PSY 245 CLINICAL PSYCHOLOGY II Assoc. Prof. Dr. BAHAR BAŞTUĞ Clinical Psychologist Behavioral Theory and Therapy This week’s focus is on behavioral theory and therapy. We should all put our science caps on. Behaviorism and its application, behavior therapy are linked to the science within academic psychology. Behaviorism and behavior therapy sprang from scientific efforts to describe, explain, predict and control observable animal and human behavior. Behaviorism and psychoanalysis are opposite each other in some ways, and similar in some ways. The biggest difference between behaviorism and psychoanalysis is: Psychoanalysis subjectively focuses on inner dynamic or mental concepts. Behaviorism objectively focuses on observable phenomena or materialistic concepts. Psychoanalysis use techniques derived from clinical practice. Behaviorism use techniques derived from scientific research. Both approaches are highly deterministic, positivistic and mechanistic perspectives to understanding human. Michael Mahoney referred to psychoanalysis and behaviorism as the yin and yang of determinism (1984). They are often considered reactions to unscientific psychoanalytic approaches. For the behaviorist, all behavior is LEARNED. The most complex human behaviors are explained, controlled, and modified through LEARNING PROCEDURES. HISTORICAL CONTEXT Three major historical stages in the contemporary behavioral approaches: • Behaviorism as a scientific attempt • Behavior therapy • Cognitive behavior therapy (CBT) HISTORICAL CONTEXT Existential-humanistic psychology is called the third force. As a third force, existential-humanistic psy is an alternative to psychoanalysis and behaviorism. Why does this behavior therapy chapter come after the existential- humanistic chapters? Although behaviorism began gaining popularity in the early 1900s, behavior therapy was not identified until the 1950s. Applied behavior therapy came later. Behaviorism In the early 1900s, a new and different mechanistic view of humans, behaviorism, was in contrast to other perspectives. Most early 20th century psychologists were interested in human consciousness and free will, and used a procedure called introspection to identify the inner workings of the human mind. Behaviorists excluded consciousness and introspection. They believed in determinism rather than free will. John Watson (1878-1958) Prior to Watson, William James, identified himself as a philosopher, claimed that psy is no science, only the hope of a science. Father of behaviorism Watson believed in psychological science. He was interested in experimental psy, the classical conditioning learning model as demonstrated by Pavlov’s dogs. For Watson, behaviorism was far beyond “the hope of a science.” He published behaviorist manifesto in 1913, and redefined psychology as a pure science. «Psy as a behaviorist views it is a purely objective branch of natural science.» He was elected to the presidency of the APA in 1915, at the age of 35. In opposition to James’s free will, the purpose of Watson’s behaviorism was the deterministic prediction and control of human behavior. Watson viewed humans and animals as indistinguishable. “Give me a dozen healthy infants, wellformed, and my own specified world to bring them up in and I’ll guarantee to take any one at random and train him to become any type of specialist I might select—doctor, lawyer, artist, merchant-chief and yes, even beggarman and thief, regardless of his talents, tendencies, abilities, vocations, and race.” Watson had a strong interest in the application of behavioral scientific principles to human suffering. This may have been because he experienced a nervous breakdown as a young man and had not found psychoanalysis helpful. Little Hans and Little Albert In 1909, Freud reported an analysis of Little Hans (5-year-old) who was afraid of being bitten by a horse because of unresolved Oedipal issues and castration anxiety. Freud explained that Little Hans’s phobia was from castration anxiety. Watson showed that Little Albert could develop a phobia from classical conditioning. Watson sought to demonstrate that severe fears and phobias were caused not by psychoanalytic constructs but by classical conditioning of a fear response. In his famous experiments with 11-month-old Little Albert, after only five trials in which Watson and his assistant Rosalie Raynor paired the presentation of a white rat to Albert with the striking of a metal bar. Albert developed a strong fear and aversion to white rats. His conditioned fear response generalized to a variety furry white objects, such as a dog, cotton wool and Santa Claus mask. Little Peter MARY COVER JONES Jones showed that fear could be extinguished through counterconditioning and/or social imitation. Little Peter In 1924, Mary Cover Jones, who was student of Watson, conducted an investigation of the effectiveness of counter-conditioning or deconditioning with a 3-year-old boy named Little Peter. It was study that illustrated the potential of classical conditioning techniques in the treatment