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214 Behavior Therapy5 Beutler LE, Engle D, Mohr D, et al: Predictors of differential response to cognitive, experiential and self-di-rected psychotherapeutic procedures. J Co nsult Clin Psychol 59:333-340, 1991.6. Dobson K: A meta-analysis of the efficacy of cognitive therapy fo r depression. J Consult Clin Psychol57:414419, 1989.7. Elkins I, Shea T,Watkins J, et al: National Institute of Mental Health Treatment of Depression Collaborative
Research Program . Arch Gen Psychiatry 46:971-982, 1989.8. Evans M, H ollon SD , DeR ubeis RJ, et al: Differential relapse following cognitive therapy and pharma-cotherapy for depres sion. Arch Gen Psychiatry 49:774-78 1, 1992.9. Fennel1 MJ : Depression. In Hawton K, Salkovskis PM , Kirk J, Clark D M (eds): Cognitive Behavior Therapyfor Psychiatric Problems. A Practical Guide. New York, Oxford University Press, 1989, pp 169-234.10. Hollon SD, Beck AT: Cognitive and cognitive-behavioral therapies. In Bergin AE, Garfield SL (eds):Handbook of Psych otherapy and Behavior Change, 4th ed. New York John W iley Sons, 1994, pp4 2 8 4 6 6 .1 I Hollon SD, DeRubeis RJ, Evans M D, et al: Cognitive therapy and pharmacotherapy for depression: Singlyand in combination. Arch Gen Psychiatry 49:774-781, 1992.12. Hollon SD, Shelton R C, Loosen PT: Cognitive therapy and pharmacothei-apy for depression. J Consult ClinPsychol 59:88-99, 1991.13. Thase ME, Beck AT: Overview of cognitive therapy. In Wright JG , Thase M E, Beck AT, Ludgate JW (eds):Cogn itive Therapy with Inpatients. New York, Guilford, 1993, pp 3-34.
42. BEHAVIOR THERAPYCarry Welch Ph .D. , and Jacqueline A. Samson, Ph.D.
1. What is behavior therapy?Behavior therapy is a scientifically based approach to the understanding and treatment of hum anproblems. It arose from laboratory exp eriments of animal behavior conducted in the early 1900s andhas developed since from a larg e body of clinical research an d experience. T he goals of behaviortherapy are:Improve daily functioningReduce emotional distressBehavior therapy first came into com mo n use in the 1960s and is now applied to a wide range ofhuman problems. Originally the emphasis was on overt, measurable behavior and the applicationof classical and operant conditioning p rinciples. However, since the 1980 s it has been expand ed toinclude cognitive aspects that emphasize the role of inner m ental processes and em otional states. Inaddition, a new consideration of the broader social context of behavior has developed. The currentfocus of behavior therapy is not only what we o vertly do , but also w hat we think and feel; all of theseelements are influenced by the fundam ental principles of learning.
Enhan ce relationshipsMax imize human potential
2. Which patients are most likely to benefit from behavior therapy?Behavior therapy has been proven effective for the treatment of specific health problems requir-ing behavior change, such as sm oking cessation, weight loss, stress, and pain m anagem ent. In addi-tion, treatment protocols for anxiety disorders and phobias such as obsessive-compulsive disorderOCD), agoraphobia, and panic disord er show success equivalent to or exceeding medication alone.Behavior therapy and token economy systems (see Question 15)have been used with good outcomein patients with develop men tal disabilities and severely disturbed psychotic patients. It is the treat-ment of cho ice for severely ill patients w ho cannot p articipate in standard insight-oriented or cogni-tive therapies.3. How do operant and classical conditioning differ?Behavior therapy draw s heavily on principles derived from classical (or Pavlovian) and operan tor instrumental) conditioning. Both forms of conditioning are im portant influences in daily life
