Running head: BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 1
A Behavioral Therapy Conceptualization and Treatment Plan for George Costanza
Liberty University
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 2
Abstract
A case study of the utilization of Behavior Therapy (BT) and Cognitive Behavior Therapy (CBT)
components to treat a client dealing with life disrupting anxiety issues was conducted. The client
was assessed behaviorally addressing three specific aspects of his life and functioning with the
goals of greatly reducing or removing the anxiety levels experienced through the elimination
(extinction) of maladaptive safety behaviors, the adoption of new behaviors, and re-conditioning
(changed associations) stimuli that triggered the anxieties. Several assessment procedures were
used to identify stimuli for onset, behavior maintenance sequences behavior, and client relevant
reinforcers for behavior acquisition. The successful interventions involved several BT and CBT
techniques (imagery, skill training, relaxation, behavioral rehearsal, shaping) used both
simultaneously and sequentially to assist the client in obtaining his goals. Consideration of the
inclusion of a Spiritual component was investigated including levels of integration with BT/CBT.
Aspects of compatibility and incompatibility with a Spiritual approach and BT/CBT tenets were
identified.
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 3
A Behavioral Therapy Conceptualization and Treatment Plan for George Costanza
The referral of a client with many anxiety issues was sent for counseling. Because some
of the behavior involved his employment and there was a concern for verifiable results in a brief
time period (two to three months), it was decided to use Behavioral Therapy (BT) and Cognitive
Behavioral Therapy (CBT). BT and CBT have been found to be effective in treating anxiety and
producing measurable observable results in short amounts of time (six months or less)
(Rachman, 2009). It is believed that utilization of BT/CBT methods will assist the client in the
acquisition of behaviors and behavioral responses that will enable him to increase behavioral
flexibility by replacing safety behaviors and use more adaptive behaviors to appropriately engage
with the challenges he encounters in his life. An important aspect if the BT/CBT approach is that
the client is very involved the process and has a responsibility to apply the principles outside of
the therapeutic sessions.
Behavioral Therapy and Cognitive Behavioral Therapy
Behavior Therapy (BT) is a collection of techniques and different models all based on the
premise that human behavior and learning is predominantly controlled by the environment. There
are times when thoughts and perceptions of the individual will be addressed as they relate to
behaviors and this added component creates the hybrid known as Cognitive-Behavior Therapy
(CBT) (Murdock, 2013). The thrust of the approach is that behavior is the resultant of
environmental experiences as the person adapts to maximize their adaption to the environment.
Behaviorism was the dominant theme in American Psychology through the first half of the 20th
century up until the 1960’s (Hergenhahn, 2009) and the common themes of BT is that the
techniques are drawn from extensively researched scientific principles of Classical Conditioning
and Operant Conditioning. BT came about as a reaction to the psychoanalytic method. Classical
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 4
Conditioning (Pavlovian Conditioning) addresses acquisitions and extinctions of associations
and responses between unconditional stimuli relevant for survival of the species (food, water,
procreation, avoidance of pain) and previously neutral stimuli. Operant Conditioning attends to
consequences of behavior as the determinants of which behaviors will become part of the
repertoire of an organism (person) and which will be extinguished (Hergenhahn, 2009, Murdoch,
2013). Whereas psychodynamic theory focuses on internal psychic forces, their development,
and their resolution, Behaviorism is concerned with the environment and the world outside the
person. In its extreme, it does not consider mental events at all. Tolman in the 1940’s introduced
a mental component when he experimentally demonstrated changed behavior without
reinforcement or punishment but by mere exposure to an environment. To a mechanistic view he
added the explanation of a mental map that could be used to make decisions. This presaged
Bandura’s research on observational (social) learning in the 1960’s (Hergenhahn, 2009,
Murdoch, 2013), although Bandura was able to express it in a cognitive frame because of the
shift in Psychology towards cognition and introduce other concepts (modeling theory and
reciprocal determinism) (Hergenhahn, 2009).
