C. W. Lejuez & Derek Hopko - The Therapeutic Alliance in Behavior Therapy

THE THERAPEUTIC ALLIANCE IN BEHAVIOR THERAPY

C. W. LEJUEZUniversity of Maryland

DEREK R. HOPKOUniversity of Tennessee

SAMANTHA LEVINE, RADHA GHOLKAR, AND LINDSAY M. COLLINSUniversity of Maryland

It may be argued that behavior therapyhas proceeded with minimal regard forthe therapeutic alliance (TA) as a keymechanism of change. However, ignor-ing the role of TA in behavior therapymay not only be problematic on a prac-tical level, but also may be inconsistentwith basic principles that underlie be-havior therapy. In beginning to addressthese issues, the authors consider therole of TA in behavior therapy with afocus on relevant basic principles.Keeping a focus on these basic princi-ples, the authors then outline three con-temporary behavior therapies that al-ready incorporate a focus on thetherapeutic relationship and concludewith a clinical case illustration.

Keywords: reinforcement and punish-ment, establishing operations, shaping,and fading

A positive therapeutic alliance (TA), or “work-ing alliance,” refers to the collaborative, mutuallyrespectful, caring partnership that characterizes a

productive patient–therapist relationship (Hor-vath, 2001). Although TA may be considered asone element of the overall therapeutic relation-ship along with transference-countertransferenceconfiguration and the “real” relationship, Gelsoand Carter (1994) suggest it may be the mostfundamental if therapy is to proceed effectivelyor at all. As defined by Bordin (1979), TA is atripartite concept encompassing the bond be-tween therapist and patient and the subsequentagreement on the goals of therapy and the tasksthat will enable the achievement of those goals.TA has been shown to be a significant predictorof treatment success and may be a commonmechanism of change underlying psychotherapyinterventions (Horvath & Luborsky, 1993).Whereas TA is a defining feature of psychody-namic and humanistic/experiential approaches(see Horvath & Luborsky, 1993 for a detailedhistorical account), its role in behavior therapyhas been less clearly explicated. With notableexceptions (Brown & O’Leary, 2000; Hyer,Kramer, & Sohnle, 2004; Klein et al., 2003),behavior therapists traditionally have assumedthat specific therapy techniques largely accountfor treatment outcome variance and that thetherapist-patient relationship generally is a “neu-tral stimulus” that has minimal relevance towardassessing treatment efficacy (cf. Kohlenberg,2000). However, it could be argued that ignoringthe role of TA in behavior therapy may not onlybe problematic on a practical level, but also maybe inconsistent with basic principles that underliebehavior therapy (Kohlenberg, 1999; Raue,Goldfried, & Barkham, 1997). We begin to ad-dress these issues by considering the role of TAin behavior therapy with a focus on relevant basicprinciples. We then outline three contemporarybehavior therapies that already incorporate a fo-cus on TA, and we conclude with a clinical caseillustration.

C. W. Lejuez, Department of Psychology, University ofMarland; Derek R. Hopko, Department of Psychology, Uni-versity of Tennessee; Samantha Levine, Radha Gholkar, andLindsay M. Collins, Department of Psychology, University ofMaryland.

The authors thank Kim Gratz and Matthew Tull for com-ments on a draft of this article.

Correspondence concerning this article should be ad-dressed to C. W. Lejuez, Department of Psychology, Univer-sity of Maryland, College Park, MD 20742. E-mail: [email protected]

Psychotherapy: Theory, Research, Practice, Training Copyright 2006 by the Educational Publishing Foundation2006, Vol. 42, No. 4, 456–468 0033-3204/06/$12.00 DOI: 10.1037/0033-3204.42.4.456

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Reinforcement, Punishment, andEstablishing Operations

The principles of reinforcement and punish-ment are the core of behavior therapy. Defining areinforcer as a stimulus that leads to an increasein a particular target behavior and a punisher as astimulus that leads to a decrease in a particulartarget behavior, the concepts of reinforcementand punishment allow for the functional analysisof behavior, including a focus on what motivatesa patient toward pursuing and continuing psycho-therapy. One key feature of this framework is thata particular stimulus will not serve as a reinforceror punisher across all individuals or even neces-sarily within individuals across situations. In thismanner, focusing interventions to address idio-graphic and contextual variables is crucial. In-deed, making efforts toward understanding thepatient’s particular unique environmental experi-ences not only increases the likelihood of identi-fying functional reinforcers or punishers withinparticular contexts, but also demonstrates empa-thy and understanding that can enhance therapeu-tic alliance.

When considering reinforcement and punish-ment, it is important to determine exactly whatcauses a particular stimulus to serve as a rein-forcer or punisher in a given situation, or stateddifferently, what motivates behavior. Althoughthe term motivation may not be a well-referencedconcept in the behaviorist’s lexicon, the notion ofestablishing operations serves as the operational-ization of motivation. In this way, establishingoperations may be defined as environmentalevents, operations, or stimulus conditions thataffect an organism’s behavior by altering thereinforcing or punishing effectiveness of otherenvironmental events and the frequency of occur-rence of that part of the organism’s repertoirerelevant to those events as consequences (Lar-away, Snycerski, Michael, & Poling, 2003). It isimpossible to account for the multitude of factorsthat influence a patient’s behavior, but efforts toconsider a patient’s current environment and pastexperiences may help the therapist more produc-tively use the concepts of reinforcement and pun-ishment in the development of TA and subse-quent application of treatment interventions.

One final issue to consider regarding punish-ment is that it should not be used in isolationfrom more positive contingency managementprocesses. For example, imagine a patient who

often behaves unproductively in therapy, perhapsusing tangential speech patterns that are irrele-vant to primary treatment goals. The therapistmay decide to punish such behavior through ex-tinction or mild verbal reprimand. However, do-ing so without understanding the particular func-tion of this behavior, and without providing thepatient with alternative strategies to address thesame function, may suppress the particular un-wanted verbal behavior but likely will have littleeffect on the initial motivation to engage in thebehavior and may simply result in the creation ofother distracting behaviors (i.e., symptom substi-tution). Thus, providing the patient with an op-portunity in therapy to address and replace prob-lematic behavior patterns with more effective andadaptive behaviors will not only improve therelationship between the patient and therapist, butalso provide useful practice for situations outsideof therapy.

