empirical Status of Behavior Therapy
One of the hallmarks of behavior therapy is its emphasis on empirical research, especially controlled outcome studies or randomized controlled trials (RCTs). Behavior therapy and cognitive behavior therapy have therefore been subjected to a greater number of controlled outcome studies than other approaches to therapy. Close to two-thirds of controlled outcome studies on therapy with children and adolescents have involved behavior therapy interventions (Weisz et al. 2017), and most of such studies with adults have involved behavioral and cognitive-behavioral interventions (Wampold & Imel 2015).
Prochaska and Norcross (2018, 221–231) have provided a helpful overview of the many meta-analyses that have evaluated the effectiveness of behavior therapy in general, as well as several specific behavior therapy interventions, and a few clinical disorders, which will now be briefly summarized. Meta-analyses of controlled outcome studies on the effectiveness of behavior therapy with children and youth (see Weisz et al. 1987, 1995, 2004; Weisz & Kazdin 2017) showed effect sizes indicating the greater effectiveness of behavior therapy compared to placebo treatment and no treatment. Meta-analyses of controlled outcome studies on the effectiveness of behavior therapy with adults (covering behavioral methods of rehearsal and self-control, covert behavioral, relaxation, desensitization, reinforcement, modeling, and social skills training) have yielded large effect sizes demonstrating the superiority of behavior therapy over no treatment and placebo treatment (see D. A. Shapiro & Shapiro 1982). An extensive meta-analysis of controlled outcome studies (Grawe, Donati, & Bernauer 1998) found positive and substantial effect sizes for behavior therapy and cognitive-behavioral therapy (e.g., social skills training, stress inoculation, and problem-solving therapy), which indicated their superiority over control treatments as well as their slight superiority over psychodynamic treatments when direct comparisons were conducted, but without controlling for the researcher’s allegiance effect. More specifically, Thomas Bowers and George Clum (1988) found that the specific effects of behavior therapies were almost double the nonspecific effects of placebo treatments.
Meta-analyses of controlled outcome studies on the effectiveness of behavior therapy with couples, called behavioral marital therapy (BMT) (e.g., communication skills training, problem-solving training, and modification of dysfunctional relationship attributions and expectations), have shown BMT to be significantly more effective than no treatment (see Hahlweg & Markman 1988; Dunn & Schewebel 1995; Shadish & Baldwin 2005). The effectiveness of behavior therapy with families, or behavioral family therapy, has also been supported by a meta-analysis of controlled outcome studies (Shadish & Baldwin 2003) that yielded moderate to large effect sizes for behavioral family therapy, thus indicating its superiority over no treatment and control treatment and at times even over other nonbehavioral approaches to family therapy (see Prochaska & Norcross 2018, 223).
Prochaska and Norcross also reviewed meta-analyses of controlled outcome studies on the effectiveness of specific behavioral methods such as autogenic training, relaxation training, social skills training, stress inoculation, biofeedback, behavioral activation, self-statement modification, contingency management, behavioral parent training, problem solving, and habit reversal therapy, mainly with positive results showing their superiority over no treatment or control conditions (2018, 223–227). They further reviewed meta-analyses of controlled outcome studies on the effectiveness of behavior therapy for specific disorders such as obsessive-compulsive disorder, panic disorder, developmental disability, eating disorders, attention-deficit hyperactivity disorder, anger disorders, autism spectrum disorder, nocturnal enuresis (bed-wetting at night), hypertension, migraine headache, insomnia, and irritable bowel syndrome, and also for enhancing prosocial behavior, mainly with positive results.
The controlled outcome research shows that behavior therapy and cognitive-behavioral therapy are often effective in treating both psychological symptoms (e.g., anxiety, depression, eating disorders) and somatic symptoms (e.g., hypertension, migraine headaches, irritable bowel syndrome). Behavior therapy is therefore an effective treatment not only for psychological or mental disorders but also for some general health conditions.
Prochaska and Norcross also reviewed the controlled outcome research on the effectiveness of three exposure therapies: implosive therapy, exposure therapy, and eye movement desensitization and reprocessing. Implosive therapy has been found to be significantly better than no treatment and placebo treatment, and equally effective, if not better, than certain other therapies (see 2018, 183). Exposure therapy, including virtual reality exposure, has been shown to be an effective treatment and one of the treatments of choice for posttraumatic stress disorder, obsessive-compulsive disorder, panic disorder, social anxiety disorder, and specific phobia, with greater effectiveness than no treatment and possibly several other treatments, and greater or similar effectiveness when compared to pharmacotherapy, medications (2018, 183–186). Finally, EMDR has been found to be an effective treatment, especially for PTSD, comparable to exposure therapy and better than no treatment and nonexposure therapies (see 2018, 191–192). The eye movements in EMDR may not be necessary for its effectiveness, which may be mainly due to the exposure component of this treatment, with further research needed to clarify the essential components of EMDR responsible for its effectiveness (Spiegler 2016, 263–264). However, a couple of recent systematic reviews concluded with some evidence for the eye movements making a distinct contribution to the effectiveness of EMDR (C. W. Lee & Cuijpers 2013; Jeffries & Davis 2013).
G. Terence Wilson (2008, 246–251) also reviewed the research evidence supporting the effectiveness of behavior therapy for a wide range of psychological disorders in various populations and settings, including education, medicine, and community living. He included behavior therapy for anxiety disorders (e.g., panic disorder, OCD, PTSD), depression (especially the use of behavioral activation), eating and weight disorders (e.g., binge eating and bulimia nervosa, obesity), schizophrenia, childhood disorders, behavioral medicine, prevention and treatment of cardiovascular disease, and other applications to diverse health-related problems (e.g., headaches, pain conditions, asthma, epilepsy, sleep disorders, nausea reactions in cancer patients receiving radiation treatment, children’s fears regarding hospitalization and surgery, and treatment compliance).
Wilson (2008) noted that the most thorough and rigorous evaluations of both psychological and pharmacological treatments and their effectiveness, efficacy, for various clinical disorders are those done by the National Institute for Clinical Excellence (NICE) in the United Kingdom (see, e.g., National Institute for Clinical Excellence 2004). Treatment guidelines issued by NICE, based on research data, are graded from A (with rigorous empirical support from well-controlled RCTs) to C (with expert opinion and strong empirical data). Behavior therapy has done very well, usually receiving A ratings from the NICE evaluations. Behavioral interventions are recommended by NICE as the psychological treatments of choice for specific anxiety and mood disorders and evaluated as being equivalent to pharmacological treatment in effectiveness. Behavior therapy has also been rated as more effective than medication for eating disorders (Wilson & Shafran 2005).
Behavior therapy has also fared very well in the list of empirically supported treatments first established in 1995 by Division 12 (Society of Clinical Psychology) of the American Psychological Association, still dominating an earlier update of such a list together with cognitive behavior therapy (see Woody, Weisz, & McLean 2005). More recently, in a 2017 updated list provided by the Society of Clinical Psychology, Martin Antony noted that more than three-quarters of the eighty listed empirically supported psychological treatments for specific disorders are behavioral or cognitive-behavioral therapies, with a few others that had behavioral components (2019, 224). Third-wave versions of behavior therapy (DBT, MBSR, MBCT, and ACT) have also received more empirical support for their therapeutic effectiveness, and more details are provided in chapter 13 of this book (see also Prochaska & Norcross 2018, 270–288; J. Sommers-Flanagan & Sommers-Flanagan 2018, 382–387). As Wilson (2008) notes, recent research has shown that behavior therapy is also effective in real-life community-based clinical settings (e.g., Foa et al. 2005; see also Van Ingen, Freiheit, & Vye 2009; Stewart & Chambless 2009) and with ethnic minority clients (e.g., Miranda et al. 2005; see also Horrell 2008).
Behavior therapy is therefore the most empirically researched approach to therapy and also the most empirically supported treatment (together with cognitive behavior therapy) available today. Its empirical status is substantial and solid, and it will continue to be the most empirically studied of all the major approaches to therapy.
Future Directions
Behavior therapy is still a significant primary theoretical orientation of psychotherapists surveyed in the United States, as evidenced in the following percentages of therapists indicating it as such (see Prochaska & Norcross 2018, 3): clinical psychologists (15 percent), counseling psychologists (2 percent), social workers (11 percent), and counselors (8 percent). Behavioral interventions are also often used by therapists who indicate cognitive therapy or eclectic/integrative therapy as their primary theoretical orientation (with much higher percentages).
The Association for Advancement of Behavior Therapy (AABT), founded in 1966 in the United States as a multidisciplinary group interested in behavior therapy (C. Glass & Arnkoff 1992, 597), changed its name in 2005 to the Association for Behavioral and Cognitive Therapies (ABCT), reflecting the trend of behavior therapy toward a more cognitive-behavioral orientation. It has a membership of over 4,500, consisting of psychologists and other mental health professionals and students with an interest in behavior therapy, cognitive behavior therapy, behavioral assessment, and applied behavioral analysis. It publishes two journals, Behavior Therapy and Cognitive and Behavioral Practice, and a newsletter, the Behavior Therapist. Further information about training in behavior therapy and membership in ABCT can be obtained through its website (www.abct.org) (see Corey 2021, 266–267).
There now are numerous behavior therapy societies and organizations worldwide, including the European Association of Behaviour Therapy, which has organized annual conferences in different European countries since 1970. Their tenth annual meeting, held in Jerusalem, became the first World Congress in Behavior Therapy. Since the publication of Behaviour Research and Therapy as the first journal solely devoted to behavior therapy in 1963, the number of journals focusing primarily or solely on behavior therapy and its various offshoots now exceeds fifty (Fishman & Franks 1992, 169). Another major behavioral organization in the United States, the Association for Behavior Analysis International (www.abainternational.org), focuses on the application of Skinner’s operant conditioning approach and resists the development of behavior therapy toward a more cognitive-behavioral orientation (Fishman & Franks 1992, 169).
Wilson (2008) has described two major challenges to behavior therapy in the twenty-first century. The first challenge is to spread the use of empirically supported behavioral interventions and techniques for various common clinical disorders more widely and effectively, with the concomitant need to further develop simpler behavioral methods so that more mental health professionals can easily learn to use them. The second challenge is to develop even more effective behavioral treatments for a wider range of clinical problems, with a focus on determining why they work. Wilson also emphasizes the need for behavior therapy to be more rooted in the latest developments in experimental psychology as well as biology, especially in the areas of genetics and neuroscience. Behavior therapists must better understand brain mechanisms and their impact on clinical disorders (e.g., Baxter et al. 1992) so that they can develop more-sophisticated theories and more-effective behavioral treatments to enable behavior change.
Prochaska and Norcross (2018, 235) have predicted that behavior therapy will continue to expand and grow in many directions in the coming years as one of the coming years as one of the premier contemporary approaches to therapy. They anticipate two future directions for behavior therapy that will be more enduring. The first involves the greater integration of behavior therapy and its many effective techniques for behavioral change into health-care practice and the health-care system, focusing not only on mental health problems but also on medical problems, including those encountered in the fields of pediatrics, dentistry, and cardiology. The second involves the more widespread use of technology, especially in this computer age. Behavior therapists are well known for using virtual reality treatments, electronic tracking of patient progress, smartphone apps, and online programs and interventions. There will be more online behavior therapy with specific interventions to fit specific cyber clients in the coming decade. The third wave of behavior therapy—including DBT, MBSR, MBCT, and ACT—will continue to develop in significant and exciting ways in the years ahead (see chap. 13 of this book).
Finally, Antony (2019, 231–232) briefly described the following significant emerging areas of research as key future directions for behavior therapy: (1) improving effectiveness of behavioral interventions to benefit more people; (2) understanding the mechanisms underlying treatment or why specific behavioral interventions are effective; (3) enhancing dissemination of effective behavioral interventions by finding ways to increase accessibility to them and therefore their use by more people; (4) the role of cognitive enhancers such as D-Cycloserine, which is an antibiotic used for tuberculosis but can be helpful for improving extinction learning in exposure therapy (see Rodriguez et al. 2014); and (5) adapting behavior therapy for diverse populations, including clients from different cultural and ethnic backgrounds, religious groups, sexual orientations, physical disability levels, educational levels, ages, socioeconomic statuses, and so forth (see Hinton & La Roche 2014; see also Hays 2009, 2016).
Recommended Readings
Antony, M. M., & Roemer, L. (2011). Behavior therapy. Washington, DC: American Psychological Association.
Barlow, D. H. (Ed.). (2021). Clinical handbook of psychological disorders: A step-by-step treatment manual (6th ed.). New York: Guilford.
Goldfried, M. R., & Davison, G. C. (1994). Clinical behavior therapy (Expanded ed.). New York: Wiley & Sons.
Herbert, J. D., & Forman, E. M. (Eds.). (2011). Acceptance and mindfulness in cognitive behavior therapy: Understanding and applying the new therapies. Hoboken, NJ: Wiley & Sons.
Kazdin, A. E. (2013). Behavior modification in applied settings (7th ed.). Long Grove, IL: Waveland.
Miltenberger, R. G. (2016). Behavior modification: Principles and procedures (6th ed.). Boston: Cengage Learning.