BT is based on the learning theories of Behaviorism which have been extensively tested
on animals and humans, and has well supported principles of behavior that are not reliant on the
mental processes of the organism (person). The application of Behaviorism to human behavioral
issues had been addressed by several researchers (Thorndike, Watson, Tolman, Guthrie, Skinner)
but it was Eysenck, a classical conditioning behaviorist, who helped establish BT at the expense
of psychoanalysis with his research indicating the ineffectiveness of psychoanalysis (Murdoch,
2013). Because of the classical conditioning orientation, Eysenck could say with conviction that
treatment amounted to simply, “Get rid of the symptom and you have eliminated the neurosis”
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 5
(1960, p. 9, as cited in Murdoch, 2013, p. 239). Change the association and the problem is gone.
No need to get mired in the mental musings of the client when a change in behavior is what is
sought anyway. One of the most powerful and elegant aspects of behaviorism in this author’s
opinion is the concept of reinforcement. While some critics have been concerned about the
circular nature of the definition (a reinforcer is something that increases the likelihood or
probability that a behavior will occur again (Hergenhahn, 2009)) it is actually very informative
and quite parsimonious. That is because it is not the deliverer of the reinforcement that
determines what a reinforcement is but it is the person (organism) and the state of the organism
(italics mine) that determines what a reinforcer is. This means the BT counselor needs to be
observant and flexible in realizing that reinforcers can be unique to individuals, states the
individuals may be in (hungry vs. not hungry) and even context. In that simple definition, though
circular it may be, is all the information necessary to cover all situations. If it did not increase the
probability or likelihood of a behavior, then it is not a reinforcement for that person and move
on.
Since behavior is learned, and the learning is driven from interaction with the
environment (anything external to the organism), then any maladaptive behavior is learned. The
symptoms are the problems and are not representative or indicative of underlying issues. They
are learned phenomena that need corrective education. These behaviors could also be the result
of not learning a behavior or deficits in skill (Murdock, 2013). “For Wolpe, the majority of
neurotic behavior… is simply habit learned in anxiety-provoking settings” and neuroses are
“persistent maladaptive learned habits in which the foremost feature is anxiety.” (Wolpe, 1990,
p.23 as cited in Murdoch, 2013, p. 249). These maladaptive behaviors can be brought about by
Classical Conditioning or vicariously. The behaviors are maintained by reinforcement
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 6
contingencies (Operant Conditioning). For Operant Conditioning, dysfunctional behaviors fall
into two broad categories - behavioral excesses (too often and too strongly) and deficits (failed to
learn appropriate behaviors) (Murdoch, 2013). Depression stems from problems in range of
actions or behavioral repertory such as Ferster proposing the overuse of passive behavior and
decreased incidence of adaptive, active behaviors (Murdoch, 2013). A cognitive component can
be included as the person will also have distorted perceptions of the environment including faulty
perceptions of self (negative self-image) and an overblown sense of responsibility for events
(excessive self-blame) (Murdoch, 2013). A person that experiences unavoidable noxious stimuli
in an environment can develop what Seligman has termed learned helplessness in which they
simply do not attempt any behaviors to change the circumstance (Huppert, Ledley, & Foa, 2006
and Rachman, 2009).
Regarding BT there is no beliefs regarding human nature. Other than genetics, they are
very much in line with Locke’s Tabula Rasa that the environment will write upon. People have
no inherent tendencies save adaptation to the environment in the interests of survival in the
broadest sense (of the species) hence the primary reinforcers linked to food and water for
individual survival and procreation for the survival of the species (Hergenhahn, 2009). The
counseling process is concerned with behavior and hence the assessment is behavioral and will
address strengths and weaknesses, reinforcements, as well as the presenting concerns. Part of the
assessment is “a functional analysis that covers four areas: stimulus, organism, response, and
consequence” (Antony & Roemer, 2011a, as cited in Murdoch). This is critical since you need to
have a base line or a beginning record with which to measure progress, which will be a change in
the incidence of a particular behavior (Rachman, 2009). An informal assessment is an interview
of the client about the presenting problem. While it is ideal to directly observe the client’s
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behavior, most circumstances for this are difficult and much information can be gained from
role-play scenarios (Murdoch, 2013). For a strict behaviorist a good therapeutic relationship is
nonessential, but virtually all BT counselors accept that Roger’s empathy, trust, and positive
regard are necessary and complementary aspects of therapy (Rachman, 2009) since empirical
research has demonstrated its effectiveness (Jones & Butman, 2011). Modern Parent-child
interaction therapy has incorporated a large humanistic component in establishing warm loving
relationships prior to the use of successful behavior management techniques with the child
(Jones & Butman, 2011). After information about the antecedents, stimuli, and consequences, a
hypothesis is done about the controlling behavior. Teaching the client the successful principles of
BT empowers the client to become, at some point, their own therapist (Murdoch, 2013).