Shaping

The principle of shaping involves the genera-tion of a desired target behavior through rein-forcement of successive approximations of thetarget behavior. Shaping is perhaps most oftenconsidered with reference to basic animal re-search (Mills, 2003). Much as animals may betrained to develop particular behaviors via shap-ing processes, there are a multitude of studiesdemonstrating the impact of shaping on the de-velopment of abnormal behavior as well as stud-ies supporting the effectiveness of shaping as anapplied clinical procedure (Delprato, 2001; Hall,2004; Marks, 2002; Ullrich, 1993). As a clinicalexample of shaping, consider a substance-dependent patient who has now become soberand must tackle the daunting task of getting fi-nances in order. Above the refrigerator sits a boxof bills dating back several months, some ofwhich the patient does not currently have themoney to pay. Of course, in the real world, thetarget response would be opening bills when theyarrive and paying them prior to the due date. Ifthis ultimate target response is not attainable forthis individual at the current time, however, ab-breviated responses are first necessary. In doingso, shaping would suggest the therapist assigneach step for subsequent sessions, giving praisefor each weekly success and providing problemsolving when a step is not successfully com-pleted. In this situation an initial behavioral ap-

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proach might involve several clearly differentia-ble steps including (a) sorting the envelopes bycompany or creditor, (b) opening the envelopesand subsequently calculating debt, (c) mailing outpayment for affordable bills, and finally (d) seek-ing information on debt consolidators to addresscurrently unmanageable bills.

As an example of shaping specific to TA, onemay imagine a patient that has difficulty disclos-ing information about past traumatic experiences.Instead of expecting the patient to immediatelydisclose the full details of an experience, thetherapist may arrange an environment in whichthe patient begins with approximations of the fulldisclosure. These approximations may include adiscussion of less traumatic events within thescope of the larger traumatic experience or ofperipherally relevant information. In line withshaping principles, the therapist may provide am-ple support for such disclosure and may not re-quire the patient to progress immediately so longas there is some general movement toward theissues of greatest concern. Such incrementallyincreasing responses provide the patient with at-tainable successes, which are verbally praised bythe therapist. Thus these shaping processes maynot only be essential toward treatment progres-sion, but may also provide a framework in whichTA can evolve and improve (through verbal in-teractions). Indeed, behavioral changes in the pa-tient will presumably be affected by verbal rein-forcement from the therapist for subthresholdresponses that typically might be ignored or un-recognized in the natural environment.

Fading

The principle of fading requires a particulartarget behavior, in its final form, for the deliveryof a reinforcer. Fading also requires the necessaryassistance of the therapist to ensure the comple-tion of the target behavior. At the outset, fadingmay include a considerable amount of prompting,which is gradually “faded” out as the individuallearns to complete the target behavior withouttherapist assistance. In this way, there is an un-derlying assumption that both therapeutic assis-tance and the patient’s completion of the targetbehavior (and corresponding reward) are essen-tial toward developing a modified behavioralrepertoire.

As was noted with shaping, in the natural en-vironment, patients rarely obtain the level of sup-

port necessary to adequately reward and therebyfacilitate continued completion of desired targetresponses, as evidenced by notoriously low levelsof social support in the lives of individuals withpsychopathology (Corrigan & Phelan, 2004).Again as with shaping, the application of fadingprocedures provides ample opportunity for ther-apists to develop a therapeutic relationship. For apatient with social anxiety, the therapist initiallymay role-play numerous social scenarios with thepatient and provide behavioral scripts for initiat-ing, maintaining, and terminating a conversationwith a stranger. As the patient develops greatersocial prowess, the therapist will praise the pa-tient’s success and perhaps only offer suggestionson ways to deal with specific situations in whichthe patient reports continued difficulty. This dis-play of respect and trust from the therapist willthen theoretically serve to further enhance thepatient’s confidence and strengthen their thera-peutic alliance.

A more general example that may be relevantacross disorders is the patient who has difficultycompleting homework assignments outside oftherapy. The therapist may provide the patientwith a considerable amount of in-session verbalpraise to supply the patient with the support nec-essary to inspire completion of the assignmentoutside of therapy. Over the course of therapy, ashomework completion becomes more routine, thein-session focus may be “faded out.” Of course,before utilizing fading, it should first be deter-mined if a better approach might be to simplifythe assignment (more in line with shaping). How-ever, if the patient has the ability to complete theassignment but simply is lacking the support nec-essary to do so, the therapist can utilize fading toprovide that support.

Three Contemporary Behavior TherapiesThat Emphasize the Therapeutic Alliance

Functional Analytic Psychotherapy

Functional Analytic Psychotherapy (FAP;Kohlenberg & Tsai, 1995) is meant to “super-charge” traditional behavior therapy by intensi-fying and personalizing the patient–therapist re-lationship and using it as the primary vehicle fortherapeutic change (Kohlenberg & Tsai, 1995).FAP may be utilized as an independent therapeu-tic modality, but it also incorporates principlesand applications that are easily integrated into

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alternative behavioral and cognitive therapy ap-plications (Hopko & Hopko, 1999; Kohlenberg,Kanter, Bolling, Parker, & Tsai, 2002). FAP alsois particularly well-suited for patients with per-sonality disorders or interpersonal problems thathave proven resistant to other forms of therapy(Callaghan, Gregg, Marx, Kohlenberg, & Gif-ford, 2004; Callaghan, Summers, & Weidman,2003; Follette, Naugle, & Callaghan, 1996).These problem social behaviors are bound tomanifest themselves in multiple relationships, in-cluding that with the therapist. Thus, the expres-sion of problematic behaviors displayed duringthe session allows for ongoing assessment andopportunities to reinforce, shape, and even onsome level punish inappropriate social behaviors(Follette, Naugle, & Callaghan, 1996). Even po-tentially mundane therapy experiences such aschecking on homework assignments or resched-uling a session can provide an opportunity for thedisplay of emotional or social clinically relevantbehaviors (CRBs) such as rebelliousness, nonas-sertiveness, and anxiety. Once these CRBs man-ifest themselves during therapy, the therapist fa-cilitates the patient’s observation and interpre-tation of his or her own behaviors, and subse-quently reinforces improvements made duringthe session while failing to reinforce (and occa-sionally punishing) more maladaptive behaviors.Along these lines, naturally occurring contin-gencies such as increased or decreased atten-tion or spontaneous verbal exclamations of affec-tion or hurt feelings might be used to reward,shape, or decrease undesirable behaviors, muchlike these principles would operate in the naturalenvironment.