Roemer, L., & Orsillo, S. M. (2020). Acceptance-based behavioral therapy: Treating anxiety and related challenges. New York: Guilford.
Spiegler, M. D. (2016). Contemporary behavior therapy (6th ed.). Boston: Cengage Learning.
Chapters 13
Mindfulness and Acceptance-Based Cognitive-Behavioral Therapies
DBT, MBSR, MBCT, and ACT
The third wave of relatively contextualistic mindfulness and acceptance-based cognitive-behavioral therapies (CBTs)—including dialectical behavior therapy (DBT), mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and acceptance and commitment therapy (ACT), briefly mentioned earlier in chapter 11 on behavior therapy in this book—now occupy a central place in contemporary behavior therapy and cognitive behavior therapy. In a recent Delphi poll, mindfulness therapies were ranked at the top of the list of psychotherapy orientations predicted to thrive or increase the most in the next decade (see Prochaska & Norcross 2018, 442). Cognitive behavior therapy is a close second, followed by integrative therapy, multicultural therapies, and motivational interviewing in the top five of the list. Third-wave therapies are now often considered a major school or approach to counseling and psychotherapy, but still part of a broader cognitive-behavioral therapy (see, e.g., Prochaska & Norcross 2018, 270–288; Messer & Kaslow 2020, 183–217). They will therefore be covered in more detail in this chapter.
The four major examples of mindfulness and acceptance-based CBTs (DBT, MBSR, MBCT, and ACT) all share a common and core emphasis on mindfulness, focusing attention on one’s immediate experience in the present moment, with acceptance or an open, curious, and receptive mindset without judgment or censure (see Baer 2014; Hayes, Follette, & Linehan 2004; Herbert & Forman 2011; Roemer & Orsillo 2009, 2020; S. L. Shapiro & Carlson 2017; also K. W. Brown, Creswell, & Ryan 2015; Ie, Ngnoumen, & Langer 2014).
The following is a widely used operational definition of mindfulness provided by Scott Bishop and colleagues: “We propose a two-component model of mindfulness. The first component involves the self-regulation of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present moment. The second component involves adopting a specific orientation that is characterized by curiosity, openness, and acceptance” (Bishop et al. 2004, 232).
Biographical sketches of the key figures in these third-wave mindfulness-based CBTs will first be provided.
Biographical Sketches of Key Figures in Mindfulness-Based Cognitive-Behavioral Therapies
Dialectical Behavior Therapy (DBT)
Marsha M. Linehan (1943–) is the founder and developer of DBT, originally created by Linehan in the 1970s to more effectively help self-injurious and chronically suicidal patients who were most frequently diagnosed with borderline personality disorder (BPD). When she was younger, she had vowed to get miserable people out of their living hell in this world. Linehan revealed her own journey through the hell of mental illness in a talk to about thirty former patients and at a later public lecture to a larger audience on the same day, on June 18, 2011, at the Institute of Living in Hartford, Connecticut. When she was seventeen years old, she was a patient there for two years and a month, in the locked unit because of her many suicide attempts and mental illness, with a diagnosis then of schizophrenia, but probably suffering from BPD. She received many treatments but was not helped by any of them. Then she made her vow that if she got out, she would help as many people as she could to climb out of their hell of suffering such mental misery. In her recent memoir, she described this period of her life as “the real origins of DBT” (Linehan 2020, 323). In developing DBT and telling her own story in public, Linehan has brought tremendous hope as well as effective therapeutic help to many patients suffering not only from BPD but also from other disorders.
Linehan obtained her PhD in experimental personality psychology from Loyola University in Chicago in 1971 and did her one-year internship at the Suicide Prevention and Crisis Clinic in Buffalo, New York. This was followed by further postdoctoral training in clinical behavior therapy with Marvin Goldfried and Gerald Davison at State University of New York at Stony Brook (see Prochaska & Norcross 2018, 274–275).
Linehan is a professor of psychology and adjunct professor of psychiatry and behavioral sciences, as well as the director emeritus of the Behavioral Research and Therapy Clinics at the University of Washington. She founded several organizations, including the DBT-Linehan Board of Certification, the International Society for the Improvement and Teaching of Dialectical Behavior Therapy, Behavioral Tech Research, Behavioral Tech, and the Linehan Institute (Linehan 2020, 339). She has also received numerous awards for her contributions to suicide research and research in clinical psychology, such as the Gold Medal Award for Life Achievement in the Application of Psychology from the American Psychological Foundation, the Grawemeyer Award in Psychology, and the Career/Lifetime Achievement Award from the Association for Behavioral and Cognitive Therapies (see Linehan 2020). She has published numerous articles and four key books on DBT (Linehan 1993a, 1993b, 2015a, 2015b).
In the afterword of her recent memoir, Linehan (2020, 335) notes that DBT has become well established beyond the United States, in Latin America, Europe, Asia, and the Middle East. It has now been found to be effective in helping people with other disorders besides BPD, such as substance dependence, PTSD, depression, and eating disorders. She shared more deeply about her own spirituality and her Catholic background. She also had training in Zen, initially from Willis Jäger, a German Benedictine monk who combines Zen and Christian mysticism. She then became a Zen teacher and a Zen master (Linehan 2020, 255–276). More recently she has been attending a Lutheran church (with a couple of good friends) that has become a wonderful community for her, nurturing her spiritual life. She feels that she has fulfilled the vow she made to God many years ago while she was a patient at the Institute of Living, but she will go on keeping that vow to help even more people with DBT. She emphasizes the crucial importance of her faith: “I love God, and I love to pray. So I am happy with all of that. . . . I can’t imagine my life without faith. The single most important gift my mother gave me was faith” (Linehan 2020, 334).
Mindfulness-Based Stress Reduction (MBSR)
Jon Kabat-Zinn (1944–) is a world-renowned writer, scientist, and mindfulness meditation teacher, who created and developed MBSR, an earlier mindfulness approach to stress reduction, especially in medical settings and with medical patients (see mindfulnesscds.com for details on Kabat-Zinn). He is professor of medicine emeritus at the University of Massachusetts Medical School, where in 1979 he founded the internationally known Mindfulness-Based Stress Reduction Clinic, and in 1995 the Center for Mindfulness in Medicine, Health Care, and Society. He retired in 2000; yet under the leadership of Dr. Saki Santorelli, the Center for Mindfulness has grown significantly, with even greater influence nationally and around the world.
Kabat-Zinn obtained his PhD in molecular biology in 1971 from MIT, under the guidance of Salvador Luria, who was a Nobel Laureate in physiology and medicine. He has applied MBSR and studied the effects of mindfulness meditation for stress reduction, chronic pain, women with breast cancer, men with prostate cancer, patients having bone-marrow transplants, as well as with inmates and staff in prison settings, with corporate and work stress, and in professional sports and multicultural contexts. His MBSR model has been used in over 720 clinics and medical centers nationally and internationally, with seventeen of them in Northern California’s Kaiser Permanente system. Kabat-Zinn has received many awards for his work in medicine and health-related areas through his MBSR programs and the implementation of mindfulness meditation, including Interface Foundation Career Award and New York Open Center’s Tenth Year Anniversary Achievement in Medicine and Health Award in 1994; Art, Science, and Soul of Healing Award from the Institute for Health and Healing, Pacific Medical Center in San Francisco, in 1998; 2nd Annual Trailblazer Award for “pioneering work in the field of integrative medicine” from the Scripps Center for Integrative Medicine in La Jolla, California, in 2001; and the 2008 Mind and Brain Prize from the Center for Cognitive Science, University of Turin, Italy, in 2008.
Kabat-Zinn has written several well-known books, including the revised and updated version of Full-Catastrophe Living (2013), Wherever You Go, There You Are (2005), and Everyday Blessings, a book on mindful parenting coauthored with his wife, Myla (M. Kabat-Zinn & Kabat-Zinn 2014). He also coauthored a self-help book on MBCT (which is based on MBSR) for depression, The Mindful Way through Depression, with J. Mark Williams, John Teasdale, and Zindel Segal, who developed MBCT (J. M. G. Williams, Teasdale, et al. 2007).
Mindfulness-Based Cognitive Therapy (MBCT)
Zindel V. Segal (1956–), with a PhD from Queens University in Kingston, Ontario, Canada, is one of the founders of MBCT, together with J. Mark Williams and John Teasdale; Segal is distinguished professor of psychology in mood disorders at the University of Toronto-Scarborough, Canada. He is director of clinical training in the clinical psychological science program and also professor in the Department of Psychiatry. Segal developed MBCT with Williams and Teasdale (based on Kabat-Zinn’s MBSR) for preventing relapse in depression, especially for patients who have had three or more previous depressive episodes (Segal, Williams, & Teasdale 2013). He has also coauthored a self-help book on MBCT for depression and chronic unhappiness (J. M. G. Williams, Teasdale, et al. 2007) and another self-help book on MBCT for depression and emotional distress (Teasdale, Williams, & Segal 2014).
Segal has continued to emphasize the relevance and usefulness of mindfulness-based clinical care in psychiatry and mental health. He is a founding fellow of the Academy of Cognitive Therapy and has received several awards, including the Hope Award from the Mood Disorders Association of Ontario in Canada, and the Douglas Utting Prize for significant contributions to the understanding and treatment of depression.
MBCT, which combines mindfulness training and cognitive-behavioral therapy, has not only been effectively used for the prevention of relapse and recurrence in major depression, but also appears promising for substance abuse, anxiety in children, externalizing disorders in adolescents, pregnant women at risk for depression, chronic fatigue syndrome, tinnitus, hypochondriasis, auditory hallucinations, social phobia, generalized anxiety disorder, panic disorder, insomnia, depression in primary care, and patients with cancer (see Segal, Williams, & Teasdale 2013, 406–407). More recently, MBCT has also been adapted for use with patients at risk for suicide (J. M. G. Williams, Fennell, et al. 2015), patients with bipolar disorder (Deckersbach et al. 2014), and patients with OCD (Didonna 2020).
J. Mark G. Williams (1952–), with a PhD from the University of Oxford, is a cofounder and developer of MBCT together with Zindel Segal and John Teasdale, and he is emeritus professor of clinical psychology and honorary senior research fellow in the Department of Psychiatry at the University of Oxford, United Kingdom. He has held previous positions at the University of Newcastle upon Tyne, the Medical Research Council in Cambridge, and the University of Wales Bangor. He is a fellow of the British Psychological Society, the Academy of Medical Sciences, and the British Academy. Although he is retired, he has continued to train teachers of mindfulness worldwide.
Williams has written several books, including being coauthor of the text on MBCT (Segal, Williams, & Teasdale 2013), coauthor of a self-help book on MBCT for depression and chronic unhappiness (J. M. G. Williams et al. 2007), coauthor of another self-help book on MBCT for depression and emotional distress (Teasdale, Williams, & Segal 2014), coauthor of a self-help book on mindfulness for finding peace in a frantic world (J. M. G. Williams & Penman 2011), and coauthor of a book on adapting MBCT for working with people at risk of suicide, in the transformation of despair (J. M. G. Williams et al. 2015).
Williams is also an ordained priest in the Church of England, as well as being honorary canon of Christ Church Cathedral in Oxford.
John Teasdale (1950–), with a PhD from the University of Cambridge, is a cofounder and developer of MBCT, together with Zindel Segal and J. Mark Williams. He held senior research appointments in the Department of Psychiatry, University of Oxford, and later in the Cognition and Brain Sciences Unit, Cambridge, United Kingdom, all funded by the Medical Research Council. He also was a visiting professor at the Institute of Psychiatry, University of London. Teasdale was a pioneer in research on and advances in cognitive therapy in the United Kingdom.
Teasdale is a founding fellow of the Academy of Cognitive Therapy, as well as a fellow of the British Academy and the Academy of Medical Sciences. He has received several awards, including the Distinguished Scientist Award from Division 12 (Society of Clinical Psychology) of the American Psychological Association. He is coauthor of some well-known books on MBCT, including the major revised text (Segal, Williams, & Teasdale 2013) and two self-help books on using MBCT for depression and emotional distress (Teasdale, Williams, & Segal 2014), and for depression and chronic unhappiness (J. M. G. Williams, Teasdale, et al. 2007).
Although Teasdale is retired, he continues to be actively involved in teaching mindfulness and insight meditation internationally.
Acceptance and Commitment Therapy (ACT)
Steven C. Hayes (1948–) is the originator and codeveloper of ACT (pronounced as a word, not as initials), together with Kirk Strosahl and Kelly Wilson, and the three coauthored the definitive text on ACT, now in its revised version (Hayes, Strosahl, & Wilson 2012). He has also coauthored a best-selling self-help book on ACT (Hayes & Smith 2005). In his later book, A Liberated Mind (Hayes 2019), he shares about his earlier struggles with panic attacks amid intense anxiety that started in the fall of 1978 (at a very heated faculty meeting), with a major recurrence in the winter of 1981 at night on sudden awakening, and how they have helped him to develop ACT. He applied what now are ACT techniques to himself and effectively dealt with his panic attacks, including using acceptance and mindfulness and cognitive defusion or distancing himself from his thoughts and simply letting them come and go rather than fixating on them and fighting them. The emphasis in ACT is on psychological flexibility. His last panic attack was more than two decades earlier, although he still experienced intense anxiety from time to time. But he has been able to successfully use ACT techniques for his anxiety (see Hayes 2019, 15–17, 29–40, 78, 145–148, 198, 259, 299–300).
