BEHAVIOR THERAPY

Focus directly on observable behavior, current determinants of behavior, learning experiences that promote change, tailoring treatment strategies to individual clients, and rigorous assessment and evaluation

has been used to treat a wide range of psychological disorders with specific client populations—anxiety disorders, depression, posttraumatic stress disorder, substance abuse, eating and weight disorders, sexual problems, pain management, and hypertension

Historical Background

4 Areas of Development

Classical Conditioning

• Learning that creates a response through pairing

• Ivan Pavlov

  • illustrated classical conditioning through experiments with dogs

• Joseph Wolpe (systematic desensitization)

Operant Conditioning

• Behaviors influenced mainly by the consequences that follow them

  • If the environmental changes are reinforcing—that is, if they provide some reward to the organism or eliminate aversive stimuli—the occurrence of behavior increases

  • if no reinforcement or produce aversive stimuli, lessened behavior occurrence

• B. F. Skinner

  • prominent spokesperson for behaviorism; father of behavioral approach to psychology

  • championed radical behaviorism, which places primary emphasis on the effects of environment on behavior

  • a determinist; did not believe that humans had free choice

  • cause-and-effect link between objective, observable environmental conditions and behavior

Social Learning/Social Cognitive Approach

• Albert Bandura

  • did pioneering work in the area of social modeling and demonstrated that modeling is a powerful process that explains diverse forms of learning

  • explored social learning theory and the prominent role of observational learning and social modeling in human motivation, thought, and action

  • social cognitive theory, which shed light on how we function as self-organizing, proactive, self-reflective, and self-regulating beings

  • broadened the scope of behavior therapy by exploring the inner cognitive-affective forces that motivate human behavior

• Richard Walters

• Investigating the triadic reciprocal interaction among the environment, personal factors (beliefs, preferences, expectations, self-perceptions, and interpretations), and individual behavior; events in the environment are governed by cognitive processes and how the individual interprets them

• interactional, interdisciplinary, and multimodal

• basic assumption: people can change their behavior and are agents of change

• Self-efficacy - one’s belief that they can master a situation and bring change they want

• Example of social learning: developing social skills after being exposed to people with good social skills

Cognitive Behavioral Therapy

• Represents the mainstream of contemporary behavior therapy

• Assumes that what people believe influences how they act and feel; has much in common with contemporary behavior therapy—mechanism of change is cognitive and behavioral

  • examples: Social skills training, cognitive therapy, stress management training, mindfulness, and acceptance-based practices

Contemporary Behavior Therapy

• has scientific view of human behavior → systematic and structured approach

• more on developing procedures that foster client’s control thus increasing “freedom”

• equipping people with skills to have more response options

Basic Characteristics and Assumptions

1. Behavior therapy is based on the principles and procedures of the scientific method. Concepts and procedures are stated explicitly, tested empirically within a conceptual framework, and revised continually. Mutual agreement of treatment goals and having means for evaluation.

2. The key characteristic of a behavior is that it is something that can be operationally defined. It is not just overt actions but internal processes as well.

3. Behavior therapists look at the current environmental events that maintain problem behaviors and help clients produce behavior change by changing environmental events through a process called functional assessment, or behavioral analysis.

4. Clients involved in behavior therapy are expected to assume an active role by engaging in specific actions to deal with their problems; learning and doing over thinking; action-oriented, takes an educational approach.

5. This approach assumes that change can take place without insight into the underlying dynamics and without understanding the origins of a psychological problem. Knowing you have a problem and knowing how to change it are two different things; changes in behavior can occur prior to or simultaneously with understanding of oneself, and that behavioral changes may well lead to an increased level of self-understanding

6. Assessment is an ongoing process of observation and self-monitoring that focuses on the current determinants of behavior, including identifying the problem and evaluating the change.

7. Behavioral treatment interventions are individually tailored to specific problems experienced by the client; "What treatment, by whom, is the most effective for this individual with that specific problem and under which set of circumstances?"

Therapeutic Goal

The general goal is to increase personal choice and to create new conditions for learning. Specific goals are clear, concrete, understood, and agreed upon by the client and the counselor before treatment.