of psychological fears and phobias. Prior to his involvement in the behavioral experiments, Little Peter exhibited fear in response to several furry objects, including rabbits, fur coats, and cotton balls. Jones proceeded to systematically decondition Little Peter’s fear reaction by pairing the gradual approach of a caged rabbit with Peter’s involvement in an enjoyable activity—eating his favorite foods. In the end, Peter’s fear response was extinguished. Early behaviorists made many important contributions to psychology: • The discovery by Pavlov, Watson, and their colleagues that emotional responses could be involuntarily conditioned in animals and humans via classical conditioning procedures. • The discovery by Mary Cover Jones that fear responses could be deconditioned by either (1) replacing the fear response with a positive response or (2) social imitation. • The discovery by Thorndike and its later elaboration by Skinner that animal and human behaviors are powerfully shaped by their consequences. Behavior Therapy In the 1950s, three different groups in three different countries independently introduced the term behavior therapy to modern psy: 1. B. F. Skinner in the United States 2. Joseph Wolpe, Arnold Lazarus, and Stanley Rachman in South Africa 3. Hans Eysenck and the Maudsley Group in the United Kingdom B. F. Skinner in the United States Skinner box Skinner (1904-1990) His early work was an experimental project on operant conditioning with rats and pigeons in the 1930s. He demonstrated the power of positive reinforcement, negative reinforcement, punishment, and stimulus control in the modification of animal behavior. Within the confines of Skinner box, he was able to teach pigeons to play ping-pong via operant conditioning procedures. Skinner In the 1940s, he began extending operant conditioning concepts to human social and clinical problems. His book Walden Two was a story of how operant conditioning procedures could be used to create an utopian society. His next book, Science and Human Behavior, was a critique of psychoanalytic concepts and a reformulation of psychotherapy in behavioral terms. In 1953, Skinner and his colleagues first used behavior therapy referring to the application of operant conditioning procedures to modify the behavior of psychotic patients. Joseph Wolpe, Arnold Lazarus, and Stanley Rachman in South Africa Joseph Wolpe was interested in conditioning procedures as a means for resolving neurotic fear. He established the first nonpsychoanalytic, empirically validated behavior therapy technique. His book Psychotherapy by Reciprocal Inhibition outlined the therapeutic procedure now called systematic desensitization. Wolpe’s approach is very similar to Jones’s counterconditioning principle wherein a conditioned negative emotional response is replaced with a conditioned positive emotional response. Wolpe’s work attracted the attention of two South African psychologists, Arnold Lazarus and Stanley Rachman. – Conditioning procedures were used as a means for resolving neurotic fear. – A conditioned negative emotional response is replaced with a conditioned positive emotional response. Lazarus advocated the integration of laboratory-based scientific procedures into existing clinical and counseling practices. He used the term behavior therapy in a journal. Rachman has influenced developing behavior therapy procedures. His contribution involved the application of aversive stimuli to treating neurotic behavior, including addictions. Hans Eysenck and the Maudsley Group in the United Kingdom British psychiatrist Hans Eysenck used the term “behaviour therapy” to describe the application of modern learning theory to the understanding and treatment of behavioral and psychiatric problems. Conclusion, All these researchers lead to born behavioır therapy. Cognitive Behavior Modification Contemporary behavior therapy now includes cognitive variables. Most behavior therapists now work with cognition. Many articles focus on thoughts, expectations, and emotions. Behavior therapy is no longer a process that focuses on external behavior. Behavior therapy continues to develop. THEORETICAL PRINCIPLES Two primary principles characterize behaviorists and behavioral theory: • Behavior therapists employ techniques based on modern learning theory. • Behavior therapists employ techniques derived from scientific research. Theoretical Models The four main models of learning form the theoretical foundation of behavior therapy. 