Behavior Therapy

Behavior therapy does not assume that, at their core, humans are inherently positive or negative. Behavior therapy assumes that, within biological constraints, humans are complex learners. Sometimes rich repertoires of positive behaviors are learned. Sometimes excesses (e.g., high anxiety or anger) or dysfunctional behaviors (e.g., substance use, aggressiveness, or inappropriate avoidance) are learned. Sometimes people have not learned needed behavior (e.g., job interviewing or assertion skills). Human functioning is heavily influenced by past learning and the requirements of current environments. The nature of the fit of the person and situation is critical. People who have the requisite cognitive, emotional, and behavioral skills needed in the current environment are likely to function well, but problems occur when the fit of the person to the environment is poor. If learning is the primary source of difficulty, then new learning can be the solution. Therefore, the goal of behavior therapy is to help the client learn to stop behaving in a certain manner and start behaving in a more effective way.

Behavior therapy is rooted in models of learning. The client’s current concerns are concretely assessed and learning-based interventions are designed for effective cognitive, emotional, and behavioral functioning. Behavior therapy is action oriented and most appropriate for clients with behaviors that need to be changed, rather than those seeking self-exploration or help with decision making. Behavior therapy can be integrated with other approaches (e.g., cognitive or family therapy). An extensive body of research evidence documents the status of behavior therapy as an empirically supported intervention. This entry describes three types of learning—classical conditioning, instrumental conditioning, and vicarious learning— and explains how these types of learning are applied in behavior therapy.

Types of Learning

Classical Conditioning

In classical conditioning, new situation-response associations are developed through temporal pairing of new situations with events that currently elicit a response. With repetition, people come to react with the old response in the new situation. Many counseling-relevant examples of classical conditioning involve emotional conditioning. For example, initially a person might find that public speaking arouses only mild anxiety. Then, while making a presentation, this person makes mistakes that lead to great fear and embarrassment. Oral presentations become paired with strong negative emotional reactions such that now the person is strongly fearful when preparing or giving a speech. Classically-conditioned fear has strong motivational properties, causing escape, avoidance, and other dysfunctional behavior.

Operant Conditioning

In operant conditioning, behavior is learned and maintained by the consequences that follow the behavior. Some consequences are external (e.g., praise from another), whereas others are internal (e.g., anxious feelings). Consequences also differ in a temporal dimension; some occur immediately, while others are delayed. Sometimes a conflict between the immediate and delayed contingences is part of the problem (e.g., avoiding a test brings a student immediate anxiety reduction but later academic difficulties). Behavior that leads to positive events (positive reinforcement) or a reduction of aversive events (negative reinforcement) will be maintained or increased. Behavior that consistently fails to lead to reinforcement (extinction) will decrease. Behavior that inconsistently or intermittently leads to reinforcement will be highly resistant to extinction and likely to persist. Behavior leading to negative, unpleasant outcomes (punishment) tends to decrease. Punishing consequences can involve the presentation of something aversive (e.g., being yelled at) or the loss of something positive or pleasant (e.g., loss of privileges).

Events co-occurring with or preceding consequences (antecedents) trigger and guide behavior because they signal likely consequences. In summary, in operant conditioning, antecedent events (internal and external) activate a person’s learned behavior. The positive, negative, or neutral consequences that follow the behavior strongly influence the person to continue or change the behavior.

Modeling or Observational Learning

In modeling, information about behaviors and their consequences is learned vicariously through observations of the situations, behaviors, and consequences experienced by others. Modeling can lead to the acquisition of new behavior (response acquisition), an increase of available behavior presently not performed (response facilitation), or a decrease in behavior (response inhibition) due to the adverse consequences to the model.

These learning processes often operate interdependently. For example, a fear might be developed through classical conditioning or modeling. Defensive, avoidant, and other dysfunctional behavior may be strengthened due to powerful negative reinforcement effects of the fear reduction produced by these behaviors.