The guiding principle of FAP is that significanttherapeutic change will result from immediatecontingent therapist reinforcement of presentlyoccurring behaviors. For example, if a patientavoids eye contact and the therapist responds byshowing boredom and pointing out this connec-tion to the patient, then the patient will under-stand a real-world association between one’s ownbehaviors and others’ responses to those behav-iors. As FAP aims to approximate real-worldinteractions that might arise in close relation-ships, it promotes the use of reinforcement strat-egies that other therapeutic interventions explic-itly avoid. For example, a reinforcer could be asincerely spoken, “I feel very close to you rightnow,” to a patient who has opened up to thetherapist after previous trouble expressing emo-

tions to loved ones. Indeed, very few topic areasare prohibited within the application of FAP,including topics that are rarely discussed in moretraditional behavior therapy, such as hurt feelingson the part of the therapist, the patient’s reactionto the physical and personality characteristics ofthe therapist, and naturally occurring therapisterrors. The patient’s reaction to any of theseissues can and should be candidly discussed andused to further progress, as similar issues oftenmanifest in some form outside of the therapeuticenvironment. This approach certainly is more en-gaging than more traditional behavioral ap-proaches, insofar as these conventional methodsemphasize addressing problems outside the ther-apy setting, with little attention to problems asthey occur within the therapy session. Moreover,FAP reinforcement contingencies also might varysubstantially from those associated with con-ventional behavior therapy and often includegenuine feedback about how a patient’s behav-ior may positively or negatively impact thetherapist’s reaction to the patient (Kohlenberg& Tsai, 1995).

In FAP, as in psychodynamic, humanistic, andexperiential approaches, TA should approximatean intimate social relationship as closely as pos-sible so that the patient can easily generalizetreatment effects from the session to the naturalenvironment. FAP would therefore be impossiblewithout a therapeutic relationship that is caring,genuine, sensitive, involving, and emotional(Kohlenberg & Tsai, 1987). An FAP therapistmust be equally invested in creating an authenticand close therapeutic alliance because both ther-apies rest on the supposition that a patient willinteract with the therapist in much the same wayas he or she behaves with peers and loved ones.FAP also requires that the therapist carefully ob-serve instances of CRBs such as patient with-drawal from or resentment toward the therapist.Kohlenberg and Tsai (1987) note that this apti-tude for observing minor changes in the patient’srelationship with the therapist is characteristic ofespecially competent psychodynamic therapistswho use transference as the primary medium oftherapeutic change. In FAP, behavior therapistsmust be similarly aware of the patient’s interper-sonal actions during session, as the basis of FAPis the assumption that the patient–therapist rela-tionship and the patient’s real-world relationshipsare functionally similar (Kohlenberg & Tsai,1995).


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The necessity of a strong therapeutic alliance isevident in the techniques and overarching theoryof FAP. For instance, the constant scrupulousobservation, which is required in FAP, would bedifficult if a therapist did not take an active andgenuine interest in the patient. Also, a therapistmust express natural emotional responses to thepatient’s CRBs, but these might seem forced andunnatural if the therapist did not have a truerapport with the patient. Thus, Kohlenberg andTsai have highlighted the notion that an intensetherapeutic alliance can be a necessary compo-nent of behavior therapy, particularly for certainpatients who have found limited success withmore technique-focused approaches. Further re-search will be helpful toward better establishingnot only the efficacy and effectiveness of thisintervention and its adjunctive use with othertreatment approaches, but also the extent towhich positive treatment outcome is associatedwith the proposed active mechanism of change,namely the patient-therapist relationship (Fol-lette, Naugle, & Callaghan, 1996).

Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT;Hayes, Strosahl, & Wilson, 1999) is a behavioraltreatment that focuses on decreasing experientialavoidance and facilitating/fostering willingnessof private experiences in the context/service ofvalued action. ACT includes five main compo-nents, however, not all components are necessar-ily used with all patients, and the therapy does notnecessarily progress through these components ina linear manner. Given the focus on experientialavoidance, ACT is particularly suitable for avoid-ance behaviors linked to substance abuse (Heff-ner, Eifert, Parker, Hernandez, & Sperry, 2003),anxiety (Zettle, 2003), eating disorders (Hayes &Pankey, 2002), and even psychotic disorders(Bach & Hayes, 2002).

Although the goals of ACT may be intraper-sonal in nature, the means are decidedly interper-sonal, that is, they hinge upon the trusting andcollaborative nature of TA. This may be bestdescribed using the two-mountains metaphorfrom ACT: The therapist and patient are concep-tualized as climbing their own separate moun-tains. While the therapist can help the patient, it isstressed that the therapist is an individual whoalso has problems climbing his or her own moun-tain. Thus, while the therapist may be vulnerable

to traps and pitfalls on his or her own mountain,the therapist does have a unique view of thepatient’s mountain that may be useful for assist-ing the patient in their struggles. Thus, as withTA, ACT is not hierarchical but instead a collab-orative process.

In the first two components of ACT, the patientmust first accept the past and current difficultiesassociated with controlling aversive private expe-riences, an acknowledgment that may be deeplyemotional and difficult for a patient who is expe-riencing significant distress. By accepting cre-ative hopelessness, the patient learns that previ-ous avoidance-based solutions have actuallybecome the problem and that there may be greatbenefits in letting go of the struggle of trying torid one’s life of uncomfortable experiences(avoidance). The therapist uses an open dialoguewith the patient, employing metaphor and ques-tioning to help the patient realize that control hasbeen the problem and that trying something newinvolves moving away from different presenta-tions of the same basic avoidance strategy. Inattempting to isolate the establishing operationsin effect via a functional analysis, the patient canarticulate information about internal and externalsetting events that precipitate the avoidance be-havior and can begin to generate novel strategies.The collaborative nature of the therapeutic bondis critical to allowing and easing the admissionof past failure and the critical examination ofone’s own behavior from a functional analyticperspective.

In a third component of ACT, the patient istaught to separate personal self from various psy-chological phenomena such as physiological re-actions, cognitions, and emotions, with a focus onthe establishing operations underlying one’s ac-tions. This technique involves a careful extrica-tion of what one is, from what one experiences.The avoidant alcoholic may successfully separatethe idea of self from the negative experiences ofbinge drinking or possessing poor social skills,and therefore would not be defined by theirsymptoms. A strong therapeutic relationship is ofgreat consequence here because it creates a venuefor highlighting the reality of the psychologicalproblem. The supportive environment that isformed when the patient exposes his or her pri-vate thoughts and feelings to the therapist is vitalto an honest analysis of the problem.

In the fourth component, the patient is asked toreexperience aversive events in order to over-


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come avoidance and pursue previously identifiedvalued directions. Using graduated exposure, thepatient’s behavior is gradually shaped to ap-proach and accept valued situations. Similarly,the reinforcement of a series of interrelated be-haviors via chaining may be utilized to develop aspecific repertoire for pursuing valued directions,and subsequently, approaching stimuli that maybe experienced as threatening. Under the princi-ple of fading, the socially avoidant alcoholic maywillingly be able to experience the anxiety ofsocial interactions, given that there will be ampleopportunity to process these experiences in ses-sion. Alternatively, this exposure could utilizeshaping, which may begin with simple positivesocial skills such as making eye contact, and thengradually include other steps in subsequent socialinteractions, again with the patient obtainingcomfort and praise from the therapist for com-pleting these steps at subsequent sessions. Theseaspects of TA encourage and provide instances ofsuccess in the patient’s pursuit of an otherwiseintimidating target behavior, until the naturalcontingencies of such behavior take hold. Shouldthe TA rupture due to mistrust, the patient may beless likely to place himself or herself in the psy-chological distress that is integral to this method.

