Traditional Techniques

of Behavior therapy

Before we discuss specific behavior therapy

techniques, let us note both the importance of the
therapeutic relationship and the tendency of
modern behavior therapists to use multiple
techniques with the same patient.

The relationship
Relationship is a contributing factor in the success of behavior
therapists therapeutic methods.

In Wolpes (1958) accounts of systematic desensitization, we find

that the therapist is exhorted to adopt an attitude of acceptance
toward patients, to explain their difficulties to them, and to make
clear the behavioral rationale for treatment.

In fact, there are data that indicate clients perceive relationship

factors to be very important to successful behavior therapy and CBT
outcome, similar to clients perceptions concerning other forms of
psychotherapy (Sloane, Staples, Cristol, Yorkston, & Whipple,
1975a).

Behavior therapists may be experienced as more open

and accepting of the clients; treatment is
collaborative and more educational in style; and
interventions are clearly linked to the problematic
behaviors that have been targeted for change by the
client and therapist (Spiegler & Guevremont, 2010).

One can never afford to ignore aspects of the relationship as

contributors to successful therapeutic intervention. After all, it is
through the therapy relationship that the patients expectations of
help can be nurtured so that behavioral therapy will be accepted as
a viable alternative (Goldfried & Davison, 1994; Spiegler &
Guevremont, 2010).

o Behavior therapy is not going to be

successful if the patient expects it to fail or is
otherwise antagonistic toward it.
-Behavior therapists have sometimes been
said to be cold and mechanistic in their
approach to patients. This is probably more
myth or stereotype than fact. Indeed, Sloane
et al. (1975a) found that behavior therapists
were generally warmer and more empathic
than other psychotherapists!

Broad Spectrum of Treatment

Behavior therapists use a variety of specific techniquesnot only for different
patients but for the same patient at different points in the overall treatment
process. Lazarus (1971a) refers to this as broad spectrum behavior therapy.
Specific techniques in behavior therapy can serve a specific purpose
but that, in reality, they are complementary.

For example, a woman who has trouble coping with a domineering husband
may undergo assertiveness training to learn specific behaviors. But when
she uses these behaviors, other sets of fears about their relationship may
begin to worry her. Therefore, she may also require therapeutic sessions
that will help her restructure her beliefs about the marriage that are
illogical and tend to perpetuate her submissive behavior. She might also
participate in modeling or observational learning to help her cope.

o A comprehensive behavioral assessment is conducted

before behavioral treatments or techniques are selected
and implemented.
For example, a functional analysis of the presenting
problem helps to identify (a) the stimulus or antecedent
conditions that bring on the problematic behavior; (b)
the organismic variables (e.g., cognitive biases) that are
related to the problematic behavior; (c) the exact
description of the problem; and (d) the consequences of
the problematic behavior. By completing such a detailed
analysis, behavior and cognitive behavioral therapists
can prescribe appropriate treatments.

Systematic Desensitization

o This technique is typically applied when a patient has the capacity

to respond adequately to a particular situation (or class of
situations), yet reacts with anxiety, fear, or avoidance. Basically,
systematic desensitization is a technique to reduce anxiety.

o Developed by Salter (1949) and Wolpe (1958), it is based on

reciprocal inhibitionthe apparently simple principle that one
cannot be relaxed and anxious simultaneously. The idea is to
teach patients to relax and then, while they are in the relaxed
state, to introduce a gradually increasing series of anxiety
producing stimuli. Eventually, the patient becomes desensitized to
the feared stimuli by virtue of having experienced them in a
relaxed state.
o Systematic desensitization has been shown efficacious for animal
phobias, public speaking anxiety, and social anxiety (Chambless
et al., 1998; Chambless & Ollendick, 2001; Spiegler &
Guevremont, 2010).

Technique and Procedures

o Systematic desensitization begins with the collection of a
history of the patients problem. The principal reason for all
of this is to pinpoint the locus of the patients anxiety. It is
also part of assessment to determine whether systematic
desensitization is the proper treatment.
o Next, the problem is explained to the patient.
o The next two phases involve training in relaxation and the
establishment of an anxiety hierarchy. While work is begun
on the anxiety hierarchy, training in relaxation is also started.

