BEHAVIOR THERAPY  G. Terence Wilson  


OVERVIEW  


Behavior therapy is a relative newcomer on the psychotherapy scene. Not until the late  1950s did it emerge as a systematic approach to the assessment and treatment of psycho logical disorders. Tn its early stages, behavior therapy was defined as thc application of  modern learning theory to the treatment of clinical problems. The phrase modern learning  theory referred to the principles and procedures of classical and operant conditioning.  Behavior therapy was scen as the logical extension of behaviorism to complex forms of  human activities.  
Behavior therapy has undergone significant changes in both nature and scope, and  it has been responsive to advances in experimental psychology and innovations in clini cal practice. It has grown more complex and sophisticated. Behavior therapy can no  longer bc defined simply as thc clinical application of classical and operant conditioning  theory.  
Behavior therapy today is marked by a diversity of views. It now comprises a broad  range of heterogeneous procedures with different theoretical rationales and open  debate about conceptual bases, methodological reguirements, and evidence of efficacy.  As bchavior therapy expands, it incrcasingly overlaps with other psychotherapeutic  approaches. Nevertheless, the basic concepts characteristic of the behavioral approach  are clear and its commonalities with and differences from nonbehavioral therapeutic  systems can be readily identified.  


Basic Concepts  


'Traditionally, three main approaches in contemporary behavior therapy have been iden tified: (1) applïed bebavior analysis, (2) a neobebavioristic mediational stimulus—response  model, and () social-cognitive theory. These three approaches differ in the extent  to which they use cognitive concepts and procedures. At one end of this continuum  is applied bebavior analysis, which focuscs cxclusively on observable behavior and  rejects all cognitive mediating processes. At the other end is social-cognitive theory, which relies heavily on cognitive theories.  


Applied Behavior Analysis  


'This approach is a direct extension of Skinner's (1953) radical behaviorisin. 1t relies on  operant conditioning, the fundamental assumption being that behavior is a function of  its conscgucnces. Accordingly, treatment procedures are based on altering relationships  between overt behaviors and their conseguences. Applied behavior analysis makes use  of reinforcement, punishment, extinction, stimulus control, and other procedures de  
rived [rom laboratory research. Cognitive processes are considered private events and  are not regarded as proper subjects of scientific analysis.  


The Neobehavioristic Mediational Stimulus—Response (S—R) Model  


'This approach features the application of the principles of classical conditioning,  and it derives from the learning theories of Ivan Pavlov, E. R. Guthrie, Clark Hull, O. H. Mowrer, and N. E. Miller. Unlike the operant approach, the S-R model is media  tional, with intervening variables and hypothetical constructs prominently featured. S-R.  
theorists have been particularly interested in the study of anxiety; the technigues of  systematic desensitization and flooding, both closcly associated with this model, are directed  toward the extinction of the underlying anxiety assumed to maintain phobic disorders.  
Private events, especially imagery, have been an integral part of this approach,  including systematic desensitization. The rationale is that covert processes follow the  laws of learning that govcrn overt bchaviors.  


Social—Cognitioe Theory  


The social cognitive approach depends on the theory that behavior is based on three  separate but interacting regulatory systems (Bandura, 1986). They are (1) external stim  ulus events, (2) external reinforcement, and (3) cognitive mediational processes.  
1n the social—cognitive approach, the influence of environmental events on behavior  is largely determined by cognitive processes governing how environmental influences arc  perceived and how the individual interprets them. Psychological functioning, according  to this view, involves a reciprocal interaction among three interlocking sets of influences:  behavior, cognitive processes, and environmental factors. Bandura put it as follows;  
Personal and cnvironmcntal factors do not function as independent determinants;  rather, they determine each other. Nor can “persons” bc considered causcs inde pendent of their behavior. It is largely through their actions that people produce  the environmental conditions that affect their behavior in a reciprocal fashion. The  experiences generated by behavior also partly determine what individuals think,  expect, and can do, which in turn affect their subseguent behavior, (1977, p. 345)  
In social-cognitive theory, the person is the agent of change. The theory empha sizes thc human capacity for self-directed bchavior change. Strongly influenced by the social—cognitive model, the clinical practicc of behavior thcrapy has incrcasingly included cognitive methods, especially those described by Aaron Beck (see Chapter 8). A primary fo cus of both cognitive and behavioral technigues is to change the cognitive processes viewed  as essential to therapeutic success. The basic assumption is that it is not so much cxperience itsclf but rather thc person's interpretation of that experience that produces psychological  disturbance. 'This position is also reflected in the work of Albert Ellis (see Chapter 6). Both 
cognitive and hehavioral methods are used to modify faulty perceptions and interpreta tions of important life events. For these reasons, it is now common to refer to “cognitive  behavior therapy” (CBT) instcad of “behavior therapy.” As Jacobson (1987) pointed our,  “incorporation of cognitive theory and therapy into behavior therapy has been so total that  it is difficulr to find pure behavior therapists working with outpatients” (pp. 4—). The terim.  “behavior therapy” is used throughout this chapter, although it could just as easily be re placed with “CBT.” Behavior therapy, in a broad sense, refers to practice based primarily on  social-cognitive theory and encompassing a range of cognitive principles and procedures. 


Common Characteristics  


Although the three preceding bchavior thcrapy approaches involvc conceptual ciffer ences, behavior therapists subscribe to a common core of basic concepts. The two foun dations of behavior therapy are (1) a psychological model of human behavior that differs  fundamentally from the traditional psychodynamic model, and (2) a commitment to the  scientific method.  
'I'he emphasis on a psychological model of abnormal behavior and the commitment  to a scientifìc approach have the following conseguences:  
1. Many types of abnormal behavior formerly regarded as illnesses or as signs and  symptoms of illness arc better construed as nonpathological “problems of living”  (key examples include anxiety reactions, as well as sexual and conduct disorders).  'This position is similar to that of Alfred Adler.  
2. Most abnormal behavior is assumed to be acguired and maintained in the same  manner as normal behavior. Tt can be treated through the application of behavioral  procedures.  
3. Behavioral as  ssment focuses on the current determinants of behavior rather than  on the analysis of possible historical antecedents. Specificity is the hallmark of be havioral assessment and treatment, and it is assumed that the person is best under stood and described by what the person does in a particular situation.  
4. Treatment requires a prior analysis of the problem into components or subparts.  Procedures arc then systematically targcted at specific componcnts.  
5. Treatment strategies are individually tailored to different problems in different  individuals.  
6. Understanding the origins of a psychological problem is not cssential for produc ing behavior change. Conversely, success in changing a problem behavior does not  imply knowledge about its etiology.  
7. Behavior therapy involves a commitment to the scicntific mcthod. This includes an  explicit, Lestable conceptual framework; treatment derived from or at least consis tent with the content and method of experimental—clinical psychology; therapeutic  technigues that have measurable outcomes and can be replicated; the cxperimental  cvaluation of trcatment methods and concepts; and emphasis on innovative research  strategies that allow rigorous evaluation of specific methods applied to particular problems instead of global assessment of ill-defined procedures applied to hetero geneous problems.


The “Third Wave” of Behavior Therapy  


Behavior therapy continues to evolve. The most recent developments, emerging in the  1990s and gathering momentum in the new century, have been labeled the “third wave”  of behavior therapy by Hayes, Follette, and Linehan (2004). According to this view,  the first wave of behavior therapy focused primarily on modifying overt behavior. The  second wave was the emphasis on cognitive factors, resulting in what is known as cognitivc behavior therapy (CBT). Hayes et al. (2004) and others, however, have argued  that the cognitive revolution in behavior therapy did not adeguately address the prob  lems of people's private experience—their thoughts and feclings. Hayes has argued that  cognitive theories in CBT have owed more Lo common-sense notions than to scicntific  analyses. The third wave comprises a group of therapeutic approaches with overlapping  conceptual and tcchnical foundations. The two most prominent forms of these devel opments are dialectical behavior therapy (DB'1) (Linchan, 1993) and acceptance and  commitment therapy (ACT) (Hayes, T.uoma, Bond, Masuda, & Lillis, 2006).  


Dialectical Behavior Therapy (DBT)  


Acceptance and Change. _ A defining feature of DBT is the focus on balancing the  tradirional emphasis on bchavior change with the value of acceptance and the impor  tance of the relationship between the two—which Linchan sees as the central dialectic  of therapy. The following clinical example may clarify this point. Paticnts with an cating  disorder typically define their self-worth in terms of body shape and weight in part be cause appcarancc and weight seem more controllable to them than other aspects of life,  Tn reality, however, they have less control over changing body shape and weight than  they wish. Nevertheless, these individuals resort to extreme and self-destructive behav iors in an effort to lose more weight than is healthy or even possible, such as starving  themselves and self-inducing vomiting. The result is that they develop an eating disor  der. By trying to change what cannot be changed, or what cannot be changed except by extreme measures that undermine health and psychological well-being, these individuals  avoid making other important life changes. The solution would be to make nutritionally  sound and psychologically adaptive lifestyle changes and then accept wharever shape  and wcight results. It is more feasible for these patients to make other changes in their  lives, such as improving interpersonal relationships and coping more effectively with  negative emotions.  
Wilson (2004) likened this balancing of acceptance with change to the practical wisdom  of the Serenity Praycr: “God, give me the serenity to accept the things I cannot change, the  courage to change the things I can, and the wisdom to know the difference.” Itisimportant to  understand that the concept of acceptance does not mean giving up or rcsigning yoursclf to 
life's problems. Rather, Linchan emphasizes that it is an active process of self-affirmation.  Similarly, Hayes and Smith (2005) explain that acceptance can be viewed as a willingness to  choose to expericncc ncgative thoughts or feelings without defense.  


Mindfulness. 


DBT makes use of typical behavior therapy techniques and strate gies as summarized above. But a distinctive and seminal therapeutic strategy in DBT is  mindfulness training. Mindfulness consists of five core skills:  
L. Observe or allend to emotions without trying to terminate them wben painful. “What  the client learns here is to allow hersell Lo expericncc with awareness, in the mo mont, whatever is happening, rather than leaving a situation or trying to terminatc  an emotion. Gcncrally, the ability to attend to events reguires a corresponding abil ity to step back from the event. Observing an cvent is separate or different from the  event itself” (Tinehan, 1993, p. 63). 
BEHAVIOR THERAPY 295  
2. _ Describe a thought or emotion. “Learning to describe requires that a person learn  not to takc cmotions and thoughts litcrally—that is, as literal reflections of environ mental events. For example, feeling afraid does nor necessarily mean rhar a situarion  is threatening . . . thoughts are often taken literally; that is, thoughts (‘I feel  unloved’) are confused with facts (‘I am unloved’)” (Linehan, 1993, p. 64). 
3. Be nonjudgmental. The goal here is to take a nonjudgmental stance when ohserving,  describing, and being aware of feclings and events. Judging is evaluating oneself or  some experience as good or bad, as worthy or worthless.  
4. Stay in the present. The principle here is to be aware of and stay in contact with  immediate cxpericncc whilc at thc samc time achicving distance from it. Wiscr and 'Telch (1999) give the example of watching “clouds moving across a sky; they are  fully present with experience, but are also outside observing it” (p. 759).  
5. Focus on one thing at a time (one-mindfully). For cxample, when cating, attend to thc act  and experience of eating without distractions such as watching TV or reading a book.  
Linehan (1993) developed DBT primarily for treating borderline personality disor der. However, thc basic concepts of DBT, such as acceptance and mindfulness, arc now  being applied to the treatment of a wide range of clinical problems including anxiety  disorders, depression, and eating disorders (Hayes, Follette, & Linehan, 2004). Lynch  and Cozza (2009) recently examined nonsuicidal self-injury (NSSI) from a behavioral  perspective that regards negative cmotions as the proximal cause of NSSI. The authors  demonstrate how to conduct a functional analysis of NSS1 and describe the utility of  DBT in the treatment of this recalcitrant disorder.  


Acceptance and Commitment Therapy (ACT)  


ACT combines grounding in behaviorism with an innovative, post-Skinnerian account  of language and cognition and how they arc involved in psychopathology (Haycs ct al., 2006). The details of the specific theory of language that is behind AC1', called relational  frame theory, are beyond the scope of the present chapter. The focus here is on core  therapeutic principles.  


Fxperiential Avoidance.
 
Experiential avoidance refers to the process of trying to  avoid negative or distressing private experiences, such as thoughts, feelings, memories,  and sensations. The basic principle is that experiential avoidance ultimately does not  work—in fact, it is more likely to make matrers worse. I'or example, there is evidence  showing that attempts to suppress negative or unwanted thoughts will, in duc coursc,  produce an increase in the very thoughts you want (o avoid. In onc study, patients with  anxiety and mood disorders were shown a brief, emotion provoking film (Campbell 
Sills, Barlow, Brown, & Hofmann, 2006). One group was instructed to suppress their  emotional reactions to the film. The other group were asked to cxpericnce thcir emo tions fully and not to struggle to control them in any way. The results showed that the  suppression group suffered from greater distress after the film and also showed greater  physiological arousal than the acceptance group during the film.  
Experiential avoidance is seen to be pervasive across different clinical disorders  (Harvey, Watkins, Mansell, & Shafran, 2004). According to Hayes et al. (2006), there  are two main reasons. First, in the outside world (ourside of the body), ir makes sense  to avoid or change what is bad. For example, il you are trapped in a dysfunctional rela 
tionship, the effective course of action is to end the relationship or to work actively on  repairing it. Rational problem solving and thoughtful action are the most effective ways  of solving this problem. Second, technigues like distraction or suppression of thoughts  or feelings often do work in the short term. The trouble is that these are maladaptive
coping strategies in the long term. For a young person plagued by self-doubt and low  sell-esteem, alcohol or drug use might well provide a guick fix, but these methods only  add to her or his problems over time.  


Acceplance


” ACT is designed to help paticnts lcarn that experiential avoidance  does not work, and that it is part of the problem rather than the solution. Patients need  to learn how to accept the thoughts and feelings they have been trying to get rid of. The  goal of acceptance in ACT is essentially thc same as in DBT, and mindfulness is taught  in both systems. Treatment employs various experiential cxerciscs during thcrapy scs sions and, as with behavior therapy in general, uses homework assignments designed to  help patients discover the benefits of acceptance over avoidance.  


Cognitioe Defusion.


This concept refers to separating thoughts from their refer ents and differentiating the thinker from the thoughts. Tt means not taking thoughts  as inherent aspects of self or as necessarily valid reflections of reality. For example, the  thought “I am so fat” is very different from the thought “I am not fat, but a normal weight person who experiences thoughts/feelings that she is fat.” The latter is morc  defuscd than thc former, and much less distressing. This is similar to the practice of describing feelings in mindfulness Lraining in DBT. The assumption is that lcarning how  to defuse language promotes acceptance and being in the present, and thus helps clients  overcome psychological problems. Defusion is basically the same concept as that of dis tancing, which is described in Aaron Beck's chapter on cognitive therapy (Chapter 8).  


Commitment.


