Chapter 9: Behavior Therapy

Behavior therapy overview

• Behavior therapy focuses on directly observable behavior, current determinants of behavior, and learning experiences.

• Anxiety disorders, depression, posttraumatic stress disorder, and so on have been treated.

• It is used in the fields of developmental disabilities, mental illness, education, community psychology, sports, medicine, and so on.

  • What goes inside a black box, what goes into this black box, what happened to this black box, and what happened afterwards—my behavior

Positive reinforcement

increase the chance for behavior

• Ex., If I smile and Karina is answering a question, I am using reinforcement (operant conditioning)

Four Areas of Development

1. Classical (or Respondent) Conditioning

2. Operant Conditioning

3. Social Learning (or Social-Cognitive) Approach

4. Cognitive Behavior Therapy

Classical (or Respondent) Conditioning

• Refers to what happens prior to learning that creates a response through pairing

• Pairing something does not trigger a response, with something that triggers a response, without that natural response, that pairing, neutral stimulus elicits a response

  • Pavilon’s dog: bell and dog, ring the bell, there’s food, dog salivates. Then, just ringing the bell causes the salivating

    • Food paired with salivating

Operant Conditioning

Focuses on a type of learning in which behaviors are influenced mainly by the consequences that follow them

• A response after, that reinforces the behavior. Positive reinforcement, negative reinforcement

  • Rat has to press the lever, food will come out. Even if the food does not come out, the rat will still press

  • Person treats other person really nice, so the person stays in hope of being treated nice again (abuse)

Social Learning (or Social-Cognitive) Approach

Gives prominence to the triadic reciprocal interaction between an individual’s behavior, personal factors, and the environment

• Less behavioral. Helping you to learn how to socialize, coaching you, how to start talking to people

Cognitive Behavior Therapy

Social skills training, cognitive therapy, stress management training, mindfulness, and acceptance-based practices all represent the cognitive behavioral tradition.

• Helping you to relax

Therapeutic Goals

• to increase personal choice and to create new conditions for learning.

  • It is your personal choice. I could be punished or rewarded for my behavior, so I will be choosing.

• Measure progress toward goals based on empirical validation.

• Goals must be clear, concrete, understood, and agreed on by the client and the counselor.

  • Therapeutic Goal: How to increase personal choice and create new conditions for learning

  • Ex. speaking up (being punished or rewarded)

    • Rewards are intrinsic or extrinsic

Behavior therapists conduct a thorough functional assessment.

• What is a functional assessment?

A-B-C model

• ABC model of behavioral therapy

A- Antecedent(s)—influenced by events that precede it

• When mom is on the phone

B- Behavior(s)—model of behavior

• And I ask for ice cream

C- Consequence(s)—influenced by events that follow it

• I will get it

Client’s Experience in Therapy

• Therapist and client have the importance of client awareness and participation in the therapeutic process.

• Teaching concrete skills through the provision of instructions, modeling, and performance feedback.

• Clients are expected to do more than merely gather insights; they need to be willing to make changes.

  • A very active participation

Relationship Between Therapist and Client

• Recognized the role of the therapeutic relationship and therapist behavior as critical factors.

• Experimental therapies emphasis on the nature of the engagement between counselor and client.

• It helps the clients’ change in the direction they wish.

  • The client needs to trust the therapist enough to believe that, what the therapist has asked me to do will actually work (ex. Homework assignment)

Operant Conditioning Techniques

• Positive and negative reinforcement

• Extinction

• Positive and negative punishment

Positive and negative reinforcement

• Goal

to increase target behavior

• think of it as a reward, giving you good thing, or removing bad thing

Positive reinforcement

Giving you a good thing to increase target behavior

• You do well.

  • So, I’ll give you a candy.

    • Result: You continue doing well.

Negative reinforcement

Taking away a bad thing to increase target behavior

• Ex., A teacher giving a day off from homework for good behavior.

Extinction

• Goal

to decrease or eliminate a behavior by withholding reinforcement from a previously reinforced response

Ex.,

• Before extinction

  • A child whines → parent gives candy → whining increases (because it’s reinforced)

• Using extinction

  • Child whines → parent does not give candy anymore → whining eventually decreases

• The child stops whining because it no longer works.

Key Idea: No reinforcement = behavior fades away over time

Positive and negative punishment

• Goal

to decrease target behavior

• Positive: adding something to decrease behavior

• Negative: removing something you like (removing stickers)

Progressive muscle relaxation

A popular method of teaching people to cope with the stresses produced by daily living.

• Relaxation becomes a well-learned response, which can become a habitual pattern if practiced daily.

• Relaxation procedures have been applied to a variety of clinical problems ranging from chronic pain to panic disorder.

Systematic Desensitization

• Focusing on anxiety

• Gradually exposing you to something you don’t like so that you gradually become less anxious (can be done by imagining)

• Based on classical conditioning, systematic desensitization (SD) was developed by Joseph Wolpe.

  SD is effective and efficient in reducing maladaptive anxiety and treating anxiety-related disorders, particularly specific phobias.