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Behavior Therapy 215because they permit a rapid behavioral response and adaptation to inner changes and external events.Learning may occur through personal experience or the experience of others i.e., through vicariouslearning and modeling). Classically conditioned reflexes generally function to maintain internalbodily processes, and the conditioned responses that arise from this conditioning are stereotypic.Operant behaviors, on the other hand, are typically instrumental in managing the external environ-ment. They involve skeletal muscles under voluntary control and the ongoing learning of a changingrepertoire of new and varied behaviors.4. Describe classical conditioning.Classical conditioning involves the acquisition of new cues or triggers) to wired-in physio-logic reflexes. These reflexes, which function naturally to protect us and to maintain our inner phys-iologic state, are principally linked to the autonomic nervous system. They are found in manyinternal bodily systems and are triggered by specific, unconditioned stimuli. For example, a nausea-vomiting reflex typically occurs in response to the eating of overly rich, diseased, or poisonous food.This reflex helps to protect us from sickness.Classical conditioning occurs when a neutral stimulus that normally does not evoke a givenreflex is paired repeatedly with the unconditioned stimulus that naturally provokes the reflex. Undersuch conditions, the neutral stimulus takes on the ability to evoke the reflex. For example, the nauseareflex in response to eating rich or poisonous food can become linked to the sight or smell of thefood or even just the thought of it). Cancer patients, who experience nausea and sickness as side ef-fects of chemotherapy treatment, may develop anticipatory nausea on entering the hospital for treat-ment. Both responses to a previously neutral stimuli result from classical conditioning.5. Give examples of classically conditionable reflexes.Many potential reflexes in the reproductive, muscular, respiratory, and circulatory systems canbe classically conditioned. Note that the emotional components of reflexes e.g., fear, pleasure, anx-iety) can be conditioned as well as the physical components. In daily life, classical conditioning canbe adaptive e.g., it helps us learn quickly to avoid danger or unpleasantness) or maladaptive.Forexample, the normal adult response of sexual arousal and pleasant feelings with genital stimulationcan become classically conditioned to inappropriate cues such as children as in pedophilia) ornonanimate objects as in fetishism).
Examules o Internal Re flexe s and Conditioned S timuliDigestive systemReproductive system
Vomiting and nausea in response to food poisoning e.g., nausea on sight or smell of target food)Sexual arousal and pleasurable feelings in response to genital stimulation e.g., arousal on view-ing erotic books or videos)Respiratory systemAsthma attack in response to allergens e.g., an asthma patient feels the beginning of an attackon seeing an allergy-producing cat enter the room)Circulatory systemPounding heartbeat and anxiety produced by involvement in an auto accident on the freewaysubsequent fear and anxiety when driving in similar circumstances)Muscular systemRelaxation response to ingestion of alcohol relaxation felt on pouring the first drink at home atthe end of a tense day)
6. Describe important principles of classical conditioning that are used in behavior therapy.Extinguishingoccurs when the conditioned stimulus is not subsequently paired with the origi-nal unconditioned stimulus; the classically conditioned response weakens and becomes less frequent.Generalizationoccurs when similar stimuli evoke a similar conditioned response. For example,a child frightened by the harking of a large dog may develop an anxious, fearful response to all dogs.