ACT focuses on action. Commitment in this context refers to mak ing mindful decisions about what is important in your life and what you are going to do  in order to live a valued life. Therapy involves helping patients choose the values they  hold dear, setting specific goals, and taking concrete steps to achieve these goals.  
ACT is increasingly being adapted to a wide range of clinical problems. One of the  reasons for its popularity among clinicians is its foundation in core therapeutic prin ciples that arc linked to psychological scicncc and have broad applicability to different  disorders. Tt emphasizes common processes across clinical disorders, making it casier  to teach fundumental treatment skills. Clinicians are then free to implement these basic  principles in diverse and creative ways.  


Other Systems  


Behavior therapy has much in common with other psychological therapies, particularly  those that tend to bc bricf and directive. In some cases, behavior therapy has borrowed  concepts and methods from other systems. For example, cognitive bchavíoral treatment  strategies have incorporated some of the concepts of Albert Ellis's rational emotive be- havior therapy and especially Beck's cognitive therapy (O'Leary & Wilson, 1987). CBT is closer to Beck's cognitive therapy than Ellis's approach because Beck emphasizes the  
importancc of behavioral procedures in correcting the dysfunctional beliefs assumed  to cause emotional distress. Fllis's REBT, despite the later inclusion of behavior in thc  name, is mainly a semantic treatment in which the goal is to alter the person's basic  philosophy of life through reason and logic. The overlap between BT and Beck's cogni tive therapy is extensive. Both systems include cognitive and behavioral components but  may differ in how these components are combined and especially in their theories about  mechanisms of therapeutic change (Hollon & Beck, 1994).  
Despite substantial overlap between behavior therapy and Beck's cognitive therapy,  there are important theoretical and practical differences between certain forms of BT  and cognitive therapy. For cxample, thc cmphasis on acceptance in DBT and ACT is inconsistent with the major cognitive therapy technigue of challenging or disputing spe cific thoughts and beliefs. In addition, the focus in more behaviorally oriented treat ments is on the function of cognitions rather than their content as in cognitive therapy.  Consider the following illustration. A common belief for someone who is depressed  would bc “T am worthless and incompetent at everything I do.” As opposed Lo guestion ing the accuracy or validity of this belief as in cognitive therapy, the behavioral activa tion approach to treating depression (see below) would focus on its impact on behavior.  A functional analysis would bc conducted to identify the conditions under which the  thought occurred and what happened as a result of the thought. The person would then  be helped to act differently in those situations (Martell, Addis, & Jacobson, 2001).  
Tn terms of clinical practice, behavior therapy and multimodal therapy are similar. The  majority of the technigues that Arnold Lazarus (1981) lists as the most frequently used in  multimodal therapy (see Chapter 11) are standard behavior therapy strategies. This is nor  surprising, given rhar T.azarus (1971) was one of the pioneers of clinical behavior therapy.  
'Therapists are guided in their formulations and treatment of different problems either  by clearly stated principles or by their personal experience and intuition. Behavior therapy  represents an attempt to move beyond idiosyncratic practíces and to base clinical prac tice on secure scientific foundations. This does not mean that clinical practicc by bchav ior therapists is always based on solid empirical evidence. Behavior therapists, not unlike  therapists from other approaches, have developed their own clinical lore, much of which  is not based on experimental rescarch. Lacking sufficient information and guidelincs from  rescarch, bchavior therapists often adopt a trial-and-error approach. Nonetheless, behav  ior therapy is clearly linked to a specifiable and testable conceptual framework.  
Behavior therapy differs fundamentally from psychodynamic approaches to treat ment. Based on a learning or educational model of human development, it rejects thc  psychoanalytic model, in which abnormal bchavior is vicwcd as a symptom of underly- ing unconscious conflicts. Psychoanalytic therapy has difficulty explaining the successes  of behavior therapy that contradict basic concepts that psychoanalysts claim are cru cial for therapeutic change. Some psychodynamic therapists state that behavioral treat ments result in symptom substitution becausc bchavioral treatment allegedly overlooks  the “real” cause of the problem. Yet the evidence is clear that symptom substitution  does not occur in successful behavior therapy (e.g., Sloane, Staples, Cristol, Yorkston, &  Whipple, 1975). Both behavioral and psychodynamic treatments attempt to modify un derlyíng causes of behavior. The difference is what proponents of each approach regard  as causes. Behavior analysts look for current variables and conditions that control be havior. Some psychodynamic approaches (e.g., psychoanalysis) ask, “How did the client  become this kind of person?” Others (e.g., Adlerian psychotherapy) ask, “What is this  person trying to achieve?” Behavioral approaches ask, “What is causing this pcrson to  behave in this way right now, and what can we do right now to change that behavior?”  
Family and systems therapists assert that individuals can best be understood and  treated by changing the interpersonal system within a family. Behavior therapy has in creasingly emphasized the importance of including family members in treatment. How ever, behavior therapists reject the assumption that every problem requires a broad-scale  intervention in the family system. The findings of outcome studies show that this is not  always necessary (Mathews, Gelder, & Johnston, 1981). For example, not only does in dividual behavior therapy for agoraphobics produce long-term improvement in phobic  avoidance, it often also results in increases in marital satisfaction and improvements in  other aspects of interpersonal functioning. Data such as these discredit thc claims of  somc family systems theorists.  
The focus on the problems of experiential avoidance, which is such a key aspect of  ACT, clearly overlaps with some experiential and humanistic therapies such as Gestalt  therapy and Rogers’s person-centered treatment. 
Most forms of psychotherapy are limited to specific populations. Traditional psycho analytic therapy, for instance, has focused predominantly on white, well-educated, socially  and economically advantaged clienrs. Behavior therapy is more broadly applicable to the  full range of psychological disorders than is traditional psychotherapy (Kazdin & Wilson,  1978). It has also been shown to be effective with diverse patient populations, including  disadvantaged minority groups (Miranda, Bernal, Kohn, Hwang, & La Fromboise, 2005).  
Overall evaluation of thc comparative efficacy of behavior therapy versus other psy chotherapies is uncertain. As described below, bchavioral treatments have been reliably  shown to be more effective than no treatment or placebo treatments. Howcvcr, thcrc arc  few well-designed head-to-head comparisons with other psychological therapies. With  rare exceptions, alternative psychological trcatments have not been submitted to rigor ous empirical evaluations. The evidence, unsatisfactory as it is, indicates that bchavior therapy is more effective than psychoanalytic and other verbal psychotherapies (Hollon  & Beck, 1994; O'Leary & Wilson, 1987).  


HISTORY.  


Precursors  


Two historical cvents stand out as foundations for behavior therapy. The first was  the rise of behaviorism in the early 1900s. The key figure in the United States was  J. B. Watson, who critícized the subjectivity and mentalism of the psychology of thc timc  and advocated bchaviorism as the basis for the objective study of behavior. Watson's  emphasis on the importance of environmental cvents, his rejection of covert aspects of  the individual, and his claim that all behavior could be understood as a result of learning  became the formal bases of behaviorism.  
Watson's position has been widely rejected by behavior therapists, and more refined  versions of behaviorism have been developed by theorists such as B. T. Skinner, whose  radical behaviorism has had a significant impact not only on behavior therapy but also  on psychology in general. Like Watson, Skinner insisted that overt behavior is thc only  acceptable subject of scientific investigation.  
The second cvent was cxperimental research on the psychology of learning. In Russia,  around the turn of the 20th century, Ivan Pavlov, a Nobel laureate in physiology, estab lished the foundations of classical conditioning. At about the same timc in thc United  States, pioneering research on animal learning by E. L. Thorndike showed the influence  of conseguences (rewarding and punishing events) on behavior.  
Research on conditioning and learning principles, conducted largely in the animal  laboratory, became a dominant part of experimental psychology in the United States  following World War II. Workers in this area, in the traditions of Pavlov and Skinncr,  were committed to the scientific analysis of behavior using the laboratory rat and pigeon  as their prototypic subjects. Among thc carly applications of conditioning principles  to the treatment of clinical problems were two particularly notablc studics. In 1924,  Mary Cover Jones described different behavioral procedures for overcoming children's  fears. In 1938, O. Hobart Mowrer and L. Mowrer extended conditioning principles to  the treatment of cnuresis. The treatment they developed is now an effective and widely  used approach (Ross, 1981). These isolated and sporadic efforts had scant impact on  psychotherapy at the time, partly because condirioning principles, demonstrated with  animals, were rejected as too simplistic for treating complex human problems. Condi  
tioning treatments were rejected as superficial, mechanistic, and naive. In addition, a  schism cxistcd between academic-experimental and clinical psychologists. The former  were trained in scientific methods, with an cmphasis on controlled experimentation  and quantitative measurement. The latter concerned themselves with thc “soft” side of psychology, including uncontrolled case studies, speculative hypotheses, and psycho dynamic hypotheses. Some efforts were made to integrate conditioning principles with  psychodynamic rheories of abnormal behavior, but these formulations only obscured  crucial differences between behavioral and psychodynamic approaches.  
The advent of behavior therapy was marked by its challenge of the status guo  through the presentation of a systematic and explicitly formulated clinical alternative  that attempted to bridge the gap between the laboratory and the clinic.  


Beginnings  


The formal beginnings of bchavior thcrapy can be traced to separate but related devel opments in the 1950s in three countries. 
Joseph Wolpe, in South Africa, presented procedural details and results of his  application of learning principles to adult neurotic disorders in his book Psychotherapy by  Reciprocal Inbibition (1958). Wolpe introduced several therapeutic technigues based on  Pavlov's conditioning principles, Hull's S-R learning theory, and his own experimental  research on fear reducrion in laboratory animals. Wolpe regarded anxiety as the causal  agent in all neurotic reactions. It was defined as a persistent response of the autonomic  nervous system acguired through classical conditioning. Wolpe developed specilic tech nigues designed to extinguish these conditioned autonomic reactions, including system atic desensitization, onc of thc most widcly used methods of behavior therapy. Wolpe  made the controversial claim that 9096 of his patients were either “cured” or “markedly  improved.” Moreover, this unprecedented success rate was apparently accomplished  within a fcw months, or cven wccks. Wolpe influenced Arnold Lazarus and Stanley  Rachman, both of whom became leading figures in thc development of bchavior therapy.  Wolpe's conditioning technigues in therapy were consistent with similar proposals that  had been put forward by Andrew Salter (1949) in New York.  
Another landmark in the development of behavior therapy was the research and  writings of Hans J. Eysenck and his students at the Institute of Psychiatry of London University. In a seminal paper published in 1959, Eysenck defined behavior therapy as  the application of modern learning theory to the treatment of behavioral and emotional  disorders. Eysenck emphasized the principles and procedures of Pavlov and Hull, as  well as learning theorists such as Mowrcr (1947) and Miller (1948). In Eysenck's formu lation, behavior therapy was an applied science, the defining feature of which was that it  was testable and [alsifiable, In 1963, Eysenck and Rachman established the first journal  devoted exclusively to behavior therapy—Behaviour Research and Therapy.  
A third force in the emergence of behavior therapy was the publication in 1953 of Skinner's book Science and Human Behavior, in which he criricized psychodynamic con cepts and reformulated psychotherapy in behavioral terms. The most important initial  clinical application of operant conditioning was with children, work carried out under  the dircction of Sidncy Bijou at thc University of Washington. The broad application of  operant conditioning to the whole range of psychiatric disordcrs rcached full cxpres sion in the 1965 publication of Leonard Ullmann and Leonard Krasner's Case Studies in Bebavior Modification. Tn 1968, the first issue of the Jaurnal of Applied Bebavior Analysis  was published. This journal provided the premier outlet for research on the modifica tion of socially significant problems through the use of operant conditioning.  
'Toward the end of the 1960s, the theoretical and research bases of behavior therapy be gan to expand. Increasingly, behavior therapists turned to social, personality, and develop mental psychology as sources of innovative therapeutic strategies. Particularly noteworthy  in this regard was Bandura's (1969) social learning theory, with its emphases on vicarious  lcarning (modcling), symbolic processes, and self-regulatory mechanisms. The 1970s wit nessed an increased emphasis on cognitive processes and procedurcs in bchavior therapy.
The 1980s and 1990s were marked by an even broader focus on developments in  other areas of psychology. Particular attention has been paid to the role of affect in thera  peutic change. The 1990s and turn of the century have also witnessed the evolution of  newer forms of bchavior therapy, such as DBT and ACT, described earlier in this chapter.  
'The experimental analysis of the complex interactions among cognition, affect, and  behavior is one of the more important areas of theory and research in contemporary be havior thcrapy. Therc is also increasing recognition of the importance of biological fac tors and brain mechanisms in many of thc disorders commonly treated with behavioral  methods (e.g., anxiety disorders and obesity). The study of biobehavioral intcractions is an increasingly significant part of behavior therapy. For example, research on brain  mechanisms has identified the specific receptors in the amygdala of the brain that are  involved in the extinction of learned fcar responses. Behavior therapy treatments such as  exposure are designed to promote extinction of phobic (fear) responses. D-cycloserine  is a drug that facilitates extinction because it is an agonisr ar these receptor sites in the  brain. Combining exposure (extinction) treatment with this drug results in significantly  more rapid reduction in fear responses in laboratory animals as well as in patients with  spccific phobias (Davis, Myers, Ressler, & Rothbaum, 2005).  


Current Status  


Behavior therapy has had a profound impact on the ficld of psychotherapy. An impor tant measure of the influence of behavior therapy is the degree to which psychothera- pists use cognitive-behavioral principles and procedures in their clinical practice. Based  on his survey of the theoretical orientations of clinical psychologists in the United States,  Darrell Smith (1982) concluded that “No single theme dominates the present development  of professional psychotherapy. Our findings suggest, however, that cognitive behavioral  options represent one of the strongest, if not the strongest, theoretical emphases today”  (p. 310). It seems likely that behavior therapy technigues will be increasingly used to treat  a broad range of psychological problems.  
Tn the 1990s, a panel of 75 expert psychotherapists comprising rcpresentatives of a  wide range of different theoretical orientations in the United States was asked to predict  what would happen to the practice of psychotherapy in the future (regardless of their per sonal preferences) (Norcross, Alford, & DeMichele, 1992). The panel largely agreed in  ranking CBT technigucs as thosc most likely to be used in the future. The reason? As health  care policy in the United States is changing to contain costs and provide coverage to more  people, the emphasis is switching to problem-focused, time limited psychological treatment.  Moreover, futurc third-party rcimbursement for mental health services will not only empha size cost containment but also demand that treatments bc demonstrably effective in pro ducing specified goals. Behavior therapy will be an important part of those interventions.  
In its formative years in the 1950s and 1960s, behavior therapy was a radical minority  movement that challenged the then-dominant psychoanalytic establishment. Today behavior  therapy is part of the psychotherapeutic establishment. Beginning in the 1960s in the United  Stares, several graduare clinical programs in some of the country's most distinguished uni 
versities placed primary emphasis on a behavioral orientation in their training of predoctoral  students. Many others began to include behavior therapy as part of an eclectic approach to  clinical training. In their analysis of the orientations of faculty in doctoral programs accred ited by thc Amcrican Psychological Association, Sayette and Mayne (1990) found that 1496  could be described as having an applied behavioral or radical behavioral approach, while an  additional 4296 emphasized cognitive behavioral or social learning approaches.  
In contrast to the impact on the training and practice of clinical psychologists, be  havior therapy has had líttle influcncc on that of other mental health professionals in the United States (Glass & Arnkoff, 1992). The minimal impact on psychiatry is ironic, given
REHAVIOR THERAPY 229  
the seminal contributions of some psychiatrists to the development of cognitive behavior  therapy (e.g., Joseph Wolpe and Aaron Beck). This is probably due to the total dominance  of psychoanalysis in American psychiatry for more than 40 years. More recently, hiologi cal psychiatry has often supplanted the psychoanalytic model in training programs. As a  result, psychological treatment has been deemphasized in the training of psychiatrists.  
Thc first bchavior therapy journal, Bebaviour Research and Therapy, was published  in 1963 in part because the psychodynamically inclined cditors of cxisting clinical jour nals were unreceptive to behavior therapy. Today there are numerous journals devoted  to behavior therapy in different countries. Moreover, behavior therapists have been edi tors and editorial board members of major all-purpose clinical psychology journals, such  us the Journal of Consulting and Clinical Psychology in the United States.  
The increasing tendency of behavior therapists to identify themselves as cognitive  behavior therapists is reflected in the decision in 2005 to change the name of the Associ ation for Advancement of Bchavioral Therapy (AABT) to the Association for Behavioral  and Cognitive Therapies (ABCT). Tt is unclear if behavior therapy will continue to be  practiced as a pure approach to therapy or if it will eventually simply become subsumed  under the general rubric of cognitive behavior therapy.  


