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  • COGNITIVE BEHAVIOR THERAPYApplying Empirically Supported Techniques in Your Practice Second Edition Edited by William O’Donohue Jane E. Fisher John Wiley & Sons, Inc.
  • This book is printed on acid-free paper.Copyright  2008 by John Wiley & Sons, Inc. All rights reserved.Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by anymeans, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted underSection 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of thePublisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center,Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750–8400, fax (978) 676–8600, or on the web atwww.copyright.com. Requests to the Publisher for permission should be addressed to the PermissionsDepartment, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748–6011, fax (201) 748–6008.Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts inpreparing this book, they make no representations or warranties with respect to the accuracy or completeness ofthe contents of this book and specifically disclaim any implied warranties of merchantability or fitness for aparticular purpose. No warranty may be created or extended by sales representatives or written sales materials.The advice and strategies contained herein may not be suitable for your situation. You should consult with aprofessional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any othercommercial damages, including but not limited to special, incidental, consequential, or other damages.This publication is designed to provide accurate and authoritative information in regard to the subject mattercovered. It is sold with the understanding that the publisher is not engaged in rendering professional services. Iflegal, accounting, medical, psychological or any other expert assistance is required, the services of a competentprofessional person should be sought.Designations used by companies to distinguish their products are often claimed as trademarks. In all instanceswhere John Wiley & Sons, Inc. is aware of a claim, the product names appear in initial capital or all capital letters.Readers, however, should contact the appropriate companies for more complete information regardingtrademarks and registration.For general information on our other products and services please contact our Customer Care Department withinthe U.S. at (800) 762–2974, outside the United States at (317) 572–3993 or fax (317) 572–4002.Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not beavailable in electronic books. For more information about Wiley products, visit our website at www.wiley.com.Library of Congress Cataloging-in-Publication Data:Cognitive behavior therapy : applying empirically supported techniques in your practice / edited by WilliamO’Donohue, Jane E. Fisher.–2nd ed. p. ; cm.Includes bibliographical references and indexes.ISBN 978-0-470-22778-7 (cloth : alk. paper)1. Cognitive therapy. I. O’Donohue, William T. II. Fisher, Jane E. (Jane Ellen), 1957-[DNLM: 1. Cognitive Therapy–methods. 2. Mental Disorders–therapy. WM 425.5.C6 C67677 2009]RC489.C63C6277 2009616.89’1425–dc22 2008026325Printed in the United States of America.10 9 8 7 6 5 4 3 2 1
  • CONTENTS Preface xiii Acknowledgments xv Contributors xvii1 Introduction 1 William O’Donohue and Jane E. Fisher2 Psychological Acceptance 4 James D. Herbert, Evan M. Forman, and Erica L. England3 Anger (Negative Impulse) Control 17 Brad Donohue, Kendra Tracy, and Suzanne Gorney4 Assertiveness Skills and the Management of Related Factors 26 Melanie P. Duckworth5 Attribution Change 35 Rebecca S. Laird and Gerald I. Metalsky6 Behavioral Activation for Depression 40 Christopher R. Martell7 Response Chaining 46 W. Larry Williams and Eric Burkholder8 Behavioral Contracting 53 Ramona Houmanfar, Kristen A. Maglieri, Horacio R. Roman, and Todd A. Ward9 Bibliotherapy Utilizing CBT 60 Negar Nicole Jacobs v
  • vi CONTENTS10 Breathing Retraining and Diaphragmatic Breathing Techniques 68 Holly Hazlett-Stevens and Michelle G. Craske11 Classroom Management 75 Steven G. Little and Angeleque Akin-Little12 Cognitive Defusion 83 Jason B. Luoma and Steven C.Hayes13 Cognitive Restructuring of the Disputing of Irrational Beliefs 91 Albert Ellis14 Cognitive Restructuring: Behavioral Tests of Negative Cognitions 96 Keith S. Dobson and Kate E. Hamilton15 Communication/Problem-Solving Skills Training 101 Pamella H. Oliver and Gayla Margolin16 Compliance with Medical Regimens 109 Elaine M. Heiby and Maxwell R. Frank17 Contingency Management Interventions 116 Claudia Drossel, Christina G. Garrison-Diehn, and Jane E. Fisher18 Daily Behavior Report Cards: Home–School Contingency Management Procedures 123 Mary Lou Kelley and Jennette L. Palcic19 Dialectics in Cognitive and Behavior Therapy 132 Armida Rubio Fruzzetti and Alan E. Fruzzetti20 Differential Reinforcement of Low-Rate Behavior 142 Mark Alavosius, Joseph Dagen, and William D. Newsome21 Differential Reinforcement of Other Behavior and Differential Reinforcement of Alternative Behavior 147 Michele D. Wallace and Adel C. Najdowski22 Directed Masturbation: a Treatment of Female Orgasmic Disorder 158 Stephanie Both and Ellen Laan
  • CONTENTS vii23 Distress Tolerance 167 Michael P. Twohig and Katherine A. Peterson24 Emotion Regulation 174 Alan E. Fruzzetti, Wendy Crook, Karen M. Erikson, Jung Eun Lee, and John M. Worrall25 Encopresis: Biobehavioral Treatment 187 Patrick C. Friman, Jennifer Resetar, and Kim DeRuyk26 Expressive Writing 197 Jenna L.Baddeley and James W. Pennebaker27 Flooding 202 Lori A. Zoellner, Jonathan S. Abramowitz, Sally A. Moore, and David M. Slagle28 Experimental Functional Analysis of Problem Behavior 211 James E. Carr, Linda A. LeBlanc, and Jessa R. Love29 Functional Communication Training to Treat Challenging Behavior 222 V. Mark Durand and Eileen Merges30 Functional Self-Instruction Training to Promote Generalized Learning 230 Frank R. Rusch and DouglasKostewicz31 Group Interventions 236 Claudia Drossel32 Habit Reversal Training 245 Amanda Nicolson Adams, Mark A. Adams, and Raymond G. Miltenberger33 Harm Reduction 253 Arthur W. Blume and G. Alan Marlatt34 Putting It on the Street: Homework in Cognitive Behavioral Therapy 260 Patricia Robinson35 The Prolonged CS Exposure Techniques of Implosive (Flooding) Therapy 272 Donald J. Levis
  • viii CONTENTS36 Cognitive Behavioral Treatment of Insomnia 283 Wilfred R. Pigeon and Michael L. Perlis37 Interoceptive Exposure for Panic Disorder 296 John P. Forsyth, Tiffany Fus´ , and Dean T. Acheson e38 Live (In Vivo) Exposure 309 Holly Hazlett-Stevens and Michelle G. Craske39 Applications of the Matching Law 317 John C. Borrero, Michelle A. Frank, and Nicole L. Hausman40 Mindfulness Practice 327 Sona Dimidjian and Marsha M. Linehan41 Moderate Drinking Training for Problem Drinkers 337 Frederick Rotgers42 Multimodal Behavior Therapy 342 Arnold A. Lazarus43 Positive Psychology: A Behavioral Conceptualization and Application to Contemporary Behavior Therapy 347 Alyssa H. Kalata and Amy E. Naugle44 Motivational Interviewing 357 Eric R. Levensky, Brian C. Kersh, Lavina L. Cavasos, and J. Annette Brooks45 Noncontingent Reinforcement as a Treatment for Problem Behavior 367 Timothy R. Vollmer and Carrie S. W. Borrero46 Pain Management 375 Robert J. Gatchel and Richard C. Robinson47 Parent Training 383 Kevin J. Moore and Gerald R. Patterson48 Self-Efficacy Interventions: Guided Mastery Therapy 390 Walter D. Scott and Daniel Cervone