The final component of ACT seeks a commit-ment between patient and therapist in pursuingbehavioral change. Behavioral principles such asshaping are integral here because the patientlikely does not possess the desired behavioralrepertoire (i.e., acceptance). Therefore, it is nec-essary to “start somewhere.” In reinforcing initialsmall yet valued actions that lead up to largertarget goals, the therapist is able to provide theimpetus for behavioral change. As commitmentdevelops, fading of other therapist-delivered aidsare necessary to make behavior modificationmore permanent and independent of the program.As with shaping, the ultimate generalization to invivo situations requires confidence on the part ofboth therapist and patient that the new behaviorwill endure despite the change in environmentalcircumstance (i.e., rewards, therapist assistance),as well as honest collaboration when these be-haviors do not occur to allow for further problemsolving. Thus, proper use of shaping and fadingtechniques is possible only when the collabora-tive spirit within the therapeutic alliance isreadily apparent and enables the patient and ther-apist to embark upon the journey of behavioralchange together, with the latter taking backseat to

the lead of the former. The tasks of therapy areinextricably linked with the goals of behavioralchange, which is furthermore strengthened by theexisting TA.

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT; Linehan,1993) is another example of a treatment approachthat demonstrates the importance of the therapeu-tic alliance in behavior therapy. DBT is a form ofpsychotherapy that incorporates principles of be-havior therapy, cognitive therapy, and Zen phi-losophy. DBT was originally developed to treatchronically suicidal, self-injurious women and isthe only psychosocial treatment found to be ef-fective for borderline personality disorder (BPD)using randomized controlled trials across multi-ple research sites (Linehan, Armstrong, Suarez,Allmon, & Heard, 1991; Koons et al., 2001).Compared to treatment-as-usual in the commu-nity, DBT has been shown to reduce the fre-quency and medical risk of parasuicidal behavior(Linehan et al., 1991), suicidal ideation, hope-lessness, depression, and expression of anger(Koons et al., 2001). In addition, reductions inpsychiatric inpatient days and improved socialadjustment have been observed over a 1-yearperiod following DBT treatment (Linehan,Heard, & Armstrong, 1993).

DBT traditionally involves six months ofweekly individual therapy sessions aimed at in-creasing motivation, weekly skills traininggroups, telephone consultation on an as-neededbasis to facilitate skill generalization and main-tain the therapeutic relationship, and consultationmeetings among therapists. Patients are encour-aged to repeat the process twice to maximizelearning. The behavior therapy component ofDBT is based on the assumption that many mal-adaptive behaviors are learned and therefore maybe replaced by more adaptive behaviors throughnew learning in the form of modeling, operantconditioning, or respondent conditioning. The di-alectics component of DBT is a process of syn-thesizing opposing elements, ideas, or events.DBT’s overarching aim is to model and teach amore balanced, synthesized, and dialectical ap-proach to thinking and behavior. Components ofthis process include improving emotion regula-tion and interpersonal relationship effectivenessin addition to promoting mindfulness (e.g.,present moment focus, nonjudgmental aware-


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ness, and attentional flexibility) and the ability totolerate emotional distress.

More so than most other forms of psychopa-thology, the nature of borderline personality dis-order demands that TA be a principal element ofDBT. DBT utilizes a collaborative patient-therapist relationship involving commitment totreatment, mutual identification of target behav-iors, comprehensive behavior analysis, and ac-ceptance and agreement that targeted behaviorsare problematic and in need of modification. Fail-ure to collaborate with the therapist and/or con-tinually overstepping the therapist’s stated limits(e.g., frequency of telephone calls) are consideredtherapy-interfering behaviors and are second onlyto suicidal and self-harm behaviors in importancefor targeting change. It is the therapist’s respon-sibility to point out how noncollaborative behav-iors interfere with the patient’s goals and inter-fere with the therapist’s ability to motivate thepatient toward change.

Two strategies utilized in DBT that fit wellwithin a focus on TA are contingency manage-ment and reciprocal communication. In contin-gency management, the therapist arranges foradaptive targeted behaviors to be reinforcedwhile related maladaptive behaviors are extin-guished through lack of reinforcement or, if nec-essary, the use of punishment. Although a pri-mary goal is to help patients develop contactwith reinforcers outside of the therapy context,therapist approval, interest, concern, warmth/affection, and reassurance directed in a contin-gent manner are crucial, especially at the onset oftherapy (Robins & Koons, 2000). In some in-stances, it may be necessary for a break fromtherapy to be implemented as a punishment, sothat access to the therapist is withheld contingentupon some behavior change or commitment. Forthe contingency management approach to be suc-cessful, the DBT therapist must work to establisha strong TA by developing a mutual and genuineattachment between the therapist and the patient.In addition, the therapist must carefully monitorhis or her own behavior and empathic inclina-tions such that reinforcing behaviors are not ex-pressed following maladaptive behavior by thepatient.

Reciprocal communication requires that a ther-apist respond in a manner that is relevant to thecontent of the patient’s statements and to theirquestions. Self-disclosure is a type of reciprocalcommunication. This may take the form of dis-

closing reactions to the patient’s behavior (e.g., “Iam very pleased to hear that you were able to useyour wise mind while talking to your father”).Alternatively, self-disclosure may reflect the ther-apist’s reaction to the patient’s act of crossingstated limits (e.g., “I was upset when you phonedme repeatedly on Friday night when we had dis-cussed that I would be at a family function”).Finally, personal self-disclosure may be used,according to the therapist’s comfort level, as aform of modeling. However, self-disclosure shouldbe closely monitored to ensure it is occurring forthe benefit of the patient and/or the enhancementof the therapeutic relationship, and not to addressany personal needs of the therapist. Another sty-listic strategy is irreverent communication, whichmay involve reframing something the patientsays in an unorthodox way or adopting the oppo-site level of intensity of the patient. For example,if the patient says, “I don’t need to do any moreof these role-plays,” the therapist may respond,“Great, I assume that all of your interpersonalrelationships have improved?” The therapistwould then carefully provide a safety net for thepatient by adding, “Let’s talk about how you canfeel more comfortable with role-playing.” Whenused appropriately in the context of a strongtherapeutic alliance and surrounded by valida-tion, this strategy can result in moments of humorand guide the patient out of a rut.