Hayes finally got into graduate school at West Virginia University in 1972, after two years of trying unsuccessfully due to a letter of reference written by a professor who made disparaging remarks about his hippie appearance. He had lived for several months in a commune with Eastern religious people in Grass Valley, California. In 1977 Hayes obtained his PhD in clinical psychology from West Virginia University, a stronghold of Skinnerian-oriented behavior analysis (see Prochaska & Norcross 2018, 271). Hayes did a one-year internship at Brown University under the strong influence and mentoring of David Barlow. He then became a faculty member at the University of North Carolina at Greensboro from 1977 to 1986 before joining the faculty at the University of Nevada in 1986 (see career influences and a brief intellectual autobiography at stevenc hayes.com).
Hayes is currently Nevada Foundation Professor in the Behavior Analysis program in the Department of Psychology at the University of Nevada. He is author of close to 650 scientific articles and 46 books, focusing mainly on the nature of human language and cognition, and on developing relational frame theory as well as acceptance and commitment therapy. He has also served as president of the APA’s Division 25 (Division of Behavior Analysis), the American Association of Applied and Preventive Psychology, the Association for Contextual Behavioral Science, and the Association for Behavioral and Cognitive Therapies (ABCT). He helped in the formation of the Association for Psychological Science and served as its first secretary-treasurer.
Hayes is a fellow of the American Association for the Advancement of Science and other scientific associations. He has received several awards, including the Lifetime Achievement Award from ABCT, the Exemplary Contributions to Basic Behavioral Research and Its Applications from APA’s Division 25, and the Impact of Science on Application Award from the Society for the Advancement of Behavior Analysis (see unr.edu on Stephen Hayes).
Hayes continues to be very involved in applying ACT to an ever-widening range of problems and issues, and in his attempts to further understand and alleviate human suffering. Recently he described the following seven major areas in which ACT has been used or applied: adopting healthy behaviors (dieting and exercise, coping with stress, sleep); mental health (depression, anxiety, substance abuse, eating disorders, psychosis); nurturing relationships (helping others nurture flexibility, parenting, relationships with romantic partners, combating abuse, overcoming prejudice); bringing flexibility to performance (tackling procrastination, learning and creativity, dealing with constraints at work, sports performance); cultivating spiritual well-being (practicing perspective-taking, cultivating forgiveness, ACT and religion); coping with illness and disability (chronic pain, diabetes, cancer, tinnitus, terminal illness); and social transformation (see Hayes 2019, viii–ix, 275–385).
Major Theoretical Ideas of Mindfulness and Acceptance-Based CBTs
Perspective on Human Nature
The basic perspective on human nature of mindfulness and acceptance-based CBTs is similar to that of CBT in general, which was covered in the preceding chapter. In a nutshell, CBT does not view human beings in a radically behavioristic way, with no free will. Instead, CBT has a broader view of human nature, including a person having some capacity for choice and self-reflection as well as self-control or self-regulation, following Albert Bandura’s (1977a, 1977b, 1986, 1997) theory of self-efficacy and reciprocal determinism. The CBT perspective, including that of third-wave mindfulness and acceptance-based approaches, however, still views human beings as essentially neutral, being neither intrinsically evil nor inherently good, although there is the potential to choose and build a life worth living (Linehan 2020).
Basic Theoretical Principles of Mindfulness and Acceptance-Based CBTs
There are at least five major characteristics or “core themes” of third-wave, or the “third-generation,” behavior therapies or cognitive-behavioral therapies, according to Michael Spiegler (2016, 400–407), that can also be considered as their basic theoretical principles. First, they have a view of psychological health that is expanded and that does not narrowly focus on symptom alleviation and the elimination or avoidance of psychological pain and suffering. Suffering or psychological pain is seen as an inevitable part of human life in this imperfect world, therefore to be accepted and even embraced, not avoided, but handled in a less engaged way through decentering or distancing. Psychological struggles and symptoms are not to be directly fought against or controlled, but more passively accepted, letting them come and letting them go as thoughts and feelings that are not the whole of a person’s self or identity.
Second, they have a broader view of what are acceptable outcomes in therapy and emphasize second-order change instead of first-order change. First-order change refers to direct reduction or alleviation of psychological symptoms such as anxiety, depression, anger, and other problems, for example, by directly trying to change maladaptive thinking through cognitive restructuring, or change problematic behaviors and feelings through coping skills training, exposure treatments, or behavioral activation, with weekly scheduling of positively reinforcing and meaningful events and experiences. These are the goals of therapy for first-wave and second-wave behavior therapists practicing traditional behavior therapy, or CBT. Second-order change is the goal of therapy for third-wave cognitive-behavioral therapists who focus on changing the function and not necessarily the form of the psychological problems. Clients learn to still live according to their core values in committed action and accomplish their goals in a life worth living, even if they continue to experience some emotional discomfort or pain. Successful or effective therapy therefore does not focus as much on symptom alleviation but more on effective living according to one’s deeply held values, which paradoxically may lead to better functioning and eventual improvement even in psychological suffering and symptoms. However, skills training for more effective living is not ignored or discounted; therefore, more traditional cognitive-behavioral coping skills and social skills training may be used, as in DBT, as well as mindfulness skills to facilitate deeper acceptance of what can and what cannot be easily changed.
Third, acceptance is another common and crucial characteristic of third-wave CBTs. Acceptance refers to “fully accepting one’s experience at the moment just as it is, without judging it” (Spiegler 2016, 402). While acceptance is central to Buddhism, it is also consistent with Christian contemplative spirituality (see Tan 2011b). It is, of course, easier to practice acceptance of pleasant experiences, but it is much more difficult to accept or embrace negative and painful experiences. Third-wave approaches to CBT focus on helping clients learn to practice acceptance.
Fourth, mindfulness is another key aspect and practice of third-wave CBTs. It refers to intentionally paying attention to the present moment in the here and now, to what is happening, without any censure or judgment. Several exercises are used to help clients experience and engage in mindfulness, such as mindful breathing, focusing on one’s breath, breathing in and out naturally. Mindfulness is closely connected with acceptance because acceptance requires mindfulness for it to be fully experienced. Third-wave CBT is therefore also called mindfulness-based and acceptance-based CBT. Mindful acceptance is a crucial skill and intervention in such therapy to help clients be more defused or distanced from their psychologically troubling thoughts and feelings, without avoiding them or trying to control them, but being less stuck on them, learning to observe them and let them come and go.
Fifth, the last major characteristic or core theme of third-wave CBT is that the ultimate overarching goal of therapy is to help clients create for themselves a life worth living, according to their own values. The aim is to lead them to experience meaning and fulfillment or happiness in their lives, not simply the alleviation of symptoms or feeling better.
Spiegler points out that there are other behavior therapies or CBTs that are related to third-generation or third-wave therapies, such as behavioral activation, functional analytic psychotherapy, and integrative behavioral couple therapy (2016, 407). However, the four major third-wave CBTs that are mindfulness- and acceptance-based are DBT, MBSR, MBCT, and ACT. There are a few other lesser-known approaches such as mindfulness-based cognitive therapy for children, mindfulness-based relapse prevention, and mindful sport performance enhancement (Spiegler 2016, 406), as well as mindfulness-based eating awareness training, mindfulness-based relationship enhancement, and mindfulness-based cancer recovery, all based on MBSR (see S. L. Shapiro & Carlson 2017, 58–59), but they will not be covered in this chapter.
Mindfulness and acceptance-based CBTs therefore differ from traditional CBT approaches by not teaching clients to directly dispute or cognitively restructure identified problematic thoughts (cognitive distortions or irrational beliefs) in attempts to control, reduce, or replace them. Instead, clients learn how to more passively accept such troubling thoughts (or painful emotions like anxiety and depression) and let them come and go, using mindfulness strategies.
Two general philosophical worldviews that CBT approaches may assume are elemental realism and functional contextualism (see Masuda & Rizvi 2020, 186–188). Elemental realism is the more commonly followed philosophical worldview referring to methodological behaviorism, which views a specific behavioral phenomenon as having crucial elements in interaction with each other. It emphasizes operationalism in clearly defining the parts that together compose the behavioral phenomenon of interest. Prediction is the ultimate goal in this scientific approach, with an emphasis on research methods that are nomothetic rather than idiographic. Functional contextualism, on the other hand, views the behavioral phenomenon being studied as the outcome of behavior-environment interactions holistically, referring to the act of a whole person in context. The focus is therefore on the function, meaning, or purpose of a specific behavioral phenomenon, discovered only in the behavior-context relation. A. Masuda and S. L. Rizvi (2020, 187) noted that MBCT tends to follow elemental realism more than DBT and ACT, and ACT tends to follow functional contextualism most, with DBT somewhat in between MBCT and ACT (see also S. Hughes 2018). The third-wave CBTs, on the whole, tend to be relatively contextualistic.
Development of Psychopathology
Third-wave CBTs do not view distorted thinking or irrational beliefs as the underlying cause of psychopathology, as traditional CBT tends to do. It is not the content or occurrence of specific thoughts and other private experiences such as feelings and perceptions that is problematic, but the way a client reacts or responds to them (Segal, Williams, & Teasdale 2013). Cognitive processes in human beings can be helpful, for example, in problem-solving for everyday events, but they can also become rigid and lead to ruminative thinking and ineffective problem-solving as well as avoidance. Emotional dysregulation and experiential avoidance are the end results, and they are viewed as the underlying cause or core process of psychopathology from a third-wave CBT perspective (Hayes, Wilson, et al., 1996).
A third-wave CBT view of psychological health can be summarized as a synthesis of three behavioral dimensions: centered, open, and engaged response styles (Masuda & Rizvi 2020, 188–189; see also Hayes, Strosahl, & Wilson 2012, 67). A centered response style can also be described as an aware and centered response style that includes attending intentionally to what one is experiencing in the here and now, moment to moment, and expanding one’s awareness and focused attention, with the self as the context of all of one’s experience. In the actual practice of third-wave CBTs, strategies used to help clients develop an aware and centered response style include present-moment awareness, self-as-context, and being mode of mind (see Hayes, Strosahl, & Wilson 2012; Segal, Williams, & Teasdale 2013). An open response style refers to experiencing the here and now, the present moment, as it is, as openly and fully as possible, without judgment or censure and therefore without reacting to it or acting on it. Third-wave CBT includes the following descriptions of this open response style: acceptance, detachment, metacognitive awareness, defusion, decentering, emotion regulation, and so on (Masuda & Rizvi 2020, 189). Finally, an engaged response style refers to engaging in daily life and activities in a way that is consistent with one’s deeply held values, which makes life meaningful and worth living.
Psychopathology, according to a third-wave CBT perspective, is usually characterized by rigidity and narrowness as well as imbalance, with behavioral deficits in the key response styles that are centered, open, or engaged, and behavioral excesses in experiential avoidance, rumination, and emotion dysregulation (Masuda & Rizvi 2020, 189–190). More specifically, the three corresponding behavioral dimensions of psychopathology that are the opposite of the healthy centered, open, and engaged response styles are (1) mindlessness, impulsivity, rumination, and lack of awareness; (2) experiential avoidance, emotion dysregulation, and low distress tolerance; and (3) narrowness or deficits in constructive behavioral repertoires (Masuda & Rizvi 2020, 190).
More specifically, from an ACT perspective, psychopathology is due to psychological inflexibility or rigidity (and psychological flexibility is characteristic of well-being and a greater quality of life). The six core pathological processes of psychological rigidity are “fusion, experiential avoidance, inflexible attention, remoteness from values, unworkable action, and fusion with self-concept” (R. Harris 2019, 33; see also Hayes, Strosahl, & Wilson 2012, 62).
Akihiko Masuda and Shireen Rizvi provide the following summary of a third-wave CBT view of psychological health or well-being in contrast to psychopathology: “In summary, greater behavioral adaptation or psychological flexibility characterized by the combination of centered, open, and engaged response styles may be viewed as an ideal state of well-being or healthy personality. These behavioral skills do not eliminate psychological struggles, but they help individuals navigate themselves through the joy and sorrow their lives bring” (2020, 191).
DBT’s view on psychopathology differs somewhat from what has been presented thus far, which is based more on ACT and MBCT. While ACT views so-called normal minds as producing psychopathological thoughts and feelings due to cognitive processes that tend to be destructive, DBT—originally developed to treat patients with borderline personality disorder (BPD)—views borderline psychopathology as resulting from genetic and social abnormalities, using a biosocial model of psychopathology. BPD is due to a biological vulnerability for intense reactions to emotionally charged situations, needing longer recovery times afterward. Patients with BPD are also especially vulnerable to social situations that punish, minimize, or ignore them, thereby leading to deep feelings of being invalidated. Experiences of physical, sexual, or emotional abuse further exacerbate or worsen their psychological pain and struggles. They often react intensely and emotionally in a very negative way—with hurt, anger, depression, anxiety, jealousy, and other feelings—to social situations that tend to trigger much milder responses in others. The eventual results are broken and strained relationships with others, including with the therapist (see Prochaska & Norcross 2018, 275; also Wang & Tan 2016).
