CHAPTER 9

BEHAVIOR THERAPY
INTRODUCTION
Behavior therapy practitioners focus on directly observable behavior, current determinants of
behavior, learning experiences that promote change, tailoring treatment strategies to individual
clients, and rigorous assessment and evaluation.

Behavior therapy has been used to treat a wide range of psychological disorders with different
client populations.

Anxiety disorders, depression, post traumatic stress disorder, substance abuse, eating and
weight disorders, sexual problems, pain management, and hypertension have all been
successfully treated using this approach (Wilson, 2011).

Behavioral procedures are used in the fields of developmental disabilities, mental illness,
education and special education, community psychology, clinical psychology, rehabilitation,
business, self-management, sports psychology, health-related behaviors, medicine, and
gerontology (Miltenberger, 2012; Wilson, 2011).
HISTORICAL BACKGROUND
The behavioral approach had its origin in the 1950s and early 1960s, and it was a radical
departure from the dominant psychoanalytic perspective.

The behavior therapy movement differed from other therapeutic approaches in its application
of principles of classical and operant conditioning to the treatment of a variety of problem
behaviors.

Contemporary behavior therapy is no longer limited to treatments based on traditional learning

theory (Antony & Roemer, 2011b).

As behavior therapy has evolved and developed, it has increasingly overlapped in some ways
with other psychotherapeutic approaches (Wilson, 2011). Behavior therapists now use a variety
of evidence-based techniques in their practices, including cognitive therapy, social skills
training, relaxation training, and mindfulness strategies.
Traditional behavior therapy arose simultaneously in the United States,
South Africa, and Great Britain in the 1950s.

In the 1960s Albert Bandura developed social learning theory, which

combined classical and operant conditioning with observational learning.
Bandura made cognition a legitimate focus for behavior therapy.

Contemporary behavior therapy emerged as a major force in psychology

during the 1970s, and it had a signifi cant impact on education,
psychology, psychotherapy, psychiatry, and social work.

The 1980s were characterized by a search for new horizons in concepts

and methods that went beyond traditional learning theory.
Two of the most significant developments in the field were:

(1) the continued emergence of cognitive behavior therapy as a major force and

(2) the application of behavioral techniques to the prevention and treatment of health-
related disorders.

Late 1990s the Association for Behavioral and Cognitive Therapies (ABCT) (formerly known
as the Association for Advancement of Behavior Therapy) claimed a membership of about
4,500.

Early 2000s, the behavioral tradition had broadened considerably, which involved
enlarging the scope of research and practice. This newest development, sometimes known
as the “third wave” of behavior therapy, includes dialectical behavior therapy (DBT),
mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT),
and acceptance and commitment therapy (ACT).
FOUR AREAS OF DEVELOPMENT
Classical conditioning (respondent conditioning) refers to what happens prior to learning that
creates a response through pairing.

Operant conditioning involves a type of learning in which behaviors are influenced mainly by
the consequences that follow them.

Social Learning Approach (or the Social-Cognitive Approach) developed by Albert Bandura and
Richard Walters (1963) is interactional, interdisciplinary, and multimodal (Bandura, 1977, 1982).
Social cognitive theory involves a triadic reciprocal interaction among the environment,
personal factors (beliefs, preferences, expectations, self-perceptions, and interpretations), and
individual behavior.

Cognitive behavior therapy (CBT) represents the mainstream of contemporary behavior

therapy and is a popular theoretical orientation among psychologists. Cognitive behavioral
therapy operates on the assumption that what people believe influences how they act and feel.
VIEW OF HUMAN NATURE

Modern behavior therapy is grounded on a scientific view of human behavior

that accommodates a systematic and structured approach to counseling.

The current trend in behavior therapy is toward developing procedures that

give control to clients and thus increase their range of freedom.

Behavior therapy aims to increase people’s skills so that they have more
options for responding.

People have the capacity to choose how they will respond to external events
in their environment, which makes it possible for therapists to use behavioral
methods to attain humanistic ends (Kazdin, 1978, 2001).
BASIC CHARACTERISTICS
AND ASSUMPTIONS
Seven key characteristics of behavior therapy:

1. Behavior therapy is based on the principles and procedures of the scientific

method. Experimentally derived principles of learning are systematically
applied to help people change their maladaptive behaviors.