One concern with using cognitive modificationprocedures is that they may be interpreted asblaming the patient (e.g., “It’s all in your head”).Thus, DBT focuses on first validating the pa-tient’s cognitions, then targeting maladaptive be-liefs and schemas, and lastly teaching self-observation through mindfulness exercises, theidentification of maladaptive cognitions, the gen-eration of alternative cognitive content, and thedevelopment of guidelines for when patientsshould question the validity of their initial inter-pretation of their cognitions (e.g., trust cognitionsless when emotions are high). For example, whena patient expresses failure in all major aspects oflife while highlighting success of others in thosesame domains, the therapist would first identifythe truth in the patient’s statement (e.g., “It doesseem as though your roommate and classmatesare productive and successful in many areas oftheir lives”), then identify the distortions in thepatient’s statements (e.g., “However, people of-ten focus on only the positive aspects of others’lives, neglecting the fact that every person has


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their own struggles to deal with,” or “Doesn’tyour roommate frequently pay her portion of therent late?”).

Consistent with the FAP and ACT approaches,the same fundamental behavior principles are rel-evant toward understanding the development of astrong therapeutic alliance in DBT. In addition tothe reinforcement and punishment strategies out-lined above, fading and shaping procedures arehighlighted as important features of DBT (Line-han, 1993). In forming the TA and progressivelymoving through the DBT protocol, for example,the therapist provides a significant degree ofmodeling, instruction, and coaching as it pertainsto skill development. Once skills are developedhowever, the therapist fades skills-training pro-cedures to an intermittent schedule, “. . .such thatthe therapist provides less frequent instructionsand coaching than the patient can provide forherself, and less modeling, feedback, and rein-forcement than the patient is obtaining from thenatural environment” (Linehan, 1993, p.343).Shaping procedures also are heavily relied uponin relationship development and skill acquisition.For example, shaping is used in the initial stagesof therapy to obtain verbal commitment tochange, and throughout therapy to develop in-creased emotional awareness and interpersonalskills with both the therapist and in group ses-sions. Indeed, it is through such basic behavioralprinciples of reinforcement, punishment, fading,and shaping that the strength of TA evolves andthe movement toward emotional acceptance andbehavioral change is recognized.

Case Study Example of the TA in BehaviorTherapy

Jennifer was a 28-year-old single Hispanic fe-male whose case nicely illustrates the relevanceof the therapeutic alliance in behavior therapy. Athorough discussion of assessment and case con-ceptualization for Jennifer, as well as the initialprogress of her treatment is available in Hopko,Sanchez, Hopko, Dvir, and Lejuez (2003). Jen-nifer was assessed using two semistructured in-terviews (Structured Clinical Interview forDSM–IV Axis I Disorders [First, Spitzer, Gibbon,& Williams, 1996] and the Structured ClinicalInterview for DSM–IV Axis II Personality Disor-ders [First, Spitzer, Gibbon, Williams, & Ben-jamin, 1997]) and her primary presenting prob-lems were major depressive disorder and

borderline personality disorder (BPD). Her mostrecent depressive episode was characterized bydysphoric mood, avolition, suicidal ideation, dif-ficulty concentrating, fatigue, excessive sleep,and feelings of low self-worth and hopelessness.BPD symptoms included intense and unstableinterpersonal relationships, affective instability,unstable self-image, a pattern of sabotaging per-sonal goals and accomplishments at the momentthey are about to be realized, suicidal ideationand behavior, and impulsivity with respect toeating. Jennifer reported “walking on eggshells”during her childhood because her father fre-quently was hostile, angry, and non-nurturing.She reported feeling as though she often had to“put on a happy face” in front of other people.Partially due to these circumstances, Jennifer de-veloped perfectionistic standards and engaged inself-punishment, developing emotional dysregu-lation over time as a consequence of living in anonvalidating environment. A functional analysisidentified rigidity of thought (i.e., polarizedthinking), avoidance behaviors, inadequate dis-tress tolerance, periodic feelings of invalidation,and discomfort with change as maintenance fac-tors associated with BPD and depressive symp-toms. Her depressive symptoms and suicidal ide-ation reportedly began at a very young age, butJennifer did not receive any mental health treat-ment until beginning college in 1994 at the age of18. During this period, Jennifer was experiencingproblems with interpersonal relationships, diffi-culties with time-management (she was also em-ployed part-time), and high levels of academicstress.

Given a primary diagnosis of major depressivedisorder, Jennifer initially was treated using theBehavioral Activation Treatment for Depression(BATD; Lejuez, Hopko, & Hopko, 2002). BATDis a behavioral treatment that may be an effectiveand parsimonious treatment for major depressivedisorder in inpatient, outpatient, and primary caresettings (Hopko, Bell, Armento, Hunt, & Lejuez,in press; Hopko, Lejuez, & Hopko, 2004; Hopko,Lejuez, LePage, Hopko, & McNeil, 2003; Le-juez, Hopko, LePage, Hopko, & McNeil, 2001).BATD seeks to assist patients in developing anenvironment in which the likelihood of obtainingreinforcement for healthy behavior increases.Systematically increased activity is considered aprecursor to the reduction of depressed mood andparasuicidal, suicidal, and self-harm behavior(Hopko, Sanchez et al., 2003). BATD involves


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efforts to reduce reinforcement for unhealthy be-haviors (e.g., via behavioral contracting), self-monitoring through daily diaries (Hopko, Ar-mento, Chambers, Cantu, & Lejuez, 2003), a lifevalue assessment, generation of behavior and ac-tivity goals through utilization of an activity hi-erarchy, and the systematic monitoring of tar-geted goals with progressively heighteneddifficulty. Treatment progress was assessed bymonitoring suicidal activity and scores on theBeck Depression Inventory, Version II (BDI-II;Beck, Steer, & Brown, 1996). When treatmentbegan, Jennifer’s BDI-II score was 43, indicatingsevere depressive symptoms.

Initial efforts to initiate BATD were under-mined by considerable resistance by the patientdue to the structured problem-focused nature ofthe treatment. Indeed, the patient had expectedtherapy to consist entirely of discussing her prob-lems, and she had not anticipated the active roleshe would have to take both within and outside ofthe therapy context. Due to (rigid) patient expec-tations and initial treatment resistance, we deter-mined that continuing to implement BATD at thispoint in therapy might seriously damage the ther-apeutic relationship. Accordingly, our treatmentteam evaluated alternative interventions thatwould better align with Jennifer’s expectationsand still effectively address her presenting prob-lems. This process also was designed to preservetherapist-patient rapport and thereby increase thelikelihood of positive treatment outcome.