  • CONTENTS ix49 Positive Attention 396 Stephen R. Boggs and Sheila M. Eyberg50 Problem-Solving Therapy 402 Arthur M. Nezu, Christine Maguth Nezu, and Mary McMurran51 Punishment 408 David P. Wacker, Jay Harding, Wendy Berg, Linda J. Cooper-Brown, and Anjali Barretto52 Rapid Smoking 415 Elizabeth V. Gifford and Deacon Shoenberger53 Relapse Prevention 422 Kirk A. B. Newring, Tamara M. Loverich, Cathi D. Harris, and Jennifer Wheeler54 Relaxation 434 Kyle E. Ferguson and Rachel E. Sgambati55 Response Prevention 445 Martin E. Franklin, Deborah A. Ledley and Edna B. Foa56 Satiation Therapy 452 CrissaDraper57 Identifying and Modifying Maladaptive Schemas 457 Cory F. Newman58 Self-Management 466 Lynn P. Rehm and Jennifer H. Adams59 Safety Training/Violence Prevention Using the SafeCare Parent Training Model 473 Daniel J. Whitaker, Dan Crimmins, Anna Edwards, and John R. Lutzker60 Self-Monitoring as a Treatment Vehicle 478 Kathryn L. Humphreys, Brian P. Marx, and Jennifer M. Lexington61 Sensate Focus 486 Lisa Regev and Joel Schmidt
  • x CONTENTS62 Shaping 493 Kyle E. Ferguson and Kim Christiansen63 Social Skills Training 502 Chris Segrin64 Squeeze Technique for the Treatment of Premature Ejaculation 510 Claudia Avina65 Stimulus Control 516 Alan Poling and Scott T. Gaynor66 Stimulus Preference Assessment 523 Jane E. Fisher, Jeffrey A. Buchanan, and Stacey Cherup-Leslie67 Stress Inoculation Training 529 Donald Meichenbaum68 Stress Management Intervention 533 Victoria E. Mercer69 Systematic Desensitization 542 Lara S. Head and Alan M. Gross70 Think-Aloud Techniques 550 Gerald C. Davison, Jennifer L. Best, and Marat Zanov71 Time-Out, Time-In, and Task-Based Grounding 557 Patrick C. Friman72 Guidelines for Developing and Managing a Token Economy 565 Patrick M. Ghezzi, Ginger R. Wilson, Rachel S. F. Tarbox, and Kenneth R. MacAleese73 Urge Surfing 571 Andy Lloyd74 Validation Principles and Strategies 576 Kelly Koerner and Marsha M. Linehan
  • CONTENTS xi75 Values Clarification 583 Michael P. Twohig and Jesse M. Crosby Author Index 589 Subject Index 623
  • PREFACEOver the last three decades there has been a significant increase in interest in cognitive behaviortherapy. This has occurred for several reasons: 1) Mounting experimental evidence supports theeffectiveness of cognitive behavioral therapy for certain psychological problems induding highincidence problems such as depression and the anxiety disorders. The well-known Chambless report,for example, identifies many cognitive behavioral therapies as being empirically supported. In fact,cognitive behavioral techniques comprise most of the list. 2) Cognitive behavior therapy tends to berelatively brief and often can be delivered in groups. Therefore it can be more cost-effective than somealternatives and be seen to offer good value. These qualities have become particularly important inthe era of managed care with its emphasis upon cost containment. 3) Cognitive behavior therapy hasbeen applied with varying success to a wide variety of problems (see Fisher and O’Donohue, 2006for over 70 behavioral health problems in which CBT can be considered an evidence based treatment.Thus, it has considerable scope and utility for the practitioner in general practice or the professionalinvolved in the training of therapists. 4) Cognitive behavior therapy is a relatively straight forwardand clearly operationalized approach to psychotherapy. This does not mean that case formulationor implementing these techniques is easy. However, CBT is more learnable that techniques such aspsychoanalysis or Gestalt therapy. 5) Cognitive behavioral therapy is a therapy system comprised ofmany individual techniques, with researchers and practitioners constantly adding to this inventory.A given behavior therapist, because of his or her specialty, may know or use only a small subset ofthese. A clinician or clinical researcher may want to creatively combine individual techniques to treatsome intransigent problem or an unfamiliar or complicated clinical presentation. This volume attempts to bring together all of the specific techniques of cognitive behavior therapy.It does this in an ecumenical fashion. Historically, and currently, there are divisions inside behaviortherapy that this book attempts to ignore. For example, cognitive and more traditionally behavioraltechniques are included. This offended some prospective authors who were clearly warriors in thecognitive-behavioral battle. We wanted to be inclusive, particularly because pragmatically the outcomeresearch favors both sides of this particular battle. Our major interest in compiling this book was twofold: First we noted the lack of a volumethat provides detailed descriptions of the techniques of cognitive behavioral therapy. Many booksmentioned these but few described the techniques in detail. The absence of a comprehensive collectionof the methods of cognitive-behavior therapy creates a gap in the training of students and in thefaithful practice of cognitive behavior therapy. Second, with the increased interest in cognitive behaviortherapy, particularly by the payers in managed care, there has been an increasing bastardization ofbehavior therapy. Some therapists are claiming they are administering some technique (e.g., relapseprevention or contingency management) when they clearly are not. This phenomenon, in ourexperience, rarely involves intentional deception but instead reflects an ignorance of the complexitiesof faith-fully implementing these techniques. This book is aimed at reducing this problem. There is an important question regarding the extent to which a clinician can faithfully implementthese techniques without a deeper understanding of behavior therapy. The evidence is not clear and ofcourse the question is actually more complicated. Perhaps a generically skilled therapist with certainkinds of clients and certain kinds of techniques can implement the techniques well. On the otherhand, a less skilled therapist dealing with a complicated clinical presentation utilizing a more subtletechnique might not do so well. There is certainly a Gordon Paul type ultimate question lurking here.Something like: ‘‘What kind of therapist, with what type of problem, using what kind of cognitive xiii
  • xiv PREFACEbehavior therapy technique, with what kind of training, can have what kinds of effects. . .’’ Withthe risk of being seen as self-promoting, the reader can learn about the learning and conditioningunderpinnings of many of thes techniques in O’Donohue (1998); and more of the theories associatedwith these techniques in O’Donohue and Krasner (1995). Fisher and O’Donohue (2006) provide adescription of particular problems that these techniques can be used with.ReferencesFisher, J.E.,& O’Donohue, W.T. (2006) Practitioner’s guide to evidence based psychotherapy. New York: Springer.O’Donohue, W., & Krasner, L. (Eds.). (1995). Theories of behavior therapy. Washington: APA Books.O’Donohue, W. (Ed.). (1998). Learning and behavior therapy. Boston: Allyn & Bacon.
