Chapter 11
BEHAVIORAL AND LEARNING MODELS

The hypotheses in this chapter apply models of learning from experimental and social psychology: operant conditioning, respondent conditioning, and social learning theory. A large proportion of treatments that are “empirically supported” incorporate these hypotheses—we need to remember that treatments that are classed as CBT incorporate behavioral as well as cognitive strategies.

Examination of research-based treatments for major disorders will reveal the use of hypotheses in this chapter. For instance, Dialectical Behavior Therapy for borderline personality disorder (Linehan, 1993a, 1993b) teaches skills for emotional regulation, an integration of Conditioned Emotional Responses and Skill Deficits hypotheses. Treatment of alcohol use disorders (McCrady, 2008) incorporates a functional analysis of drinking behaviors (Antecedents and Consequences hypothesis), modification of conditioned responses to alcohol (Conditioned Emotional Responses hypothesis), and learning of drink-refusal and relapse-prevention skills (Skills Deficit hypothesis).

Once learning principles are understood, we see them operating in many forms of therapy, besides those that carry the label behavioral. Operant conditioning occurs when therapists selectively reward specific client behaviors during therapy sessions: Even Carl Rogers was found to respond differentially with his interest, warmth, and emotional presence, based on the client’s adherence to the therapeutic task. Deconditioning of the fear of experiencing one’s own painful emotions occurs in any type of therapy when the therapist encourages the client to express emotions while providing a safe and supportive relationship. It is also helpful when the therapist functions as a role model and promotes development of social skills.

There are many benefits for deliberately applying hypotheses based on models of learning:

SUGGESTED READINGS

Because these hypotheses are commonly integrated in the clinical and research literature, a single list of suggested readings and resources is provided here.

Alberti, R. E., & Emmons, M. L. (2008). Your perfect right: Assertiveness and equality in your life and relationships (9th ed.). Atascadero, CA: Impact.

Antony, M, M., & Swinson, R. P. (2000). Phobic disorders and panic in adults: A guide to assessment and treatment. Washington, DC: American Psychological Association.

Barkley, R. A. (1997). Defiant children: A clinician’s manual for assessment and parent training (2nd ed.). New York, NY: Guilford Press.

Barlow, D. H. (Ed.). (2008). Clinical handbook of psychological disorders: A step-by-step treatment manual (4th. ed.). New York, NY: Guilford Press.

Bourne, E. J. (2010). The anxiety & phobia workbook (5th ed.). Oakland, CA: New Harbinger.

Craske, M. G., Antony, M. M., & Barlow, D. H. (2006). Mastering your fears and phobias: Therapist guide (2nd ed.). New York, NY: Oxford University Press.

Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (2009). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York, NY: Guilford Press.

Frank, R. G., & Elliot, T. R. (2000). Handbook of rehabilitation psychology. Washington, DC: American Psychological Association.

Goldfried, M., & Davison, G. C. (1994). Clinical behavior therapy (expanded ed.). New York, NY: John Wiley & Sons.

Hersen, M. (2002). Clinical behavior therapy: Adults and children. New York, NY: John Wiley & Sons.

Haynes, S. N., & O’Brien, W. H. (1999). Principles and practice of behavioral assessment. New York, NY: Plenum Press.

Hyman, B. M., & Pedrick, C. (2010). The OCD workbook: Your guide to breaking free from obsessive compulsive disorder (3rd ed.). Oakland, CA: New Harbinger.

Knapp, S. E., & Jongsma, A. E. (2004). The parenting skills treatment planner. Hoboken, NJ: John Wiley & Sons.

Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.

Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press.

Markway, B., & Markway, G. (2003). Painfully shy: How to overcome social anxiety and reclaim your life. New York, NY: St. Martin’s Griffin.

Martin, G., & Pear, J. (2010). Behavior modification: What it is and how to do it (9th ed.). Upper Saddle River, NJ: Prentice Hall.

McKay, M., Davis, M., & Fanning, P. (2009). Messages: The communication skills book (3rd ed.). Oakland, CA: New Harbinger.

McKay, M., Wood, J. C., & Brantley, J. (2007). Dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation, & distress tolerance. Oakland, CA: New Harbinger.

McMahon, R. J., & Forehand, R. (2005). Helping the noncompliant child: Family-based treatment for oppositional behavior (2nd ed.). New York, NY: Guilford Press.

Olsen, M. H., & Hergenhahn, B. R. (2008). Introduction to the theories of learning (8th ed.). Upper Saddle River, NJ: Prentice Hall.

Pryor, K. (2009). Don’t shoot the dog! The new art of teaching and training (rev. ed.). New York, NY: Bantam.

Steele, R. G., Elkins, T. D., & Roberts, M. C. (2008). Handbook of evidence-based therapies for children and adolescents: Bridging science and practice. New York, NY: Springer.

Stout, C. E., & Hayes, R. A. (2004). The evidence-based practice: Methods, models, and tools for mental health professionals. Hoboken, NJ: John Wiley & Sons.

Watson, D. L., & Tharp, R. G. (2006). Self-directed behavior (9th ed.). Belmont, CA: Wadsworth.

Weissman, M. M., Markowitz, J., & Klerman, G. L. (2007). Clinician’s quick guide to interpersonal therapy. New York, NY: Oxford University Press.

RECOMMENDED BEHAVIOR THERAPY JOURNALS

  1. Advances in Behavior Research and Therapy
  2. Behavior Modification
  3. Behavior Research and Therapy
  4. Behavior Therapy
  5. Behavioral Assessment
  6. Behavioral Psychotherapy
  7. Child and Family Behavior Therapy
  8. Journal of Applied Behavior Analysis
  9. Journal of Behavior Analysis and Therapy (electronic journal)
  10. Journal of Behavior Therapy and Experimental Psychiatry
  11. Journal of the Experimental Analysis of Behavior

ANTECEDENTS AND CONSEQUENCES

This hypothesis originated with the operant conditioning experiments of B. F. Skinner. These experiments demonstrated how behavior can be under the control of (a function of) its consequences. Picture a poor hungry rat in a cage emitting random behaviors until it presses a bar and receives a pellet of food; the bar pressing increases, and the rat would end up fat and happy if the fiendish experimenter did not decide to conduct new experiments, such as varying the intervals and frequencies for delivering the reward (reinforcer). Other experiments demonstrated that animals would learn a behavior that terminated aversive stimuli, a process labeled negative reinforcement. If the experimenter stopped giving rewards, the rat would eventually stop pressing the bar, a condition called extinction. For the behavior to be resistant to extinction, it is best to put the animal through the extinction process and then reinstitute rewards on an intermittent basis.

Further experiments demonstrated how behavior can be under the control of (a function of) its antecedents—the stimuli which precede it. A discriminative stimulus is a cue or signal that indicates that performance of the behavior will lead to reinforcement. The absence of this stimulus means that no reinforcer will be forthcoming for a particular behavior. If the experimenter adds a cue for delivery of the reward (e.g., red light), then the animal learns to press the bar only when that light is present, and to not press it with a different stimulus (e.g., green light). The behavior is “under stimulus control” when a certain cue needs to be present for the behavior to occur; we can say that it triggers the occurrence of the behavior. The concept of stimulus generalization was also demonstrated in these laboratories: When the trigger is a red light, the response will occur to lights of various shades of pink or orange. Planning for generalization is important in clinical practice to ensure that the behaviors successfully performed with the therapist will also occur outside the therapy office.

The application of these principles of learning in clinical settings formed the foundation of Behavior Modification; these principles provide the rationale for interventions currently used in Behavior Therapy and Cognitive-Behavioral Therapy. Many texts are available that teach principles of learning and therapeutic methods based on them (e.g., Goldfried & Davison, 1994; Haynes & O’Brien, 1999; Hergenhahn & Olson, 2004; Kanfer & Goldstein, 1991). The idea of “behavioral diagnosis” (Kanfer & Saslow, 1965) formed the foundation of applied behavioral analysis, a systematic method for gathering data, creating hypotheses, and developing interventions. Behavioral analysis is so powerful because it allows clinicians to focus on specific variables amid complexity, and design treatments that can be empirically validated. Perhaps the best way to learn these principles and processes is by initiating your own behavior change project, using the classic guide to self-directed behavior change by Watson and Tharp (2006). The best journal for case studies that demonstrate the use of these methods is the Journal of Applied Behavioral Analysis.