At this juncture, it seemed clear that treatmentwould be most effective through the introductionof DBT treatment strategies such as emotionalvalidation, mindfulness and distress tolerancetraining, and communication skill development.Although not completely distinct from BATDstrategies, the packaging of these skills withinDBT seemed more consistent with Jennifer’s pre-conceptions of the therapeutic process. It shouldbe noted that we did not intend to terminateBATD, but rather to develop an alternative, com-patible, and effective mode of therapy that wouldsimultaneously provide a supportive and com-fortable environment from which the patientcould work. Although DBT strategies clearlywere important toward addressing BPD symp-toms, their use along with venting time alsoserved as a reinforcer for completing BATD as-signments. In line with the principle of establish-ing operations, addressing Jennifer’s particular

longer-term goals and expectations, as well asshorter-term needs, could be used to motivate herto complete her BATD goals, with the intentionthat as she progressed and ultimately terminatedtherapy, she would continue to prioritize her in-creased activity level and exposure to positiveexperiences. In line with fading principles, ther-apy sessions initially were conducted in a highlystructured manner, with decreased prompting andincreased patient independence as therapy pro-gressed. Shaping procedures also were utilized inthat BATD strategies progressively were inte-grated with DBT components, together allowingfor systematic development of the patient’s be-havioral repertoire.

Throughout the initial integrated DBT/BATDtreatment approach (12 sessions), suicidal ide-ation decreased substantially, although there wasminimal impact on other depressive symptoms(Hopko, Sanchez et al., 2003). After a break fromtherapy during the summer, the therapist’s inten-tion was to reinitiate BATD to address the intrac-table depressive symptoms, but in a way thatwould encourage greater patient commitment andsimultaneously develop a stronger therapeutic re-lationship. Based on previous patient contact, itwas clear that Jennifer greatly enjoyed her “vent-ing time.” Originally this time lasted for 10 min-utes at the end of each session and was providedregardless of her treatment compliance. In anattempt to improve Jennifer’s completion rate forBATD activities, a contingency system was im-plemented. Specifically, Jennifer was given 10minutes of venting time if she completed 80% ofher activities and only 5 minutes if less than 80%of the activities were completed. Thus, consistentwith shaping applications, the final goal was100% completion each week, but in the mean-time, 80% compliance initially would be consid-ered sufficient for reinforcement. This approachworked with moderate success, but it was deter-mined that the opportunity to gain 5 minutes ofventing time for less than 80% completion ofhomework interfered with her progress, and oftenresulted in her omitting activities that were es-sential to primary goals she had set (e.g., chang-ing careers).

Although we were somewhat concerned aboutalienating the patient, we also were aware of thestrong reinforcing value of venting time and de-cided to use this to increase treatment compli-ance. For the final 7 months of therapy (24 ses-


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sions), a more stringent contingency system wasestablished whereby if Jennifer did not completeall activities for the week, the session ended 30minutes early and did not include any “ventingtime.” This strategy utilized the DBT problem-solving principle of reducing the therapist’savailability, creating a direct link between failureto complete homework and the contingency thataccess to the therapist was reduced. Compliancewith BATD activities improved significantly andthere were only a few sessions during the final 7months of therapy in which Jennifer had notcompleted all of her activities.

The enforcement of a strict contingency man-agement system was balanced by the need tocontinue to develop the TA. Prior to changing thecontingency system, the rationale for the changewas discussed and the patient agreed that the newsystem would help reduce her self-sabotagingbehaviors. When Jennifer completed 100% of heractivities, she received verbal praise. On the fewoccasions when she did not complete all activitiesand the session ended early, the contingency andthe rationale behind it were reiterated and shewas encouraged to complete all activities thefollowing week. Again, for a patient who greatlyvalued “venting time,” there was a risk in with-holding it if assignments were not completed.However, the strong TA established prior to im-plementing the contingency system and the care-ful discussion surrounding application of the pun-isher resulted in successful outcome. Jennifer didnot feel abandoned by the therapist, even on theweeks when she was not allowed to “vent,” dueto the strong therapeutic alliance which had pre-viously been built. The trust and respect whichhad already been established with her therapisthelped Jennifer accept this new punishment tech-nique without feeling rejected or resentful, de-spite her tendency toward such feelings in herother interpersonal relationships.

Despite the incompatibility traditionally asso-ciated with the combined use of behavioral tech-niques and an emphasis on therapeutic alliance,strategies based upon basic principles actuallyenhanced the therapeutic relationship, which inturn led to further compliance with the utilizedbehavioral techniques on the part of the patient.For example, a major factor related to Jennifer’snegative mood was dissatisfaction with her job,and switching jobs was identified as a primarytreatment goal. However, this task was extremely

anxiety-provoking for Jennifer because she re-portedly felt like a failure for not having com-pleted her combined baccalaureate/master’s pro-gram and for being in her midtwenties withouthaving established a career. For nearly a year,steps toward changing careers were actively pur-sued. However, associated activities were fre-quently omitted from her BATD activities. Underthe revised contingency system, compliance im-proved but progress remained slow, with deci-sions (e.g., whether to pay the deposit at a schoolto which she had been admitted) belabored forweeks to months. This provided the therapist witha challenge in balancing orientation to changewith validation of the patient’s emotions.Through use of the strict contingency system, avalidating environment, and a strong TA, towardthe end of her two and a half years of treatment,Jennifer was able to overcome her fear of pursu-ing another educational program, chose a newprofession, applied to a professional school, andbegan training for her new career. Ultimately, theprimary mechanism of change could be concep-tualized as a strong therapeutic alliance that ini-tially evolved through therapist flexibility andvalidation experiences that previously had beenquite foreign to Jennifer. Together with initiallearning of distress tolerance strategies and com-munication skill development that provided forverbal reinforcement from the therapist as well asmore natural social contingencies, these factorsallowed Jennifer to develop a stronger relation-ship with the clinician. This alliance was reflectedin Jennifer’s increased acceptance of the fadingand shaping processes as implemented in thecontext of BATD as well as periodic in-sessionpunishment strategies, all of which were centralto positive treatment outcome.

In the final two months of therapy, Jenniferbegan a part-time professional education programand was employed part-time. She had also com-menced with bible studies and attending churchon a regular basis, two goals that were identifiedat the beginning of treatment. Jennifer’s BDI-IIscores and self-reported mood improved duringthe final three months of therapy, with her BDI-IIscore decreasing from a high of 51 to a low of 10at the final session. In addition, her score on theBorderline Symptom List (Bohus, Limberger, Ul-rike, Ingrid, Tanja, & Stieglitz 2001) decreasedfrom 126 when assessed in February 2004, to 43in November 2004, indicating an improvement in


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borderline personality characteristics into a non-clinical range. At discharge, Jennifer reportedfeeling significantly better and being comfortablewith taking a break from therapy. She stated thatshe had never reached this point in therapy beforeand appeared hopeful about her future. In addi-tion to the activities practiced using BATD andthe skills learned using DBT, both the therapistand the patient felt as though a large part ofJennifer’s significant progress throughout treat-ment was the result of the supportive environ-ment created in therapy and the strong therapeu-tic alliance that was created.