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216 Behavior TherapyDiscriminationoccurs when the individual learns to respond differently to two similar or re-lated stimuli. For example, the child frightened of dog s may subsequently learn that large dogs thatbark aggressively are more dangerou s than small, quiet dogs.Counter-conditioningoccurs wh en a conditioned stimulus is paired with a new stimulus that
produces an incompatible or opposite response. The original, problematic conditioned response isextinguished by this technique, and new, healthy c onditioning is introduced simultaneously. For ex-am ple, a patient w ith a spider phob ia can be taught relaxation techn iques and then in therapy beasked to recreate the relaxed feeling during sim ultaneous exposure to the anxiety-provoking spiderstimulus. Under such cond itions, the old conditioned anxiety resp onse to spiders weakens.Aversive counter-conditioning s used to reduce problematic behaviors that are pleasurable.For example, an alcoholic patient may be given disulfiram (Antabuse) so that drinking alcoh ol be-com es associated with nausea and unpleasantness, thereby helping to reduce the frequency of laterdrinking.Covert conditioning is classical conditioning that occurs through imagery techniqu es ratherthan actual (in vivo) experience.7. Describe operant conditioning and its important principles.Consequencesshape and modify behavior in operant conditioning (also known as trial-and-error learning). Behavior that produces g ood effects becomes m ore frequent (positive reinforcementoccurs), whereas behavior that pro duces bad effects becom es less frequent (negative reinforcementoccurs). Learning occurs when the consequences are contingent (interpreted to be causally linked)on the operant behavior.Situational antecedent cues influence behavior in operant conditioning; any given operantbehavior may produce g ood effects in on e situation but bad effects in another. Thus we learn to dis-criminate between situations in which behavior may be rewarded or punished. Fo r example, steppingon the gas pedal when driving a car produces good effects when traffic lights are green (the drivercan proceed quickly w ith the intended journey) but bad effects when they are red (the driver may re-ceive a speeding ticket or have a serious accident).Shaping occurs when new, complex behaviors ar e learned through reinforcement of succes-sive approximations of the desired goal behavior.Discriminationoccurs w hen an individual learns to respond differently to two similar predic-tive cues through differential reinforcement (i.e., one predicts reinforcement and the other does not,or one predicts m ore reinforcemen t than the other). For exam ple, a shopper may drive to store Arather store B because he or she has learned that store A has better bargains.Generalizationoccurs when stimuli that resemble a predictive cu e become cue s to the operant
behavior. For example, a child who learns to bang in a nail with a hamm er may then enjoy hammer-ing many objects that look like a nail.Understanding important situational cu es and the negative or positive consequences of behaviorare the two keys to u nderstanding how o perant behavior arises and is su bsequently maintained,shaped, or extinguished.8. Describe systematic desensitization.Systematic desensitization, which is used principally in the treatment of phobias and OCD,combines counter-conditioningwith extinction. It can be carried out through patient imaginationor (m ore effectively) in vivo. This approach reduces the cond itioned anxiety response by p airing in-
compatible, positive feelings (e.g., relaxa tion, calm ) with th e origin al anxiety-provoking, condi-tioned stimulus.The patient first learns relaxation techniqu es. Then a hierarchy of anxiety-provoking situationsis identified by the therapist and patient to guide treatment planning . The patient is taught to rate theconditioned anxiety he o r she feels on a scale from 0 (e.g., no fear or anxiety) to 10 (e.g., extremefear, panic) to provide im med iate feedback during each treatment exercise. Then, in therapy and inhomework, the patient is systematically exposed to g raded levels of conditioned anxiety throughimagination or in vivo. At each anxiety-provo king level, the patient pairs relaxed feelings and
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Behavior Therapy 217thoughts with the conditioned stimulus and endures the conditioned stimulus until the anxiety sub-sides to a low level.For exam ple, a patient with a fear of flying may work through a hierarchy of fears by goin gthrough airport procedures before a flight, sitting in a plane, taking off, and then finally flying andlandin g. Th is process often is preceded by practice sessions in the office in which ea ch phas e isimagined along with a paired relaxation exercise. The aim of treatment is for the patient to feel littleanxiety in the most difficult flying-related situations.Research has show n that the relaxation com ponent of systematic desensitization is not alwaysnecessary for successful treatment.9. Describe the use o f exposure with response prevention in the treatment o f simple phobias.In this method, the conditioned anxiety reaction is extinguished through enduring exposure tothe feared phobic object. This strategy is combined w ith prevention of usual escap e (avoidance) be-haviors that provided reinforcement in the past through negative reward (i.e., relief from phobic anx-iety). For example, if a patient with a spider pho bia is exposed to pictures or thoughts of spiders