Therapist Function & Role

Functional Assessment (or Behavior Analysis)

• The goal is to identify the maintaining conditions, gathering information through the ABC model: situational antecedents (A), the dimensions of the problem behavior (B), and the consequences/events that follow it (C).

  Antecedent events cue behavior

  Consequences maintains behavior thru increasing/decreasing

  Relying on Empirical Evidence

  • This approach relies on the use of the scientific method. The therapist must have skills in selecting and applying treatment methods. It is directive, but use techniques such as summarizing, reflection, clarification, and open-ended techniques.

• behavioral assessment interview

  • therapist identifies antecedents and consequences

• therapists are empiricists, using treatments that are evidence-based and proven to be effective → promotes sustainability of behavior change

• regular evaluation to tailor treatment as they see fit on the current progress of the client, also teach clients how to deal with “relapse” of behavior or failing to maintain behavior change

Client’s Experience in Therapy

Clearly Defined Roles

• The client is active. While the therapist teaches concrete skills, the client rehearses them with feedback until skills are well learned. They also engage in homework to help clients apply what they learned in therapy to daily life.

• clients are expected to cooperate → low cooperation would decrease chances of successful therapy

• walk the talk

Relationship Between Therapist & Client

A Collaborative Working Relationship

• However, they content that warmth, empathy, authenticity, permissiveness, and acceptance are necessary but not sufficient for behavior change to occur.

  The relationship is just the foundation on which behavioral strategies are built to help clients change in the direction they wish.

Application

Therapeutic Techniques and Procedures

• BT uses various empirically-supported techniques which were shown to be effective for various problems and can be incorporated into other therapeutic approaches.

• Tailor techniques to the needs of the client

Applied Behavioral Analysis

• Operant Conditioning Techniques

  • The use of positive and negative reinforcement as a consequence to reinforce desired behavior.

  • Extinction, withholding reinforcement (negative punishment) from a previously reinforced response, can also be used (such as in the case of parenting strategies).

  • Punishment, or aversive control, has the goal of decreasing target behavior. Although some practitioners are averse to using punishment, preferring positive reinforcement instead.

Progressive Muscle Relaxation

• Clients are given a set of instructions that teaches them to relax.

  • Clients fully experience tension building up and to hold that state of tension. Then, they are taught to relax all muscles while visualizing parts of the body, with emphasis on facial muscles

• Relaxation becomes a well-learned response, which can become a habitual pattern if practiced about 25 minutes each day.

• Applied in managing pain, stress and anxiety, psychosomatic symptoms, and others.

Systematic Desensitization

• Systematic desensitization is a principle based on classical conditioning where clients imagine successively more anxiety-arousing situations at the same time that they engage in a behavior that competes with anxiety

• Sufficient background information about the anxiety and other related information is gathered through interviews, which can last several sessions.

  • What circumstances elicit the conditioned fears?

  • Client observes and records situations during the week that elicit the anxiety response.

  Steps in Systematic Desensitization

  • PROGRESSIVE MUSCLE RELAXATION TRAINING - can be asked to create an imagery that helps them reach a state of calm and peacefulness

  • DEVELOPMENT OF A GRADUATED ANXIETY HIERARCHY - Clients analyze stimuli that evoke the anxiety response and list all the situations that evoke it. The list is then arranged into a hierarchy from the most to the least anxiety provoking that the client can imagine

  • SYSTEMATIC DESENSITIZATION - Begins once the client has had enough time to practice and learn relaxation; the client is made to relax and then asked to imagine the anxiety-provoking stimuli starting from the bottom of the hierarchy

When the client begins to experience anxiety, the scene is terminated. Relaxation is induced again until the client experiences little anxiety.

Treatment ends when the client is able to remain relaxed while imagining the scene that was most anxiety-provoking.

Homework remains essential. Clients must practice relaxation daily, at which time they visualize scenes completed in previous sessions.

1. Begin with a relaxation procedure.

2. Decide what specific behavior or situations evoke anxiety reactions for you.

3. Construct a hierarchy, which should be arranged from the worst situation you can imagine to a situation that evokes the least anxiety.

4. Apply the relaxation procedures you have learned; keep your eyes closed, and begin by imagining yourself in the least anxiety-arousing situation on your hierarchy. Then, while imagining a peaceful and pleasant scene, allow yourself also to imagine yourself in the next most anxiety-arousing situation.

