Counseling and Psychotherapy Theories in Context and Practice, with Video Resource Center_ Skills, Strategies, and Techniques

THEORETICAL PRINCIPLES 231

operant conditioning is more complex than most sitting inside an automobile. Because of the lack
people believe. of cognitive processing involved in classical con-
ditioning, when an individual experiences a purely
Classical Conditioning: The Neobehavioristic, classically conditioned fear response, often he or
Mediational Stimulus-Response Model she might say something like, ‘‘I don’t know why,
The neobehavioristic mediational SR model is but I’m just afraid of elevators.’’
based on classical conditioning principles. Its tenets
were developed and articulated by Pavlov, Watson, Classical conditioning principles also include
Mowrer, and Wolpe. stimulus generalization, stimulus discrimination,
extinction, counterconditioning, and spontaneous
Classical conditioning is sometimes referred to as recovery.
associational learning because it involves an associ-
ation or linking of one environmental stimulus with Stimulus generalization is defined as the exten-
another. In Pavlovian terms, an unconditioned sion or generalization of a conditioned fear response
stimulus is one that naturally produces a specific to new settings, situations, or objects. For example,
physical-emotional response. The physical response in the preceding example, if the man begins expe-
elicited by an unconditioned stimulus is mediated riencing intense fear when sitting in an airplane,
through smooth muscle reflex arcs, so higher-order stimulus generalization has occurred. Similarly, in
cognitive processes are not required for condi- the case of Little Albert, stimulus generalization
tioning to occur. The following clinical example occurred when Albert experienced fear in response
described by Wolpe illustrates how fear or anxiety to objects (stimuli) similar in appearance to white
responses are classically conditioned. rats (e.g., Santa Claus masks or cotton balls).

A 34-year-old man’s four-year fear of being in Stimulus discrimination occurs when a con-
automobiles started when his car was struck from ditioned fear response is not elicited by a new or
behind while he was waiting for a red light to different stimulus. For example, if the 34-year-old
change. At that moment he felt an overwhelming man can sit in a movie theater without experiencing
fear of impending death; subsequently he was fear, stimulus discrimination has occurred. Appar-
afraid to sit inside even a stationary car. That the ently the movie theater setting (stimulus) is different
fear was purely a matter of classical autonomic enough from the car setting that it doesn’t elicit the
conditioning (automatic response to the ambience conditioned response. In the case of Little Albert,
of a car’s interior) was evidenced by the fact that stimulus discrimination occurred when Little Albert
he had no expectation of danger when he sat in a did not have a fear response when exposed to a fluffy
car. (Wolpe, 1987, pp. 135–136) white washrag.

In Wolpe’s example, the experience of being Extinction involves the gradual elimination of
struck from behind while waiting for a red light is a conditioned response. It occurs when a condi-
the unconditioned stimulus (Wolpe, 1987). This tioned stimulus is repeatedly presented without a
stimulus automatically (or autonomically) pro- previously associated unconditioned stimulus. For
duces a reflexive fear response (or unconditioned example, if Watson had kept working with Lit-
response). As a consequence, the 34-year-old man tle Albert and repeatedly exposed him to a white
suffered from a debilitating fear of impending death rat without a frightening sound of metal clanging,
(a conditioned response) when exposed to the inte- eventually Little Albert might lose his conditioned
rior of an automobile (a conditioned stimulus). As response to rats. Extinction is not the same as
Wolpe emphasizes, this scenario represents clas- forgetting; instead, it involves relearning that the
sical autonomic conditioning or learning because conditioned stimulus is no longer a signal that pre-
the man has no cognitive expectations or cognitive cedes the unconditioned stimulus.
triggers that lead to his experience of fear when
In contrast, Mary Cover Jones’s work with Little
Peter is an example of successful countercondi-
tioning or deconditioning. Counterconditioning

232 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

involves new associative learning. The subject learns use assertive behavior in social situations. Conse-
that the conditioned stimulus brings with it a posi- quently, the purpose of assertiveness skills training
tive emotional experience. For example, when Jones (a behavioral treatment) is to teach clients assertive-
repeatedly presented the white rat to Little Peter ness skills through modeling, coaching, behavior
while he was eating some of his favorite foods, rehearsal, and reinforcement.
eventually the conditioned response (fear) was
counter-conditioned. The same countercondition- Interestingly, the successful outcomes associated
ing principle is in operation in Wolpe’s systematic with assertiveness training can be explained through
desensitization. either classical conditioning or operant models.
For example, Wolpe considers assertive behavior
Spontaneous recovery within a classical condi- to be incompatible with anxiety; therefore an anxi-
tioning paradigm was initially discussed by Pavlov ety response is counter-conditioned and replaced
(1927). Spontaneous recovery occurs when an by an adaptive, incompatible response (Wolpe,
old response suddenly returns (is recovered) after 1973). In contrast, contemporary assertiveness
having been successfully extinguished or counter- trainers usually focus more on the contingencies—
conditioned. For example, if after successful coun- reinforcements and punishments—that establish
terconditioning through systematic desensitization, and maintain passive, aggressive, and assertive social
Wolpe’s client suddenly begins having fear symp- behavior (Alberti & Emmons, 2008).
toms associated with the interior of automobiles, he
is exhibiting spontaneous recovery. As a means of better understanding client psy-
chopathology, behaviorists apply scientific meth-
Theory of Psychopathology ods to clinical or counseling settings. Behaviorists
systematically:
For behaviorists, maladaptive behavior is always
learned and can be either unlearned or replaced by • Observe and assess client maladaptive or unskilled
new learning. The idea that human learning is at behaviors.
the core of human behavior guides how behavior
therapists approach client assessment and treat- • Develop hypotheses about the cause, mainte-
ment. Truax (2002) articulates this link between nance, and appropriate treatment for maladaptive
psychopathology, assessment, and treatment: or unskilled behaviors.

The basic assumption in behavioral theory is that • Test behavioral hypotheses through the applica-
both adaptive and maladaptive behaviors are tion of empirically justifiable interventions.
acquired, maintained, and changed in the same
way: through the internal and external events that • Observe and evaluate the results of their inter-
proceed and follow them. This means that vention.
behavioral case conceptualization involves a
careful assessment of the context within which a • Revise and continue testing new hypotheses about
behavior occurs, along with developing testable ways to modify the maladaptive or unskilled
hypotheses about the causes, maintaining factors, behavior(s) as needed.
and treatment interventions. (p. 3)
Behaviorists are on the cutting edge when it
Psychopathology may be a function of inadequate comes to applying specific treatment procedures
learning or skill deficits. For example, an underlying to specific clinical problems. More than any
premise of assertiveness or social skills training is other practitioner group, behavior (and cognitive-
that individuals who exhibit too much passive or too behavioral) therapists insist on empirical support
much aggressive behavior simply have social skill for their treatment methods. As a consequence,
deficits; they haven’t learned how to appropriately the majority of empirically supported treatments
(ESTs) are behavioral or cognitive-behavioral
(Chambless et al., 1998; Chambless et al., 2006;
Chambless & Hollon, 1998).

THE PRACTICE OF BEHAVIOR THERAPY 233

THE PRACTICE OF BEHAVIOR Some theories texts include these new generation
THERAPY behavior therapies in the behavior therapy chapter.
However, partly because we’d rather not risk
When preparing to do behavior therapy, be sure to the wrath of the late, great Joseph Wolpe, we
get out your clipboard, because behavior therapists view them as horses of a different therapeutic
take notes and think like scientists. You may even color. Consequently, we review DBT, ACT, and
need graph paper or a white board for illustrating EMDR in Chapter 14. And although you may be
concepts to clients. As a behaviorist, you’re a teacher chomping at the therapeutic bit (to continue our
and educator: Your job is to help clients unlearn stretched horse metaphor), you’ll have to delay your
old, maladaptive behaviors and learn new, adaptive gratification and learn more about these three very
behaviors. important evidence-based therapy approaches later.

A sample excerpt from a behaviorally oriented Assessment Issues and Procedures
informed consent form is included in Putting it in
Practice 7.1. In a perfect behavioral assessment world, behavior
therapists would directly observe clients in their
What Is Contemporary Behavior Therapy? natural environment to obtain specific information
about exactly what happens before, during, and
In this chapter we’ve included a description of ther- after the occurrence of adaptive and maladaptive
apeutic interventions that are primarily behavioral behaviors. The main goal of behavioral assessment
but that occasionally focus on cognitive variables. is to determine the external (environmental or sit-
Not all the therapies in this chapter are purely uational) stimuli and internal (physiological and
behavioral. Similarly, although the next chapter sometimes cognitive) stimuli that directly precede
includes interventions derived from the cognitive and follow adaptive and maladaptive client behav-
therapy movement and that are predominantly ioral responses.
cognitive in nature—we recognize that nearly all
cognitive therapies are used in conjunction with the Functional Behavior Analysis
primarily behavioral techniques described in this Behaviorists typically refer to a formal assessment of
chapter. behavior contingencies as a functional behavioral
analysis (FBA) or assessment (Drossel, Rummel, &
This leaves us in a conundrum regarding the Fisher, 2009; Haun & Truax, 2007). An FBA can
definition of cognitive-behavioral therapy (CBT). also be described as an assessment of the behavioral
As you may already know, CBT is currently the most ABCs (Spiegler & Guevremont, 2010):
popular and scientifically evaluated approach to
psychotherapy. This approach explicitly combines • A = The behavior’s antecedents (everything that
cognitive and behavioral techniques, viewing them happens just before the maladaptive behavior is
as both compatible and as enhancing one another’s observed).
impact.
• B = The behavior (the client’s problem specifically
To make matters more complex, there are now defined in concrete behavioral terms; e.g., rather
several 2nd generation cognitive-behavioral thera- than being called an ‘‘anger problem,’’ it’s referred
pies. These therapies include: to as ‘‘yelling or swearing six times a day and
punching others twice daily’’).
• Dialectical Behavior Therapy (DBT)
• C = The behavior’s consequences (everything
• Action and Commitment Therapy (ACT) that happens just after the maladaptive behavior
occurs).
• Eye Movement Desensitization Reprocessing
(EMDR)

234 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

PUTTING IT IN PRACTICE 7.1

A Behavioral Informed Consent Form

The following is a sample excerpt from a behavior therapy informed consent. As you
read it, pretend you’re sitting in a therapist’s waiting room, about to go in for your first
behavior therapy session.

I specialize in behavior therapy, a research-based and highly effective form of therapy
based on modern learning theories.

Humans are constantly learning. As you know from experience, humans learn
everything from tying shoelaces and riding bicycles to complex emotional responses,
like love, jealousy, and nervousness. Everyone has a tremendous capacity for learning.

Whether you’ve come to therapy because of a difficult situation, a problem relationship,
or a troubling emotion, I’ll help you unlearn old troubling habits and learn new, more pos-
itive habits. Research has proven that behavior therapy is very helpful for many problems.

Sometimes people think behavior therapy is boring and impersonal, but nothing could
be further from the truth. In therapy, we’ll work as a team, and we’ll talk in detail about
some of the hardest things you’re facing in your life. Then we’ll develop a plan for helping
you overcome the problems and symptoms that cause you distress.

In most cases, our plan will include several different approaches to learning and to
changing. Some new learning will happen right in our sessions, and some will happen
outside our sessions. That means I’ll give you assignments to complete between our
meetings. If you complete your assignments, then the new learning we’re working on will
happen even faster.

Behavior therapy is a brief therapy. You won’t come to therapy forever; depending on
your problem and your situation, it may take only a few therapy sessions or it may take
several months. We’ll regularly evaluate our work together and talk openly and directly
about your progress.

My job is to work in partnership with you to improve your life and relieve your
uncomfortable symptoms. Therefore, I’ll regularly explain exactly what we’re doing and
why we’re doing it. And whenever you have questions, feel free to ask; I’ll do my best to
provide you with the answers you deserve.

A functional behavior analysis is designed to the FBA is to develop a functional causal model
determine the function of a given behavior. The (or hypothesis) to explain behavior (O’Brien &
basic question we try to answer in an FBA is: What Carhart, 2011). For example, if a child client is
reinforcers are operating in the environment to disrupting class in school, unobtrusively observing
maintain a specific problem behavior? A goal of the child at various times during the day could be

THE PRACTICE OF BEHAVIOR THERAPY 235

scheduled. Through direct observation, the behav- or ‘‘anxious’’ or ‘‘hyper.’’ Instead, behaviorists seek
ior therapist gathers data and watches for patterns. concrete, specific behavioral information. Typical
The child’s class disruptions may be preceded by queries during a behavior therapy intake interview
a particular stimulus. Perhaps this stimulus (e.g., might include:
in-class reading assignments) produces an aversive,
uncomfortable state (i.e., anxiety) and so the child • ‘‘Tell me about everything that happens during
experiences negative reinforcement when the read- the course of a day when you’re depressed. Let’s
ing assignment is avoided. Or, perhaps the child start with when you wake up in the morning and
is obtaining positive reinforcement (e.g., attention cover everything that happens until you go to bed
from the teacher and classmates) immediately after at night . . . and I even want to know what happens
engaging in disruptive behavior. throughout the night until the next morning.’’

Unfortunately, direct behavioral observation is • ‘‘Describe the physical sensations you experience
inefficient. First, most therapists can’t afford the in your body when you’re feeling anxious.’’
time required to go out and observe clients. Second,
many clients object to having their therapist come • ‘‘You said you were acting ‘hyper.’ Tell me what
into their home or workplace to conduct a formal that looks like . . . describe it to me so I can see
observation. Third, even if the client agreed to it, as if I were a mouse in the corner watching it
have the therapist come perform an observation, happen.’’
the therapist’s presence is unavoidably obtrusive
and therefore influences the client’s behavior. Behaviorists value information about both the
The therapist observer is more than an observer, internal (mood or physiology) and the external
also becoming a participant within the client’s (behavior), as long as the information is clear,
environment—which means that an objective and specific, and measurable.
natural observation cannot be obtained.
Despite many practical advantages of behavioral
Because behavior therapists usually cannot use or clinical interviews, this assessment procedure also
direct behavioral observation, they typically employ has several disadvantages:
a variety of less direct methods to gather data and
construct a functional causal hypothesis. • Low interrater reliability.

The Behavioral Interview • Lack of interviewer objectivity.
The clinical or behavioral interview is the most
common assessment procedure (Craig, 2005; J. • Inconsistency between behavior in a clinical
Sommers-Flanagan & R. Sommers-Flanagan, 2009). interview and behavior outside therapy.
During interviews, behavior therapists directly
observe client behavior, inquire about antecedents, • False, inaccurate, and subjective reports from
problem behaviors, and consequences, and oper- clients.
ationalize the primary therapy targets (Cormier,
Nurius, & Osborn, 2009). For behaviorists, the Behavior therapists compensate for the inconsis-
operational definition or specific, measurable char- tent and subjective nature of interviews through two
acteristics of client symptoms and goals are crucial strategies: First, they employ structured or diagnos-
behavioral assessment components. tic interviews such as the Structured Clinical Interview
for the Diagnostic and Statistical Manual of Mental
Defining the client’s problem(s) in precise behav- Disorders, fourth edition, which helps improve inter-
ioral terms is the first step in a behavioral assess- view reliability (American Psychiatric Association,
ment interview. Behavior therapists are not satisfied 2000; First, Spitzer, Gibbon, & Williams, 1997).
when clients describe themselves as ‘‘depressed’’ Second, they use additional assessment methods
beyond interviewing procedures, to obtain client

236 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

information ( J. Sommers-Flanagan & R. Sommers- Operant Conditioning and Variants
Flanagan, 2009).
In the tradition of Skinner and applied behavior
Self-Monitoring analysis, perhaps the most straightforward appli-
Although it’s often impractical for behavior ther- cation of behaviorism to therapy is direct operant
apists to directly observe client behavior outside conditioning. Skinner’s emphasis is completely on
therapy, they can train clients to observe and mon- environmental manipulation rather than processes
itor their own behavior. For example, clients can of mind or cognition. In one of his more dramatic
monitor food intake or keep track of the num- statements, he noted:
ber of cigarettes they smoke. In cognitive-behavior
therapy, clients frequently keep thought or emo- I see no evidence of an inner world of mental
tion logs that include at least three components: life. . . . The appeal to cognitive states and
(1) disturbing emotional states, (2) the exact behav- processes is a diversion which could well be
ior engaged in at the time of the emotional state, responsible for much of our failure to solve our
and (3) thoughts that occurred when the emotions problems. We need to change our behavior and
emerged. we can do so only by changing our physical and
social environments. (Skinner, 1977, p. 10)
Client self-monitoring has advantages and dis-
advantages. On the positive side, self-monitoring Contingency Management and Token Economies
is inexpensive and practical. The other big benefit Using operant conditioning for human problems
is that self-monitoring is not simply an assessment requires an analysis of the naturally occurring
procedure, it also typically shows therapeutic bene- behavioral consequences in the client’s physical
fits (Davies, Jones, & Rafoth, 2010; Young, Medic, and social environment. This process is sometimes
& Starkes, 2009). The downside is the client can referred to as contingency management. Contin-
easily collect inadequate or inaccurate information, gency management is formally defined as:
or resist collecting any information at all.
the systematic delivery of reinforcing or punishing
Standardized Questionnaires consequences contingent on the occurrence of a
Behaviorists famously prefer ‘‘objective’’ assessment target response, and the withholding of those
measures over more ‘‘subjective’’ projective assess- consequences in the absence of the target
ment procedures (Groth-Marnat, 2009). Objec- response. (Schumacher et al., 2007, p. 823).
tive psychological measures include standardized
administration and scoring. Additionally, behavior- Contingency management is used most fre-
ists prefer instruments with established reliability quently in institutional, educational, family, and
(i.e., internal consistency and consistency over time) drug treatment settings.
and validity (i.e., the instrument measures what
it purports to measure). Radical behaviorists also To illustrate contingency management in action,
emphasize that objective measurement must focus let’s return to the parents who wanted their 15-year-
solely on overt or observable behaviors rather than old to stop speaking disrespectfully. If you recall,
internal mental processes. the parents’ efforts to modify their teen’s behavior
using positive reinforcement and punishment back-
Overall, behaviorists employ questionnaires as fired. Essentially, the parents failed because they
one way of determining whether a specific treatment didn’t use the procedure appropriately. Operant
is working. Objective measurement isn’t perfect, conditioning involves several systematic steps.
but repeated measurement of client symptoms and
behavior help keep therapist and client on the right First, the parents need to operationalize the tar-
track. Case examples in this chapter illustrate behav- get behaviors and identify behavioral objectives.
ior therapist’s use of standardized questionnaires. This requires precisely defining behaviors of inter-
est. It also requires determining whether they want
to increase or decrease the frequency of each target

THE PRACTICE OF BEHAVIOR THERAPY 237

behavior. In conjunction with their applied behavior modification of existing environmental and social
analyst, the parents agreed on the following goals: contingencies.