PERSONALITY  


Theory of Personality  


'Therc arc specific thcorctical differenccs within the broad framework of contemporary be havior therapy. These differences are most noticeable in the personality theories on which  the respective approaches are based, For example, Eysenck (1967) has developed an elab 
orate trait theory of personality. Briefly, Eysenck classifies people on two major personality  dimcnsions. The first, introversion—extraversion, refers to characteristics usually associated  with the words introverted and extraverted. The second dimension is neuroticism—emotional  stability, ranging from moody and touchy at one extreme to stable and even-tempered at  the other. Eysenck believed these personality dimensions are genetically determined and  that introverts are more responsive to conditioning procedures than extraverts. In general,  however, personality theory appears to have had little impact on clinical behavior therapy,  and most behavior therapists have rejected trait theories of personality.  
Applied behavior analysis, derived directly (rom Skinner's radical behaviorism, restricts  itself to the study of overt behavior and environmental conditions that presumably regulate  behavior. Covert, unobservable clements, such as needs, drives, motives, traits, and con flicis, are disregarded. Skinner's analyses of behavior, for example, arc couched in terms of  conditioning processes, such as reinforcement, discrimination, and generalization.  
Radical behaviorism has been criticized for losing sight of the importance of the  person and for lacking a thcory of personality. Humanistic psychologists believe applicd  behavior analysts treat people as though they were controlled only by external, situ atíonal forces. A solution to this clash between two extreme viewpoints is to recognize  that the characteristics of the environment 1m/erac/ with the nature of the people in it.  Both commonsense and experimental findings demonstrate the folly of ignoring either  side of this crucial interaction. A social lcarning framework of personality development  and change provides a detailed and sophisticared analysis of rhis interaction berween  person and situation (Bandura, 1969; Mischel, 1968, 1981).  
Many people have debated whether the person or the situation is more important  in predicting behavior. However, this guestion is unanswerable. The relative importance  of individual differences and situations will depend on the situation selected, thc typc of  behavior assessed, the particular individual differences sampled, and the purpose of the  assessment (Mischel, 1973).
230 a. TERENGE WILSON  
Evidence clearly shows that an individual's behavioral patterns are generally stable  and consistent over time. However, the specificity of behavior in different situations  poses a problem for trait theories of personality. The central assumption of such theories  is that stablc and generalized pcrsonality traits determine bchavioral consistency in a  wide variety of different situations. Yet, as Mischel (1968) has pointed out, the correla 
tions between different measures of the same trait are usually very low, and there is little  consistency in bchavior pattcrns across different situations.  
Psychodynamic conceptualizations of personality assume that thc underlying per sonality structure is stable ss situations. Overt behavior is of interest to psycho  dynamic theorists only to the extent that the behavior provides signs of deep-seated  personality traits. Psychodynamic theorists believe that behavior cannot be taken at face  value but must be interpreted symbolically because the personality's defense mecha nisms disguise and distort the “real” motivations being expressed. However,  
the accumulated findings give litde support for the utility of clinical judgments. . . .  Clinicians guided by concepts about underlying genotypic dispositions have not  been able to predict behavior better than have the person's own direct self-report,  simple indiccs of dircctly rclcvant past bchavior, or demographic variables. (Mischcl,  1973, p. 254)  
Social-cognitive theory readily accounts for the discriminatory nature of human be havior. A person would be predicted to act consistently in ditfcrent situations only to the  extent that similar behavior leads, or is expected to lead, to similar conseguences. An  illustration from Mischel helps clarify this key concept:  
Consider a woman who seems hostile and fiercely independent some of the time but  passive, dependent, and feminine on other occasions. What is she rcally like? Which  one of these two patterns reflecis the woman that she really is? Ts one pattern in the  service of the other, or might both be in the service of a third motive? Must she be a  really aggressive person with a facade of passivity—or is she a warm, passive dependent  woman with a surface defense of aggressiveness? Social learning thcory suggests that it  is possible for her to be all of these—a hostile, fiercely independent, passive, dependent,  
feminine, aggressive, warm person all in one. Of course, which of these she is at any par ticular moment would not be random and capricious; it would depend on discriminative  stimuli—who she is with, when, how, and much, much more. But each of these aspects  of herself may be a guite genuinc and real aspect of her total being. (1976, p. 86)  
The difference between the behavioral and psychodynamic approaches in explain  ing thc development of abnormal bchavior can be illustrated by Freud's case of Little  Hans. This child developed a phobia of horses, which Freud attributed to castration  anxiety and oedipal conflict. In their reinterpretation of this case, Wolpe and Rachman  (1960) point out that Little Hans had recently experienced four incidents in which  horses were associated with frightening events that could have created a classically con ditioned phobic reaction. For example, Hans was terrified when he saw a horse that  was pulling a loaded carr knocked down and apparently killed. From a psychodynamic  viewpoint, the external stimuli (what Little Hans saw) had little effect on the phobia;  the fear of horses per se was less significant than the underlying conflict. As Freud put  it, “the anxiety originally had no reference to horses but was transposed onto them  sccondarily.” This interpretation does not account for the discriminative pattern of the  boy's reactions. For example, he was fearful of a single horsc pulling a loaded cart  (viewed by I'reud as a symbol of pregnancy) but not of two horses, of large horses  but not small ones, and of rapidly moving horse-drawn carts but not slowly moving  ones. How is this pattern predicted by a global, internal construct such as an oedipal  conflict? In the accident that the boy witnessed, a single, large horse, moving rapidly, was believed to have heen killed, A conditioning explanation emphasizes that specific stimulus elements clicit particular responses and therefore accounts plausibly for the  discriminative fear responses of Little Hans.  
Trait theories emphasize difíerences among people on dimensions selected by the  clinician. For some purposes, such as gross screening (e.g., administering the Minncsota  Multiphasic Personality Inventory [MMPT] to a clicnt) or group comparisons, a trait  approach is uscful. But it does not aid the therapist in making treatment decisions about  a particular individual. Tor example, consider the trait of introversion—extraversion.  According to Eysenck's theory, particular treatments will havc different effects on  clients who vary along thcsc dimensions. In a well-controlled study, Paul (1966) corrclated performance on paper-and-pencil personality tests measuring extraversion,  emotionality, and anxiety, among other traits, with the therapeutic success obtained by  treating public speaking anxiety with systematic desensitization. His results revealed no  relationship whatsoever between global personality measures and therapeutic outcome.  'This result is typical of other outcome studies.  


Variety of Concepts  


Learning Principles  


The use of learning principles in behavior therapy is summarized ín Agras and Wilson  (2005). The case of Little Hans illustrates the role of classical conditioning. When a  previously neutral stimulus is paired with a frightening event (the unconditioned stimu lus, or US), it can become a conditioned stimulus (CS) that elicits a conditioned response  (CR) such as anxiety. Current analyses of classical conditioning have moved away from  the once popular notion that what was learned consisted of simple S-R bonds. Rather,  people learn that there are correlational or contingent relationships between the CS and  US. This lcarning defines the conditioning process. Classical conditioning is no longer  seen as the simple pairing of a single CS with a single US. Instead, correlations between  entire classes of stimulus events can be learned. People may be exposed to traumatic  
events (contiguity), but not develop phobic rcactions unless a correlational or contin gent relationship is formed between the situation and the traumatic event.  Operant conditioning emphasizes that behavior is a function of its environmental  conseguences. Behavior is sirengthened by positive and negative reinforcement; it is  weakened by punishment. Positive reinforcement refers to an increase in the frequency  of a response followed by a favorable cvent. An cxamplc would be a teacher or parent  praising a child for obtaining a good report card. Negative reinforcement refers to an  increase in behavior as a result of avoiding or escaping from an aversive event that onc  would have expected to occur. For example, an agoraphobic, fearing loss of control and  panic in a crowded shopping mall, will escape this aversive prospect by staying at home.  This individual then experiences relief from anxiety by having avoided this panic and  finds it increasingly difficult to leave the house.  
Tn punishment, an aversive event is contingent on a response; the result is a decrcasc  in the freguency of that response. If a child is criticized or punished by his parents for  speaking up, he is likely to become an inhibited and unasserrive adulr.  
FExtinction refers to the cessation or removal of a response. For example, the family  of an obsessive—compulsive client might be instructed to ignore reguests for reassurance  froin the client that he has not done something wrong. The reinforcer that is no longer  presented is inappropriate attention.  
Discrimination learning occurs when a response is rewarded (or punished) in one situa tion but not in another. Behavior is then under specific stiudus control. This process is par ticularly important in explaining the flexibility of human behavior. For cxamplc, an obese  client who goes on eating binges may show good sclf-control under some circumstances but  ]osc control in predictable situations (e.g., when alone and feeling frustrated or depressed). 
Generalization refers to the occurrencc of bchavior in situations other than that in  which it was acguired. A therapist might help a client to become more asscrtivc and cx pressive during treatment sessions. But the ultimate goal of therapy is to have the client  act more assertively ín real-life situations.  
Social-cognitive theory recognizes both the importance of awareness in learning  and the person's active cognitive appraisal of environmental events. Learning is facili tated when people are aware of the rules and contingencies governing the consequences  of thcir actions. Reinforcement does not involve an automatic strengthening of behavior.  Learning is a conseguencc of the informative and incentive functions of rewards, By ob serving the conseguences of behavior, a person learns what action is appropriate in what  situation. By symbolic representation of anticipated future outcomes of behavior, one  generates the motivation to initiate and sustain current actions (Bandura, 1977). Often,  people's expectations and hypothcscs about what is happening to them may affect their  behavior more than the objective reality.  
The importance social-cognitive theory attaches to vicarious learning (modeling) is  consistent with its emphasis on cognitive processes. In this form of learning, people acquire  new knowledge and behavior by observing other people and events, without engaging in  the behavior and withour any direct conseguences to themsclves. Vicarious learning may  occur when people watch what othcrs do. Thc influence of vicarious learning on human be havior is pervasive, and this concept greatly expands the power of social-cognitivc thcory.  


Person Variables  


People do not passively interact with situations with empty heads or an absence of  feelings. Rather, they actively attend to environmental stimuli, interpret them, encode  them, and selectively remember them. Mischel (1973) has spelled out a series of person  variables that explain the interchange between person and situation. These person vari 
ables are the products of each person's social experience and cognitive development that,  in turn, determine how future experiences influence him or her. Briefly, they include the  individual's competencies to construct diverse behaviors under appropriate conditions. In  addition, there is the person's categorization of events and people, including the self.  To understand how a person will perform in particular situations also requires atten 
tion to his or her expectancies, the subjective values of any expected outcomes, and the  individual's self-regulatory systems and plans.  
A full discussion of thcsc person variables is beyond the scope of the present chapter,  but some illustrative examples may be given. For example, consider the role of personal  constructs. It is common in clinical practice to find clients who constantly put themselves  down, cven though it is clcar to the objective onlooker that they are competent and that  they are distorting reality. In cases like these, behavior is mainly under the control of inter 
nal stimuli rather than environmental events. Different people might respond diffcrently  to the same objective stimulus situation, depending on how they interpret what is happen ing to them. Therapy concentrates on correcting such faulty cognitive perceptions. But  the bchavior therapist must also assess a client's cognitive and behavioral competencies  to ascertain whether he or she really can respond in a particular way. A client may be  depressed not because he misperceives the situation bur because he actually lacks the  appropriate skills to secure rewards. A case in point would be a shy, underassertive col lege freshman who is motivated to date but who realizes he does not have the social skills  needed to cstablish relationships with women. Therapy would be geared to overcoming  his behavioral deficit, helping the student acguire thc requisite interpersonal skills.  
Self-efficacy refers to one’s belief about being able to perform certain tasks or achicvc  certain goals (Bandura, 1998). Self-efficacy is assessed simply by asking a person to indi cate the degree of confidencc that he or shc can do a particular task. 
Such person variables differ from traits in that they do not assume broad cross- situational consistency but depend on specific contexts. Constructs such as gencralized expectancies have not proved fruitful in predicting behavior. However, specific evalua tions of individuals” efficacy expectations with respect to particular tasks are useful.  
Applied behavior analysts reject cognitive mediating processes and have little use for  person variables, They agree that the environment interacts with the person but contend that the role of the person is best explained in terms of past bistory of reinforcement. To  illustrate the differences between the social-cognitive approach and the radical behav- iorist position, imagine a client who is phobic abour flying, This client typically becomes highly anxious when he hears the plane’s landing gear retracting. A therapist with a social— cognitive view might attribute this anxiety reaction to the clicnt's perception that something  is wrong. The radical bchaviorist would suggest that the client is reacting not only to thc present environment (the sudden noise) bur also to stories he has heard in the past about engines falling off and planes crashing. This example makcs it clear that radical behav- iorism is not free from inferential reasoning. The guestion is not whether inferences will be made in trying to account for human behavior, but what sort of inference is the most useful. There is now evidence to demonstrate that taking person variables into account improves prediction about behavior and enhances therapeutic efficacy (O'Leary & Wilson, 1987).  