1. Operant Conditioning: Applied Behavior Analysis 2. Classical Conditioning: Neobehavioristic, Mediational Stimulus-Response Model Operant Conditioning: Applied Behavior Analysis • B. F. Skinner • Applied behavior analysis is a clinical term referring to a behavioral approach based on operant conditioning principles. • The operant conditioning position is straightforward: Behavior is a function of its consequences. • Operant conditioning is a stimulus-response theory. Applied Behavior Analysis Applied behavior analysis is a clinical term, based on Skinner’s operant conditioning principles. Behavior is a function of its consequences. «Operant» refers to how behaviors operate on the environment, thereby producing specific consequences. Applied Behavior Analysis Operant conditioning is a stimulus-response (SR) theory. Applied behavior analysis focuses on observable behaviors. Therapy proceeds through the manipulation of environmental variables to produce behavior change. Applied Behavior Analysis The main procedures are reinforcement, punishment, extinction, and stimulus control. These procedures are used to manipulate the environmental contingencies (rewards and punishments). The goal is to increase adaptive behavior through reinforcement and stimulus control and to reduce maladaptive behavior through punishment and extinction. Several behavior therapy techniques, such as assertiveness training, the token economy, and problem-solving training are derived from applied behavior analysis. Classical Conditioning: Neobehavioristic, Mediational Stimulus-Response Model The neobehavioristic mediational SR model is based on classical conditioning principles. Its principles were developed and articulated by Pavlov, Watson, and Wolpe. Classical conditioning is sometimes referred to as associational learning because it involves an association of one environmental stimulus with another. Classical Conditioning: Neobehavioristic, Mediational Stimulus-Response Model In Pavlovian terms, an unconditioned stimulus is one that naturally produces a specific physical-emotional response. The physical response elicited by an unconditioned stimulus is mediated through smooth muscle reflex arcs, so higher-order cognitive processes are not required in order for conditioning to occur. Classical Conditioning: Neobehavioristic, Mediational Stimulus-Response Model The experience of being struck from behind while waiting for a red light is the unconditioned stimulus. This stimulus automatically (or autonomically) produces a reflexive fear response (or unconditioned response). After only a single, powerful experience, the 34-year-old man suffers from a debilitating fear of impending death (a conditioned response) whenever he is exposed to the interior of an automobile (a conditioned stimulus). Classical Conditioning: Neobehavioristic, Mediational Stimulus-Response Model As Wolpe emphasizes, this scenario represents classical autonomic conditioning or learning because the man has no cognitive expectations or cognitive triggers that lead to his experience of fear when he is sitting inside an automobile. Because of the lack of cognitive processing involved in classical conditioning, when an individual experiences a purely classically conditioned fear response, often he or she will say something like, “I don’t know why it is, but I’m just afraid of elevators.” Classical Conditioning: Neobehavioristic, Mediational Stimulus-Response Model Classical conditioning principles include: stimulus generalization, stimulus discrimination, extinction, counter-conditioning, and spontaneous recovery. Classical conditioning principles Stimulus generalization: the generalization of a conditioned fear response to new settings, situations, or objects. In the case of Little Albert, stimulus generalization occurred when Albert experienced fear in response to stimuli similar in appearance to white rats (e.g., Santa Claus masks, cotton balls, etc.). . Classical conditioning principles Stimulus discrimination occurs when a conditioned fear response is not elicited by a new or different stimulus. In the case of Little Albert, stimulus discrimination occurred when Little Albert did not have a fear response when exposed to a fluffy white washrag. Classical conditioning principles Extinction: the gradual elimination of a conditioned response. It occurs when a conditioned stimulus is repeatedly presented without a previously associated unconditioned stimulus. If Watson had kept working with Little Albert and repeatedly exposed him to a white rat without a frightening sound of metal clanging, Little Albert would lose his conditioned response to rats. Extinction is not the same as forgetting. Classical conditioning principles Counter-conditioning.New associative learning. Mary Cover Jones’s work with Little Peter is an example of successful counter-conditioning or deconditioning. Counter-conditioning involves new associative learning. The subject learns that the conditioned stimulus brings with it a positive emotional experience. When Jones repeatedly presented the white rat to Little Peter while he was eating some of his favorite foods, eventually the conditioned response (fear) was counter-conditioned. Classical conditioning principles Spontaneous recovery occurs when an old response suddenly returns after having been successfully extinguished or counterconditioned. If, after successful counter-conditioning through systematic desensitization, Wolpe’s client suddenly begins having fear symptoms associated with the interior of automobiles, he has experienced spontaneous recovery. Theory of Psychopathology MALADAPTIVE BEHAVIOR