• Decrease profanity (use of traditional ‘‘cuss The parents were instructed in a very specific
words’’) in the home or toward the parents. reinforcement and extinction procedure.

• Decrease disrespectful gestures or nonverbal • The parents initiated a $10 weekly allowance
behaviors (e.g., giving ‘‘the finger,’’ rolling her program. This program provided their teen with
eyes, giving long heaving sighs). money to spend as she wished. The only contin-
gency for receiving the money was that whenever
• Decrease derogatory comments about the parents the 15-year-old used profanity, disrespectful ges-
or their ideas, such as ‘‘You’re stupid,’’ ‘‘That tures, or derogatory comments, she automatically
sucks,’’ or ‘‘This family is so lame.’’ lost $1 of the allowance, which she was scheduled
to receive every Friday at 6 p.m.
• Increase their 15-year-old’s smiling behavior,
compliments toward the parents and younger • In response to the previously identified unde-
sibling, and compliance with parental suggestions sirable behaviors, the parents would calmly and
and advice. immediately state, ‘‘Okay, that’s one dollar you’ve
lost.’’
Second, the therapist helped the parents develop
a system for measuring target behaviors. They were • Using a variable-ratio reinforcement schedule,
each given a pencil and notepad to track their the parents provided one of the four reinforcers
15-year-old’s behaviors. Additionally, they used a (a meal out, online DVD rental, extra phone
digital audiotape recorder to keep an ongoing record time, or practice driving) immediately after
of verbal interactions preceding and following their their teen displayed one of the aforementioned
daughter’s behaviors. desirable target behaviors. To implement the
variable ratio schedule, the parents were given
After analyzing the parents’ notepads and audio- a six-sided die. They were instructed to roll the
recorder data, the therapist helped the parents die and then, depending upon the number they
identify contingencies that were maintaining dis- rolled, provide a positive reinforcer after that
respectful speech and lack of respectful speech. number of positive behaviors. Then, immediately
During a 2-week baseline monitoring period, 16 after providing a reward, they rolled the die again
incidents of undesirable behavior and 3 incidents (privately, of course), and if the die came up
of desirable behavior were recorded. Their home ‘‘3,’’ they planned to reward her again after three
was an aversive environment for all four family desirable behaviors. To reduce the number of
members. positive reinforcements they provided, thereby
fading her from the reinforcement program, the
It was determined that the parents’ reaction to the parents were given an additional die to use after
disrespectful speech—giving into demands, getting every 2 weeks of increasing positive behaviors.
emotionally upset, or engaging in a protracted
argument—were positively reinforcing problem Third, the parents were instructed on how to
behavior, whereas their relative lack of response continuously monitor and evaluate the effects of
to more pleasant behaviors was extinguishing the their new contingency schedule. This is a key factor
behaviors they wanted to increase. Further, a variety in operant conditioning. The therapist explained
of potential positive reinforcements were identified, this important principle to the parents:
including (a) taking their daughter to dinner, (b)
allowing her to rent DVDs online, (c) taking her for As behaviorists, we believe the only way we can
driving lessons, (d) allowing extra cell phone time tell if something is a positive reinforcer is to test it.
in the evening, and (e) spending money on her. What you discovered last time you tried positive
This analysis led to the third stage of treatment:

238 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

reinforcement with your 5- and 15-year-olds was contingency management can interfere with that
that hugging and high fives functioned as positive desire. For example, Kohn (2005) stated:
reinforcements for your 5-year-old, but not for
your 15-year-old. Perhaps the most important I once heard someone . . . declaring that ‘‘human
part of our intervention with your 15-year-old is nature is to do as little as necessary.’’ This
for us to evaluate her response to the specific prejudice is refuted not just by a few studies but by
consequences you provide. This will help us the entire branch of psychology dealing with
understand how to increase and how to decrease motivation. Normally, it’s hard to stop happy,
her behaviors. satisfied people from trying to learn more about
themselves and the world, or from trying to do a
After using this operant conditioning program job of which they can feel proud. The desire to do
for eight weeks, the parents and therapist agreed that as little as possible is an aberration, a sign that
continued therapy was unnecessary. The parents something is [terribly] wrong. It may suggest that
said in their last session, ‘‘Thank you so much for someone feels threatened and therefore has fallen
your help. It’s like we’re getting acquainted with a back on a strategy of damage control, or that
new daughter.’’ rewards and punishments have caused that
individual to lose interest in what he’s doing, or
Following Skinner’s original work aimed at mod- that he perceives a specific task—perhaps
ifying the behavior of psychotic patients, operant incorrectly—as pointless and dull. (p. 90)
conditioning or contingency management within
institutions came to be known as token economies Kohn (2005) believes that applying tangible
(Ghezzi, Wilson, Tarbox, & MacAleese, 2009; Skin- rewards to people who are already motivated
ner, 1954). Within token economy systems, pa- undermines intrinsic motivation. In fact, many
tients or students are provided points or poker studies have shown that positive reinforcement
chips (symbolic rewards) for positive or desirable adversely affects intrinsic motivation (Deci, 1971;
behaviors. These tokens are used like money, to Deci, Koestner, & Ryan, 2001; Ryan, Lynch,
obtain goods (e.g., food or toys) or privileges (e.g., Vansteenkiste, & Deci, 2011). Of course, there’s
computer or recreational time). also a body of literature rebutting this hypothesis
and claiming that positive reinforcement, when
Token economies have been both lauded as properly conceptualized and administered, can
highly effective and criticized as coercive and as increase intrinsic motivation (Carton & Nowicki,
not having lasting effects that generalize to the 1998; Maag, 2001). In the end, if you want to
world outside the institution (Glynn, 1990; Mat- employ operant techniques in a consistently helpful
son & Boisjoli, 2009; Reitman, Murphy, Hupp, & fashion, additional training is needed.
O’Callaghan, 2004). In an ideal behavioral setting,
reinforcements and punishments would be tightly Although positive reinforcement has had its share
controlled and then, after desirable behavior pat- of criticism, punishment or aversive conditioning
terns are well established, behavioral contingencies as a therapeutic technique generates far more con-
would be slowly decreased (as in the case of the troversy. Historically, Thorndike (1932), Skinner
15-year-old teen whose reinforcements were pro- (1953), and Estes (1944) all concluded that pun-
gressively decreased). This procedure is referred to ishment led to behavior suppression but wasn’t an
as fading and is designed to generalize learning effective method for controlling behavior. Punish-
from one setting to another. The desired outcome ment was viewed as insufficient to completely elim-
occurs when a child, teen, or institutionalized adult inate a learned response. Somewhat later, Solomon
internalizes the contingency system and continues (1964) reopened the book on punishment by report-
positive behaviors independent of a token system. ing that punishment alone could generate new,
learned behavior. Currently, although punishment
Critics of behaviorism contend that people have is a powerful behavior modifier, it’s also viewed as
a natural desire to behave in positive ways and that

THE PRACTICE OF BEHAVIOR THERAPY 239

having major drawbacks. In particular, within the percentage of line-crossers, and their general
attachment and trauma literature, excessive punish- failure to improve their children’s behavior,
ment by caregivers leads to what has been referred points to a larger truth: punishment changes
to as trauma bonding. A description of Harry Har- parents’ behavior for the worse more effectively
low’s studies on attachment behaviors in monkeys than it changes children’s behavior for the better.
(see Harlow, Harlow, Dodsworth, & Arling, 1966; And, as anyone knows who has physically
Harlow, Harlow, & Suomi, 1971) provides a vivid punished a child more harshly than they meant
example of the terrors of mixing love and pun- to—and that would include most of us—it feels
ishment: ‘‘When Harlow presented baby macaques just terrible. (pp. 15, 16, 17)
with mechanically devised spike-sprouting surro-
gates or mothers that suddenly puffed blasts of air, Kazdin’s point about how using punishment
the infants gripped all the tighter to the only security changes the parent’s behavior for the worse is
they knew’’ (Hrdy, 1999, p. 398). another example of operant conditioning. Specif-
ically, when parents spank children, immediate
Despite problems with punishment as a learning compliance often occurs, which relieves parents of
tool, aversive conditioning (the term used to tension and discomfort. This cycle gives parents a
describe the use of punishment for behavior modi- powerful dose of negative reinforcement for using
fication purposes) is sometimes used to reduce un- physical punishment.
desirable and maladaptive behavior. It has been
applied with some success to smoking cessation, In a meta-analysis of the effects of corporal pun-
repetitive self-injurious behavior, alcohol abuse or ishment on children’s behavior (Gershoff, 2002;
dependency, and sexual deviation. Gershoff & Bitensky, 2007), punishment was asso-
ciated with 1 desirable outcome (i.e., immediate
While discussing the use of corporal punishment behavioral compliance) and 10 undesirable out-
with children, former American Psychological Asso- comes, including less internalization of moral prin-
ciation President and renowned behaviorist Alan ciples, potential abuse, delinquent behavior, and
Kazdin (2008) provides an excellent description later abuse within adult relationships. Despite this
of what the research says about using punishment fairly clear scientific indictment of corporal pun-
(including spanking children): ishment, many adults remain in favor of its use as
a disciplinary technique (Baumrind, Larzelere, &
study after study has proven that punishment all Cowan, 2002; Gershoff & Bitensky, 2007).
by itself, as it is usually practiced in the home, is
relatively ineffective in changing behavior. . . . Behavioral Activation
Over half a century ago, Skinner suggested that
Each time, punishing your child stops the depression was caused by an interruption of healthy
behavior for a moment. Maybe your child cries, behavioral activities that had previously been main-
too, and shows remorse. In our studies, parents tained through positive reinforcement. Later, this
often mistakenly interpret such crying and wails of idea was expanded based on the initial work of
I’m sorry! as signs that punishment has worked. It Ferster (1973) and Lewinsohn (Lewinsohn, 1974;
hasn’t. Your child’s resistance to punishment Lewinsohn & Libet, 1972) who focused on obser-
escalates as fast as the severity of the punishment vations that:
does, or even faster. So you penalize more and
more to get the same result: a brief stop, then the depressed individuals find fewer activities pleasant,
unwanted behavior returns, often worse than engage in pleasant activities less frequently, and
before. . . . obtain therefore less positive reinforcement than
other individuals. (Cuijpers, van Straten, &
Bear in mind that about 35% of parents who Warmerdam, 2007, p. 319)
start out with relatively mild punishments end
up crossing the line drawn by the state to define
child abuse: hitting with an object, harsh and cruel
hitting, and so on. The surprisingly high

240 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

From the behavioral perspective, the thinking treatment for depression (BATD) manual and a
goes like this: more recent 10-session revised manual (Lejuez,
Hopko, Acierno, Daughters, & Pagoto, 2011).
• Observation: Individuals experiencing depression
engage in fewer pleasant activities and obtain less Implementation of the BATD protocol is
daily positive reinforcement. described in a short vignette later in this chapter.

• Hypothesis: Individuals with depressive symptoms Relaxation Training
might improve or recover if they change their Edmund Jacobson was the first modern scientist to
behavior (while not paying any attention to their write about relaxation training as a treatment pro-
thoughts or feelings associated with depression). cedure ( Jacobson, 1924). In Progressive Relaxation,
he outlined principles and techniques of relaxation
Like good scientists, behavior therapists have training that therapists still employ in the twenty-
tested this hypothesis and found that behavior first century ( Jacobson, 1938). Progressive muscle
change—all by itself—can produce positive treat- relaxation (PMR) was initially based on the assump-
ment outcomes among clients with depression. The tion that muscular tension is an underlying cause
main point is to get clients with depressive symp- of a variety of mental and emotional problems.
toms to change their behavior patterns so they Jacobson claimed that ‘‘nervous disturbance is at
engage in more pleasant activities and experience the same time mental disturbance. Neurosis and
more positive reinforcement. psychoneurosis are at the same time physiological
disturbance; for they are forms of tension disorder’’
Originally, behavioral activation was referred ( Jacobson, 1978, p. viii). For Jacobson, individu-
to as activity scheduling and used as a component als can cure neurosis through relaxation. Currently,
of various cognitive and behavioral treatments for PMR is viewed as either a counterconditioning or
depression (A. T. Beck, Rush, Shaw, & Emery, 1979; extinction procedure. By pairing the muscle-tension
Lewinsohn, Steinmetz, Antonuccio, & Teri, 1984). conditioned stimulus with pleasurable relaxation,
During this time activity scheduling was viewed as muscle tension as a stimulus or trigger for anxiety is
one piece or part of an overall cognitive behavior replaced or extinguished.
treatment (CBT) for depression.
Progressive muscle relaxation remains a common
However, in 1996, Jacobson and colleagues con- relaxation training approach, although others—
ducted a dismantling study on CBT for depression. such as breathing retraining, meditation, autogenic
They compared the whole CBT package with activ- training, imagery, and hypnosis—are also popular
ity scheduling (which they referred to as behavioral (Benson, 1976; Logsdon-Conradsen, 2002; Philip-
activation), with behavioral activation (BA) only, pot & Segal, 2009). However, clinical training
and with CBT for automatic thoughts only. Some- guidelines suggest that beginning therapists under-
what surprisingly, BA by itself was equivalent to stand how, when, and for how long relaxation proce-
the other treatment components—even at two-year dures should be implemented (Castonguay, Boswell,
follow-up (Gortner, Gollan, Dobson, & Jacobson, Constantino, Goldfried, & Hill, 2010; Lilienfeld,
1998; Jacobson et al., 1996). 2007). This is because of the well-documented
research finding that ironically, relaxation can trig-
As is often the case, this exciting research ger anxiety (Braith, McCullough, & Bush, 1988;
finding stimulated further exploration and research Heide & Borkovec, 1984; Ley, 1988).
associated with behavioral activation. In particular,
two separate research teams developed treatment Information on implementing relaxation pro-
manuals focusing on behavioral activation. Jacobson cedures with clients is outlined in Putting it in
and colleagues ( Jacobson, Martell, & Dimidjian, Practice 7.2. Be sure to discuss appropriate imple-
2001) developed an expanded BA protocol and mentation of these procedures in class and with your
Lejuez, Hopko, Hopko, and McNeil (2001) supervisor.
developed a brief (12-session) behavioral activation

THE PRACTICE OF BEHAVIOR THERAPY 241

PUTTING IT IN PRACTICE 7.2

Prepping Clients (and Yourself) for Progressive Muscle Relaxation

Before using relaxation training with clients, you should experience the procedure yourself.
You can accomplish this either by going to a behavior therapist and asking to learn the
procedure, using a PMR CD or podcast, or asking your professor to demonstrate the
procedure in class.

We recommend that you make your own PMR recording and use it for practicing.
Getting comfortable with the right pace and voice tone for inducing a relaxed state is
important. It’s also helpful to try out your relaxation skills with your classmates and ask
for feedback.

When working with clients, keep the following issues in mind:

• Have a quiet room and a comfortable chair available. Noise and discomfort are
antithetical to relaxation. Reclining chairs are recommended. Lighting should be
dim, but not dark.

• Give clients clear information as to why you’re teaching PMR. If the rationale isn’t
clear, they may not participate fully.

• Explain the procedure. Say something like ‘‘I’ll be instructing you to create tension
and then let go of tension in specific muscle groups. Research shows that tensing
your muscles first and then relaxing helps you achieve a deeper relaxation than if
you just tried to relax them without tensing first.’’ You might demonstrate this by
flexing and then relaxing your arm or shoulder muscles.

• Seat yourself in a position that’s not distracting. A face-to-face arrangement can
make clients uncomfortable. Instead, place seats at a 90◦ to 120◦ angle.

• Emphasize that, like most skills, the ability to relax is best learned through repeated
practice. Assure your client that it is possible to learn to be relaxed and peaceful.

• Tell your clients that they’re in control of the relaxation process. To become relaxed,
all they have to do is listen to you and follow along, but whether they listen and
follow along is totally their choice.

• Warn clients that they may feel unusual body sensations: ‘‘Some people feel tingling,
others feel light and maybe a little dizzy, and still others feel heavy, like they’re
sinking into the chair. I don’t know exactly how you’ll feel, but we’ll take a few
minutes afterward to talk about how it felt to you.’’

242 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

• Let clients know they can keep their eyes open or shut. Some clients are
uncomfortable closing their eyes and their discomfort should be respected. Don’t
worry about whether your client’s eyes are open or shut. Relaxation is possible
either way and more likely if the client is doing whatever is comfortable.

• Let clients know they can move around if it helps them be more comfortable. If
they wear glasses, they might want to remove them. The key is to facilitate physical
comfort.

• Check for physical conditions (e.g., a knee or back problem) that might be aggravated
by tensing muscles. Omit painful or injured body parts from the procedure.

• Let clients know their minds may wander while you’re talking and they’re relaxing.
That’s okay. If they notice their minds wandering, all they need to do is gently bring
attention back to whatever you’re saying.

• Help clients have realistic, but optimistic, expectations: Most people who do
progressive relaxation find that it helps them relax a bit, but don’t find it amazing
or dramatic. Some people find it extremely relaxing and wonderful.

• Be sure to acknowledge that practicing relaxation actually causes some people to
feel more anxious. This can be due to unusual sensations, a trauma history, feeling
a loss of control, or fears that something bad may happen during the process
(Castonguay et al., 2010; Goldfried & Davison, 1994; Lilienfeld, 2007).

Additional detailed information about using PMR is available from several sources
(Bernstein & Borkovec, 1973; Field, 2009; Goldfried & Davison, 1994).

Systematic Desensitization and Other After clients are trained in PMR techniques,
they build a fear hierarchy in collaboration with
Exposure-Based Treatments the therapist. Systematic desensitization usually
proceeds in the following manner:
Joseph Wolpe (1958) formally introduced system-
atic desensitization as a treatment technique. In his • The client identifies a range of various fear-
original work, Wolpe reported a highly controver- inducing situations or objects.
sial treatment success rate of 80%, and therapists
(especially psychoanalysts) criticized and challenged • Typically, using a measuring system referred to
his procedures and results (Glover, 1959). However, as subjective units of distress (SUDs), the client,
Wolpe staunchly defended his claim of impressive with the support of the therapist, rates each fear-
success rates for systematic desensitization (Wolpe inducing situation or object on a scale from 0 to
& Plaud, 1997). 100 (0 = no distress; 100 = total distress).

Systematic desensitization is a combination of • Early in the session the client engages in PMR
Jones’s deconditioning approach and Jacobson’s (see Putting it in Practice 7.2).
PMR procedure (M. C. Jones, 1924). Jacobson
articulated the central place of relaxation in curing • While deeply relaxed, the client is exposed, in
clients of anxious or disturbed conditions, stating vivo or through imagery, to the least feared item
that ‘‘to be relaxed is the direct physiological in the fear hierarchy.
opposite of being excited or disturbed’’ ( Jacobson,
1978, p. viii).