Technique and Procedures

o Relaxation. Behavior therapists frequently use the progressive relaxation
methods of Jacobson (1938). The patient is first taught to tense and relax
particular muscle groups and then to distinguish between sensations of
relaxation and tensing
o Generally, about six sessions are devoted to relaxation training. In some
instances, hypnosis may be used to induce relaxation. More commonly, the
patient may be asked to imagine relaxing scenes and/or breathing exercises
are used to enhance relaxation.

Technique and Procedures

o

The Anxiety Hierarchy. In discussions about specific

problems, the situations in which they occur, and their
development, the patient and the therapist work together to
construct a hierarchy.

A typical anxiety hierarchy consists of 20 to 25 items in

approximately equal intervals from low through moderate to
extreme.

Technique and Procedures

The following anxiety hierarchy was that of a 24-year-old female student who
experienced severe examination anxiety (Wolpe, 1973):
1. Four days before an examination.
2. Three days before an examination.
3. Two days before an examination.
4. One day before an examination.
5. The night before an examination.
6. The examination paper lies face down before her.
7. Awaiting the distribution of examination papers.
8. Before the unopened doors of the examination room.
9. In the process of answering an examination paper.
10. On the way to the university on the day of the examination.

Technique and Procedures

o This hierarchy illustrates two points. First, it is organized largely
along spatial-temporal lines. Second, the items are not exactly
organized in a logical fashion.
o In the desensitization procedure, the patient is asked to imagine
the weakest item in the hierarchy (the item that provokes the
least anxiety) while being completely relaxed. The therapist
describes the scene, and the patient imagines (for about 10
seconds) being in the scene. The therapist moves the patient up
the hierarchy gradually (between two and five items per
session).

Technique and Procedures

o However, if at any time the level of anxiety begins to increase, the patient is
instructed to signal, whereupon the therapist requests that the patient stop
visualizing that scene. The therapist then helps the patient to relax once more.
After a few minutes, the procedure can be started again. Ideally, over a period of
several sessions, the patient will be able to imagine the highest item in the
hierarchy without discomfort.

Technique and Procedures

o

A typical example of the instructions given to a male patient

during desensitization is provided by Goldfried and Davison
(1994):

(The client has been relaxing on his own in the reclining chair.) OK,
now just keep relaxing like that, nice and calm and comfortable. You
may find it helpful to imagine a scene that is personally calm and
relaxing, something well refer to as your pleasant scene. Fine.
Now, you recall that 0 to 100 scale weve been using in your
relaxation practice, where 0 indicates complete relaxation and 100
maximum tension. Tell me approximately where youd place yourself
on that scale. (Therapist is advised to look for a rating that reflects
considerable calm and relaxation, often in the range of 15 to 25.)

Technique and Procedures

Fine. Soon I shall ask you to imagine a scene. After you hear the description of
the situation, please imagine it as vividly as you can, through your own eyes,
as if you were actually there. Try to include all the details in the scene. While
youre visualizing the situation, you may continue feeling as relaxed as you are
now. If so, thats good. After 5, 10, or 15 seconds, Ill ask you to stop imagining
the scene and return to your pleasant image and to just relax. But if you begin
to feel even the slightest increase in anxiety or tension, please signal this to
me
by raising your left forefinger. When you do this, Ill step in and ask you to stop
imagining the situation and then will help you get relaxed once more. Its
important that you indicate tension to me in this way, as we want to maximize
your being exposed to fearful situations without feeling anxious. OK? Do you
have any questions? Fine, well have ample opportunity afterwards to
discuss things in full.

Rationale
o Wolpes explanation for the success of systematic desensitization is
based on the principle of counterconditioning (the substitution of
relaxation for anxiety), others are not so sure (Davison & Wilson,
1973). Some have argued that the operative process is really
extinction. That is, when the patient repeatedly visualizes anxietygenerating situations but without ensuing bad experiences, the
anxiety responses are eventually extinguished (Wilson & Davison,
1971).
o Alternatively, Mathews (1971) argues on behalf of a habituation
hypothesis. Finally, some suggest that cognitive factors may be
responsible for the beneficial effects of systematic desensitization

Rationale
o The standard method of desensitization is to present scenes in a graduated
ascending fashion to avoid premature arousal of anxiety that would disrupt
the procedure.
o Consequently, the patients expectations for improvement may affect the
process. Another crucial element may be positive reinforcement from the
therapist following the patients reports of reduced anxiety, improvement
outside the consulting room, or the successful completion of anxiety
hierarchies.
o Goldfried (1971) regards systematic desensitization as training in selfcontrol.