Steps in a Behavioral Analysis

A behavioral analysis or behavioral assessment is the process of clearly identifying both problem behaviors and desired behaviors, and then discovering the contingencies that will allow you to bring these behaviors under control. The data for the analysis come not only from clinical interviews but also from client homework, behavioral observation, and self-report surveys. It is important to establish a baseline of problem and desired behaviors so that improvement can be recognized and documented. When cognitive data are included in the analysis; the Dysfunctional Self-Talk (C4) hypothesis should be integrated.

Define Behaviors

The beginning of the analysis is clear definition of problem behaviors and desired behaviors (the outcome goals). The problem falls into one of two categories: excess behaviors, which need to be reduced or eliminated, and deficient behaviors, which need to be increased. The behaviors need to be operationalized: described with enough clarity so that the occurrence or nonoccurrence can be recognized and measured. A vague and general definition of a problem would be “overeating.” Three different operational definitions would be: Continues eating after attaining feelings of fullness; exceeds 2,500 calories per day; eats more than two servings of bread per day. In a research study, a binge-eating episode was defined as “the consumption of more than 500 calories while the participant reported feeling out of control” (Bosch, Miltenberger, Gross, Knudson, & Breitwieser, 2008).

Sometimes the desired behavior is obvious—exercise, studying, medication compliance—but other times it requires effort to clarify: What would the client do instead of the negative behavior? For instance, if a person wants to give up smoking, what activity will she substitute when her friends are sitting and smoking over coffee? In clarifying a desired behavior, it is essential to determine whether such behavior has ever occurred: Is the desired behavior already in the client’s behavior repertoire? You cannot increase a behavior if it is never performed. Instead, you need to apply the Skills Deficit (BL3) hypothesis and focus on shaping and training the desired behavior from scratch.

Identify Antecedents

Antecedents, also called discriminative stimuli or triggers, are stimuli that precede a behavior in time and function as cues for the occurrence of a behavior. You need to search for antecedents to both the problem and the desired behavior. For instance, the refrigerator is a trigger for overeating; a trigger for self-control could be a big picture on the fridge of a smaller-size dress that you would love to wear. The term antecedent can apply to a context or a situation, such as work, school, home, restaurant, or party. Furthermore, antecedents come from internal states and mental activity, as shown in the following:

  • Biological conditions: The behavior could occur during certain phases of the menstrual cycle, above a certain threshold of pain, under the influence of alcohol, or above a certain level of sexual arousal.
  • Emotional states: The behavior might only occur with a certain type of emotion and when the emotion is above a certain level. The SUDS should be used for quantitative measure of emotions.
  • Cognitive triggers: As discussed under Dysfunctional Self-Talk (C4), internal speech can function as a trigger for behavior. Other types of cognitive triggers are expectancies, evaluation of self-efficacy, attributions, and appraisals of threat.

To clarify antecedents, it is important to discover circumstances under which the problem behavior does not occur. You can ask: Can you think of a time when you were in that situation and the problem didn’t occur? What was different about that situation? It is also useful to identify factors that influence the rate of responding and the effectiveness of rewards (McGill, 1999; Michaels, 1993), such as deprivation (e.g., of food, water, stimulation, activity, sleep, and attention) and characteristics of the demands placed on the individual (e.g., novelty, difficulty, and disliked). For instance, the likelihood of engaging in binge eating is reduced when the individual eats frequent snacks to avoid a state of deprivation.

Identify Consequences

Consequences are those events that follow the specified behavior. You need to search for positive reinforcement (achievement of tangible or social rewards), negative reinforcement (cessation of unpleasant stimuli), punishment (aversive stimuli following behaviors), and lack of positive consequences for adaptive behavior. It is important to attend to concurrent schedules of reinforcement—one for healthy, desirable behaviors and one for unhealthy, undesirable behaviors—and to look at the immediacy of rewards, the rate of reinforcement, reinforcement quality (high versus low preferred stimuli), and the degree of effort required to achieve the reward (Sturmey, 2008). There are several questions that help clarify consequences:

  • What follows the behavior? This can be environmental events as well as self-talk and changes in emotional states.
  • How do significant others respond to the problem? You want to see if there is social reinforcement for the problem.
  • How do others respond when you begin to improve? It is common for there to be punishments in the social environment for positive change.
  • Was there a time when the adaptive behavior was getting more rewards? What changed?

Discover Potent Reinforcers

For planned reinforcement to be effective, the therapist and client must select the most powerful reinforcers for that individual. Although there are many things with a high probability of being pleasurable and rewarding, it is important not to make assumptions. Elementary school teachers realize that public praise can be a reward for one child but a punishment for another. Also, what you think is “no reward,” such as ignoring a behavior, can be a punishment (rudeness and neglect) from the other person’s point of view. There are individual differences in the strength of social needs, such as the need for recognition, approval, control, sociability, and solitude, which will affect the choice of reinforcers. Furthermore, the rewards need to be appropriate for the client’s goals: M&M candies are obviously not a good choice for people attempting to reduce their consumption of sweets. You can recognize reinforcers by identifying behaviors that the person voluntarily spends time doing—like watching TV, reading a book, listening to music, or going to a shopping mall. If someone is willing to endure physical discomfort to do something pleasurable (standing in the rain to wait for concert tickets), it is probably a strong reinforcer. What are the aversive stimuli that the client will seek to evade? For instance, wearing tight clothes provides a negative reinforcer for eating behavior: By eating less, the client can attain physical comfort.

Clarify Social and Cultural Supports for the Problem and Desired Behaviors

This next step in the behavioral analysis is often neglected, but it is extremely important not only for planning treatment but also in preparing for possible sabotage of the client’s improvement. Clarify the following with the client:

  1. Cultural norms: What are the norms in the client’s sociocultural milieu for the problem behaviors? For the desired behaviors? Are there conflicts between norms in different settings?
  2. Family/social systems: Which people or groups have the most control over current behavior, either by supporting and encouraging problem behaviors or by punishing desired behaviors? Who objects to the behavior? Who persuaded the client to seek help? How would others be affected if the problems were resolved? Who else in the family/social network should be included in therapy?
  3. Social support: If the client engages in a behavior change program, will there be social support for the change? Would the client be willing to join a group to obtain support?

Conduct a Cost-Benefit Analysis of “Change” Versus “No Change”

Any time therapists set goals with clients, it is important to examine the pros and cons of change; perhaps the benefits of staying the same outweigh the benefits of changing. Instead of waiting for resistance to appear in the implementation of the plan, it is wiser to explore, up front, sources of ambivalence, secondary gains, and fears of change:

  1. What are some payoffs and benefits for having this problem? There are advantages of staying the same, and eliminating the problem might result in loss of certain satisfactions and benefits. Examples of benefits include being relieved of responsibilities, gaining an acceptable excuse for failure, and avoiding the risks of emotional closeness. The psychodynamic concept of secondary gains refers to the rewards of holding on to symptoms and problem behaviors.
  2. What satisfactions would be gained by changes in problematic behavior? Especially if the problem behavior is pleasurable (e.g., excessive eating, drug use), it is important to clarify the benefits of change and to discover ways that achievement of a long-term goal can be more rewarding than immediate gratification.
  3. What (from the client’s point of view) are the risks, dangers, and feared consequences of changing? Change can bring new demands, be experienced as loss, or symbolize “giving in” to the demands of others.)

Clarify the Sequences

At the simplest level, there are three components to the behavioral analysis:

equation

Therapists also include internal events (thoughts, feelings, images) in the analysis, represented by the O in the acronym SORC:

equation

Once you have clarity about the behaviors you want to reduce or eliminate and the behaviors you want to elicit or increase, you need to clarify sequences of external and internal events:

  • What precedes the problem behavior (e.g., cues, triggers, settings and contexts, behavior of others, self-talk, moods, or biological states)?
  • What is the internal process (e.g., sequences among feelings, bodily sensations, thinking, and imagery)?
  • What follows the behavior (e.g., responses of people, reduction of anxiety, or the impact the behavior has on the environment)?