Much research has been done regarding the efficacy of the BT and CBT approaches. It
has been found as or more effective as drug treatments on generalized anxiety disorder (Linden,
Zubraegel, Baer, Franke, & Schlattmann, 2005, Murdoch, 2013). BT has been found to be as
effective as CBT in the treatment of the depressed and those dealing with symptoms of
compulsion and obsession (Murdoch, 2013). BT and CBT have been found to be effective
reducing hallucinations, delusions, and improving skill sets for schizophrenics (Kurtz & Mueser,
2008 as cited in Murdoch, 2013). There have been so many different symptoms that BT
strategies have been effective with (eating disorders, chronic pain, insomnia, tension headaches,
shame, mood disorders, substance abuse disorders (Antony & Roemer, 2011b as cited in
Murdoch, 2013, Hedman, Strom, Stunkel, & Mortberg, 2013, Ledley & Huppert, 2007), that
Antony and Roemer opined, “In fact, there are few problems for which behavioral therapies have
not been found to bring at least some relief” (as cited in Murdoch, 2013, p. 267).
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 8
This treatment approach is appropriate for the client because it has a variety of techniques
that have been successful in changing behaviors and dealing with anxiety. The client has many
dysfunctional behaviors and this approach will be very good because it deals with the behaviors
and does not ascribe any blame or fault to any of the participants (fellow employees, women he
dates, friends, or family) in his life. Since BT also seeks to establish a base line or reference,
progress can be seen, noted, and new behaviors modified to maximize results. It does look like
much of his conduct is engaged in avoidance behaviors that help maintain anxiety driven
dysfunctional behaviors. George’s concerns and issues are in life now and BT is ideal because it
is problem focused and present focused. Allowing him to learn new behaviors in anxiety
producing situations helps him to confront the anxiety he is avoiding facing. The maladaptive
behavior functions as a short term safety behavior, but by never experiencing the situation it
denies him the opportunity to learn that the anxiety will decrease as he stays in the situation
(Huppert, Ledely, & Foa, 2006). BT is also ideal because the client is taught the principles and
how to use them so that he will actively be his own therapist during the week, self-monitoring
and doing homework designed to initiate more adaptive behaviors. In this way the client and the
therapist are partners in the learning and healing process. Another large advantage is that the
approach is time specific and the targeted results are observable and can be designed to address
concerns of both the client and the employer (New York Yankees).
There are no anticipated ethical issues arising from this theory because there are no
personality theories or assumptions about a person accept that they have learned behaviors that
are not the best adaptive choices for them at this time in their positions. “The self is nothing but
an aggregation or composite of the person’s empirical characteristics” (Jones & Butman, 2011, p.
171).Thus, it becomes a matter of new learnings to reduce or eliminate behaviors or add new
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 9
ones in the appropriate contexts. BT and CBT have been found to be multiculturally friendly and
accessible to both individualistic and collectivistic cultures (Murdoch, 2013).
The use of this approach in a crisis situation is ideal. It gives techniques to the client to
change their behaviors to the crisis and can effectively address the attendant high levels of
anxiety that the client is experiencing. BT can address the situation and with the client determine
which behaviors are ineffective and devise a plan and direction to develop more adaptive and
effective behaviors. In the immediate experience of a crisis, CBT techniques include exercises to
aide in relaxation and have recently embraced a third wave of BT that is cognitively oriented and
addresses thoughts, the effects of thoughts, and life satisfaction (Hayes, Luoma, Bond,
Masuda,& Lillis, 2006 as cited in Murdoch, 2013). These techniques will help in crisis
circumstances easily because there is no theory involved, no inner dynamics to resolve, it is
simply the organism and the environmental interplay.
Presenting Concerns
George Costanza is a character from the popular (now in syndication) TV show Seinfeld.