2. Behavior is not limited to overt actions a person engages in that we can

observe; behavior also includes internal processes such as cognitions, images,
beliefs, and emotions. The key characteristic of a behavior is that it is something
that can be operationally defined.
3. Behavior therapy deals with the client’s current problems and the factors
influencing them, as opposed to an analysis of possible historical determinants.

4. Clients involved in behavior therapy are expected to assume an active role by

engaging in specific actions to deal with their problems. Rather than simply talking
about their condition, clients are required to do something to bring about change.

5. This approach assumes that change can take place without insight into underlying
dynamics and without understanding the origins of a psychological problem. Behavior
therapists operate on the premise that changes in behavior can occur prior to or
simultaneously with understanding of oneself, and that behavioral changes may well
lead to an increased level of self-understanding.
6. Assessment is an ongoing process of observation and self-monitoring that
focuses on the current determinants of behavior, including identifying the
problem and evaluating the change; assessment informs the treatment
process.

7. Behavioral treatment interventions are individually tailored to specific

problems experienced by the client. An important question that serves as a
guide for this:

“What treatment, by whom, is the most effective for this individual with
that specific problem and under which set of circumstances?”
THE THERAPEUTIC PROCESS

THERAPEUTIC GOALS

Goals occupy a place of central importance in behavior therapy. The

general goals of behavior therapy are to increase personal choice and to
create new conditions for learning.

Continual assessment throughout therapy determines the degree to

which identified goals are being met. It is important to devise a way to
measure progress toward goals based on empirical validation.

Goals must be clear, concrete, understood, and agreed on by the client

and the counselor.
THERAPIST’S FUNCTION AND ROLE

Behavior therapists conduct a thorough functional assessment (or behavioral

analysis)to identify the maintaining conditions by systematically gathering
information about situational antecedents

(A), THE DIMENSIONS OF THE PROBLEM BEHAVIOR (B), AND THE CONSEQUENCES
(C) OF THE PROBLEM.

-This is known as the ABC model, and the goal of a functional assessment of a
client’s behavior is to understand the ABC sequence.

This model of behavior suggests that behavior (B) is influenced by some

particular events that precede it, called antecedents (A), and by certain
events that follow it, called consequences (C).
ANTECEDENT EVENTS

cue or elicit a certain behavior.

For example, with a client who has trouble going to sleep, listening to a relaxation tape may
serve as a cue for sleep induction.

Turning off the lights and removing the television from the bedroom may elicit sleep
behaviors as well.

CONSEQUENCES

are events that maintain a behavior in some way, either by increasing or decreasing it.

For example, a client may be more likely to return to counseling

after the counselor offers verbal praise or encouragement for having come in or
for having completed some homework.
BEHAVIORAL ASSESMENT INTERVIEW

The therapist’s task is to identify the particular antecedent and consequent events that
influence, or are functionally related to, an individual’s behavior(Cormier, Nurius, & Osborn,
2013).

Behaviorally oriented practitioners tend to be active and directive and to function as

consultants and problem solvers.

They rely heavily on empirical evidence about the efficacy of the techniques they apply to
particular problems.

Behavioral practitioners must possess intuitive skills and clinical judgment in selecting
appropriate treatment methods and in determining when to implement specific techniques
(Wilson, 2011).

They use some techniques common to other approaches, such as summarizing, reflection,
clarification, and open-ended questioning.
The therapist strives to understand the function of client behaviors, including how
certain behaviors originated and how they are sustained.

The behavioral clinician uses strategies that have research support for use with a
particular kind of problem. These evidence-based strategies promote generalization
and maintenance of behavior change.

The clinician evaluates the success of the change plan by measuring progress toward
the goals throughout the duration of treatment. Outcome measures are given to the
client at the beginning of treatment (called a baseline) and collected again periodically
during and after treatment to determine whether the strategy and treatment plan are
working. If not, adjustments are made in the strategies being used.

A key task of the therapist is to conduct follow-up assessments to see whether the
changes are durable over time.
CLIENT’S EXPERIENCE IN THERAPY

One of the unique contributions of behavior therapy is that it provides the

therapist with a well-defined system of procedures to employ.

Both therapist and client have clearly defined roles, and the importance
of client awareness and participation in the therapeutic process is
stressed.

Behavior therapy is characterized by an active role for both therapist and

client.

A large part of the therapist’s role is to teach concrete skills through the
provision of instructions, modeling, and performance feedback.
The client engages in behavioral rehearsal with feedback until skills are well
learned and generally receives active homework assignments (such as self-
monitoring of problem behaviors) to complete between therapy sessions.