IS LEARNED AND CAN ALWAYS BE EITHER UNLEARNED OR REPLACED BY NEW LEARNING. PSYCHOPATHOLOGY MAY BE A FUNCTION OF INADEQUATE LEARNING OR SKILL DEFICITS. Theory of Psychopathology An underlying principle of assertiveness training is that individuals who exhibit too much passive or too much aggressive behavior simply have skill deficits; they haven’t learned how to appropriately use assertive behavior in social situations. The purpose of assertiveness training is to teach clients assertiveness skills through modeling, coaching, behavior rehearsal, and reinforcement. Theory of Psychopathology Behaviorists systematically apply following scientific methods: •Observe and assess client maladaptive behaviors. •Develop hypotheses about the cause, •Test behavioral hypotheses through the application of empirically justifiable interventions. •Observe and evaluate the results of their intervention. •Revise and continue testing new hypotheses as needed. THE PRACTICE OF BEHAVIOR THERAPY To practice behavior therapy requires that you take notes and think like a scientist. You are a teacher. Your job is to help clients unlearn old maladaptive behaviors and learn new, adaptive behaviors. What Is Contemporary Behavior Therapy? – Nearly all cognitive therapies are used in conjunction with behavior therapies. – There are now several new-generation cognitive-behavioral therapies. These therapies include: • Dialectical Behavior Therapy (DBT) • Acceptance and Commitment Therapy (ACT) • Eye Movement Desensitization Reprocessing (EMDR) Assessment Issues and Procedures Behavior therapists would be able to directly OBSERVE clients in their natural environment to obtain specific information about what happens before, during, and after adaptive and maladaptive behaviors occur. The main goal of behavioral assessment is to determine the external (environmental or situational) stimuli and internal (physiological and cognitive) stimuli that directly precede and follow adaptive and maladaptive client behavioral responses. Both internal and external stimuli may be of interest. Assessment Issues and Procedures Functional Behavior Analysis (FBA): This assessment procedure is sometimes referred to as obtaining information about the client’s behavioral ABCs: • A = The behavior’s antecedents (everything that happens just BEFORE the maladaptive behavior is observed) • B = The behavior: operant definition by concrete terms • C = The behavior’s consequences (everything that happens just AFTER the maladaptive behavior occurs) Assessment Issues and Procedures Through direct observation, the behavior therapist gathers information. But, direct behavioral observation is inefficient, for several reasons: 1. Most therapists can’t afford the time required to observe clients in their natural settings. 2. Many clients object to having their therapist come into their home or workplace to conduct a formal observation. Assessment Issues and Procedures 3. Even if the client agreed to have the therapist come perform an observation, the therapist’s presence influences the client’s behavior. Because behavior therapists usually cannot use direct behavioral observation, they employ a variety of less direct data collection procedures. The Behavioral Interview The clinical or behavioral interview is the most common assessment procedure. During interviews, behavior therapists directly observe client behavior, inquire about behavioral antecedents and consequences, and operationalize the targets of therapy. The operational definition or specific, measurable characteristics of client symptoms and goals are crucial behavioral assessment components. Defining the client’s problem(s) in behavioral terms is the first step in a behavioral assessment interview. Behavior therapists are not satisfied when clients describe themselves as “depressed” or “anxious”. Instead, behaviorists seek concrete, specific behavioral information. The Clinical or Behavioral Interview Despite many practical advantages of behavioral interviews, this assessment procedure also has several disadvantages: (1) low interrater reliability, (2) lack of interviewer objectivity, and (3) frequent inconsistency between behavior in a clinical interview and behavior outside therapy. (4) false, subjective clients’ report. The Clinical or Behavioral Interview Behavior therapists compensate for the inconsistent and subjective nature of interviews through two strategies: 1. They employ structured or diagnostic interviews such as the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (SCID-DSM-IV). 