THE PRACTICE OF BEHAVIOR THERAPY 243

• Subsequently, the client is exposed to each feared Note that exposure via systematic desensitization
item, gradually progressing to the most feared and the other procedures detailed hereafter are
item in the hierarchy. distinctively behavioral. However, the concept that
psychological health is enhanced when clients
• If the client experiences significant anxiety at any face and embrace their fears is consistent with
point during the imaginal or in vivo exposure existential and Jungian theory (van Deurzen, 2010;
process, the client reengages in PMR until see online Jungian chapter: www.wiley.com/go/
relaxation overcomes anxiety. counselingtheories).

• Treatment continues systematically until the There are three ways to expose clients to their
client achieves relaxation competence while fears during systematic desensitization. First, expo-
simultaneously being exposed to the entire range sure to fears can be accomplished through mental
of his or her fear hierarchy. imagery. This approach can be more convenient
and allows clients to complete treatment without
In the traditional systematic desensitization pro- ever leaving their therapist’s office. Second, in vivo
tocol clients were taught PMR and exposed to a (direct exposure to the feared stimulus) is also pos-
feared stimuli using visual imagery. More recent sible. This option can be more complex (e.g., going
research suggests that PMR is not necessary and to a dental office to provide exposure for a client
that in-vivo exposure is superior to imaginal expo- with a dental phobia), but appears to produce out-
sure (D. Dobson & Dobson, 2009). comes superior to imaginal exposure (Emmelkamp,
1994). Third, computer simulation (virtual reality)
Imaginal or In Vivo Exposure and Desensitization has been successfully used as a means of exposing
Systematic desensitization is a form of exposure clients to feared stimuli (Emmelkamp et al., 2001;
treatment. Exposure treatments are based on the Emmelkamp, Bruynzeel, Drost, & van der Mast,
principle that clients are best treated by exposure 2001).
to the very thing they want to avoid: the stimulus
that evokes intense fear, anxiety, or other painful Psychoeducation is critical to effective exposure
emotions. Mowrer (1947) used a two-factor theory treatment. D. Dobson and K. S. Dobson (2009)
of learning, based on animal studies, to explain how state:
avoidance conditioning works. First, he explained
that animals originally learn to fear a particular stim- A crucial element of effective exposure is the
ulus through classical conditioning. For example, a provision of a solid rationale to encourage your
dog may learn to fear its owner’s voice when the client to take the risks involved in this strategy. A
owner yells due to the discovery of an unwelcome good therapeutic alliance is absolutely essential for
pile on the living room carpet. Then, if the dog exposure to occur. (p. 104)
remains in the room with its owner, fear continues
to escalate. Further, D. Dobson and K. S. Dobson (2009)
provide a sample client handout that helps inform
Second, Mowrer explained that avoidance behav- clients of the exposure rationale and procedure.
ior is reinforced via operant conditioning. Specifi-
cally, if the dog manages to hide under the bed or Exposure treatment means gradually and
dash out the front door of the house, it is likely systematically exposing yourself to situations that
to experience decreased fear and anxiety. Conse- create some anxiety. You can then prove to
quently, the avoidance behavior—running away and yourself that you can handle these feared
hiding—is negatively reinforced because it relieves situations, as your body learns to become more
fear, anxiety, and discomfort. Negative reinforce- comfortable. Exposure treatment is extremely
ment is defined as the strengthening of a behavioral important in your recovery and involves taking
response by reducing or eliminating an aversive controlled risks. For exposure treatment to work,
stimulus (like fear and anxiety). you should experience some anxiety—too little
won’t be enough to put you in your discomfort
zone so you can prove your fears wrong. Too

244 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

much anxiety means that you may not pay vivo control conditions. These results suggest that
attention to what is going on in the situation. If virtual reality exposure may be as efficacious or even
you are too uncomfortable, it may be hard to try more so than in vivo exposure.
the same thing again. Generally, effective exposure
involves experiencing anxiety that is around 70 out Interoceptive Exposure
of 100 on your Subjective Units of Distress Scale. Typical panic-prone individuals are highly sensitive
Expect to feel some anxiety. As you become more to internal physical cues (e.g., increased heart rate,
comfortable with the situation, you can then move increased respiration, and dizziness). They become
on to the next step. Exposure should be structured, especially reactive when those cues are associated
planned, and predictable. It must be within your with environmental situations viewed as potentially
control, not anyone else’s. (p. 104) causing anxiety (Story & Craske, 2008). Physical
cues or sensations are then interpreted as signs
Massed (Intensive) or Spaced (Graduated) of physical illness, impending death, or imminent
Exposure Sessions loss of consciousness (and associated humiliation).
Behavior therapists continue to optimize methods Although specific cognitive techniques have been
for extinguishing fear responses. One question developed to treat clients’ tendencies to catas-
being examined empirically is this: Is desensitization trophically overinterpret bodily sensations, a more
more effective when clients are directly exposed behavioral technique, interoceptive exposure, has
to feared stimuli during a single prolonged session been developed to help clients learn, through expo-
(e.g., one 3-hour session; aka: massed exposure) or sure and practice, to deal more effectively with
when they’re slowly and incrementally exposed to physical aspects of intense anxiety or panic (Lee
feared stimuli during a series of shorter sessions et al., 2006; Stewart & Watt, 2008).
(such as five 1-hour sessions; aka: spaced exposure)?
Initially, it was thought that massed exposure might Interoceptive exposure is identical to other
result in higher dropout rates, greater likelihood exposure techniques except that the target exposure
of fear relapse, and a higher client stress. However, stimuli are internal physical cues. There are at least
research suggests that massed and spaced expo- six interoceptive exposure tasks that reliably trigger
sure desensitization strategies yield minimal differ- anxiety (Lee et al., 2006). They include:
ences in efficacy (Ost, Alm, Brandberg, & Breitholz,
2001). • Hyperventilation

Virtual Reality Exposure • Breath holding
Technological advancements have led to potential
modifications in systematic desensitization proce- • Breathing through a straw
dures. Specifically, virtual reality exposure, a pro-
cedure wherein clients are immersed in a real-time • Spinning in circles
computer-generated virtual environment, has been
empirically evaluated as an alternative to imaginal • Shaking head
or in-vivo exposure in cases of acrophobia (fear of
heights), flight phobia, spider phobia, and other anx- • Chest breathing
iety disorders (Krijn et al., 2007; Ruwaard, Broek-
steeg, Schrieken, Emmelkamp, & Lange, 2010). Of course, before interoceptive exposure is ini-
tiated, clients receive education about body
In a meta-analysis of 18 outcome studies, Powers sensations, learn relaxation skills (e.g., breathing
and Emmelkamp (2008) reported a large effect size training), and learn cognitive restructuring skills.
(d = 1.11) as compared to no treatment and a Through repeated successful exposure, clients
small effect size (d = .35) when compared to in become desensitized to previously feared physical
cues (Forsyth, Fuse´, & Acheson, 2009).

THE PRACTICE OF BEHAVIOR THERAPY 245

Response and Ritual Prevention other fearful children, Jones reported that social
Mowrer’s two-factor theory suggests that, when imitation (participant modeling) was one of two
a client avoids or escapes a feared or distressing effective deconditioning strategies ( Jones, 1924).
situation or stimulus, the maladaptive avoidance
behavior is negatively reinforced (i.e., when the Like most behavioral techniques, to have a
client feels relief from the negative anxiety, fear, or positive effect, participant modeling needs to be
distress, the avoidance or escape behavior is rein- conducted in an appropriate and sensitive manner.
forced or strengthened; Spiegler & Guevremont, For example, individuals with airplane or flight
2010). Many examples of this negative reinforce- phobias generally don’t find it helpful when they
ment cycle are present across the spectrum of mental watch other passengers getting on a plane without
disorders. For example, clients with Bulimia Ner- experiencing distress. In fact, such observations
vosa who purge after eating specific ‘‘forbidden’’ can produce increased feelings of humiliation and
foods are relieving themselves from the anxiety hopelessness; seeing others easily confront fears
and discomfort they experience upon ingesting they find paralyzing is discouraging to phobic
the foods (Agras, Schneider, Arnow, Raeburn, & clients. The problem is that there is too large of a gap
Telch, 1989). Therefore, purging behavior is neg- in emotional state and skills between the model and
atively reinforced. Similarly, when a phobic client the observer so maximal vicarious learning doesn’t
escapes from a phobic object or situation, or when a occur. Instead of providing clients with general
client with obsessive-compulsive symptoms engages models of fear-free behavior, behavior therapists
in a repeated washing or checking behavior, nega- provide models of successful coping that are more
tive reinforcement of maladaptive behavior occurs relevant or close to what clients are capable of
(Franklin & Foa, 1998; Franklin, Ledley, & Foa, accomplishing. This is why published treatment
2009; March, Franklin, Nelson, & Foa, 2001). protocols for panic disorder often recommend
using a group therapy format to take advantage
It follows that, to be effective, exposure-based of participant modeling effects (Craske, 1999;
desensitization treatment must include response Freeman, Pretzer, Fleming, & Simon, 2004).
prevention. With the therapist’s assistance, the
client with bulimia is prevented from vomiting Skills Training
after ingesting a forbidden cookie, the agoraphobic
client is prevented from fleeing a public place Skills training techniques are primarily based on
when anxiety begins to mount, and the client with skill deficit psychopathology models. Many clients
obsessive-compulsive disorder is prevented from suffering from behavioral disorders haven’t acquired
washing his or her hands following exposure to requisite skills for functioning across a broad range
a ‘‘contaminated’’ object. Without response or of domains. Consequently, behavior therapists
ritual prevention, the treatment may exacerbate evaluate their clients’ functional skills during the
the condition it was designed to treat. Research assessment phase of therapy and then use specific
indicates that exposure plus response prevention skills training strategies to remediate client skill
can produce significant brain changes in as few as deficits. Traditional skills training targets include
three psychotherapy sessions (Schwartz, Gulliford, assertiveness and other social behavior as well as
Stier, & Thienemann, 2005; Schwartz, Stoessel, problem solving.
Baxter, Martin, & Phelps, 1996).
Assertiveness and Other Social Behavior
Participant Modeling In the behavioral tradition, Wolpe, Lazarus, and
In addition to operant principles, social learning others defined assertiveness as a learned behavior
principles have been empirically evaluated for (Alberti & Emmons, 1970; Lazarus, 1973). Gener-
anxiety treatment (Bandura, Blanchard, & Ritter, ally, individuals are evaluated as having one of three
1969). Recall that, in her work with Little Peter and possible social behavior styles: passive, aggressive,

246 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

or assertive. Passive individuals behave in submis- • Relaxation training: For some clients, relaxation
sive ways; they say yes when they want to say no, training is needed to reduce anxiety in social
avoid speaking up and asking for instructions or situations.
directions, and let others take advantage of them.
Aggressive individuals dominate others, trying to get Assertiveness training remains a viable treatment
their way through coercive means. In contrast, ideal option for many clients. However, most practi-
or assertive individuals speak up, express feelings, tioners will be more likely to use the terms skills
and actively seek to meet needs without dominating training or social skills training instead of assertive-
others. ness. Components of assertiveness training for indi-
viduals with specific social anxiety and social skills
Assertiveness training became popular as an deficits are still of great interest. For example, Social
individual, group, or self-help treatment for social Phobia—a condition characterized by an excessive,
difficulties in the 1970s. A number of self-help irrational fear of being scrutinized and evaluated by
books on this treatment were published, including others—is frequently treated with a combination of
the highly acclaimed Your Perfect Right: Assertiveness relaxation and social skills training that includes
and Equality in Your Life and Relationships, now in its almost all the components of traditional asser-
ninth edition (Alberti & Emmons, 2008). The most tion training (e.g., instruction, feedback, behavior
common social behaviors targeted in assertiveness rehearsal, social reinforcement) and graduated or
training are (a) introducing oneself to strangers, massed exposure to challenging social situations and
(b) giving and receiving compliments, (c) saying interactions (McNeil, Sorrell, Vowles, & Billmeyer,
no to requests from others, (d) making requests 2002). Additionally, DBT includes a social skills or
of others, (e) speaking up or voicing an opinion, assertiveness training component (see Chapter 14).
and (f ) maintaining social conversations. Within
a counseling context, assertive behavior is taught Problem-Solving Therapy
through the following strategies: D’Zurilla and Goldfried (1971) originally described
a therapeutic approach that eventually became
• Instruction: Clients are instructed in assertive eye known as problem-solving therapy (PST). PST is
contact, body posture, voice tone, and verbal a behavioral treatment with cognitive dimensions.
delivery. PST is based on the rationale that effective problem
solving is a mediator or buffer that helps clients
• Feedback: The therapist or group members give manage stressful life events more effectively and
clients feedback regarding how their efforts at therefore achieve improved personal well-being
assertive behavior come across to others. (Chang, D’Zurilla, & Sanna, 2004; D’Zurilla &
Nezu, 2010).
• Behavior rehearsal or role playing: Clients are given
opportunities to practice specific assertive behav- There are two main components to problem-
iors, such as asking for help or expressing dis- solving therapy:
agreement without becoming angry or aggressive.
1. Problem orientation.
• Coaching: Therapists often whisper feedback and
instructions in the client’s ear as a role-play or 2. Problem-solving style.
practice scenario progresses.
Problem orientation involves teaching clients
• Modeling: The therapist or group members to have a positive attitude toward problem solving.
demonstrate appropriate assertive behavior for This attitude includes: (a) seeing problems as a
specific situations. challenge or opportunity; (b) seeing problems
as solvable; (c) believing in one’s own ability to
• Social reinforcement: The therapist or group mem- solve problems; and (d) recognizing that effective
bers offer positive feedback and support for problem-solving requires time and effort (A. C. Bell
appropriate assertive behavior. & D’Zurilla, 2009).

THE PRACTICE OF BEHAVIOR THERAPY 247

Problem-solving style refers to how individuals (i.e., the talking cure). In contrast, many contem-
approach social problems. In PST, clients are taught porary therapies focus more on therapists providing
a rational problem-solving style that includes four clients with an educational experience. Behavior
steps (A. M. Nezu & C. M. Nezu, in press): therapy is a good example of an approach that
actively teaches new life skills. Although behavior
1. Problem definition: Clarifying a problem, identi- therapy also involves client-learning activities, ther-
fying goals, and identifying obstacles. apists place a strong emphasis on psychoeducation.
The following case vignettes capture this style.
2. Generating of alternatives: Brainstorming a range
of potential solutions designed to overcome Vignette I: Behavioral Activation Treatment for
obstacles and solve the problem. Depression (BATD)
This vignette briefly illustrates an approach called
3. Decision making: Predicting likely outcomes, con- the revised behavioral activation treatment for
ducting a cost-benefit analysis, and developing depression (BATD-R). The full BATD-R manual
a solution plan (this is sometimes referred to as is published in Behavior Modification and forms for
means-ends thinking or consequential thinking). this therapy are free online (Lejuez et al., 2011).
Although BATD-R is a 10-session manualized pro-
4. Solution implementation and verification: Trying tocol, research supports its flexible application.
out the solution plan, monitoring outcomes, and
determining success. The authors (Ruggiero, Morris, Hopko, &
Lejuez, 2007) describe the case:
PST has been employed as an intervention for
coping with and resolving a wide range of problems, Adrienne was a 17-year-old European American
including depression, suicide ideation, non-cardiac high school student referred for treatment to
chest pain, and many other stressful life circum- address symptoms of depression as well as
stances (Malouff, Thorsteinsson, & Schutte, 2007; difficulties in her relationship with her foster
Nezu et al., 2007; A. M. Nezu & C. M. Nezu, mother. She was socially pleasant and was of
2010). PST has also been used as a treatment for average intelligence. She lived with her foster
working with children and adolescents with con- mother and several younger children, all of whom
duct disorder (Kazdin, 2010; Kazdin, Siegel, & Bass, were unrelated to Adrienne (two were foster
1992). In addition to teaching some variant on the children, two were the foster mother’s biological
four-step approach previously listed, child and ado- children). (p. 67)
lescent behavior therapists often focus specifically
on a number of cognitive and behavioral concepts, Adrienne attended an initial assessment session.
such as means-ends thinking, generating behavioral During this session, Adrienne was accompanied
alternatives, consequential thinking, and perspec- by her caseworker (the foster mother could not
tive taking (Shure, 1992; J. Sommers-Flanagan & R. attend) and the behavior therapist conducted a
Sommers-Flanagan, 2007b; Spivack, Platt, & Shure, semi-structured clinical interview to determine
1976). Step 2 of the problem-solving approach (gen- her presenting symptoms and possible comorbid
erating behavioral alternatives) is illustrated in one complaints. In the behavioral tradition, behavioral
of the chapter vignettes. antecedents and consequences were also explored
and analyzed. Ruggiero and colleagues reported
Behavior Therapy in Action: that Adrienne had:
Brief Vignettes
[S]everal symptoms of depression and expressed
As you may recall from Chapter 1, traditional ap- concern about verbal conflicts with her foster
proaches to counseling and psychotherapy tended to mother that had been escalating in frequency.
emphasize clients achieving insight through talking When asked for details about her daily routine,
Adrienne described that she typically had minimal

248 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

time to herself, rarely spent time with friends after down the specific patterns was challenging, the
school, and had numerous household and therapist found:
babysitting responsibilities.
• Parent-child conflict was ‘‘temporally connected’’
BA is based on the fundamental premise that to the foster mother’s increased after school
clients with depressive symptoms are experiencing volunteer commitments and activities.
too few positive reinforcements and too many
aversive stimuli. As a consequence, a thorough be- • Adrienne was expected to babysit the four younger
havioral assessment process was initiated with children for several hours after school.
Adrienne. This process involved guiding her in how
to complete two assessment instruments: (1) the • Because the foster mother was more fatigued,
Beck Depression Inventory (BDI); and (2) the Daily she was asking Adrienne to complete additional
Activity Log (Hopko, Armento, Cantu, Chambers, household tasks.
& Lejuez, 2003).
• Conflicts were also ‘‘linked to unpredictable,
Adrienne obtained a score of 13 (mildly de- uncontrollable, and/or short-notice requests to
pressed) on the BDI. Her responses to the DAL, a baby-sit or perform household tasks’’ (p. 70).
24-hour daily monitoring form were very revealing
and help capture the rigor of behavioral assessment: • Partly due to her increased workload at home
and partly due to her own poor choices regard-
The completed DAL covered 152 hours (6.3 days) ing healthy social and physical behavior, Adri-
during which her activities were allocated roughly enne had discontinued her previously enjoyable
as follows: 50 hours of sleep (about 8 hours per activities (e.g., going to the mall with friends,
day), 35 hours in school, 24 hours of chores and photographing birds and animals).
responsibilities unrelated to school (e.g., cleaning
the house, chores for her foster mother), 22 hours Although the treatment process and progress was
of school-related and miscellaneous activities (e.g., more complex than described below, in conjunction
homework, preparation for school and church, with the foster mother’s acknowledgment that Adri-
meals), and 21 hours of discretionary time. enne needed more discretionary time, the following
Perhaps most striking, of her 21 hours of behavioral interventions were implemented. This
discretionary time, none were used to description provides you with a sense of the detail
communicate and/or visit with similar-age peers involved in a BATD intervention:
and nearly all were spent watching television and
using the Internet. One hour was used to interact [T]hree feasible and pleasurable activities were
with adult neighbors, and 2 to 3 hours were used prescribed for the following week and monitored
to entertain young children. with the Weekly Behavior Checkout (form 8).
The three activities were (a) to make at least one
Based on this assessment information combined phone call to at least one friend on each of 5 days,
with information from the initial clinical interview, (b) to exercise for at least 30 minutes on each of 3
two primary goals were established. different days, and (c) to take one or more pictures
of animals or natural settings on at least 1 day.
• Goal 1: Reduce frequency of verbal conflict These activities were selected because they were
between Adrienne and her foster mother. identified by Adrienne as pleasurable, were related
to multiple life-goal domains, and were all clearly
• Goal 2: Reduce depressive symptoms. within household rules. Also, they had all been
activities in which she had engaged at least once
To guide BA treatment, the therapist gathered during the prior month, suggesting that likelihood
additional information pertaining to the anteced- for success was satisfactory. (p. 71)
ents and consequences associated with Adrienne-
foster mother verbal conflicts. Although nailing The authors reported a positive outcome in this
case. At her final BATD session, Adrienne obtained

