BEHAVIOR THERAPY
Slides created by
Barbara A. Cubic, Ph.D.
Professor
Eastern Virginia Medical School
To accompany
Current Psychotherapies 10
Learning Objectives
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This presentation will focus on:
• Overview of behavior therapy
• Principles of learning and cognitive
theory relevant to psychotherapy
• History of behavior therapy
• Applications of behavior therapy
• Review of behavioral techniques
Basic
Concepts
Behavioral therapy
(blends with CBT and REBT)
integrates the behavioral
techniques derived from
principles of learning and
cognitive restructuring
techniques based on
cognitive theories.
Features of Behavior Therapy
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Focuses on changing behavior.
Rooted in empiricism.
Assumes behaviors have a function.
Emphasizes maintaining factors rather
than factors that may have initially
triggered a problem.
Features of Behavioral Therapy
 Empirically
supported
 Active
 Transparent
Comparing Behavior Therapy to
Other Approaches
Most Different
Most Similar
Psychoanalytic
Client-Centered
REBT
Multimodal
Cognitive
Behavior Therapy and
Psychoanalytic Approaches
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Includes family members as needed.
Does not create symptom substitution
as predicted.
More broadly applicable than most
therapies.
Empirical studies generally show it to
be more effective.
Treatment of choice for phobias, OCD,
sexual dysfunction and many childhood
disorders.
History of Behavioral Therapy
Early Examples

Pliny the Elder, over 2,000 years ago,
used spiders at the bottom of a glass
to treat alcoholism.
• Aversion therapy
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Victor of Aveyron (Wild Boy of
Aveyron) treated by Jean-MarcGaspard Itard (1962).
• Used strategies of modeling, shaping,
and reinforcement.
Ivan Pavlov
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Russian physiologist
completed classical
conditioning
experiments.
Paired two stimuli so
that a neutral stimulus
(e.g., a light or bell)
signaled occurrence of
a second non-neutral
stimulus (e.g., food or
shock).
John B. Watson
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Credited as the founder of
behaviorism.
Believed only observable behaviors
should be the focus of psychology.
With Rayner, conducted a classic
experiment in which an infant (Little
Albert) learned to fear a white rat
after the presence of the rat was
paired with a loud noise.
Other Early Key Players
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Mary Cover Jones
• Used a combination of modeling and
exposure to treat a boy with rabbit phobia.
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Mowrer & Mowrer
• Used classical conditioning principles to
treat childhood bed-wetting (bell and pad).
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E. L. Thorndike
• First to describe operant conditioning.
Operant/Instrumental
Conditioning (B.F. Skinner)
 A response is emitted
— perhaps randomly at
first — and results in
consequences.
 Hence, the probability
of the response’s future
occurrence is changed.
Systematic Desensitization
(graduated exposure therapy)
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Used to treat phobias
and anxiety disorders.
Developed by Joseph
Wolpe.
The process is as
follows:
• Patient taught relaxation
skills in order to control
fear.
• Hierarchy of fears created.
• Patient learns to cope and
overcome the fear in each
step of the hierarchy.
Social-Cognitive Theory
(Albert Bandura)
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Interconnection
between stimulus,
reinforcement and
cognition.
Critical role of vicarious
learning, cognitions,
self regulation and
expectations.
Person is seen as the
agent for change.
Self efficacy seen as a
critical variable.
Behavior Therapy
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Practical, here-and-now, experiential
emphasis.
Techniques can be adapted to meet
the developmental level of the patient.
Action-oriented, which matches fact
that children learn by doing.
Incorporates rewards, which helps
engage the patient.
THEORY OF
PERSONALITY
Behavior Therapy’s
View of Personality
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Historically, behaviorists saw behavior as
situation-specific/rejected trait theories.
• But strict behavioral view is not strongly
supported by research.
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Strong evidence supports the notion of
individual temperaments.
Now, most behavior therapists
acknowledge temperament affects
behavior.
Behaviorists also recognize behavior varies
across situations.
Costa and McCrae’s (1992)
Big Five Model
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Currently most influential approach to
describing core domains of
personality:
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Openness
Conscientiousness
Extraversion
Agreeableness
Neuroticism
Broad factors assumed to be clusters
of narrowly focused traits.
Basic
Principles of
Learning
Learning
A relatively permanent
change in behavior, not
due to fatigue, drugs, or
maturation.
