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.