BEHAVIOR THERAPY
Slides created by
Barbara A. Cubic, Ph.D.Professor
Eastern Virginia Medical School
To accompany
Current Psychotherapies 10
Learning Objectives This presentation will focus on:
• Overview of behavior therapy• Principles of learning and cognitive
theory relevant to psychotherapy• History of behavior therapy• Applications of behavior therapy• Review of behavioral techniques
Basic Concepts
Behavioral therapy (blends with CBT and REBT) integrates the behavioral techniques derived from principles of learning and cognitive restructuring techniques based on cognitive theories.
Features of Behavior Therapy
Focuses on changing behavior. Rooted in empiricism. Assumes behaviors have a function. Emphasizes maintaining factors rather
than factors that may have initially triggered a problem.
Features of Behavioral TherapyFeatures of Behavioral Therapy
Empirically supported Active Transparent
Comparing Behavior Therapy to Other Approaches
Most Different Most Similar
Psychoanalytic REBT
Client-Centered Multimodal
Cognitive
Behavior Therapy and Psychoanalytic Approaches
Includes family members as needed. Does not create symptom substitution
as predicted. More broadly applicable than most
therapies. Empirical studies generally show it to
be more effective. Treatment of choice for phobias, OCD,
sexual dysfunction and many childhood disorders.
History of Behavioral Therapy
Early Examples Pliny the Elder, over 2,000 years ago,
used spiders at the bottom of a glass to treat alcoholism.• Aversion therapy
Victor of Aveyron (Wild Boy of Aveyron) treated by Jean-Marc-Gaspard Itard (1962).• Used strategies of modeling, shaping,
and reinforcement.
Ivan Pavlov Russian physiologist
completed classical conditioning experiments.
Paired two stimuli so that a neutral stimulus (e.g., a light or bell) signaled occurrence of a second non-neutral stimulus (e.g., food or shock).
John B. Watson Credited as the founder of
behaviorism. Believed only observable behaviors
should be the focus of psychology. With Rayner, conducted a classic
experiment in which an infant (Little Albert) learned to fear a white rat after the presence of the rat was paired with a loud noise.
Other Early Key Players Mary Cover Jones
• Used a combination of modeling and exposure to treat a boy with rabbit phobia.
Mowrer & Mowrer • Used classical conditioning principles to
treat childhood bed-wetting (bell and pad).
E. L. Thorndike • First to describe operant conditioning.
Operant/Instrumental Conditioning (B.F. Skinner)
A response is emitted — perhaps randomly at first — and results in consequences.
Hence, the probability of the response’s future occurrence is changed.
Systematic Desensitization(graduated exposure therapy)
Used to treat phobias and anxiety disorders.
Developed by Joseph Wolpe.
The process is as follows:• Patient taught relaxation
skills in order to control fear.
• Hierarchy of fears created.• Patient learns to cope and
overcome the fear in each step of the hierarchy.
Social-Cognitive Theory(Albert Bandura)
Interconnection between stimulus, reinforcement and cognition.
Critical role of vicarious learning, cognitions, self regulation and expectations.
Person is seen as the agent for change.
Self efficacy seen as a critical variable.
Behavior Therapy Practical, here-and-now, experiential
emphasis. Techniques can be adapted to meet
the developmental level of the patient. Action-oriented, which matches fact
that children learn by doing. Incorporates rewards, which helps
engage the patient.
THEORY OF PERSONALITY
Behavior Therapy’s View of Personality
Historically, behaviorists saw behavior as Historically, behaviorists saw behavior as situation-specific/rejected trait theories.situation-specific/rejected trait theories.• But strict behavioral view is not strongly But strict behavioral view is not strongly
supported by research.supported by research. Strong evidence supports the notion of Strong evidence supports the notion of
individual temperaments.individual temperaments. Now, most behavior therapists Now, most behavior therapists
acknowledge temperament affects acknowledge temperament affects behavior.behavior.
Behaviorists also recognize behavior varies Behaviorists also recognize behavior varies across situations.across situations.
Costa and McCrae’s (1992) Big Five Model Currently most influential approach to
describing core domains of personality:• Openness• Conscientiousness • Extraversion• Agreeableness• Neuroticism
Broad factors assumed to be clusters of narrowly focused traits.