This individual is interesting because although he seems to be very bright, he also seems to suffer
from many neuroses that affect his life. He also appears to have extreme anxiety issues about
many and varied topics: what he would like to do versus what society or people expect him to
do, he feels he is unable or has much difficulty doing “normal” things (hold a job, have a steady
girlfriend), he has a lack of self-confidence in many areas of his life, and a seeming
preoccupation with prioritizing short cuts to avoid work, save money, get out of obligations and
responsibilities.
George says his life is frustrating because he never gets a “break.” It is clearly not his
fault because he is operating from, what he believes, are reasonable, justified, and good
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 10
intentions. He wonders aloud why life is so frustrating, disappointing, and unfulfilling. People
don’t understand everything he has to deal with. George sees his life as a series of misses and
disappointments and aggravations - his parents berate and yell at him, his lack of success at a
job, and relationship issues (girls won’t like him and then when they do there is either something
wrong with them or they will find out some aspect of his personality that will drive them away).
George is open to counseling (since it was a requirement of his company to deal with his
sometimes indulgent and unusual behavior). He does approach therapy with a pessimistic
attitude in that he does not believe anything much will come of it since he believes his
maladaptive life was caused (and is maintained) by his parents (an attitude reflected by close
friend Jerry Seinfeld, who knew him through middle and high school). His company (New York
Yankees) is paying for the therapy and they are not asking for content information from his
sessions. Their only requirement is that the therapist report whether George is capable of
professionally executing his responsibilities at the company. His lifestyle is also compromised by
his frequent adoption of unusual criteria regarding his understanding of a satisfying life (access
to better quality bathroom facilities where he works, capricious decisions regarding who he
works for) and the way to achieve it.
George is willing to come to therapy. He sees this as the opportunity to be understood and
for someone to appreciate and sympathize what he has to deal with in his life. He is not hesitant
to admit to less than acceptable behavior, but will quickly explain that it was either not that
unusual or that given the circumstances it was not possible to do differently or better. In
conversation he demonstrates good logical processes and thinking, however the priorities he
chooses to start from and values he adopts are rigid, often non-contextual and atypical (e.g. while
bringing a celebrity to a fund raising banquet he chose to ignore the appointment to chase a car
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 11
whose driver was perceived to have insulted the celebrity resulting in the celebrity never making
it to the event).
Establishing rapport with George is fairly easy since he tends to be loquacious. What is
important is to keep him on topic, get his sense of why is here and how he understands what the
counseling goals are regarding his company, himself, and me. Our rapport will develop as he
realizes I am there to listen and help him lead a fuller, more satisfying life as he understands it
and not to subscribe to be continue to engage in unproductive and ill adaptive behaviors. Our
discussion of the process and goals will allow us to have a better communication and
appreciation of our direction and progress.
Case Conceptualization
George Costanza experiences much anxiety over many situations in his life. At times the
emotions he expresses almost seem manic in extremes. I am very concerned with how strongly
and how often he feels anxious. When faced with a problem or if he feels that he may not be able
to complete a task he becomes anxious and will often engage in escapist behaviors that reduce
the anxiety, changing the situation by disengaging. Assessment was accomplished by
accompanying George through a work day under guise that the therapist was a trainee. It seems
that the stimuli for the onset of most of his anxieties at work are his understandings of
expectations, specific or implied, in his job responsibilities. Interestingly, if he is asked to do
something he has successfully completed before, he is comfortable with the assignment and
experiences no distress or anxiety. If he perceives the standard to be “too easy” or “too hard” or
“somebody else’s responsibility” he finds himself at odds to complete the task. His response
seems to be independent of the delivery of the request (written, spoken nicely, or demanded). At
this point the maladaptive behavior is to not engage the task but to comment about the task,
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 12
consider it philosophically, and generate discourse and enlist others to agree with his assessment
about the uselessness or futility of him completing the task. While doing the maladaptive
behavior, George is clearly agitated and bothered. All these behaviors successfully remove him
from possible poor performance, evaluation, and embarrassment. If he still is required to
complete the assignment (escape is unavoidable) he will continue experiencing and behaving
anxiously (easily agitated, nervous, rushed movements and rushed thoughts), and this will carry
over into his social life as he enlists others to commiserate and support him in avoidant attitude
and behavior. These behaviors, he recognizes, are reasons he has had difficulty staying employed
over the years. The goal is for the client to comfortably (little to no anxiety) (conditioned
response) engage new tasks and responsibilities (neutral stimulus) as he is given them. A
successful example of this would be George assessing a new assignment and deciding the
component parts and steps necessary (operant conditioning) to complete it calmly (conditioned
response). The target is how close (shaping may be necessary) in similarity to the manner in
which he responds (operant conditioning) to previously accomplished or routine tasks
(conditioned response).