THE PRACTICE OF BEHAVIOR THERAPY 249

a score of 2 on the BDI. She also recognized how The transcript below begins 10 minutes into the
her daily routine and depressive symptoms were session.
related. She reported engaging in a much wider
range of healthy social and recreational activities Boy: He’s gotta learn sometime.
and had expanded her social contacts. Interestingly,
the authors noted that because Adrienne possessed JSF: I mean. I don’t know for sure what the absolute
positive social skills, she didn’t need to have social best thing to do to this guy is . . . but I think
skills training be a focus of her treatment. before you act, it’s important to think of all the
different options you have.
BA treatment as reported in this case and as
described in treatment manuals doesn’t address Boy: I’ve been thinking a lot.
client cognitive processes. This is an advantage for
some clients—especially clients who are either less JSF: Well, tell me the other ones you’ve thought of
cognitively inclined or perhaps too capable of over- and let’s write them down so we can look at the
analyzing or overthinking life situations. Hopko and options together.
colleagues (2003) provide a nice description of this
important distinction between behavioral activation Boy: Kick the shit out of him.
and cognitive approaches to treating depression and
a fitting conclusion to this case vignette: JSF: Okay, I know 2 things, actually maybe 3, that
you said. One is kick the [crap] out of him, the
Based on this paradigm, activation partially other one is to do nothing . . .
involves teaching patients to formulate and
accomplish behavioral goals irrespective of Boy: The other is to shove something up his a**.
certain aversive thoughts and mood states they
may experience. This clear focus on action makes JSF: And, okay—shove—which is kinda like kicking
it unnecessary to attempt to control and change the s*** out of him. I mean to be violent toward
such thoughts and mood states directly. (Hopko him. [Notice John is using the client’s language.]
et al., 2003, p. 703)
Boy: Yeah, Yeah.
BA is a promising approach for both clients and
therapists who prefer to focus on behaviors rather JSF: So, what else?
than cognitions.
Boy: I could nark on him.
Vignette II: Generating Behavioral Alternatives
With an Aggressive Adolescent JSF: Oh.
As noted previously, problem-solving therapy
(PST) focuses on teaching clients steps for rational Boy: Tell the cops or something.
problem solving. In this case vignette, the thera-
pist ( John) is trying to engage a 15-year-old white JSF: And I’m not saying that’s the right thing to
male client in stage 2 (generating solutions) of the do either. [Although John thinks this is a better
problem-solving model. At the beginning of the ses- option, he’s trying to remain neutral, which is
sion, the client had reported that the night before, important to the brainstorming process; if the
a male schoolmate had tried to rape his girlfriend. client thinks John is trying to ‘‘reinforce’’ him
The client was angry and planning to ‘‘beat the for nonviolent or prosocial behaviors, he may
s*** out’’ of his fellow student. During the session, resist brainstorming.]
John worked on helping the boy identify behavioral
alternatives to retributive violence. Boy: That’s just stupid. [This response shows why
it’s important to stay neutral.]

JSF: I’m not saying that’s the right thing to do . . . all
I’m saying is that we should figure out, cause I
know I think I have the same kind of impulse in
your situation. Either, I wanna beat him up or
kinda do the high and righteous thing, which is
to ignore him. And I’m not sure. Maybe one of
those is the right thing, but I don’t know. Now,
we got three things—so you could nark on him.

250 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

[ John tries to show empathy and then encourages and get some. . . . [Reading back the alternatives
continuation of brainstorming.] allows the client to hear what he has said.]

Boy: It’s not gonna happen though. Boy: Um . . . couple of those are pretty unrealistic,
but. [The client acknowledges he’s being unreal-
JSF: Yeah, but I don’t care if that’s gonna happen. istic, but we don’t know which items he views as
So there’s nark, there’s ignore, there’s beat the unrealistic and why. Exploring his evaluation of
s***. What else? the options might be useful, but John is still work-
ing on brainstorming and relationship-building.]
Boy: Um. Just talk to him, would be okay. Just go
up to him and yeah . . . I think we need to have JSF: We don’t have to be realistic. I’ve got another
a little chit-chat. [The client is able to generate unrealistic one. I got another one . . . Kinda to
another potentially prosocial idea.] start some shameful rumor about him, you know.
[This is a verbally aggressive option which can be
JSF: Okay. Talk to him. risky, but illustrates a new domain of behavioral
alternatives.]
Boy: But that’s not gonna happen either. I don’t
think I could talk to him without, like, him pissing Boy: That’s a good idea.
me off and me kicking the s*** . . . [Again, the
client is making it clear that he’s not interested JSF: I mean, it’s a nonviolent way to get some
in nonviolent options.] revenge.

JSF: So, it might be so tempting when you talk to Boy: Like he has a little dick or something.
him that you just end up beating the s*** out of
him. [ John goes back to reflective listening.] JSF: Yeah, good, exactly. [John inadvertently pro-
vides positive reinforcement for an insulting idea
Boy: Yeah. Yeah. rather than remaining neutral.]

JSF: But all we’re doing is making a list. Okay. Boy: Maybe I’ll do all these things.
And you’re doing great. [This is positive rein-
forcement for the brainstorming process—not JSF: Combination.
outcome.]
Boy: Yeah.
Boy: I could get someone to beat the s*** out of
him. JSF: So we’ve got the shameful rumor option to add
to our list.
JSF: Get somebody to beat him up. So, kind
of indirect violence—you get him back Boy: That’s a good one. (Excerpted and adapted
physically—through physical pain. That’s kind from J. Sommers-Flanagan & R. Sommers-
of the approach. Flanagan, 1999)

Boy: [This section is censored.] This case illustrates what can occur when thera-
pists conduct PST and generate behavioral solutions
JSF: So you could [do another thing]. Okay. with angry adolescents. Initially, the client appears
to be blowing off steam and generating a spate of
Boy: Someone like . . . aggressive alternatives. This process, although not
producing constructive alternatives, is important
JSF: Okay. We’re up to six options. [ John is showing because the boy may be testing the therapist to see
neutrality or using an extinction process by not if he will react with judgment (during this brain-
showing any affective response to the client’s storming process it’s very important for therapists
provocative maladaptive alternative that was to remain positive and welcoming of all options,
censored for this book.] no matter how violent or absurd; using judgment
can be perceived and experienced as a punishment,
Boy: That’s about it. . . . which can adversely affect the therapy relationship).

JSF: So. So we got nark, we got ignore, we got beat
the s*** out of him, we got talk to him, we got
get somebody else to beat the s*** out of him,

CASE ANALYSIS AND TREATMENT PLANNING 251

As the boy produced various aggressive ideas, he his home because of fears of having a panic attack.
appeared to calm down somewhat. Also, the behav- He reported experiencing more than 10 attacks in
ioral alternatives are repeatedly read back to the the past month. These attacks were increasing in
client. This allows the boy to hear his ideas from intensity. During his intake session he indicated that
a different perspective. Finally, toward the end, the panic attacks trigger fears that he’s having a heart
therapist joins the boy in brainstorming and adds attack. Richard’s father died of a massive heart attack
a marginally delinquent response. The therapist is at age 59.
modeling a less violent approach to revenge and
hoping to get the boy to consider nonphysical alter- Richard’s health was excellent. He had been
natives. This approach is sometimes referred to as rushed to the emergency room during two recent
harm reduction because it helps clients consider less panic episodes. In both cases Richard’s cardiac
risky behaviors (Marlatt & Witkiewitz, 2010). Next functioning was evaluated and found to be within
steps in this problem-solving process include: normal limits. Nonetheless, his fear of panic attacks
and heart attacks was escalating, and his increasing
• Decision making seclusion was adversely affecting his employment as
a professor at a local vocational college. His wife,
• Solution implementation and verification Linda, accompanied him to his intake session. At
the time of the referral, Richard had stopped driving
As the counseling session proceeded, John em- and was having his wife transport him.
ploys a range of different techniques, including
‘‘reverse advocacy role playing’’ where John plays Richard was administered the Anxiety Disorders
the client and the client plays the counselor and Interview Schedule for DSM-IV (Grisham, Brown, &
provided ‘‘reasons or arguments for [particular Campbell, 2004). This semistructured interview
attitudes] being incorrect, maladaptive, or dysfunc- indicated that Richard’s symptoms were consistent
tional’’ (A. M. Nezu & C. M. Nezu, in press). with panic disorder with agoraphobia.

CASE ANALYSIS During the intake interview, Richard was
AND TREATMENT PLANNING instructed in self-monitoring procedures and given
a packet of rating scales to further assess the quality
Discerning differences between cognitive and and quantity of his panic and agoraphobic symp-
behavioral therapies is difficult. Most behavior ther- toms. He was asked to use the self-monitoring
apists use cognitive treatments and most cognitive scales to rate the duration, intensity, situational
therapists use behavioral treatments. This is why context, and symptom profile of each panic attack
the most popular current terminology for these that occurred during the 10 days between his intake
approaches is cognitive-behavioral therapy. interview and his first treatment session. Richard
also kept a food and beverage log during this 10-day
Although the following case illustrates a period to determine if there were any links between
cognitive-behavioral approach, in this chapter we food and beverage consumption and his anxiety
focus on the behavior therapy techniques for panic symptoms.
disorder, while in the next chapter (Chapter 8)
we continue this case, adding cognitive components In Richard’s case there were two primary rea-
from a comprehensive cognitive-behavioral ap- sons to seek a medical consultation. First, panic and
proach for panic disorder and agoraphobia (Craske, agoraphobic symptoms can be caused or exacer-
1999a). bated by various medical conditions. These condi-
tions include heart disease, diabetes, hypoglycemia,
Richard, a 56-year-old white male, referred hyperthyroidism, mitral valve prolapse, stroke, and
himself for therapy due to anxiety, phobic, and more. Second, clients who obtain behavioral treat-
depressive symptoms. Richard was afraid to leave ment for panic and agoraphobia often receive
pharmacological treatment. However, adding med-
ications appears to help some clients while adversely

252 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

affecting others due to physical side-effect sensitiv- Each behavior therapy session included four
ity and motivation reduction. Empirically oriented parts: (1) check-in and homework review, (2) edu-
behavior therapists often consult with medical pro- cational information about panic and behavior
fessionals to determine whether pharmacological therapy, (3) in-session behavioral or cognitive tasks,
treatment should be offered in each individual case. and (4) new homework assignments.

Based on Richard’s medical information, it was Sessions 1 and 2. Richard’s homework was
determined that he was suffering from primary reviewed. During the 10 days since his intake
rather than secondary panic symptoms (i.e., he did interview, he left home eight times and had four
not have any medical conditions that were either panic attacks. Although specific environmental cues
causing or maintaining his anxiety symptoms). Addi- were not identified for every panic attack, his panic
tionally, after a conference with Richard and his symptoms were associated with caffeine consump-
physician regarding his physical sensitivity to medi- tion: Three of four panic episodes were preceded by
cations, it was determined that behavioral treatment consumption of caffeinated sodas, coffee, or both.
should initially proceed without adjunctive pharma-
cological treatment. The first two sessions primarily focused on
psychoeducation.
The Problem List
Therapist: Richard, excellent job on your home-
One characteristic of behavior therapy is the work. Looking this over gives us both a much
generation of a clear and concrete problem list. better idea of how to get you back on track in
These problems are defined in behavioral terms your life.
and measurable.
Richard: Well, thanks.
Richard’s problem list included:
Therapist: One of our main goals for today is to talk
1. Specific fears of having a panic attack: Fear of a about what your panic symptoms mean. Let’s
heart attack, fear of death, and fear of public start there.
humiliation.
Richard: Okay. That sounds good.
2. Repeated un-cued panic attacks: Physical symptoms
included heart palpitations, sweating, dizziness, Therapist: First, even though the intense panic feel-
shortness of breath. Richard’s symptoms trig- ings you’ve been getting seem strange, they’re
gered catastrophic thoughts of death and dying completely natural. Humans are designed to
(a cognitive symptom also associated with Prob- experience panic just like you’ve been experi-
lems 1, 3, and 4). encing it. Why do you suppose that is?

3. Social isolation/withdrawal: Richard reported di- Richard: Um. I’ve always figured that when my
minished social contact. heart starts pounding and I get dizzy and all that,
it must mean that something is terribly wrong.
4. Loss of independence: Richard had begun relying
on his wife and others to transport him to various Therapist: Exactly! The human internal panic
destinations. response is an alarm system. Some people call it
the fight-or-flight response. When it’s working
5. Depressive symptoms: Richard also had several properly, the panic alarm is a great survival
depressive symptoms including low mood most device. It increases blood pressure, tenses up
days, anhedonia, and self-deprecatory thoughts; muscles, and gets you ready to run or fight. It’s
however, these symptoms were viewed as sec- supposed to go off exclusively during moments
ondary to his anxiety and therefore not a primary of extreme danger—like when you’re crossing a
target of treatment. street and a car is barreling straight at you, or
when you’re attacked by a mugger. Your main
problem is that your alarm is misfiring. It’s going
off when you don’t need it. You’ve been having

CASE ANALYSIS AND TREATMENT PLANNING 253

a series of false alarms. Think about that. When Problem Formulation
you’ve had your panic attacks, have there been
any extreme dangers you’re facing? During the preceding exchange the therapist is
using psychoeducation to inform Richard regarding
Richard: Not exactly. But when I start to feel pan- the natural role of panic and anxiety in humans.
icked, I’m sure I must be having a heart attack, This education is both an initial component of a
just like my dad did when he was about my age. behavioral intervention as well as an example of
collaborative problem formulation.
Therapist: What have the doctors said about that?
During these sessions the following points are
Richard: Well, they’ve told me my heart is fine. highlighted:
That it’s in good shape.
• Anxiety is composed of three parts: thoughts,
Therapist: So the false alarm you’re feeling has feelings, or sensations, and actions.
two parts. There are physical symptoms of heart
pounding, dizziness, and shortness of breath— • With practice, Richard can become better
that’s one part. And then there’s the thought at objectively observing his anxiety-related
of ‘‘I’m going to die from a heart attack just thoughts, feelings, and actions.
like my dad’’ that grabs you. Both these signals,
the physical sensations and the thought you’re • His panic symptoms, although very disturbing
going to die, are false. There is no immediate big and uncomfortable, are harmless.
danger, and your heart is fine. Right?
• His panic symptoms are not caused by a ‘‘chemical
Richard: That’s what they say. imbalance.’’ Anxiety and panic are natural human
responses to danger.
Therapist: I know it feels incredibly scary and it’s a
horrible feeling. I don’t expect you to instantly • When Richard feels intense physical sensations
believe what I’m saying or what your doctor is associated with panic, but there is no clear external
saying, because the feelings are real and you’ve danger, his mind tries to find an explanation for
been having them repeatedly. But let’s take it a his panic.
step further. What would happen if you were in
a movie theater and a false alarm went off? What • Even though his father died from a heart attack
would happen if you just sat there, because you when he was Richard’s age, there’s no medical
knew it was only a false alarm? evidence that the same thing will happen to
Richard. (We explore this cognitive dimension
Richard: I—um, I think, uh, I’d get pretty freaked to his panic in Chapter 8.)
out sitting there if everybody else was rushing
out. • Because Richard leaves or avoids situations where
he expects he might have a panic attack and then
Therapist: Perfect. So you’d feel fear, but let’s say his symptoms decrease or abate, he’s experienc-
you just sat there anyway and felt your fear, but ing negative reinforcement (reduction of aversive
you realize it’s a false alarm and so you know feelings when leaving or avoiding stressful situ-
that jumping up and running out isn’t necessary. ations). This is a big part of the learning that
What would eventually happen? contributes to Richard’s panic. He’s not giving
himself a chance to learn that his symptoms will
Richard: I guess your point is that the fear would subside even when he stays in the situation.
eventually go away. Is that it?
As a consequence of this behavioral problem
Therapist: That’s right. Just like we talked about formulation, it becomes logical to conclude that
during your intake interview, eventually your solutions to Richard’s panic include the following:
heart stops pounding and returns to normal, (a) learn new skills for coping with the symptoms,
your breathing slows down, and your body’s
alarm shuts off and it returns to normal.

254 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

(b) use these skills to face the panic symptoms, (c) Therapist: And keep up your self-monitoring panic
relearn through deconditioning that there’s nothing log. The more we know about the patterns and
to fear from his physical panic symptoms. symptoms, the better our work together will go.

Interventions Session 3. The main purpose of this session is
to introduce breathing retraining as a method of
To address these specific problems, Richard’s relaxation and symptom control. It begins with
behavior therapist used a five-component panic a hyperventilation overbreathing demonstration.
disorder protocol developed by Barlow and Craske After a discussion of Richard’s homework (he
(Barlow & Craske, 2000; Craske, 1999b). The five managed to make it one week without caffeine,
components included: had only one panic attack, and completed his panic
log very thoroughly) the therapist moves into a
1. Education about the nature of anxiety (which has learning activity.
already begun).
Therapist: Richard do you remember last week
2. Breathing retraining. we talked about your panic symptoms being a
natural, but false, alarm?
3. Cognitive restructuring.
Richard: Yeah, I remember.
4. Interoceptive exposure.
Therapist: I got the impression that you weren’t
5. Imaginal or in vivo exposure. totally convinced of that idea, so if you want, we
can discuss it a bit further, do a brief demonstra-
In the preceding therapy excerpt it was obvious tion, and then focus on a new breathing technique
that Richard didn’t completely buy the new expla- that will help you calm yourself.
nation for his panic. Nevertheless, the next steps are
distinctly behavioral: Richard needs to (a) cut down Richard: Yeah, I’m a skeptic about everything. But
on his caffeine intake (because it contributes to I have to admit I’m feeling a little better, and I
symptom emergence), (b) develop behavioral cop- think the no caffeine rule is helping.
ing skills, and (c) directly experience panic, face it,
and deal with it effectively. Therapist: I’m sure it is, because like we’ve talked
about, caffeine produces some of the physical
Therapist: Okay, Richard, we’re about done for sensations that trigger a panic attack. When the
today, but of course I’ve got some homework for caffeine hits your system and your heart rate
you again. You did such a great job with the first and breathing increase just a little bit, your body
set, I’m guessing that doing homework comes notices it, and the false alarm can start that much
naturally. This week I’d like you to slowly cut easier.
back on the caffeine intake. How do you think
you might accomplish that? Richard: Yeah. That seems right to me.