Do a Functional Analysis

This is what all the prior steps have been leading to: an analysis of specific contingencies that maintain problem behaviors along with an analysis of the necessary contingencies for desired behavior to replace problem behavior. The term function is used in a mathematical sense to describe contingencies.

[B]ehavior Is a Function of [A]ntecedents and [C]onsequences. Function is also a term for the inferred purpose of the behavior, with four functions commonly identified:
  1. Escape: The behavior serves to remove the client from a person, event, environment, or requests to perform an activity.
  2. Tangible rewards: The behavior attains a specific item or activity or occurs when something has been denied or taken away.
  3. Attention: The behavior achieves attention and recognition from specific individuals or class of people (e.g., peers versus adults).
  4. Sensory: The behavior feels good or meets a sensory need—it is intrinsically reinforcing. For this category, the term automatic reinforcement is used.

Having gathered data in the preceding categories, you are ready to develop hypotheses about relations among variables: When the client understands behavioral principles and has several weeks of homework charts to examine, he can recognize functional relations such as those seen in the following example of a man who wants to quit smoking: I tend to smoke with coffee, when I smell smoke, and when I am in the company of other smokers. The result of smoking is that I feel more relaxed and have pleasant interactions with strangers.

[B]ehavior of smoking is a function of [A]ntecedents of drinking coffee, smelling smoke, and socializing with smokers, and [C]onsequences of reduction of anxiety and attainment of social rewards.

Excessive eating is a common target behavior for people who are dissatisfied with their weight or who have medical problems affected by unhealthy eating and excessive weight. Here are examples of functional analyses:

  1. Hypothesis related to antecedents: Her excessive eating is under the stimulus control of being in the kitchen with a full refrigerator, while tired, after work. Cognitions can be antecedents: Her excessive eating is a function of negative self-talk: I’m so fat, what difference does it make?
  2. Hypotheses related to consequences: Her excessive eating is maintained by pleasant feelings of fullness, pleasurable tastes in her mouth, and the belief that she is nurturing herself. Excessive eating terminates the boring and frustrating experience of working at her computer.

Design an Intervention Plan

Treatment plans follow logically once the functional analysis is stated. Using brainstorming to generate a list of strategies with the client can stimulate creative thinking (Egan, 2009). For instance, in the example of the smoker, the strategy would be to change or modify the antecedents, eliminate the rewards, and, most importantly, identify a positive behavior that is incompatible with smoking and reward it. A sample plan would include reinforcing new behaviors for anxiety reduction (e.g., doing 5 minutes of breathing and stretching) and socializing with new people (remove the contingency between smoking and chatting with people by scheduling “social breaks” at random times). More discussion about treatment appears in the subsequent section on Treatment Planning.

When Is This Hypothesis a Good Match?

This hypothesis is a good match whenever you can clearly operationalize specific problem and desired behaviors, and the occurrence of these behaviors is not better explained by the Conditioned Emotional Responses (BL2) hypothesis. There are three situations in which operant principles are used:

  1. The client wants to change his or her own behavior: The client wants to eliminate behaviors (e.g., smoking, drug use, or gambling) or reduce behaviors (e.g., overeating, alcohol consumption, social avoidance, procrastination, or yelling at children). The client wants to increase behaviors: self-care activities, time spent exercising, speaking up in meetings, or time spent removing clutter from house. A couple wants to reduce conflict and increase enjoyable time together.
  2. The client wants to change another person’s behavior: The client can be taught the skills of behavioral analysis, and can be helped to design a behavior change strategy: a parent wants to increase his child’s cooperative behavior; a classroom teacher wants to reduce acting-out behaviors. Knapp and Jongsma (2004) and Barkley (1997) integrate behavioral techniques in their approaches to building parenting skills.
  3. The therapist (or other interventionist) integrates behavioral principles into the intervention: Clients with a chronic illness (singly or as members of a group) are reinforced for medication compliance. A program that integrates behavioral principles is developed to help welfare mothers return to work. In a session, the therapist praises the client’s efforts to meet new people, gives warm nonverbal reinforcement when the client opens up about painful experiences, and refuses to extend the session when the client brings up an important topic during the last 5 minutes.

There is extensive empirical support for behavioral interventions for a broad range of disorders and problems. Because functional analysis is, by definition, an individualized assessment method, empirical support is most commonly provided in rigorous single case studies. The most stringent method is to experimentally demonstrate the causal relations among variables prior to intervention. A review of these studies (Hanley, Iwata, & McCord, 2003) found that more than 70% of these published studies involved children, and the three most common problems were self-injury, aggression, and disruption. Table 11.1 provides a list of disorders and problems, the behavioral treatment, and the research source; this list is by no means exhaustive. It is recommended that you use the PsycInfo database to combine the name of a problem or disorder with the terms “behavioral treatment or reinforcement or functional analysis.”

Table 11.1 Samples of Disorders Treated With Operant Interventions

Disorder/Problem Behavioral Treatment References
ADHD Provide immediate rewards for on-task behavior (attending without disruptive behavior); progressively increase delay over time. Neef & Northup, 2007
Autism Discrete Trial Training (also called ABA): antecedent is a request or directive; behavior is the child’s response; and consequence is therapist’s reaction, positive or negative. Lovaas, 2003
Dementia Wandering behavior: Identify the exact reinforcer by observation; then restrict access and instead deliver the reinforcer contingent on intervals with no wandering. Heard & Watson, 1999
Depression “Behavioral activation”: set small specific goals that bring the person in contact with available reinforcement for nondepressed behavior. Lejuez, Hopko, & Hopko, 2001, 2002;
Drug Addiction Use vouchers to reward clean urine; impose fines for positive toxicology screen. Higgins, Heil, & Sigmon, 2007
Intellectual Deficits Functional communication training (FCT) reduces challenging behavior by teaching a functionally equivalent communication response; then teach client to request a desired tangible reward in words in presence of a discriminative stimulus indicating its availability. Carr & Durand, 1985; Fisher, Kuhn, & Thompson, 1998
Delusions and Hallucinations Combine reinforcement of rational speech with termination of interview following delusional speech. Liberman, Teigen, Patterson, & Baker, 1973
Separation Anxiety disorder Contract for reward upon completion of “alone” tasks from hierarchy. Silverman & Pina, 2008
Self-Harm Functional approach to self-harm to identify which function(s) the behavior serves (e.g., termination of negative private events, positive states of excitement; getting other people to understand severity of suffering, method of self-punishment for bad thoughts). Klonsky, 2007
Smoking Internet-based voucher reinforcement program for smoking reduction and abstinence. Video recordings of clients taking breath samples and measuring carbon monoxide provide evidence of level of smoking. Dallery & Glenn, 2005
Social Behaviors Contingency management program in residential setting for homeless vets: Use of point system increased altruistic social activities. LePage Bluitt, McAdams, Merrell, & House-Hatfield, 2006

Treatment Planning

There are two broad goals of intervention: (1) increasing desired behavior and (2) reducing or eliminating undesired behavior. When the goal is to eliminate a behavior completely—to stop doing it—then it is important to find something to fill the void: The goal of doing nothing is impossible to achieve. A treatment plan would usually combine the elimination or reduction of undesired behavior with the increasing of desired behavior. Pryor (1999), in an entertaining book on dog training, explains the principles and tactics of behavior change. Table 11.2 follows her outline in explaining eight strategies.