PSYCHOTHERAPY  


Theory of Psychotherapy  


Learning  


Behavior therapy emphasizes corrective lcarning experiences in which clients acguire new coping skills, improve communication, or learn to break maladaptive habits and  overcome self-defeating cmotional conflicts. These corrective learning expericnces  volve broad changes in cognitive, affective, and behavioral functioning: They are not limited to modifications'of narrow response patterns in overr behavior. 
The learning that characterizes behavior therapy is carefully structured. Perhaps more than any other form of treatment, behavior therapy involves asking a patient to do some- thing such as practice relaxation training, self-monitor daily caloric intake, engage in as- sertive acts, confront anxiety-eliciting situations, and refrain from carrying out compulsive rituals. The high degree to which behavior therapists emphasize the client's activities in the real world between therapy sessions is one of the distinctive features of the behavioral approach. However, behavior therapy is not a one-sided influence process by the therapist  to effect changes in a client’s beliefs and behavior. It involves both dynamic interaction between therapist and client and directed work on the part of the client. A crucial factor in all forms of therapy is the client's motivation, the willingness to cooperate in the ardu 
ous and challenging task of making significant changes in real-life behavior. Resistance to  change and lack of motivation arc common reasons for treatment failures in behavior ther- apy. Much of the art in therapy involves coping with these issues (Lazarus & I'ay, 1982).  


The Therapeutic Relationship  


Behavior therapy demands skill, sensitivity, and clinical acumen. Brady et al. (1980) underscore the importance of the therapeutic relationship as follows:  
There is no question that gualitative aspects of the therapist-patient relationship can  greatly influence the coursc of therapy for good or bad. In general, if the patient's  relationship to the therapist is characterized by belief in the therapist's competence(knowledge, sophistication, and training) and if the patient regards the therapist  as an honest, trustworthy, and decent human being with good social and ethical  values (in his own scheme of things), the patient is more apt to invest himsclf in the  thcrapy. Equally important is the quality and tone of the relationship he has with the  therapist. That is, if he fecls trusting and warm toward the therapist, this generally  will facilitate following the treatment regimen, will be associated with higher cxpec- 
tations of improvement, and other generally favorable factors. ''he feelings of the  therapist toward the patient are also important. Tf the therapist feels that his patient  is not a desirable person or a decent human being or simply does not like the pa tient for whatever reasons, he may not succeed in concealing thesc attitudes toward  the patient, and in general they will have a delererious effect. (1980, pp. 285—286)  
As opposed to the neutral and detached role that the psychoanalytically oriented  therapist is taught to assume, the behavior therapist is directive and concerned—a prob lem solver and a coping modcl. Tn their comparative study of behavior therapy and psy choanalytically oriented psychotherapy, Staples, Sloanc, Whipple, Cristol, and Yorkston  concluded:  
Differences between behavior therapy and analytically-oriented psychotherapy . . .  involved the basic patterns of interactions between patient and therapist and the  type of relationship formed. Behavior therapy is not psychotherapy with special  “scientific technigues” superimposed on the traditional therapeutic paradigm;  rather, the two appear to represent guite different styles of treatment although they  share common elements. (1975, p. 1521)  
The behavior therapists in this study were rated as more directive, more open, more  genuine, and more disclosing than their psychoanalytically oriented counterparts.  
  strong therapeutic alliancc is cssential for effective behavior therapy, including  manual-based treatment. For example, it is important in cngaging the patient in treat ment process, enhancing motivation to change, and facilitating adherence to homework  assignments. Nonetheless, the therapeutic alliance does not mediate treatment outcome  in behavior therapy (DcRubeis et al., 2005). It is necessary but not sufficient. Treatment  method accounts for more variance than measures of therapeutic alliance (Loeb et al.,  2005). It is a misconception that manual-based treatment undermines the therapeutic  relationship because the therapist is focused on administering a somewhat standard ized treatment protocol. Studies show that competently conducted manual-based CBT  results in highly positivc therapeutic alliance as in earlier forms of behavior therapy as  noted above.  


Ethical Issues  


In behavior therapy the client is encouraged ro participate actively. Consider, for  example, the important issue of who determines the goals of therapy. Because it is  fundamental to behavior therapy that the client should have the major say in setting  trcatmcnt goals, it is important that the client is fully informed and consents to and  participates in setting goals. A distinction is drawn between how behavior is to be  changed—in which the therapist is presumably expert—and thc objectives of thcrapy.  'The latter ultimately must be determined by the client. The client controls what; the  therapist controls how. The major contribution of the therapist is to assist clients by  helping them to generate alternative courses of action and to analyze the conseguences  of pursuing various goals. Because this process involves an expression of the thcrapist's  own values, the therapist should identify them and explain how they might affect his or  her analysis of therapeutic goals.
BEHAVIOR THERAPY 235  
Selecting goals is far more complicated in the case of disturbed clients (such as in stitutionalized paticnts who arc struggling with psychosis) who are unablc to participate  meaningfully in deciding treatment objectives. To ensure that treatment is in the client’s  best interests, it is important to monitor program goals and procedures through confer cnces with othcr professionals (Rislcy & Shcldon-Wildgen, 1982).  
All forms of therapy involve social influence. The critical ethical guestion is whether  therapists are aware of this influence. Behavior therapy entails an explicit recognition  of the influence process and emphasizes specific, client-oriented behavioral objectives.  Behavior therapists have formulated procedures to guarantee the protection of human  rights and personal dignity of all clients (Stolz, 1978; Wilson & O'Leary, 1980).  


Process of Psychotherapy  


Problem Identification and Assessment  


'The initial task of a behavior therapist is to identify and understand the client's pre senting problem(s). The therapist seeks detailed information about the specific dimen sions of problems, such as initial occurrence, severity, and freguency. What has the  client donc to cope with the problems? What does the client think about his or her  problem and any previous therapeuric conracts? Obtaining answers to such searching  guestions is facilitated by a relationship of trust and mutual understanding. To achieve  this, the therapist is attentive, trying to be objective and empathic. The therapist then  proceeds to make a functional analysis of the client's problem, attempting to identify  specific environmental and person variables that are thought to be maintaining mal adaptive thoughts, feelings, or behavior. The emphasis on variables currently main taining the problem does not mean that the client's past history is ignored. IIowever,  past experiences are important only to the degree that they directly contribute to thc  clicnt's present distress.  


Assessment Methods  


In the behaviorally oriented interview, the therapist seldom asks the client why gues tions, e.g., “Why do you become anxious in crowded places?” Ouestions starting  with bow, wben, where, and what arc morc uscful. The therapist docs not necessarily  take everything the client says at face value and is constantly looking for inconsis  tencies, evasiveness, or apparent distortions. Nevertheless, the therapist relies heavily  on clients’ self-reports, particularly in assessing thoughts, fantasies, and feelings. Self report has often proved to be a supcrior predictor of behavior when compared to  clinicians’ judgments or scores on personality tests (Mischel, 1981). Of course, thera  pists must ask the right guestions if they are to get meaningful answers. Given the ten dency of most people to describe themselves with broad personality labels, therapists  may have to help clients to identify specific behavioral referents for global subjective  impressions.  


Guided Imagery  


  useful method for assessing clients’ reactions to particular situations is to have them  symbolically recreate a problematic life situation. Instead of asking clients simply to talk  about an cvent, the therapist has them imagine thc cvent actually happening to them.  When clients have conjured up an image of a situation, they are then asked to verbalize  any thoughts that come to mind, an especially useful way of uncovering the specific  thoughts associated with particular events.


Role-Playing  


Another option is to ask clients to role-play a situation. This method lends itsclf to thc  assessment of interpersonal problems, with the therapist adopting the role of the person  with whom the client reports problems. Role-playing provides the therapist with a sample  of the problem behavior, albcit under somcwhar artificial circumstances. If the therapist  is assessing a client couple, the two partners are asked to discuss chosen issues that enable  the therapist to observe first-hand the extent of their interpersonal skills and thcir ability  to resolve conflict.  


Physiological Recording  


Technological progress in monitoring different psychophysiological reactions has made  it possible to objectively measure a number of problems. Monitoring a client’s scxual  arousal in response to specific stimuli that cause changes in penile or vaginal blood flow  (Rosen & Keefe, 1978) is an cxample of the use of physiological recording instruments  in behavioral assessment and treatment strategies.  


Self- Monitoring  


Clients are typically instructed to keep detailed, daily records of particular cvents or psy chological rcactions. Obese clients, [or example, are asked to self-monitor daily caloric  intake, the degree to which they engage in planned physical activities, the conditions  under which they cat, and so on. In this way it is possible to detect behavioral patterns  in clients' lives functionally related to their problems.  


Behavioral Observation  


Assessment of overt problem behavior, ideally, is based on actual observation of rhe cli  ent's behavior in thc natural environment. Accordingly, behavior therapists have devel oped sophisticated behavioral observation rating procedures. These procedures most  often have been used with children and hospitalized patients. Parcnts, teachers, nurses,  and hospital aides have been trained as behavioral observers. Once these individuals  
have learncd to observe behavior, they can be taught to make a behavioral analysis of  a problem and then instructed to alter thcir own behavior to influence the problem behavior of another person.  


Psychological Tests and Questionnaires  


In general, behavior therapists do not use standardized psychodiagnostic tests. Tests such  as the MMPI may bc useful for providing an overall picture of the client’s personality  profile, but they do nor yield the kind of information necessary for a functional analysis  or for the development of therapeutic intervenrions. Projective tests are widely rejected  because of a lack of acceptable evidence for their validity or uriliry (T.ilienfeld, Tynn, &  Lohr, 2003). Behavior therapists do use checklists and guestionnaires, such as the Marks  and Mathews Fear Questionnaire (1979), self-report scales of depression like the Beck  Depression Inventory (Beck, Rush, Shaw, & Emcry, 1979), assertion inventories like the  Rathus (1973) questionnaire, and paper and-pencil measures of marital satisfaction such  as the Lockc and Wallace (1959) inventory of marital adjustment. These ment  devices are not sufficient for carrying out a functional analysis of the determinants of a  problem, but are useful in establishing the initial scverity of the problem and charting therapeutic efficacy over the course of treatment. 


Treatment Technigues  


Behavior therapy offers a wide range of differenr treatment methods and attempts to  tailor the principles of social-cognitive Lheory to each individual's unique problem. In  selecting trcatment techniques, the behavior therapist relies heavily on empirical evidence about the efficacy of that techniguc applied to the particular problem, In many cases, the empirical evidence is unclear or largely noncxistent. Here the therapist is influenced by accepted clinical practice and the basic logic and philosophy of a social-cognitive ap- proach to human bchavior and its modification. In the process, the therapist must often 
use intuitive skill and clinical judgment to select appropriate treatment methods and determine the best time to implement specific techniques. Both science and art influ ence clinical practice, and the most effective therapists are awarc of the advantages and limitations of cach.  
The following are some selectivc illustrations of the varied methods the typical behavior therapist is likely to employ in clinical practice.
  
Imagery-Based Technigues. 


In systematic desensitization, after isolating specific  events that Lrigger unrealistic anxiety, the therapist constructs a stimulus hierarchy in which different situations that the client fears are ordered along a continuum from mildly stressful to very threatening. The client is instructed to imagine each event while he or she is deeply rclaxcd. Wolpe (1958) adapted Jacobson's (1938) method of progres- sive relaxation training as a means of producing a response incompatible with anxiety. Bricfly, this consists of training clients to concentrate on systematically relaxing differ 
ent muscle groups. When any item produces excessive anxicty, the client is instructed  to cease visualizing the particular item and to restore feelings of relaxation. The item is then repeated, or the hierarchy adjusted, until the client can visualize the scene without experiencing anxiety. Only then does the therapist present the next item of the hierar- chy. Real-life exposure, where possible, is even more powerful than using imagination and is the technique of choicc for treating anxiety disorders. An example of exposure  treatment for an agoraphobic client is described in the “Applications” section.  
Symbolically generated aversive reactions arc used to treat diverse problems such  as alcoholism and sexual disorders (e.g., exhibirionism). In this procedure, the client  is asked to imagine aversive conseguences associated with the problem behavior. An alcoholic might be asked to imagine experiencing nausea at the thought of a drink; an exhibitionist might be asked to imagine being apprehended by the police. This method is often referred to as covert sensitization (Caurela, 1967). A hierarchy of scenes that re- liably elicit the problem urge or behavior is developed, and each scene is systematically  presented until the client gains control over the problem.  


Cognitive Restructuring.


The treatment technigues in this catcgory arc based on the assumption that emotional disorders result, at least in part, from dysfunctional think- ing. The task of therapy is to alter this maladaptive thinking. Although there is some overlap with Ellis's REBT, the cognitive restructuring method most commonly used by bchavior therapists is derived from Beck's cognitive therapy. An cxample of this method is illustrated in thc following excerpt from a therapy session. Notice how the therapist  prompts the patient to examine his dysfunctional assumptions and how behavioral tasks  are used to help the patient to alter his assumption (P — Patient; T = Therapist):  


P: In the middle of a panic attack, I usually think T am going to faint or collapse . . .  
T:Havc you ever fainted in an attack?  
P:No.  
T:What is it then that makes you think you might faint?  
P:I fecl faint, and the feeling can be very strong. 
T: So,to summarize, your evidence that you are going to faint is the fact that you feel  faint?  
P: Yes.  
T: How can you then account for the fact that you have felt faint many hundreds of  times and have not yet fainted?  
P: So far, the attacks have always stopped just in time or T havc managed to hold onto  something to stop myself from collapsing.  
T: Right.So one explanation of the fact that you have frequently felt faint, had the  thought that you would faint, but have not actually fainted, is that you havc always  done something to save yourself just in timc. However, an alternative explanation is  that thc fecling of faintness that you get in a panic attack will never lead to you col 
lapsing, even if you don't control it.  
P: Yes,Isuppose.  
T: In order to decide which of these two possibilities is correct, we need to know what  has to happen to your body for you to actually faint. Do you know?  
P: No.  
T: Your blood pressure needs to drop. Do you know what happens to your blood  pressure during a panic attack?  
p: Well, my pulse is racing. I guess my blood pressure must be up.  
'T: That’s righr. Tn anxiety, heart rate and blood pressure tend to go together. So, you  are actually less likely to faint when you are anxious than when you are not.  
P: That's very interesting and helpful to know. However, if it’s true, why do T fcel so  faint?  
T: Your fecling of faintness is a sign that your body is reacting in a normal way to  the perception of danger. Most of the bodily reactions you are experiencing when  anxious were probably designed to deal with the threats expericnced by primitive  people, such as being approached by a hungry tiger. What would be the best thing  to do in that situation?  
P: Run away as fast as you can,  
T: That's right. And in order to help you run, you need the maximum amount of energy  in your muscles. This is achicved by sending more of your blood to your muscles  and relatively less to the brain. This means that there is a small drop in oxygen to  the brain and that is why you feel faint. However, this feeling is misleading because  your overall blood pressure is up, not down.  
P: That's very clear, So next time I feel faint, I can check out whether I am going to  faint by taking my pulse. If it is normal, or guicker than normal, I know T won't faint. (Clark, 1989, pp. 76-77)  


Assertiveness and Social Skills Training.