  • ACKNOWLEDGMENTSWe wish to thank all the chapter authors. They uniformly wrote excellent chapters and completedthese quickly. We’d also like to thank our editor at John Wiley & Sons, Patricia Rossi. She shared our vision forthis book, gave us some excellent suggestions for improvement, and has been wonderful to workwith. We’d also like to thank Linda Goddard for all her secretarial skills and expert assistance in allaspects of the manuscript preparation; she was invaluable. Finally, we’d like to thank our families for their support, and especially our children, Katie andAnnie, for their enthusiasm and delightfulness. xv
  • CONTRIBUTORSJonathan S. Abramowitz Jennifer L. Best, Ph.D.University of North Carolina University of North CarolinaChapel Hill, NC Charlotte, NC Arthur W. Blume, Ph.D.Dean T. Acheson University of North CarolinaUniversity at Albany, SUNY Charlotte, NCAlbany, NY Stephen R. Boggs, Ph.D. University of FloridaJennifer H. Adams Gainesville, FLUniversity of Colorado at DenverDenver, CO John C. Borrero, Ph.D. University of MarylandMark A. Adams, Ph.D., B.C.B.A Baltimore, MDBest Consulting, Inc.Fresno, CA Carrie S.W. Borrero, Ph.D.K. Angeleque Akin-Little Kennedy-Krieger InstituteMassey University Baltimore, MDAuckland, New Zealand Stephanie Both, Ph. D.Mark Alavosius, Ph.D. Leiden University Medical CenterUniversity of Nevada, Reno Leiden, NetherlandsReno, NV J. Annette Brooks, Ph. D.Claudia Avina, Ph.D. New Mexico VA Healthcare SystemUniversity of Nevada, Reno Albuquerque, NMReno, NV Jeffery A. BuchananJenna L. Baddeley, M.A. Minnesota State UniversityThe University of Texas at Austin Mankato, MNAustin, TX Eric BurkholderAnjali Barretto, Ph.D. Dublin Unified School DistrictGonzaga University Department of Special EducationSpokane, WA Dublin, CAWendy K. Berg, M.A. James E. Carr, Ph.D.University of Iowa Western Michigan UniversityIowa City, IA Kalamazoo, MI xvii
  • xviii CONTRIBUTORSLavina L. Cavasos Sona Dimidjian, Ph.D.New Mexico VA Healthcare System University of ColoradoAlbuquerque, NM Boulder, CODaniel Cervone, Ph.D. Keith S. Dobson, Ph.D.University of Illinois at Chicago University of CalgaryChicago, IL Calgary, CanadaStacey M. Cherup Brad Donohue, Ph.D.University of Nevada, Reno University of Nevada, Las VegasReno, NV Las Vegas, NVKim Christiansen Crissa DraperCarson City, NV University of Nevada, Reno Reno, NVLinda J. Cooper-Brown, Ph.D.University of Iowa Children’s Hospital Claudia Drossel, Ph.D.Iowa City, IA University of Nevada, Reno Reno, NVMichelle G. Craske, Ph.D.UCLA Melanie P. Duckworth, Ph.D.Los Angeles, CA University of Nevada, Reno Reno, NVDan Crimmins, Ph.D.The Marcus Institute V. Mark DurandAtlanta, GA University of South Florida St. Petersburg, FLWendy CrookUniversity of Nevada, Reno Anna Edwards, Ph.D.Reno, NV The Marcus Institute Atlanta, GAJesse M. CrosbyUtah State University Albert Ellis, Ph.D.Logan, UT DeceasedJoseph Dagen Erica L. EnglandUniversity of Nevada, Reno Drexel UniversityReno, NV Philadelphia, PAGerald C. Davison, Ph.D. Sheila M. Eyberg, Ph.D.UCLA University of FloridaLos Angeles, CA Gainesville, FLKim DeRuyk, Ph.D. Kyle E. Ferguson, M.A.Boys’ Town Riverview HospitalBoys’ Town, NE Coquitlam, BC, Canada
  • CONTRIBUTORS xixJane E. Fisher, Ph.D. Robert J. Gatchel, Ph.D.University of Nevada, Reno University of Texas at ArlingtonReno, NV Arlington, TXEdna B. Foa, Ph.D. Scott Gaynor, Ph.D.University of Pennsylvania Western Michigan UniversityPhiladelphia, PA Kalamazoo, MIEvan M. Forman Patrick M. Ghezzi, Ph.D.Drexel University University of Nevada, RenoPhiladelphia, PA Reno, NVJohn P. Forsyth, Ph.D. Elizabeth V. Gifford, Ph.D.University at Albany (SUNY) University of Nevada, RenoAlbany, NY Reno, NVMaxwell R. Frank Alan M. GrossUniversity of Hawaii at Manoa University of MississippiHonolulu, HI University, MIMichelle A. Frank Kate E. HamiltonKennedy-Krieger Institute Peter Lougheed CentreBaltimore, MD Calgary, CanadaMartin E. Franklin, Ph.D. Jay Harding, Ed.S.University of Pennsylvania University of IowaPhiladelphia, PA Iowa City, IAPatrick C. Friman, Ph.D. Cathi D. Harris, M.A.Father Flanagan’s Boys’ Home Washington Special Commitment CenterBoys’ Town, NE Steilacoom, WAArmida R. Fruzzetti Nicole L. HausmanUniversity of Nevada, Reno Kennedy-Krieger InstituteReno, NV Baltimore, MDAlan E. Fruzzetti, Ph.D. Steven C. HayesUniversity of Nevada, Reno University of Nevada, RenoReno, NV Reno, NVTiffany Fuse, Ph.D. Holly Hazlett-StevensNational Center for PTSD University of Nevada, RenoJamaica Plain, MA Reno, NVChristina G. Garrison-Diehn Lara S. Head, Ph.D.University of Nevada, Reno University of WisconsinReno, NV Madison, WI
  • xx CONTRIBUTORSElaine M. Heiby Linda A. LeBlanc, Ph.D.University of Hawaii at Manoa Western Michigan UniversityHonolulu, HI Kalamazoo, MIJames D. Herbert, Ph.D. Deborah A. Ledley, Ph.D.Drexel University University of PennsylvaniaPhiladelphia, PA Penn Valley, PARamona Houmanfar, Ph.D. Jung Eun LeeUniversity of Nevada, Reno University of Nevada, RenoReno, NV Reno, NV Eric R. Levensky, Ph.D.Kathryn L. Humphreys, Ph.D. New Mexico VA Healthcare SystemNational Center for PTSD, Albuquerque, NM VA Boston Healthcare SystemBoston, MA Donald J. Levis, Ph.D. Binghamton UniversityNicole N. Jacobs, Ph.D. Binghamton, NYUniversity of Nebraska Jennifer M. Lexington, Ph.D.Alyssa H. Kalata, M.A. University of Massachusetts AmherstWestern Michigan University Amherst, MAKalamazoo, MI Marsha M. Linehan, Ph.D.Mary Lou Kelley, Ph.D. University of WashingtonLouisiana State University Seattle, WABaton Rouge, LA Steven G. Little, Ph.D.Brian C. Kersh, Ph.D. Massey UniversityNew Mexico VA Healthcare System Auckland, New ZealandAlbuquerque, NM Andy Lloyd, Ph.D.Kelly Koerner U.S. ArmyEBP Jessa R. LoveSeattle, WA Western Michigan University Kalamazoo, MIDouglas Kostewicz, Ph.D.University of Pittsburgh Tamara M. Loverich, Ph.D.Pittsburgh, PA Eastern Michigan UniversityEllen Laan, Ph.D. Jason B. Luoma, Ph.D.University of Amsterdam Portland Psychotherapy ClinicAmsterdam, Netherlands Portland, ORArnold A. Lazarus, Ph.D. John R. Lutzker, Ph.D.Rutgers, The State University of New Jersey The Marcus InstitutePiscataway, NJ Atlanta, GA
  • CONTRIBUTORS xxiKenneth R. MacAleese, M.A., B.C.B.A. Raymond G. Miltenberger, Ph.D., B.C.B.A.Reno, NV University of South Florida Tampa, FLKristen A. Maglieri, Ph.D.Trinity College Sally A. MooreDublin, Ireland University of Washington Seattle, WAChristine Maguth Nezu, Ph.D.Drexel University Kevin J. MoorePhiladelphia, PA Oregon Social Learning Center, Community ProgramsGayla Margolin, Ph.D. Eugene, ORUCLALos Angeles, CA Karen Murphy University of Nevada, RenoG. Alan Marlatt, Ph.D. Reno, NVUniversity of WashingtonSeattle, WA Adel C. Najdowski Center for Autism and RelatedChristopher Martell Disorders, Inc.Private Practice Tarzana, CASeattle, WA Amy E. Naugle, Ph.D. Western Michigan UniversityBrian P. Marx, Ph.D. Kalamazoo, MINational Center for PTSD, VA Boston Healthcare System Cory F. Newman, Ph.D.Boston, MA University of Pennsylvania Philadelphia, PAMary McMurranUniversity of Nottingham Kirk A.B. Newring, Ph.D.Nottingham, United Kingdom Nebraska Dept. of Correctional ServicesDonald Meichenbaum, Ph.D. William D. NewsomeUniversity of Waterloo University of Nevada, RenoWaterloo, Ontario, Canada Reno, NVVictoria E. Mercer Arthur M. Nezu, Ph.D.University of Nevada, Reno Drexel UniversityReno, NV Philadelphia, PAEileen Merges Amanda Nicholson-Adams, Ph.D., B.C.B.A.St. John Fisher College California State University at FresnoRochester, NY Fresno, CAGerald I. Metalsky, Ph.D. William T. O’Donohue, Ph.D.Lawrence University University of Nevada, RenoAppleton, WI Reno, NV
  • xxii CONTRIBUTORSPamella H. Oliver, Ph.D. Richard C. Robertson, Ph.D.California State University, Fullerton Baylor University Medical CenterFullerton, CA Dallas, TXJennette L. Palcic Frederick Rotgers, Psy.D., ABPPLouisiana State University Philadelphia College of OsteopathicBaton Rouge, LA Medicine Philadelphia, PAGerald R. Patterson, Ph.D.Oregon Social Learning Center Frank R. Rush, Ph.D.Eugene, OR Pennsylvania State University University Park, PAJames W. PennebakerThe University of Texas at Austin Joel Schmidt, Ph.D.Austin, TX VA Northern California Healthcare System Oakland, CAMichael L. Perlis, Ph.D. Walter D. Scott, Ph.D.University of Rochester University of WyomingRochester, NY Laramie, WYKatherine A. Peterson Christine SegrinUtah State University University of ArizonaLogan, UT Tucson, AZWilfred R. Pigeon, Ph.D. Rachel E. SgambatiUniversity of Rochester Medical Center Carson City, NVRochester, NY Deacon ShoenbergerAlan Poling, Ph.D. University of Nevada, RenoWestern Michigan University Reno, NVKalamazoo, MI David M. SlagleLisa Regev, Ph.D. University of WashingtonUniversity of Nevada, Reno Seattle, WAReno, NV Rachel S.F. TarboxLynn P. Rehm, Ph.D. The Chicago School of ProfessionalUniversity of Houston Psychology at Los AngelesHouston, TX Los Angeles, CAJennifer Resetar, Ph.D. Kendra TracyBoys’ Town University of Nevada, Las VegasBoys’ Town, NE Las Vegas, NVPatricia Robinson, Ph.D. Michael P. Twohig, Ph.D.Mountainview Consulting Group, Inc. Utah State UniversityZillah, WA Logan, UT