Table 11.2 Behavior Change Strategies Using Operant Learning Principles

Principle Intervention Strategy
Increasing Desired Behavior
Positive Reinforcement:
The experience of a rewarding, pleasurable consequence (e.g., food, money, praise, a good grade) following the behavior will lead to the behavior being repeated. If the behavior is not yet in the repertoire, a process of shaping can be instituted: the rewards can be applied to an inexact approximation of the desired behavior, with the standards for receiving a reward becoming successively more stringent.		 Identify potent reinforcers, and schedule these rewards to follow the desired behavior:
When the child completes homework, she gets to watch her favorite TV show.
Negative Reinforcement:
Behavior is repeated if it results in the cessation of an unpleasant stimulus, such as a painful emotional state, a scolding, or a frown of disapproval.		 Arrange for an unpleasant event or stimulus to be halted or avoided when the desired behavior occurs: When the child apologizes to his mother, he gets to leave the time-out corner.
Contingency Contracting:
Set up an agreement whereby performance of specific behaviors is rewarded or punished.		 Using a written contract increases the effectiveness. You treat yourself to a movie when you maintain your desired eating plan for 7 days.
Planning Reinforcement:
A detailed plan will specify the timing and the size of the reinforcer and schedules of reinforcement.		 The 1st week on the exercise program, reward yourself every day if you complete 15 minutes of exercise. On the 2nd week, you need to exercise 20 minutes to get a reward. On the 6th week, reward yourself once a week if you completed 30 minutes on 4 days.
Eliminating and Reducing Undesired Behavior
Stimulus Control:
Determine the antecedents for the undesired behavior and then remove those stimuli (or learn to avoid those situations, contexts, and people).		 Remove the trigger: Ask the server in the restaurant to remove bread from the table and replace junk food snacks at home with cut-up vegetables.
Leave the environment: Recovering addicts are told to avoid people and places that trigger their substance use.
Change the environment: A person with insomnia moves the home office out of the corner of the bedroom so that the bedroom can be solely a cue for sleeping.
Extinction:
Remove the rewards so that the undesired behavior does not receive the reinforcing consequences, and will thereby be eliminated. You need to figure out exactly what is rewarding the behavior. Parents often discover that they are inadvertently rewarding an undesired behavior.		 In studies of self-harm behavior in children, it was discovered that some children bang their heads for attention (positive reinforcement), some do it to terminate a demand or a difficult task (negative reinforcement), and others do it for the automatic reward of the stimulation it provides (Hanley, Iwata, & McCord, 2003). The logical intervention in each case, respectively, is to not provide attention, to continue to demand the task, and to provide head gear, which diminishes the sensations.
Punishment:
An aversive stimulus that is contingent on a response results in the decrease or elimination of the response. However, when used on another person, it has undesirable effects such as producing hostility toward the punisher and desires for revenge. There is also the risk of unethical use when the punishment deprives an individual of basic rights.
A punishment strategy should be combined with a positive strategy to increase the desired behavior.		 In contingency contracting, the term response cost is used when the individual has to forfeit something positive when a positive goal is not met. For instance, the adolescent loses tokens when curfew is violated; the adult has to send a $10 check to the political party she despises when she fails to exercise 3 days that week.
Reward an Incompatible Behavior:
Use rewards to increase a behavior that is physically incompatible with the undesired behavior.		 A mother was worried that her son was spending too much time at the computer. She enrolled him in a karate class. At first, she planned to give him rewards for attendance, but then she discovered that there were plenty of rewards built into the program.

General Guidelines

The client should be actively involved in planning and implementing the treatment. Homework assignments are intrinsic parts of treatment. Many intervention programs provide training in self-management techniques, which include self-monitoring, self-evaluation, and self-reinforcement. Encourage the client to interpret the data and apply behavioral principles to build skills for behavioral management of future problems. For instance, the client can seek relevant books, find good role models among acquaintances, and make plans for practice between sessions.

Implement Behavioral Techniques With Empathy and Flexibility

Behavior therapists structure the session, typically beginning with an agenda and ending with a homework assignment. Although in most circumstances it is appropriate to stick to this structure, there will be times when something is happening in the client’s life that takes priority. There is evidence that clients who rate their therapist as warm and caring at the beginning of therapy will have better outcomes.

Discover Reasons for Client’s Noncompliance With Treatment Plan

Explore with the client reasons for noncompliance, and conduct another cost-benefit analysis of change versus no change. Adhering to behavioral principles, you might need to search for more potent reinforcers, provide reinforcement for smaller steps toward the goal, or gather more data to improve the functional analysis. The Internal Parts (P1) hypothesis is always useful when clients are not fully engaged in their change programs. You can ask to hear from the “inner parts” that oppose the direction of therapy. For instance, “the drinker” is in conflict with “the abstainer.” It is possible that the problem behavior serves a self-protective function, and the Unconscious Dynamics (P4) hypothesis might be considered: For instance, because a doctoral degree represents achieving the highest level of success in the family, unconsciously the student might equate completion of the dissertation with shaming his father. Framing this in behavioral terms, the avoidance behavior is reinforced by reduction of guilty feelings.

Two Examples of Behavioral Treatment

Depression and marital distress are two examples of problems for which behavioral methods have been shown to be effective.

Behavioral Treatment of Depression

The earliest behavioral theory of depression was that depression is caused or maintained by the absence of positive reinforcement in a person’s life (Ferster, 1973; Lewinsohn, 1974; Lewinsohn, Antonuccio, Steinmetz, & Teri, 1984). Depression is associated not only with inertia and low energy but also with social withdrawal, which deprives the person of positive social reinforcement. The logical treatment plan is to have the individual adhere to a plan of gradually increasing activity that brings rewarding consequences.

This strategy is incorporated in Behavioral Activation (BA; Martell, Addis, & Jacobson, 2001), a treatment program for depression with two components: (1) increasing behaviors that lead to positive affect and a sense of mastery, and (2) replacing avoidance patterns with alternate coping responses. Because most depressed clients believe that their mood must improve before they can become more active, therapists must persuade them that if they increased activity first, a more positive mood would follow. Several research studies that conducted a component analysis of CBT for depression found that the behavioral activation component was sufficient to explain recovery, and that the cognitive component did not add significantly to the outcome (e.g., Jacobson, Martell, & Dimidjian, 2001).

With a thorough behavioral analysis of “depressive behavior,” one of the following four hypotheses (Kanter, Cautilli, Busch, & Baruch, 2005) can lead to individualized plans.

  1. A lack of or reduction in positive reinforcement. Circumstances that result in the loss of positive reinforcement include the death of a loved one, loss of a job, geographic relocation, and loss of physical or cognitive activity from aging or injury. Sometimes the reinforcer is still available but occurs so rarely or requires so much effort that the person gives up the behavioral responses that would lead to reinforcement.
  2. Too much punishment of behavior. This can lead to escape and avoidance, further lessening the chance to receive positive reinforcement. This hypothesis may fit the depression of children with academic difficulty or living in a home with a high rate of parental conflict.
  3. Reinforcement of depressive behaviors. Some depressive behaviors (e.g., complaining, pacing, crying) can be maintained by negative reinforcement: they serve to terminate or avoid aversive stimuli. Positive reinforcement for depressive behaviors occurs when there are solicitous responses from partners or acquisition of tangible benefits that would not be awarded without depression.
  4. Deficiencies in behavioral repertoire. The behaviors needed to obtain reinforcement have either been extinguished or were never learned (the Skill Deficits (BL3) hypothesis should be integrated).

Marital Behavior Therapy

Datillio (1998) reviewed cognitive behavioral principles and provided cases where behavioral interventions are integrated with systems approaches. A behavioral assessment usually reveals that the partners are exchanging many negative behaviors and few positive behaviors. The therapist adds behavioral observation of the couple’s interaction in the office to their separate self-reports. Because each spouse probably has a different behavioral definition for love, they need to define the loving behaviors they desire from their spouse. Then each spouse agrees to voluntarily provide those behaviors, perhaps scheduling “caring days” (Stuart, 1980) or making contracts to exchange these positive behaviors. The increase of positive behaviors leads to the growth of affection and the cessation of hostility that has caused misery and loss of sexual interest.

Behavioral analysis of couples’ interactions will show circular causation: he withdraws because she nags; she nags because he withdraws. Each person’s aversive behavior is a discriminative cue for the other’s aversive behavior. Marital therapists can help change the pattern by getting the partners to contract that each individual will engage in positive behaviors that are not contingent on the other person’s actions. Christensen and Jacobson (2000), in what is called Integrative Behavioral Couple Therapy, add another component to behavior therapy: they help each partner recognize behaviors in the spouse that cannot be changed, and learn to respond with acceptance.

CONDITIONED EMOTIONAL RESPONSES

This hypothesis is based on the classical conditioning paradigm: Pavlov’s experiments demonstrated how pairing presentation of food with the sound of a bell resulted in a dog salivating when a bell rings in the absence of food.