It is important for clients to be motivated to change, and they are expected to

cooperate in carrying out therapeutic activities, both during therapy sessions
and in everyday life.

Clients are encouraged to experiment for the purpose of enlarging their

repertoire of adaptive behaviors.

Clients are as aware as the therapist is regarding when the goals have been
accomplished and when it is appropriate to terminate treatment.
RELATIONSHIP BETWEEN THERAPIST AND
CLIENT
Antony and Roemer (2011b) acknowledge that examining the efficacy
of particular behavioral techniques has been given more emphasis
than the quality of the therapeutic relationship in behavior therapy.

Behavioral practitioners have increasingly recognized the role of the

therapeutic relationship and therapist behavior as critical factors
related to the process and outcome of treatment.

Today, most behavioral practitioners stress the value of establishing a

collaborative working relationship with their clients.
For example, Lazarus (1993) believes a flexible repertoire of relationship styles, plus a wide
range of techniques, enhances treatment outcomes.

He (Lazarus) emphasizes the need for therapeutic flexibility and versatility above all else.

Lazarus contends that the cadence of client–therapist interaction differs from individual to
individual and even from session to session.

The skilled behavior therapist conceptualizes problems behaviorally and makes use of the
client–therapist relationship in facilitating change.

The experiential therapies (existential therapy, person-centered therapy, and Gestalt

therapy) place primary emphasis on the nature of the engagement between counselor and
client.
Most behavioral practitioners contend that factors such as warmth,
empathy, authenticity,permissiveness, and acceptance are
necessary, but not sufficient, for behavior change to occur.

The client–therapist relationship is a foundation on which

therapeutic strategies are built to help clients change in the direction
they wish.
APPLICATION: THERAPEUTIC
TECHNIQUES AND PROCEDURES

A strength of the behavioral approaches is the development of specific

therapeutic procedures that must be shown to be effective through
objective means.

A hallmark of the behavioral approaches is that the therapeutic

techniques are empirically supported and evidence-based practice is
highly valued.

The therapeutic procedures used by behavior therapists are specifically

designed for a particular client rather than being randomly selected from a
“bag of techniques.”
APPLIED BEHAVIORAL ANALYSIS: OPERANT
CONDITIONING TECHNIQUES
Positive reinforcement involves the addition of something of value to the individual
(such as praise, attention, money, or food) as a consequence of certain behavior. The
stimulus that follows the behavior is the positive reinforcer.

Negative reinforcement involves the escape from or the avoidance of aversive

(unpleasant) stimuli. The individual is motivated to exhibit a desired behavior to avoid
the unpleasant condition.

Another operant method of changing behavior is extinction, which refers to

withholding reinforcement from a previously reinforced response. In applied settings,
extinction can be used for behaviors that have been maintained by positive
reinforcement or negative reinforcement.
APPLIED BEHAVIORAL ANALYSIS: OPERANT
CONDITIONING TECHNIQUES
Another way behavior is controlled Miltenberger (2012) describes two kinds of
is through punishment, sometimes punishment that may occur as a consequence
referred to as aversive control, in of behavior:
which the consequences of a
certain behavior result in a decrease In positive punishment an aversive stimulus is
of that behavior. The goal of added after the behavior to decrease the
reinforcement is to increase target frequency of a behavior
behavior, but the goal of
punishment is to decrease target In negative punishment a reinforcing stimulus is
removed following the behavior to decrease the
behavior.
frequency of a target behavior
PROGRESSIVE MUSCLE RELAXATION

Progressive muscle relaxation has become increasingly popular

as a method of teaching people to cope with the stresses
produced by daily living. It is aimed at achieving muscle and
mental relaxation and is easily learned.

After clients learn the basics of relaxation procedures, it is

essential that they practice these exercises daily to obtain
maximum results.
SYSTEMATIC DESENSITIZATION

Systematic desensitization is an empirically researched behavior therapy

procedure that is time consuming, yet it is clearly effective and efficient in
reducing maladaptive anxiety and treating anxiety-related disorders,
particularly in the area of specific phobias.