Another problematic area George has is in relationships. Though he has friends that he
has known for years, he seems unable to develop and maintain close relationships with women.
He was engaged, but that felt forced and occurred because his friend became engaged. Although
he seeks a close relationship, he repeatedly becomes anxious about what seem to be non-related
issues. Through interview and brief role-play, it was identified that when George experienced a
level of familiarity that would be becoming more personally revealing (favorites, hobby
activities, personal information), George would become very anxious and feel vulnerable. At this
time his responses would change the quality of the communication or he might even leave the
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 13
venue and the person. He again expressed concern that he would either reveal something about
himself that would cause the person to reject him or he would reject them first. These
occurrences are throughout his adolescent and adult life. The goal is for George to enjoy an
evening shared with a female companion, perhaps even sharing some aspect of his personal life
with her. The achievement of the goal will be from a self-report by the client, but progress will
be in approximations as he engages women in casual conversation (co-workers, at a diner, at a
party) as homework assignments.
George Costanza, even when unemployed and uninvolved in a relationship, has expressed
that he still gets very anxious (conditioned response) in diverse social situations (undefined
conditioned stimulus). Interactions with his parents generate much anxiety (conditioned
response) since he still lives with them, as does his own sense of lack of accomplishment (no
career yet, little money saved) for an adult of his age (conditioned stimulus), perception
(conditioned stimulus) of not being in control of his feelings and the perception (conditioned
stimulus) of not being able to influence or change the circumstances he finds himself in. He does
have brief episodes of depression exemplifying the view of “Ferster (1983) … [who] proposed
that depressed people have “(1) a limited view of the world, (2) a ‘lousy’ view of the world, and
(3) an unchanging view of the world” (p. 379) (Murdoch, 2013, p. 250). The stimuli that are
associated with these anxiety situations seem to be two different ones that overlap slightly. His
parents occasionally remind him of his dependence on them financially which causes great
inescapable anxiety. This is classically conditioned from when he was much younger and his
parents used a similar tone of voice (conditioned stimulus) to reprimand (punishment) him for
some misbehavior (operant behavior) considered not appropriate for his age. The anxiety
response (conditioned response) has an element of shame associated with it that likely came from
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 14
his childhood experiences. The other stimulus that elicits a very similar response (with less of a
shame component) is social comparison. When George engages in social comparison (operant
behavior), a resultant unfavorable comparison (conditioned stimulus) generates the anxiety
(conditioned response), which is related (classically conditioned) to the perception that he is
lacking or underperforming (not appropriate for his age). The goal is for George to engage in a
thought behavior (operant conditioning) other than social comparison and to learn new thought
patterns that enable him to live a fuller life.
Interventions
Employment – Since George is engaging in escape behavior in reaction to the anxiety he
experiences when presented with unfamiliar tasks the technique of choice, especially since this is
a work environment is exposure and response prevention, and modeling. Exposure and response
prevention involve stopping the urge to escape (leave the room) or use safety behavior
(complain, verbal comments) to avoid the situation (Rachman, 2009). This is the first step to
both getting George to experience that he can survive the anxiety and the situation and to be able
to engage in new behaviors. The high maintenance of escape behaviors is because the person
never learns that it is survivable and that other choices are possible. Having the client remain in
the situation allows the next step which is to use information from successful models who have
successfully adapted. There are two models that we decided to use. The first was George. When
faced with tasks done in the past, George responds appropriately. So modeling what George did
first, how he approached a familiar task, what was the sequence of actions (both thought and
physical) that worked, and how did he know he was making progress. We also decided to model
other employees with similar responsibilities to assess how they dealt with new and unfamiliar
assignments. Their processes were similar to George’s with the addition of being comfortable
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 15
while gathering information (asking questions because of not knowing) as part of the sequence of
actions. With rehearsal on simpler and less complex unfamiliar tasks, George was able to
successfully learn a sequence of thoughts and actions while experiencing little anxiety. After
much repetition and reinforcement, (initially praise, then absence of anxiety functioning as a
reinforcer, then a sense of control and accomplishment, anticipation of salary increase or
promotion), he became more comfortable and the escape behavior was extinguished.