  1. Unconditioned stimulus: Causes a response without any learning or training (e.g., blink at bright light, flinch at loud noise, fight-flight reaction when attacked by wild beast). In Pavlov’s experiment, food is an unconditioned stimulus for salivation.
  2. Conditioned stimulus: Meaningless in themselves (e.g., ringing of bell, colored light, or money), these stimuli have been paired with an unconditioned stimulus. Pavlov presented the bell immediately before food.
  3. Stimulus generalization: The response will occur to stimuli that are similar to those of the original learning experience.
  4. Extinction: If the unconditioned stimulus never appears again, the conditioned response fails to occur. The sound of the bell returns to being a neutral stimulus.

In order for extinction to occur (for the response to be deconditioned from the conditioned stimulus), it is necessary for the animal to remain in contact with (be exposed to) the conditioned stimulus long enough to learn that the unconditioned stimulus is not forthcoming. Experiments with escape training are particularly relevant to clinical situations because they show why extinction does not occur in the natural course of experience.

This example actually contains both classical and operant conditioning: The excessive, inappropriate fear was caused by classical conditioning; the escape/avoidance behavior is an operant that received negative reinforcement—it terminated the aversive, painful stimuli. Effective treatment does not require discovery of the original conditioning situation or exploration of buried issues, quests that would require a lengthy amount of time. A short-term structured approach that targets the emotional overreaction and promotes new learning experiences achieves the desired outcome in a cost-effective way.

Relaxation is a physiological and emotional state that is incompatible with distressing emotions. Wolpe’s (1958) treatment model for anxiety, which he called reciprocal inhibition, was to pair relaxation with the cue for anxiety, thereby performing counterconditioning to supplant the original conditioning. He developed the treatment approach of systematic desensitization, which uses an imagery technique for counterconditioning of anxiety: clients learn how to relax, and then learn to trigger their relaxation response while exposed, in imagery, to conditioned stimuli for anxiety. In this treatment method, the therapist and the client prepare a hierarchy of situations, starting with a situation that is relatively distant from the feared stimulus. The client progresses step-by-step up the hierarchy, after successfully maintaining composure during exposure to progressively more distressing situations.

In contrast to Wolpe’s approach of gently going up a hierarchy (called graded exposure), keeping fear within manageable doses, the techniques of implosive therapy (Stampfl & Levis, 1967) and flooding (e.g., Foa, Blau, Prout, & Latimer, 1977) involve triggering the maximum amount of anxiety/fear to achieve extinction. The success of two opposite approaches led to the view that “the key element in fear reduction was simply sufficient exposure—preferably in vivo—to evocative cues until distress diminished” (McNally, 2007).

New Developments

One new development in behavioral treatment is the use of virtual reality exposure therapy (VRET), in which patients are immersed in a computer-generated virtual environment, often with body tracking devices (Krihn, Emmelkamp, Olafsson, & Biemond, 2004; Krijn, Emmelkamp, Olaffsson, Schuemie, & Van der Mast, 2007). This method has been found effective for people with fear of heights, flying, and spiders, and there have been examples of successful case studies for claustrophobia, fear of driving, fear of public speaking, pan disorder, and PTSD.

Another area of progress is the emotional processing theory of Foa and colleagues (e.g., Foa, Huppert, & Cahill, 2006). They describe two types of habituation that result in reduced fear: within-session habituation weakens the association between the feared stimuli and the fear response (the patient learns that he can experience the feared stimulus with a low level of fear) and between-session habituation represents a restructuring of the fear memory.

Significant progress in understanding the conditioning and extinction of fear responses is being made in neuroscience research. The medial prefrontal cortex (mPFC), a region of executive functions, contributes to suppression of conditioned fear. Based on studies of rodents and PTSD subjects, McNally (2007) suggests that “any intervention that can boost activity in the mPFC during exposure to fear provoking stimuli may yield therapeutic benefits” (p. 755). The amygdala is the second brain region of relevance. McNally summarizes research on the discovery that administration of chemicals that affect glutamatergic receptors prior to exposure therapy can lead to faster extinction by fostering within-session habituation. Bentz, Michael, de Quervain, and Wilhelm (2010) describe their successful use of glucocorticoid treatment in combination with exposure therapy. Clearly, the Mind-Body Connections (BE3) hypothesis is relevant to anxiety disorders.

When Is This Hypothesis a Good Match?

There are many situations where extreme emotional reactions are justified, such as being a victim of social injustice (Social Problem Is a Cause [SC5]). If your goal were only to reduce unpleasant emotions, you would fail to engage in necessary problem solving and action. You need to establish that the emotional responses are not appropriate to the situation and are causing undesired consequences.

Is There Cognitive Mediation?

In dealing with excessive emotional responses, it is important to gather data about cognitive triggers. If there are cognitive triggers, then Antecedents and Consequences (BL1) combined with Dysfunctional Self-Talk (C4) will lead to a cognitive behavioral intervention: Develop more adaptive self-talk and the excessive emotional reaction will diminish. With many clients, however, the emotional reaction occurs without conscious thinking. The client already may know that the feelings—anxiety, fear, or anger—are irrational responses. Under those circumstances, Conditioned Emotional Responses (BL2) is the best-fitting hypothesis.

Empirically Supported Treatments

In comprehensive review chapters, Emmelkamp (1994, 2004) reported substantial research support for the effectiveness of exposure in vivo for anxiety disorders (simple phobia, panic disorder, agoraphobia, social anxiety, or social phobia) and obsessive-compulsive disorder (OCD). Posttraumatic stress disorder (PTSD) responds to imaginal exposure and generalized anxiety disorder is improved through relaxation training (see Table 9.4 in Chapter 9 for relaxation training techniques). Table 11.3 presents a list of disorders for which there are empirically supported exposure-based treatments.

Table 11.3 Examples of Disorders Treated With Exposure Interventions

Disorder/Problem Behavioral Treatment References
Disorders with emotional avoidance (e.g., anxiety, mood, somatoform, and eating disorders) Target subtle emotional avoidance strategies, use emotional awareness training and imaginal exposure tailored to symptoms Allen, McHugh, & Barlow, 2008
OCD Exposure and response prevention (ERP) Abramowitz, Braddock, & Moore, 2009
Steketee & Pigott, 2006
Panic disorder Panic Control Treatment (PCT). Exposure to interoceptive stimuli voluntarily increase activities that bring about symptoms, for example, spin chair to get dizzy. Craske, Barlow, & Meadows, 2000
Forsyth, Fusé, & Acheson, 2009
Morissette, Bitran, & Barlow, 2010
Specific phobia Systematic desensitization; graded in vivo exposure; in vivo flooding; virtual reality exposure. Choy, Fyer, & Lipsitz, 2007
Social phobia/Social anxiety disorder Exposure, using a hierarchy from least to most anxiety-producing social situations. Barlow, Raffa, & Cohen, 2002
Beidel & Turner, 1998
Rodebaugh, Holaway, & Heimberg, 2004
Trauma-related disorders Imaginal exposure to trauma memory; in vivo exposure to treat phobic avoidance of reminders of trauma. Foa, Keane & Friedman, 2000
Hembree & Feeny, 2006
Keane & Barlow, 2002

Treatment Planning

Regardless of the differences in specific strategies and techniques, the core elements of treatment are achieving extinction through exposure and counterconditioning a new response to the conditioned stimulus.

Imaginal or In Vivo Treatment?

In vivo refers to treatments occurring in the real world, outside of the therapist’s office, as well as facing the real object within the office. For instance, if the person is afraid of snakes, instead of using imagery, the therapist could bring a harmless caged snake into the office or go with the client to the snake exhibit at the zoo. Exposure to interoceptive stimuli is an in vivo method that occurs in the office: To help a person with panic disorder reduce her fear of dizziness, she is told to twirl around in a chair until she becomes dizzy. The success of imaginal methods depends on the client’s capacity to create images that produce physiological arousal; not all people can do that. Imaginal methods may be particularly appropriate for PTSD because the feared stimulus is in fact the recollection in memory, rather than an external situation.

Even when in vivo exposure is the treatment of choice, therapists may be reluctant to leave their offices and schedule time more flexibly. There are circumstances when it is necessary to use imagery, as when the client refuses (or is not yet prepared) to face the object in reality or the real situation is not available. Moulds and Nixon (2006) emphasize that exposure involves situations that evoke fear but are objectively safe; therapists do not want clients to confront or recreate a potentially life-threatening event.