  SD entails relaxation training, development of a graduated anxiety hierarchy, and presentation of hierarchy items while client is deeply relaxed.

In Vivo Desensitization

Involves client exposure to the actual anxiety-evoking events rather than simply imagining these situations

• Must be done in person

Flooding

In vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of time without the feared consequences

• can be in-person or imagined

Ex., Going to functions for work. I am required to go to functions. I keep on going and going, this is flooding.

Eye Movement Desensitization and Reprocessing

An exposure-based therapy

Involves imaginal flooding, cognitive restructuring, and the use of rhythmic eye movements and other bilateral stimulation to treat traumatic stress disorders

Extensive research has validated EMDR.

• Requires specialized training

• Helpful for PTSD, especially when verbal cousneling does not work, almost in the subconscious

EMDR compresses three-pronged methodology to identify and process:

1. memories of past adverse life experiences that underlie present problems

2. current situations that elicit disturbance

3. needed skills that will provide positive memory templates to guide the client’s future behavior

Social Skills Training

• Helps clients develop and achieve skills in interpersonal competence.

  • May involve behavioral techniques (e.g., psychoeducation, modeling, behavior rehearsal, and feedback).

    • If clients can correct their problematic behaviors in practice situations, they can then apply these new skills in daily life.

Self-Management Programs and Self-Directed Behavior

• In S-M programs, people make decisions concerning specific behaviors they want to control or change.

• The process includes selecting goals, translating goals into target behaviors, self-monitoring, working out a plan for change, and evaluating an action plan.

• S-M strategies have been successfully applied to many populations and problems.

Multimodal Therapy: Clinical Behavior Therapy

• A comprehensive, systematic, holistic approach to behavior therapy developed by Arnold Lazarus.

• Grounded in social-cognitive learning theory.

• Applies diverse behavioral techniques to a wide range of problems; that encourages technical eclecticism.

Mindfulness and Acceptance-Based Approaches

Emphasizes limits for behavioral therapists include mindfulness, acceptance, the therapeutic relationship, spirituality, and values.

• The five interrelated core themes follow:

1. Psychological health

2. Acceptable outcomes in therapy

3. Acceptance

4. Mindfulness

5. Creating a life worth living

Mindfulness

is “the awareness that emerges through having attention on purpose, in the present moment.”

Acceptance

is a process involving receiving one’s present experience without judgment or preference.

Mindfulness and Acceptance-Based Approaches

• The 4 major approaches

1. Dialectical behavior therapy

2. Mindfulness-based stress reduction

3. Mindfulness-based cognitive therapy

4. Acceptance and commitment therapy

Mindfulness-Based Stress Reduction (MBSR)

• not a form of psychotherapy per se, but it can be an adjunct to therapy

• assists people in learning to live more fully in the present.

• The skills taught in MBSR include sitting meditation and mindful yoga, aimed at cultivating mindfulness.

• offered in hospitals, clinics, schools, workplaces, offices, law schools, prisons, and health centers.

  • Help people coach behavior of mindfulness, like meditation: coaching you to do the breathing, relaxing, etc

Mindfulness-Based Cognitive Therapy (MBCT)

• An eight-week group treatment program of two-hour weekly sessions adapted from MBSR that includes components of cognitive behavior therapy (CBT).

• Clients learn to respond in skillful and intentional ways to their automatic negative thought patterns.

• Kindness and self-compassion are essential components.

  • Self talk, what do you tell yourself

Dialectical Behavior Therapy (DBT)

• A promising blend of behavioral and psychoanalytic techniques for treating borderline personality disorders and other issues

• Includes both acceptance-oriented and change-oriented strategies

• Skills are taught in four modules: mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance.

• 4 components: how to regulate emotions, how to make person tolerate stress, increase interpersonal skills, mindfulness

Four modules of Dialectical Behavior Therapy (DBT)

1. mindfulness

2. interpersonal effectiveness

3. emotional regulation

4. distress tolerance.

Four components of Dialectical Behavior Therapy (DBT)

1. how to regulate emotions

2. how to make person tolerate stress

3. increase interpersonal skills

4. mindfulness

DBT Application Examples

• Scenario 1: Emotional Regulation in a Teen with Intense Mood Swings

• Context: Samantha, a 16-year-old, struggles with intense emotional reactions. When she feels rejected by friends, she often becomes overwhelmed, yells, and later feels guilty.

• DBT Application?

In therapy, Samantha learns emotion regulation and distress tolerance skills. For instance, she practices identifying her emotions, naming them (“I feel rejected and angry”), and using coping strategies like paced breathing or “opposite action” (doing something kind instead of withdrawing). Over time, she becomes more aware of her emotional triggers and can respond without escalating conflict.

• Borderline personality disorder

• DBT, learn how to regulate emotions

• Behavioral Therapy Coaching: teaching them to use words and what words

DBT Application Examples

• Scenario 2: Interpersonal Effectiveness for an Adult with Borderline Personality Disorder

• Context: Mark, 32, had difficulty maintaining relationships. He fears abandonment and often reacts with anger or desperation when his partner wants space.

• DBT Application?

