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.