Therapeutic Process and Relationship
While there are some similarities in how third-wave CBTs engage clients in the therapeutic process and relationship, there are also several differences among the four major third-wave CBTs: DBT, MBSR, MBCT, and ACT.
DBT therapists, who often treat patients with BPD who have had many experiences of being invalidated, relate as healthy parental figures to their patients, using strong validation strategies such as responsiveness, genuineness, engagement with warmth, and self-disclosure (Linehan 1993a), all in a genuine and radically accepting therapeutic relationship. However, appropriate limits are also set on the patients’ heightened emotional reactions and reactivity, with the DBT therapist engaging in a dialectic or balance between being empathic and warm at times and being appropriately firm and confrontational at other times, just as a good and responsive parent would be. The DBT therapist is available and on call at all times for emergencies. As therapy goes on, the DBT therapist will move on from a parenting style to more of a teaching and then consulting style, including providing behavioral or social skills training. Due to the demands and danger of burnout in working with intensely emotional and highly reactive patients with BPD, who can be very disruptive in therapy, DBT therapists need to have access to supportive supervisory consultations and groups (see Prochaska & Norcross 2018, 277).
MBCT therapists, like MBSR practitioners, actually refer to themselves as instructors more than as therapists. They guide and instruct their patients like good spiritual guides in secularized versions of mindfulness meditation, usually in groups of about twelve participants, to engage more in the being mode of mind instead of the doing mode of mind, which is often stuck in hyperactive problem-solving, attending more to the moment and here-and-now experience. The MBCT therapist, like the MBSR practitioner or trainer, also needs to be a practitioner of mindfulness to effectively serve as a model of mindfulness, focusing on the present moment in therapy with the being mode of mind, for their patients (see Prochaska & Norcross 2018, 279; see also Segal, Williams, & Teasdale 2013).
ACT therapists typically relate as coaches or trainers to their clients or patients, helping them to deal more effectively with troubling thoughts and painful emotions in a mindful and accepting way, letting them come and letting them go, rather than trying to control, decrease, or even avoid them. They therefore serve as mindfulness trainers for their clients, teaching them mindfulness and acceptance strategies and skills, with helpful exercises. As therapy continues, the ACT therapist will also engage in values clarification with clients so that they come up with the values that are most crucial to them, to live a meaningful and fulfilling life. They are then encouraged to be practically involved in committed action and activities in their lives, following their core values, even amid struggles with troubling thoughts and feelings, with the ACT therapist providing support and accountability. All this is done with radical acceptance and respect for clients. ACT therapists will also use skills training and other interventions from more traditional behavior therapy, or CBT, to help clients with specific skill deficits such as in the area of social skills, and thus serve as behavior analysts with their clients. The ultimate goal for clients is not so much to feel better but to live better, with more meaning and fulfillment in life because they are authentically living according to their deepest values (see Prochaska & Norcross 2018, 274).
The therapeutic relationship with the client is therefore crucial in third-wave CBTs, with radical acceptance and respect for the client, much as in person-centered therapy. However, in all the four major approaches of DBT, MBSR, MBCT, and ACT, direct teaching and training in mindfulness and acceptance strategies, as well as in behavioral skills training where and when needed, are also provided in the therapeutic process of helping clients. The major therapeutic techniques and interventions of these four third-wave CBT approaches will now be covered in more detail.
Major Therapeutic Techniques and Interventions
Dialectical Behavior Therapy (DBT)
DBT, originally developed by Marsha Linehan (1993a, 1993b, 2015a, 2015b) to treat patients with BPD, has a comprehensive standard treatment program that includes case management, skills training (in groups or individually), skills coaching in between sessions, and a consultation team for the DBT therapist. This standard treatment can also have pharmacotherapy and acute-inpatient psychiatric care if and when needed. However, DBT skills training is often provided as a stand-alone treatment by many therapists in private-practice settings, and it is apparently also effective (Linehan 2015b). DBT especially emphasizes the therapeutic relationship with the patient as a crucial part of effective therapy, as mentioned earlier, with genuineness and radical respect and acceptance for the client (see Wang & Tan 2016), but also with firmness and confrontation, when necessary, to set appropriate limits.
DBT helps clients to handle their intense emotions and reactivity by teaching them mindfulness and acceptance skills. The four major components of DBT are regulating affect, tolerating distress, improving interpersonal relationships, and training in mindfulness. The focus is on the integration of opposing ideas or dialectic balancing, especially in incorporating acceptance and change at the same time (see Tan 2011b). More specifically, in the mindfulness component of DBT, three “states of mind” are described: reasonable mind, which is rational or logical; emotional mind, which reacts with intense feelings that control thinking and acting; and wise mind, which balances and integrates reasonable mind with emotional mind. Six “mindfulness skills” are also taught: three “what” skills of mindfulness covering observing, describing, and participating; and three “how” skills of mindfulness, in a style that is described as nonjudgmental, mindfully unified, and effective (see S. L. Shapiro & Carlson 2017, 60; also Tan 2011b, 245).
It takes time and practice for clients to learn DBT skills and incorporate them into their lives. DBT therefore usually lasts for at least a year and consists of individual sessions and group skills training. It has been used not only in the treatment of BPD but also for a variety of other problems and in different settings (Dimeff & Koerner 2007; Dimeff, Rizvi, & Koerner 2021), including the private-practice office (Marra 2005). Several other helpful books, in addition to the texts by Linehan, are now available for learning DBT skills, both for professional therapists (see, e.g., Koerner 2011; Pederson 2015; Van Dijk 2013), as well as for laypeople and clients (see, e.g., M. McKay, Wood, & Brantley 2007; Pederson 2012).
The individual therapy provided in DBT usually has four overlapping stages (see Spiegler 2016, 420–421). After a comprehensive behavioral assessment is conducted and goals are collaboratively set by both the client and the therapist, with specific target behaviors and treatment methods agreed upon, stage 1 of DBT begins. Clients are at their worst level of functioning at this first stage, especially those with BPD, who may be highly suicidal and reactive, including engaging in self-injurious behaviors and behaviors that interfere with therapy. The main goal in stage 1 is therefore to protect the client and keep the client safe, alive, and in treatment. The DBT therapist also helps the client to cope better with other co-occurring problems such as substance abuse and depression, and learn skills needed to start developing a meaningful and worthwhile life.
In stage 2 of individual DBT, the therapist helps the client to react less intensely or emotionally to painful experiences or traumatic memories from the past, and thus to be more connected to their environment. This often involves the use of behavioral interventions such as exposure therapy to help the client be desensitized to painful or traumatic experiences; therefore, stage 2 can be challenging and difficult for the client. Exposure and other behavioral interventions need to be conducted sensitively and judiciously, in a way that will not further overwhelm the client.
In stage 3 of individual DBT, the therapist helps the client to strengthen what has been learned, to grow in self-efficacy and self-respect, competence, and in overall quality of life and ties with the environment. Finally, in stage 4 of individual DBT, the client learns to experience a deeper sense of freedom, joy in living, or spiritual meaning and fulfillment.
DBT also usually includes weekly two-and-a-half-hour sessions of group skills training that are conducted concurrently with the individual weekly sessions, over the course of a year or more. The group sessions are led by a skills trainer who is different from the individual therapist, in a structured way following a manual with handouts for specific skills training exercises (see Spiegler 2016, 421–423). To facilitate homework practice and use of these skills, a mobile phone application, DBT Coach, was developed and has been effectively used by clients with BPD and substance-use disorders in managing intense emotional reactions as well as urges to use substances (Rizvi et al. 2011).
The DBT group skills training covers four major skills: (1) core mindfulness skills based on Zen Buddhist techniques to help clients focus on the present moment with a nonjudgmental mindset, and to cultivate a wise mind as a balance between reasonable mind and emotional mind; (2) interpersonal effectiveness skills, including assertiveness skills and problem-solving skills, to help clients get what they want in appropriate ways, not be taken advantage of by others, and more effectively handle interpersonal conflicts; (3) emotion regulation skills, to help clients understand emotions and how they are affected by their feelings, to use mindfulness skills to observe and describe their emotions without judging or censuring them, and to debunk and let go of common myths about emotions (e.g., there is a right way to feel in every situation; painful or negative emotions are bad and should be avoided); and (4) distress tolerance skills to help clients tolerate and accept discomfort or distress especially in crisis situations by using the following skills: distracting, self-soothing, improving the moment (e.g., through cognitive restructuring), and thinking through the pros and cons of tolerating distress (see Spiegler 2016, 423).
The research evidence supporting the effectiveness of DBT for BPD as well as a number of other disorders will be covered later in this chapter.
Mindfulness-Based Stress Reduction (MBSR)
MBSR, originally developed by Jon Kabat-Zinn (2013) in 1979, is a more general third-wave CBT that has been used to help clients deal more effectively with stress and other medical conditions such as chronic pain and cancer. A specific shortened version of MBSR to help cancer patients, called mindfulness-based cancer recovery, was developed by Linda Carlson and her team in the late 1990s (L. Carlson & Speca 2010). Other examples of mindfulness-based therapies built upon MBSR include mindfulness-based eating awareness, mindfulness-based relationship enhancement, and mindfulness-based art therapy (see S. L. Shapiro & Carlson 2017, 58–59). The most significant third-wave CBT, based on MBSR, is MBCT, which will be covered in more detail later in this chapter.
MBSR is an intensive intervention that involves teaching clients several mindfulness practices, including practice meditation and gentle yoga daily for forty-five minutes, six days per week, at home. The following specific mindfulness techniques are used in homework practice: the body scan (by stages slowly paying attention to one’s immediate sensations or experience from one’s feet up to one’s hands, thus regarding one’s whole body with acceptance, awe, reverence, and kindness, without being judgmental), sitting meditation (with focus on the breath), walking meditation (with focus on walking movements), gentle yoga, and informal brief daily practice of mindfulness (by simply focusing on the breath) (see S. L. Shapiro & Carlson 2017, 53–56; see also Tan 2011b, 244).
MBSR has been used in hundreds of medical centers and clinics in the US and abroad. It has also been applied to a wider range of problems and settings. Besides the revised and updated text on MBSR by Kabat-Zinn (2013), there are also several helpful books on MBSR for clients and the lay public (see, e.g., Alidina 2015; Goldstein & Stahl 2015; Stahl & Goldstein 2019). The research evidence supporting the effectiveness of MBSR will be covered later in this chapter.
Mindfulness-Based Cognitive Therapy (MBCT)
MBCT, developed by Zindel Segal, J. Mark Williams, and John Teasdale (2013), is an integration of traditional CBT with MBSR for the prevention of relapse in depression, targeting specifically patients who have experienced three or more previous episodes of depression. It was not originally intended to be a treatment for acute major depression but to prevent recurrence of such depression. MBCT is a structured eight-week treatment, two hours per week, typically conducted in small groups, with a maximum of twelve patients who have had recurrent major depressive episodes. It consists of the following interventions: the body scan, sitting meditation, walking meditation, and informal daily mindfulness.
A specific and unique technique used in MBCT is called the “three-minute breathing space,” in which clients learn to take the first minute to be mindful of what their experience is right now at that moment with acceptance, the next minute to pay full attention to their breath, breathing in and out, and the third minute to refocus their attention on their whole body (e.g., facial expression, posture, feelings), with nonjudgmental acceptance (see S. L. Shapiro & Carlson 2017, 56–57; also Tan 2011b, 245). This technique or exercise can be adapted to be used simply as a mini-mindfulness practice that does not need to last three minutes or be a form of meditation. It can therefore be used anywhere and anytime by clients to help them shift from the doing mode, which focuses on analytical problem solving and often gets stuck in dysfunctional rumination, to the being mode, which focuses on the present-moment experience in a fully open and nonjudgmental posture, likewise an antidote to rumination. While rumination does not cause depression, it does lead to greater vulnerability to depression because it increases problem-solving that is self-focused (see Segal, Williams, & Teasdale 2013; also Rosales & Tan 2017). Dysphoric, depressive moods tend to trigger more negative thinking or rumination, which leads to further dysphoria. MBCT therefore focuses on teaching clients to be less reactive to dysphoric moods by using mindfulness skills and thus decentering from ruminative thoughts (see Rosales & Tan 2017, 76).
MBCT is conducted as a training course that is closed, so that no new members can be added once the eight-week group intervention has started. It is also standardized with two main phases:
Sessions 1–4 focus on teaching clients basic mindfulness skills, using techniques such as the body scan or sitting meditation (attending to one’s breath). These skills will help clients to respond to ruminative negative thoughts and feelings by decentering from them.