without escape o r avoidance, he or she will experience a gradual reduction of anxiety and fear as thepresence of the unconditioned stimulus (the spider) persists. In therapy, patients are taught the ratio-nale behind the treatment, receive specific exposure with response prevention treatments, practicehomework assignments at fixed times, discuss homework with the therapist, receive new assign-ments, and carry o ut m aintenance exercises in follow-ups if needed.For sim ple phobias, exposure in vivo is generally preferred to exposure through im agination ofthe phobic ob ject. Exp osur e and cognitive restructuring approaches (used to overcome irration alfears and negative thoughts) have become the psychosocial treatments of choice for panic, agora-phobia, and social phobia (see Chapters 14 and 15).10. Name the essential elements of behavior therapy for obsessive-compulsivedisorder.Behavioral assessment identifies the nature of obsessional thoughts and compulsive rituals aswell as related fear and anxiety responses.Gradual exposure in vivo to the problematic conditioned stimuli (e.g., exposure to dirty ob-jects fo r patients with fears of dirt and contam ination) is based on a hierarchy drawn up by the p a-tient and therapist. This exposure allows extinction of the conditioned anxiety response.Response prevention is applied to obsessive rituals (e.g., compulsive hand-washing behaviors)used by the patient to alleviate anxiety after exposure to the feared situation.Faulty patient cognitions (self-talk) are identified.Ongoing structured homew ork includes further exposure and response prevention assignmentsand correction of maladaptive self-talk.11. Describe flooding.In flooding , patients are exposed in vivo or through imagination to their con ditioned object offear at the most anxiety-provoking level possible until the fear and anxiety responses have been ex-tinguished. Flooding differs from systematic desensitization, in which graded levels of exposure areintroduced. Furthermore, in flood ing the therapist controls the exposure, whereas in systematic de-sensitization the patient determines progression through the hierarchy of conditioned fears. Floodingmay b e poorly tolerated by som e patients because of the high level of unpleasant feelings. In vivoflooding generally is considered m ore effective than flooding through im agination.12. What is the Premack principle?If, as a precondition made in therapy, the patient m ust complete desired low-frequency behaviorbefore high-frequency behavior can be carried out, the desired behav ior will increase in frequency. Forexample, if an obese patient in behav ior therapy for w eight control contracts to complete a 20-minutewalk each evening before sitting down to watch a favorite television show (something the patient doesoften), regular walking will increase in frequency and w eight loss and health gains will be more likelyto occur. The high-frequ ency behavior typically is pleasurable and prov ides positive reinforcem ent forthe low -frequency behaviors . This principle is applied in many forms of behavior therapy.
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218 Behavior Therapy13. What is the role of cognitive factors in behavior therapy?An understanding of the role of cognitive factors in the development and maintenance of prob-lem behaviors enab les the therapist to identify cog nitive distortions (negative self-talk and beliefs)arising from false assumptions or interpretations of life experiences and fear-inducing self-instruc-tions. Cognitive interventions aim to teach the patient to recognize distortions of thinking and to re-place them with more realistic, positive thoughts. They are particularly helpful in the treatment ofanticipatory anxiety, demoralization, avoidance behaviors, and low self-esteem (see Chapter 41).14. What is assertiveness training?Assertiveness training uses principles of operant reinforcement to improve social skills throughshaping, modelingof appropriate social behaviors by the therapist, role rehearsalof new skills intherapy sessions, and patient homework assignments. Typical problems include poor refusal skills;difficulties w ith self-disclosure, exp ression of negative emo tions, and giving or receiving criticism;and opening, maintaining, and closing conversations. Such deficits can be incorporated into abroader treatment plan for the presenting clinical problem.Treatm ent begins with a careful recording of the problem atic social situations and the circum-stances under which problem behaviors and thoughts arise. Patients are taught new social responsesfor each specific problem atic social situation. Problem solving is used in reviews of patient homew orkexercises, and new goals are set as the patient progresses to more challenging social situations basedon a previously agreed hierarchy of social difficulty. Mastery