Once it has been determined that systematic desensitization is an appropriate

form of treatment, a three-step process unfolds: (1) relaxation training, (2)
development of a graduated anxiety hierarchy, and (3) systematic
desensitization proper that involves the presentation of hierarchy items while
the client is in a deeply relaxed state (Head & Gross, 2008).
IN VIVO EXPOSURE AND FLOODING

Exposure therapies are designed to treat fears and other negative emotional
responses by introducing clients, under carefully controlled conditions, to the
situations that contributed to such problems.

In Vivo Exposure In vivo exposure involves client exposure to the actual

anxiety-evoking events rather than simply imagining these situations. Live
exposure has been a cornerstone of behavior therapy for decades.

Self-managed in vivo exposure — a procedure in which clients expose

themselves to anxiety-evoking events on their own is an alternative when it is
not practical for a therapist to be with clients in real-life situations.
IN VIVO EXPOSURE AND FLOODING

Flooding Another form of exposure therapy is flooding, which refers to either in

vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of time.

In vivo flooding consists of intense and prolonged exposure to the actual anxiety-
producing stimuli. Remaining exposed to feared stimuli for a prolonged period without
engaging in any anxiety-reducing behaviors allows the anxiety to decrease on its own.

Imaginal flooding is based on similar principles and follows the same procedures
except the exposure occurs in the client’s imagination instead of in daily life. An
advantage of using imaginal flooding over in vivo flooding is that there are no
restrictions on the nature of the anxiety-arousing situations that can be treated.
EYE MOVEMENT DESENSITIZATION AND
REPROCESSING

Eye movement desensitization and reprocessing (EMDR) is a form of

exposure therapy that entails assessment and preparation, imaginal
flooding, and cognitive restructuring in the treatment of individuals with
traumatic memories.

The treatment involves the use of rapid, rhythmic eye movements and other
bilateral stimulation to treat clients who have experienced traumatic stress.

The treatment consists of three basic phases involving assessment and

preparation, imaginal flooding, and cognitive restructuring.
SOCIAL SKILLS TRAINING

Social skills training is a broad category that deals with an individual’s

ability to interact effectively with others in various social situations; it is
used to help clients develop and achieve skills in interpersonal
competence.

Social skills involve being able to communicate with others in a way that
is both appropriate and effective.
SOCIAL SKILLS TRAINING
A popular variation of social skills training is anger management training, which is
designed for individuals who have trouble with aggressive behavior.

Assertion training One specialized form of social skills training consists of teaching
people how to be assertive in a variety of social situations. Many people have difficulty
feeling that it is appropriate or right to assert themselves.

Assertion training can be useful for those:

(1) who have difficulty expressing anger or irritation, (2) who have difficulty saying no, (3)
who are overly polite and allow others to take advantage of them, (4) who find it difficult
to express affection and other positive responses, (5) who feel they do not have a right to
express their thoughts, beliefs, and feelings, or (6) who have social phobias.
SELF-MANAGEMENT PROGRAMS AND SELF-
DIRECTED BEHAVIOR

Self-management strategies include self-monitoring, self-reward, self-

contracting, and stimulus control. The basic idea of self-management
assessments and interventions is that change can be brought about by
teaching people to use coping skills in problematic situations. Generalization
and maintenance of the outcomes are enhanced by encouraging clients to
accept the responsibility for carrying out these strategies in daily life.

In self-management programs people make decisions concerning specific

behaviors they want to control or change. People frequently discover that a
major reason they do not attain their goals is the lack of certain skills or
unrealistic expectations of change.
SELF-MANAGEMENT PROGRAMS AND
SELF-DIRECTED BEHAVIOR

For people to succeed in such a program, a careful analysis of the context of the behavior
pattern is essential, and people must be willing to follow some basic steps such as those
provided by Watson and Tharp (2007):

1. Selecting goals. Goals should be established one at a time, and they should be measurable,
attainable, positive, and significant for you. It is essential that expectations be realistic.

2. Translating goals into target behaviors. Identify behaviors targeted for change. Once
targets for change are selected, anticipate obstacles and think of ways to negotiate them.

3. Self-monitoring. Deliberately and systematically observe your own behavior, and keep a
behavioral diary, recording the behavior along with comments about the relevant antecedent
cues and consequences.
4. Working out a plan for change. Devise an action program to bring
about actual change. Various plans for the same goal can be
designed, each of which can be effective.

5. Evaluating an action plan. Evaluate the plan for change to

determine whether goals are being achieved, and adjust and revise
the plan as other ways to meet goals are learned.
MULTIMODAL THERAPY: CLINICAL
BEHAVIOR THERAPY

Multimodal therapy is a comprehensive, systematic, holistic approach to

behavior therapy developed by Arnold Lazarus.