Relaxation Training

The first part of many treatment plans is giving the client the opportunity to learn to relax. Table 9.4 in Chapter 9 (Mind-Body Connections [BE3] hypothesis) describes several methods of relaxation training. The choice of approach is a pragmatic one: Use what works best for the client. The therapist teaches the method in the office, and assures that the client is mastering it. Then the client is given homework to practice it on a daily basis, sometimes with an audio tape provided, often recorded in the client’s own voice. A goal of relaxation training, and the prerequisite for many interventions, is the ability of the client to enter a relaxed state (to lower the SUDS level) in a few seconds.

Systematic Imaginal Desensitization

In this technique, anxiety-producing cues are imagined vividly while the client stays in a relaxed state, thereby successfully pairing that set of stimuli with a relaxation response instead of anxiety. The therapist structures the sessions, starting with the lowest item on the hierarchy. When the client can imagine it without a rise in anxiety, then the second item in the hierarchy is introduced. The therapist assures that the scenes are presented at an appropriate pace, asking the client to report his SUDS level.

Conduct a functional analysis: Wolpe (1995) described how he conducted a functional analysis with a man whose anxiety symptoms interfered with his job’s requirement to visit managers of companies in their offices. The variables that determined the intensity of the anxiety were particularly important when it was time to prepare a hierarchy from “easy” (low anxiety) to “most difficult” situations:

Develop a Hierarchy

With this information, it was easy to construct hierarchies for different components of the problem: familiarity of people, closeness of toilet, importance of occasion, importance of other person, amount of time waiting in the waiting room, and duration of interviews. In Wolpe’s (1995) hierarchy for time spent with a manager, the lowest item was Imagine that you have just entered the office of a manager who has a rule that no representative is permitted to spend more than 2 minutes in his office. The length of time with the manager was gradually extended until the client, by the ninth session, could imagine a 60-minute meeting without anxiety. Then a new hierarchy for anticipatory anxiety was begun. The use of the SUDS scale is useful for developing a hierarchy of emotion-evoking stimuli. The lowest item is something that is very easy to deal with (say, a SUDS of 5), and each successive item should represent a very small step up the ladder toward the top of the hierarchy. By using the SUDS, you can compare the client’s rating of the situation before the imagery activity and after; the goal could be to terminate when the SUDS level is 3.

Here are some examples of low, medium, and high items for several problems:

Fear of freeways

  • Low: You are studying a map and planning a trip, running your finger over a major freeway.
  • Medium: You are driving on a freeway very early on a Sunday morning, without any traffic.
  • High: You are on a very crowded freeway during rush hour and need to change lanes to exit.

Anxiety about dating

  • Low: You are studying in the cafeteria and notice a girl reading a book.
  • Medium: You are asking a girl in your class to study together for an exam.
  • High: You are having dinner with a girl, and there is a long silence.

Easily provoked to road rage

  • Low: You notice that someone several cars ahead of you changes lanes without signaling.
  • Medium: Someone cuts ahead of you on the freeway.
  • High: You are driving slowly and a car speeds past you with the driver pressing on the horn, while the passenger gives you a rude hand signal.

Graduated In Vivo Exposure

Instead of or in combination with imagery techniques, the therapist and the client create a hierarchy of real-world situations, and the client must first successfully accomplish an activity before moving up the hierarchy. This approach is effective for phobias (e.g., flying in a plane; freeway driving) and for situations where high anxiety interferes with performance (e.g., public speaking anxiety, social anxiety).

Implosion and Flooding

Instead of using a gradual hierarchy, this approach uses intensely distressing scenes from the beginning, and therapists use imagery to intensify the emotion. By forcing the client to face the feared image or object, the emotional response will be experienced and then extinguished. Therapists must be careful that they stay with a scene until the anxiety has been noticeably reduced and at least partly extinguished. If they were to end a session when the anxiety was still at its peak, they would actually be sensitizing the client, and the anxiety and avoidance might be worse. Wanderer and Ingram (1990) reported the use of a flooding treatment for phobias that used a blood pressure monitoring device to ascertain that anxiety reached a peak and then diminished with repetitious exposure to the feared stimuli.

Aversive Conditioning

The principles of emotional conditioning can be used as part of treatment when the client wants to stop doing a behavior that he or she enjoys. For instance, if someone wants to stop drinking alcohol, she could smell a nausea-inducing substance at the same time that she sips the beverage. To stop smoking, a person could sit in a very small closed space and continue to chain smoke until vomiting is induced.

Covert Sensitization

This technique is the same as aversive conditioning except that the paired stimulus and response are imagery. The client would imagine consuming an alcoholic beverage while the therapist describes disgusting scenes. This method can also be used when the client wants to stop being sexually aroused by certain stimuli. For instance, a criminal sex-offender might benefit from pairing imagery of painful experiences to the images that stimulate criminal behavior.

Response Prevention for Obsessive-Compulsive Disorder

An extinction method for people suffering from OCD is called response prevention. The compulsive rituals were assumed to have been conditioned by the negative reinforcement paradigm: They are maintained by reducing an aversive emotional state. As long as the rituals occur, the anxiety does not have a chance to be extinguished. When the compulsive ritual is prevented, the client initially feels a rise in distress. However, anxiety can then be extinguished. Hyman and Pedrick (2005) have a self-help manual for sufferers of OCD that integrates this technique.

Group Treatment for Social Anxiety

Exposure Group Therapy (Hofmann, Newman, Becker, Taylor, & Roth, 1995) consists of 8 to 12 weekly sessions with the following components: in-session in vivo exposure to social performance situations, video feedback, didactic training, and homework assignments (e.g., asking participants to face real-life situations that were simulated in role-plays, and instructing them to remain in the situation until their anxiety goes down). Groups may take a field trip to practice facing fears in real life. A humorous portrayal of this approach was shown on the TV show Cheers, when the psychiatrist Frasier Crane took his “self-esteem group” to the bar to socialize. The group format also includes social skills training and cognitive change, often focused on self-perceptions (e.g., the belief “If others get to know me, they won’t like me”; Hofmann, 2000).

Anchoring

Anchoring is a method that prepares people for situations that are anxiety producing, such as taking the GREs or sitting for an oral examination. It uses classical conditioning principles, pairing a relaxed state to a cue that is under the client’s control. The cue can be a word (calm), a phrase (let it go), a visual image (picturing a waterfall), or the sense of touch (pressing a freckle on the hand). The imagery method at the end of Table 9.4 is useful for this technique. To set up an anchor, use the following steps:

  • Conditioning phase: Have the client enter the imaginary scene and use all of her senses to induce a very relaxed state. When that state is achieved, she uses the cue (e.g., pressing the freckle for several seconds) and then returns to an alert state. The pairing of cue and relaxation is repeated two more times.
  • Testing: Now, the client is asked to just use the cue. The desired result is for there to be a sudden switch back to the relaxed state. If this does not occur, repeat the conditioning phase.
  • Homework: The client is instructed to practice the conditioning and testing at home, at least once a day.

Once the relaxed state is successfully anchored, the client has a very useful coping tool: The lowering of anxiety or anger is now under control by simply pressing the freckle. This technique is useful for therapists as well as for clients: you could use it in a session when you are experiencing a high level of anxiety.

Integration of Cognitive Methods

Even when cognitive change is not the direct target, and the treatment modality is based on conditioning models, there will inevitably be major change in the client’s cognitive map. The client comes to believe: “Instead of being a passive victim to emotional storms that are out of my control, I can control my emotional response.” Objects and situations that were mislabeled as threatening are relabeled as harmless. Overgeneralization is replaced with appropriate discrimination: “Rapists are dangerous, but sex with my loving husband is not.” In the emotional processing theory of Foa and colleagues (2006), “new corrective information” is an essential ingredient for change. Therefore, direct focus on cognitive variables can contribute to positive outcome. For instance, when conducting exposure techniques, it can be helpful to teach coping statements (see “stress inoculation” [Meichenbaum, 1977] in the Dysfunctional Self-Talk [C4] hypothesis section).