Unassertive clients often fail to cxpress  their emotions or to stand up for their rights. They arc often cxploited by others, feel  anxious in social situations, and lack self-esteem. In behavior rehearsal, the therapist  may model the appropriate assertive behavior and may ask the client to engage repeat 
edly in a graduated seguence of similar actions (Alberri & Emmons, 2001). Initíally, the  therapist focuses on expressivc bchavior (e.g., body posture, voice training, and eye con tact). The therapist then encourages the client to carry out assertive actions in the real  world to ensure generalization. Behavior therapy is freguently conducted in a group as  well as on an individual basis. Behavior rehearsal for assertiveness training is well suited  to group therapy, because group members can provide more varied sources of educa tional feedback and can also offer a diversified range of modeling influences.  
The instructional, modeling, and feedback components of behavior rehearsal facilitate  a broad range of communication competencies, including active listening, giving personal  feedback, and building trust through self-disclosure. These communication principles,drawn from nonbehavioral approaches to counseling but integrated within a behavioral  framework, are an important ingredient of bchavioral marital therapy (Margolin, 1987). 
 
Self- Control Procedures.


Behavior therapists use a number of self-control proce dures (Bandura, 1977; Kanfer, 1977). Fundamental to successful self-regulation oí be havior is self-monitoring, which reguires helping the clicnt sct goals or standards that  guide behavior. In the treatmcnt of obesity, for example, daily caloric goals are murually  selected. Behavioral rescarch has identified certain properties of goals that incrcase the  probability of successful self-control. For example, one should sct highly specific, unam.  biguous, and short-term goals, such as consumption of no more than 1,200 calories each  day. Compare this to thc goal of “cutting back” on eating for the “next week.” Failure  to achicvc such vague goals elicits negative self-evaluative reactions by clients, whercas  successful accomplishment of goals produces self-reinforcement that increases the likeli  hood of maintaining the new behavior.  
Self-instructional training, described above, is often used as a self-control method  for coping with impulsivity, stress, excessive anger, and pain. Similarly, progressive re laxation training is widely applied as a self-control method for reducing different forms  of srress, including insomnia, tension headaches, and hypertension (O'Leary & Wilson,  1987). Biofeedback methods used to treat a variety of psychophysiological disorders also  fall under the category of self-control procedurcs (Yatcs, 1980).  


Real-Life Performance-Based Technigues.


The foregoing technigucs are applied  during treatment sessions, and most are routinely coupled with instructions to clients to  complete homework assignments in their natural environment.  
'The divcrsity of behavioral treatment methods is seen in the application of operant  conditioning principles in settings ranging from classrooms to institutions for people  affected by retardation or mental illness. An excellent illustration is the use of a token  economy. The main elements of a token rcinforcement program can be summarized as  follows: (a) carcfully specified and operationally defined target behaviors, (b) backup  rcinforcers, (c) tokens that represent the backup reinforcers, and (d) rules of cxchange  that specify the number of tokens reguired to obtain backup reinforcers.  
A token economy in a classroom might consist of the teacher, ar regular intervals, mak ing ratings indicating how well a student had behaved, both academically and socially. At  the end of the day, good ratings could be exchanged for various small prizes. These proce dures reduce disruptive social behavior in the classroom and can improve acadcmic per formance (O'Leary & O'Leary, 1977). In the case of psychiatric inpaticnts, the staff might  make tokens contingent upon improvements in sclf-carc activities, reductions in belliger ent acts, and cooperative problem-solving behavior (Kazdin, 1977). The behavior therapist  designs the token economy and monitors its implementation and efficacy, The procedures  themselves are implemented in real-life settings by tcachcrs, parents, nurses, and psychiatric  aides—whoever has most direct contact with the patient. Ensuring that these psychological  assistants arc wcll trained and supervised is the responsibility of the behavior therapist.  


Length of Trealment.


There are no established guidelines for deciding on the  length of therapy. Much of behavior therapy is short-term treatment, but therapy last ing from 25 to 50 sessions is commonplace, and still longer treatment is not unusual.  'Therapy in excess of 100 sessions is relatively rare. The usual approach in clinical prac tice is to carry out a detailed behavioral assessment of a client's problem(s) and to cm bark upon interventions as rapidly as possible. Assessment is an ongoing process, as the  conseguences of initial treatment interventions are evaluated against Lherapeutic goals.  Unless treatment time is explicitly limited from the start, the length of therapy and the  scheduling of the trcatment sessions are contingent upon the patient's progress.
'Typically, a behavior therapist might contract with a patient to pursue a treatment  plan for two to threc months (approximately 8 to 12 sessions) and reevaluate progress  at the end of this period. The relative absence of any discernible improvement is cause  for the therapist to reevaluate whether he or she conceptualized the problem accurately,  whether he or she is using the appropriate techniques or needs to switch tactics, whether  there is some personal problem with him or her as the therapist, or whether a referral to  another therapist or another form of treatment might be necessary.  
In terminating a successful case, the behavior therapist usually avoids abruptness.  A typical procedure is to lengthen gradually the time between successive therapy  sessions, from wcckly to fortnightly to monthly and so on. These concluding sessions  may be shorter than earlier ones, with occasional telephonc contact.  


Manual-Based Treatments  


Thc usc of standardized, manual-based treatments in clinical practice represents a new  and controversial development with far-rcaching implications for clinical practice. Cog nitive behavioral therapists have been at the forefront of this development (Wilson,  1998), and there are now evidence-based CBT treatment manuals for a variety of clinical  disorders, including different anxiety disorders, depressions, and eating disorders.  
A treatment manual describes a limited and set number of technigues for treating a  specific clinical disorder, These technigues are implemented in the same seguence over  a more or less fixed number of treatment sessions, and all patients diagnosed with the  disorder in guestion arc treated with the same manual-based approach. For example, all  patients with the eating disorder of bulimia nervosa would be treated in essentially the  same fashion using the cognitive behavior therapy manual developed specifically for this  disorder by Fairburn and his colleagues (Fairburn, Marcus, & Wilson, 1993).  
A particular strength of these manuals is that they describe treatment programs that  have been evaluated in controlled clinical trials. Treatment manuals make psychological  therapy, whatever its particular form, more consistent and more widely available. They  make it easier for therapists to learn specific Lreatment strategies and to acquire skill in using  them. They not only facilitate the training of therapists but also make it easier for supervi 
sors to monitor their trainees’ expertise. The structured and time-limited nature of treat ment manuals results in morc highly focused treatment than might otherwise be the case.  Nonetheless, manual based treatments have been criticized by practitioners, includ ing some behavior therapists, because the standardized approach limits the role of the  therapist's clinical judgment in tailoring specific interventions to the individual patient's  needs (Davison & Lazarus, 1995). In response, proponcnts of manual-based treatments  argue that therapists’ clinical judgments are often highly subjective, relying more on in tuition than empirical evidence.  
'The limitations of clinical judgment have been well documented. Clinical judgment  as a form of human inference is no better, and is worse in some situations, than actu arial prediction in which patients’ behavior is predicted by viewing them as members  of an aggregate (e.g., a diagnostic category) and by derermining whar variables generally  predict for that aggregate or diagnostic category (Dawes, 1994). Empirically supported,  manual-based treatments are consistent with the actuarial approach. The relative ef fectiveness of manual-based bchavior therapy versus reliance on the therapist's clinical  judgment is the subject of ongoing clinical investigation.  


Mechanisms of Psychotherapy  


Research on behavior therapy has demonstrated that particular trcatment mcthods arc  effective and has identified what components of multifaceted treatment methods and  programs are responsible for therapeutic success. For example, empirical evidence has established that the changes produced by token reinforcement programs are due to the  learning principles of operant conditioning on which they are based (Kazdin, 1977).  


Learning Processes  


Ayllon and Azrin (1965) described a pioneering token reinforcement program with  predominantly schizophrenic patients on a psychiatric hospital ward. The target behnviors in this investigation were self-care and improved capacity for productive  work. Rewards were made contingent on improvement in these two areas. Following  a period during which thc job assignments of all 44 paticnts on the entire ward were  rewarded contingently (phase A), tokens were administered on a noncontingent basis  (phase B). In phase B, patients were given tokens each day regardless of their  performance, which broke the contingency between reinforcer and response. This  ensured that the amount of social interaction between the attendants and ward staff  who administered the tokens and the patients remained unchanged. Any dctcrioration  in pcrformancc was then directly attributable to the precise functional relationship  between behavior and reinforcement.  
Phase C marked a return to contingent reinforcement as ín phase A. The results  showed that “free” reinforcemcnt (phasc B) was totally incffectivc. Similarly, the com plete withdrawal of all tokens resulted in performance decreasing to less than one-fourth  the rate at which it had previously been maintained by contingently rewarding the  patients with tokens.  
No single, monolithic theory cncompasses the diverse methods and applications of  the different behavior therapies. Although operant conditioning principles explain rhe efficacy of a hrond range of behavioral procedures, they do not account for the success  of a number of other methods. Classical conditioning and different cognitive processes  all play a part in determining the effects of the various cognitive behavioral treatment  methods described in this chapter. In many cases, the mechanisms responsible for  the therapeutic success of a method remain unclear. Consider exposure treatment Íor  phobic and obsessive-compulsive disorders. The effectiveness of this method has been  well established, but its explanation is still a matter of some controversy. Originally, the  explanation was based on Mowrcr's (1947) two-factor theory of learning, according to  which repeated exposure to anxiety-eliciting situations, as in systematic desensitization,  resulted in the extinction of the classically conditioned anxiety that mediates phobic  avoidance behavior. However, other research (Bandura, 1986) casts doubt on the valid ity of this cxplanation.  


Gognitive Mechanisms  


In terms of social-cognitive theory, exposure leads not to the extinction of any under lying anxiety drivc statc, but rather to modification of thc clicnt's cxpectations of self efficacy (Bandura, 1982). Self-efficacy refers to clients’ beliefs that they can cope with  formerly feared situations. For ellicacy expectations to change, the client must make a  self-attribution of behavioral change. For example, it is not uncommon for an agorapho bic client to approach situations she has avoided without increases in self-cfficacy or rc ductions in fcar. The cxplanation seems to be that some clients do not credit themselves  for the behavioral change. The agoraphobic might say that she was “lucky” that she did  not have a panic attack or that she just happened to have one of those rare “good days.”  'The therapist must be prepared to hclp the clicnt use cognitivc mcthods to artribute  changes to herself so that her sense of personal efficacy increases. 
Initial studies with phobic subjects have generally provided empirical support for self- efficacy theory, although the findings are mixed. Fixperiments by Bandura and his associates have shown that efficacy expectations accurately predicted reductions in phobic avoidance
regardless of whether they were created by real-life exposure or symbolic modeling, covert  modcling, or systematic desensitization. Moreover, measures of personal efficacy predicted  differences in coping behavior by different individuals receiving the same treatment and  even specific performance by subjects in dillerent tasks. Consistent with the theory, par 
ticipant modeling, a performance-based treatment, produced greater incrcascs in level and  strength of efficacy cxpcctations and in related behavior change (Bandura, 1986).  


APPLICATIONS  


‘Who Can We Help?  


Behavior therapy can be used to treat a full range of psychological disorders in differ ent populations (Kazdin & Wilson, 1978). It also has broad applicability to problems  in education, medicine, and community living. The following arc sclected cxamples of  problems for which behavior therapy is an effective treatment.  


Anxiety Disorders  


Several well-controlled studics have established that behavior therapy is an effective form  of treatment for anxiety disorders. Simple phobias arc succcssfully eliminated within a  short number of sessions by using guided exposure treatment in which paticnts arc helped  to gradually approach and confront the objects or situations they [ear and avoid. For  example, Tom Ollendick and his colleagues (2009) demonstrated that even a one-session  in vivo graduated exposure treatment of up to threc hours was superior to an education  support treatment and treatment effects were maintained at follow-up. Behavior therapy  also is the treatment of choice for more complex and debilitating disorders such as panic  disorder and obsessive-compulsive disorder.  


Panic Disorder.


Panic disorder is defined by a discrete period of intense fear that  develops suddenly and involves physiological symptoms such as a pounding heart, short ncss of breath, sweating, dizziness, and fear of going crazy. Effective treatment typically  combines both bchavioral and cognitive components. At Oxford University in England,  David Clark and his colleagues tested the cffects of a treatment that focused mainly on  changing panic patients’ catastrophic interpretation of bodily sensations. I'his cognitive  bchavioral treatment proved to be superior to pharmacologicul therapy with imipramine,  an antidepressant often assumed to be thc thcrapy of choice for panic disorder. Patients  treated with cognitive-behavioral therapy maintained their improvement over a one-year  follow-up period, whereas patients treated with imipramine tended to relapse when the  drug was discontinued (Clark, Salkovskis, Hackmann, Middleton, & Gelder, 1994).  
Tn the United States, studies by David Barlow and his colleagues have evaluated the  effects of a panic control treatmenr (PCT) that includes both behavioral and cognitive  components, The two main behavioral components are (1) progressive relaxation training  designed to help patients cope with their anxiety and (2) exposure (extinction) treatment  in which patients are systematically exposed to cues (mainly internal bodily sensations)  that typically trigger panic attacks. The treatment eliminates the panic reactions via the  process of extinction. PCT was more cffective than a wait list control condition (in which  patients were assessed but their treatment delayed) or relaxation training alone. A two 
ycar follow-up showed that 8196 of patients treated with PCT were panic-frce (Craske,  Brown, & Barlow, 1991). A subscquent large, controlled study of panic disorder showed that both CBT' and imipramine were effective trcatmcnts in the short term. Again, the  therapeutic effects of CBT were maintained over follow-up, whercas paticnts withdrawn  from their medication tended to relapse (Barlow, Gorman, Shear, & Woods, 2000). Most recently, Craske and her colleagues have shown that this form of cognitive behavior  therapy can be successfully implemented to treat panic disorder in primary-carc medical  settings where the customary therapy has been anridepressant medicarion. Adding cogni tive behavioral rreatment ro the medication results in significantly superior results than  medication alone (Craske et al., 2005).  


Obsessive—Compulsive Disorders. 


Traditional psychothcrapy is incffcctive in Lreat ing obscssive—compulsive disorder (OCD). A significant advance was made in the 1970s  with the development of specific behavioral methods. The most effective treatment  is exposure and response prevention, which can be illustrated with compulsivc hand  washers. The differcnt objects or activitics lcading thc paticnt to wash his or her hands arc first identified through behavioral assessment. Then, following a thorough explana tion of the technigue and its rationale, and with the patient’s fully informed consent,  touching objects that trigger hand washing is systematically encouraged. This is thc ex posure part of treatment. Once thc paticnt has touched what is unrcalistically viewed as  contaminated, he or she refrains from washing. This is the response prevention part of  treatment. The patient’s anxiety typically rises after initially touching the object and then  decreases over the course of the session. Focusing the patienUs atLention on fear of con Lamination assists the treatment. The goal of treatment is to break thc negative reinforc ing valuc of the compulsion, extinguish the anxiety elicited by the contaminated object,  and enhance the patient’s sclf-cfficacy in coping with this kind of situation. Imaginal  exposure is used in cases when in vivo exposure is impractical or impossible. Patients  are instructed to conjure up detailed imagery of compulsive activities and stay with these  images until their anxiety decreases.  
Rescarch has shown that roughly 65 to 7596 of patients with OCD show marked  improvement following behavioral treatment (Barlow, 2002). This therapeutic success is  maintained during follow-ups as long as two years after treatment. Of particular interest  is the finding that exposure treatment influences the biological basis of OCD. Success fully trcated patients show significant changes in glucose metabolism in the caudate  nucleus, a specific region of the brain that is known to be connected with anxiety. These  changes are identical to those produced by successful pharmacological treatment (Baxter  etal., 1992).