Lazarus claims that the term “multimodal behavior therapy” is somewhat

of a misnomer.

Multimodal therapy is an open system that encourages technical

eclecticism in that it applies diverse behavioral techniques to a wide range
of problems.
MINDFULNESS AND ACCEPTANCE-BASED
COGNITIVE BEHAVIOR THERAPY

Newer facets of cognitive behavior therapy, labeled the “third wave” of behavior therapy,
emphasize considerations that were considered off limits for behavior therapists until
recently, including:

mindfulness
acceptance
the therapeutic relationship
spirituality
values
meditation
being in the present moment
and emotional expression.
Third-generation behavior therapies have been
developed that center around five interrelated core
themes:

An expanded view of psychological health

A broad view of acceptable outcomes in therapy

Acceptance

Mindfulness

Creating a life worth living

MINDFULNESS AND ACCEPTANCE-BASED
COGNITIVE BEHAVIOR THERAPY

Mindfulness involves being aware of our experiencing in a receptive way

and engaging in activity based on this nonjudgmental awareness.

Acceptance is a process involving receiving one’s present experience

without judgment or preference, but with curiosity and kindness, and
striving for full awareness of the present moment.
THE FOUR MAJOR APPROACHES IN THE RECENT DEVELOPMENT OF THE BEHAVIORAL TRADITION
INCLUDE:

Dialectical behavior therapy (dbt)- which has become a recognized treatment for borderline
personality disorder.

DBT SKILLS ARE TAUGHT IN FOUR MODULES:

Mindfulness helps clients to embrace and tolerate the intense emotions they experience when
facing distressing situations.

Interpersonal effectiveness involves learning to ask for what one needs and learning to cope
with interpersonal conflict.

Emotion regulation includes identifying emotions, identifying obstacles to changing emotions,

reducing vulnerability, and increasing positive emotions.

Distress tolerance is aimed at helping individuals to calmly recognizing emotions associated

with negative situations without becoming overwhelmed by these situations.
Mindfulness-based stress reduction (mbsr) - which involves an 8- to 10-
week group program applying mindfulness techniques to coping with stress
and promoting physical and psychological health.

Mindfulness-based cognitive therapy- which is aimed primarily at treating

depression.

Acceptance and commitment therapy- which is based on encouraging

clients to accept, rather than attempt to control or change, unpleasant
sensations.
APPLICATION TO GROUP COUNSELING

Behavioral group counseling focuses on teaching clients self-management, coping strategies,

and restructuring thoughts to handle challenges effectively.

Group leaders take an active and directive role, modeling behaviors, guiding sessions, and
providing continuous feedback through structured, time-limited interventions.

Techniques like relaxation, behavioral rehearsal, modeling, coaching, mindfulness, and

meditation are commonly used, while skills training often includes assertiveness and social
skills.

Groups may vary, including social skills training, psychoeducational themes, stress
management, multimodal therapy, and mindfulness-based approaches.
BEHAVIOR THERAPY FROM A
MULTICULTURAL PERSPECTIVE

Strengths From a Diversity Perspective- Behavior therapy supports diverse clients by

focusing on specific behaviors, problem-solving, and actionable plans. It considers
cultural, social, and environmental factors while emphasizing present issues. Ethical
practice requires cultural competence and sensitivity to norms, spirituality, and client
perspectives.

Shortcomings From a Diversity Perspective- Behavior therapy may overlook

sociocultural factors by focusing too narrowly on individual problems. Therapists
must assess cultural and interpersonal dimensions, address social justice issues,
and prepare clients for the complexities of change within their environments.
CONTRIBUTIONS OF BEHAVIOR THERAPY

Behavior therapy challenges us to reconsider our global approach to counseling. Behavior

therapy focuses on creating actionable plans and uses specific techniques to achieve change.

It emphasizes research-based practices, ethical accountability, and client control in goal-setting.

Its evidence-based methods effectively address various mental health conditions.

LIMITATIONS AND CRITICISMS OF BEHAVIOR THERAPY

Behavior therapy may change behaviors, but it does not change feelings.

Behavior therapy does not provide insight.

Behavior therapy treats symptoms rather than causes.

Behavior therapy involves control and social infl uence by the therapist.
THANK YOU!