  • CONTRIBUTORS xxiiiTimothy R. Vollmer, Ph.D. Larry W. Williams, Ph.D.University of Florida University of Nevada, RenoGainesville, FL Reno, NVDavid P. Wacker, Ph.D. Ginger R. Wilson, Ph.D.University of Iowa Children’s Hospital The ABRITE OrganizationIowa City, IA Santa Cruz, CAMichelle D. Wallace, Ph.D. J. M. WorrallCalifornia State University, Los Angeles University of Nevada, RenoLos Angeles, CA Reno, NVTodd A. Ward Marat ZanovUniversity of Wellington University of Southern CaliforniaWellington, New Zealand Los Angeles, CAJennifer Wheeler, Ph.D. Lori A. Zoellner, Ph.D.Private Practice University of WashingtonSeattle, WA Seattle, WADaniel J. Whitaker, Ph.D.The Marcus InstituteAtlanta, GA
  • 1 INTRODUCTION William O’Donohue and Jane E. FisherCognitive behavior therapy (CBT) is an approach recent decades there has been an unfortunateto human problems that can be viewed from sev- trend away from a philosophical understandingeral interrelated perspectives: philosophical, the- of behavior therapy to a more technique-orientedoretical, methodological, assessment oriented, understanding.and technological. This book focuses on the last The second aspect of behavior therapy is itsaspect, so crucial to clinical practice, but sit- theoretical structure. Here the issues are lessuated in the other four, much as any one of philosophical—less about general epistemica cube’s six sides is situated among all of the issues—and more about substantive assertionsothers. regarding more specific problems as well as Philosophically, CBT can be viewed as being the principles appealed to in making theseassociated (or, according to some who put it more assertions. What is panic? What are its causes?strongly, derived) with one or another variety What is the role of operant conditioning inof behaviorism (O’Donohue & Kitchener, 1999). children’s oppositional behavior? How does oneThe behaviorisms are generally philosophies of prevent relapse? Should cognitions be modifiedscience and philosophies of mind—that is, ways or accepted?of defining and approaching the understand- There are also a wide variety of theoriesing of the problems traditionally associated with associated with behavior therapy (O’Donohuepsychology. & Krasner, 1995), including: There are at least two broad issues at thephilosophical level: (1) What particular form of • Reciprocal inhibitionbehaviorism is being embraced (O’Donohue & • Response deprivationKitchener, 1999, have identified at least 14), and • Molar regulatory theory(2) what is the nature of the relationship or associ- • Two-factor fear theoryation between this philosophy and the practice of • Implosion theoryCBT? Some have argued that behaviorism is irrel- • Learned alarmsevant to behavior therapy—that one can practice • Bioinformational theorybehavior therapy and either reject behaviorism • Self-control theoryor be agnostic with regard to all forms of it. • Developmental theoriesWhile an individual practitioner can behave in • Coercion theorythis way, some of the deeper structure that can • Self-efficacy theorybe generative and guiding is lost. One can drive • Attribution theorya car without an understanding of its workings, • Information processing theorybut one probably can’t design a better car or • Relational frame theorymodify an existing car without such an under- • Relapse preventionstanding. Similarly, a knowledge of behaviorism • Evolutionary theoryallows greater understanding of the choice points • Marxist theoryimplicit in any technology. For example, why not • Feminist theoryview the client’s problem as a neurological dif- • Dialectical theoryficulty and intervene at this level? Behaviorism • Acceptance theoryoften provides possible answers to this kind of • Functional analytic theorygeneral challenge. However, we suggest that in • Interbehavioral theory 1
  • 2 COGNITIVE BEHAVIOR THERAPY Theories can provide answers or at least & Jarrett, 1987). Some of the chapters in thistestable hypotheses for questions regarding more volume deal with assessment techniques eitherspecific problems, such as these: What is the basic because they are central to therapy or becausenature of this kind of clinical problem? How assessment methods themselves are so reactivedoes this problem develop? What maintains this that they may be seen, in part, as treatment.problem? What are its associated features and However, in the main, this book does not focuswhy? How is this problem possibly modified? on the measurement aspect, leaving that task toWhat makes this technique work? What are con- other fine anthologies (e.g., Haynes & Heiby , intraindications? What are boundary conditions? press). The third aspect of CBT is its program for The final aspect of CBT is techne—skilledknowledge generation. In the main, CBT is exper- practice. No amount of philosophy or theoryimental and relies on a mixture of group experi- will relieve clinicians from this level of analy-mental designs (e.g., the randomized controlled sis. A surgeon may be a biological deterministtrial) and single-subject experimental designs philosophically and may hold to certain the-(although in the largest perspective it can be ories of cancer and cancer treatment, but toseen to include correlational designs and even help patients the surgeon still needs to imple-case studies). Methodologically, CBT generally ment surgical technique in a skilled manner.embraces constructs such as social validity, clin- Similarly, cognitive behavior therapists need toical significance, follow-up measurements, man- be skilled in the execution of their techniques.ualized treatment, adherence and competence In fact, an interesting set of research questionschecks, the measurement of process variables, involves the relationship between the degree ofindependent replications, and real-world effec- skill (e.g., poor, novice, experienced, master) andtiveness research. This toolbox is complex, but therapy outcome. This may also be a functionone can discern a few distinct styles—such as of specific technique (e.g., progressive musclethat of the applied behavior analyst and that relaxation may have different relationship withof the cognitive therapist (O’Donohue & Houts, skill level than emotional regulation training).1985). Other styles can be seen when the nature For example, if a clinician arranges potentialof the question differs—for example, when the positive reinforcers that are too distal in contin-interest is in measurement development and gency manager it will be less effective. Similarly,validation or in the questions typically associ- if a clinician conducts systematic desensitiza-ated with experimental psychopathology. CBT tion with only a few steps in a fear hierarchy,is solidly in the stream of ‘‘clinical science’’ with weakly trained progressive muscle relax-and as part of this general approach views an ation skills, and pairings that are few and of veryexperimental approach as key (see Lilienfeld short duration, it is unlikely to be as effective asand O’Donohue, 2007, for a fuller exposition it could otherwise be.of clinical science). We’ve identified approximately 80 distinct The fourth aspect of CBT is its approach to techniques in CBT, covering both standardmeasurement. Here, a key issue is how to accu- behavior therapy and cognitive therapyrately detect and quantify variables of interest. techniques, and relatively recently developedCognitive behavior therapy is associated with procedures such as acceptance strategies andboth a distinctive delineation of the domain of mindfulness. This number has to qualify CBT asinterest and distinct methods for measuring this. one of the most variegated therapy systems. ThisIn general, behavioral assessment can be dis- diversity no doubt derives from an interplay oftinguished from more traditional measurement complex factors:approaches by its focus on sampling of behaviorrather than looking for signs of more abstract • The multiple learning theories upon whichconstructs. There are diverse streams of thought traditional behavior therapy is basedwithin the CBT tradition, however, from the (O’Donohue, 1998).embrace of traditional psychometric standards • The multielemental nature of each of theseto the radically functional (e.g., Hayes, Nelson, theories (e.g., setting events, discrimination