Posttraumatic stress disorder (PTSD).
PTSD develops following an intensely  stressful event that is likely Lo cause significant distress in most people. Common  examples are traumatic experiences in military combat and rape-related trauma. The  major symptoms of PTSD include: (1) re-experiencing symptoms, flashbacks, fecling as if the cvcnt wcrc rc-occurring, nightmares, and distressing intrusive images; (2) avoid  ance, in which people try to suppress memories of the event; (3) hyperarousal, including  hypervigilance for threat, irritability, difficulty concentrating, and sleep difficultics; and  (4) emotional numbing, including thc lack of ability to cxpcricncc feclings and amnesia  for significant aspects of the event. Associated difficulties, such as depression, substance  abuse, and interpersonal problems, are commonplace.  
Different combinations of both cognitive and behavioral technigues have been used  to treat PTSD, but the strongest evidence supports exposure therapy (Foa, Hembree,  Cahill, Rauch, & Riggs, 2005). In this treatment, following detailed assessment and ed ucarion about the nature of trauma, the therapist and patient develop a hierarchy of  threatening situations. Homework exercises are designed to have the patient confront  Lhese siLuations in a graded fashion. In addition, using imaginal exposure, therapy ses sions are devoted to having the patient re-experience the trauma itself, for cxamplc, be ing raped by a stranger. The paticnt's rcactions to thcsc imaginal cxposure sessions are  discussed and progress carefully monitored. In a large treatment study of rape survivors,Foa et al. (2005) showed that 12 sessions of this therapy not only produced significant  improvement in PTSD, but also associated depression, work, and social functioning.  


Depression  


Beck's cognitive therapy (CT) for depression is described in Chapter 8. CT is a mix of  cognitivc and behavioral strategies. Several well-controlled treatment outcome studies  have shown that CT is an cffectivc treatment for depression, including severe depres sion among adults. What is especially significant is that CT appears to be as effective as  antidepressant medication (DeRubeis, Brotman, & Gibbons, 2005). Morcover, CT may  be cven morc cffective over the long term because when medication is discontinued,  patients often relapse rapidly. In short, paticnts would have to continue taking medica tion over a period of years in order Lo equal the enduring effects of scvcral months of  CT (Hollon, Stewart, & Strunk, 2006). Importantly, CT is effective not just in research  conducted at major universities, but also in routine clinical practice and with minority  groups who are typically underserved (Miranda et al., 2005).  
CT comprises rhe following overlapping series of different strategics: Systematic  sell-observation (self-monitoring); behavioral activation; monitoring thoughts; challeng ing accuracy of thoughts; exploring underlying core beliefs or whar are called schemas;  and relapse prevention (Hollon, 1999). Notice that the strategies begin with behavioral  techniques (sclf-monitoring and behavioral activation) and become progressively more  cognitive in nature as the therapy develops. An important theoretical and practical gues tion is which of these strategies accounts for the success of the approach? Jacobson and  his collcagues (1996) conducted a component analysis of CT in order to determine the  necessary and sufficient treatment clements of this approach. They compared the full CT  treatment package, which by definition focused on modifying dysfunctional cognitions, to  the behavioral component that they labeled behavioral activation (BA). The focus in BA  is helping patients to become more active. They learn to self-monitor their daily activities,  assess pleasure from engaging in different activities, complete increasingly difficult tasks  designed to promote a sense of mastery, and overcome deficits in social skills. The results  showed that BA was as effective as the full CT package in decreasing depression both at  thc end of therapy and at 6-month and 2-year follow-ups (Gortner, Gollan, Dobson, &  Jacobson, 1998). Furthermore, BA was egually effective in altering negative thinking in  these depressed patients. Jacobson et al. (1996) concluded that CT is no more effective  than the behavioral component of the full treatment package.  
The results of the Jacobson et al. (1996) study have been replicated by Dimidji  
ct al. (in press). These investigators found no difference between a behavioral activa tion treatment and the full CT approach. Howcver, when the results from only the most  severely depressed patients were analyzed, behavioral activation proved more effec tive than CT. Finally, the apparent efficacy of behavioral activation is consistent with  the finding that most of the improvement ín CT occurs early in treatment (Ilardi &  Craighead, 1994). As noted above, the behavioral component is especially prominent  during the early part of CT, and these findings collectively call into gucstion the added value of specific cognitive procedures for treating depression.  
Another innovative treatment for depression is mindfulness-hased cognitive behav ior therapy, or MBCT (Segal, Teasdale, & Williams, 2004). This therapy has many features  of Beck's CT, with two importanr differences. First, instead of encouraging patients to  actively challenge the validity of their beliefs, MBCT reaches patients to use mindfulness  skills in reacting to negative thoughts or bad feelings. The focus is on whar Segal et al.  (2004) call meta-cognitive awareness—this is essentially the same concept as defusion or  distancing as described carlíer in this chapter in the section of DBT and ACT. Second,  and consistent with behavioral activation and ACT, the focus is on dealing with the 
BEHAVIOR THERAPY 245  
functional consequences of thoughts and bcliefs rather than on analyzing their content  or truth value. Preliminary findings indicate that MBCT is effective in reducing relapse.  'Two additional [orms of behavior therapy have been used successfully to treat depres sion. One, developed by Peter Lewinsohn, combines many of the cognitive strategies of  Beck's approach with a more traditional behavioral emphasis on increasing the range of pa Líents” positive reinforcers. This approach has been shown to be effective in overcoming de pression in adolescents (Lewinsohn, Clarke, Hops, & Andrews, 1990). The other is a form  of behavioral marital therapy. The goal in this treatment is to modify the interpersonal influ cnces on unipolar depression by reducing marital conflict and facilitating increased feelings of closeness and open sharing of thoughts and feclings (O'Lcary & Beach, 1990). This treat ment seems especially effective with depressed women who also have marital problems.  Dobson et al. (2008) conducted a randomized controlled trial that compared the  cffectivencss of cognitive therapy, behavioral activation, and antidepressant medication.  These researchers found no significant difference between bchavioral activation and  cognirive therapy, bur each treatment was at least as efficacious as continued treatment  with antidepressant medication, and the psychological treatments were longer lasting  and actually cost less than continued treatment with antidepressant medications.  


Eating and Weight Disorders  


Binge Eating and Bulimia Nervosa.


Bulimia nervosa (BN) is an eating disorder that  occurs mainly in adolescent and young adult women. It is characterized by a severe dis turbance of eating in which determined attempts to restrict food intake arc punctuated  Dby binge eating, namely, episodes of uncontrolled consumption of very large amounts of  food. Binges are commonly followed by purging (self-induced vomiting or the misuse of  laxatives). BN patients have dysfunctional concerns about body shape and weight and  judge their self-worth in terms of shape and weight. Other psychiatric disorders, such as depression, substance abuse, and personality disorders, are commonly associated with  BN. Binge eating disorder (BED) is diagnosed if patients show recurrent binge eating in  the absence of extreme attempts at weight control such as purging. Whereas BN patients  are typically of normal weight, BED patients are usually overweight or obese.  
Manual-based CBT for BN (Fairburn et al., 1993) is designed to eliminate binge  eating and purging, replace rigid dieting with more normal and flexible eating patterns,  and modify dysfunctional thoughts and feelings about the personal significance of body  weight and shape. Patients are helped to achieve enhanced self-acceptance instead of  struggling to conform to unrcalistic socictal ideals of feminine beauty. In addition, cog 
nitive and behavioral strategies are used to help patients cope more adaptively wíth  stressful events instead of resorting to binge eating.  
Numcrous controlled studics in the United States and Europe have demonstrated  the effectiveness of CBT in treating BN (Wilson & Fairburn, 2002). CBT has proved  to be more effective than several other psychological treatments, including supportive  psychotherapy, supportive—expressive psychotherapy, stress management therapy, and a  
form of behavior therapy that did not address the cognitive features of bulimia nervosa.  The cxception is interpersonal psychotherapy (IPT). A major comparative outcome  study found thar ar the end of treatment, TPT was less effectivc than CBT, but during a  one-year follow-up, the difference between the two treatments disappeared due to con 
tinuing improvement among the patients who received IPT (Fairburn et al., 1995).  Antidepressant medication has also been shown to be an effective treatment for BN.  Rescarch studics cvaluating thc relative and combined effectiveness of CBT and anti depressant drug treaunent have, as a whole, shown that CBT is supcrior to medication  alone. Combining CBT with medication is significantly more effective than medication  alone. Combining the two has produced few benefits over CBT alone on the reduction of the core features of bulimia nervosa. Tn contrast to the data on CBY', there is virtually no  evidence of the long-term effect of pharmacological treatment on BN (Wilson, 1997).  CBT is also effective in treating binge eating and associated psychopathology in BED  paticnts, but does not produce significant weight loss (Wilson, Grilo, & Vitousek, 2007).  


Obesity.
A comprehensive behavioral weight control program, comprising com ponents of improved eating habits, lifestyle change, sound nutrition, and increased ex ercise, is widely viewed as the treatment of choice for mild to moderate cases of obesity.  Short-term results are good. Following 5 months of treatment, behavioral treatment  combined with moderate dietary restriction (1,200 calories of self-sclected foods daily)  results in a mean weight loss of roughly 20 pounds, togerher with significant decreases in  depression and body image dissatisfaction. The problem is that these rreatmenr effecrs  arc not maintained over time (Wadden, Butryn, & Byrne, 2004),  
'The pattern of weight loss and regain in behavioral treatment is consistent. The rate  of initial weight loss is rapid but then slowly declincs. The low point is reached after ap proximately 6 months. Weight regain then begins and continues gradually until weight  stabilizes ncar bascline levels. Obesity is a chronic condition that may reguire treatment  of indefinite duration. Continuing therapist contact appears to be a key element in suc- cessful maintenance programs (Perri, 1998).  


Schizophrenia  


In the early days of behavior therapy, the treatment of schizophrenic patients con sisted of token cconomy programs in mental hospitals. The most prominent example  of this approach was a study by Paul and Lentz (1977). They treated chronic mental  patients, all of whom were diagnosed as process schizophrenic and were of low socio cconomic status, These patients had been confined to a mental hospital for an average of  17 years and had been treated previously with drugs and other methods without success.  Approximately 9096 were taking medication at the onset of the study. Their level of  sell-care was too low and the severity of their bizarre behavior too great to permit com munity placement. According to Paul and Lentz, these subjects were “the most severely  debilitated chronically institutionalized adults ever subjected to systematic study” (p. v).  Tn the most detailed, comprehensive, and well-controlled evaluation of the treatment of  chronic mental hospital patients ever conducted, Paul and Lentz produced a wealth of  objective data, including evidence of cost effectiveness, showing that behavioral proce durcs (predominantly a sophisticated token reinforcement program) were cffective.  
1n the 1980s, rescarch began to show that family environment was decisive in deter  mining whether schizophrenic patients discharged from hospital relapsed or maintained  their improvement. As a result, family interventions were developed for preventing rclapsc,  and some of these were strongly behavioral in nature (Tarrier & Wykes, 2004). Given the  success of cognitive behavioral treatment for anxiety and other disorders, the same strate gies began ro be applied to schizophrenic patients. The treatments were designed to mod ily schizophrenic symptoms that proved resistant to medication as well as acute psychotic  episodes. Overall, the evidence that these treatments are effective is promising, but not de finitive. Tarrier and Wykes (2004) note that there has been a tendency for more behavioral  intervcntions ro be more effective than those relying on cognitive methods.


Childhood Disorders  


Children have been treated (rom thc carlicst days of behavior therapy. Treatment pro grams have addressed problems ranging from circumscribed habit disorders in children  to multiple responses of children who suffer all encompassing excesses, deficits, or  bizarre behavior patterns. Thcsc problems include conduct disorders, aggression, and 
BEHAVIOR THERAPY 247  
delinguency. Hyperactivity is widely treated by behavioral methods, such as token rein forcement programs. The documented success of the behavioral approach, particularly  in improving the academic performance of these children, suggests that it can sometimes  be used as an alicrnative to drug treatment (O'Lcary, 1980).  
Autism is a particularly severe early childhood disorder with a very poor prognosis. Tra ditional psychological and medical treatments have proved ineffective. Behavioral methods,  however, havc achicved notable success. Lovaas (1987) has reported that intensivc, long term behavioral treatment of autistic children resulted in 4796 achieving normal intellectual and educational functioning. Another 4096 were mildly retarded and assigned to special classes for the language delayed. Of a control gronp of autistic children, only 2% achieved normal functioning, These findings arc the most positive ever obtained with autistic children  and illustrate the efficacy of behavioral methods with scrious childhood disorders.  
Childhood psychoses have also been rreared with behavioral rechnigues. Self  stimulatory and self-destructive behavior such as biting and head banging have been  eliminated with aversive procedures. Positive behaviors have been developed to improve  language and speech, play, social interaction and responsiveness, and basic academic skills (O'Lcary & Carr, 1982).  
One of the most effectively treated childhood problems has been cnurcsis. The bell-and pad method has produced improvement rates greater than 8096 in many reports. Toileting  accidents have been effectively altered with other behavioral procedures (Ross, 1981).  


Behavioral Medicine 
 
Behavioral medicine has been defined as the “interdisciplinary field concerned  with thc development and integration of bchavioral and biomedical science knowledge  and technigues relevant to health and illness and application of this knowledge and these  technigues to prevention, diagnosis, treatment and rehabilítation” (Schwartz & Weiss, 1978, p. 250). Behavior therapy has helped to catalyze the rapid growth of this field.  


Prevention and Treatment of Cardiovascular Disease  


Specific behavior patterns appear to increase the risk of needless or premature cardio vascular disease. Modification of these behavior patterns is likely to produce significant  reductions in cardiovascular discasc. Among the risk factors that have been the target  of behavioral treatment programs are cigarette smoking, obesity, lack of exercise, stress,  hypertension, and excessive alcohol consumption. Substance abuse is typically treated  with a combination of the self-control procedures. Stress and hypertension have been  successfully treated using methods such as rclaxation training. Bchavior intervention  methods have been applied not only to identified clients in both individual and group  
therapy sessions but also to essentially healthy individuals in the workplace and the com munity in programs designed to prevent cardiovascular disease.  