of problem situations may combine withnewfound enjoyment of social activities to reinforce new behaviors through positive reward.15. Describe token economies and their use.Token economies are based on the operant conditioning principle that positive reward of a de-sired behavior increases its frequency . They o ften involve the use of behavior shaping (i.e., the selec-tive reinforcement of successive approximations to the target behavior). All token econ omies have incomm on a clear definition of the app ropr iate behavior that the therapist wishes to promote a nd acontract with the patient that details the explicit rewards for carrying out desirable behaviors. Targetbehaviors may range from simple tasks related to feeding, personal hygiene, or politeness to com-plex social interaction behaviors that are the end result of a systematic behavior-shaping schedule.Token economies may b e based on the use of primary reinforcers (e.g., food, drink) or sec-ondary acquired) reinforcers (e.g., tokens, points, praise, sm iles). Tokens or points are accum u-lated by the patient and exchan ged for tangibles such as television time, toys, or privileges. Points ortokens also may b e taken away fo r inappropriate behavior (negative punishment). Note that so meprimary reinforcers, such as food (e.g., candy), m ay be problematic as they can reach levels of satia-tion, whereas secondary rewards (e.g., tokens) cannot.Token economies have been used to promote adaptive, normal, or healthy behaviors in class-rooms, adult day hospitals, sheltered workshops, and patient psych iatric settings; to help familyfunctioning; and to promo te individual self-development.16. What is stimulus control?Large numb ers of stimuli from the environment and from w ithin our bodies influence behavioralresponses in any given situation at a given point in time. Depending o n past learning, significant stim-uli may be 1 ) unconditioned or conditioned stimuli that produce classical responses, (2) discriminantstimuli that predict ope rant responses, or (3) stimuli that operate in both capacities. Treatment ap-proaches based on stimulus control involve the identification of this array of antecedent stimuli througha careful behavioral assessment and imp lementation of strategies to limit their influence. Stimulus con-trol approaches have been used notably in the man agement of obesity and sm oking cessation.For exam ple, obes e patients are taught to recognize conditioned stimuli (from previous classicallearning) and predictive stimuli (from previous operant learning) that may p romo te eating when thepatient is not hungry. A patient who eats when depressed, bored, or angry is taught to recogn izethese cues and is instructed to carry out healthier, incom patible behavior instead (e.g., go for a w alk,phone a friend). Food can be hidden from view outside of mealtimes, and eating can be restricted to
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Behavior Therapy 219the dining table only instead of while watching television or reading). The patient may be givenspecific exercises to slow down the rate of eating and to increase awareness of consumption. Aslower eating speed with improved awareness of the pleasurable, hedonic value of food may reduceoverall calorie intake. In addition, slower eating is thought to give the brain sufficient time to re-spond appropriately to rising blood glucose levels that provide feedback signals of satiety.17. How does biofeedback work?Biofeedback involves the use of specific machines that provide information feedback) aboutvariations in one or more of the patients physiologic processes that are not ordinarily perceived i.e.,brain wave activity, muscle tension, blood pressure). Feedback over a period of time may help thepatient to learn to control certain target physiologic processes i.e., anxiety, muscle tension re-sponses) through operant conditioning. For example, awareness of alpha wave patterns through agraphic representation of wave activity on a biofeedback monitor may help the patient to elicit a re-laxation response see Chapter 46).18. How is behavior therapy structured?The foundation of behavior therapy is the initial behavior analysis a process of careful docu-mentation and recording of the specific conditions under which presenting problem behaviors aroseand are maintained. Based on the behavioral analysis, a specific series of treatment tasks devisedby the therapist and patient are implemented in therapy sessions and in regular patient homework.Because behavior therapy is highly goal-oriented, treatment goals are clearly spelled out for the pa-tient, progress is assessed and discussed, and new goals are set for the next stage of treatment.Treatment gains are maintained with follow-up sessions and ongoing homework assignments.Through this process, behavior therapy reshapes the problem behavior in a more desirable direction.The treatment plan may include a microanalysis that focuses on the conditions surrounding thepresenting clinical problem and a macroanalysis that relates the presenting problem to other broaderproblem areas e.g., social skill deficits, marital problems).19. Wh at differentiates behavior therapy from psychodynam ic therapy?