Classical Conditioning
Pavlov’s Study
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Food is presented to the dog and the
dog salivates; no learning involved.
A neutral stimulus is presented to the
dog (a tone); the dog does not salivate.
The tone is presented simultaneously with
the food; the dog salivates.
Then, the tone is presented alone and the
dog salivates; learning has occurred.
Classical Conditioning
UCS
UCR
Unconditional Stimulus
Unconditioned Response
(sight of food)
(salivation)
CS
Conditioned Stimulus
(tone)
CR
Conditioned Response
(salivation)
Why Would a Dog
Salivate to a Bell?
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The UCS and CS are
repeatedly paired
together until the
UCR is elicited by the
CS.
In other words, the
CS elicits the same
behavior and is now
termed the CR.
Would the Dog Salivate
to Other Sounds?
Maybe
 If stimulus generalization occurs,
the dog responds to related
stimuli with the same or similar
response.
 If stimulus discrimination occurs,
the dog does not respond.
Extinction
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After learning has occurred,
removing the UCS ultimately
results in a decreased probability
that the CR will be made.
 This is because the dog learns that
the bell no longer means food will
follow.
Spontaneous Recovery
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After a time delay, if the stimulus
is represented, the CR will
reoccur.
 This behavior will extinguish rapidly
if the UCS does not follow quickly.
Examples of How This is
Related to Mental Health
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Related to acquisition of maladaptive
physiological responses.
 Relaxation response to nicotine use.
 Eating paired with stimuli that are not
hunger related.
 Acquisition of phobias such as
fainting at the sight of blood.
Reinforcement
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A reinforcer is defined by its
effects.
Any stimulus is a reinforcer if it
increases the probability of a
response.
Punishment
 A punisher is defined by its
effects.
 Any stimulus is a punisher if it
decreases the probability of a
response.
Helpful Hint
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In behavioral terms, “positive”
and “negative” are used
differently than in general
language.
• Positive = Add
• Negative = Take Away
Operant Learning
Add Stimulus
Remove Stimulus
Behavior Positive
to
Reinforcement
increase
Negative
Reinforcement
Behavior Positive
to
Punishment
decrease
Negative
Punishment
Continuous Reinforcement
Every response is followed by a
reinforcement, resulting in fast
learning (acquisition).
• Also results in fast extinction.
Intermittent
(or Partial) Reinforcement
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Not every response is reinforced,
but this ultimately yields a
stronger response.
Fixed Ratio Schedule
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Delivers reinforcement after a
fixed number of responses and
produces high response rate.
• Example: Commission work
Fixed Interval Schedule
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Reinforces the next response
that occurs after a fixed period
of time elapses.
• Example: Scheduled exam
Variable Interval Schedule
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Deliver reinforcements after
unpredictable time periods.
• Example: Pop quizzes or fishing
Variable Ratio Schedule
 Yields
the highest rates of
response and greatest
resistance to extinction.
• Example: Gambling
Behavioral Effect of the
Reinforcement Schedules
Schedule
Effect
Fixed ratio
Fixed interval
Relatively fast rate of response.
Response rate drops to almost
zero after reward; picks up
rapidly before next reward.
Slow, steady response.
Variable
interval
Variable ratio
Constant high rate of response;
may be hardest behavior to
break.
Secondary Reinforcement
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A symbol or a token gains
reinforcement value due to its
association with a real reinforcer.
• Example: Dollar bill
Reset Function
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Sometimes one error eliminates
any accumulated responses.
 i.e., Errors mean restart at baseline.
Reset functions are typical in skill
building.
 Impact is more cautious behavior
and more frustration when errors
are made as behavior proceeds.
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• Example: House of cards
Would the Dog Salivate
to Other Sounds?
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Generalization:
• Occurrence of a learned behavior in
situations other than those where the
behavior was acquired.
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Discrimination learning:
• Response is reinforced or punished
in one situation but not in another.
Extinction
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A behavior that stops occurring
because it is no longer followed
by a positive consequence.
• Example: Children learn to stop
throwing tantrums when the
tantrums are no longer reinforced.
How is This Related to
Mental Health?
Reinforcing adherence
 Designing interventions carefully
to be initially successful (small
changes)
 Premack principle
 Using secondary reinforcers
 Involving the family
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Vicarious Learning
(Modeling)
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Learning that occurs
through observation.