  • 1 • INTRODUCTION 3 training, schedules of reinforcement, general- (i.e., what process or pathway it may be asso- ization processes, fading, etc.). ciated with), and some of the evidence for its• The influence of other elements of experimen- effectiveness. The major section of the chapter is tal psychology such as experimental cognitive a step-by-step guide that explains exactly how science. to implement the technique. Finally, we asked• The influence of other branches of psychology authors to include a brief table outlining the such as social psychology. major elements of the technique.• The influences of other intellectual domains The very number and diversity of CBT tech- (dialectics) or other fields of inquiry (mind- niques place a significant burden on any practi- fulness). tioner of CBT and, even more so, on the student.• The interface of these with a particular kind of It is our hope that this volume, by clearly and clinical problem (e.g., borderline personality concisely describing these techniques, will ease disorder). this burden. We also hope that precision about• The creativity and ambitions of the devel- techniques can help the field continue to keep opers. its eye on Gordon Paul’s (1969) classic ques- tion: What techniques, delivered by what type But whatever the source of this tremendous of therapist, for what kind of client, with whatvariety, the presence of such a large number kind of clinical problem, in what kind of setting,of major distinctive techniques leaves no doubt produces what kind of result, by what kind ofas to the multifactorial nature of contemporary process?CBT. It leaves an interesting question regardinghow broad competence ought to be across these Referencestechniques in order for one to be considered awell-trained cognitive behavior therapist. One Haynes, S., & Heiby, E. (in press). The encyclopedia ofof the key variables emerging in the medical behavioral assessment. Hayes, S. C., Nelson, R. O., & Jarrett, R. (1987). Treat-literature regarding quality is number of times ment utility of assessment: A functional approachthe physician has implemented the particular to evaluating the quality of assessment. Americantechnique. One generally finds that hundreds Psychologist, 42, 963–974.or thousands of times produces outcomes better Lilienfeld, S., & O’Donohue, W. (Eds.). (2007). The greatthan those in the dozens. Thus, there can be a ideas of clinical science. New York: Routledge.bandwith/fidelity trade-off in behavior therapy O’Donohue, W. (Ed.). (1998). Learning and behavior ther-that can have interesting associations with qual- apy. Boston: Allyn and Bacon. O’Donohue, W., & Houts, A. C. (1985). The two dis-ity. Those that know more techniques may be ciplines of behavior therapy. Psychological Record,less skilled at implementing any particular one. 35(2), 155–163. We’ve asked each of the chapter authors to fol- O’Donohue, W., & Kitchener, R. (1999). Handbook oflow a standard format, because we thought these behaviorism. San Diego: Academic Press.main topics would delineate a bit of the context O’Donohue, W., & Kramer, L. (Eds.). (1995). Theories ofand all of the essential features needed to com- behavior therapy. Washington, DC: APA Books.petently execute these techniques. We wanted Paul, G. L. (1969). Behavior modification research: Design and tactics. In C. M. Franks (Ed.),them to describe who might benefit from this Behavior therapy: Appraisal and status (pp. 29–62).technique, contraindications, other factors rele- New York: McGraw-Hill.vant to making the decision to use or not to usethe technique, how the technique might work
  • 2 PSYCHOLOGICAL ACCEPTANCE James D. Herbert, Evan M. Forman, and Erica L. EnglandIn one form or another, all psychotherapies conceived to include distressing thoughts andseek to produce change. Individuals seek con- feelings in addition to overt behavior. Althoughsultation from psychotherapists when they are one might need to accept temporary, short-termexperiencing emotional pain, struggling with life distress associated with certain interventions,problems, or when they are not functioning well the overall focus was on changing the form orin school, work, or relationships. The explicit goal frequency of distressing behaviors rather thanis to achieve changes that will reduce pain or suf- accepting them. This approach was dramaticallyfering, resolve outstanding problems, or enhance successful. Effective technologies were devel-functioning. There has also been a longstand- oped to increase social skills, desensitize fears,ing recognition that such change requires some and manage disruptive behavior among chil-sense of self-acceptance, understood as the ability dren, as well as to address many other problemsto respond less self-critically and judgmentally, (Bongar & Beutler, 1995; Goldfried & Davison,thereby establishing the context for more effec- 1994). As behavior therapy matured throughtive functioning. Prior to the advent of behavior the last decades of the twentieth century, theretherapy, psychotherapists traditionally focused evolved an increased focus on changing thoughtsless on changing distressing symptoms them- and beliefs, and the field itself came to be knownselves, concentrating instead on modifying other by the term cognitive behavior therapy (CBT). Theprocesses on the assumption that changes in various clinical strategies and techniques fallingsuch processes would result in more fundamen- under the rubric of CBT all shared a focus ontal, profound, and permanent improvements in directly targeting problems using instrumentaldistress (Sulloway, 1983). Psychoanalysts sought change strategies. Although acceptance of one’sto increase insight into the developmental ori- distressing experiences was indirectly targetedgins of unconscious conflicts. By rendering the in some cases (e.g., acceptance of anxious sen-unconscious conscious, unacceptable drives and sations during exposure-based therapies), evenfantasies become acceptable to the ego. Humanis- then the ultimate goal was change (e.g., anxietytic therapists likewise sought to increase congru- reduction), and the overall focus of clinical inter-ence between different facets of the self, thereby ventions remained squarely on direct change.promoting a sense of self-acceptance. Althoughthe ultimate goal was change, the prevailingclinical wisdom was that targeting distressing THE GROWTH OF PSYCHOLOGICALthoughts, feelings, or behavior directly would be ACCEPTANCE IN CBTineffective at best, and possibly even counter-productive. It is perhaps ironic, then, that the field of CBT Early behavior therapists rejected the idea that currently finds itself at the forefront of a move-change required interventions focusing on pro- ment that questions the utility of such directcesses not directly related to actual presenting change strategies under certain circumstancesproblems. Instead, they directly targeted their and promotes instead the rather paradoxicalpatients’ difficulties. Behavior therapists focused idea that more pervasive and enduring improve-on modifying environmental factors thought to ments in suffering and quality of life maybe responsible for problematic behavior, broadly result from accepting, rather than attempting to 4
  • 2 • PSYCHOLOGICAL ACCEPTANCE 5 40 35 30 25 20 15 10 5 0 2000 2001 2002 2003 2004 2005 2006 2007 Publication YearFIGURE 2.1 PsychInfo Citations for Keywords ‘‘Experiential Acceptance,’’ ‘‘Psychological Acceptance,’’ or‘‘Experiential Avoidance.’’change, one’s distressing subjective experience. The recent growth of interest in these ap-This distinction between direct change efforts proaches is undeniable. For example, as illus-and psychological acceptance as a vehicle for trated in Figure 2.1, the PsychInfo databasechange has been described in various ways, reveals a steady growth in the hits of theincluding first-order versus second-order keywords experiential acceptance, its synonymchange, change in content versus context, and psychological acceptance, and experiential avoidancechange in form versus function (Hayes, 2001). (which is an antonym for the first two) from 2Regardless of terminology, a number of CBT in 2000 to 35 in 2007. Parallel increases can bemodels have emerged over the past decade that found in related databases (e.g., Medline), andhighlight efforts to accept, rather than directly in the titles of conference proceedings (e.g., the annual meeting of the Association for Behavioralchange, distressing experiences, including and Cognitive Therapies).thoughts, beliefs, feelings, memories, and sen- This increased emphasis on psychologicalsations. These approaches have not abandoned acceptance is the result of several factors (Hayes,all direct change strategies. Rather, as described 2004; Longmore & Worrell, 2007). First, anlater, they suggest that changes in some areas accumulating body of experimental researchare best facilitated by acceptance in others. It demonstrates that efforts to suppress thoughtsis worth noting that there is no hard-and-fast generally result in rebound effects in which thedistinction between traditional change-oriented frequency and intensity of thoughts increaseand acceptance-oriented models of CBT (Orsillo, upon termination of active suppression effortsRoemer, Lerner, & Tull, 2004). A key ultimate (Abramowitz, Tolin, & Street, 2001; Wenzlaffgoal of both approaches is behavior change & Wegner, 2000). Such findings suggest that(broadly writ), and both draw on technologies CBT interventions such as thought stopping,that either implicitly or explicitly seek to increase in which distressing thoughts are deliberatelypsychological acceptance. Rather, the models suppressed, might be seriously misguided.differ in the relative degree of emphasis on In fact, most CBT scholars now disavow thisacceptance versus change processes. technique (Marks, 1987). Thought suppression