Other Applications  


Behavioral technigues have been successfully applied to such diverse health-related  problems as tension headaches, different forms of pain, asthma, epilepsy, sleep disor dcrs, nausea reactions in cancer patients (resulting from radiation therapy), and chil dren's fears about being hospitalized and undergoing surgery (Mclamcd & Sicgel, 1980).  Behavior therapy has also been applied successfully to the treatment of alcoholism  (McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2009), suicidal adults with border linc personality and substancc dependence disorders (Harned et al., 2008), and suicidal adolescents (Miller, Rathus, & Linehan, 2007). Finally, cognitive-behavioral principles show promise in increasing compliance with medical treatments (Meichenbaum &  Turk, 1987).  


Treatment  


Some clinical details of a cognitive-bchavioral approach to therapy may be illustrated by  the treatment of agoraphobia, a complex anxiety disorder. Initially, thc thcrapist carrics  out a careful assessment of the nature of the problem and the variables that seem to be  maintaining it. Subsequent treatment may vary, but it is probable that some Íorm of real 
life exposure will bc a central part of thcrapy. Together, therapist and client work out a  hierarchy of increasingly fear-eliciting situations that the clicnt has been avoiding. Re peated and systematic exposure to these situations occurs until avoidance is eliminated  and fear is decreased.  
'The therapist is careful to distinguish systematic exposure {rom the unsystematic  and ill-considered attempts clients have typically made to enter feared situations too  guickly. Preparation for cach cxposurc cxpcricnce involves anticipating the inevitable  fearful reactions and teaching clients appropriate coping skills. This includes recogniz  
ing and accepting feelings of fear, identifying cognitive distortions that elicit or exacer bate fear, and counteracting cognitive distortions.  
'The therapist might accompany the client during rcal-lifc exposure sessions, provid ing encouragement, support, and social reinforcement. Although empathic, the therapist  remains firm about the necessity for systematic exposure, Once the client enters the feared  situation, it is important for the client not to leave until his or her anxiety has decreased.  
Following exposure, therapist and client analyzc what happened. This provides the  therapist an opportunity to see how the client interprets his or her expericncc and to  uncover any faulty cognitive processing. For example, people coping with agoraphobia  tend to discount positive accomplishments, do not always attribute success experiences  to their own coping ability, and therefore do not develop greater self-efficacy.  
Clients are given specific instructions about exposure homework assignments be tween therapy sessions and are asked Lo keep detailed daily records of what they at tempted, how they felt, and what problems they encountered. These self-recordings are  reviewed by the therapist at the beginning of each session. In addition to providing the  therapist with information on clients’ progress (or lack of progress), these daily records  facilitate the process of changing clients’ cognitive sets abour their problems. By dircct ing their attention to the records of their own experience, the therapist helps clients to  gain a more objective and balanced view of their problems and progress.  
Homework assignments typically require the active cooperation of the client's  spouse (or some other family member). The therapist invites the spouse to one or more  therapy sessions to assess his or her willingness and abilíty to provide the necessary sup  port and to explain what is required. It is common practice to use treatment manuals  for both the client and the spousc in which they detail each step of real-life exposure  treatment and describe mutnal responsibilities. Tn many cascs, these manuals can greatly  reduce the number of sessions the couple spends with the therapisr.  
Clients often fail to complete homework assignments. There are several possible rea  sons for lack of compliance, ranging from poorly chosen homework assignments to resis tance to change. Another possibility is that thc spouse is uncooperative or tries to sabotage  therapy. One of the advantages of including the spouse in treatment is that this resistance  to progress is rapidly uncovered and can be addressed directly in therapy sessions.  
To supplemcnt real-life cxposure, some clients need assertiveness training, whereas  others need to acguire ways of coping with suppressed anger. Before terminating suc cessful treatment, the therapist works on relapse prevention training with clicnts. Bricfly,  clients are told that it is possible that they might experience an unexpected return of
BEHAVIOR THERAPY 249  
some fear at unpredictable points in the future. Using imagery to project ahcad to such  a recurrence of fear, clients learn to cope with their feelings by reinstituting previously  successful coping responses. They are reassured that these feelings are quite normal and  time-limited and do not necessarily signal a relapse. Clients learn that it is primarily  thc way they interprer rhese feelings that determines whether or not they experiencc a  relapse. Specifically, the therapist tries to inoculate them against such anxicry-inducing  cognitive errors as catastrophizing or selecrive focus on an isolated anxiety symptom.  


Evidence  


Behavior therapy consists of a broad range of different strategies and technigues, some  of which are differentially effective for different problems. Hence, it is difficult to evalu ate some global cntity called “behavior therapy.” Instead, evaluation must be dirccted at  specific methods applied to particular problems. 
 
Research Strategies  


Behavior therapists have developed various research strategies (or evaluating therapy out come. Single-case experimental desigms are important because they cnable cause-effcct re lationships to be drawn between treatments and outcome in the individual case. The ABA,  or reversal, design was illustrated in the Ayllon and Azrin (1965) study previously described.  
In the multiple-baseline design, different responses are continuously measured. 'Treatmcnt  is then applied successively to each response. If the desired behavior changes maximally  only when treated, then a cause-effect relationship can be inferred. Limitations of single subject methodology include the inabiliry to cxamine the interaction of subject variables  
with specific treatment cffects and difficulty in generalizing findings to other cases.  Laboratory-based studies permit the evaluation of specific technigucs applied to  particular problems under tightly controlled conditions; for examplc, evaluating fear re duction methods with snake-phobic subjects (Bandura, 1986). The advantages of this  methodology include the use of multiple objective measures of outcome, the selection of  homogencous subject samples and therapists, and the freedom to assign subjects to ex perimental and control groups. Limitations include the possibility that findings with only  mildly disturbed subjects might not be generalizablc to more severely disturbed dlients.  'The treatment package strategy evaluates the effect of a multifaceied treatment pro gram. If the package proves to be successful, its effective components are analyzed in  subseguenr research. One way of doing this is to use the dismantling strategy, in which  components of the treatment package are systematically eliminated and the associated  
dtucment in treatment outcome is measurcli  
The comparative rcscarch strategy is directed toward determining whethcr some  therapeutic techniques are superior to others. Comparative studies arc most appropriate  after specific technigues have been shown to be effective in single-subject or laboratory based research. Different group dcsigns require different control groups, depending on  the research question addressed. The no-treatment control group controls for the possible  therapeutic cffects of assessment of outcome, maturation, and other changes in clicnts'  behavior that occur independently of formal treatment. Attention-placebo control groups  are used to parcel out the contribution to treatment effects of facrors rhar are common to  most forms of therapy and often called nonspecific factors. These factors include the rela tionship between therapist and client, expectations of therapeutic progress, and sugges tion. For example, hehavior therapy has been increasingly compared with antidepressant  medicarion in the treatment of anxiety, mood, and eating disorders (as mentioned earlier  in this chapter) in what are called randomized controlled trials (RCTs). In the basic design,  the antidepressant medication and the bchavioral treatment are compared with each other and with a pill-placebo. If the medication or behavioral treatment is significantly more  effective than the pill-placebo condition, the treatment has been shown to have a specific  thcrapcutic effect above and beyond so-called “nonspecific” factors.  
In research on the effecis of both pharmacological and psychological trcatmcnts, a  distinction is made between efficacy and effectiveness studies. An ¢fficucy study is tightly  controlled, with random assignment of patients to different treatments, the use of manual based treatments, the inclusion of therapists who have been carcfully trained in thc usc  of the specific treatments, and rigorous assessment of outcome by independent evalua  tors. They are typically conducted in specialty university and medical school settings. In  contrast, effectiveness studies are usually less well-controlled: Formal therapy manuals  are not used, there is no specific training or supervision of therapists for the purposes of  the study, and the study is conducted under conditions of routine clinical practice (e.g.,  in a community mental health center). The goal of effecriveness research is ro evaluate  the “clinical representativeness” of ellicacy outcome research. We need to assess how  well the results of controlled rescarch gencralize to diverse patient populations, clinical  settings, and different therapists.  


Research Findings  


The cfficacy and cffectivencss of bchavior therapy has been studied more intensively  than in any other form of psychological treatment. In addition to traditional gualitative  reviews of the evidence for different disorders, numerous meta analyses exist that provide comprehensive and quantitative evaluations of the findings of large numbers of dif ferent treatment outcome studies (Nathan & Gorman, in press). The most rigorous and complete evnluations of both psychological and pharmacological treatment of different  clinical disorders are those of the National Tnstitute for Clinical Excellence (NICF) in  the United Kingdom (NICE, 2004). NICE issues treatment guidelines that are a product  of a multidisciplinary process in which the standard is consistent across all of medicine.  The guidelines are based on data and are graded from A (strong empirical support from  well-controlled RCTs) to C (expert opinion with strong empirical data).  
Behavior therapy has fared well in the NICE evaluations of the evidence for the  various clinical disorders. The level of empirical support for behavioral treatments is  typically rated as A. These treatments are recommended as the psychological treatment  of choice for specific mood and anxicty disorders and cvaluated as equally effectivc as  pharmacological therapy. In the case of eating disorders, behavior therapy has been  evaluated as even more effective than medication (Fairburn, Cooper, & Shafran, 2008;  Wilson & Shafran, 2005). Examples of individual rescarch studies documenting the efficacy of behavior therapy have been summarized in the earlier section on Applications.  Tn another evaluation of the evidence for different psychological treatments, Divi sion 12 of the American Psychological Association established criteria for judging treat ments as “empirically supported.” For example, a treatment had to have at least two  well-controlled studics, conducted by different investigators, that showed the treatment  to be significantly more effecrive than a pill, psychological placebo, or other form of  treatment. They then identified those treatments that met these standards of evidence  (Woody, Weisz, & McLean, 2005). Behavioral treatments dominate the list of what have  been called empirically supported therapies.  
The treatments that have been cvaluated in thc NTCE guidelines and by Woody  et al. (2005) have been traditional behavioral and cognitive behavioral interventions.  Evidence on third-wave forms of behavior therapy is gradually emerging. DBT for  borderline personality disorder clearly enjoys empirical support, as summarized earlier  (Lieb et al., 2004; Linchan et al., 2006). The evidencc on ACT is promising albcit still at  a rudimentary stage (Hayes et al., 2006).
BEHAVIOR THERAPY 251  
Most of the evidence in support of behavior therapy treatments for different dlinical  disorders is based on well-controlled efficacy research, It is important to point out, how ever, that effectiveness studies are beginning to show that the results of the efficacy stud ies do generalize to routine clinical practice (Wilson, 2007). For example, thcrc is now  evidence that cognitive and bchavioral treatments for anxicty disorders and depression  arc effective in helping minority group members in community based treatment settings  (e.g., Ï'oa et al., 2005; Miranda et al., 2005). Demonstrating the relevance of cvidence based psychological therapy for members of minority groups is a rcscarch priority given  that thesc individuals tend to be underrepresented in RCTs in specialized university and  medical school settings.  


Psychotherapy in a Multicultural World  


Junko Tanaka-Matsumi (2008) has examined rhe interface berween rwo growing domains in  psychorherapy: mulriculturalism and the demand for empirically supported psychotherapy.  She noted the importance of providing culturally responsive cognitive-behavioral therapy  to people of diverse cultural backgrounds and points out that the minority population in  the United States grew 11 times as rapidly as the non-Hispanic population between 1980  and 2000. This rapid growth of the minority population in the United States shows no sign  of abating. However, Tanaka-Matsumi also notes that the well-documented effectiveness of  behavioral therapy is largely based on evidence derived from Caucasian groups from North  America or with Europcan cultural backgrounds, and there is a pressing need to develop  cvidence from diverse populations around the globe. She writes:  
globalization will encourage training of multicultural mental health professionals  who can apply universally applicable principles of behavior changc and implement  culturally spccific treatment. Functional analysis is a flexible and individualized  method that can identify culture-relevant content in cognitive-behavior therapy for  diverse clients. (p. 191)  


CASE EXAMPLE'  
1 'This casc cxamplc consists of a composite of features from more than one patient in order to fully ensure confidentiality. The therapentic stratepies summarized in this case study are described in detail in Fairburn e al. (1993) and Wilson (2004).