Characteristics of Behavior Therapy

Behavior therapists attempt to understand behavior within these learning models and employ learning-based strategies to bring about positive change. This learning-based understanding of human behavior leads to some broad characteristics of behavior therapy.

Behavioral Specificity

Learning can be very situation specific. A person may respond effectively in one situation and poorly in another. For example, clients may not be “unassertive.” They may respond respectfully and appropriately with coworkers, anxiously and acquiescently with supervisors, and aggressively with intimate partners. A corollary is that behavior therapists do not conceptualize client concerns in terms of broad intrapersonal characteristics (e.g., low self-esteem or chronic anxiety). Instead, they see problems as happening in specific contexts. Sometimes, the range of contexts is quite broad, but behavior therapists try to understand client concerns in terms of specific contexts, forms of responding, and outcomes or consequences.

Because learning histories are so varied, behavior therapists do not assume that the same stated client concern results from similar factors in different clients. For example, three clients might present with social anxiety. One may have conditioned strong emotional/physiological arousal that interferes with functioning and leads to avoidance. Another may never have developed needed social skills and consequently suffers interpersonal rejection. A third may have adequate skills but excessively high performance expectations and be highly demanding and self-critical, thereby being overly vigilant and anxious. Similar problems may be due to very different factors and require quite different interventions.

Behavioral Assessment

Behavior therapists approach client concerns with a careful assessment of antecedent-response-consequence cycles to understand the meaning of the client’s stated concerns. Behavioral assessment often involves detailed interviewing and exploration of specific examples. Since not all issues can be understood by talking about them, assessment often involves observation during naturalistic conditions (e.g., marital discussion), simulations (e.g., role-play of giving negative feedback), or imagery review (e.g., visualization of a recent social encounter). With client permission, information may be obtained from others (e.g., parents, employers, teachers, or intimate partners). Archival information (e.g., nursing notes, school records) also may be sought. Issue-specific questionnaires (e.g., a speech anxiety or assertiveness questionnaire) may be administered. The results of these are not used normatively, but as samples of the person’s report about responses in the situation.

Information from these various sources is integrated, and clients and therapists develop a detailed, shared behavioral understanding of the antecedent-behavior-consequence sequence that forms the client’s concerns. This understanding also leads to ways of monitoring key elements (e.g., frequency of behavior, anxiety intensity ratings on 0-10 scale, daily completion of the Beck Depression Inventory), which furthers ongoing understanding and assists in evaluating therapy effectiveness.

Behavioral Interventions

If behavior is primarily learned responding, then learning-based interventions that alter one or more element of the antecedent-behavior-consequence sequence should increase desired outcomes. Since internal responding (i.e., feelings, imagery, self-talk) follows the same learning processes, learning-based interventions also can be brought to bear on internal responses.

Modifying Antecedents

Problematic behavior often exists in complex chains of behavior, so altering antecedents can change behavior in a number of ways. One strategy is for the person to avoid cues for problem behavior (e.g., someone with a drinking problem not socializing with an alcohol-abusing friend, couples not discussing problems when they are tired or consuming alcohol). Another strategy is building in a pause or a time-out, thereby interrupting the chain of events leading to problem behavior. When clients are about to engage in the problem behavior (e.g., yelling at their children), they remove themselves from the environment so that they interrupt their automatic, overlearned behavior and it does not continue. The clients may rehearse effective behavior (e.g., calmly making a request of their children) during this pause as well.

A variant is for the client to record undesired behavior before engaging in it. The act of recording breaks up the chain of antecedents and provides greater control over the behavior. Some environments trigger multiple, conflicting behaviors. For example, an insomniac may read, ruminate, worry, do work, watch television, and eat in bed, making falling asleep difficult. Such insomnia may respond to stimulus narrowing in which all behaviors, other than sleep and sexual activity, take place in other environments. Other problem behaviors that occur in many environments (e.g., overeating, sulking, worrying) respond to stimulus narrowing (e.g., engaging in them only at a specific place and time).