Basic Basic Principles of Principles of
Learning Learning
Learning
A relatively permanent change in behavior, not due to fatigue, drugs, or maturation.
Classical ConditioningPavlov’s Study
• Food is presented to the dog and the dog salivates; no learning involved.
• A neutral stimulus is presented to the dog (a tone); the dog does not salivate.
• The tone is presented simultaneously with the food; the dog salivates.
• Then, the tone is presented alone and the dog salivates; learning has occurred.
Classical Conditioning
UCS UCRUCS UCRUnconditional Stimulus Unconditioned Response
(sight of food) (salivation)
CS CRCS CRConditioned Stimulus Conditioned Response
(tone) (salivation)
Why Would a Dog Salivate to a Bell?
The UCS and CS are repeatedly paired together until the UCR is elicited by the CS.
In other words, the CS elicits the same behavior and is now termed the CR.
Would the Dog Salivate to Other Sounds?MaybeMaybe If stimulus generalization occurs,
the dog responds to related stimuli with the same or similar response.
If stimulus discrimination occurs, the dog does not respond.
ExtinctionExtinction After learning has occurred,
removing the UCS ultimately results in a decreased probability that the CR will be made. This is because the dog learns that
the bell no longer means food will follow.
Spontaneous Recovery After a time delay, if the stimulus
is represented, the CR will reoccur. This behavior will extinguish rapidly
if the UCS does not follow quickly.
Examples of How This is Related to Mental Health
Related to acquisition of maladaptive physiological responses. Relaxation response to nicotine use. Eating paired with stimuli that are not
hunger related. Acquisition of phobias such as
fainting at the sight of blood.
Reinforcement A reinforcer is defined by its
effects. Any stimulus is a reinforcer if it
increases the probability of a response.
A punisher is defined by its effects.
Any stimulus is a punisher if it decreases the probability of a response.
PunishmentPunishment
Helpful Hint In behavioral terms, “positive”
and “negative” are used differently than in general language.• Positive = Add • Negative = Take Away
Operant LearningOperant Learning Add Stimulus Remove Add Stimulus Remove
StimulusStimulusBehavior to increase
Positive Reinforcement
Negative Reinforcement
Behavior to decrease
Positive Punishment
Negative Punishment
Continuous Reinforcement Every response is followed by a
reinforcement, resulting in fast learning (acquisition).• Also results in fast extinction.
Intermittent (or Partial) Reinforcement
Not every response is reinforced, but this ultimately yields a stronger response.
Fixed Ratio Schedule Delivers reinforcement after a
fixed number of responses and produces high response rate.• Example: Commission work
Fixed Interval Schedule
Reinforces the next response that occurs after a fixed period of time elapses.• Example: Scheduled exam
Variable Interval Schedule Deliver reinforcements after
unpredictable time periods.• Example: Pop quizzes or fishing
Variable Ratio Schedule
Yields the highest rates of response and greatest resistance to extinction.• Example: Gambling
Behavioral Effect of the Reinforcement Schedules
Schedule EffectFixed ratio Relatively fast rate of response.
Fixed interval Response rate drops to almost zero after reward; picks up rapidly before next reward.
Variable Slow, steady response.
interval
Variable ratio Constant high rate of response; may be hardest behavior to break.
Secondary Reinforcement A symbol or a token gains
reinforcement value due to its association with a real reinforcer.• Example: Dollar bill
Reset Function Sometimes one error eliminates
any accumulated responses. i.e., Errors mean restart at baseline.
Reset functions are typical in skill building.
Impact is more cautious behavior and more frustration when errors are made as behavior proceeds.• Example: House of cards
Would the Dog Salivate to Other Sounds? Generalization:
• Occurrence of a learned behavior in situations other than those where the behavior was acquired.
Discrimination learning:• Response is reinforced or punished
in one situation but not in another.
Extinction
A behavior that stops occurring because it is no longer followed by a positive consequence.• Example: Children learn to stop
throwing tantrums when the tantrums are no longer reinforced.
How is This Related to Mental Health?
Reinforcing adherence Designing interventions carefully
to be initially successful (small changes)
Premack principle Using secondary reinforcers Involving the family
Vicarious Learning (Modeling)
Learning that occurs through observation.