2. They use additional assessment methods beyond interviewing procedures. Self-Monitoring Sometimes, to directly observe client behavior outside therapy is impractical. Clients are trained to monitor their own behavior. In CBT, clients frequently keep thought or emotion logs that include at least three components: (1) disturbing emotional states, (2) the exact behavior engaged in at the time of the emotional state, and (3) thoughts that occurred when the emotions emerged. Advantages of selfmonitoring is cheap, practical, and usually therapeutic. Disadvantages of selfmonitoring is that the client can collect inadequate or inaccurate information, or resist collecting any information. Clients may not make accurate recordings of their behavior. Standardized Questionnaires Objective psychological measures include standardized administration and scoring. Behaviorists prefer instruments that have established reliability and validity. These are often used to determine outcomes. Operant Conditioning and Variants In the tradition of Skinner and applied behavior analysis, the application of behaviorism to therapy is direct operant conditioning. Skinner’s emphasis is on environmental manipulation rather than processes of mind or cognition. Contingency Management and Token Economies Using operant conditioning requires an analysis of behavioral consequences in the client’s physical and social environment. This process is contingency management. It’s used more common in educational, family, institutional and drug treatment settings. Contingency Management and Token Economies An appropriate use of operant conditioning involves several systematic steps: 1. The parents need to operationalize the target behaviors and identify behavioral objectives. 2. The therapist helped the parents develop a system for measuring the target behaviors. They were each given a pencil and notebook to follow the frequency of their teen’s behaviors. 3. The parents were instructed on how to monitor and evaluate the effects of their new contingency schedule. Contingency Management and Token Economies Operant conditioning principles have been applied to educational and institutional settings. Following Skinner’s work aimed at modifying the behavior of psychotic patients, operant conditioning within institutions has come to be known as a TOKEN ECONOMY. Within token economy systems, individuals are givencoins or symbolic rewards for positive or desirable behaviors. These tokens are used like money, to obtain goods or privileges. Contingency Management and Token Economies Token economies have been criticized as forcible and as not having lasting effects that generalize to the world outside the institution. After the desirable behavior patterns are well established, the behavioral contingencies would be slowly decreased. This procedure is referred to as fading and is designed to maximize the likelihood of generalization of learning from one setting to another. The desired outcome occurs when the subject internalizes the contingency system. Contingency Management and Token Economies Positive reinforcement faces some criticism. Thorndike, Skinner concluded that punishment led to behavioral supression, but it wasn’t effective for controlling behavior. Then, Solomon claimed that punishment could generate new, learned behavior. Contingency Management and Token Economies Now, it is accepted that punishment is a powerful behavior modifier, but it has disadvantage. In the attachment and trauma literature, excessive punishment leads to trauma bonding. There is a debate on using punishment as a learning tool. Contingency Management and Token Economies The direct application of punishment, or aversive conditioning, is used to reduce undesirable and maladaptive behavior. It has been applied with some success to smoking cessation, repetitive self-injurious behavior, alcohol abuse or dependency, and sexual deviation. Behavioral Activation (BA) For Skinner, depr was caused by an interruption of healthy behavioral activities. Depressed individuals engage in fewer pleasant activities and obtain less positive reinforcement than others. So, if they change their behavior, they may improve or recover. Behavioral Activation (BA) BA was previously referred to as activity scheduling and used as a component of various cognitive and behavioral treatments for depression. Recent research suggests BA may be as good as the whole CBT package for depressive disorders. Relaxation Training Edmund Jacobson was the first scientist to write about relaxation training as a treatment procedure. Progressive muscle relaxation (PMR) was initially based on the assumption that muscular tension is an underlying cause of a variety of mental and emotional problems. Relaxation Training – PMR is an evidence-based treatment. – But PMR can make some clients more anxious. Systematic Desensitization and Other Exposure-Based Treatments Joseph Wolpe introduced systematic desensitization as a technique. Systematic desensitization = Jone’s deconditioning approach + Jacobson’s PMR procedure. “To be relaxed is the direct physiological opposite of being excited or disturbed.” (Jacobson, 1978, p. viii) Systematic Desensitization and Other Exposure-Based Treatments After clients are trained in PMR techniques, they build a fear hierarchy in collaboration with the therapist. Systematic desensitization usually proceeds in the following way: 1.The client identifies a range of various fearinducing situations or objects. Systematic Desensitization and Other Exposure-Based Treatments 2. Using a measuring system referred to as subjective units of distress, the client, with the support of the therapist, rates each fearinducing situation or object on a scale from 0 to 100 (0 = no distress; 100 = total distress). 