  • 6 COGNITIVE BEHAVIOR THERAPYstudies (in which individuals who deliberately ago (see Dobson, 1989, for a review of thesesuppress thoughts demonstrate increased older studies). Finally, preliminary componentrebound of these thoughts relative to those control studies, in which direct cognitivewho do not engage in suppression strategies) change interventions were extracted fromhave been cited as evidence to suspect the larger CBT protocols, have generally failed toadvisability of cognitive restructuring, one support the incremental effects of such cognitiveof the most commonly used CBT techniques interventions (e.g., Dimidjian et al., 2006; Hope,(Hayes, in press). The concern is that attempting Heimberg, & Bruch, 1995; Jacobson et al., 1996).to restructure distressing thoughts may lead These observations led several psychotherapypatients to suppress them, resulting in inten- innovators to develop approaches that highlightsification and elaboration. However, it is not acceptance of distressing experiences. Suchclear that cognitive restructuring is analogous to innovations include comprehensive psycho-thought suppression (Arch & Craske, in press; therapy models such as acceptance andHofmann & Admundson, 2008). Second, some commitment therapy (ACT; Hayes, Strosahl,cognitive therapists have recently challenged & Wilson, 1999), dialectical behavior therapyon theoretical grounds the idea that directly (DBT; Linehan, 1993a), mindfulness-based stresstargeting thoughts can produce cognitive reduction (MBSR; 1990) and functional analyticor affective changes (Teasdale, 1997). Third, psychotherapy (FAP; Kohlenberg & Tsai, 1991),experimental psychopathology studies have as well as models focused on a particular clinicalfound that instructions to accept experimentally domain, such as integrative couples therapyinduced distress resulted in better outcomes (ICT; Jacobson et al., 2000), mindfulnesss-basedthan instructions to control such distress. cognitive therapy (MBCT; Coelho, Canter, &For example, acceptance-oriented instructions, Ernst, 2007; Segal, Williams, & Teasdale, 2002)relative to distraction or control-oriented instruc- for recurrent depression, and the work of leadingtions, have been shown to result in greater pain CBT theorists such as Borkovec (1994), Wellstolerance in cold pressor tasks (Hayes et al., (2000), Marlatt and colleagues (2004), and others.1999), in lower behavioral avoidance and fearresponse following exposure to CO2 enriched airamong high anxiety–sensitivity women (Eifert CONCEPTUALIZATIONS OF ACCEPTANCE& Heffner, 2003) and panic disorder patients(Levitt, Brown, Orsillo, & Barlow, 2004), and in No consensus definition of psychologicalreducing chocolate cravings in food-responsive acceptance has yet emerged, although existingindividuals (Forman, Hoffman, et al., 2007). definitions share several common themes. ButlerFourth, psychotherapy process studies often and Ciarrochi (2007) define acceptance as ‘‘ahave failed to support the theorized mechanism willingness to experience psychological eventsof cognitive mediation, raising questions about (thoughts, feelings, memories) without havingthe centrality of cognitive change as a prereq- to avoid them or let them unduly influenceuisite for changes in other areas (Longmore & behavior’’ (p. 608). These authors also note thatWorrell). Fifth, although standard CBT strategies acceptance is the mirror image of Hayes and col-have been applied to an increasing number of leagues’ (1999) concept of experiential avoidance,problems and psychological disorders over the which is defined as maladaptive attempts to alterpast 30 years, outside of a few specific areas (e.g., the form or frequency of internal experiencespanic disorder, Craske & Barlow, 2008; social even when doing so causes behavioral harm.anxiety disorder, Clark et al., 2006, Herbert Cordova (2001), writing from a behavior analyticet al., 2005) progress has slowed or even perspective, defines acceptance as ‘‘allowing, tol-stalled in many key areas. For example, it erating, embracing, experiencing, or making con-is not clear that recent studies of CBT (e.g., tact with a source of stimulation that previouslyDeRubeis et al., 2005; Dimidjian et al., 2006) for provoked escape, avoidance, or aggression’’depression produced larger effect sizes than (p. 215), and also as ‘‘a change in the behaviorstudies conducted two or even three decades evoked by a stimulus from that functioning to
  • 2 • PSYCHOLOGICAL ACCEPTANCE 7avoid, escape, or destroy to behavior functioning Likewise, the prohibition against experientialto pursue or maintain contact’’ (p. 215). avoidance in ACT is neither absolute nor These definitions share several common dogmatic, but rather pragmatic. (In fact, whilethemes. First, they specify that psychological ACT practitioners are skeptical of experientialacceptance is relevant in those situations avoidance, including many cognitive changethat evoke escape, avoidance, or aggressive strategies, their use is explicitly advised whenbehaviors designed to modify or otherwise they work without undue costs.) Second,terminate contact with a stimulus. There is a acceptance is conceptualized as an activeclass of subjective experiences (thoughts, images, process, more akin to an embracing of one’sfeelings, sensations) that are experienced as ongoing process of experiencing, rather than asunpleasant and distressing to the point at which passive resignation. Finally, consistent with theone becomes highly motivated to reduce or historical focus in CBT on change, psychologicaleliminate them through either direct mental acceptance is generally viewed as a means toefforts or through environmental modification an end rather than an end in-and-of itself. Insuch as escape or avoidance. Acceptance is fact, this last point is one of the key featuresgenerally not relevant to situations that are that distinguishes psychological acceptancenot experienced as aversive, which are usually in CBT from acceptance in certain spiritualnaturally embraced without difficulty. Second, or religious contexts, and even in popularpsychological acceptance refers primarily to the culture. Meditative practices in Eastern religiousinternal experience of distress rather than to the traditions view acceptance as part of a desiredsituations evoking this distress. In the case of a state of consciousness. Within CBT, the value ofphobia of heights, for example, acceptance refers acceptance is as a tool to reduce overall sufferingto a willingness to experience anxiety—without and especially to foster behavior change thatattempting to control or otherwise change it—in will lead to better functioning.the presence of heights, and not an acceptancethat one can never approach heights. Third,the conceptualizations of acceptance implicitly CLINICAL INTERVENTIONS TO PROMOTEchallenge the rule that overt behavior is a direct PSYCHOLOGICAL ACCEPTANCEproduct of cognition and affect, and that thelatter must therefore necessarily be changed in A number of techniques have been developedorder to produce a change in behavior. to promote psychological acceptance. Although In addition, several additional aspects of psy- comprehensive review of such techniques is wellchological acceptance emerge from the literature. beyond the scope of this chapter, we provideOn the basis of the literature on thought sup- representative examples of such strategies below.pression, experimental psychopathology, and Barlow and colleagues (1989) introducedpsychotherapy outcome and process described the technique of interoceptive exposure in theearlier, including the preliminary effectiveness context of their treatment of panic disorder.of newer CBT interventions that eschew direct Interoceptive exposure refers to the graduated,cognitive change, many acceptance-oriented systematic exposure to somatic sensationspsychotherapists have come to believe that associated with panic attacks. Various exercisesdirect efforts to suppress or otherwise change are used that reliably elicit panic-like symptoms,highly distressing internal experiences will often including cardiovascular exercises, inhalationprove ineffective, will result in unacceptable of carbon dioxide, spinning in an office chair,costs, or both (e.g., Eifert & Forsyth, 2005; breathing through a cocktail straw, and shakingSegal, Teasdale, & Williams, 2004). This is not one’s head vigorously side to side. The patientto suggest that all such efforts are doomed is instructed to notice the sensations that ariseto failure. DBT, for example, is based on the dispassionately. Although not specificallycareful, ongoing balance between acceptance framed as a technique to promote psychologicaland change and does not abandon the possibility acceptance, interoceptive exposure is consistentof direct cognitive or affective change efforts. with an acceptance focus.