Sessions 5–8 focus on helping clients to practice decentering, be engaged in the being mode instead of the doing mode, and therefore let go of ruminations by using mindfulness skills even more, especially the “three-minute breathing space.” The last two sessions (7–8) are used to help clients learn to be more aware of their own warning signs of possible depression and to take specific steps to prevent the recurrence of depression, for example, by being involved in pleasant events and other activities that contribute to a sense of mastery (behavioral activation). The doing mode may be more helpful at this later stage, which includes some constructive problem-solving (see Segal, Williams, & Teasdale 2013; also Masuda & Rizvi 2020, 194–195; Rosales & Tan 2017, 77).
The MBCT therapist or instructor not only follows the structured course material for the group sessions, but also needs to have a personal mindfulness practice in order to lead or teach the group (Segal, Williams, & Teasdale 2013; see also Rosales & Tan 2017, 77).
MBCT has now been used to treat a wider range of disorders beyond the prevention of relapse or recurrence in major depression. It has also been adapted or shortened to a one-hour-per-session version (instead of two-hour sessions), in treating depression in diabetes patients with some success (Tovote et al. 2013). The research evidence for the effectiveness of MBCT will be covered later in this chapter.
Several other helpful books on MBCT are also available for professional therapists (see, e.g., Crane 2017; Woods, Rockman, & Collins 2019) and for clients and laypeople (see, e.g., Teasdale, Williams, & Segal 2014; J. M. G. Williams, Teasdale, et al. 2007; also J. M. G. Williams & Penman 2011).
Acceptance and Commitment Therapy (ACT)
ACT, developed by Steven Hayes with his colleagues Kirk Strosahl and Kelly Wilson (2012), is based on relational frame theory (RFT) and has six core processes or components in the ACT hexaflex: (1) acceptance, (2) defusion (focusing on developing flexibility versus rigidity in thinking), (3) flexible attention to the present moment (or contacting the present moment), (4) self-as-context (with a transcendent sense of self), (5) values, and (6) committed action (according to one’s core values) (see also Rosales & Tan 2016; Tan 2011b). The ACT hexaflex has also been described more simply as the ACT triflex; it consists of three major functional units that make up psychological flexibility (see R. Harris 2019, 8): (1) Be Present, consisting of self-as-context (or the noticing self) and contacting the present moment, involving flexibly attending to the here-and-now experience of the moment; (2) Open Up, consisting of defusion and acceptance that involve separating thoughts and feelings and accepting them for what they are, and letting them come and go; and (3) Do What Matters, consisting of values and committed action that involve initiating and maintaining meaningful and fulfilling or life-enhancing action based on one’s deeply held values (even amid troubling or painful thoughts and feelings). Psychological flexibility can therefore be described as “the ability to ‘be present, open up, and do what matters’” (R. Harris 2019, 9). ACT has been succinctly described as “ACT: Accept, Choose, Take Action” (Hayes, Strosahl, & Wilson 2012, 23).
In the context of choice or “choose,” Russ Harris (2019) has described a helpful tool or technique called the choice point, which quickly helps to clarify and delineate problems, locate the sources of suffering, and provide ACT interventions to deal with them. The choice point can be used anytime and for various purposes during therapy with ACT but is often brought up in the first session to help clients understand the ACT approach better and for informed consent to be obtained (R. Harris 2019, 9). In a nutshell, the choice-point technique asks clients—when they are facing or experiencing situations, thoughts, and feelings, especially difficult or painful ones—whether they will choose to engage in behaviors (covert and overt) that are hooked to moving them away from what they really want from successful therapy, or in behaviors that are unhooked to moving them toward what they really want from successful therapy. If they choose to be unhooked to move toward what they really want, then the following ACT interventions can be helpful: acknowledging whatever thoughts and feelings are being experienced, noticing and naming them, and being centered or grounded in the present moment with self-as-context—these are often part of the early steps in unhooking; later steps in unhooking usually involve using defusion and acceptance, including self-compassion skills; finally, connecting with one’s core or inner values also helps in unhooking and vice versa, and committed action according to such values will eventually result (see R. Harris 2019, 9–17). Harris (2019, 17) also clarifies that unhooking skills include all four core ACT processes of mindfulness (acceptance, defusion, self-as-context, and contacting the present moment), but any combination of them can be used by clients to “unhook” themselves from the troubling thoughts and feelings that may be adversely affecting them. Toward moves refer to psychological and physical action that is done with commitment to one’s core values. Hooked refers to two crucial processes underlying most of our psychological pain, according to ACT: cognitive fusion (being controlled or dominated by our thoughts) and experiential avoidance (trying to eliminate or avoid painful and unwanted thoughts and feelings).
In helping clients to accept painful experiences instead of trying so hard to control or change or avoid them, as well as to live in accordance with their deepest values in the midst of unpleasant feelings and thoughts, the ACT therapist has many techniques and exercises, including metaphors and the ACT matrix, to use with clients (see R. Harris 2013, 2019; Hayes, Strosahl, & Wilson 2012; see also Gordon & Borushok 2017; Hayes 2019; Luoma, Hayes, & Walser 2017; Polk et al. 2016; Stoddard & Afari 2014; Walser 2019; Westrup 2014). One example in helping clients engage in cognitive defusion from getting stuck in their troubling thoughts—so they see more clearly that they are not their thoughts, and a thought is just a thought—is to teach them to say, “I’m having the thought that I am useless” whenever they think to themselves “I’m useless.” Another example is for clients to imagine their thoughts written on leaves falling onto a moving stream and floating by, letting their thoughts simply come and go in the leaves-on-a-stream exercise (see Tan 2011b, 244; see also R. Harris 2019, 174–175). A final example in the process of helping clients to discover and connect with their deepest or core values is the exercise called “What Do You Want Your Life to Stand For?” Clients are asked to close their eyes and relax for a few minutes and then imagine that they have died but are present in spirit at their funeral, listening to the eulogies being given by family members, relatives, and friends, and then to focus on what they really want to hear said about them and their lives. They therefore try to answer the question “What do you want your life to stand for?” and, in doing so, learn to connect with their deepest values. A shorter variation of this exercise is to simply ask a client to write a brief eulogy on a tombstone in their imagination. These “Funeral” and “Tombstone” exercises can be helpful to clients for getting in touch with their core values and then subsequently to live in committed action in line with such values. However, these exercises may be too challenging or difficult for some clients because they may be reminded too much of their own mortality. The exercises can then be modified to what may be said at a retirement party or engraved on a gift watch (Hayes, Strosahl, & Wilson 2012, 304–307).
ACT interventions can therefore be diverse and flexible (see Rosales & Tan 2016, 269); the actual therapy delivered has included protocols conducted over thirty sessions, or even as short as one session (Öst 2014).
In addition to the revised and updated text by Hayes, Strosahl, and Wilson (2012), there are other helpful books on ACT for professional therapists (see, e.g., Gordon & Borushok 2017; R. Harris 2013, 2019; Levin, Twohig, & Krafft 2020; Luoma, Hayes, & Walser 2017; Tirch et al. 2019; Walser 2019; Westrup 2014), and also for clients and laypeople (see, e.g., Ciarrochi, Hayes, & Bailey 2012; R. Harris 2008; Hayes 2019; Hayes & Smith 2005; Scarlet 2017; Suro 2019).
ACT is a widely known and practiced third-wave CBT today, with a huge and growing literature on its applications to an ever-widening range of problems and contexts (see Hayes 2019). The research supporting the effectiveness of ACT will be covered later in this chapter.
Mindfulness and Acceptance-Based CBT in Practice
This hypothetical transcript of a small part of an ACT session with a client demonstrates the therapist’s use of several ACT techniques. First, the therapist shows warmth and empathy in summarizing what the client expresses in terms of struggling with negative thoughts and feelings of depression and anxiety, showing acceptance of the client. Then the therapist, like a coach or trainer, uses the choice-point tool to further explain the ACT process to the client and provide the client with a perspective or framework in which to understand what is happening and the choice point that is before the client. It takes a little time for the therapist to explain or sketch this out. The ACT exercises of focusing on a thought as simply a thought by saying, “I am having the thought . . . ,” and of the “Leaves on a Stream” exercise are used by the therapist to further help the client get unhooked in order to move toward what the client wants in committed action, according to the client’s core values, including caring for or loving others.
Client: I feel depressed with all these negative thoughts of how long this COVID-19 pandemic will continue to go on. . . . It feels hopeless, and I cannot control it, and I really miss social contact with people, especially with my family and close friends; . . . it feels so lonely and hard; . . . I think and feel so useless . . . and often feel down and anxious too.
ACT Therapist: Sounds like it’s been really hard and painful for you, facing this pandemic that is still going on, . . . feeling down, being isolated and away from family and friends, and hopeless about how much longer this will go on: . . . thinking and feeling useless, . . . is this correct?
Client: Yeah, and I just can’t seem to control my thoughts and feelings. . . . I want to get rid of them because they are so negative and they suck! I really try to replace them with positive thinking, but it doesn’t work. The more I try to control them, the more stuck it seems I am, and the thoughts and feelings continue to bother me, and I think I’m useless, and I feel so lousy and helpless and hopeless too, that I cannot get out of this hole or shake myself free from these horrible thoughts or feelings . . .
ACT Therapist: Let’s see if I can help you put this in some perspective: so what we’re trying to do in our therapy sessions here makes sense to you, using, as you know, Acceptance and Commitment Therapy or ACT, which focuses more on letting things come and letting them go rather than directly trying to fight them or control them or avoid them because they are painful and negative, like some of the thoughts and feelings you’ve just mentioned. Let me share with you the idea of a choice point. You have described your situation in this ongoing pandemic with your negative thoughts and feelings, including feeling depressed and thinking to yourself, “I’m useless.” And you’ve tried to fight or control these thoughts and feelings, so at your choice point here in the situation you’re in, with all the negative stuff, you can choose to be hooked into it and try to fight it, but you get more stuck, and it takes you away from what you want and the life you want to live. However, at your choice point now, you can also choose a different path and go into the direction of being unhooked or unstuck from all this negative stuff, then moving toward what you really want and the meaningful life you want to live according to your deepest values and what’s most important to you. In order to choose this more fulfilling way, we need to help you learn some methods to be unhooked so you can move toward living a more meaningful and fulfilling life, as you have told me you would like to live, including caring more for people and reaching out to them, like through phone calls, Skype, Zoom meetings, or simply texts and emails, at this time of the pandemic that unfortunately still requires some social isolation and social distancing. How would you like to respond, knowing that you have a choice point now before you?
Client: I know that I cannot go on being stuck in my efforts to directly control my negative thoughts and feelings and try to change them into more positive thoughts. As you said, I am hooked or stuck, and it’s moving me away from the life I want to live and what I really want, which includes reaching out to people and caring for them more, rather than being so self-absorbed and stuck in my depression and anxiety and feeling paralyzed and not wanting to do anything at all! I’m glad you pointed out that I have a choice, and at my choice point now, I do want to get unhooked or unstuck from all this negative stuff so that I can move toward the life I really want to live, being freer and doing what really matters and caring for others. What can I do to handle all this negative stuff better and move in the direction that I want?
ACT Therapist: I sense that you are open to trying a different way, being at your choice point now to choose to be unhooked to move toward what you really want, including caring for others. Am I tracking with you?
Client: Yeah, you got it! I’m stuck, and I need some help to move in another direction.
ACT Therapist: I have a couple of suggestions that may help you become unhooked or unstuck. First of all, we tend to let our thoughts govern or control us, forgetting that thoughts are just thoughts, and we are not our thoughts per se. We are more than our thoughts, and our sense of self or our essential identity as a human person is larger than our thoughts. A specific technique I want to share with you is to simply say to yourself, “I am having the thought that I’m useless,” instead of saying to yourself, “I am useless.” Do this as often as you have negative or troubling thoughts to remind you that they are just thoughts, but do not try to control them or avoid them. Observe them nonjudgmentally simply as your thoughts. Would you like to try this out right now?
Client: Sure. So what do I do?
ACT Therapist: Just close your eyes and focus for a minute or so simply on your breathing to be mindful of the present moment and your here-and-now experience of your breath, without judging yourself. Simply breathe in . . . and . . . out . . . naturally, and attend to your breath . . . in . . . and . . . out. . . . Now I want you to think your usual thought “I am useless . . . ”
Client: Yes. I am thinking “I am useless” and it feels bad.
ACT Therapist: Okay, keep on with the thought, but now I would like you to simply modify it a little by saying: “I am having the thought that I am useless.” Just repeat this modified version several times.
Client: Okay. I am saying to myself, “I’m having the thought that I am useless . . .” over and over again.
ACT Therapist: Good. How are you feeling now? What are you experiencing?
Client: I actually feel a bit better and saying “I’m having the thought . . .” helps me to distance myself and my sense of self from my thoughts, which are just thoughts. I am able more simply to observe my thoughts as thoughts without getting stuck in them. I am not avoiding them or trying to control them and change them into positive thoughts, but just accepting them as thoughts. I can see how this can help me to be more unhooked from all this negative stuff going on in my head or thoughts. Any other ideas that may help me?