Relationships – It seems that George has difficulty with relationships and has a limited
repertoire of behaviors from which to choose. While role playing a dating scenario, George
repeatedly did not feel comfortable talking beyond 15-20 minutes with the other person. If the
conversation went to a topic he was unfamiliar (conditioned stimulus) with, he became anxious
(conditioned response), and anticipated a negative behavior (rejection, disapproval) from the
other person. We decided that we would use a combination of repeated and gradual exposures
while maintaining a relaxed state to address the anxiety (imagery of the dating scenarios to evoke
the anxiety) (Hedman, Strom, Stunkel, & Mortberg, 2013). After significantly reducing the
anxiety to these imageries which were assigned homework, he then felt ready to take the next
step which was to engage in simple and brief conversations with females in common daily
situations (work, store, library, shopping). This second step of skill learning was also rehearsed
with role playing and was intended to develop and rehearse skills of conversation (operant
behavior) and interchange with women. He had limited conversational range and this allowed
him to grow and learn to adapt to different dialoging scenarios. His success with his new skills
(reinforcement) combined with the lessened anxiety (negative reinforcement) made him repeat
the exercises and gain noticeable confidence and comfort within six weeks.
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Generalized anxiety – extinction of old thought pattern via punishment and new thought
patterns via reinforcement. George’s generalized anxiety seems to be a response to social
comparison. This seems to be a habitual pattern modeled by his parents. Using comparisons to
encourage him when he was younger to “stand up, like the other children” or “why can’t you be
more like him” were meant to be corrective, however they were repeated associations that
conditioned anxiety to that process (comparisons). Though unintentional, that thought process is
still very present and very anxiety producing. An advantage of BT is that little time is spent on
the past except to identify conditioning origins and address them in the present along with the
other generalized instances. For George it is a relief to hear there is nothing wrong with him and
that the work involved is on changing the thought pattern of comparison to something else. After
some discussion, it was decided that admiring, acknowledging, or appreciating differences
between people was acceptable, reasonable, and do-able. George noted he has often admired
athletes or artistic performers and not compared himself to them. George’s task was to admire
and appreciate the athletes and performers and their unique abilities. He did this for one week
and experienced pleasure (reinforcement) noting that people could accomplish these acts. He was
reinforced also because he was not anxious when thinking about what these people had
accomplished. The following week, the homework assignment was to admire, acknowledge, or
appreciate people with lesser accomplishments, enjoying the diversity of life and people. These
were people that were necessary for society’s functioning, but not public figures (mailman,
doctor, store clerk, teacher, or mechanic). As he continued to be reinforced (no anxiety) for this
assignment, he was enjoying noticing aspects of people in different ways. The third and fourth
weeks were designed to generalize the stimulus to strangers that he came across in stores, on the
street, or on the subway. Again, he was to just enjoy the different types and varieties of people
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 17
and life styles and to compare those noticing differences in a non-critical way. Reinforcement
was in the form of no anxiety experienced and self-evaluative praise (“this is interesting,” “this is
fun”). When George had this process habituated (new operant behavior maintained by
reinforcement of learning and negative reinforcement of reduced/eliminated anxiety), we then
made the connection of looking at other people that he knew. This three week shaping process
was to help him generalize to more varied stimuli. The final two weeks of homework involved
George noticing people he knew, comparing their different strengths or abilities and then
considering himself as a person with unique qualities just as the other people he was
appreciating. These last two weeks required extra reinforcers in the form of self-delivered verbal
encouragement and verbal evaluations to maintain the new habit at this critical point. George
admitted surprise when the formerly omnipresent anxiety did not return automatically. We
discussed other supportive techniques (relaxation) if he should sense further conditioning were
necessary.