SKILL DEFICITS

All approaches to therapy produce new learning, even when the therapist does not formulate the approach in those terms. Rogerian therapy builds skills in self-exploration and self-direction. Psychoanalytic therapy teaches people the skills of tolerating painful affect without needing to distort reality. Existential therapy helps people develop the skills of creating meaning and taking responsibility. Almost any problem can be put in the frame of “needing to learn something new.” Even if there is a biological cause, the individual needs to cope with impairments and required changes in lifestyle. When neuroscientists talk about “new pathways in the brain,” “neural integration,” and “plasticity of the brain,” they are describing the physiological underpinnings of new learning.

Stating Goals as Competence Objectives

The target of learning becomes clear if you word your outcome goals in terms of skills, performance, behavior, and competence (see Chapter 4 for a more thorough discussion of outcome goals). The following goals for the problem Excessive conflict in marriage show the progression from initial, abstract goals to specific competence objectives:

  • Less conflict in marriage.
  • Have tools to resolve conflict effectively.
  • Have the ability to control defensive responses to criticism and express anger and disagreement without hostility and blame.

Modeling

Bandura (1977, 1989) supplemented conditioning principles of learning by describing how people learn from models. The learner needs to observe and mimic a person who already has the skill. The model can be someone on videotape, the therapist giving a demonstration, a peer participant in a group who already has the desired level of competence, an acquaintance of the client, or characters in books and movies. The client can even be asked to create, in imagery, a model of competent performance. One important principle to remember is that people learn better when the model is not “perfect,” but rather is close to their current skill level. If the model is too far above them in competence, they will not be able to imitate successfully. As the client improves, more proficient models will be appropriate.

Shaping

Shaping consists of taking a very small tendency in the right direction and rewarding it. You start with the client’s current level of functioning, finding something to praise about the performance. Then step-by-step, a higher standard is required to earn praise. The term successive approximations is used for this gradual progression toward the ultimate competence goal. When different components of a complex skill have been learned separately, rewards are given for combining them together, a process called chaining. A planned shaping program follows established rules, such as how to raise the criteria for reinforcement, training one aspect of a behavior at a time, and ending on a positive note.

When Is This Hypothesis a Good Match?

The therapeutic outcome for all participants in psychotherapy is improved skills, whether or not the therapist framed their problems as “skill deficits.” The Skill Deficits hypothesis can be applied to virtually every problem. Skills are necessary for success in every one of the life domains in Table 3.2. The topics of skills was addressed previously in Chapter 8 (health-promoting skills) and Chapter 9 (cognitive skills). Table 11.4 illustrates categories of functioning that can be treated with a skills-training approach.

Table 11.4 Examples of Skills-Training Domains

Interpersonal Skills
Basic Communication
There are many good texts on basic communication (e.g., McKay, Davis, & Fanning, 2009) that teach the following skills: (a) awareness of nonverbal behavior in other people as well as in oneself; (b) attentive listening (and overcoming blocks to listening); (c) expression of all facets of awareness, including thoughts, feelings, observations, and wants; (d) use of “I-messages”; and (e) empathic responding to other person’s feelings and meaning. Tannen (2001) explained the differences in communication styles between men and women and gave tips for building skills of intergender communication. Intercultural communication requires specialized knowledge and skills: Some clients will recognize a need to develop what Dresser (2005) calls multicultural manners.
Social Skills
Social-skills training fits the needs of varied clients at different levels of functioning. Chronic mental patients need social-skills training both for practical tasks (e.g., shopping) and to increase their positive interactions. Autistic children are usually provided with intensive one-on-one therapy to shape their behavior. Social-skills training for adults combines anxiety reduction with practice in skills of appropriate nonverbal behavior, initiating a conversation, offering appropriate self-disclosure, following up on “free information” that the other person gives, making small talk, and asking for a date. Social-skills groups for children are effective for conduct disorders (Alvord & Grados, 2005) and social phobia (Beidel, Turner, & Morris, 2000). Classroom programs like “Teaching Students to Get Along” (Canter & Petersen, 1995) can prevent mental health problems of children at risk.
Assertiveness
Assertiveness is defined as self-expression that respects the rights of others; in contrast, aggressiveness violates others’ rights and causes hurt, and nonassertiveness involves the failure to express feelings, needs, and limits. Effective strategies of Assertiveness Training (AT; Alberti & Emmons, 2008; Lange & Jakubowski, 1978) were developed to help people overcome both the passivity that stems from fear and lack of confidence, and the aggressiveness that comes from excessive anger. In addition to skills for managing emotions and restructuring thinking (e.g., building a sense of rights), AT teaches how to make requests, say no, and give and receive negative feedback. The goal of “setting interpersonal boundaries” can be broken down into specific skills (Whitfield, 1987).
Marital Relationship
Many of the prior topics are relevant for couples in committed relationships. Gottman (2002) teaches couples to avoid the “Four Horsemen of the Apocalypse”: criticism, defensiveness, contempt, and stonewalling. Christensen and Jacobson (2000) teach couples to negotiate for change as well as to recognize traits and behaviors that can’t be changed, but instead require acceptance. Schnarch (1998) teaches couples to practice “hugging until relaxed” as the first step toward creating a fulfilling sexual relationship. The program called Practical Application of Intimate Relationship Skills (PAIRS; www.pairs.com) includes skills in confiding, building self-esteem, and “complaining without blaming.”
Parenting
Competence in parenting includes the ability to be empathically attuned; to understand developmental stages; and to be a good role model of communication, emotional maturity, and intimacy. Parent training programs generally combine several skills components, such as communication, problem solving, anger management, stress management and self-control, skills of behavior management, and skills of “turning over control” to children as they advance in maturity. Knapp and Jongsma (2004) provide a treatment planner for parenting skills. When parents improve their skills at coping with their own stress, they interact more positively with their aggressive children, who then behave better (Kazdin & Whitley, 2003).
A strict, consistent, directive parenting style, combined with warmth, increases academic achievement of inner-city children (McLoyd, 1998). Oliver and Ryan (2004) wrote Lesson One: The ABCs of Life—The Skills We All Need But Were Never Taught to help parents build the following skills in their children: “self-control time” (breathing to relax), self-confidence, responsibility and consequences, problem solving, and cooperation. Barkley (1997) provides a program for parents of defiant children.
Life Skills
Problem Solving/Decision Making
Effective problem solving requires a systematic approach: (1) Identify and clarify the problem; (2) Gather information and search for explanations; (3) Brainstorm alternative solutions; (4) Evaluate the costs and benefits of each option and choose the best; (5) Implement action plan and monitor results. The therapist can teach clients decision-making skills by using a chart, listing all possible alternatives on the left and creating columns for “advantages” and “disadvantages.” Effective programs for children use video models of good problem-solvers (Webster-Stratton & Hammond, 1997). Shure and Spivack (1980) developed a successful school-based program called “I Can Problem Solve.”
Psychosocial Rehabilitation
Liberman (1992) was a pioneer in developing the field of psychosocial rehabilitation for chronic mental patients. Partial Hospital Programs or Day Treatment Programs are settings where people can get training in varied skills, including activities of daily living (e.g., how to cook, comparison shop, plan a menu, and budget money). These programs are relevant for groups such as the chronically mentally ill, including the homeless (A. Gonzalez, F. Gonzalez, & Aguirre, 2001); people recovering from strokes; and mentally ill substance abusers (Anderson, 1997).
Employment/School
For people with severe disabilities, development of vocational skills may include sheltered work experiences, placement into volunteer jobs, or transitional employment placement to learn work skills. Participants with chronic mental illness are taught how to complete a job application form, what they do and do not have to tell employers about their illness, and how to write a resume. Many complaints of anxiety, fear of failure, and low job dissatisfaction can be formulated as deficits in the skills needed to succeed in the school or work setting. These include study skills, test-taking skills, project management skills, supervisory/management skills, and skills for participating in/leading teams.
Time and Life Management
Time management skills apply not only in business but also in setting and achieving personal and family goals. Lakein (1996) provides tools of time management to achieve both short and long-term goals. Covey (2004) also teaches life management skills, including how to categorize tasks along two dimensions—importance and urgency. People often lack skills in money management and financial planning.