3. Early in the session the client engages in PMR. 4. While deeply relaxed, the client is exposed, in vivo or through imagery, to the least feared item in the fear hierarchy. Systematic Desensitization and Other Exposure-Based Treatments 5. The client is exposed to each feared item, gradually progressing to the most feared item in the hierarchy. 6. If the client experiences anxiety at any point during the imaginal or in vivo exposure process, the client reengages in PMR until relaxation overcomes anxiety. 7.Treatment continues systematically until the client achieves relaxation competence while simultaneously being exposed to the entire range of fear hierarchy. Imaginal or In Vivo Exposure and Desensitization Systematic desensitization is an exposure treatment. In the exposure treatments, clients are treated by exposure to the thing they want to avoid: the stimulus that evokes intense fear, anxiety, or painful emotions. Imaginal or In Vivo Exposure and Desensitization There are three ways in which clients are exposed to their fears during systematic desensitization: 1. Exposure to fears can be accomplished through mental imagery. Computer simulation (virtual reality) has been used in therapist’s office. 2. In vivo exposure to feared stimuli. In vivo exposure involves direct exposure to reallife situations. 3. computer simulation (virtual reality) has been used as a means of exposing clients to feared stimuli. Psychoeducation and a good therapeutic alliance are essential for exposure. Massed (Intensive) or Spaced (Graduated) Exposure Sessions Is desensitization more effective when clients are exposed to feared stimuli during a single prolonged session or when they are slowly exposed to feared stimuli during a series of shorter sessions? Either approach can be used effectively. Virtual Reality Exposure (VRE) a procedure wherein clients are immersed in a real-time computer-generated computer environment. It has been empirically evaluated as an alternative to imaginal or in vivo exposure in cases of acrophobia (fear of heights), flight phobia, and spider phobia. VRE has been empirically validated. Interoceptive Exposure It is similar to other exposure techniques but focuses on internal anxiety signals or triggers. Research on Panic Disorder has showed that some clients who experience intense fear are responding less to situational stimuli and more to internal physical sensations. Interoceptive Exposure Panic-prone individuals are sensitive to internal physical cues (e.g., increased heart rate, increased respiration). They interpret those sensations as signs of physical illness, death, or loss of consciousness. Although specific cognitive techniques have been developed to treat clients’ tendencies to catastrophically overinterpret bodily sensations, interoceptive exposure has been developed to help clients learn, through exposure and practice, to deal more effectively with the physical aspects of intense anxiety or panic. Interoceptive Exposure Six introceptive exposures that trigger anxiety: Hyperventilation Breath holding Breathing through a straw Spinning in circles Shaking head Chest breathing Interoceptive Exposure Before interoceptive exposure, the client receive education about body sensations, learn relaxation techniques, and learn cognitive restructuring skills. Through repeated successful exposure, the client becomes desensitized to feared physical cues. Response Prevention and Ritual Prevention According to Mowrer, when a client avoids a feared or distressing situation or stimulus, the maladaptive avoidance behavior is negatively reinforced. For example, clients with Bulimia Nervosa who purge after eating specific “forbidden” foods are relieving themselves from the anxiety and discomfort they experience upon ingesting the foods. Purging behavior is negatively reinforced. Similarly, when a phobic client escapes from a phobic object or situation, or when a client with OCD engages in a repeated washing or checking behavior, negative reinforcement of maladaptive behavior occurs. Response Prevention and Ritual Prevention With the therapist’s assistance, the client with bulimia is prevented from vomiting after ingesting a forbidden cookie, the agoraphobic client is prevented from fleeing a public place when anxiety begins to mount, and the client with OCD is prevented from washing hands following exposure to a “contaminated” object. Participant Modeling Social learning principles have been evaluated for anxiety treatment. For example, individuals with airplane or flight phobias don’t find it helpful when they watch other passengers getting on a plane without experiencing distress. In fact, such observations can produce increased hopelessness. There is too large a gap in emotional state and skills between the model and the observer, so vicarious learning does not occur. Participant Modeling