Richard: I suppose I can get some of that caffeine- Therapist: What we want is for you to be able
free soda. Well, actually my wife already picked to turn off the false alarm. One of the best
some up. ways to do that is to practice a little controlled
breathing. Watch me. [Therapist demonstrates
Therapist: Excellent. So you’ve got an option diaphragmatic breathing, inhaling for about 3
waiting at home for you, and your wife is very seconds and exhaling for about 3 to 4 seconds.]
supportive. And make that same switch to decaf Okay, now you try it. The point is to breathe
coffee. in slowly for about 3 seconds and then breathe
out slowly for 3 or 4 seconds. If you keep this up
Richard: Okay. for a minute, you end up taking about 10 breaths

CASE ANALYSIS AND TREATMENT PLANNING 255

in a minute. [Richard places one hand on his time, so I’ll be here and you’ll get control back
abdomen and begins the breathing process.] over your body. Ready?

Therapist: Okay, that’s great. Now let’s have you Richard: Okay. [Richard rises from his chair,
try it for 1 minute. overbreathes for about 30 seconds, then sits down
and, guided by his therapist, breathes steadily and
Richard: Okay. [Richard breathes slowly for 1 slowly for about 90 seconds.]
minute.]
Therapist: Now, Richard, tell me what you felt when
Therapist: Nice job, Richard. You had a slow and overbreathing and what you’re feeling now.
steady pace. How did it feel?
Richard: I’m okay now, but I did get dizzy. And my
Richard: It was fine. I felt a little uptight to start, hands got tingly. It was amazingly similar to my
but it got easier, smoother as I went along. attacks. But I’m okay now, maybe a little shaky,
but okay.
Therapist: Excellent. Now I’m going to show
you something that’s called overbreathing or Therapist: So you feel okay now. Actually, you look
hyperventilation. Watch. [Therapist stands up good too. And you gave your body an excellent
and breathes deeply and rapidly, as if trying to lesson. Your body is starting to know that the
quickly blow up a balloon. After about 1 minute, panic alarm can get turned on intentionally and
he sits down and slows down his breathing again.] that you can turn it back off yourself.
So, Richard, what did you see happening to me
as I did the overbreathing? Richard and his therapist continue debriefing his
overbreathing experience. The therapist explains
Richard: I don’t know what you felt like on the the exact physiological mechanisms associated with
inside, but your face got red and when you sat hyperventilation. At the end Richard was asked to
down you looked a little unsteady. practice diaphragmatic breathing for 10 minutes,
twice daily, until his next weekly session. He also
Therapist: Right. I intentionally hyperventilated was asked to continue abstaining from caffeine and
and felt some of what you feel during a keeping his panic logs.
panic attack. I got dizzy, light-headed, and my
hands felt tingly. When I sat down and did At the beginning of Session 4, Richard and his
the diaphragmatic breathing I could feel my therapist begin working on cognitive restructuring.
heartbeat slowing back down. The next phases of Richard’s cognitive-behavioral
therapy for panic disorder are in Chapter 8.
Richard: That’s pretty intense.
Outcomes Measurement
Therapist: You can probably guess what’s next. I
want you to try the same thing, and as soon as you Behavior therapists routinely use a variety of
start to feel any dizziness or heart pounding or outcomes measures. These measures are geared to
any of the symptoms that bother you, I want you the client’s specific symptoms.
to sit down and do your diaphragmatic breathing
until the feelings subside. Got it? Richard was given several standardized objec-
tive assessment instruments to provide treatment
Richard: I’m not so sure. How do you know I won’t planning, monitoring, and outcomes information.
have a full-blown attack? These included the:

Therapist: Actually, that’s a big part of this activity. • Body Sensations Questionnaire (Chambless,
If you have a full-blown attack, I’ll be here Caputo, Bright, & Gallagher, 1984)
and guide you through the breathing and the
symptoms will pass. Of course, our goal is for • Mobility Inventory Questionnaire (Chambless,
you to just feel a tiny bit of the symptoms and Caputo, Gracely, Jasin, & Williams, 1985)
then sit down and relax and breathe. But even if
it gets more extreme for you, we have plenty of

256 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

• Agoraphobia Cognitions Questionnaire (Chamb- Although some research indicates behavioral
less et al., 1984) treatments are effective with minority clients
(Penedo et al., 2007; Pina, Silverman, Fuentes,
Depending on client problems and symptoms, Kurtines, & Weems, 2003; Weber, Colon, &
behaviorists use many other behaviorally oriented Nelson, 2008), Craske (2010) admits that generally
questionnaires to monitor progress and outcomes. cognitive and behavioral therapies are not yet
proven efficacious in the multicultural domain.
CULTURAL AND GENDER This means behavior therapists need to make
CONSIDERATIONS multicultural adjustments. Therapy should proceed
cautiously, with openness to the client’s reaction
Consistent with the medical model, behavior ther- to specific treatment approaches. For example, if
apy focuses directly on specific client problems and Richard (from the case example discussed earlier)
symptoms. As illustrated in the preceding case, happened to be a Native American client, the thera-
client cultural background is less important than pist might say:
symptom presentation. When a client like Richard
comes to counseling with anxiety symptoms, You have symptoms that fit with a panic disorder
an evidence-based intervention will be offered— diagnosis. Fortunately we have a scientifically
regardless of cultural or ethnic background. supported treatment for panic disorder available.
However, I should also tell you that most of the
As scientists, behavioral and cognitive-behavioral research has been with white clients, although
therapists are drawn toward using evidence- there have been a few Native Americans and
based treatments. When presenting behavioral and clients from other cultures involved in the research
cognitive-behavioral therapies to consumers, behav- studies. It’s likely this approach will be helpful to
ior therapists tend toward explaining their practice you, but as we proceed, let’s talk about how it’s
by telling clients they’re ‘‘scientifically inclined’’ working for you. If there’s anything about this
and use ‘‘techniques that have been shown to be treatment that doesn’t feel right, please let me
effective in carefully performed research studies’’ know and we’ll make adjustments. Is that okay
(Ledley, Marx, & Heimberg, 2010, p. 86). with you?

When we review the evidence (in the next There are several ways in which scientifically
section) we’ll see behavior therapists are speaking supported behavior therapies might not fit for cul-
truthfully when they say they use treatments that are turally diverse clients. For example, a behavioral
scientifically supported. However, this statement activation protocol like the one implemented with
doesn’t address an important question. That is: Is Adrienne might not work if Adrienne and her family
behavior therapy efficacious with culturally diverse had strong collectivist values. It could be offensive
clients? to conceptualize solutions to Adrienne’s problem as
requiring time away from the family . . . and Adri-
Michelle Craske (2010), a prominent cognitive- enne might resist behavioral activation homework
behavioral therapist comments on this issue: if she doesn’t view her personal and independent
pleasure as important.
The empirical support for CBT [cognitive-
behavioral therapy] derives almost entirely from This discussion may lead you to worry that offer-
studies with white middle class Europeans or ing diverse clients treatments that are scientifically
Westerners. In general, CBT is aligned with supported by research predominantly with white
European and North American values of change, clients is culturally insensitive. However, it turns
self-disclosure, independence and autonomy, and out that regardless of empirical support for treat-
rational thinking, all of which are at odds with ment outcomes, many ethnic minority clients prefer
values of harmony, family and collectivism, and an active, directive, problem-focused form of ther-
spirituality that define many other cultures. apy over less-directive insight oriented therapies
(p. 123) (Atkinson, Lowe, & Mathews, 1995). D. W. Sue

EVIDENCE-BASED STATUS 257

and D. Sue (2008) discuss why diverse clients might supports women and helps them feel empowered
prefer directive therapies: to address their symptoms, it can be seen as
supporting a feminist perspective. However, if
the culturally diverse client is likely to approach the individual practitioners blame women for their
counselor with trepidation: ‘‘What makes you any symptoms and ignore systemic problems that create
different from all the Whites out there who have and exacerbate women’s problems and symptoms,
oppressed me?’’ ‘‘What makes you immune from then feminist therapists would be highly critical.
inheriting the racial biases of your forebears?’’
‘‘Before I open up to you [self-disclose], I want An electronic search for professional books and
to know where you are coming from.’’ . . . [W]e articles specifically focusing on gender, gay, lesbian,
contend that the use of more directive, bisexual, and transgender issues revealed very little
active, and influencing skills is more likely empirical work in this area (Martell, 2008). Again,
to provide personal information about where this finding is likely due to the apolitical scien-
the therapist is coming from (self-disclosure). tific stance of most behavior therapists. However,
Giving advice or suggestions, interpreting, to the extent behavior therapists are interested in
and telling the client how you, the counselor working with and advocating for GLBT popula-
or therapist, feel are really acts of counselor tions, additional intentional focus on these areas is
self-disclosure . . . [and] . . . a culturally diverse needed.
client may not open up (self-disclose) until you,
the helping professional self-disclose first. (p. 147) EVIDENCE-BASED STATUS

Overall, like most contemporary counseling and Behavioral and cognitive therapies are far and away
psychotherapy approaches, behavior therapists have the largest producers and consumers of therapy
more work to do to determine the cultural accept- outcomes research. Behaviorists (including cogni-
ability and efficacy of specific behavioral interven- tive therapists) produce more empirical research
tions (Craske, 2010). in 1 year than all other theoretical orientations
combined produce in a decade. Because research
QUESTIONS FOR REFLECTION on behavioral approaches is so voluminous, space
does not allow us to provide a systematic review
With more diverse students enrolling in counseling here. Instead, we offer a quick overview of research
and psychology programs, minority therapists will related to intervention approaches discussed in this
increasingly be working with white clients. How do chapter.
you think the trust issues articulated by Sue and Sue
might affect a white client working with an African To begin, we should note that the most recent
American, Latino, Asian, or Native American therapist? APA Division 12 list of ESTs includes 60 different
treatment protocols, most of which are behavioral or
Behavior therapy doesn’t specifically address or cognitive-behavioral. Consistent with this empirical
ignore women’s issues. Most likely, the extent to orientation, all the behavior therapy approaches
which behavior therapy is viewed in a positive light featured in this chapter have a substantial empirical
by feminists depends on individual practitioners. base. We offer a brief sampling of this support:
As in the vignette with Adrienne, behavior therapy
can be very empowering for women . . . even though • Token economies and contingency management
it doesn’t necessarily endorse a political agenda systems are effective treatments within institu-
explicitly focused on empowering women (Hunter tional programs. A meta-analysis of contingency
& Kelso, 1985; Wolfson, 1999). Overall, as long management outcomes with individuals who were
as behavior therapy is implemented in a way that both homeless and abusing cocaine showed that
day treatment and contingency management and

258 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY

contingency management alone were more effec- determinism in the psychological sciences which
tive in producing drug abstinence than day treat- can perhaps best be illustrated by a brief exchange
ment alone (Schumacher et al., 2007). which I had with Prof. B. F. Skinner of Harvard at
a recent conference. A paper given by Dr. Skinner
• Extensive research indicates that behavioral acti- led me to direct these remarks to him. ‘‘From
vation is effective in treating depression in a what I understood Dr. Skinner to say, it is his
wide range of different clinical populations (e.g., understanding that though he might have thought
college students, hospitalized patients, clients he chose to come to this meeting, might have
with suicide ideation; Cuijpers, van Straten, thought he had a purpose in giving his speech,
& Warmerdam, 2007; Sturmey, 2009). such thoughts are really illusory. He actually made
certain marks on paper and emitted certain sounds
• Progressive muscle relaxation and other forms here simply because his genetic make-up and his
of relaxation are often used as a treatment past environment had operantly conditioned his
component in behavioral and cognitive behavioral behavior in such a way that it was rewarding to
therapies. However, for treating insomnia and make these sounds, and that he as a person doesn’t
panic disorder, relaxation training alone shows enter into this. In fact if I get his thinking
efficacy (Morin et al., 2006; Ost et al., 1995; correctly, from his strictly scientific point of
Spiegler & Guevremont, 2010). view, he, as a person, doesn’t exist.’’ In his reply
Dr. Skinner said that he would not go into the
• Exposure plus response or ritual prevention is question of whether he had any choice in the
one of the most well researched procedures, matter (presumably because the whole issue is
consistently producing robust outcomes. It has illusory) but stated, ‘‘I do accept your
demonstrated its efficacy as a treatment for many characterization of my own presence here.’’ I do
different anxiety disorders as well as bulimia not need to labor the point that for Dr. Skinner
nervosa (Forsyth et al., 2009; McIntosh, Carter, the concept of ‘‘learning to be free’’ would be
Bulik, Frampton, & Joyce, 2011; Powers & quite meaningless. (Rogers, 1960, pp. 15–16)
Emmelkamp, 2008).
Although Rogers offers an amusing critique of
• Problem-solving therapy has substantial research Skinner, contemporary behavior therapy has moved
support for treating depression and for contrib- beyond rigid determinism. In fact, behavior ther-
uting to effective treatment with children and apy represents not only a flexible approach to
adolescents with behavioral disorders (Bell & therapy, but is also open to incorporating new tech-
D’Zurilla, 2009; Cuijpers et al. 2007; Kazdin, niques. The only rigidity inherent in the behavioral
2010; A. M. Nezu & C. M. Nezu, 2010). approach is its strict adherence to scientific valida-
tion of therapeutic techniques. Most of the behavior
CONCLUDING COMMENTS therapy perspective can be summed up in one sen-
tence: If it can’t be empirically validated, then it’s
During their careers, B. F. Skinner, a strong not behavior therapy.
proponent of behavioral determinism, and Carl
Rogers, long an advocate of free will and human Overall, behavior therapists deserve credit for
dignity, had numerous professional interactions. demonstrating that their particular approaches are
In the following excerpt, Rogers comments on effective—based on a quantitative scientific-medical
an exchange they had while presenting their work model. Even more impressive is the fact that behav-
together on a conference panel. ior therapy research has begun identifying which
specific approaches are more likely to be effective
Along with the development of technology has with which specific problems. However, the
gone an underlying philosophy of rigid question remains open regarding whether behavior
therapy techniques are generally more effective
than other techniques or whether behavior therapy

CHAPTER SUMMARY 259

researchers are simply better at demonstrating effi- Contemporary behavior therapy consists of a
cacy. Either way, we close with Skinner’s remarks as variety of empirically based assessment and inter-
an apt summary of the behavioral scientist’s credo: vention procedures. Assessment procedures include
(a) functional behavioral assessment (including self-
Regard no practice as immutable. Change and be monitoring); (b) behavioral interviewing; and (c)
ready to change again. Accept no eternal verity. standardized questionnaires.
Experiment. (Skinner, 1970, p. viii)
Although there are many evidence-based behav-
CHAPTER SUMMARY ior therapy procedures, in this chapter we focused
primarily on five. These included (1) token econo-
The behaviorism movement strongly shaped Amer- mies and contingency management; (2) behavioral
ican psychology beginning in the early 1900s. activation; (3) relaxation training; (4) systematic
Perhaps most significantly, Mary Cover Jones con- desensitization and exposure treatments; and
ducted research on young children with fears and (5) skills training.
phobias in the 1920s that identified treatment prin-
ciples that continue to guide contemporary behavior Behavior therapy tends to focus exclusively on
therapy for anxiety problems. Led by B. F. Skinner, symptoms, sometimes ignoring social and political
Joseph Wolpe, Arnold Lazarus, and other leading factors contributing to client problems. Although
researchers and practitioners, behavior therapy was this focus is helpful for symptom reduction, fem-
officially born in the 1950s. inists and multiculturalists tend to complain that
behavior therapy can blame clients for their prob-
Behaviorists are first and foremost scientists. lems. There is also little research that specifically
Over the years they’ve primarily focused only on addresses whether behavior therapy is efficacious or
procedures and processes that are observable and effective for minority populations.
supported by scientific research.
The good news is that behavior therapy is
There are three main behavioral theoretical proven efficacious and effective for a wide range
models. These models include: (1) operant condi- of problems for members of the dominant culture.
tioning (aka: applied behavior analysis); (2) classical This is partly because behaviorists are inclined to
conditioning (aka: the neobehavioristic, mediational conduct research, embrace the modern scientific
stimulus-response model); (3) social learning theory paradigm, and are comfortable with the medical
(which is discussed in Chapter 8). For all behavior model. Most of the therapies listed as highly
therapists, psychopathology is caused by maladap- efficacious or likely to be efficacious by Division
tive learning and is treated by providing clients new 12 of the American Psychological Association are
learning experiences. either behavior therapies or cognitive-behavioral
therapies.

BEHAVIOR THERAPY KEY TERMS Contingency management
Conditioned response
Applied behavior analysis Conditioned stimulus
Assertiveness training Counterconditioning
Aversive conditioning Exposure treatment
Behavioral ABCs Extinction
Behavioral activation
Classical conditioning

260 CHAPTER 7 BEHAVIORAL THEORY AND THERAPY Punishment
Response prevention
Fading Self-monitoring
Functional behavioral analysis Skills training
Imaginal and in vivo exposure Spontaneous recovery
Interoceptive exposure Stimulus discrimination
Massed versus spaced exposure Stimulus generalization
Negative reinforcement Stimulus-response (SR) theory
Neobehavioristic mediational SR model Systematic desensitization
Operant conditioning Token economy
Overbreathing Unconditioned response
Participant modeling Unconditioned stimulus
Positive reinforcement Virtual reality exposure
Problem-solving therapy
Progressive muscle relaxation

RECOMMENDED READINGS AND RESOURCES

The following resources provide additional information on behavior theory and therapy.

BEHAVIOR THERAPY JOURNALS Behavior Therapy
Child and Family Behavior Therapy
Although there are dozens more behavior therapy journals Journal of Applied Behavior Analysis
available, we only list some of the main professional Journal of Behavior Therapy and Experimental Psychiatry
resources here.

Behavior Modification
Behaviour Research and Therapy

READINGS ON BEHAVIORAL APPROACHES

Bernstein, D. A., & Borkovec, T. D. (1973). Progressive Goldfried, M. R., & Davison, G. C. (1994). Clinical
relaxation training: A manual for the helping professions. behavior therapy (Exp. ed.). Oxford, England: John
Champaign, IL: Research Press. Wiley & Sons.