Rationale
o In general, systematic desensitization has proven to be a
moderately useful form of psychological intervention for a variety of
clinical conditions. As might be expected, research suggests that it
is most effective when used to treat anxiety disorders, particularly
specific phobias, social anxiety, public speaking anxiety, and
generalized anxiety disorder.

Exposure Therapy

o The term exposure therapy describes a behavior therapy

technique that is a refinement of a set of procedures originally
known as flooding or implosion.

o In exposure therapy, patients expose themselves to stimuli or

situations that were previously feared and avoided. The
exposure can be in real life (in vivo) or in fantasy (in imagino).
In the latter version, patients are asked to imagine themselves in
the presence of the feared stimulus (e.g., a spider) or in the
anxiety-provoking situation (e.g., speaking in front of an
audience).

Several researchers suggest that certain features must be present in exposure

treatments for the patient to achieve maximum benefit (Barlow & Cerny,
1988):
1. Exposure should be of long rather than short duration.
2. Exposure should be repeated until all fear/anxiety is eliminated.
3. Exposure should be graduated, starting with low-anxiety
stimuli/situations and progressing to high-anxiety stimuli/situations.
4. Patients must attend to the feared stimulus and interact with
it as much as possible.
5. Exposure must provoke anxiety.

o Exposure treatment can be used as a self-contained treatment or as one

component of a multimodal treatment.
o For example, Barlow and Cerny (1988) describe a psychological treatment
for panic disorder that includes relaxation, cognitive restructuring, and
exposure components. They have patients expose themselves to interoceptive
cuesinternal physiological stimuli such as rapid breathing and dizziness.
o This modification was necessary because individuals suffering from panic
disorder typically report that their panic attacks are unpredictable and
come out of the blue. In such cases, no external anxiety-provoking
stimulus or situation is apparent.
o In contrast, individuals with other non-panic anxiety disorders report acute
anxiety primarily in the face of certain external stimuli or situations.

o Craske, Rowe, Lewin, and Noriega-Dimitri (1997) compared the

effectiveness of two forms of treatment for panic disorder with
agoraphobiaone that included interoceptive exposure and
one that incorporated breathing retraining instead of
interoceptive exposure. Although both forms of treatment were
effective, results indicated that panic disorder patients who
received the interoceptive exposure component reported less
impairment and fewer panic attacks at posttreatment and at
follow-up. Thus, the addition of the interoceptive exposure
component had some beneficial effects.

Another example of an exposure based empirically supported treatment:

Foa (1996) provides an overview of a typical exposure plus response
prevention treatment for OCD:
1. Fifteen 2-hour exposure sessions are conducted over the course of three
weeks.
2. During these sessions, patients are exposed to the situations or objects
that seem to trigger the obsessions. For example, a patient who obsesses
about dirt and germs might be asked to rub newspaper print all over his arms
and face.
3. In addition, patients are asked to imagine that the tragic consequences they
anticipate occurring if they do not engage in compulsive behavior did
occur. In this way, patients can begin thinking about these catastrophes
without being markedly fearful.
4. Homework is assigned and involves repeating these exposure experiences.

5. At the same time that exposure is introduced, the therapist

ensures that ritualistic compulsions that typically occur in the face
of the obsessional fear do not occur. For example, the patient who
obsesses about dirt and germs and engages in excessive hand
washing or showering would not be allowed to engage in these
behaviors. At a later point in time, normal hand washing and
showering will be introduced.
6. Finally, a maintenance phase of treatment involves about ten
office visits or phone calls aimed at encouraging the patient and
reinforcing the therapeutic gains.
o Exposure plus response prevention is the most successful
psychological treatment for obsessive compulsive disorder
(Emmelkamp, 2004; Rosa-Alcazar et al., 2008).