Behavior therapists provide models of successful coping. Group therapy provides an excellent opportunity for participant modeling and vicarious learning. Skills Training Skills training techniques are based on skill deficit models of psychopathology. Many clients have not acquired the necessary skills for functioning. Behavior therapists evaluate their clients’ functional skills during the assessment phase of therapy and then use specific skills training strategies to treatment the clients’ skill deficits. Traditional skills training targets include assertiveness and other social behavior as well as problem solving. Assertiveness and Other Social Behavior Wolpe and Lazarus defined assertiveness as a learned behavior. Individuals are evaluated as having one of three possible social behavior styles: passive, aggressive, or assertive. Passive individuals behave in submissive ways; they say yes when they want to say no. Aggressive individuals dominate others. Assertive individual speaks up, expresses feelings. Assertiveness and Other Social Behavior Assertiveness and Other Social Behavior The most common social behaviors targeted in assertiveness training are: introducing oneself to strangers, giving and receiving compliments, saying no to requests from others, making requests of others, speaking up or voicing an opinion, and maintaining social conversations. Assertive behavior is taught through the following strategies: • Instruction: Clients are instructed in assertive eye contact, body posture, voice tone & verbal delivery. • Feedback: The therapist or group members give clients feedback regarding how their efforts at assertive behavior come across to others. • Behavior rehearsal or role playing: Clients are given opportunities to practice specific assertive behaviors, such as asking for help or expressing disagreement without becoming angry or aggressive. • Coaching: Therapists whisper feedback and instructions in the client’s ear as a role-play or practice scenario progresses. • Modeling: The therapist or group members demonstrate appropriate assertive behavior for specific situations. • Social reinforcement: The therapist or group members offer positive feedback and support for assertive behavior. • Relaxation training: It is needed to reduce anxiety in social situations. Assertiveness training for individuals with specific social anxiety and social skills deficits are used. Social Phobia—a condition characterized by an excessive, irrational fear of being scrutinized and evaluated by others—is treated with a combination of relaxation and social skills training that includes almost all the components of traditional assertion training and graduated or massed exposure to challenging social situations and interactions. Problem Solving Therapy (PST) It is a behavioral treatment with cognitive dimensions. For rationale of PST, effective problem solving is a mediator that helps clients manage stresful life events. It focuses on: • Problem orientation: This involves teaching clients to have a positive attitude toward problems. Problems are opportunity, are solvable. Believing in own ability to solve problems and recognizing that effective problem solving requires time and effort. Problem Solving Therapy (PST) Problem-solving style: Clients are taught a rational problem-solving style: 1. Define the problem. 2. Identify the goal. 3. Generate options. 4. Choose the best solution. 5. Evaluate the outcome Discerning the differences between cognitive and behavioral therapies is difficult. Most behavior therapists use cognitive treatment and most cognitive therapists use behavioral treatments. Cognitive-behavioral therapy. One characteristic of behavior therapy is the generation of a clear and concrete problem list. Items in the problem list are defined in behavioral terms and measurable. Each behavior therapy session includes four parts: 1.check-in and homework review 2. psychoeducation about the patient’s disorder and behavior therapy 3. in-session behavioral or cognitive tasks 4. new homework assignments. Cultural and Gender Considerations Some research indicates behavioral treatments are effective with minority clients; however, Craske (2010) admits that generally cognitive and behavioral therapies are not yet proven multiculturally efficacious. Behavior therapists need to make multicultural adjustments in their practices. Evidence-Based Status Behavioral and cognitive therapies are far and away the largest producers and consumers of therapy outcomes research. The most recent APA Division 12 list of ESTs includes 60 different treatment protocols, most of which are behavioral or cognitive-behavioral. Token economies and contingency management>> Behavioral activation>>depr Progressive muscle relaxation>> Exposure+response prevention>>anx dissorders Problem solving therapy>>depr. Concluding Comments Behavior therapy deserves credit for demonstrating that particular approaches are effective—based on a quantitative scientific-medical model. If it can’t be empirically validated, then it’s not behavior therapy.