Particularly relevant to children, but applies to all ages.
By observing a model, one grasps entire behaviors as well as component parts.
May remain dormant until a situation warrants expression of the learned behavior.
How is This Related to Mental Health?
Modeling is an effective technique for treating dental and medical phobias.
Clinicians are viewed as role models; therefore, patients may learn more from observation than words.
Related to why support groups are effective.
Helps in understanding why so many problems are intergenerational.
Rule-Governed Behavior
Contingencies learned indirectly through information heard or read.• A person learns to look both ways
before crossing the street because of comments made by their parents.
• A person develops a strong dislike of another individual based on gossip.
Therapeutic Process
A strong therapeutic relationship is important in behavior therapy.
Self-help approaches are more effective when therapist-administered.
Ambivalence about treatment can be addressed with motivational interviewing.• A client-centered approach designed to
help clients explore and resolve sources of ambivalence about therapy.
Format and Structure of BT Quite diverse Behavioral interventions can be
offered by therapists and many others (teachers, parents, physicians).
Sessions vary in length based on interventions.
Generally 10-20 sessions max.
Ethical Issues in BT Misconception that behavior therapy Misconception that behavior therapy
is coercive.is coercive.• Therapists must be aware of their potential
influence on the client.• Only make recommendations that are in the
client’s best interests.
Importance of shared goalsImportance of shared goals BT often involves activities outside BT often involves activities outside
of the office.of the office.• Confidentiality in public places must be Confidentiality in public places must be
maintained.maintained.
Some Areas Where Behavior Some Areas Where Behavior Therapy Has Proven EfficacyTherapy Has Proven Efficacy
Anxiety disorders• Phobias, panic disorder, OCD, PTSD
Depression Marital problems Behavioral medicine Childhood disorders
• Behavioral problems, hyperactivity, autism, enuresis
Substance use Eating disorders Schizophrenia
Efficacy and effectiveness of behavior therapy has been studied more intensively than in any other form of psychological treatment.
TREATMENT APPROACHES
Behavioral Assessment Identify goals for change. Operationalize the behavior and
thoughts. Separate traits from behaviors.
• Distinguish overt from covert behaviors.
• Obtain a baseline. Complete a functional analysis.
Sample Functional Analysis
AAntecedent
BBehavior
CConsequence
Job stress
Driving car
Watching TV
Anxiety
Smoke a cigarette
Satisfaction
Relaxation/calm
Lung diseases
Cardiac illnesses
Discoloration of teeth/skin
Treatment Planning
Establish target behaviors to change.Establish target behaviors to change.• Behaviors to increase and to decrease.Behaviors to increase and to decrease.• Behaviors should be small, discrete, and Behaviors should be small, discrete, and
chosen based on severity, immediacy, chosen based on severity, immediacy, centrality and potential for success.centrality and potential for success.
Develop a behavioral contract with Develop a behavioral contract with goals and rewards.goals and rewards.
Problem-solve about possible Problem-solve about possible obstacles.obstacles.
Periodically reevaluate.Periodically reevaluate.
Behavior Therapy Treatment Techniques
Behavioral activation Exposure-based
• Invivo• Imaginal• Interoceptive
Response prevention Operant-conditioning strategies
• Applied behavior analysis
Reinforcement-based strategies• Differential reinforcement• Contingency management
Behavior Therapy Treatment Techniques
Punishment-based strategies• Aversive conditioning
Physiological monitoring Role-playing Self-monitoring Behavioral observation Cognitive restructuring (see Chapter 7) Assertiveness training Social skills training Stimulus control techniques
Relaxation TechniquesDiaphragmatic breathingBreath-focusing exercisesMini-relaxationsMind focusingCoupling breathing and imaginationProgressive muscle relaxationRepetitive motionSelf-hypnosisVisualization
Required Elements for the Relaxation Response
1. A quiet, calm environment with as few distractions as possible.
2. A mental device to prevent “mind-wandering.”
3. A passive, “let-it-happen” attitude.
4. A comfortable position to prevent muscular tension.
Breathing Awareness Close your eyes. Put your right hand
on your abdomen, right at the waistline, and put your left hand on your chest, right in the center.
Without trying to change your breathing, simply notice how you are breathing. Which hand rises the most as you inhale – the hand on your chest or the hand on your belly?