Behavior Rehearsal
The Technique. According to Goldfried and Davison (1994), the use of
behavior rehearsal involves four stages.
o

The first stage is to prepare the patient by explaining the necessity for
acquiring new behaviors, getting the patient to accept behavior rehearsal
as a useful device, and reducing any initial anxiety over the prospect of
role-playing.

o.

The second stage involves the selection of target situations. At this point,
many therapists will draw up a hierarchy of role-playing or rehearsal
situations.

Behavior Rehearsal
o A sample hierarchy of target situations:
1. You ask a secretary for information about a class.
2. You ask a student in class about last weeks assignment.
3. After class, you approach the instructor with a question about
the lecture.
4. You go to the instructors office and engage her in conversation
about a certain point.
5. You purposely engage another student, who you know
disagrees with you, in a minor debate about some issue.

Behavior Rehearsal
o The third stage is the actual behavior rehearsal. Moving up the hierarchy,
the patient plays the appropriate roles, with the therapist providing both
coaching and feedback regarding the adequacy of the patients
performance.
o The final stage is the patients actual utilization of newly acquired skills in
real-life situations. After such in vivo experiences, the patient and the
therapist discuss the patients performance and feelings about the
experiences.

Behavior Rehearsal
Assertiveness Training. One application of behavioral rehearsal
is assertiveness training. Wolpe regarded assertive responses as
an example of how reciprocal inhibition works. That is, it is
impossible to behave assertively and to be passive simultaneously.
o But assertiveness training has also been used in treating
sexual problems, depression, and marital conflicts. It is
important to note that cognitive self-statements (e.g., I was
thinking that I am perfectly free to say no) may enhance the
effects of assertiveness training. In fact, many procedures can
be used to increase assertiveness. Behavior rehearsal is
perhaps the most obvious one.

Behavior Rehearsal
Lack of assertiveness may stem from a variety of sources:
o The cause may be a simple lack of information, in which case the treatment
might center largely on providing information.
o In other instances, a kind of anticipatory anxiety may prevent persons from
behaving assertively. In such cases, the treatment may involve
desensitization.
o Other individuals may have unrealistic (negative) expectations about what
will ensue if they become assertive. Some clinicians would deal with such
expectations through interpretation or rational-emotive techniques.
Similar techniques might be applied to patients who feel that assertiveness is
wrong.

Behavior Rehearsal
o Finally, there are patients whose lack of assertiveness involves
a behavioral deficitthey do not know how to behave
assertively. For such patients, behavior rehearsal, modeling,
and related procedures would be used.
o Assertiveness training is not the same as trying to teach
people to be aggressive. It is really a method of training people
to express how they feel without trampling on the rights of
others in the process (Wolpe & Lazarus, 1966).

Contingency Management

A variety of Skinnerian or operant techniques are all referred to as

contingency management procedures. They share the common goal
of controlling behavior by manipulating its consequences. Because
many children are brought by their parents to receive psychological
treatment, particularly for acting-out or rule-breaking behavior,
contingency management techniques are used very commonly with
child and adolescent patients.

Techniques
o

Shaping: A desired behavior is developed by first rewarding any

behavior that approximates it. Gradually, through selective
reinforcement of behavior more and more closely resembling
the desired behavior, the final behavior is shaped. This
technique is sometimes called successive approximation.

Time-out: Undesirable behavior is extinguished by removing

the person temporarily from a situation in which that behavior
is reinforced. A child who disrupts the class is removed so that
the disruptive behavior cannot be reinforced by the attention of
others.

Techniques
o Contingency contracting: A formal agreement or contract is struck between
therapist and patient, specifying the consequences of certain behaviors on
the part of both.
o Grandmas rule: The basic idea is akin to Grandmas exhortation, First you
work, then you play! It means that a desired activity is reinforced by
allowing the individual the privilege of engaging in a more attractive
behavior. For example, the child is allowed to play ball after homework is
completed. This
method is sometimes referred to as the Premack principle (Premack, 1959).

Token Economies
In establishing a token economy, there are three major
considerations (Krasner, 1971):
o First, there must be a clear and careful specification of the
desirable behaviors that will be reinforced.
o Second, a clearly defined reinforcer (or medium of exchange
e.g., colored poker chips, cards, or coins) must be decided
upon.
o Third, backup reinforcers are established.