Spiritual Applications
I do not see any challenge including Christian counseling as part of the treatment plan.
BT and CBT do not have any theories of personality or any inherent techniques that are
exclusive of Scripture. The client himself has little to no spirituality, but that does not mean that
the counselor cannot come from a Christian worldview as far as morality and values. It would be
wrong to include prayer if the client did not express an interest. However while establishing
agreed up on goals, treatments, and norms that will define the aspects and parameters of our
collaborative healing journey, it would be acceptable to include (and expected for the counselor)
values and norms in alignment with Christian values and norms. The Christian worldview
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 18
considers the whole person and BT and CBT effectively address just the behavioral aspect and
are a useful subset of the larger conception of the client.
Resources and referrals besides the Bible, church, and prayer that can be recommended to
the client to include joining a Christian anxiety support group. A discussion of values, norms, and
morals can be included because the client also has a reference. Addressing just the behaviors of
my client will leave him less prepared to adapt to new situations without an internal reference.
George will be encouraged to consider his life and think of a larger worldview, especially now
that he has experienced that change is possible and maintainable will the skills and techniques he
has used and knows.
A reason Christian counseling is compatible with BT is because Boivin has argued that
the purely naturalistic view of BT allows for a Christian overlay since “Only our relationship and
responsibility to God makes us qualitatively different from animals” (Boivin, 1985, as cited in
Murdoch, 2013, p. 180). Understood in this way, there is no conflict. A second way that they are
compatible is that both are oriented to improving the quality of life, BT through more adaptive
behaviors and Christians to live more in line with Christ like ways and the avoidance of sin
(Murdoch, 2013). A third way is that the focus on the present of BT encourages accountability
and encourages growths, which are also Christian values (Jones & Butman, 2011). A fourth way
is that the counseling arrangement is similar to the Christian model of stewardship requiring
documenting the efficacy of their work which is a cornerstone of BT.
There are several areas of incompatibility between BT and Christianity. The first is that
naturalism is very atomistic and does not address the whole person. The interplay of the body
and the soul/spirit and our transcendent nature with God are completely missing (Jones &
Butman, 2011). A second are of incompatibility is that what is normal or adaptive in BT has no
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 19
moral reference or definition. Christians have explicit norms and behaviors that are part of the
faith. A third conflict is that BT posits environmental control (or at least great influence) and
does not allow for free will or human choice, which is completely opposite Christian worldview
(Jones & Butman, 2011). We are responsible for our actions (free will) but BT’s determinism
says it is all the environment (although a brief rebuttal allowed that causes do not have to be
exclusionary and that both can coexist). A fourth (non-rebutted) disagreement is that there is no
holistic view of the person. The complete person is not addressed in BT, just the behaviors. A
Christian approach addresses all of the needs of the person including behavior and relationship
with God. A fifth conflict is that all motivation in BT is related to survival of the species (food,
water, procreation) and there are no higher motives which are core to the Christian worldview.
Conclusion
This therapeutic method was chosen because of its well documented success with anxiety
issues. The brief time frame and measurable observable progress aspects were of great appeal to
both the client and the employer (New York Yankees). BT is present oriented which is where the
concerns were for the client and employer. An appealing aspect in this case was that the client
had blamed many other individuals and circumstances for his situation and behavioral
limitations. BT/CBT philosophy is that behaviors are just behaviors, they are learned and they
can be changed, removing aspects of blaming, empowering the individual in their life and
increasing choice and growth. By having a collaborative relationship the responsibility for
progress was also on the client, and more importantly, the maintenance and continued growth
(adaptability to new challenges and responsibilities at work and in personal life) became the
possession of the client. Another significant reason is the universal adoption of an operant
principle by Christian universities and institutes of higher learning. This high endorsement far
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 20
exceeds any other approach utilized in the educational field. Unfortunately it was not advisable
to adopt punishment, no matter how ubiquitously embraced and endorsed by Christian programs
and instructors, because of its limited effectiveness shaping and encouraging growth and new
behaviors. However, punishment has significant prominence in the educational arena, even in its
role as the behavioral elephant in the room no one wishes to talk about, as the behavior
influencing agent of choice.
BT/CBT CONCEPTUALIZATION AND TREATMENT COSTANZA 21
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