Treatment Planning

It may be helpful to orient the client to the “learner role,” which requires an acceptance that achievement of proficiency requires effort, practice, and acceptance of mistakes. The learner must understand that there are stages to becoming competent. Sports analogies are useful. For instance, in tennis, the learner will practice forehand, backhand, and serves extensively before putting the skills together to play a game.

Evaluating Competence

The most important question is: Is the skill in the client’s repertoire? Does the client lack the skill completely or can he or she perform it with even a small degree of competence in at least one context? Sometimes the person has a high level of skills in one context but not in another. For instance, a poor public speaker can be a very effective communicator in one-on-one dialogue. When the presenting problem is anxiety or fear regarding a specific situation (e.g., public speaking, going on a blind date, or accepting a promotion at work), it is essential to evaluate the client’s competence.

Sources of data include the client’s self-report as well as the clinician’s observations. In some contexts, such as psychiatric wards, residential treatment centers, and classrooms, direct in vivo observation is possible. For academic skills, standardized tests and grades provide data about competence. The client’s behavior with the therapist is an important source of data about interpersonal competence and cognitive skills. In conjoint therapy, therapists can assign a task to the couple or family, and then evaluate their skills in communication, problem solving, negotiation, and delivering positive messages.

If the person lacks competence, fear of failure is justified; if you reduce anxiety without helping the client improve performance, she may encounter very punishing and demoralizing consequences for risk taking. When clients set goals for competence in certain areas, you may need to help them evaluate their limits as well as their strengths. People have individual differences in their talents, abilities, and potential, and sometimes a client has reached the ceiling of competence. For instance, not all people will succeed in doctoral programs, sell their screenplays, or become successful entrepreneurs. According to The Peter Principle (Peter, 1969), corporations often promote people to positions for which they lack abilities. For example, a brilliant engineer might be an ineffective team leader.

Graduated Tasks and Homework

The skill is broken down into components, and a step-by-step plan is developed. As we would expect when learning a sport or a musical instrument, there is a need to develop a hierarchy of difficulty. An important principle in planning is that success must be ensured at each step. If the gap between consecutive steps is too great, the therapist must devise an intermediate step. With this approach, there is no failure for the client. If the client fails to do a homework assignment, the therapist will set a smaller goal for next time. Some of the tasks will be in the therapy session; for social skills training, group modalities are the treatment of choice so that clients can practice with peers. Other tasks will be assigned for in vivo practice between sessions.

Behavioral Rehearsal

The following instructions are adapted from Clinical Behavior Therapy (Goldfried & Davison, 1994) and Responsible Assertive Behavior (Lange & Jakubowski, 1978). Before implementing the actual behavioral rehearsal technique, take the following steps:

  1. Evaluate the client’s developmental level: Be sure that the client has the psychological maturity to differentiate role-playing from reality, and be ready to stop the activity immediately if the client takes the role-play for a real interaction. This is especially necessary if the therapist is going to play the part of someone who is hostile and critical.
  2. Clarify outcome: The client’s behavior, not the other person’s response, defines success. Be sensitive to cultural differences, showing awareness of what the client believes is appropriate in the specific situation for which the client is preparing.
  3. Explain the technique: Keep the explanation brief and encourage the client to try it first and discuss it later.
  4. Use of SUDS: Teach the use of this scale (if the client has not already learned it) and explain that you will be asking for SUDS numbers at various points in the rehearsal. The SUDS level should be in the 4 to 6 range for the most effective performance (relaxation training methods are explained under the Mind-Body Connections [BE3] hypothesis).
  5. Cognitive tools: In preparation for rehearsal, help the client build a sense of rights, challenge catastrophic fantasies of a possible outcome, and substitute adaptive self-talk for maladaptive self-talk.
  6. Establish a hierarchy of situations: In preparing the client to face a particular encounter, start with easier situations and work up to the target situation.

Interpersonal Therapy (IPT)

Klerman, Weissman, and colleagues (Klerman & Weissman, 1993; Klerman, Weissman, Rounsaville, & Chevron, 1984; Weissman, Markowitz, & Klerman, 2007) developed a treatment approach for depression built on the theory of Harry Stack Sullivan (1968) and Bowlby’s attachment theory (1988). Their structured approach focuses on four problem areas: grief, interpersonal disputes, role transitions, and interpersonal deficits. IPT has been empirically supported as a treatment not only for depression (e.g., David-Ferdon & Kaslow, 2008; DeMello, de Jesus Mari, Bacaltchuk, Verdeli, & Neugebauer, 2005) but also for eating disorders, social phobia, marital distress, substance use, and borderline personality disorder (e.g., Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Markowitz, Bleiberg, Pessin, & Skodol, 2007; Wilfley et al. 2002). The website for practitioners of IPT is www.interpersonalpsychotherapy.org

Therapy includes a communication analysis: the client describes, in detail, specific interactions with a significant other, recreates the dialogue, and is guided to recognize their emotions and to report, objectively, the responses of the other person. Markowitz and colleagues (2007) describe a typical session:

Dialectical Behavior Therapy (DBT)

Linehan (1993a, 1993b) developed this therapeutic approach for treating borderline personality disorder (BPD). The final module in her program is called interpersonal effectiveness skills. Clients are taught to analyze challenging interpersonal encounters, attending to factors such as priorities, timeliness, authority, rights, long- and short-term goals, and the potential impact of communication on self-respect and the future relationship. To prepare for an encounter, performance goals are selected (e.g., “Ask firmly, resist no” versus “Ask tentatively, take no”) and decide on a strategy. The acronym “DEAR MAN” encompasses seven skills: Describe the problem, Express feelings, Assert what is wanted, Reinforce the message, stay Mindful, Appear confident, and Negotiate.

Group Treatment for Social Skills Training

Group interventions are the preferred modality for building social skills because they promote reduction of anxiety through exposure and support, offer opportunities for rehearsal and feedback, and provide varied role models. When CBT is delivered in a group format for anxiety and depression, it usually incorporates a skill-building component. Beidel, Turner, and Morris (2000) developed Social Effectiveness Therapy for Children (SET-C) for children with social phobia and found significant clinical improvement in its participants, compared to a control group. The skills-training component included instruction, modeling, behavioral rehearsal, corrective feedback, and homework. One innovative component was a “peer generalization session”: a weekly social event such as bowling or a pizza party with an equal number of peers who demonstrated good social skills and “a desire to work with shy children.” Their analysis of follow up data illustrates why skills training is such a potent intervention: there was continued improvement during the 6 months following treatment termination. Skills training is also imbedded into HIV prevention programs for adolescents (Ingram, Flannery, Elkavich, & Rotheram-Borus, 2008).

Community Resources

Once goals of skill development and competence are established, you will probably be able to recommend resources in the community for learning opportunities. For instance, parents who want to increase their competence can take parenting classes at schools and religious organizations, find websites that provide information and support, and join support groups where advice and encouragement is exchanged. An organization like Toastmasters helps build public speaking skills. University extension schools have courses in assertiveness and communication skills, and employers often offer training in time-management and supervisory skills.

Skill Development Can Be Integrated With All Hypotheses

In CBT, skills training is integrated with cognitive interventions. Here are some examples of how it fits with other hypotheses:

  • Situational Stressors (CS2): Clients who are dealing with stress need coping skills to manage their own emotions and lower their stress reactions, engage in problem solving, and take needed actions.
  • Developmental Transition (CS3): As people move to a new developmental stage, they need new skills: Adolescents need dating skills, newlyweds need conflict resolution skills, and retired individuals need skills for managing a life without the structure of work. Parents need new skills as their children progress through developmental phases.
  • Deficits in Self and Relational Capacities (P3): This hypothesis is based on the premise of deficiencies in the quality of early childhood relationships, and is a core hypothesis for psychodynamic theories. However, the needed competencies can be described in behavioral terms and can be framed as skills, such as those described by Marsha Linehan (1993a, 1993b) in treatment for people diagnosed with Borderline Personality Disorder.
  • Social Roles and Systems (SC4): When people assume new social roles and/or enter new social systems, they need new skills. For instance, when someone receives a promotion at work to a supervisory or managerial position, she may need to develop skills in communication, leadership, and project management.