Token Economies
o Token economies are used to promote desired behavior through the control
of reinforcements.
o Tokens are used because the effect of reinforcement is greater if the
reinforcement occurs immediately after the behavior occurs.

Aversion Therapy

Aversion therapy consists, operationally, of administering an aversive

stimulus to inhibit an unwanted emotional response, thereby
diminishing its habit strength (Wolpe, 1973).

Aversion Therapy
o An unpleasant stimulus is placed in temporal contiguity with the
undesirable behavior. The idea is that a permanent association
between the undesirable behavior and the unpleasant stimulus will be
forged, and conditioning will take place.
o Aversion therapy techniques have been around for eons, often in the
form of such unsophisticated practices as spanking, Go to your room,
and No TV tonight for you. Modern aversive therapy techniques differ
from these examples in at least two important ways. First, the
presentation of the aversive agent is done systematically. The
temporal contiguity is very carefully monitored. Second, the
punishment is consistently applied.

Aversive Agents
o Among the aversive agents that have been used most frequently are
electrical stimulation and drugs.
o For example, strong emetic drugs have been used aversively for many years
(see, e.g., Voegtlin & Lemere, 1942), especially in the treatment of
alcoholism. The patient is given a drug that produces nausea or vomiting
and then takes a drink (or the drug may be mixed with the drink). The
patient soon becomes ill. This combination of alcohol and emetic is given for
a week to 10 days. Eventually, just the sight of a drink is sufficient to induce
nausea and discomfort.
o Wolpe (1973) has described a variety of other aversive agents, including
holding ones breath, stale cigarette smoke, vile-smelling solutions of
asafetida, intense illumination, white noise, and shame. Clearly, the range of
potential aversive agents is limited only by the imagination of resourceful

Covert Sensitization
o Cautela (1967) developed a set of procedures, known as covert
sensitization, that rely on imagery rather than the actual use of
punishment, drugs, or stimulation.
o Patients are asked to imagine themselves engaging in the behaviors
they wish to eliminate. Once they have the undesired behaviors clearly
in mind, they are instructed to imagine extremely aversive events.
Some of the instructions are vivid to say the least. A rather mild
example from the treatment of a case of overeating should suffice: As
you touch the fork, you can feel food particles inching up your throat.
Youre just about to vomit (Cautela, 1967, p. 462). The ensuing
descriptions become more graphic.

Other Techniques
o Response cost is a technique in which positive reinforcers (e.g., tokens in a
token economy system) are removed following an undesired response (e.g.,
a temper tantrum) made by a patient (Spiegler & Guevremont, 2010).
o Another technique is called overcorrection. Here, the idea is that having the
patient or client overcorrect the consequences of an act will make the
behavior less likely to recur (Spiegler & Guevremont, 2010).

Second Thoughts
Prominent behaviorists (e.g. Skinner) have questioned the effectiveness of
punishment in influencing and controlling behavior, and many clinicians
have de-emphasized aversion methods in their behavioral therapy
approaches.
o Lazarus (1971a), for example, stated that the building of better
response repertoires and the reduction of anxiety produce longerlasting results than do aversion techniques.
o Many critics, both within and without the behavior therapy movement,
have been highly critical of aversion therapy. The concentration on
punishment and the use of what are sometimes terrifying stimuli often
seem totally incompatible with human dignity. Whether or not patients
present themselves voluntarily for treatment is beside the point.

Second Thoughts
o Others, however, maintain that aversive techniques, used in a sensitive
fashion by reputable professionals, have real merit. Most often, aversive
techniques are used after everything else has failed.
o Furthermore, patients are not dragged kicking and screaming into the
situation. Usually, the procedures are applied to people who have seriously
debilitating problems (alcoholism, excessive smoking, sexual deviations) and
who are in despair because nothing else has worked.

Second Thoughts
o Spiegler and Guevremont (2010) remind us to keep several additional
points in mind as we are evaluating the ethics of aversion therapy: (a)
The aversive stimulus is of relatively brief duration and does not have
long lasting effect; and (b) clients are not required to engage in this
treatment but do so by choice. Such people voluntarily undertake
aversion therapy as the lesser evilin the same spirit, perhaps, that
one submits yearly to that terrifying torture at the hands of a friendly
dentist.

Reference
Clinical Psychology by Trull and Prinstein

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