Another way of modifying antecedents is to explain to clients how to systematically present cues for the desired behavior. For example, depressed clients might place a colored dot on their watch and rehearse realistic, positive self-appraisals whenever they look at the watch. The social environment may be reprogrammed so that friends and family prompt desired behavior. Clients can also preprogram the environment to reduce problem-eliciting antecedents (e.g., removing alcohol or high calorie foods). The person’s internal environment may be altered so that negative self-talk or feelings such as anxiety do not trigger problem behavior. Developing specific self-instructions for initiating desired behavior also can be effective. In summary, undesired behaviors can be decreased and desired behaviors increased by clients’ systematically changing the antecedent events that prompt them.

Modifying Behavior

Sometimes the goal is developing new, effective behaviors (e.g., job seeking or parenting skills). Behavior therapists focus on identifying needed skill components and providing experiences in which those skills are rehearsed until clients can use them naturally. Two examples, relaxation coping and assertiveness skills training, are described below.

Highly anxious, stressed, or angry clients may not know how to calm themselves and use skills they have to cope with the situation. Relaxation coping skills programs address these deficits.

First, clients are taught to recognize the internal and external cues for problem emotions so they know when to employ relaxation. Sensitivity to distress cues is developed by activities such as keeping diaries on emotional experience, attending to areas of greatest tension during relaxation practice, and attending to arousal during in-session coping practice. Simultaneously, clients learn a basic relaxation response, usually through progressive relaxation training. As clients become proficient at relaxing, they learn ways to initiate relaxation quickly (e.g., relaxation without tension, cue-controlled relaxation). Then they are provided in-session training in applying relaxation for emotional control. For example, anxious clients might visualize anxiety arousing situations, experience anxiety for 30 to 60 seconds, and then initiate relaxation to lower arousal.

During early therapy sessions anxiety arousal is mild to moderate, and therapists provide assistance in initiating relaxation. As clients experience success, the anxiety level is increased and the therapist assistance decreased so clients gain full self-control over their initiation of relaxation. Clients also practice the application of relaxation coping skills in external problem situations so they can employ relaxation whenever needed. Relaxation coping skills programs are effective with anxiety, fear, stress, anger, headaches, pain, and related forms of emotional discomfort.

Some clients’ difficulties involve problems in assertiveness. Assertiveness requires an active, positive, expression of self, while respectfully entertaining and supporting the expression of others. Assertiveness is not a single behavior. For shy, inhibited individuals, assertiveness may mean giving voice to thoughts, feelings, and preferences; making reasonable requests of others; standing up for one’s rights; setting interpersonal limits; expressing positive feelings toward others; and doing so without anxiety and reticence. For angry, aggressive individuals who express themselves but override and disrespect others, assertiveness may mean slowing down, not jumping to conclusions, actively listening to others, expressing themselves in calmer ways, sharing preferences without demand and intimidation, and respectful negotiation.

When assertiveness deficits and situations in which they occur are identified, therapist and client discuss appropriate behaviors for the situation. The therapist may model examples. Then, one or two aspects of the desired responding are specified (e.g., content of response, voice volume, or nonverbal behavior) and the client role-plays and rehearses those behaviors. The rehearsal is then debriefed; the client describes the experience, and the therapist reinforces and supports gains and clarifies remaining issues. The experience is repeated with attention to old and new behavioral elements.

Assertive behaviors are practiced in a natural setting with positive elements reinforced and troublesome behavior addressed in subsequent sessions. Over time, clients develop general principles and strategies of assertiveness and a flexible repertoire of assertive behaviors. Assertiveness training is effective with timid, acquiescent individuals and with angry, aggressive individuals, and it is used in psychoeducational experiences for enhancing the well-being of nonclients.