Particularly relevant to
children, but applies to all
ages.
By observing a model, one
grasps entire behaviors as
well as component parts.
May remain dormant until a
situation warrants
expression of the learned
behavior.
How is This Related to
Mental Health?
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Modeling is an effective technique for
treating dental and medical phobias.
Clinicians are viewed as role models;
therefore, patients may learn more
from observation than words.
Related to why support groups are
effective.
Helps in understanding why so many
problems are intergenerational.
Rule-Governed Behavior
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Contingencies learned indirectly
through information heard or read.
• A person learns to look both ways
before crossing the street because of
comments made by their parents.
• A person develops a strong dislike of
another individual based on gossip.
Therapeutic Process
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A strong therapeutic relationship is
important in behavior therapy.
Self-help approaches are more
effective when therapist-administered.
Ambivalence about treatment can be
addressed with motivational
interviewing.
• A client-centered approach designed to
help clients explore and resolve sources of
ambivalence about therapy.
Format and Structure of BT
Quite diverse
 Behavioral interventions can be
offered by therapists and many
others (teachers, parents,
physicians).
 Sessions vary in length based on
interventions.
 Generally 10-20 sessions max.
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Ethical Issues in BT
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Misconception that behavior therapy
is coercive.
• Therapists must be aware of their potential
influence on the client.
• Only make recommendations that are in the
client’s best interests.
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Importance of shared goals
BT often involves activities outside
of the office.
• Confidentiality in public places must be
maintained.
Some Areas Where Behavior
Therapy Has Proven Efficacy
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Anxiety disorders
• Phobias, panic disorder, OCD, PTSD
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Depression
Marital problems
Behavioral medicine
Childhood disorders
• Behavioral problems, hyperactivity,
autism, enuresis
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Substance use
Eating disorders
Schizophrenia
Efficacy and effectiveness
of behavior therapy has
been studied more
intensively than in any
other form of
psychological treatment.
TREATMENT
APPROACHES
Behavioral Assessment
 Identify goals for change.
 Operationalize the behavior and
thoughts.
 Separate traits from behaviors.
• Distinguish overt from covert
behaviors.
• Obtain a baseline.
 Complete a functional analysis.
Sample Functional Analysis
A
Antecedent
Job stress
Driving car
B
C
Behavior Consequence
Smoke a
cigarette
Satisfaction
Relaxation/calm
Watching TV
Lung diseases
Anxiety
Cardiac illnesses
Discoloration of
teeth/skin
Treatment Planning
 Establish target behaviors to change.
• Behaviors to increase and to decrease.
• Behaviors should be small, discrete, and
chosen based on severity, immediacy,
centrality and potential for success.
 Develop a behavioral contract with
goals and rewards.
 Problem-solve about possible
obstacles.
 Periodically reevaluate.
Behavior Therapy
Treatment Techniques
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Behavioral activation
Exposure-based
• Invivo
• Imaginal
• Interoceptive
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Response prevention
Operant-conditioning strategies
• Applied behavior analysis
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Reinforcement-based strategies
• Differential reinforcement
• Contingency management
Behavior Therapy
Treatment Techniques
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Punishment-based strategies
• Aversive conditioning
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Physiological monitoring
Role-playing
Self-monitoring
Behavioral observation
Cognitive restructuring (see Chapter 7)
Assertiveness training
Social skills training
Stimulus control techniques
Relaxation Techniques
Diaphragmatic breathing
Breath-focusing exercises
Mini-relaxations
Mind focusing
Coupling breathing and imagination
Progressive muscle relaxation
Repetitive motion
Self-hypnosis
Visualization
Required Elements for
the Relaxation Response
1. A quiet, calm environment with as
few distractions as possible.
2. A mental device to prevent “mindwandering.”
3. A passive, “let-it-happen” attitude.
4. A comfortable position to prevent
muscular tension.
Breathing Awareness
 Close your eyes. Put your right hand
on your abdomen, right at the
waistline, and put your left hand on
your chest, right in the center.
 Without trying to change your
breathing, simply notice how you are
breathing. Which hand rises the most
as you inhale – the hand on your
chest or the hand on your belly?
 If your chest moves up and down with
each breath, you need to learn how to
breathe from your diaphragm
(abdomen).