  • 8 COGNITIVE BEHAVIOR THERAPY One of the most common approaches to pro- skills, emotional regulation skills, interpersonalmoting psychological acceptance is mindfulness effectiveness skills, and distress tolerancemeditation. The use of meditation was spear- skills. Each module outlines specific clinicalheaded by Jon Kabat-Zinn in the context of techniques. Mindfulness skills are generallyMBSR, which was initially introduced in 1979 taught first, as they are foundational for theas a complement to medical treatment of a vari- other skill areas. The DBT mindfulness moduleety of chronic conditions. MBSR incorporates emphasizes observing and labeling emotionalthe practice of mindfulness meditation with cer- states from a detached, nonjudgmental, accept-tain core principles and ‘‘key attitudes,’’ such as ing perspective. Patients are taught to integrateacceptance, patience, and the ‘‘beginner’s mind,’’ the ‘‘emotional mind’’ and ‘‘reasonable mind’’that is, viewing experiences as though for the into the ‘‘wise mind’’ that can inform decisionsfirst time (Kabat-Zinn, 1990). The typical for- from an informed, balanced, holistic perspective.mat through which MBSR is delivered consists A potentially unresolved issue with DBTof eight weekly classes (often with 30 or more concerns the reconciliation of experientialparticipants), and a ‘‘Day of Mindfulness,’’ a acceptance and change. DBT explicitly teachesfull-day retreat focusing on the practice of medi- a number of emotion regulation strategies, suchtation and yoga. A key technique used in MBSR is as the principle of ‘‘opposite action,’’ which‘‘sitting meditation,’’ in which participants prac- refers to attempting to change an emotionaltice nonjudgmental awareness and acceptance of state by behaving in a way that is contrary totheir thoughts and other experiences. In addi- its usual behavioral manifestation. For example,tion to meditation and yoga, participants are a phobic who approaches rather than avoidstaught various techniques designed to promote a fear-inducing stimulus is displaying themindfulness, such as the ‘‘body scan,’’ which principle of opposite action. The emphasisinvolves gradually shifting awareness through- on emotion regulation in DBT highlights theout the body, taking notice of any feelings and dialectic between acceptance and change thatsensations (Tacon, Caldera, & Ronaghan, 2004). is characteristic of the model. However, asAlthough similar to the traditional behavior ther- discussed above, there may be situations inapy technique of relaxation training, in the case which attempting to change one’s experienceof mindfulness meditation relaxation is not the only intensifies it. Thoroughgoing acceptancegoal, but rather the adoption of a nonjudgmen- of distressing thoughts or feelings may betal stance with respect to one’s experience as it precluded if one remains focused on changingoccurs in real time. Mindfulness meditation is such experiences. An obese individual sufferingalso contrasted with other meditative traditions from episodes of binge eating, for example,in which one attempts to narrow the focus of may not fully accept distressing emotionalattention to a specific area (e.g., an image or states that trigger binges, and therefore mayvocal mantra). By fostering the observation of not completely disconnect links between suchone’s experience without reactively attempting experiences and her behavior, if in the backto escape from or otherwise change it, mind- of her mind she is still struggling with tryingfulness meditation is believed to interrupt mal- to change her experience. As described below,adaptive behavioral habits and to set the context ACT takes a more radical—although arguablyfor more effective responding. more consistent—stance with respect to efforts Mindfulness meditation is also a key feature to control distressing experiences.of DBT, developed by Linehan (1993a) as a Working from a cognitive perspective, Wellscomprehensive treatment model for borderline (2000) proposes that psychopathology is relatedpersonality disorder. DBT proposes that the to problematic self-regulation of attentionalchange-oriented emphasis in traditional CBT control, resulting in rumination, increasedcan be perceived as invalidating of the expe- threat monitoring (including self-focusedrience of patients with borderline personality attention), and coping behaviors that fail todisorder. Linehan (1993b) describes modules provide corrective experiences. The roots offor teaching four key skill areas: mindfulness these self-regulatory attentional problems are
  • 2 • PSYCHOLOGICAL ACCEPTANCE 9dysfunctional metacognitive beliefs, or beliefs could simply observe his urge, and say toabout beliefs. For example, a person with himself, ‘‘I’m having the thought of shouting outgeneralized anxiety disorder might hold a right now. That’s an interesting thought.’’ Themetabelief such as ‘‘if I review things over idea is to help the patient to achieve distanceand over again it will reduce the chances of from his experience and to accept the thought assomething bad happening.’’ Wells distinguishes simply a mental event, rather than as necessarilysuch metacognitions from the conscious, reflecting anything whatsoever about his world.propositional beliefs that are the typical targets Another example derived from ACT is theof standard cognitive therapy. He suggests inter- ‘‘cards’’ exercise. In one variation of this exercise,vention efforts to target such metacognitions, the patient is instructed to carry on a con-while simultaneously accepting the stream of versation with the therapist. As she does so,one’s ongoing conscious thoughts and feelings. the therapist tosses index cards, on each ofUnlike traditional CBT approaches, such change which is written one of the patient’s typicalis not accomplished by questioning the beliefs distressing thoughts, one-by-one at the patient,directly, but by encouraging greater attentional who is then instructed either to deflect themcontrol while simultaneously encouraging a away, or to gather them and stack them neatlyheightened sense of awareness of, and an together, all while continuing the conversation.accepting stance toward, one’s thoughts as mere Needless-to-say, this is a difficult task, and themental events. As part of his metacognitive conversation is inevitably negatively impacted.therapy, Wells describes a procedure known as The exercise is then repeated, this time with thethe attention training technique (ATT), in which patient instructed simply to let the cards fallvarious sounds are presented as distractions where they may, without trying to catch or orga-while subjects remain focused on a visual nize them. Following the exercise, the therapistfixation point, accept whatever thoughts enter and patient note how much more difficult theconsciousness without struggling with them, conversation was to maintain in the first sce-and attempt to direct their attention in various nario, and the effort to gather and organize theways as directed by the therapist. ATT has cards is framed as analogous to the effort to con-been shown in preliminary studies to result in trol one’s distressing thoughts. The ACT modelchanges in distressing thoughts and symptoms, is rich with similar exercises designed to promotedespite not directly targeting them, as well as psychological acceptance.in increases in metacognitive awareness (for a Roemer and Orsillo (2002) utilize the ACTrecent review, see Wells, 2007). framework to develop an acceptance-based ACT makes use of a variety of metaphors intervention for generalized anxiety disorder.and experiential exercises in order to promote Their model draws on the work of Borkovecacceptance. A great number of such exercises (1994), who conceptualizes worry as anhave been developed, and clinical innovations avoidance method that serves to reduce thein this area continue apace. One technique has perceived likelihood of feared future events, asthe patient precede discussions of distressing well as to distract the worrier from distressingthoughts or feelings by verbally (and subse- internal anxiety. Worry, in turn, is negativelyquently subvocally) inserting the phrase ‘‘I’m reinforced by the resulting decrease in distress.having the thought [or feeling] that . . . ’’ before According to Roemer and Orsillo, by learningthoughts. For example, an individual who to accept unpleasant internal events ratherimagines that he might suddenly shout out a than struggling with them, individuals canprofanity-laced, heretical statement in church reduce their experiential avoidance of perceivedwould be highly motivated to suppress the future threats. Roemer and Orsillo’s treatmenturge to do so as well as the linked thoughts incorporates various techniques to promoteand images. Attempts to suppress thoughts mindfulness, acceptance, and behavior change.or images of such behavior would likely only For example, the ‘‘mindfulness of sound’’increase their salience and intensity, thereby exercise, borrowed from Segal and colleaguesfurther increasing distress. Instead, this person (2002), encourages patients to notice aspects of