Modifying Consequences

The law of effect draws attention to the fact that we can modify the consequences that follow behavior to develop desired behavior. Therapists, clients, and others can deliver consequences. Client and therapist can arrange for positive events to follow desired behavior (positive reinforcement). For example, parents might allow their youngster extra time with friends for expressing displeasure in a nonaggressive manner, or depressed clients might provide themselves with contingent amounts of video watching for initiating and engaging in social and physical activity.

Following a low-frequency but desired behavior with a higher-frequency, nonproblem behavior is also positively reinforcing. For example, a depressed person could follow a subvocal repetition of positive self-statements with a sip of coffee or tea.

Negative reinforcement (strengthening behavior by the reduction of negative outcomes) also can be employed. For example, a problem drinker might visualize starting to drink followed by an intense sensation of being about to vomit, and then visualize throwing the drink into the sink and experiencing relief of these aversive feelings. Initially, desired behaviors are reinforced every time they occur to maximize success. Over time, however, the frequency of reinforcement is reduced to make the behavior more likely to persist.

Punishment is another contingency that can be used to suppress behavior. For example, a man who ruminated obsessively about his ex-partner could self-administer a strong rubber band snap to decrease rumination. Punishment is used sparingly to prevent negative side effects. Where possible, removal of positive events is preferred over contingent presentation of painful stimuli. Every effort is made to combine punishment with the reinforcement of desired behavior. For example, smokers or alcoholics might visualize initiating problem consumption immediately followed by a noxious event such as vomiting (punishment). In other visualizations, they visualize initiating problem behavior, but stopping before consumption followed by a great sense of relief from not vomiting, thereby negatively reinforcing the desired behavior (i.e., resistance to temptation).

Extinction

Extinction (not following a behavior with reinforcement) can reduce undesired behavior. One example is the use of exposure and response prevention in treating anxiety. Initially, certain situations elicit strong anxiety in the client, leading to dysfunctional avoidance and escape. These undesirable behaviors are strengthened by the negative reinforcement of anxiety reduction. To reverse this, clients are exposed to the cues that cause anxiety, but they are not allowed to avoid or escape, thereby preventing reinforcement of the undesirable behavior. With repetition, the association between the eliciting cues and anxiety is extinguished, as is the connection between anxiety and avoidance. Generally, exposure is gradual (i.e., it starts with low levels of anxiety and increases over time). Exposure and response prevention is often combined with interventions to enhance effective behavior. Exposure-based interventions are highly effective with phobic, panic, posttraumatic, and obsessive-compulsive issues.

Flexible Structure

Behavior therapy may not follow a regularly scheduled hour in the office. For example, exposure and response prevention and parenting skills training often require greater time. Intervention may take place in naturalistic settings (e.g., in a store with an unassertive client returning an item) or in simulated environments (e.g., in front of a camera for speech-anxious people). Behavior therapists employ homework and contracted tryouts outside counseling to extend and solidify clients’ behaviors in their natural environments. Clients keep records of the assignments they complete outside the counseling sessions, and these are reviewed and used in planning further intervention efforts. Behavior therapists construct learning experiences to be efficacious, rather than limit them to an office hour.

Maintenance and Relapse Prevention

Behavior therapists expect difficulty in maintaining gains for many reasons. New behaviors are fragile and old behaviors are often highly reinforced. Environments and reinforcement contingencies shift. Times of stress may reinstate old conditions and reactions. Behavior therapists inform clients to expect slips and discuss maintenance and relapse prevention in the late stages of therapy. For example, conditions that often contribute to relapse are identified, and strategies to minimize them are rehearsed. Clients may continue recording behaviors to keep a focus on maintenance. Therapists review records, reinforce maintenance, and troubleshoot problems. Later sessions might be scheduled further apart so clients have greater opportunity for relapse, which is addressed in subsequent sessions. Brief intervals of new counseling might be initiated to address relapse. Whatever the format, maintenance and relapse prevention are anticipated, normalized, and addressed.

Client Readiness

Behavior therapists expect resistance to change. Clients may not wish to give up reinforcement. Clients may have learned to externalize the source of behavior and blame others. Change may be avoided because it is associated with anxiety. Clients may not understand the nature of their issues, much less be ready to change. Such things lower client readiness for change.