ACT Therapist: You are doing really well! One more exercise I suggest that may help you further along is what is called the “Leaves on a Stream” exercise. It involves you imagining your thoughts written on leaves falling onto a moving stream, and then letting them simply flow by or flow along, therefore letting your thoughts come and letting them go. Would you like to try this exercise also?
Client: Yes.
ACT Therapist: Good. So again just close your eyes and focus on your breathing. . . . Now I would like you to think of the thought “I am useless” and imagine it being written on a leaf, and let it fall down onto a moving stream, and let it simply flow by, letting the thought come and go, . . . and then do the same with another thought or the same thought. . . . How are you feeling now?
Client: Wow. That was actually helpful and somewhat relaxing and soothing to simply let my negative and other thoughts come and go, like leaves falling on a moving stream and floating by. I will certainly try doing these exercises on my own to see if they will help me in my day-to-day life.
Critique of Mindfulness and Acceptance-Based CBT: Strengths and Weaknesses
The strengths and weaknesses of third-wave mindfulness and acceptance-based CBT are similar to those already mentioned for traditional CBT in the preceding chapter of this book.
First, third-wave CBT, like traditional CBT, is a versatile and comprehensive approach to therapy that has been used for a wide range of clinical problems and disorders in a variety of practice settings, and with diverse populations (see Masuda & Rizvi 2020; Spiegler 2016). It is relatively short-term, except for DBT, which typically takes at least a year with BPD patients (but even then it is relatively short-term) and fits well with managed care’s emphasis on short-term and effective and efficient therapies.
Second, third-wave CBT, like traditional CBT, has specific goals in therapy that are set by the client in collaboration with the therapist, with client progress regularly monitored in therapy, so there is accountability in outcomes measurement.
Third, this third-wave CBT, like traditional CBT, is more present-oriented in dealing with the presenting problems or complaints of the client and focusing on the client’s internal cognitive processes and the environmental or situational contexts that are related to the client’s present symptoms. Third-wave CBT therefore does not focus on the past or feelings in detail and is a good corrective to other therapy approaches that may involve too much time and energy in dealing with past issues and feelings.
Fourth, third-wave CBT also empowers the client to choose their own goals for therapy in collaboration with the therapist, as well as preferred treatment options or interventions.
Fifth, third-wave CBT, like traditional CBT, is open to the use of psychiatric medication, pharmacotherapy, for severe psychological disorders if it is workable or helpful, and therefore to combined treatments of third-wave CBT and pharmacotherapy where appropriate and needed.
Sixth, third-wave CBT also has a large armamentarium of therapeutic interventions or techniques that can be effectively used to treat a wide range of psychological disorders and somatic conditions. Clients who prefer to have a more directive and structured approach to therapy, with empirically supported interventions that are relatively short-term, can receive effective and efficient help through third-wave CBT.
Seventh, third-wave CBT also highly values controlled outcome research and thus joins traditional CBT and behavior therapy as the most empirically researched and supported therapy approach currently for a wide variety of psychological disorders.
Eighth, third-wave CBT is flexible enough to be used in a culturally sensitive and responsive way with clients from diverse cultures and various countries, letting clients choose goals that are consistent with their own cultural and societal values (see Iwamasa & Hays 2018; see also G. C. N. Hall & Ibaraki 2016). However, mindfulness and acceptance-based third-wave CBT in particular needs to pay attention to how mindfulness and acceptance-based practices may need to be sensitively adapted, especially for clients from Asian cultures, which are more interdependent and communal than individualistic, as in Western culture (see G. C. N. Hall et al. 2011). Westernized or secularized versions of mindfulness, focused on the self and values that are more individualistic, may be potentially at odds with some less acculturated Asian American or Asian clients (see Yip et al. 2021).
Ninth, while third-wave CBT initially provided secularized or Westernized versions of mindfulness and mindfulness meditation, it has recently been more open to integrating religion and spirituality more explicitly and directly in a constructive and sensitive way (see, e.g., Nieuwsma, Walser, & Hayes 2016; see also Knabb 2016, 2017; Ord 2014).
Finally, third-wave CBT, like traditional CBT, can also be helpful to clients with physical disabilities or challenges, helping them cope more effectively with their limits and limitations, as they learn to accept and live with such struggles.
Third-wave CBT, like traditional CBT, also has several general weaknesses, as well as some weaknesses specific to its mindfulness and acceptance-based approach. First, third-wave CBT, like traditional CBT, may focus too much on dealing with the client’s current presenting problems and not enough on the whole person and the total life context of the client. However, the emphasis on values and action committed to one’s core values in ACT, and the focus on building a life worth living in DBT, are good correctives because they do go beyond simply symptom alleviation to helping the whole person to live a more meaningful and fulfilling life.
Second, third-wave CBT can place too much emphasis on techniques, with many exercises and tools available to help clients in specific ways, and the therapeutic relationship may become less salient or crucial. However, third-wave CBT does emphasize the importance of radical acceptance and compassion in the therapeutic relationship with the client.
Third, third-wave CBT may not attend sufficiently to a client’s past and unresolved issues; more time and deeper processing may be needed to deal with them.
Fourth, third-wave CBT may ignore unconscious processes such as transference and countertransference and dreams, which may be potentially helpful in dealing with some issues for some clients.
Fifth, while traditional CBT may not deal adequately with existential issues due to its problem-solving approach to the presenting symptoms of the client, third-wave CBT is less susceptible to this criticism or weakness since it does directly help the client to deal with existential issues such as finding meaning in life by clarifying and choosing authentic values and living according to them, as in ACT and DBT.
Sixth, third-wave CBT, like traditional CBT, is a structured and directive therapy in which the therapist typically functions as a coach or teacher in a somewhat expert role. Thus there is a potential danger of the therapist imposing personal values and techniques on a client. However, third-wave CBT does focus on radical acceptance and compassion for the client, letting the client choose their own goals and values to live by.
Seventh, like traditional CBT, third-wave CBT involves directively teaching clients some skills and exercises, including specific mindfulness and acceptance-based techniques, often in a structured way, with an assumption that clients learn best by such a direct and structured approach. Some clients may benefit more with a less directive approach and a more reflective, self-initiated process.
Eighth, like traditional CBT, third-wave CBT also has many techniques that can be easily misused or misapplied by poorly trained or inexperienced therapists. To avoid simply being into “techniques,” and to conduct more elegant and competent third-wave CBT, the therapist needs to have adequate training and supervision. DBT specifically requires therapists to have a consultation team.
Ninth, third-wave CBT, like traditional CBT, may not attend sufficiently to larger environmental and sociopolitical factors, such as discrimination, marginalization, and oppression, which can significantly contribute to the client’s problems in certain national or cultural contexts. The client may need more empowerment to effectively deal with such external or environmental stressors, not just accept them.
Tenth, third-wave CBT, like traditional CBT, needs to be especially sensitive to how a mindfulness and acceptance-based approach that is more Westernized and self-focused or individualistic can adversely affect the client if it clashes with the cultural and social or familial values of significant others in the client’s life, as well as of the actual client, values that may be more communal and interdependent and less individualistic.
Finally, more specific to third-wave CBT and its mindfulness-based interventions, the potential harm of mindfulness-based programs has recently received some attention in a review of conceptual issues and empirical findings (see Baer et al. 2019). In general, 3 to 10 percent of psychotherapy clients get worse after therapy; it is estimated, with some caution, that about 0 to 10.6 percent of participants in mindfulness-based interventions also experience negative effects or adverse events, such as higher levels of anxiety, depression, alienation, confusion, and physical pain, and even some psychotic symptoms. The following are potential sources of harm in mindfulness-based programs or interventions.
1. Program factors. These are the what and how components of mindfulness, which should include both awareness of the present-moment experience as well as its nonjudgmental and nonreactive aspects; intensity of the mindfulness practice with greater intensity and duration possibly having higher risk for harmful effects; and psychoeducational and structural support for mindfulness practices or meditation and the need to provide such support, including an adequate pre-course interview to prepare clients for the mindfulness-based program.
2. Participant factors. Preexisting depression and anxiety could be worsened by Buddhist meditation, but most mindfulness-based programs have been effective and helpful even with participants who have comorbid conditions, severe symptoms, and other specific vulnerabilities, although 0 to 10 percent of them may report adverse or severely adverse events or consequences, which is not more than in control groups.
3. Teacher/clinician factors. This refers to provider characteristics, such as having empathy and understanding of the client and the problems presented, clearly communicating about what the program involves and skillful conducting of the intervention, effectively handling difficulties and challenges that come up, and supportively facilitating treatment adherence and compliance by the client (see Baer et al. 2019, 108–110).
Studies on potentially harmful effects specifically of mindfulness-based programs or interventions are still sparse, and additional systematic research is needed in this area (see Barlow 2010; Castonguay et al. 2010; Dimidjian and Hollon 2010; Lilienfeld 2007; D. McKay and Jensen-Doss 2021; Tan 2008c).
A Biblical Perspective on Third-Wave CBT
A biblical perspective on third-wave CBT will include much of what was covered in the previous chapter on a biblical perspective on traditional CBT (see Sidebar 12.2, “A Biblical Approach to CBT”). However, the following are some more specific reflections on a biblical or Christian perspective on third-wave CBT (see Tan 2011b), and in particular on DBT (see Wang & Tan 2016), MBCT that is based on MBSR (Rosales & Tan 2017), and ACT (Rosales & Tan 2016).
First, Tan (2011b) has provided a Christian perspective or approach to third-wave CBT as a whole. He has emphasized the need to use third-wave CBT interventions in the context of a Christian contemplative tradition (see Blanton 2019; Coe & Strobel 2019) that focuses on being mindful of the sacrament or sacredness of the present moment, involving self-abandonment or surrender to God and divine providence in every moment and every area of life, even the mundane (see Caussade 1989; see also Boyd 2010; Koessler 2019; Lawrence 1982; Shigematsu 2013). A Christian approach is God-centered (see Blanton 2019), “letting go and letting God” take control. For example, clients are encouraged not so much to simply let their thoughts come and go like leaves falling on a moving stream and floating passively by (as in ACT), but by letting their thoughts come and go to Jesus, surrendering them to him, and therefore every thought is brought captive to his control (cf. 2 Cor. 10:5) (see Tan 2011b, 246).
Tan (2011b, 246–247) has also pointed out that the content of one’s thoughts is still important, since biblical truth based on Scripture is eternal and crucial and our thinking does affect our feelings and behaviors: we are set free by knowing and believing biblical truth (John 8:32) and transformed by the renewing of our minds (Rom. 12:2, Phil. 4:8). Third-wave CBT, unlike traditional CBT, does not pay specific attention to the content of our thoughts but focuses instead on decentering (MBCT) or defusing ourselves from them as simply thoughts that come and go (ACT). Biblical truth is comprehensive and touches every aspect of our being and our lives, especially in relation to God as well as one another, centered in loving God and loving others (Mark 12:30–31). It also includes having eschatological hope of life in heaven, coming in the future, because of eternal life in Christ that starts now and goes on forever in heaven (cf. Rom. 8:18; 2 Cor. 4:17–18; see also 1 Cor. 15:19). A Christian perspective therefore includes being future-oriented, with solid hope in Christ, and waiting for heaven to come (see Crabb 2020); it cannot only or solely be present-oriented, as third-wave CBT emphasizes in attending to the present moment, the here-and-now experience, with mindfulness exercises and radical acceptance nonjudgmentally. Secularized versions of third-wave CBT do not subscribe to ultimate biblical truth and need to be subjected to Scripture and eternal truth.
The emphasis in ACT on values and committed action in accordance with one’s values is generally good, for Scripture also affirms that true faith leads to works and action (James 1:22; 2:15), by the power of the Holy Spirit (see Zech. 4:6; Eph. 5:18; Acts 1:8); yet the values that ACT therapists help clients discover are chosen by clients and can be relativistic and idiosyncratic. A Christian approach will have values and virtues that are based on Scripture as God’s inspired and eternal Word (2 Tim. 3:16), and not on relativistic or purely humanistic or secular considerations that may contradict biblical truth and ethics and morality (see Tan 1987a, 2007b).
Second, with specific reference to DBT (see Wang & Tan 2016, 73–74), the concept of a wise mind (that integrates reasonable mind and emotional mind in a dialectic balancing way) can be viewed from a Christian perspective that affirms both rationality (cf. 1 Cor. 13:11; Isa. 1:18–20) and emotion (cf. Eccles. 3:4–6; Prov. 17:22; Mark 14:32–34) in an integrated way in the true self of the person created in the image of God. Practicing nonjudgment is foundational to DBT and other third-wave CBT approaches, but a biblical perspective includes the need for appropriate judgment or discernment (cf. 1 Cor. 5:12–13), yet with mercy (cf. James 2:12–13) and without a desire to be judging or condemning others (cf. Matt 7:1–2). It may be more biblical to speak about suspending judgment for a limited time, especially of our own troubling thoughts, feelings, and behaviors, so we can see and experience them more clearly in the context of God’s grace and compassion for our suffering and struggles, rather than eliminating all judgment or appropriate discernment (see Hoover 2018). It is also important and helpful to focus on knowing and experiencing the reality that God loves us and also likes us (e.g., Zeph. 3:17; Rom. 8:31–38) and wants to be with us (see Holsclaw & Holsclaw 2020) with grace and compassion, so we can willingly surrender ourselves and our pain to him. The focus on mindfulness and attending to present experience in the moment, in DBT, needs to be tempered with being future-oriented as well, with biblical hope in heaven to come.