Farmer, R. F., & Nelson-Gray, R. O. (2005). The Jones, M. C. (1924). The elimination of children’s fear.
history of behavior therapy. Washington, DC: American Journal of Experimental Psychology, 8, 382–390.
Psychological Association.
Mahoney, M. (1979). Self-change: Strategies for solving
Gershoff, E. T. (2002). Corporal punishment by parents personal problems. New York, NY: Norton.
and associated child behaviors and experiences: A
meta-analytic and theoretical review. Psychological Pavlov, I. P. (1972). Conditioned reflexes (G. V. Anrep,
Bulletin, 128(4), 539–579. Trans.). London, England: Oxford University Press.

CHAPTER SUMMARY 261

Skinner, B. F. (1953). Science and human behavior. New Watson, J. B. (1924). Behaviorism. Chicago, IL: University
York, NY: Macmillan. of Chicago Press.

Skinner, B. F. (1971). Beyond freedom and dignity. New Wolpe, J. (1958). Psychotherapy by reciprocal inhibition.
York, NY: Knopf. Stanford, CA: Stanford University Press.

Skinner, B. F. (1977). Why I am not a cognitive Wolpe, J., & Plaud, J. J. (1997). Pavlov’s contributions to
psychologist. Behaviorism, 5, 1–10. behavior therapy: The obvious and the not so obvious.
American Psychologist, 52 (9), 966–972.
Spiegler, M. D., & Guevremont, D. C. (2010). Con-
temporary behavior therapy (5th ed.). Belmont, CA:
Wadsworth/Cengage Learning.

TRAINING ORGANIZATIONS AND WEBSITES

Association for Behavioral and Cognitive Therapies Association for Applied Behavior Analysis International
(ABCT; www.abct.org) (ABAI; www.abainternational.org)

VIDEOS/DVDs Persons, J. B., Davidson, J., & Tompkins, M. A. (2000).
Activity scheduling [DVD]. Washington, DC: American
Goldfried, M. R. (1994). Cognitive-affective behavior ther- Psychological Association.
apy [DVD]. Washington, DC: American Psychological
Association. Turner, S. M. (1998). Behavior therapy for Obsessive-
Compulsive Disorder [DVD]. Washington, DC:
Harris, J. (2006). Behavioral counseling and psychother- American Psychological Association.
apy [DVD]. North Amherst, MA: Microtraining
Associates.

Hays, K. (2007). Exercise [DVD]. Washington, DC:
American Psychological Association.

GOING FARTHER AND DEEPER

Additional behavioral counseling and psychotherapy resources are available at johnsommersflanagan.com.



8C H A P T E R

Cognitive-Behavioral Theory and Therapy

THIS CHAPTER

Reviews key figures and factors in the history and development of cognitive theories of behavior
change
Outlines and describes key concepts of social learning theory and cognitive appraisal theories and
their integration into cognitive-behavioral theory and therapy
Describes how cognitive-behavioral theorists and therapists view psychopathology
Describes and discusses principles and procedures associated with cognitive-behavioral counseling
and psychotherapy practice, including

Assessment procedures
Psychoeducation
Methods for identifying and exploring automatic thoughts and core beliefs
Implementation of specific cognitive-behavioral techniques
Offers case vignettes to demonstrate cognitive-behavioral techniques in action
Illustrates how treatment planning, outcomes assessment, and gender and cultural issues can be
integrated into a cognitive-behavioral approach
Reviews empirical evidence supporting cognitive-behavioral therapy practice
Offers ideas for further study

In the beginning, most behaviorists made it very Therapy (AABT then, Association for Behavioral
clear that they didn’t really want to think much and Cognitive Therapy now; ABCT), we listened
about cognition. Nevertheless, a few behaviorists as Wolpe condemned Michael Mahoney’s use of
purposefully included cognition in their work. One ‘‘mirror time’’ or ‘‘streaming’’ with a very disturbed
such behaviorist, Joseph Wolpe, opened Skinner’s young man. Streaming involved having the client
black box just enough to let in a little mental imagery free-associate while looking at himself in a mirror
for doing systematic desensitization (Wolpe, 1958). (Williams, Diehl, & Mahoney, 2002). Wolpe was
In some ways, this implies that Wolpe was at adamant: There were events happening at the
least partially responsible for starting the cognitive conference far outside the behavior therapy realm.
movement in behavior therapy. Mahoney and other ‘‘cognitive types’’ had stepped
over the line.
We suspect Wolpe wouldn’t appreciate our
observation. At the 1983 annual meeting of the But this wasn’t the first behavioral-cognitive spat.
Association for the Advancement of Behavior As Meichenbaum (2003) noted years later, a 1970s

264 CHAPTER 8 COGNITIVE-BEHAVIORAL THEORY AND THERAPY

zeitgeist caused a split between behaviorists who As J. Beck noted, CBT
embraced cognition and behaviorists who eschewed
cognition. In an interview, he recalled: is the popular term

• [A] letter by a very senior and prominent when referring to cog-
behavior therapist was circulated in AABT to
have individuals who advocated for cognitive nitive-behavioral ther-
factors in therapy to be kicked out of the behavior
therapy association. apy. However, because

• The number of presentations on cognitive factors we emphasized behav-
at AABT conferences were limited, if not
excluded. ior therapy in the pre-

• Certain behavioral journals would not permit the Judith Beck vious chapter, this chap-
use of the word ‘‘cognition’’ in any articles. ter, as in the past,

• Researchers in . . . CBT were professionally focuses primarily on the cognitive dimension of
threatened if they continued to challenge the
behavioral approach. CBT. Our main emphasis is on exploring the ori-

• CBT researchers were challenged as being ‘‘oxy- gins, nature, and practice of integrating cognition
moronic’’ and were labeled as ‘‘malcontents.’’
(Meichenbaum, 2003, p. 127) into the behavior therapy process (see Putting it in

Of course, pressure from behaviorists didn’t Practice 8.1 for Judith Beck’s explanation for why
dampen the ‘‘cognitivists’’’ resolve. They pushed
back and in 1977 a new journal, Cognitive Therapy she’s a cognitive behavior therapist).
and Research, was founded, with Michael Mahoney
as editor. HISTORICAL CONTEXT AND

Although there were initial conflicts and a split BIOGRAPHICAL INFORMATION
between staunch behaviorists and cognitivists, in
recent years there has been substantial rapproach- Wilhelm Wundt used introspection as a scientific
ment and integration. As a consequence, when one technique when he established the first psychology
of our favorite reviewers suggested we rename laboratory in 1879. Introspection was viewed as
this chapter from Cognitive Theory and Ther- a method of studying internal cognitive processes
apy to Cognitive-Behavioral Theory and Therapy, . . . or cognition (Wozniak, 1993). Wundt studied
we happily complied because it’s now nearly impos- sensation, perception, memory, reaction time, and
sible to distinguish between cognitive therapy other psychological processes. Although 1879 seems
and cognitive-behavioral therapy. In keeping with like long ago, introspection doesn’t begin with
this trend, Judith Beck (Kaplan, 2011) recently Wundt. It dates at least back to Socrates, who
announced: often used an approach now referred to as Socratic
questioning to uncover and discover an individual’s
[W]e are changing our name from the Beck In- method of reasoning.
stitute for Cognitive Therapy to the Beck Institute
for Cognitive Behavior therapy because people In the first half of the 20th century, introspection
now seem more familiar with the term CBT. as a means of studying consciousness was on
(p. 36) the decline. John Watson and B. F. Skinner had
banished it from academic psychology and might
well have considered holding a memorial service
to celebrate its death. But as far as we know, that
particular cognition never crossed their minds.

It’s just as well. Cognition is a slippery and
persistent phenomenon that just keeps popping up.
Have you ever tried to banish a particular set of
cognitions (thoughts) from your mind? Typically,
when humans try to stop thinking about something,

HISTORICAL CONTEXT AND BIOGRAPHICAL INFORMATION 265

PUTTING IT IN PRACTICE 8.1

Why Do I Practice Cognitive Behavior Therapy?

The following commentary was written by Judith S. Beck, PhD, president of the Beck
Institute for Cognitive Behavior Therapy at the University of Pennsylvania.

Why do I practice cognitive therapy? Aside from the familial connection (my father,
Aaron T. Beck, MD, is the ‘‘father’’ of cognitive therapy), it is the most widely researched
form of psychotherapy; it has been shown in several hundred research studies to be
effective. If I had an ear infection, I would first seek the treatment that has been
demonstrated most efficacious. Why should it be different for psychiatric disorders or
psychological problems?

Other than research efficacy, it is the one form of psychotherapy that makes sense
to me. Take a typical depressed patient. Nancy, a 32-year-old married sales clerk with
a young child, has been clinically depressed for almost a year. She has quit her job,
spends much of the day in bed, has given over most of her child-rearing responsibilities
to her mother and husband, goes out only infrequently, and has withdrawn from family
and friends. She is very sad, hopeless, weighted down, self-critical; she gets little if any
pleasure from activities or interactions with others and little sense of achievement from
anything she does.

It just makes sense to me to work directly on the problems Nancy has today, teaching
her cognitive and behavioral skills to get her life in order and decrease her depression.
Behaviorally, I help Nancy plan a schedule: getting out of bed at a reasonable time each
morning, getting bathed and dressed immediately, and preparing breakfast for herself and
her daughter. We include calling friends, doing small household tasks, taking walks, and
doing one errand. Cognitively I help her identify and respond to her negative thinking.
Some of her dysfunctional thoughts are related to the behavioral tasks I have suggested:
‘‘I’ll be too tired to get out of bed. I won’t know what to make for breakfast. [My friend]
Jean won’t want to hear from me. It won’t help to take a walk.’’ Other dysfunctional
thoughts are about herself (‘‘I’m worthless’’), her world (‘‘Life is too hard’’), and the future
(‘‘I’ll never get better’’).

We tackle Nancy’s problems one by one. In the context of discussing and solving
problems, I teach her the skills she needs. Cognitive skills include identifying her depressed
thoughts, evaluating her thinking, and developing more realistic, adaptive views. I also
help her respond to her deeper-level ideas, her beliefs or basic understandings that shape
her perception of her experience, ideas that, left unmodified, might contribute to a relapse
sometime in the future.

266 CHAPTER 8 COGNITIVE-BEHAVIORAL THEORY AND THERAPY

While doing cognitive therapy, I need to use all my basic counseling skills to establish
and maintain a strong therapeutic alliance. I am highly collaborative with the patient,
working with her as a ‘‘team’’ to help her get better; I provide rationales for the strategies
I use; I use active listening and empathy, and I provide support. And I ask for feedback
at every session to make sure that I have understood the patient correctly and that the
process of therapy is amenable to her. But perhaps most importantly, I am quite active
in the session—providing direction, offering suggestions, teaching her skills. Doing all of
these things helps the patient recover most quickly.

Why do I specialize in cognitive therapy? Because it is humane, it is effective, and it
is the quickest way to alleviate suffering.

the banished thoughts return . . . sooner or later. father as a minimally successful businessman who
Humans are a very cognitive species and so despite was often away from home. He described his mother
Watson’s and Skinner’s best efforts, cognition as self-absorbed and as having bipolar tendencies.
(now sometimes disguised as ‘‘information process- Ellis became very sick with a kidney ailment at
ing’’) returned to academic psychology and has age 5 and was hospitalized eight times from age 5
become central to contemporary counseling and to 7 years. He believed his health struggles taught
psychotherapy. him to confront feelings of inferiority. His parents
divorced when he was 12 years old.
Three primary historical figures and trends
characterize the history and evolution of cognitive Initially, Ellis wanted to be a writer, but his
therapy. These include: first eight novels were rejected. Eventually he
entered the Columbia University clinical psychol-
• Albert Ellis and Rational Emotive (Behavior) ogy program in 1942. After graduating he pursued
Therapy training in psychoanalysis and, like Fritz Perls (see
Chapter 6), was analyzed by Karen Horney.
• Aaron Beck and Cognitive Therapy
Ellis formulated his approach after progressively
• Donald Meichenbaum and Self-Instructional discovering he was ineffectual in his traditional
Therapy psychoanalytic practice. But he didn’t blame himself
for his being ineffectual. Instead, he blamed the
Albert Ellis and Rational Emotive psychoanalytic method. In his own words, here’s
Behavior Therapy what he discovered about psychotherapy (Ellis &
Grieger, 1977):
Albert Ellis is generally
I realized more clearly that although people have
credited with the initial remarkable differences and uniquenesses in their
tastes, characteristics, goals, and enjoyments, they
discovery and promo- also have remarkable sameness in the ways in
which they disturb themselves ‘‘emotionally.’’
tion of modern rational People have, of course, thousands of specific
irrational ideas and philosophies (not to mention
(cognitive) approaches superstitions and religiosities) which they
creatively invent, dogmatically carry on, and
to psychotherapy. Ellis stupidly upset themselves about. But we can easily
put almost all these thousands of ideas into a few
was born in Pittsburgh, general categories. Once we do so, and then

Albert Ellis Pennsylvania, in 1913 to
Jewish parents. Similar

to Adler (see Chapter 3) he had a challenging child-

hood. Eldest of three children, he described his

HISTORICAL CONTEXT AND BIOGRAPHICAL INFORMATION 267

actively look for these categories, we can fairly One day when Epictetus was working in the
quickly find them, show them to disturbed fields chained to an iron stake, his master
individuals, and also teach them how to give them approached him with the idea of tightening his leg
up. (pp. 4–5) shackle. Epictetus suggested that making the
shackle tighter was not needed to keep him from
This statement is an efficient summary of five running away, but would merely break his leg.
bedrock components of Ellis’s approach: The master was not persuaded, and sure enough
Epictetus’s leg was broken. But he did not protest
1. People dogmatically adhere to irrational ideas or give any sign of distress. His master asked him
and personal philosophies. why, and was told that since the leg was already
irreversibly broken, there was really no point in
2. These irrational ideas cause people great distress getting upset about it. His master was so
and misery. impressed by this demonstration of unflappability
that he eventually set Epictetus free, and sent him
3. These ideas can be boiled down to a few basic away with money so he could become an itinerant
categories. philosopher. Epictetus considered this preferable
to being a philosopher chained to a stake, and
4. Therapists can find these irrational categories eventually came to Rome, then the capital of the
rather easily in their clients’ reasoning. Western world. Among the prominent Romans he
influenced was the emperor Marcus Aurelius.
5. Therapists can teach clients how to give up their (Retrieved October 12, 2011: http://www.anxiety
misery-causing irrational beliefs. insights.info/read/page/jwb_epictetus_fundamentals
.htm)
Ellis began using more directive therapy ap-
proaches in the late 1940s and early 1950s. He Ellis initially referred to his therapy approach
acknowledges that many of his contemporaries were as rational psychotherapy, later changing the name
already heading the same direction—away from to Rational-Emotive Therapy. In 1993, he inserted
traditional psychoanalysis and toward more active- the word behavior, thus creating Rational Emotive
directive, cognitive-oriented therapy. He wrote: Behavior Therapy (REBT), a phrase that better
reflects the strong behavioral components of his
Actually, they attributed to me more originality therapy approach.
than I merited. By the late 1940s quite a few other
therapists, most of them trained as I was in the There’s little argument that Ellis was one of the
field of psychoanalysis, had begun to see the severe biggest characters in the history and practice of
limitations and myths of the analytic approach and psychotherapy. His influence was profound, from
had, whether they consciously acknowledged it or the publication and dissemination of many rational
not, moved much closer to Adler than to Freud. humor songs (including the infamous Albert Ellis
(Ellis & Grieger, 1977, p. 4) Christmas Carols), to the direct training of thou-
sands of REBT practitioners. When we heard him
Not only does Ellis credit Adler’s pioneering speak, there were two consistent occurrences. First,
acceptance of cognition, he also noted that his he found a reason to break into song (despite his
‘‘rational psychotherapy’’ is based, in part, on the very poor voice and tune carrying abilities). Second,
philosophical writings of ancient Greek and Roman he always managed to slip the ‘‘F’’ word into his
stoics, particularly Epictetus. The late J. W. Bush presentations.
(2002) described Epictetus’s history.
Given Ellis’s eccentric, direct, and sometimes
The first cognitive behavior therapist, so to speak, abrasive characteristics, it’s tempting to minimize
in the Western world was the philosopher his accomplishments. But he produced more than
Epictetus (c. 50–138 a.d.). He was born a slave in 700 scholarly journal articles and 60 professional
the Greek-speaking Roman province of Phrygia, books. Additionally, he probably provided therapy
in what is now central Turkey.

268 CHAPTER 8 COGNITIVE-BEHAVIORAL THEORY AND THERAPY

to more individuals than any other practitioner in Many psychoanalytic colleagues ostracized Beck
the history of psychotherapy. In 1987 alone, he for questioning Freud (Weishaar, 1993). However,
reported he was working with 300 individual clients over time, Beck’s work on depression was recog-
and five groups, while demonstrating his procedures nized as empirically valid. His theory of depression
at weekly ‘‘Five-Dollar Friday Night Workshops’’ and specific approaches to its treatment represents
in New York City (Ellis, 1987). Moreover, he one of the best-known and most scientifically sup-
continued this incredible pace into the twenty-first ported discoveries in the field of counseling and
century—amassing more than 50 years of applied psychotherapy.
clinical experience. For detailed information on
Ellis’s personal history, see Dryden (1989). Beck described how he discovered the centrality
of cognition to human functioning while conducting
Not long after Ellis began formulating his psychoanalysis:
rational approach to psychotherapy another formal
cognitive approach entered the scene. [T]he patient volunteered the information that
while he had been expressing anger-laden
Aaron Beck and Cognitive Therapy criticisms of me, he had also had continual
thoughts of a self-critical nature. He described
Aaron Beck was born two streams of thought occurring at about the
same time; one stream having to do with his
in 1921 in Providence, hostility and criticisms, which he had expressed in
free association, and another that he had not
Rhode Island. His par- expressed. He then reported the other stream of
thoughts: ‘‘I said the wrong thing . . . I shouldn’t
ents were Russian Jew- have said that . . . I’m wrong to criticize him . . . I’m
bad . . . He won’t like me . . . I’m bad . . . I have no
ish immigrants. He was excuse for being so mean.’’ (Beck, 1976, pp. 30–31)

the youngest of five chil- This finding led Beck to conclude that focusing
on this other stream of consciousness was more valuable
dren. By the time he was than the free association material targeted by
traditional Freudian analysts.
Aaron Beck born an older brother
and older sister had died Beck’s approach to therapy has come to be known
simply as cognitive therapy. He reasoned that:
of influenza, causing his mother to become very
[P]sychological problems can be mastered by
depressed. Beck reportedly saw himself as a replace- sharpening discriminations, correcting
misconceptions and learning more adaptive
ment for his deceased older siblings (Weishaar, attitudes. Since introspection, insight, reality
testing, and learning are basically cognitive
1993). processes, this approach to the neuroses has been
labeled cognitive therapy. (Beck, 1976, p. 20)
Similar to Adler and Ellis, Beck also had a
Similar to Ellis’s REBT, which often is delivered
physical problem during childhood. He broke his more forcefully, cognitive therapy has taken on
many of Beck’s personal qualities. As a therapist,
arm and missed a substantial amount of school due Beck has always been recognized as someone
who provided therapy in a collaborative and
to a long recovery period in the hospital. During practical manner. His approach was always as
gentle as Ellis’s approach is forceful. Beck isn’t
this time he was held back a year in school and

began believing he was not very smart. He overcame

this difficult situation and his negative thoughts,

eventually obtaining a medical degree from Yale in

1953.