Mark works on interpersonal effectiveness skills. He practices the DEAR MAN technique (Describe, Express, Assert, Reinforce, Mindful, Appear confident, Negotiate) to communicate needs without being aggressive. For example, he learns to say, “I feel anxious when I don’t hear from you all day. Could we check in once during the afternoon? Instead of sending angry texts.

• Coach how to talk and how to regulate

• Not fixing, but helping

Acceptance and Commitment Therapy (ACT)

• Involves fully accepting present experience and mindfully letting go of obstacles.

  • There is little emphasis on changing the content of a client’s thoughts. Instead, the emphasis is on acceptance (nonjudgmental awareness) of cognitions.

    • We don’t want to change whatever you thinking, but we need to accept that we have those thoughts, we help them accept them not focus on these thoughts

• Uses acceptance and mindfulness strategy to increase psychological flexibility.

Application to Group Counseling

• Rely on empirical support and tend to be brief

• Emphasize self-management skills and thought restructuring

• The specific unique characteristics include the following:

  • Conducting a behavioral assessment

  • Spelling out collaborative treatment goals

  • Formulating specific procedure appropriate to a particular problem

  • Evaluating the outcomes of therapy

The four approaches applied to the practice of behavioral groups follow:

• Social skills training groups (teaching and demonstrating)

• Psychoeducational groups with specific themes (workshops)

• Stress management groups (meditation, relaxation)

• Mindfulness and acceptance-based behavior therapy in groups

Strengths From a Diversity Perspective

• Behavior therapy may appeal to culturally diverse clients for many reasons.

• Behavior therapy emphasizes on brief interventions, teaching coping strategies, and problem-solving orientation.

• Behavior therapy focuses on environmental, social, and political conditions that contribute to a client’s problems.

  • Very tangible: brief, and teaches you how to cope

  • Looks at “in this context” or “in this situation”

Shortcomings From a Diversity Perspective

• Some counselors may use a variety of techniques in narrowly treating specific behavioral problems.

  • Missing out in the thoughts and relationships

• Therapists who do not assess the interpersonal and cultural dimensions of the client’s problem may not adequately be prepared for the consequences of newly acquired social skills.

Contributions of the Behavior Therapy

• The specificity of the behavioral approaches helps clients translate unclear goals into concrete plans of action.

  • Focus is very helpful, especially insurance wise

• A wide variety of specific behavioral techniques have been developed.

• Behavioral interventions have been subjected to more rigorous evaluation than other approaches.

• Behavior therapy emphasizes ethical accountability

Limitations and Criticisms of the Behavior Approach

• Heavy focus on behavioral change may detract from client’s experience of emotions.

  • Empathize with the ambivalence but then engage in behavior

• Some counselors believe the therapist’s role as a teacher deemphasizes the important relational factors in the client–therapist relationship.

• Behavior therapy does not provide insight.

Limitations and Criticisms of the Behavior Approach (that can be seen as contributions)

• Behavior therapists emphasize changing current environmental circumstances to change behavior.

  • Sometimes we really cannot change the environment which is why it is a limitation

    • (ex. Asking the teacher to be more engaging rather than asking the kids to change their behavior)

• Behavior therapy recognizes the importance of making the social influence process explicit, and it emphasizes client-oriented behavioral goals.

• Therapy progress is continually assessed, and treatment is modified to ensure that the client’s goals are achieved.

  • Very focused: behavior, anxiety, phobia (behavior therapy) – is this the therapy of choice for this condition

Criticism of behavior therapy

Four modules of dialectical behavior therapy

1. mindfulness skills

2. distress tolerance skills

3. emotional regulation skills

4. interpersonal effectiveness skills

The first two DBT skills offer a path to acceptance of reality as it is; the last two are change skills that help people make changes that will lead to a meaningful existence.

Mindfulness

first module of DBT

• The act of focusing on the present moment, without judgment and without attachment.

  • Teaches individuals to be aware of and accept the world as it is and to respond to each moment effectively.

  • Permeates the whole of DBT.

  • Clients learn to embrace and tolerate the intense emotions they experience when facing distressing situations, which helps reduce pain and increase happiness.

Distress tolerance

second module of DBT

• Aimed at helping individuals recognize emotions associated with negative situations without becoming overwhelmed by these situations.

  • Clients learn how to tolerate crisis situations effectively by finding solutions to sources of stress.

Emotional regulation

third module of DBT

• Includes identifying emotions, identifying obstacles to changing emotions, reducing vulnerability, and increasing positive emotions.

  • Clients learn the benefits of regulating emotions such as anger, depression, and anxiety.

Interpersonal effectiveness skills

fourth module of DBT

• Clients learn how to ask for what they need and how to say “no” while maintaining self-respect and relationships with others.

  • Increasing the chances that a client’s goals will be met without damaging the relationship.

ABC model of behavioral therapy

• A

Antecedent(s)—influenced by events that precede it

ABC model of behavioral therapy

• B

Behavior(s)—model of behavior

ABC model of behavioral therapy

• C

Consequence(s)—influenced by events that follow it

Techniques in Mindfulness-Based Cognitive Therapy