FOCUS
GO L
STRUCTURE
ehavior TherapyConditions surrounding current proble-matic behavior and past circumstancesthat may highlight maladaptive learn-ing relevant to the current problemsImprove problematic behaviors, cogni-tions, and emotions directly, throughapplication of principles of classicaland operant learning theory and cognitive therapyHighly structured and goal- and outcome-oriented
Psychodvnamic TherauvHistorical and early life experiences,parenting dynamics, enduring per-sonality traits; links between theseand current life experiences and
problematic emotions and behaviorsReshape the intrapsychic structureofthe patient to produce favorablesymptom change based on specifictheories about the nature of earlychildhood nurturance experiencesand parenting dynamicsUnstructured approach facilitatesun-expected associations and derivesnew information and insights into
the causes of current problemsAlthough behavioral and psychodynamic therapies differ markedly i n theoretical basis andtreatment approach, elements of each may be found in the other. Information gathering is importantin both, as part of the continual exploration for new ideas and connections. Repeated discussion ofanxiety-producing concerns in the comfortable environment of psychodynamic therapy sessionsmay lead to extinction of a conditioned anxiety response (as in systematic desensitization). In be-havior therapy, open-minded questions and chance discussions in unstructured parts of a treatment
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220 Pla nne d Brief Psych othe rapysession may lead to important insights into the broader psychosocial context of specific problematicbehaviors (e.g., the presence of marital or work difficulties that exacerbate problem behaviors).
BIBLIOGRAPHYI Baldwin JD, Baldwin J: Behavior Principles in Everyday Life. Englewood Cliffs, NJ, Prentice-Hall, 1981.2. Emmelkamp PMG: Behavior therapy with adults. In Bergin AE, Garfield S L (eds) : Handbook ofPsychotherapy and Behavior Change, 4th ed. New York, John Wiley and Sons, 1994, pp 3 7 7 4 2 7 .3. Emmelkamp PMG, Bourman TK, ScholingA Anxiety D isorders. A P ractitioners Guide. Chichester, JohnWiley Son s, 1992.4. Griest JH: Behavior therapy for obsessive compulsive disorders. J Clin Psycho1 55:60-68, 1994.5. Noyes R: Treatments of choice for anxiety disorders. In Coryell W, Winokur G (eds): The Clinical6. Sloane R, Staples F, Cristol A, et al: Psychotherapy Versus Behavior Therapy. Cambridge, M A , Harvard7. Wachtel P: Psychoanalysis and B ehav ior Therapy. New York Basic Books, 1977.
Management of Anxiety Disord ers. New York, Oxford University Press, 1991.University Press, 1975.
43. PLANNED BRIEF PSYCHOTHERAPYMark A. Blais, Psy D
1. What is the natural course of psychotherapy?Despite the common perception that psychotherapy is a long-term, even timeless, enterprise,most of the existing d ata indicate that psychotherapy as it is practiced in the real world is a time-lim-ited process. National outpatient psychotherapy u tilization dat a from 1987 (obtained before the na-tionwide impact of managed care) reveals that 70 of psychotherapy users received 10 or fewersessions, and only 15 received 21 or mo re sessions.I8 These data are highly co nsistent with find-ings from o ther utilizations studies. Clearly, most patients have a time-limited or brief psychother-apy experience.This chapter will help you deliver psychotherap y in an org anized, planned, and thoug htfulmanner that more closely matches the natural course of psychotherapy.2. How did brief psychotherapy develop?
Freud was on e of the first practitioners of brief psychothe rapy. A review of his early cases re-veals that he treated many patients in a span of weeks to m onths rather than years. Ov er time, as psy-choanalytic theory became more co mplex , the goals of psychoanalysis b ecame m ore amb itious, andthe length of treatment increased greatly. As early as 1925 this trend had bec ome a concern to som e.Alexander and French can b e conside red the true fathers of brief psychotherapy. T heir booksychoanalytic sychotherapy outlined the first systematic attempt to develop a shorter and moreefficient form of psychotherapy. Although not generally accepted in its time, this work laid the foun-dation for both psychoanalytic p sychotherapy and m odem brief psychotherapy.Th e modern era of brief treatment began with the work of Malan an d of Sifne os. At present,brief psychoanalytic psychotherapies are supplemented by several other time-limited treatments,
such as Becks cognitive therapy, Manns existential psychotherapy, and Klermans interpersonaltreatment of depression.3. How does brief psychotherapy differ from long-term psychotherapy?Four dimensions, considered common to all brief therapies, differentiate short-term from themore traditional long-term therapies: 1 ) the setting of a fixed time limit for the treatment, (2) hold-ing to specific patient selection criteria, 3 ) using a treatment focus to limit the scope of the therapy,and (4) requiring increased activity by the therapist.