Like Adler, Rogers, Perls, and Ellis, Beck was

psychoanalytically trained. Early on, he became

interested in validating Freud’s anger-turned-

inward-upon-the-self theory of depression. Instead

he ended up rejecting Freud’s theory and articulat-

ing his own (A. T. Beck, 1961; A. T. Beck, 1963; A.

T. Beck, 1970).

HISTORICAL CONTEXT AND BIOGRAPHICAL INFORMATION 269

interested in rational argument with clients. Instead, the therapist to directly influence what the client
cognitive therapists using Beck’s style engage in says to himself. (Meichenbaum & Cameron, 1974,
what Beck called collaborative empiricism. The p. 117)
therapist works together with clients to help them
discover for themselves the maladaptive nature During his early career, Meichenbaum’s focus
of their automatic thoughts and core beliefs. was on self-instructional training (SIT), which,
A key distinction between these two cognitively consistent with his behavioral roots, he referred
oriented therapists is that whereas Ellis emphasizes to as cognitive behavior modification (Meichen-
the forceful eradication of irrational thoughts, baum, 1977). He emphasized that ‘‘behavior change
Beck emphasizes the collaborative modification of occurs through a sequence of mediating processes
maladaptive thoughts (A. T. Beck, Rush, Shaw, & involving the interaction of inner speech, cogni-
Emery, 1979; D. A. Clark, Beck, & Alford, 1999). tive structures, and behaviors and their resultant
outcomes’’ (Meichenbaum, 1977, p. 218).
Donald Meichenbaum
and Self-Instructional Strategies He later developed stress inoculation training
(also SIT), a specific approach for helping clients
Unlike Adler, Ellis, and Beck, Donald Meichen- manage difficult stressors (Meichenbaum, 1985).
baum followed the path of behavior therapy into the Throughout this early and middle phase of his
field of cognitive therapy and beyond. He described career, Meichenbaum focused on empirical research
himself as learning to be a people-watcher as he and validation of highly practical approaches to
grew up in New York City. He noticed that people helping clients. His style was similar to Beck’s;
on the streets in New York would sometimes talk he was collaborative and worked to help clients
to themselves. change their inner speech. Meichenbaum’s model
emphasized self-instructional coping skills more
In his early research Meichenbaum focused on than Ellis or Beck. His style is also more openly
impulsive schoolchildren and hospitalized adults empathic and emotionally oriented than many
diagnosed with schizophrenia. To his surprise, he cognitive therapists.
discovered that both schizophrenics and children,
similar to people on the New York streets, could More recently, along with other behavioral and
improve their functioning after being taught to talk cognitive therapists, Meichenbaum shifted toward
to themselves or to think aloud (Meichenbaum, an empirically oriented constructive model (Hoyt,
1969; Meichenbaum & Goodman, 1971). 2000; Meichenbaum, 1992). As his thinking evolves,
he’s redefining cognitive therapy as an integrational
A consummate observer and researcher, Mei- approach. For example, at the Second Evolution of
chenbaum’s perspective has evolved over time. Ini- Psychotherapy Conference, he stated:
tially, he integrated the work of Soviet psychologists
Vygotsky (1962) and Luria (1961) with Bandura’s [Cognitive behavior therapy,] which is
(1965) vicarious learning model and the oper- phenomenologically oriented, attempts to explore
ant conditioning principle of fading to develop a by means of nondirective reflective procedures the
systematic method for teaching children to use client’s world view. There is an intent to see the
self-instructions to slow down and guide them- world through the client’s eyes, rather than to
selves through challenging problem-solving situa- challenge, confront, or interpret the client’s
tions. His work with self-instruction led him to thoughts. A major mode of achieving this objective
conclude that is for the [cognitive behavior] therapist to ‘‘pluck’’
(pick out) key words and phrases that clients offer,
[E]vidence has convincingly indicated that the and then to reflect them in an interrogative tone,
therapist can and does significantly influence what but with the same affect (mirroring) in which they
the client says to [the therapist]. Now it is time for were expressed. The [cognitive behavior] therapist
also may use the client’s developmental accounts,
as well as in-session client behavior, to help the

270 CHAPTER 8 COGNITIVE-BEHAVIORAL THEORY AND THERAPY

client get in touch with his or her feelings. A significant portion of human learning is obser-
(Meichenbaum, 1992, pp. 117–118) vational in nature (Bandura, 1971). For example, in
Bandura’s famous Bobo doll experiment, he showed
Meichenbaum’s progression—from behavior observational or vicarious learning was a power-
therapy, to cognitive behavior modification, to cog- ful behavior changing force (Bandura, Ross, & Ross,
nitive-behavioral therapy, to constructive cognitive- 1963). This process is also referred to as modeling.
behavioral therapy—reflects a trend toward integra- Observational learning includes covert or private
tion that we’ll explore more later (see Chapter 14). mental processes that cannot be directly observed
by experimenters (or therapists).
THEORETICAL PRINCIPLES
Social learning theory also emphasizes recip-
CBT was never intended to become a school, nor rocal interactions that occur between the indi-
a fad. It does not advocate a specific treatment vidual’s behavior and the environment (Bandura,
approach, nor orientation. CBT is a critically- 1978). Bandura postulated that individuals can have
minded, empirically based treatment approach. thoughts about the future, behavioral consequences,
(Meichenbaum, 2003, p. 128) and goals. These thoughts form a sort of feedback
loop and influence current behavior. In combina-
Like behavior therapy, CBT is based on learning tion with observational learning, it becomes possible
theory. This means that whenever we examine for clients to learn how to approach or avoid spe-
cognitive-behavioral theory, we’re also looking cific situations never having directly experienced
directly at the two learning theories discussed in positive or negative reinforcement—based com-
the previous chapter: pletely on watching what happened to someone
else. These reciprocal interactions make individuals
1. Classical conditioning capable of self-directed behavior change. In contrast
to Skinner and Watson, Bandura sees free will and
2. Operant conditioning self-determination as possible.

Cognitive-behavioral therapy also functions on One of Bandura’s most important cognitive
the basis of two additional learning theories: (1) concepts is self-efficacy (Bandura & Adams, 1977;
social learning theory; and (2) cognitive appraisal Bandura, 1977). Self-efficacy is defined as:
theory. These theories emphasize cognition in
initiating and sustaining specific behaviors. The conviction that one can successfully execute
the behavior required to produce an outcome.
Social Learning Theory (Bandura, 1977, p. 193)

Social learning theory was developed by Albert Self-efficacy is different from self-esteem or self-
Bandura (Bandura & Walters, 1963). As a theoret- confidence. Its specificity has made it more helpful
ical model, it’s viewed as an extension of operant to researchers and clinicians. There are many
and classical conditioning. Social learning theory different self-efficacy measures in the scientific
includes stimulus-influence components (classical literature.
conditioning) and consequence-influence compo-
nents (operant conditioning), but it also adds a Self-efficacy can have an interactive or reciprocal
cognitive mediational component. influence on client behavior. As a positive expecta-
tion or belief about the future, higher self-efficacy
Social learning theory emphasizes two main is associated with more persistence, greater effort,
cognitive processes: observational learning and person- and willingness to face obstacles. For example, if
stimulus reciprocity. you really believe in your skills to study and suc-
cessfully pass an upcoming midterm in this class,
you have high self-efficacy and will behave in ways
that make your success more likely to become

THEORETICAL PRINCIPLES 271

reality. However, lower self-efficacy is associated methods’’ (Watson, 1924, p. 158). Watson’s objec-
with negative self-talk or preoccupation, giving up tion was scientific; introspection was subjective and
easily, and reduced concentration. As you can see, not amenable to measurement and so it was out-
low self-efficacy won’t help with your exam-taking side the purview of behaviorism. In contrast, for
success. cognitive theorists, discovering the client’s subjec-
tive interpretation of reality is the whole point. For
Several factors can increase or improve client example, many clients have classically conditioned
self-efficacy: fear responses, but these responses are cognitively
mediated. Research supports this cognitive medi-
• Incentives. ation theory. Individuals with anxiety disorders
tend to:
• Knowledge and skills.
• Pay too much attention to negative incidents or
• Positive feedback. cues.

• Successful performance accomplishment. • Overestimate the likelihood of a negative event
occurring.
Based on Bandura’s reciprocal interactions mod-
el, a primary therapy goal would be to help • Exaggerate the significance or meaning of poten-
clients develop and strengthen their self-efficacy. tial or real negative events. (Davey, 2006)
For example, a client who comes to therapy to quit
smoking cigarettes may initially have little confi- Similarly, if we look at Skinner’s theoretical posi-
dence in her ability to quit. If therapy is to be tion, ‘‘Behavior is a function of its consequences,’’
successful, it will be necessary to enhance the client’s then cognitive theory transforms ‘‘consequences’’
smoking cessation self-efficacy. This may come from an objective to a subjective phenomenon.
about when the therapist teaches the client self- Now, behavior is a function of what the organism
monitoring procedures, progressive muscle relax- thinks about its consequences.
ation, and strategies for coping with uncomfortable
feelings associated with nicotine withdrawal. As the The cognitive revision of behavioral stimulus-
client’s skills develop, so might her belief in her abil- response (S-R) theory is stimulus-organism-
ity to successfully quit smoking. Therapists also may response (S-O-R) theory. Beck (1976) stated it
model a strong and positive belief in their client’s this way:
success. In this way behavioral techniques can pro-
duce change indirectly; they provide clients with [T]here is a conscious thought between an external
tools that positively impact their beliefs in their abil- event and a particular emotional response. (p. 27)
ity for success at a variety of challenging tasks.
Cognitive theory emphasizes the individual
Cognitive Appraisal Theories organism’s processing of environmental stimuli as
the force determining his or her specific response
The essence of cognitive theory can be summarized
in one sentence that Ellis attributes to Epictetus The ABCDEF Cognitive Model
(Ellis & Dryden, 1997): In Ellis’s REBT model humans are viewed as having
the potential for thinking rationally. However,
People are disturbed not by things, but by the humans also have a strong tendency to think in
view which they take of them. exaggerated, tangled, contradictory, mistaken, and
irrational ways—and this is the primary source of
Cognitive theory and, in particular, cognitive human misery.
behavioral theory are expansions of behavior ther-
apy. Consider Watson’s position that ‘‘Introspec- Ellis used an A-B-C model to describe and
tion forms no essential part of [behavior therapy] discuss S-O-R theory. In REBT, ‘‘A’’ represents

272 CHAPTER 8 COGNITIVE-BEHAVIORAL THEORY AND THERAPY

the activating event or stimulus that has occurred Ellis was well known for his direct and confronta-
in an individual’s life; ‘‘B’’ refers to the belief about tional therapy style. Although it’s easy to directly
the activating event; and ‘‘C’’ refers to consequent associate Ellis’s style with REBT, not all Ratio-
emotion and behavior linked to the belief. nal Emotive Behavior therapists are as direct and
confrontational as Ellis.
The REBT ABCs are best illustrated through
an example: Ellis’s main intervention is to dispute (D) the
irrational belief. He might directly dispute Jem’s
Jem comes to therapy feeling angry, depressed, belief by asking,
hurt, and resentful. Last night his romantic partner,
Pat, wasn’t home at 6 p.m. for dinner as they had • Is it true that Pat must always be home right on
arranged. This event troubled him greatly. In REBT time to prove you’re loved?
terms, the fact that Pat wasn’t home on time is the
activating event (A). When Pat was late, Jem began • Isn’t it true that sometimes Pat can be late and
thinking, ‘‘Pat doesn’t care enough about me to be that it’s really not all that awful—it doesn’t mean
home for dinner on time.’’ He also started imagining you’re not lovable, but instead it’s an inconvenient
Pat was romantically involved with someone else. behavior that sometimes happens to the best of
Jem found himself thinking over and over: ‘‘Pat couples?
doesn’t really love me and prefers to spend time
with someone else.’’ If all goes according to theory, Ellis’s disputa-
tion (D) of Jem’s irrational belief (and Jem’s own
Pat finally arrived home at 7:45 p.m. The subsequent and ongoing disputations of his irra-
explanation, ‘‘I was stuck in a meeting at work tional belief) will have an emotional effect (E) on
and couldn’t call because my cell phone battery was Jem. Hopefully, this effect will be the development
dead’’ didn’t convince Jem; his feelings continued of a set of alternative, rational beliefs. Finally, if
to escalate. He yelled at Pat for being so insensitive therapy is successful, Jem will experience a new
and then said, ‘‘I know what’s going on. You can’t feeling (F).
fool me. I’ve seen the way you look at that younger
man from your office.’’ QUESTIONS FOR REFLECTION

When Jem shows up for his appointment with In this example, Jem concluded that because Pat was
Dr. Ellis, the doctor says: ‘‘What the Hell. You can late that Pat’s having an affair. As he waits home
blame Pat for your problems if you want, but you’re alone at the dinner table, what other interpretations
the one making yourself miserable.’’ He spells out or beliefs could Jem use to explain Pat’s lateness?
the ABCs: Have you ever had a similar experience?

A. Jem’s Activating Event: Pat is late for dinner. Beck’s Cognitive Theory
The theoretical principles of Beck’s cognitive
B. Jem’s Belief: Pat doesn’t love or respect him therapy are similar to Ellis’s REBT. Similarities
anymore. Pat’s probably having an affair. include:

C. Jem’s Consequent Anger: sadness, hurt, resent- • Cognition is at the core of human suffering.
ment, and jealousy.
• The therapist’s job is to help clients modify
D. Feelings and Behavior: yelling and accusing Pat distress-producing thoughts.
of having an affair.
There are several distinctions between cognitive
The main thrust of REBT is to demonstrate therapy and REBT. Beck criticizes Ellis’s use of
to Jem that his current belief about Pat’s lateness
is irrational. Ellis referred to this as an irrational
belief (iB). The purpose of REBT is to substitute
a rational belief (rB) for an irrational belief
(iB), which will result in more positive and more
comfortable new feeling (F).

THEORETICAL PRINCIPLES 273

‘‘irrational’’ to describe the rules by which people his experiences in terms of whether he is
regulate their lives. For example, he stated: competent and adequate, his thinking may be
dominated by the schema, ‘‘Unless I do everything
Ellis (1962) refers to such rules as ‘‘irrational perfectly, I’m a failure.’’ Consequently, he reacts
ideas.’’ His term, while powerful, is not accurate. to situations in terms of adequacy even when they
The ideas are generally not irrational but are too are unrelated to whether or not he is personally
absolute, broad, and extreme; too highly competent. (Beck et al., 1979, p. 3)
personalized; and are used too arbitrarily to help
the patient to handle the exigencies of his life. To You may notice that Beck’s core beliefs sound
be of greater use, the rules need to be remolded so like Adler’s style of life. Automatic thoughts are also
that they are more precise and accurate, less very similar to basic mistakes (Schulman, 1985).
egocentric, and more elastic. (Beck, 1976, p. 33)
Beck’s cognitive theory also promotes a differ-
Beck’s cognitive theory includes the following ent procedure (than Ellis’s system) for modifying
five components: client thinking. Although both theorists empha-
sized teaching and learning, cognitive therapists use
1. Due to genetic predisposition, modeling by early a more temperate approach, collaborative empiri-
caregivers, and/or adverse life events, individuals cism, to help clients discover inaccurate or maladap-
develop negative and/or inaccurate beliefs about tive thoughts. Collaborative empiricism includes
themselves. three main components:

2. These deep beliefs about the self—also referred 1. Client and therapist work together collabora-
to as self-schema—lie dormant in the individual tively.
until they’re activated by stressful life events
or negative mood states, especially events and 2. The therapist employs Socratic questioning to
mood states that match or are consistent with uncover the client’s idiosyncratic and maladap-
the underlying belief or schema. tive cognitive rules or thinking patterns.

3. When these beliefs are activated, individuals 3. The therapist uses Socratic questioning and a
respond with automatic thoughts that are inac- variety of different techniques to help clients
curate or systematically distorted in line with the evaluate or test the validity or usefulness of their
underlying beliefs. automatic thoughts and core beliefs.

4. Repeated activation of underlying negative This approach requires therapists to try to see
beliefs results in biased information processing the world through the client’s eyes (Shaw & Beck,
and cognitive content consistent with specific 1977). It emphasizes that clients aren’t irrational or
mental disorders. defective but may need to adjust the lens through
which they’re viewing the world (A. T. Beck, Emery,
5. These automatic thoughts, core beliefs, and & Greenberg, 1985; Craske, 2010).
their associated emotional disturbances, can be
modified via cognitive therapy—a procedure that Meichenbaum’s Self-Instructional Theory
doesn’t require exploration of the past. (Adapted Meichenbaum’s cognitive self-instructional model
from J. S. Beck, 2005, p. 953) emphasizes internal speech or verbal mediation. He
stated that,
A. Beck provides an example of how his theory
plays out: [B]ehavior change occurs through a sequence of
mediating processes involving the interaction of
[C]ognitions (verbal and pictorial ‘‘events’’ in [the] inner speech, cognitive structures, and behaviors
stream of consciousness) are based on attitudes or and their resultant outcomes. (Meichenbaum,
assumptions (schemas), developed from previous 1977, p. 218)
experiences. For example, if a person interprets all

274 CHAPTER 8 COGNITIVE-BEHAVIORAL THEORY AND THERAPY

His model is a reciprocal one; it emphasizes an [E]very single time my clients talk about their
interactive relationship between the individual and depression, obsession, or compulsion, I can
the environment. quickly, when using RET, within a few minutes,
zero in on one, or two, or three of their major
Meichenbaum’s self-instructional model is one musts: ‘‘I must do well; you must treat me
small step removed from behavior therapy. He takes beautifully; the world must be easy.’’ I then show
inner speech or self-talk out of the client’s head and these clients that they have these musts and teach
brings it into the therapy office. Then he works with them to surrender them. Now, they have many
clients to develop more adaptive speech. Finally, he subheadings and variations on their musts but they
works with clients to internalize a newly learned all seem to be variations on a major theme, which I
and more adaptive way of talking to themselves. call ‘‘musterbation, absolutistic thinking or
dogma,’’ which, I hypothesize, is at the core of
Similar to REBT and cognitive therapy, self- human disturbance. (Ellis, 1987, p. 127)
instructional training focuses on patterns of
responding to stressful life events (e.g., activating Like Ellis, the REBT theory of psychopathology
events or emotional triggers). How clients handle is direct, straightforward, and sometimes offensive.
stressful events is addressed temporally. To further capture his perspective, another quo-
tation is pertinent: ‘‘I said many years ago, that
• Preparation: Inner speech that occurs before the masturbation is good and delicious, but musterba-
stressful situation. tion is evil and pernicious’’ (Ellis, 1987, p. 127).