When behavior therapists accept a client who is not yet ready for change, readiness for change becomes the initial focus of intervention. For example, rather than trying to convince angry, externalized clients to reduce their anger and aggression, behavior therapists might focus on an exploration of the consequences of client behavior. They could explore whether the clients are getting everything they want from their behavior or have their clients collect information from others regarding the impact of their behavior. Change may become the focus of therapy, but only when the clients are ready for change.

Behavioral Groups

Behavior therapy is often provided in groups. Groups are time limited, issue focused (e.g., anxiety reduction or assertiveness training), and sequentially structured to provide learning experiences that maximize success and minimize anxiety. For example, a group of unassertive, timid clients could be introduced to the notion of assertiveness and assisted in a series of graded steps to identify, rehearse, and employ assertive responding in daily life.

Behavioral groups offer the efficiency of group counseling and other benefits. Groups provide many different models and styles for behavioral rehearsal. Groups also provide different opinions about effective behavior, thereby leading to uniquely satisfying definitions of behavior for the individual. Modeling effects may be enhanced by group work. In individual therapy, the therapist may be perceived as an expert, thereby making the gap between therapist and client too large for effective modeling. This problem is reduced in behavioral groups, because other group members serve as models during behavioral rehearsal. Other members also serve as powerful prompts for the desired behavior, and they can reinforce the desired behavior both within and between sessions (e.g., in a group of displaced workers, group members can call each other and support each other’s job search behaviors). Behavioral groups can also occur in psychoeducational contexts in which nonclient participants are brought together to develop desired behaviors (e.g., stress or anger management).

Behavioral Consultation

Behavior therapists often consult with other professionals by conducting behavioral assessments and by designing and evaluating interventions. For example, behavior therapists might consult with school staff to design and implement interventions to diminish students’ problem behavior. They might consult with nursing home staff to identify behavioral strategies that will increase client activity level and self-sufficiency and decrease depression. In this role, behavior therapists are a resource to the primary agents of change.

Self-Directed Change

Behavioral interventions can be highly self-directed. People may take classes on general principles of behavioral analysis and change or topic-specific classes (e.g., weight management or parenting skills). Instructors provide learning strategies and serve as consultants in the design and implementation of self-change projects. People may undertake self-directed change without professional assistance by using some of the detailed behavioral self-help materials that are available.

Other Behavior Therapy Issues

Therapeutic Relationship

Behavior therapy regards the counseling relationship and alliance as very important, but not necessarily as the central factor in change. Clients may withdraw from therapy if the behavior therapist is not a warm, supportive, empathic listener, because the client does not feel safe and trusting. A positive relationship allows clients to feel safe enough to reveal details about their lives from which collaborative conceptualization and intervention can be developed. Without a positive relationship, behavior therapists cannot conduct a thorough analysis of client concerns and clarify examples of critical antecedent-behavior-consequence sequences. Moreover, a positive relationship is very powerful in encouraging and reinforcing clients as they undertake new behaviors or take steps toward trying out anxiety-laden behaviors. For these reasons, the counseling relationship is considered a necessary condition for successful behavior therapy. The relationship supports and makes possible changes in environmental and learning conditions, which are the necessary conditions for lasting change.

Attention to Emotion

Behavior therapy is sensitive to feelings and emotions. Sometimes feelings (e.g., fear, depression, resentment, shame, and/or guilt) are primary issues and the target of intervention (e.g., anxiety or anger reduction). Learning to use a facilitative emotional tone is often an important part of a client’s skill development. For example, emotional tone and paralinguistic characteristics are important elements of rehearsed behavior in assertiveness training (e.g., requests should be initiated in a calm, firm, respectful manner and compliments should be given with a positive voice inflection). Furthermore, behavior therapy may focus on behaviors and activities that increase positive emotions. Interventions may help clients scan for and take advantage of naturally occurring positive events or increase behaviors leading to positive feelings and a sense of mastery and self-efficacy.