If your chest moves up and down with each breath, you need to learn how to breathe from your diaphragm (abdomen).
Diaphragmatic Breathing Find a comfortable place to sit or lie on
your back. Place your hands just below your belly
button. Close your eyes and imagine a balloon
inside your abdomen. Visualize the balloon. What color is it?
Each time you breathe in, imagine the balloon filling up with air.
Each time you breathe out, imagine the balloon collapsing.
Breath Counting Sit or lie in a comfortable position with your
arms and legs uncrossed and your spine straight.
Breathe in deeply into your abdomen. Let yourself pause before you exhale.
As you exhale, count “one” to yourself. As you continue to inhale and exhale count each exhalation: “two…three…four…”
Continue counting your exhalations in sets of four for 5-10 minutes.
Notice your breathing gradually slowing, your body relaxing, and your mind calming as you practice this breathing meditation.
Relaxing Sigh Sit or stand up straight. Sigh deeply, letting out a sound of deep
relief as the air rushes out of your lungs.
Don’t think about inhaling, just let the air come in naturally.
Take 8-12 of these relaxing sighs and let yourself experience the feeling of relaxation. Repeat whenever you feel the need for it.
Letting Go of Tension Sit comfortably in a chair with your feet on
the floor. Breathe deeply into your abdomen and say to
yourself, “Breathe in relaxation.” Let yourself pause before you exhale.
Breathe out from your abdomen and say to yourself, “Breathe out tension.” Pause before you inhale.
Use each inhalation as a moment to become aware of any tension in your body.
Use each exhalation as an opportunity to let go of tension.
You may find it helpful to use your imagination to picture or feel the relaxation entering and the tension leaving your body.
Progressive Muscle Relaxation PMR is based on the premise that the
body responds to anxiety-provoking thoughts and events with muscle tension.• This tension then increases the subjective
experience of anxiety. Deep muscle relaxation reduces
physiological tension and is incompatible with anxiety.
Each muscle or muscle group is tensed for 5-10 seconds and then relaxed for 20-30 seconds.
Visualization Loosen your clothing, lie down in a quiet
place, and close your eyes. Scan your body, seeking tension in specific
muscles and relaxing as much as you can. Form mental sense impressions. Imagine not
only walking on the beach, but also the sound of the ocean and the feel of the sand on your feet.
Use affirmations. Repeat positive statements such as “I am letting go of tension.”
Practice is easiest in the morning and night while lying in bed.
Problem-Solving Training
Define the problem Identifying possible solutions Evaluate the solutions Choose the best solution Implementation
Third Wave Therapies
Dialectical behavior therapy (DBT)
Acceptance and commitment therapy (ACT)
Dialectical Behavior Therapy Acceptance and change Mindfulness:
• Observe or attend to emotions without trying to terminate painful ones.
• Describe a thought or emotion.• Be nonjudgmental.• Stay in the present.• Focus on one thing at a time.
Acceptance and Acceptance and Commitment Therapy Commitment Therapy
Experiental avoidance Acceptance Cognitive defusion Commitment
Compared to Cognitive Therapy Compared to Cognitive Therapy
“Third Wave” approaches emphasize acceptance.• CT challenges beliefs.
Behaviorists focus on the functions of cognitions.• CT focuses on the cognitive content.
APA-Division 12 ESTs Behavioral treatments dominate the list
of empirically-supported treatments. The case for behavioral and CBT
treatments is more developed than the case for any other form of psychotherapy.
National Institute of Clinical Excellence (NICE)
Behavior therapy treatments are typically rated an A
A = Strong empirical support from well-controlled RCTsC = Expert opinion with strong empirical dataF = No evidence
Taking an Empirical Approach in the Therapy Office
Awareness of one’s biases about clients and their problems.
Awareness of one’s biases about treatment.
Collect data throughout the course of therapy to test out assumptions about the variables that maintain a client’s problems.
Collect data over the course of treatment to evaluate outcomes.
BT and a Multicultural World
Core principles/methods underlying BT assumed to be universal, applicable across cultures and species.
BT must find ways to encourage clients to use methods that may not fit with their cultural assumptions and beliefs.
Research on treating individuals across diverse groups with BT early in its development.