Summary and Conclusions

Relative to other treatment modalities, it maybe argued that behavior therapy has proceededwith minimal regard for the therapeutic allianceas a key mechanism of change. As illustrated inpreceding sections, however, basic behavioralprinciples at the core of behavior therapy arefundamental both to the development of a strongtherapeutic alliance and to the provision of morespecific behavioral applications that are based onthese principles. Indeed, the contextual philoso-phy of behaviorism and its reliance on functionalanalysis stress that all contingencies in a situationmust be examined in accounting for certain be-haviors, and it is evident that even the most subtleand unplanned therapist actions may serve toelicit or reinforce patient behaviors, and viceversa (Kohlenberg, 2000). Contemporary behav-ioral interventions such as FAP, ACT, and DBThave capitalized on these assertions. These inter-ventions strongly emphasize the interrelation-ships among basic principles and their relevanceto therapeutic alliance and interconnected inter-vention strategies, and available treatment out-come data are encouraging insofar as supportingthe contention that therapeutic relationship vari-ables may be integral to understanding the suc-cess of behavioral interventions (Hayes, Masuda,Bissett, Luoma, & Guerrero, 2004; Hayes, Ma-suda, & DeMey, 2003; Robins & Chapman,2004). In moving forward, behavior therapistsmay be wise to continue in such explicit attemptsto incorporate TA directly into interventions bothon a clinical and research level, using assessmentinstruments developed to measure alliance suchas the Working Alliance Inventory (Horvath,1982), the California Psychotherapy AllianceScales (Gaston, 1991), and the Combined Alli-

ance Short Form (Hatcher & Barends, 1996) toprovide the type of empirical data that epitomizesthe behavior therapy tradition.

References

BACH, P., HAYES, S. C. (2002). The use of acceptance andcommitment therapy to prevent the rehospitalization ofpsychotic patients: A randomized controlled trial. Jour-nal of Consulting and Clinical Psychology, 70(5), 1129–1139.

BECK, A. T., STEER, R. A., & BROWN, G. K. (1996).Manual for the BDI-II. San Antonio, TX: The Psycho-logical Corporation.

BOHUS, M., LIMBERGER, M. F., ULRIKE, F., INGRID, S.,TANJA, G., & STIEGLITZ, R. D. (2001). Development ofthe Borderline Symptom List (BSL). PsychotherapiePsychosomatik Medizinische Psychologie, 51, 201–211.

BORDIN, E. S. (1979). The generalizability of the psycho-analytic concept of the working alliance. Psychother-apy: Theory, Research & Practice, 16(3), 252–260.

BROWN, P. D., & O’LEARY, D. K. (2000). Therapeuticalliance: Predicting continuance and success in grouptreatment for spouse abuse. Journal of Consulting andClinical Psychology, 68(2), 340–345.

CALLAGHAN, G. M., GREGG, J. A., MARX, B. P., KOHLEN-BERG, B. S., & GIFFORD, E. (2004). FACT: The utility ofan integration of functional analytic psychotherapy andacceptance and commitment therapy to alleviate hu-man suffering. Psychotherapy: Theory, Research, Prac-tice, Training, 41, 195–207.

CALLAGHAN, G. M., SUMMERS, C. J., & WEIDMAN, M.(2003). The treatment of histrionic and narcissistic per-sonality disorder behaviors: A single subject demon-stration of clinical improvement using functional ana-lytic psychotherapy. Journal of ContemporaryPsychotherapy, 33, 321–339.

CORRIGAN, P. W., & PHELAN, S. M. (2004). Social sup-port and recovery in people with severe mental ill-nesses. Community Mental Health Journal, 40, 513–523.

DELPRATO, D. J. (2001). Comparisons of discrete-trialand normalized behavioral intervention for young chil-dren with autism. Journal of Autism and DevelopmentalDisorders, 31, 315–325.

FIRST, M. B., SPITZER, R. L., GIBBON, M., & WILLIAMS, J.(1996). Structured Clinical Interview for DSM–IV Axis IDisorders – Patient Edition (SCID-I/P, Version 2.0).New York: Research Department, New York Psychiat-ric Institute.

FIRST, M. B., SPITZER, R. L., GIBBON, M., WILLIAMS, J., &BENJAMIN, L. (1997). Structured clinical interview forDSM–IV Axis II personality disorders (SCID-II). NewYork: Biometrics Research Department, New YorkPsychiatric Institute.

FOLLETTE, W. C., NAUGLE, A. E., & CALLAGHAN, G. M.(1996). A radical behavioral understanding of the ther-apeutic relationship in effecting change. Behavior Ther-apy, 623–641.

GASTON, L. (1991). Reliability and criterion-related va-lidity of the California Psychotherapy Alliance Scales-patient version. Psychological Assessment, 3, 68–74.

GELSO, C. J., & CARTER, J. A. (1994). Components of thepsychotherapy relationship: Their interaction and un-


466

folding during treatment. Journal of Counseling Psy-chology, 41, 296–306.

HALL, G. A. (2004). Towards a balanced account ofautism etiology. Analysis of Verbal Behavior, 20, 37–43.

HATCHER, R. L., & BARENDS, A. W. (1996). Patient’sview of the alliance in psychotherapy: Exploratory fac-tor analysis of three alliance measures. Journal of Con-sulting and Clinical Psychology, 64, 1326–1336.

HAYES, S. C., MASUDA, A., BISSETT, R., LUOMA, J., &GUERRERO, L. F. (2004). DBT, FAP, and ACT: Howempirically oriented are the new behavior therapy tech-nologies? Behavior Therapy, 35, 35–54.

HAYES, S. C., MASUDA, A., & DEMEY, H. (2003). Accep-tance and commitment therapy and the third wave ofbehavior therapy. Gedragstherapie, 36, 69–96.

HAYES, S. C., PANKEY, J. (2002). Experiential avoidance,cognitive fusion, and an ACT approach to anorexianervosa. Cognitive and Behavioral Practice, 9, 243–247.

HAYES, S. C., STROSAHL, K. D., & WILSON, K. (1999).Acceptance and commitment therapy: An experientialapproach to behavior change. New York: GuilfordPress.

HEFFNER, M., EIFERT, G. H., PARKER, B. T., HERNAN-DEZ, D. H., & SPERRY, J. A. (2003). Valued directions:Acceptance and commitment therapy in the treatmentof alcohol dependence. Cognitive and Behavioral Prac-tice, 10, 378–383.