Diaphragmatic Breathing
 Find a comfortable place to sit or lie on
your back.
 Place your hands just below your belly
button.
 Close your eyes and imagine a balloon
inside your abdomen. Visualize the
balloon. What color is it?
 Each time you breathe in, imagine the
balloon filling up with air.
 Each time you breathe out, imagine the
balloon collapsing.
Breath Counting
 Sit or lie in a comfortable position with your
arms and legs uncrossed and your spine
straight.
 Breathe in deeply into your abdomen. Let
yourself pause before you exhale.
 As you exhale, count “one” to yourself. As you
continue to inhale and exhale count each
exhalation: “two…three…four…”
 Continue counting your exhalations in sets of
four for 5-10 minutes.
 Notice your breathing gradually slowing, your
body relaxing, and your mind calming as you
practice this breathing meditation.
Relaxing Sigh
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Sit or stand up straight.
Sigh deeply, letting out a sound of deep
relief as the air rushes out of your
lungs.
Don’t think about inhaling, just let the
air come in naturally.
Take 8-12 of these relaxing sighs and let
yourself experience the feeling of
relaxation. Repeat whenever you feel
the need for it.
Letting Go of Tension
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Sit comfortably in a chair with your feet on
the floor.
Breathe deeply into your abdomen and say to
yourself, “Breathe in relaxation.” Let yourself
pause before you exhale.
Breathe out from your abdomen and say to
yourself, “Breathe out tension.” Pause before
you inhale.
Use each inhalation as a moment to become
aware of any tension in your body.
Use each exhalation as an opportunity to let
go of tension.
You may find it helpful to use your
imagination to picture or feel the relaxation
entering and the tension leaving your body.
Progressive Muscle Relaxation
 PMR is based on the premise that the
body responds to anxiety-provoking
thoughts and events with muscle
tension.
• This tension then increases the subjective
experience of anxiety.
 Deep muscle relaxation reduces
physiological tension and is incompatible
with anxiety.
 Each muscle or muscle group is tensed
for 5-10 seconds and then relaxed for 2030 seconds.
Visualization
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Loosen your clothing, lie down in a quiet
place, and close your eyes.
Scan your body, seeking tension in specific
muscles and relaxing as much as you can.
Form mental sense impressions. Imagine not
only walking on the beach, but also the
sound of the ocean and the feel of the sand
on your feet.
Use affirmations. Repeat positive statements
such as “I am letting go of tension.”
Practice is easiest in the morning and night
while lying in bed.
Problem-Solving Training
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Define the problem
Identifying possible solutions
Evaluate the solutions
Choose the best solution
Implementation
Third Wave Therapies
Dialectical behavior therapy
(DBT)
 Acceptance and
commitment therapy (ACT)
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Dialectical Behavior Therapy
Acceptance and change
 Mindfulness:
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• Observe or attend to emotions
without trying to terminate painful
ones.
• Describe a thought or emotion.
• Be nonjudgmental.
• Stay in the present.
• Focus on one thing at a time.
Acceptance and
Commitment Therapy
Experiental avoidance
 Acceptance
 Cognitive defusion
 Commitment
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Compared to Cognitive Therapy
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“Third Wave” approaches
emphasize acceptance.
• CT challenges beliefs.
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Behaviorists focus on the functions
of cognitions.
• CT focuses on the cognitive content.
APA-Division 12 ESTs
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Behavioral treatments dominate the list
of empirically-supported treatments.
The case for behavioral and CBT
treatments is more developed than the
case for any other form of
psychotherapy.
National Institute of
Clinical Excellence (NICE)
Behavior therapy treatments are
typically rated an A
A = Strong empirical support
from well-controlled RCTs
C = Expert opinion with strong
empirical data
F = No evidence
Taking an Empirical Approach
in the Therapy Office
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Awareness of one’s biases about
clients and their problems.
Awareness of one’s biases about
treatment.
Collect data throughout the course of
therapy to test out assumptions about
the variables that maintain a client’s
problems.
Collect data over the course of
treatment to evaluate outcomes.
BT and a
Multicultural World
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Core principles/methods underlying BT
assumed to be universal, applicable
across cultures and species.
BT must find ways to encourage clients
to use methods that may not fit with
their cultural assumptions and beliefs.
Research on treating individuals across
diverse groups with BT early in its
development.