5. The idea is to move progressively up the hierarchy until you can imagine the scene that produces the greatest degree of anxiety and still be able to induce relaxation again.

In Vivo Exposure and Flooding

• Exposure Therapies

  • Contact with what they find fearful, either through imagination or in vivo (live) under carefully controlled conditions

  • For in vivo exposure, assessment is done like systematic desensitization and clients can also learn muscle relaxation

    • Still considering clients safety and ethical boundaries, the therapist can accompany clients to feared situations in a safe setting

  • In flooding, the client is exposed to the feared stimulus (either live or imagined) for a prolonged period of time

Eye Movement Desensitization Reprocessing

• EMDR (Francine Shapiro)

  • A form of exposure therapy that entails assessment and preparation, imaginal flooding, and cognitive restructuring in the treatment of individuals with traumatic memories

  • Involves the use of rapid, rhythmic eye movements and other bilateral stimulation to treat clients who have experienced traumatic stress

  • There is some controversy over whether the eye movements themselves create change or whether cognitive techniques paired with eye movements act as change agents.

Social Skills Training

• A broad category that deals with an individual's ability to interact effectively with others in various social situations

• Involves behavioral techniques such as psychoeducation, modeling, behavioral rehearsal, and feedback

• Clients must actively apply these in roleplay with feedback and reinforcement from the therapist; then, they apply these skills in daily life

Self-Management Programs and Self-Directed Behavior

• Teaching clients to make decisions concerning specific behaviors that they want to control or change by teaching them skills they need to manage their own lives effectively

• Advantages: minimal costs, can be extended to the larger population that traditional approaches to therapy cannot, increased involvement and commitment to their treatment

  Basic Steps by Watson and Tharp (2014)

  1. SELECTING GOALS

     • SMART goals; measurable, attainable, positive, and significant; expectations must be realistic

  2. TRANSLATING GOALS INTO TARGET BEHAVIORS

     • Identify target behaviors, anticipate obstacles, and think of ways to negotiate them

  3. SELF-MONITORING

     • Deliberately and systematically observe your own behavior, keep a behavior diary and record actions, thoughts, and feelings, along with comments about the relevant antecedent cues and consequences. This diary can help you identify what you need to change.

  4. WORKING OUT A PLAN FOR CHANGE

     • Substituting new thoughts and behaviors for ineffective ones; devise an action program to bring about changes in line with your goals; reinforcement is the cornerstone of modern behavior therapy

  5. EVALUATING AN ACTION PLAN

     • Evaluate whether goals are being achieved, adjust and revise the plan as other ways to meet goals are learned; adjust as necessary

More Developments

• Multimodal Therapy: Clinical Behavior Therapy

  • Grounded on social cognitive learning theory; focuses on the seven discrete but related modalities in therapy: Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal factors, and Drug/Biological considerations (the BASIC ID)

• Mindfulness and Acceptance-Based Approaches

  • The third wave in BT; considers mindfulness, acceptance, the therapeutic relationship, spirituality, values, meditation, being in the present moment, and emotional expression; This includes Dialectic Behavior Therapy (DBT), Mindfulness-Based Treatments, and Acceptance and Commitment Therapy (ACT)

  • Mindfulness is “the awareness that emerges through having attention on purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment by moment”

  • Acceptance is a process involving receiving one’s present experience without judgment or preference, but with curiosity and kindness, and striving for full awareness of the present moment

Application to Groups

BT in Group Counseling

• Teaches self-management skills, coping behaviors, cognitive restructuring.

• Group leaders are teachers. They are active and apply a directive, structured, collaborative, and psychoeducational model of therapy which can include assessment and data collection.

• Techniques that can be used: assertiveness and social skills training, relaxation procedures, behavioral analysis, modeling, coaching, meditation, and mindfulness techniques

Strengths

• specificity

• task orientation

• focus on objectivity

• clearly defined techniques

• evidence-based

• action-oriented

• problem-solving orientation

• socially and culturally sensitive

Shortcomings

• may overlook significant issues in the lives of clients

• does not address new consequences of behavior change