HOPKO, D. R., ARMENTO, M. E., CHAMBERS, L., CANTU,M., & LEJUEZ, C. W. (2003). The use of daily diaries toassess the relations among mood state, overt behavior,and reward value of activities. Behaviour Research andTherapy, 41, 1137–1148.

HOPKO, D. R., BELL, J. L., ARMENTO, M. E. A., HUNT,M. K., & LEJUEZ, C. W. (in press). Behavior therapy fordepressed cancer patients in primary care. Psychother-apy: Theory, Research, Practice, Training.

HOPKO, D. R., & HOPKO, S. D. (1999). What can func-tional analytic psychotherapy contribute to empirically-validated treatments? Clinical Psychology and Psycho-therapy, 6, 349–356.

HOPKO, D. R., LEJUEZ, C. W., & HOPKO, S. D. (2004).Behavioral activation as an intervention for coexistentdepressive and anxiety symptoms. Clinical Case Studies,3, 37–48.

HOPKO, D. R., LEJUEZ, C. W., LEPAGE, J. P., HOPKO,S. D., & MCNEIL, D. W. (2003). A brief behavioralactivation treatment for depression: A randomized trialwithin an inpatient psychiatric hospital. Behavior Mod-ification, 27, 458–469.

HOPKO, D. R., SANCHEZ, L., HOPKO, S. D., DVIR, S., &LEJUEZ, C. W. (2003). Behavioral activation and theprevention of suicidal behaviors in patients with bor-derline personality disorder. Journal of Personality Dis-orders, 17, 460–478.

HORVATH, A. (1982). Working alliance inventory (re-vised). Unpublished manuscript No. 82.1, Simon FraserUniversity, Vancouver.

HORVATH, A. O. (2001). The alliance. Psychotherapy:Theory, Research, and Practice, 38, 365–372.

HORVATH, A. O., & LUBORSKY, L. (1993). The role of thetherapeutic alliance in psychotherapy. Journal of Con-sulting and Clinical Psychology, 61, 561–573.

HYER, L., KRAMER, D., & SOHNLE, S. (2004). CBT witholder people: Alterations and value of the therapeutic

alliance. Psychotherapy: Research, Practice, Training,41(3), 276–291.

KLEIN, D. N., SCHWARTZ, J. E., SANTIAGO, N. J., VIVIAN,D., VOCISANO, C., CASTONGUAY, L. G., ET AL. (2003).Therapeutic alliance in depression treatment: Control-ling for prior change and patient characteristics. Jour-nal of Consulting and Clinical Psychology, 71(6), 997–1006.

KOHLENBERG, B. S. (2000). Emotion and the relationshipin psychotherapy: A behavior analytic perspective. InM. J. Dougher (Ed.), Clinical behavior analysis (pp.271–289). Reno, NV: Context Press.

KOHLENBERG, R. H., KANTER, J. W., BOLLING, M. Y.,PARKER, C., & TSAI, M. (2002). Enhancing cognitivetherapy for depression with functional analytic psycho-therapy: Treatment guidelines and empirical findings.Cognitive and Behavioral Practice, 9, 213–229.

KOHLENBERG, R. J., & TSAI, M. (1987). Functional ana-lytic psychotherapy. In N. S. Jacobson (Ed.), Psycho-therapists in clinical practice: Cognitive and behavioralperspectives (pp. 388–443). New York: Guilford Press.

KOHLENBERG, R. J., & TSAI, M. (1995). Functional ana-lytic psychotherapy: A behavioral approach to inten-sive treatment. In W. O’Donahue & L. Krasner (Eds.),Theories of behavior therapy: Exploring behaviorchange (pp. 637–658). Washington, DC: American Psy-chological Association.

KOONS, C. R., ROBINS, C. J., TWEED, J. L., LYNCH, T. R.,GONZALEZ, A. M., MORSE, J. Q., ET AL. (2001). Efficacyof dialectical behavior therapy in women veterans withborderline personality disorder. Behavior Therapy, 32,371–390.

LARAWAY, S., SNYCERSKI, S., MICHAEL, K., & POLING, A.(2003). Motivating operations and terms to describethem: Some further refinements. Journal of AppliedBehavior Analysis, 36, 407–414.

LEJUEZ, C. W., HOPKO, D. R., & HOPKO, S. D. (2002).The brief behavioral activation treatment for depression(BATD): A comprehensive patient guide. Boston: Pear-son Custom Publishing.

LEJUEZ, C. W., HOPKO, D. R., LEPAGE, J., HOPKO, S. D.,& MCNEIL, D. W. (2001). A brief behavioral activationtreatment for depression. Cognitive and BehavioralPractice, 8, 164–175.

LINEHAN, M. M. (1993). Cognitive-behavioral treatmentof borderline personality disorder. New York: GuilfordPress.

LINEHAN, M. M., ARMSTRONG, H. E., SUAREZ, A.,ALLMON, D., & HEARD, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal bor-derline patients. Archives of General Psychiatry, 48,1060–1064.

LINEHAN, M. M., HEARD, H. L., & ARMSTRONG, H. E.(1993). Naturalistic follow-up of a behavioral treatmentfor chronically parasuicidal borderline patients. Ar-chives of General Psychiatry, 50, 971–974.

MARKS, I. M. (2002). Reduction of fear: Towards a uni-fying theory. Psicoterapia-Cognitiva-e-Comportamentale,8, 63–66.

MILLS, D. S. (2003). Medical paradigms for the study ofproblem behaviour: A critical review. Applied AnimalBehaviour Science, 81, 265–277.

RAUE, P. J., GOLDFRIED, M. R., & BARKHAM, M. (1997).The therapeutic alliance in psychodynamic-interpersonal


467

and cognitive behavioral therapy. Journal of Consultingand Clinical Psychology, 65, 582–587.

ROBINS, C. J., & CHAPMAN, A. L. (2004). Dialecticalbehavior therapy: Current status, recent developments,and future directions. Journal of Personality Disorders,18, 73–89.

ROBINS, C. J., & KOONS, C. R. (2000). The therapeuticrelationship in dialectical behavior therapy. In A. N.Sabo & L. Havens (Eds.), Real world guide to psycho-therapy practice (pp. 237–266). Cambridge, MA: Har-vard University Press.

ULLRICH, H. E. (1993). Cultural shaping of illness; Alongitudinal perspective on apparent depression.Journal of Nervous and Mental Disease, 181, 647–649.

WILSON, G. T. (1998). Manual-based treatment and clin-ical practice. Clinical Psychology: Science and Practice,5, 363–375.

ZETTLE, R. D. (2003). Acceptance and commitment ther-apy (ACT) vs. systematic desensitization in treatmentof mathematics anxiety. The Psychological Record, 53,197–215.


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C. W. Lejuez & Derek Hopko - The Therapeutic Alliance in Behavior Therapy