Emotional reactions may be involved in another way. Clients are not likely to engage in new behavior that is culturally incongruent or generates conflict with their important attitudes and values (e.g., angry clients may initially be unwilling to try assertive behaviors because they interpret assertiveness as a sign of weakness or vulnerability). In behavior therapy such interpretations and feelings become the focus of intervention (e.g., helping clients understand how the behavior fits positively valued constructs and is therefore a sign of strength and self-empowerment). Thus, behavior therapy is very emotionally focused, even if some of its language is not.

Insight

Behavior therapy does not assume that deep cognitive and emotional exploration of family of origin or early traumatic issues is necessary for change. Behavior therapy may focus on earlier life issues to learn what they can teach about current problems and their maintenance and change. If the client’s anxieties or dysfunctional behaviors are linked strongly to earlier issues, therapy may focus on these issues. The goal is not to provide insight, however, but to reduce anxiety and develop alternative, positive coping strategies. Behavior therapists do not believe that a deep understanding of earlier life issues is sufficient to affect a resolution of current concerns.

Cultural Sensitivity

Behavior therapy is very sensitive to culture. In a general sense, culture is a broad set of norms, expectations, and sanctions for behavior. Behavior therapists assess these cultural norms and sanctions and make interventions consistent with the person’s cultural experiences. Failure to do so would encourage clients’ dysfunctional behavior and resistance to change, in addition to increasing the likelihood that clients will drop out of therapy. For example, relaxation interventions may be inconsistent with the beliefs of certain ethnic or religious groups. In a situation where the client belongs to such a group, a form of relaxation that fits with the client’s cultural beliefs would be sought and integrated into therapy.

Culture may be a focus of behavioral intervention in at least two other ways. First, people may experience a cultural conflict where settings call for different behaviors (e.g., the client’s culture of origin encourages deference to authority, whereas a current work environment encourages challenges to authority and an open, animated expression of ideas). Conflict, ambivalence, and avoidance may ensue. Therapy explores different cultural expectations and reinforcement structures and how to behave differently, yet comfortably, in different cultural contexts.

On other occasions, a change in culture may be considered. For example, delinquents and substance abusers often exist in subcultures that model and reinforce deviant, self-defeating behavior. Intervention may focus on the client’s changing environments, developing skills to resist reentering deviant environments, and developing new skills and reinforcement structures.

Conclusion

Behavior therapy emphasizes the action-oriented psychological interventions based on learning theory that are most useful for clients who wish to change behaviors. The underlying premise of behavior therapy is that dysfunctional behaviors are learned and that clients can learn to discontinue those dysfunctional ways of behaving and substitute more effective ways of behaving in their place. Behavior therapy can be used by itself or integrated with other therapeutic approaches. An extensive body of research documents the effectiveness of behavior therapy.

References:

  1. Alberti, R. E., & Emmons, M. L. (2001). Assertiveness and social skills training: A practical therapist guide. Atascadero, CA: Impact.
  2. Alberti, R. E., & Emmons, M. L. (2001). Your perfect right: Assertiveness and equality in your life and relationships (8th ed.). Atascadero, CA: Impact.
  3. Best practices for therapy: Empirically based treatment protocol series (a series of behavior therapy manuals for issues such as anxiety, depression, phobias, obsessive-compulsive disorder, and anger). Oakland, CA: New Harbinger.
  4. Hays, P. A., & Iwamasa, G. Y. (2006). Culturally responsive cognitive-behavioral therapy: Assessment, practice, and supervision. Washington, DC: American Psychological Association.
  5. Watson, D. L., & Tharp, R. G. (2001). Self-directed behavior: Self-modification for personal adjustment (8th ed.). Belmont, CA: Wadsworth.
  6. Wolpe, J. (1992). The practice of behavior therapy (4th ed.). New York: Allyn & Bacon.

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