Melissa was a 22-year-old graduate student who sought treatment at the counseling cen ter of her university because of her eating disorder. Her body mass index was 23, which  is in the middlc of thc normal (healthy) range.  
During the first session Dr. Jones, the female clinical psychologist to whom she had  been assigned, asked a number of guestions to learn as much as possible about Mclissa's  problems, such as when thc cating disorder had started and how it had developed.  Dr. Jones also inguired about any other associated problems (e.g., substance abuse,  depression, and anxiety), as well as Melissa's social interactions with family and friends.  Melissa's score on the Beck Depression Inventory (BDI) was 25, indicating a high probability of clinical depression.  
As she talked about her problems, Melissa became teary and mentioned how ashamed  she felt about her behavior. Dr. Jones expressed empathy, saying that she knew how up set Melissa was and how hard it must have been the last few months struggling with  the eating disorder without confiding in anyone, including her boyfriend. She praised  Melissa for having the courage to seek treatment and reassured her that they could work  together to help her overcomc the problem. Dr. Joncs explained that Melissa's pattern of regular binge eating followed by sel(-induced vomiting, together with her atrempts to  diet to lose more weight, were consistent with bulimia nervosa (BN). She gave Melissa  a copy of Overcoming Binge Eating, an evidence-based self-help book written by Chris  Fairburn (see Fairburn, 1995), onc of thc world's lcading authorities on eating disorders. She asked Melissa to read the first half of the book that described thc naturc of  cating disorders like BN. Dr. Jones also asked Melissa to keep a daily written record of  everything she ate and drank, when, and under what circumstances—i.e., she was asked  to practice sell monitoring. Dr. Jones took care to explain why this was important—it would provide valuable information for her as the therapist but would also immediately begin to help Melissa understand and begin to take control of her eating behavior. After  explaining sclf-monitoring, Dr. Jones asked Melissa what she thought about it. Did it make sense to her? Could she anticipate any obstacles that would interfere with self monitoring? Melissa answered that she understood the purpose of the assignment and  expressed her willingness (0 work on the task. When leaving, she thanked Dr. Jones and  said that she felt a great sense of relief in finally having confided in someone, especially  someone who was caring and seemed to understand the problem.  
At the beginning of thc sccond scssion, Dr. Jones and Melissa jointly reviewed her  self-monitoring records. She had kept excellent records for 5 of thc 7 days, although over  the weekend her recording was very spotty. Melissa ruefully stated that the week had  been a bad onc, although she had not binged or vomited on two of the days. Dr. Jones  made a point of praising Melissa's self-monitoring whilc at thc same time encouraging  her to keep accurate daily records. She also checked to see if Melissa had read the self help book. She had and was encouraged to learn that other young women like her had  successfully overcome the problem. As she would do every session, Dr. Jones then set  the agenda for the rest of the session. She explaincd that she wanted to go over the rea sons Melissa was binge eating and vomiting and to explore what was different between  the two days that Melissa had not binged and the rest of the past week. Dr. Jones invited  Melissa's feedback on the agenda and asked if she wanted to cover any other issue so as  to reinforce the concept of collaboration between therapist and patient.  
Dr. Jones then presented the cognitive behavioral model of the factors that maintain  BN. The core of the model is that extreme concerns about the importance of body shape  and weight lead individuals to diet in dysfunctional and unhealthy ways. This leads to  bingc cating for both biological (hunger) and psychological (setting rules for eating that  are too rigid and unrealistic) rcasons. Finally, vomiting and laxative abuse are attempts  to compensate for the binge eating to avoid weight gain. The vomiting induccs shamc  and only leads to more unhealthy attempts to diet—thereby perpetuating the problem.  
Melissa agreed that thc model accurately described what was happening to her  and understood that she would have to deal with her over-conccrn about body shape  and weight and change her unhealthy dieting to overcome BN. But she expressed her  reluctance to give up dieting. She worried that this would lead to weight gain—the thing  she feared most. In response to Dr. Jones's gentle guestioning, Melissa made clear her  ambivalence about change—shc wanted to stop binge eating and vomiting, but she  feared the potential consegnences associated with these changes. Dr. Jones empathized  with Melissa's conflict and asked her to complete the following homework assignment.  Melissa was to write down (1) the advantages and disadvantages of continuing to diet;  and (2) the corresponding advantages and disadvantages of stopping dysfunctional  dieting (see Wilson [2004] for details of this stratcgy for overcoming mbivalence).  
In the third session, Dr. Jones reviewed Melissa's self-monitoring and homework. She  had concluded that, on the whole, it was worth changing her dysfunctional behavior—the  advantages wcrc greater than the disadvantages. Dr. Jones then explained what needed to  be done to change dysfunctional dieting into healthy cating patterns. The first step would  be to eat regular meals—breakfast, lunch, and dinner, with planned snacks in the morning and afternoon. Melissa could still choose “safe” foods but needed to change her pattern  of skipping meals. Dr. Jones also asked Melissa to weigh herself no more than once a week  instead of weighing multiple times each day. Melissa expressed her concern that without  freguent daily weighing she wonld gain weighr. Dr. Jones suggested that Melissa think of  this task as an experiment—she was encouraged to try it for the next 2 weeks and see what  would happen to her weight. Melissa liked this idea and agreed to give it a try.  
1n the next two sessions the focus remained on Melissa self-monitoring, adopting a  regular cating pattern, and wcighing hcrsclf weekly. She was able to accomplish cach of  these goals. Her binge eating stopped and her depression score on the BDI that Dr. Jones  administered each session dropped significantly (BDI — 16). IIowever, Melissa was still  eating in a very restrictive fashion. She avoided so-called “forbidden” foods out of fear that  they would trigger binge cating. Dr. Jones encouraged her to try another cxperiment—one  
in which she planned to eat a “forbidden [ood” such as ice cream. She was to do this one  afternoon when she had not skipped breakfast or lunch, and when she felt good about  herself. Melissa was amazed to discover that she did not experience an urge to binge and  felt in control. The goal of this behavioral experiment was to show Melissa that she could  eat a wider range of foods than she previously believed without losing control.  
The focus in Sessions #6 and #7 remained on overcoming dysfunctional dieting.  Melissa was no longer binge eating, but she still occasionally resorted to vomiting as a  mcans of coping with negative feclings about hersclf. Based on her self-monitoring records,  it was clear that these occasions were typically triggered by conflicts with her boyfricnd.  
Tn Sessions 48 through 10, therapy focused on hclping Melissa to become more as sertive (see Alberti & Emmons, 2001) and not allow herself to be treated badly by her  boyfriend. She learned to express her feelings and to insist on being treated with respect.  This led to her lcaving her boyfriend and dating somconc clsc with whom she developed a  close and caring relationship. Her self-esteem increased, her mood improved (BDI = 6),  and she stopped vomiting.  
Despite her good progress, Melissa remained over-concerned about the importance of  her body shapc and wcight. She continued to “fecl fat” even though, objectively, she was  of normal weight. She constantly worried about her appearance and how people would  judge her. As is typical in BN, she constantly “body-checked,” such as pinching parts of  her body to see how fat she was and checking herself out in mirrors. She also avoided some  situations that would expose her body, such as wearing form-fitting clothes or a bikini at  the shore.  
Dr. Jones explained how important it was to stop this pathological body-checking  and body-avoidance. Over the course of Sessions 411 through 14, she encouraged  Melissa to try another behavioral experiment, namely, stopping all body-checking and  secing what cffect it would havc. Mclissa was afraid that by being less vigilant shc would  gain weight, just as she was previously worried about giving up weighing herself mul  
tiple times a day. To her surprise, she found that her weight remained stable and her  preoccupation with body weight diminished. Dr. Jones also encouraged her to combat  body-avoidance by wearing clothes she liked and by participating in fun social events.  
1n Sessions #13 and #14, Dr. Jones used a mindfulness-based procedure in which she  asked Melissa to stand in front of a full-size mirror. Her task was to observe and describe  her body, from her head to her toes, in a nonjudgmental fashion while staying in the pres ent (see Wilson, 2004). Initially Melissa found this task very upsetting—she was very judg mental and focused exclusively on her stomach and thighs, the areas she always worried  about. With practice, however, she was able to describe her whole body and “let go” of  negative [eelings without reacting to them. She learned to “distance” herself from thoughts  and feelings that she was fat and to say to herself that she was a normal-weight woman who  was often beset by thoughts that she was fat. She complemented this in-session mirror  cxposurc with homework assignments in which shc tried to adopt a mindful approach to looking at herself in a mirror. Shc used a mirror only for an agreed-upon purpose and  timc, and never in response to an urge to check her body because she “felt fat.” Melissa  became more accepting of her body shape and weight and happier with her life.  
Melissa's last two sessions focused on relapse prevention. With the help of Dr. Jones,  Melissa wrote up her own personal maintenance manual in which she summarized the im provements she had made, what she needed ro focus on in the furure, and what she would  do if she ever slipped and binged or vomited again. Therapy terminated with Melissa confi dent and prepared to maintain the improvement she had made in working with Dr. Jones.  


SUMMARY.  


Behavior therapy helped to change the face of psychotherapy in thc latter half of the  20th century by generating innovative treatment strategies and influencing how we con duct rescarch on psychological treatment. In turn, behavior therapy itself has changed  and continues to evolve. Its theoretical foundations have broadened and its trcatment  technigues have become more diverse. In the process, its overlaps with other systems  of psychothcrapy havc become more apparent. Nonetheless, it remains a distinctive ap proach to assessment and treatment.  
Methodological rigor and innovation have been major contributions of behavior  therapy to the field of psychotherapy. Behavioral treatments have been subjected to  more rigorous evaluation than any other psychological therapy.  
Behavior therapy faces rwo immediare challenges in the 21st century. One is the  need to improve the dissemination and adoption of demonstrably effective behavioral  treatments for a number oÍ common disorders. Although behavior therapy has become  an accepted part of the psychotherapeutic establishment, its methods are not bcing used  as widely as the evidence would warrant (Persons, 1997). As noted carlier in this chap  
ter, the growing demand for accountability in health care will provide an impetus for  more widespread application of behavioral methods.  
The evidence supporting behavior therapy comes mainly from well-controlled re search studics conducted at universities where therapists are carefully selected and highly  trained and patients are recruited specifically for the treatment studies. However, many  practitioners guestion the relevance of this type of research to actual clinical practice in  which they are confronted with a diverse mix of patients and varying clinical problems.  Encouragingly, an increasing emphasis on clinical research focused on evaluating the  gencralizability of the findings from tightly controlled, university-based research to dif ferent service settings such as mental health clinics and independent practice is showing  that the research findings are holding up in routine clinical practice.  
Another likely trend will be thc use of a stepped-care approach to treatment ser viccs. In a stepped-care framework, which is widely used in medicine, treatments are  provided sequentially according to need. Initially, all patients receive the lowest step—  the simplest, least intrusive, and most cost-effective treatment. More complex or inten sive interventions are administered to patients who do not respond to these initial cfforts.  To date, most behavior therapy treatments have been designed for use within specialist  scttings and reguire professional training. Relatively few therapists are sufficiently well  trained in these specialized, manual-based treatments (Wilson, 1998). Morcovcr, there  are unlikely ever to be sufficient specialist trcatment resources for all patients. Briefer  and simpler mcthods that can be used by a wide range of different mental health profes sionals are needed. 1t will be challenging but critical to identify reliable predictors of  patients for whom these cost-effective methods are appropriate.  
'The second major challenge confronting bchavior therapy is thc nced to develop  more effective treatments for a broader range of problems. At present, even the most effective treatments arc often not good cnough. ical rcscarchcrs and practitioners  nced to cooperate ín devising innovative and improved methods for treating patients  who do not respond to the best available treatments.  
Whereas considerable progress has been made in developing effectivc treatments,  thc ficld has lagged bchind in understanding how these treatments achieve their thera  peutic effects. We need to learn more about the mechanisms of therapeutic change. Un derstanding the mechanisms through which behavior therapy methods operate is vital to  the development of innovative and more potent interventions. With respect to current  manual-bascd trcatments, active therapeutic procedures could be enhanced and inactive  elements discarded. Theory-driven, experimenral analysis of therapy ourcome and its  mechanisms of action is a priority for future research.  
Finally, to fulíill its original promise o linking clinical practice to advances in sci entific research, behavior therapy must be responsive to developments both in experi mental psychology and in biology. Dramatic breakthroughs in genetics and ncuroscience  have already revolutionized the biological sciences. Progress will continue in unlock  ing the secrets of the brain. A better understanding of the role of brain mechanisms in  the development and maintenance of clinical disorders will lead to better theories and  thcrapics for bchavior change.  


ANNOTATED BIBLIOGRAPHY  


Barlow, D. H. (Ed.). (2008), Clinical bandbook of psychalogical  disorders (4th ed.). New York: Guilford Press. 
 
'This edited volume provides detailed clinical descriptions of the cognitive-behavioral treatment of several adult clin ical disorders. A particularly informative feature is the ex tensive use of transcripts from actual therapy sessions with individual paticnts.  


Linehan, M. M., & Dexter-Mazza, E. T. (2008). Dialecti- cal behavior therapy for borderline personality dis- order. In Barlow, D. H. (Ed.), Clinical bandbook of psychological disorders: A step-by-step treatment manual  
(4th ed.). (pp. 365—420). New York: Guilford Press. 


This chapter is an excellent introduction to the practice of dialectical behavior therapy (DBT). 
 
Luoma, J. B., Hayes, S. C. & Walser, R. D. (2007). Learning ACT: An acceptance and commitment therapy skills-training manual for therapists. Oakland, CA: New Harbinger  Publications.  


This skills manual is a good introduction to acceptance  and commitment therapy that will introduce you to the  thcory and practice of ACT; an accompanying DVD offers role-played examples of core ACT methods.  


Martell, C., Addis, M., & Jacobson, N. S. (2001). Depression  in context. New York: Norton.  


This volume provides a detailed and very practical de- scription of thc clinical application of bchavioral activation  (BA) treatment for depression. Informative clinical illus trations are used to highlight differences between BA and cognitive therapy.  


Roemcr, L., & Orsillo, S. M. (2009). Mindfulness- and acceptance- based bebavioral therapies in practice. New York: Guilford. 


'This book present a synthesis of several of the mindfulness and acceptance-based behavioral therapies, including accep- tance and commitment therapy, mindfulness-based cognitive  therapy, mindfulness-based relapse prevention, integrative bchavioral couple therapy, and dialccrical bchavior therapy. The aurhors propose n general model that involves three related mechanisms: a maladaptive relationship to internal experience (such as fusion, judgment, and/or lack of awarc ness), experiential avoidance, and behavioral constriction.  




CASE READINGS  


Barlow, D. (1993). Covert sensitization for paraphilia. In J.R. Cautcla, A.J. Kearncy, L. Ascher, A. Keamcy, & M. Kleinman. (Eds.), Covert conditioning casebook (pp. 188-197). Pacific Grove, CA: Cengage Learning. [Reprinted in D. Wedding & R. J. Corsini (Lds.), (2011). Case studies in psychotberapy.  Belmont, CA: Brooks/Cole.]  


This is a detailed case that demonstrares the use of co vert sensitization in the treatment of a deeply troubled minister.  


Bond, T. W. (2004). ACT for stress. In S. C. Hayes and K. Strosabl (Eds), A practical guide to acceptance and commitment  therapy (pp. 275-294). New York: Springer.  


This chapter provides a detailed account of clinical case conceprualization and application of techniques in the use  ol ACT for common stress-related problems.  


Craske, M. G., & Barlow, D. H. (2001). Panic disorder and  agoraphobia. In D. H. Barlow (Ed.), Clinical handbook
256 G. TERENCE WILSON  of psychological disorders (3rd ed., pp. 1-59). New York:  Guilford Press.  


This chapter provides a detailed clinical case illustrarion,  with therapist-patient dialogue, of DBT in the treatment of panic disorder.  


Foa, E. B., & Franklin, M. E. (2001). Obsessive-compnlsive  disorder. In D. II. Batlow (Ed.), Clinical bandbook of psycho logical disorders (3rd ed., pp. 209-263). New York: Guilford  Press.  


This chapter provides a detailed clinical case illustration,  with thcrapist-patient dialogue, of DBT in the treatment of obsessive-compulsive disorder.  


Linehau, M. M., Cochran, B. N., & Kehrer, C. A. (2001). Dia- lectical behavior therapy for Borderline Personality Disorder. In D. IL Barlow (Ed.), Clinical handbook of psycbological dis- arders: A step-hy-step treatment manual Grd ed., pp. 470-522). New York: Guilford Press  


This chapter provides a detailed clinical case illustration, with therapist-parient dialoguc, of DBT in the treatment of borderline personality disorder.  


Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depres.  sïon in context. New York: Norton.  


Chapter 8 provides explicit clinical cxamples of the application of behavioral activation treatment for depression  


Wilson, G. T., & Pikc, K. (2001). Eating disorders. In D. H. Batlow (Ed.), Clinical handbook of psychological disorders (31d ed.). New York: Guilford Press.  


This chapter provides an in-depth illustration of the trcat ment of a female patient with bulimia ncrvosa, an cating disorder that is common among college-aged and young  adulr women  


Wolf, M. M., Risley, T., & Mees, H. (1965). Application of op- erant condirioning procedures to the behavior problems of an autistic child. In L. P. Ullmann & L. Krasner (Eds.), Case stud- ies in bebavior modification (pp. 138-145). New York: Holt, Rinchart and Winston.  


This classic case study illustrates the application of operant  principles and procedures to the treatment of an autistic  child. The assessment and trcatmcnt approach described  here provide a modcl for the use of behavioral methods  with a wide range ol problems among rhe developmentally disabled.  


Wolpe, J. (1991). A complex: case. The practice of bebavior therapy (4th ed.). New York: Pergamon. [Reprinted in D. Wedding & R. ). Corsini (Eds.). (1995). Case studies in psycbotberapy. ltasca, IL: F. F, Pencock.]  


This case study describes the way onc of the founders of behavior therapy treated a 31-year old man who presented with symptoms of anxiety and au obsession about his wifc’s premarital loss of virginity.