Third, with specific reference to MBCT that is based on MBSR (see Rosales & Tan 2017, 78–80), the emphasis on the being mode over the doing mode may need to be nuanced in a Christian perspective that values both a contemplation more akin to the being mode as well as an action more akin to the doing mode, in seeking and experiencing God in all areas of life, even in the mundane, as practicing the presence of God, and not just in contemplative practices (see, e.g., Lawrence 1982; Shigematsu 2013). MBCT also focuses on decentering as the antidote to rumination that can lead to further depression, and through decentering to shift one’s attention to an experience that is broader than one’s troubling thoughts and emotions, but it is still self-experience. A Christian approach to decentering or mindfulness through contemplation is really about refocusing attention on God and therefore on God-experience (see Blanton 2019). There are also other more direct and traditional CBT techniques that can be used to deal with rumination in depression, in rumination-focused CBT for depression (see Watkins 2016). Finally, MBCT’s approach to mindfulness, based on MBSR, is probably the most spiritually oriented, based on Buddhism and Zen meditation; ACT uses mindfulness more as a technology, with DBT in between. MBCT practitioners must have their own personal mindfulness practice, with a preference toward Buddhist or Zen meditative practices. Although both MBCT and MBSR have been secularized for wider use and dissemination, the Buddhist roots are strong and may be problematic for Christian clients and therapists who will need to use more of a Christian contemplative approach and Christian meditation based on Scripture and centered on God (e.g., see Garzon & Ford 2016; Knabb 2021; Knabb & Frederick 2017; Trammel & Trent 2021; see also Blanton 2019; Coe & Strobel 2019; Symington & Symington 2012; Van Aalderen, De Haas-de Vries, & Luiten-van de Vliert 2016).
Fourth and finally, with specific reference to ACT (see Rosales & Tan 2016, 271–273), the six ACT core processes of defusion, acceptance, being present, observing self, values, and committed action, especially in dealing with experiential avoidance and enhancing psychological flexibility, need to be nuanced from a Christian perspective, some of which were already mentioned earlier (see Tan 2011b) and will not be repeated here. This has been well done in Christian adaptations and versions of ACT, especially in the work of Joshua Knabb, using Scripture and the contemplative prayer practices and wise sayings of the early church’s desert fathers and mothers (Knabb 2016, 2017; see also McMinn, Goff, & Smith 2016). In this context, more explicitly Christian meditation approaches focusing on humble detachment and surrender to God and his providential care (Knabb, Vazquez, Wang, & Bates 2018; see also Knabb 2021) have been developed as viable alternatives to mindfulness or meditation practices that are based more on Zen or Buddhism in third-wave CBT; recent preliminary findings have shown some empirical support for the efficacy of these Christian approaches in treating repetitive negative thinking, recurrent worry, and daily stress (see, e.g., Knabb, Vasquez, Garzon, et al. 2020; see also Knabb, Frederick, & Cumming 2017; Knabb & Vazquez 2018; Knabb, Vazquez, Wang, & Bates 2018). ACT has also more explicitly and generally integrated religion and spirituality in practice (see, e.g., Nieuwsma, Walser, & Hayes 2016), going beyond being just a secularized version of third-wave CBT.
Research: Empirical Status of Third-Wave CBT
Third-wave CBT approaches have also been subjected to many empirical evaluations of their effectiveness for various disorders, despite some criticisms (see, e.g., Öst 2014; also P. W. B. Atkins et al. 2017 for a critique of Öst 2014; then Öst 2017 for a rebuttal of P. W. B. Atkins et al. 2017). Dimidjian, Arch, et al., in a systematic review of twenty-six meta-analyses of third-wave CBTs (DBT = 5, MBCT = 6, and ACT = 8, with 7 for behavioral activation), concluded that there is now growing and strong empirical evidence supporting the efficacy of these therapies—usually with moderate to large effect sizes for between-group comparisons—mainly with waiting-list or treatment-as-usual control groups, or within-group comparisons, for various problems and populations such as patients with anxiety, depression, borderline personality disorder and suicidal behaviors, and eating disorders (2016, 898). The research or empirical evidence for each of the four major third-wave CBTs will now be briefly reviewed.
Empirical Status of DBT
DBT is the most well-researched therapy for borderline personality disorder (BPD) and is considered a well-established empirically supported treatment. It has at least fifteen randomized controlled trials (RCTs)—conducted independently in North America, Europe, and Australia (see Neacsiu & Linehan 2014)—supporting its efficacy for BPD, including long-term posttreatment effectiveness (Kliem, Kröger, & Kosfelder 2010). Wang and Tan briefly reviewed the outcome literature on RCTs for DBT for other disorders besides BPD, finding empirical evidence supporting the effectiveness of DBT in treating depression, anxiety, hopelessness, anger, global psychopathology, eating disorders, and impulsive behaviors, as well as improving general functioning, interpersonal functioning, and reasons for living (2016, 70–71). DBT has also been adapted for effective treatment of BPD and PTSD secondary to childhood sexual abuse, of school-refusal behavior in adolescents, and of certain adolescents, especially suicidal adolescents (A. L. Miller, Rathus, & Linehan 2007; McCauley et al. 2018; Mehlum et al. 2014, 2019).
More specifically, DBT has been found to be more effective than treatment as usual in decreasing suicide attempts and parasuicidal behaviors (Panos et al. 2014), and equally effective as the collaborative assessment and management of suicidality treatment for preventing suicide attempts and suicidal or self-harming behaviors (Andreasson et al. 2016). DBT is also effective, when adapted with integration of some traditional and spiritual Native beliefs and processes, in the treatment of Native American/Alaska Native adolescents with substance use disorders (Beckstead et al. 2015; see J. Sommers-Flanagan & Sommers-Flanagan 2018, 383).
In the systematic review by Dimidjian, Arch, et al. (2016), empirical evidence was reported for the efficacy of DBT for BPD, self-directed violence, comorbid substance use, and binge eating and purging; in reducing nonsuicidal self-injury and suicide attempts; and in use of crisis services, especially for anger and depression (see also DeCou, Comtois, & Landes 2019). Another meta-analytic review (Linardon et al. 2017) concluded that DBT is probably efficacious in treating individuals with binge eating, with or without purging (see Masuda & Rizvi 2020, 208; see also Lenz et al. 2014).
Some RCTs have been conducted on the effectiveness of DBT skills training alone (instead of the complete DBT protocol), and some empirical support has been found indicating that DBT skills training by itself is effective for reducing depression, anxiety, binge eating, ADHD symptoms, intimate-partner violence, and aggression and impulsivity (see Wang & Tan 2016, 71). However, in a more recent systematic review of the outcome literature on the use of DBT skills training as a stand-alone treatment, Valentine et al. (2015) concluded that the empirical evidence for its effectiveness is somewhat mixed or equivocal.
Finally, most of the outcome research that has been conducted on DBT has been with female patients, with only two studies involving male patients in forensic settings, and no study on multicultural populations (Rizvi, Steffel, & Carson-Wong 2013; see Prochaska & Norcross 2018, 281). Future research on the effectiveness of DBT should include more male and multicultural samples.
Empirical Status of MBCT and MBSR
MBCT, for depression-relapse prevention with patients who have a history of recurrent depressive episodes, has received strong empirical support from six meta-analyses (Dimidjian, Arch, et al. 2016), which found a consistent reduction of relapse risk of around 35 to 50 percent across studies. A recent individual patient data meta-analysis reported that patients who had MBCT experienced significantly reduced relapse risk for depression over sixty weeks compared with treatment as usual (Kuyken et al. 2016). However, outcome studies of MBCT have been critiqued for being of moderate methodological rigor and often not including assessment for treatment fidelity (Dimidjian, Arch, et al. 2016). There is also more empirical support for the effectiveness of MBCT for treating acute depression (Lenz, Hall, & Smith 2016), but the empirical evidence for the effectiveness of MBCT for acute anxiety is more mixed or unstable (Dimidjian, Arch, et al. 2016). MBCT has also been used to treat bipolar disorder but with mixed results, with wait-list controlled studies supporting its effectiveness (e.g., J. M. G. Williams et al. 2008), and a recent RCT comparing MBCT to treatment as usual and reporting no additional benefit from MBCT (Perich et al. 2013). In summary, caution is still needed although there is growing empirical evidence supporting the effectiveness of MBCT for a widening range of psychological disorders (see Rosales & Tan 2017, 78). Segal, Williams, and Teasdale have pointed out that MBCT appears to be promising, with some adaptations, for treating substance abuse, anxiety in children and externalizing disorders in adolescents, pregnant women at risk for depression, chronic fatigue syndrome, tinnitus, hypochondriases, auditory hallucinations, social phobia, generalized anxiety disorder, panic disorder, insomnia, depression in primary care, and cancer patients (2013, 406–407). MBCT has also more recently been adapted to treat patients at risk of suicide (J. M. G. Williams, Fennell, et al. 2015), patients with bipolar disorder (Deckersbach et al. 2014), and patients with obsessive-compulsive disorder, OCD (Didonna 2020). However, further controlled outcome research and RCTs are needed before more definitive conclusions can be made about the effectiveness of MBCT for many of these various problems and conditions.
There is also a need for more process research on the specific mechanisms enabling MBCT to be effective. This is true for the other third-wave CBT approaches as well (see Dimidjian & Segal 2015). A recent meta-analysis of 43 studies with 1,427 participants in MBCT and MBSR found a significant but modest association (r = 0.26) between home practice of mindfulness and treatment outcome, with an average of 64 percent of assigned homework practice completed by the participants (C. E. Parsons et al. 2017; see Prochaska & Norcross 2018, 281). Mindfulness practice may therefore be a crucial part of MBCT and its effectiveness.
Additionally, there are a dozen or so other meta-analyses on the effectiveness of a number of mindfulness-based treatments in general, which include outcome studies on meditation and mindfulness practices, as well as DBT, MBSR, MBCT, and ACT (see Prochaska & Norcross 2018, 282–283), and they will be briefly summarized. With regard to anxiety disorders, a meta-analysis of nineteen outcome studies (with eleven uncontrolled), including those on MBCT (eight studies), MBSR (four studies), and ACT (two studies), reported an overall rating for group d of 0.83 for decrease in anxiety symptoms, using a no-treatment control group (Vollestad, Nielsen, & Nielsen 2012). Another meta-analysis of thirty-six RCTs of meditative therapies for reducing anxiety in medical patients (K. W. Chen et al. 2012) found an overall effect size of 0.52 in comparison to wait-list controls, 0.59 in comparison to attention controls, and 0.29 in comparison with other treatments. Interestingly, a significantly larger effect size (0.77) was found in studies done in Eastern countries (China, Japan, India) compared with those conducted in Western countries (0.46).
With regard to stress, ten studies evaluating MBSR on stress in healthy participants reported significantly larger within-group effect (d = 0.74) for reducing stress and for enhancing spirituality (d = 0.82) than within control groups (Chiesa & Seretti 2009). Practicing MBSR techniques may therefore benefit both practitioners and clients (see also Irving, Dobkin, & Park 2009).
With regard to chronic pain, a meta-analysis (Veehof, Oskam, et al. 2011) of twenty-two studies on third-wave therapies for chronic pain (fifteen studies on MBSR and seven on ACT) found moderate-effect sizes for pain reduction (0.47) and decrease in depression (0.64) when pre-post changes in treatment groups were compared. However, when only the ten RCTs were considered, the reported effect sizes for treatment versus control group were small for both pain (0.25) and depression (0.25).
With regard to cancer patients, ten outcome studies found medium effects (0.48) for the MBSR treatments for mental health outcomes and small but significant effects (0.18) for physical health outcomes in cancer patients (Ledesma & Kumano 2008).
With regard to somatization disorders, a meta-analysis of thirteen RCTs on various mindfulness-based treatments for somatization disorders (Lakhan & Schofield 2013) found small to medium positive effects compared to wait-list or support group controls for decreasing pain (d = 0.21), symptom severity (d = 0.40), and depression (d = 0.23), and thus enhancing quality of life (d = 0.39). These are still promising results.
With regard to other multiple disorders, a large meta-analysis of 209 studies on various mindfulness-based treatments for multiple disorders (such as anxiety, depression, cancer, and other psychiatric and medical conditions) found effect sizes indicating that mindfulness therapies are moderately to largely effective for multiple disorders and especially for reducing anxiety, depression, and stress, but not more effective than other cognitive-behavioral treatments (Khoury et al. 2013). However, only 109 of the 209 studies were RCTs, and many uncontrolled studies and poor-quality studies were included in the meta-analysis, so the conclusions may be somewhat overstated.