• Coping: Inner speech that occurs during the Initially, Ellis compiled a list of 12 basic irrational
stressful situation. beliefs that caused emotional suffering. He later
added a 13th; other REBT writers have added
• Aftermath: Inner speech that occurs after the even more irrational beliefs. Ellis eventually decided
stressful situation. that all irrational beliefs could be boiled down to
the three basic beliefs, all of which connect to
When clients learn to give themselves helpful musterbation:
instructions before, during, and after stressful
events, the events are handled more smoothly and 1. I must do well and be approved by significant
competently. others, and if I don’t do as well as I should or
must, there’s something really rotten about
QUESTIONS FOR REFLECTION me. It’s terrible that I am this way and I am a
pretty worthless, rotten person. That irrational
Meichenbaum’s model emphasizes inner speech. Is his belief leads to feelings of depression, anxiety,
model compatible with Ellis’s and/or Beck’s? Where despair and self-doubting. It’s an ego must.
would you place Meichenbaum’s ongoing, coping- I have to do well or I’m no good.
oriented inner speech in Ellis’s ABC model and Beck’s
model? 2. ‘‘You other humans with whom I relate, my
original family, my later family that I may
Theory of Psychopathology have, my friends, my relatives, and people
with whom I work, must, ought, and should
In REBT, psychopathology is a direct function of treat me considerately and fairly and even
irrational beliefs. Ellis’s theory of psychopathology specially, considering what a doll I am! Isn’t
is largely consistent with Horney’s (1950) ‘‘tyranny it horrible that they don’t and they had better
of the shoulds.’’ Ellis described his views with his roast in hell for eternity!’’ That’s anger, that’s
usual flair: rage, that’s homicide, that’s genocide.

3. ‘‘Conditions under which I live—my environ-
ment, social conditions, economic conditions,
political conditions—must be arranged so that I

THE PRACTICE OF COGNITIVE-BEHAVIORAL THERAPY 275

easily and immediately, with no real effort, have Beck’s theoretical work on depression has had an
a free lunch, get what I command. Isn’t it hor- immense impact on the formulation and treatment
rible when those conditions are harsh and when of depressive disorders.
they frustrate me? I can’t stand it! I can’t be
happy at all under those awful conditions and From the perspective of self-instructional theory,
I can only be miserable or kill myself!’’ That’s psychopathology is a function of dysfunctional inner
low frustration tolerance. (Ellis, 1987, p. 126) speech. For example, individuals with anxiety tend
to engage in disturbing inner speech long before
Beck’s theory of psychopathology is similar to facing stressful situations. To prepare for difficult
Ellis’s. However, in contrast to focusing on three situations they’re likely saying very unhelpful things
basic irrational beliefs, Beck emphasizes cognitive to themselves (e.g., ‘‘Lions, tigers, and bears, oh
distortions or faulty assumptions and misconceptions. my!’’). Instead of engaging in coping self-talk
As described previously, these distortions, triggered during an incident, they’re likely in the midst of
by external or internal events (e.g., a romantic break- a self-critique that takes away from their ability
up or drug/endocrine reaction) produce automatic to focus on and deal with the situation. Finally,
thoughts, which are linked to core beliefs or after the incident ends, they’re probably talking to
schemas. Beck has defined seven different types themselves about how they’re an abject failure who
of cognitive distortions, some of which overlap will never be able to handle difficult tasks.
somewhat with one another and are similar to
Ellis’s irrational beliefs (Beck, 1976; Beck et al., THE PRACTICE OF
1979, 1985). Other authors have identified up to 17 COGNITIVE-BEHAVIORAL
different distorted thinking styles (D. Burns, 1989; THERAPY
Leahy, 2003). A list and description of some of the
most common and practical cognitive distortions Sometimes cognitive-behavioral therapy seems very
are in Table 8.2. simple. It’s as easy as 1, 2, 3:

Beck also theorized that specific automatic 1. Access clients’ irrational or maladaptive thoughts
thoughts and core beliefs were indicative of par- or dysfunctional inner speech.
ticular mental disorders (Beck, 1976). As a conse-
quence of his extensive research on depression, he 2. Instruct clients in more adaptive or more
identified a cognitive triad associated with depres- rational thinking and/or teach internal verbal
sive conditions. Beck’s negative cognitive triad instructional coping strategies.
consists of:
3. Support clients as they apply these new and
• Negative evaluation of self: ‘‘I am unworthy.’’ developing skills in their lives.

• Negative evaluation of the world or specific Unfortunately, cognitive therapy isn’t as easy
events: ‘‘Everything is just more evidence that as it appears. Whatever model you follow, you’ll
the world is falling apart.’’ need extensive training and supervision to achieve
competence. For example, in the now classic text
• Negative evaluation of the future: ‘‘Nothing will Cognitive Therapy of Depression, Beck and his col-
ever get better.’’ leagues included an 85-point checklist to measure
therapist competency (Beck et al., 1979).
To help make Beck’s cognitive triad clearer, we
like to present it as the adolescents with whom we CBT begins with the initial contact between
work express it: therapist and client. During this initial contact
cognitive-behavioral therapists focus on developing
• I suck. a positive therapy relationship and on educating

• The world sucks.

• Everything will always suck.

276 CHAPTER 8 COGNITIVE-BEHAVIORAL THEORY AND THERAPY

clients about CBT (a sample excerpt from a cog- Welcome to therapy. We have a number of items
nitive-behavioral informed consent is included in to take care of today, but there’s also flexibility.
Putting it in Practice 8.2). The first two items on my list are to go over the
consent form and then discuss confidentiality.
Assessment Issues and Procedures After that I’d like to do an interview with you,
focusing on the problems and symptoms that
According to Ledley, Marx, and Heimberg (2010) bring you to therapy. Finally, toward the end we
two primary goals are associated with CBT can talk about an initial plan for how we can best
assessment. address the problems we discuss today. How does
that sound to you?
1. Arriving at a diagnosis that best describes client
symptoms. Depending on the cognitive-behavioral thera-
pist’s style and preference a more formal structured
2. Developing a tentative cognitive-behavioral clinical interview might be used (e.g., the Struc-
treatment formulation that can be used for treat- tured Clinical Interview for DSM-IV ; SCID-IV;
ment planning. (p. 40) First, Spitzer, Gibbon, & Williams, 1997) or a less
formal interview loosely focused on generating a
To accomplish these goals, cognitive-behavioral problem list could be initiated.
therapists employ various assessment strategies.
These strategies include collaborative interviewing, The Problem List
setting an agenda, developing an initial problem A central assessment task is to establish a clear and
list, self-rating scales, cognitive-behavioral self- comprehensive problem list. Items on the problem
monitoring, and case formulation. list should be described in simple, descriptive,
concrete terms. Persons and Tompkins (1997)
Collaborative Interviewing recommend including about five to eight items on
In contrast to other theoretical orientations, some a problem list. For example, Susanna, a 25-year-old
CBT practitioners consider the therapy relationship female, generated the following problem list during
secondary. This is partly because CBT is focused on a collaborative interview:
remediation of client problems and partly because
existing research on whether the therapeutic alliance 1. Depressive thoughts. Susanna reports depressive
contributes to positive outcomes is mixed (Kazdin, thoughts. She believes she is a worthless loser
2007). Overall, some cognitive-behavioral thera- (negative evaluation of self ), that the world is a
pists are more focused on developing a positive rotten place (negative evaluation of the world),
therapy relationship (Hardy, Cahill, & Barkham, and that her life will continue to be miserable
2007) and others consider the therapy relationship (negative evaluation of the future).
as less important (Craske, 2010).
2. Social isolation. She is greatly dissatisfied with her
Cognitive-behavioral therapists universally em- social life. She has social contact outside of her
phasize collaboration. The therapist is not the workplace only once weekly or less.
expert on whom all therapy success depends.
Instead, expertise is achieved when the client and 3. Procrastination and lack of self-discipline. She strug-
therapist join together, using collaborative empiri- gles with timely payment of bills, keeping her
cism to guide assessment and treatment. house clean, personal hygiene, and organization.

Setting an Agenda 4. Internet preoccupation. She spends many hours
CBT is agenda-driven. The norm is to set an agenda a day on the Internet. She reports enjoying
in the first few minutes. During an initial session the this, but that her Internet activity increases
therapist might begin with an organizing statement: markedly when she needs to pay bills, has a
social opportunity, or is facing deadlines.

THE PRACTICE OF COGNITIVE-BEHAVIORAL THERAPY 277

PUTTING IT IN PRACTICE 8.2

A Cognitive-Behavioral Informed Consent

I specialize in cognitive-behavioral therapy. Cognitive-behavioral therapy (or CBT for
short) has more scientific research supporting its effectiveness than any other therapy
approach.

CBT is an active, problem-focused approach to helping you improve your life. There
are several important and unique parts of CBT.

CBT is collaborative: When many people think of therapy they sometimes think they’ll
be coming to see an all-knowing therapist who will make pronouncements about the
causes of their problems. That’s not the way CBT works. Instead, because you’re the best
expert on what’s going on in your life, we’ll work together to develop ideas and plans for
how to reduce whatever symptoms or troubles you’re having.

CBT is educational: As we work together, I’ll share with you essential information
about how thinking and behavior patterns effect emotions. This doesn’t mean I’ll be
lecturing you; instead, I’ll offer demonstrations about the ways in which situations,
thoughts, behaviors, and emotions affect each other.

CBT is time-limited and active: Research shows that CBT is most effective when we
work together actively to address the problems in your life. This means there will be
homework and I’ll act as both coach and cheerleader in helping you face your problems
and complete your homework.

CBT focuses on current thoughts and behaviors: Most people develop problems due
to events that happened during childhood or due to traumatic experiences. Even though
the cause of your problems is important, we’ll spend most our time talking about what’s
happening right now in your life.

CBT is not for everyone: Although CBT has more scientific evidence behind it than
any other treatment approach, it’s not a perfect therapy for everyone. You may have
uncomfortable reactions to some parts of CBT. When this happens I want you to tell
me and hopefully we can work it through. Therapy isn’t always comfortable and I’ll be
encouraging you to face and deal with the problems that are blocking you from what you
want in life. However, if you have strong cultural or personal values that don’t fit well
with CBT we should talk and I can try to connect you with a professional who will offer
you the treatment you want.

I look forward to working with you to solve your problems. Please feel free to ask me
questions at any time. My goal is for us to work together to achieve your treatment goals.

278 CHAPTER 8 COGNITIVE-BEHAVIORAL THEORY AND THERAPY

5. Lack of academic progress. She would like to finish Self-Rating Scales
her bachelor’s degree, but after enrolling quits At the beginning and throughout therapy, cog-
attending class. nitive-behavioral therapists make liberal use of
self-rating scales. For example, Beck developed
6. Disrupted sleep patterns. She reports difficulty the widely used Beck Depression Inventory (BDI) to
sleeping, which she sees as related to problems evaluate and monitor depression during treatment
with procrastination. (A. T. Beck, Ward, Mendelson, Mock, & Erbaugh,
1961). Empirically minded therapists often have
Generating a problem list is helpful in several their clients complete the BDI at the beginning
ways. First, it gives therapists a chance to show of each session. Similar rating scales that cognitive
interest in and compassion for client problems. therapists frequently use include the Beck Anxiety
Second, as clients describe their problems, cognitive Inventory (A. T. Beck, Epstein, Brown, & Steer,
and behavioral antecedents and consequences are 1988), the Penn State Worry Questionnaire (Meyer,
identified and initial hypotheses about client core Miller, Metzger, & Borkovec, 1990), and the
beliefs can be generated. Third, as therapists utilize Children’s Depression Inventory (Kovacs, 1992).
Socratic questioning to explore problems, clients
become oriented to the CBT process. Cognitive-Behavioral Self-Monitoring
Cognitive-behavioral self-monitoring is effective
Greenberger and Padesky (1995) provided spe- for helping clients develop awareness of auto-
cific examples of questions to use when exploring matic thoughts and associated emotions and behav-
client problems. These questions help elucidate the iors. Cognitive-behavioral self-monitoring and the
client’s cognitive world: exploration of maladaptive or irrational thoughts
begin within therapy sessions, but self-monitoring
• What was going through your mind just before homework is also very important (D. D. Burns &
you started to feel this way? Spangler, 2000).

• What does this say about you? Several cognitive-behavioral self-monitoring
procedures are available. Persons (1989) recom-
• What does this mean about you . . . your life . . . mended using a generic ‘‘thought record.’’ To use a
your future? thought record, clients are instructed to jot down
the following basic information immediately after
• What are you afraid might happen? experiencing a strong emotional response:

• What is the worst thing that could happen if this • Date and time of the emotional response.
were true?
• Situation that elicited the emotional response.
• What does this mean about the other person(s) or
people in general? • Behaviors the client engaged in.

• Do you have images or memories in this situation? • Emotions that were elicited.
If so, what are they? (Greenberger & Padesky,
1995, p. 36) • Associated thoughts that occurred during the
situation.
In Susanna’s case, she reported feeling like ‘‘a
loser’’ who had ‘‘no willpower’’ and who had • Any other related responses.
always ‘‘been a miserable failure at initiating social
relationships.’’ She also thought others were cri- The client’s thought record provides a founda-
tiquing her inadequacies. These core beliefs became tion for cognitive interventions. Beck and colleagues
the main target for change in her therapy.

THE PRACTICE OF COGNITIVE-BEHAVIORAL THERAPY 279

Table 8.1 Thought Record Sample

Situation Emotion Automatic Cognitive Rational response Outcome/new
thoughts distortion feeling

Briefly describe Specify and rate State the Classify the Replace the automatic Rate the feelings
the situation the emotion automatic cognitive thought with a more again to see if
linked to the (Sad, Anxious, thought that distortion rational (or adaptive) the rational
unpleasant Angry) on a accompanied present within response response
feelings 0–100 scale the emotion the automatic modified them
thought
Home alone on Sad: 85 ‘‘I’m always alone. Being home on Saturday Sad: 45
Saturday No one will ever Dichotomous night is better than
night love me. No one thinking and being with someone I
will ever want catastrophizing don’t like. Just
to be with me.’’ because I’m not in a
relationship now
doesn’t mean I’ll never
be in one.

(Beck et al., 1979), and other cognitive authors treatment. Although manualized treatments are
(Burns, 1989), recommend transforming generic available, rarely do clients in the real world
thought records into more specific theory-based present with an uncomplicated single disorder (Per-
tools by having clients use the language of auto- sons, 2008). A case formulation helps practitioners
matic thoughts, cognitive distortions, and ratio- develop a treatment plan that comprehensively
nal responses. Table 8.1 provides a sample of addresses individual client issues.
an expanded thought record. Therapists operating
from an REBT perspective would use the A-B-C- Persons (2008) described four key elements for
D-E-F model articulated by Ellis (1999a). cognitive-behavioral case formulation:

QUESTIONS FOR REFLECTION 1. Creating a problem list.

If you were a client, can you imagine using a three- 2. Identifying mechanisms underlying or causing
column cognitive self-monitoring log or Thought disorders and problems.
Record on a regular basis? What might stop you from
using this sort of assessment procedure on yourself? 3. Identifying precipitants activating current client
What would motivate you to use a Thought Record? problems.

Case Formulation 4. Consideration of the origins of the client’s
In CBT, case formulation (aka case conceptual- current problems.
ization) is an essential bridge from assessment to
You may be surprised to see a CBT problem
formulation that includes ‘‘consideration of the
origins of the client’s current problems.’’ Consistent
with Beck’s original work, cognitive therapists
are open to talking about the past—even though
the past is not a primary focus. The purpose of

280 CHAPTER 8 COGNITIVE-BEHAVIORAL THEORY AND THERAPY

considering the past is twofold: First, clients often Therapist: Perfect. So you’ve demonstrated that
believe that talking about the past is important, so it’s not the thud that produces your emotional
allowing some past discussion can facilitate rapport. reaction, but what you think about the thud.
Second, glimpsing the origins of a problem can Tell me, when you first said you’d probably be
give therapists greater insight into the thoughts and scared in reaction to the thud, what thoughts
behaviors that are maintaining the problem in the went through your mind that would lead to that
present. feeling?

Psychoeducation Client: I thought you were suggesting that the thud
meant that a burglar had broken into my house,
Psychoeducation is an essential CBT component and then of course I’d be scared.
( J. S. Beck, 2005; Leahy, 2004). Most clients don’t
enter treatment with much knowledge about the Therapist: Exactly. In the absence of information
nature of their problems. Just as physicians edu- about what caused the thud, you inserted the
cate patients about medical rationale, problems, and possibility of a burglar, and that would, of course,
procedures, cognitive-behavioral therapists educate produce fear. But if you think it’s a pesky dog,
their clients about the psychological (CBT) ratio- then you feel annoyed. And how about if your
nale, problems, and procedures. grandmother was staying at your house and you
heard an unusual thud, what might come to mind
Psychoeducation for CBT Rationale then?
It’s generally recommended that cognitive-
behavioral therapists educate clients, but lecturing Client: I’d feel scared that she might have hurt
is not desirable (Ledley et al., 2010). Instead, many herself. I’d get right up and go check on her.
therapists use stories, demonstrations, and life
examples to illustrate CBT rationale (Freeman, Therapist: So now you’re telling me that what you
Pretzer, Fleming, & Simon, 2004). We sometimes think not only directly affects your emotions, but
use a ‘‘bump in the night’’ scenario to initiate a also your behavior, because if you thought it was
discussion of how cognition can influence emotion. a burglar then you probably wouldn’t jump up
and check, you’d do something different, right?
Therapist: I know it’s hard to believe that what you
think has such a big influence on your emotions, Client: I’d hide under the covers in my bed!
but it’s true. Let me give you an example.
Therapist: And I suppose that might work, but my
Client: Okay. point is that it’s not the thud or what happens to
you that produces your emotions and behavior,
Therapist: Let’s say you’re lying in bed at night, it’s what you’re thinking about a situation. It’s
trying to go to sleep, and suddenly, out of your assumption or belief about the situation that
nowhere, you hear a thud somewhere in your causes you to feel and act in particular ways.
house. What would you feel?
Client: I see what you mean.
Client: I’d probably be scared.
In this example the therapist used Socratic
Therapist: Okay, so the first thing that comes to questioning and dialogue to educate the client about
mind is that you’d feel scared. How about if you the cognitive theory of emotional disturbance.
were taking care of a very pesky dog for a friend
of yours, how would you feel then? Psychoeducation About Client Problems
J. Beck (2005) provides an example of using psy-
Client: Well, if I knew it was the dog being pesky, choeducation to discuss the problem of depression.
then I’d feel annoyed. I’d feel irritated that the
dog was making noise while I’m trying to sleep. Therapist: You know, these are all important
questions you have, essential questions. And I
think therapy can help you figure out some