Empirical Status of ACT
Since a well-known and oft-cited review of ACT, including its model, processes, and outcomes, was published over fifteen years ago (Hayes et al. 2006), with much promise of its effectiveness for many disorders and conditions, there now are at least 170 RCTs evaluating ACT more carefully (P. W. B. Atkins et al. 2017). ACT is considered a well-established and empirically supported treatment for chronic pain, and a probably efficacious treatment for depression, mixed anxiety disorders, obsessive-compulsive disorder, and psychosis, by Division 12 of the American Psychological Association (see Rosales & Tan 2016, 270). In a systematic review and meta-analysis of ACT, Lars-Göran Öst (2014) was more critical of some of the outcome studies done on ACT and arrived at more-cautious conclusions. In his updated meta-analysis of 60 RCTs (with a total of 4,234 participants) on psychiatric disorders, somatic disorders, and work stress, Öst (2014) found a mean effect size across all comparisons of 0.42, which is smaller than the mean effect size of 0.68 that he reported in an earlier meta-analysis (Öst 2008). There was also only a small and nonsignificant effect size of 0.16 when ACT was compared to other cognitive and behavioral treatments. Öst (2014) conducted an evidence-based evaluation of ACT and concluded that it is not yet a well-established treatment for any disorder (contradicting the views of Division 12 of the American Psychological Association) but is probably efficacious for chronic pain and tinnitus, and possibly efficacious for depression, psychotic symptoms, OCD, mixed anxiety, drug abuse, and work stress, but only “experimental” for other disorders. Others (P. W. B. Atkins et al. 2017) have critiqued Öst’s (2014) meta-analysis and conclusions; Öst has also provided a rebuttal to their critique (Öst 2017).
Paul Atkins et al. (2017), with others, provided their own review of the data and also examined more recent outcome and process evidence available since Öst’s (2014) review (see also A-Tjak et al. 2015; Bluett et al. 2014; L. S. Hughes et al. 2017; E. B. Lee et al. 2015; Veehof, Trompetter, et al. 2016). They concluded that ACT is a transdiagnostic treatment that is more effective than wait-list and treatment-as-usual control conditions, especially for chronic pain, substance use, and anxiety disorders including obsessive-compulsive disorder, and that ACT is at least as effective as traditional CBT or other evidence-based therapies. ACT outcomes also seem to be mediated by ACT processes consistent with ACT’s theoretical assumptions (see Masuda & Rizvi 2020, 208). ACT has also been found to be as effective as traditional CBT, and better than controls, in the treatment of tinnitus (ringing in the ears), whether provided in person or via the internet (Hesser et al. 2012). ACT is well accepted and overall effective even when it is delivered in a web-based way (M. Brown et al. 2016; see Prochaska & Norcross 2018, 280).
Hayes has recently described seven major areas in which ACT has been used, reflecting how widely it has impacted the field of mental health and beyond: adopting healthy behaviors, mental health, nurturing relationships, bringing flexibility to performance, cultivating spiritual well-being, coping with illness and disability, and social transformation (see Hayes 2019, viii–ix, 275–385). However, further controlled outcome research and RCTs are needed to further evaluate the effectiveness of ACT in many of these areas of application.
Future Directions
The future directions of third-wave CBT are similar to the directions of traditional CBT and even behavior therapy, already described in the preceding two chapters (11–12) of this book. However, there are several more-specific or unique directions that third-wave CBT may take in the years ahead.
Third-wave CBTs—especially DBT, MBSR, MBCT, and ACT—are a substantial part of mindfulness therapies that now stand at the top of the leading therapy orientations predicted to increase the most in the next decade by a Delphi poll, followed closely by CBT, and then integrative therapy, multicultural therapies, and motivational interviewing in the top five (see Prochaska & Norcross 2018, 442). If more-specific third-wave CBTs are mentioned, then DBT is ranked seventh, and ACT eleventh (with Aaron Beck’s cognitive therapy ranked tenth, behavior therapy fourteenth, psychodynamic therapy nineteenth, and classical psychoanalysis twenty-eighth out of thirty-one therapy orientations). Third-wave CBT already is, and will continue to be, a prominent and substantial part of contemporary counseling and psychotherapy; if incorporated within CBT as a whole, it will only be strengthened in its position as the leading therapy orientation to thrive and increase the most in the coming years, becoming crucial and central components of both mindfulness therapies and CBT in general. CBT itself is becoming more process-based, much like third-wave CBT (see Hayes & Hofmann 2018).
Third-wave CBT, like traditional CBT, has been effectively and successfully used, with growing empirical support, to treat a wide range of psychological and medical conditions; it will continue to be a leading, evidence-based therapy approach that will be most welcomed by managed care and insurance companies looking for such evidence-based treatments. Third-wave CBT, together with traditional CBT and behavior therapy, will continue to be the most researched therapy approach, including conducting more RCTs to further strengthen its empirical support.
Third-wave CBT, following traditional CBT, has begun to explicitly integrate religion and spirituality into its practice, especially for ACT (see Nieuwsma, Walser, & Hayes 2016). Christian approaches to ACT have recently been developed (see Knabb 2016, 2017; Ord 2014), with more of a Christian meditation and contemplative prayer approach that is directly God-focused (see also Knabb 2021), with some preliminary empirical support for its effectiveness against repetitive negative thinking (Knabb, Vasquez, Garzon, et al. 2020; see also Knabb, Vazquez, Wang, & Bates 2018), recurrent worry (Knabb, Frederick, & Cumming 2017), and daily stress (Knabb & Vazquez 2018). It has also been applied to shifting from trauma-based ruminations to ruminating on God (Knabb, Vazquez, & Pate 2019). In the future, this area of spiritually and religiously oriented or integrated ACT (and other third-wave CBTs) will receive greater attention in both clinical practice and research (see, e.g., the special issue of the Journal of Psychology and Christianity, 2020, 39 [1] on meditation, prayer, and contemplation; also Knabb, Johnson, & Garzon 2020; Ford & Garzon 2017; T. L. Jones, Garzon, & Ford 2021; Trammel 2018; Trammel, Park, & Karlsson 2020).
Third-wave CBT is also open to new interventions that are empirically supported and integration with other therapy orientations, as with positive psychology and its focus on finding happiness and flourishing in life (see Kashdan & Ciarrochi 2013), and with Paul Gilbert’s (2010) compassion-focused therapy (see Tirch, Schoendorff, & Silberstein 2014; see also P. Gilbert & Choden 2014; Kolts 2016) and Christopher Germer’s (2009) mindful self-compassion (see also K. Neff & Germer 2018). Third-wave CBTs focus beyond symptom alleviation to building a life worth living, as in DBT (Linehan 2020), and pivoting to what matters in living a fulfilling life according to one’s deepest values, as in ACT (Hayes 2019)—these features will also appeal to existential therapists and spiritually oriented therapists, helping their clients to deal with fear of death and to find meaning in life or in meaning-making. A Christian approach to compassion-based therapy for Christian clients seeking freedom from shame and negative self-judgments, focusing on a deeper love relationship and attachment to God, has recently been developed and described by Joshua Knabb (2019). Third-wave CBTs’ integration with compassion-based therapies and emphasis on a compassionate, kind, and gentle approach to life and relationships, which may be based on Zen Buddhism, are also consistent with a biblical or Christian perspective focusing on the centrality of agape, Christlike love in our lives and relationships (1 Cor. 13). Agape love is the fruit of the Holy Spirit (Gal. 5:22–23) and the Spirit’s empowering work in our lives, not due to our self-effort (see Tan 2011b, 247). This important distinction points us to surrender to God and his loving providential care for us, and not to feverish self-focused efforts on our own strength. A Christian approach is grace-based, energized, and enabled by the presence and power of the Holy Spirit, not legalistic or fueled by self-effort.
ACT, in particular, is a comprehensive third-wave CBT approach that contains a wide variety of interventions for facilitating psychological flexibility and overcoming psychological rigidity or inflexibility, seen as the core process underlying psychopathology, which cuts across specific diagnoses and disorders. Steven Hayes, who helped develop ACT, has emphasized with his colleagues that “ACT seeks a modified model of behavior change applicable to human beings in general, not just those fitting certain diagnostic criteria” (Hayes, Pistorello, & Levin 2012, 978). In this sense and context, ACT can be viewed as an example of a third-wave CBT transdiagnostic treatment of emotional disorders, cutting across different psychological problems, thus not just for a specific condition or diagnosis (see Sauer-Zavala et al. 2017; see also Meidlinger & Hope 2017)—much like the Unified Protocol developed by David Barlow and his colleagues (see Barlow et al. 2018), described in the preceding chapter of this book. Transdiagnostic treatments will receive greater attention in both clinical practice and research further evaluating their effectiveness for various disorders, and their presumed efficiency in training and supervision of therapists and practitioners (see Dalgleish et al. 2020; see also Tan 2020).
Third-wave CBT is also being widely disseminated through self-help books and programs, internet or computer-based interventions, and the use of technology such as apps on smartphones; it will continue to impact many more people in general, and especially therapists and clients. This needs to be done in a responsible and ethical way, with appropriate cultural sensitivity to diverse populations and sufficient humility not to overpromise or overreach, especially in the context of self-help materials(see D. E. Davis and Hook 2021).
Finally, there are ample opportunities for counselors and therapists to receive further training and skills in third-wave CBT approaches. In addition to the books already mentioned for both professionals as well as clients and the general public that are now available on DBT, MBSR, MBCT, and ACT, the following are websites where more information, resources including DVDs, and training opportunities or programs can be found (see Corey 2021, 267): DBT at www.behavior altech.com; MBSR at www.ummhealth.org/center-mindfulness; MBCT at www.guilford.com/MBCT_materials, with a master’s degree in MBCT available in the United Kingdom at Oxford University and the University of Exeter, and a master’s degree in mindfulness covering both MBSR and MBCT at Bangor University (see Segal, Williams, & Teasdale 2013, 420–421); ACT at www.meditation andpsychotherapy.org; and Self-Compassion Resources at www.self-compassion.org.
Marsha Linehan established the Linehan Institute to nurture therapists and offer mindfulness training to caregivers, and Behavioral Tech to disseminate evidence-based therapies for disorders that are usually resistant to treatment and to train DBT practitioners to competence. She also started the International Society for the Improvement and Teaching of DBT, with annual conferences (see Prochaska & Norcross 2018, 279). She is developing more training programs in DBT and DBT skills, especially via computerized learning, with her daughter Geraldine’s help, and is also involved in training and certifying DBT therapists through the DBT-Linehan Board of Certification (see Linehan 2020, 334).
Similarly, ACT has many resources available for further development as a therapist in ACT skills and interventions (see appendix B in Luoma, Hayes, & Walser 2017, 420–421; and appendixes A, B, & C in R. Harris 2019, 352–357), including the following websites: for online courses in ACT by Russ Harris, go to http://www.ImLearningACT.com; for the Learning ACT Resource Guide to accompany Luoma, Hayes, & Walser 2017, see http://www.learningact.com; for the major professional organization for ACT, which is the Association for Contextual Behavioral Science (ACBS) that holds annual conventions and has eight thousand members worldwide, go to http://www.contextualscience.org. The official journal of ACBS is the Journal of Contextual Behavioral Science, which started in 2012. ACT workshops are also usually scheduled at the annual convention of the Association for Behavioral and Cognitive Therapies (ABCT).
Third-wave CBT will grow and flourish in the years ahead, continuing to have a place of prominence in the field of counseling and psychotherapy, sharing a very bright future as part of CBT and with CBT, as a leading and even possibly the premier contemporary approach to therapy.
Recommended Readings
Blanton, P. G. (2019). Contemplation and counseling: An integrative model for practitioners. Downers Grove, IL: IVP Academic.
Harris, R. (2019). ACT made simple: An easy-to-read primer on acceptance and commitment therapy (2nd ed.). Oakland, CA: New Harbinger.
Hayes, S. C. (2019). A liberated mind: How to pivot toward what matters. New York: Avery.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: Guilford.
Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness (rev. ed.). New York: Bantam Books.
Knabb, J. J. (2016). Faith-based ACT for Christian clients: An integrative treatment approach. New York: Routledge.
Linehan, M. M. (2015). DBT skills training manual (2nd ed.). New York: Guilford.
Linehan, M. M. (2020). Building a life worth living: A memoir. New York: Random House.
Luoma, J. B., Hayes, S. C., & Walser, R. D. (2017). Learning ACT: An acceptance and commitment therapy skills training manual for therapists (2nd ed.). Oakland, CA: New Harbinger Publications.
Nieuwsma, J. A., Walser, R. D., & Hayes, S. C. (Eds.). (2016). ACT for clergy and pastoral counselors: Using acceptance and commitment therapy to bridge psychological and spiritual care. Oakland, CA: Context Press.
Pederson, L. (2015). Dialectical behavior therapy: A contemporary guide for practitioners. Malden, MA: Wiley-Blackwell.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). New York: Guilford.
Stahl, B., & Goldstein, E. (2019). A mindfulness-based stress reduction workbook (2nd ed.). Oakland, CA: New Harbinger.
Teasdale, J., Williams, M., & Segal, Z. (2014). The mindful way workbook: An 8-week program to free yourself from depression and emotional distress. New York: Guilford.