  • 10 COGNITIVE BEHAVIOR THERAPYsound without labeling and judgment (Orsillo, noting that acceptance is rarely appropriate forRoemer, & Holowka, 2005). the former but almost always for the latter. For Marlatt and colleagues have incorpo- example, an individual suffering from depres-rated mindfulness and acceptance into their sion can distance herself from and accept feelingswork on substance abuse treatment (Leigh, of dysphoria and thoughts of worthlessness andBowen, & Marlatt, 2005; Marlatt et al., 2004; suicide, but without accepting her behavior ofWitkiewitz, Marlatt, & Walker, 2005). Marlatt’s staying in bed all day. Historically importantrelapse-prevention model involves mindful memories (e.g., one’s memories of a traumaticacceptance of urges and cravings. A key experience) are especially important to accept,intervention of their program is known as ‘‘urge as considerable research suggests that avoidantsurfing,’’ in which the patient is instructed to coping strategies are problematic for such mem-imagine a craving as an ocean wave (Larimer, ories (Folette et al., 1998; Hayes et al., 1996).Palmer, & Marlatt, 1999). Rather than allowing Likewise, one’s ongoing stream of thoughts, feel-urges to overwhelm them, patients are taught ings, and sensations also tend to be appropriatethat cravings surge to a peak relatively quickly targets for acceptance. For example, Hayes andand will then subside. By focusing on the Pankey (2003) note that a pedophile’s sexualidea that distressing emotions will eventually behavior toward children should be directly tar-subside, they are more readily tolerated while at geted for change, whereas his associated feelingstheir most intense. The patient is encouraged to and urges are unlikely to be amenable to directobserve the craving as though detached from it, change, and should therefore be accepted. It is inand to practice mindful acceptance of the urge fact precisely this decoupling of subjective expe-until it dissipates. riences from overt behavior that is at the heart of Regardless of approach, the ultimate goal of acceptance-based CBTs.each of these techniques is the promotion of It is critical to distinguish psychologicalacceptance toward one’s experience on an ongo- acceptance of a thought from belief in theing basis in real time. literal truth of that thought. Acceptance implies the willingness to experience a thought while simultaneously refraining from evaluating itsWHEN IS ACCEPTANCE RECOMMENDED, truth value. This distinction is critical whenAND WHEN IS IT LIKELY TO BE LESS EFFECTIVE? considering the patient’s personal narrative, or what Hayes et al. (1999) term the self-as-content.As noted above, efforts to exert direct control Given the powerful human drive to makeover one’s experience can be considered adaptive sense of one’s experience, we inevitablywhen they work and do not result in excessive construct narratives that tie together importantcosts. Of course, this begs the question of how historical events, and that crystallize into broadone might ascertain when direct control efforts personality descriptors. The problem with suchare likely to be effective and when psychological narratives is that once formed, they tend toacceptance is instead indicated. Several theorists be taken literally and strongly defended fromhave addressed this question, although a clear question, which can in turn lead to a narrowingconsensus has yet to emerge. Cordova (2001) of one’s behavioral repertoire. For example, asuggests that the decision is a judgment call, college student may recall academic successesmade collaboratively by the patient and ther- in school, attribute these to her intelligenceapist, on whether aversion behavior (escape, and strong work ethic, and develop an identityavoidance, or aggression toward a stimulus) is as an ‘‘exceptionally smart, hardworkingmore likely to be effective, or lead to excessive student.’’ Imagine that she then finds herselfnegative consequences, over the long term. Of in a difficult class and not understanding thecourse, this begs the question of exactly what fac- lecture material. If she holds strongly to hertors should determine such a judgment. Hayes personal narrative, she may refrain from asking(2001) distinguishes maladaptive overt behavior a question because doing so would conflictfrom acceptance of one’s subjective experiences, with her self-identity as an exceptionally bright
  • 2 • PSYCHOLOGICAL ACCEPTANCE 11student. As verbal animals, humans have all cognitive and affective control efforts are nec-evolved to seek patterns in the ongoing barrage essarily doomed to failure, which may not be theof sensory input (Shermer, 2002), and as part of case. Some experiences are neither fully volun-this process, we construct stories that weave key tary (like hand/feet movements) nor involuntarydetails of our lives into a seamless narrative. (such as heart rate). Attention is a prime example.Once constructed, there is a natural tendency In fact, a number of experiences (e.g., thoughtto believe such narratives and to defend them contents, muscle tension) are on a continuum offrom challenge. Psychological acceptance in controllability. Psychological acceptance can bethis context means accepting one’s personal understood as gentle attempts to influence suchnarrative as an inevitable product of an active, experiences where possible, while acknowledg-pattern-seeking mind without either believing ing without struggle the inevitable limitations ofor disbelieving it. this influence. Farmer and Chapman (2008) propose three Consider the case of test anxiety. As with otherprinciples in deciding if psychological accep- anxiety disorders, it is easy to appreciate howtance is indicated. First, is acceptance ‘‘justified’’? an accepting stance with respect to catastrophicA justified response is one that is warranted thoughts and anxious sensations evoked by testsby the situation, such as a fear response in the could be beneficial. However, to be successful itpresence of a phobic stimulus. If the response is not enough to accept one’s subjective distress;is justified, then acceptance is in order; if the one must also focus one’s attention in order toresponse is not justified, then one either attempts orient toward the test itself. Approaches suchto change the response or at least to change as Wells’ (2000) attentional training technique,the behavior elicited by the response (consistent in which flexible attentional control is targetedwith the DBT principle of ‘‘opposite action’’). For without attempting to change ongoing thoughtsexample, distressing thoughts about being over- or feelings, may provide a useful approach toweight are justified in an obese individual, but such cases.the same thoughts are unjustified in a woman Finally, consistent with Farmer and Chap-suffering from anorexia. Of course, determina- man’s (2008) notion of justified responses, theretion of whether a thought is justified requires at are situations in which the literal truth of aleast some degree of analysis of the truth value thought or belief is, in fact, critical to evaluate. Aof the thought, which runs the risk of interfering man with tachycardia, shortness of breath, andwith attempts to accept it. Second, is the reaction chest pains needs to know whether he is dyingor situation changeable or unchangeable? Obvi- of a heart attack or simply having a panic attack.ously, acceptance is indicated for unchangeable A woman who believes that she is being stalkedexperiences. Finally, are the patient’s responses by an ex-boyfriend must evaluate the evidenceeffective or ineffective? Effective responses are for this belief before simply accepting her feel-conceptualized as those that are consistent with ings dispassionately. In such cases, psychologicalvalued goals, whereas ineffective responses are acceptance becomes relevant after an objectiveinconsistent. When responses are ineffective in evaluation of the relevant evidence (e.g., a med-this sense, they call for acceptance. ical workup for the individual with chest pains, A common rule of thumb among acceptance- consultation with appropriate law enforcementoriented CBT clinicians is that psychological authorities for the woman who believes she isacceptance is indicated for any distressing per- being stalked). In many other cases, however,sonal experiences, such as painful memories, one may be tempted to evaluate the truth ofdisturbing thoughts, and difficult feelings or thoughts when doing so may not be necessary.sensations, as well as for personal narratives. By An individual with public speaking anxiety willcontrast, direct change efforts should be reserved almost certainly have thoughts concerning nega-for overt behaviors, that is, things involving one’s tive evaluation by the audience in anticipation ofhands, feet, mouth, and so on. Although superfi- a speech. An objective evaluation of the evidencecially appealing, such a distinction becomes more for such beliefs would not only be difficult todifficult upon closer examination. It assumes that achieve, but is not necessary. The individual can
  • 12 COGNITIVE BEHAVIOR THERAPYlearn simply to notice his catastrophic thoughts value of cognitions is clearly necessary. Althoughand associated feelings of anxiety and to give the at first glance such efforts may appear incom-speech anyway. The issue of determining when patible with experiential acceptance, acceptanceto evaluate versus when to accept distressing may actually enhance one’s efforts along thesethoughts is discussed further below. lines. Many existing acceptance-based innova- tions have not attended sufficiently to the inte- gration of change and acceptance strategies, andUNRESOLVED ISSUES AND DIRECTIONS the reconciliation of these apparently inconsis-FOR FUTURE RESEARCH tent themes. It may in fact be the case that even the mostGiven the relatively recent emphasis of staunch acceptance-oriented therapists covertlyacceptance-based therapies within CBT, there or implicitly do evaluate the validity of theirremain a number of unresolved questions patients’ thoughts, and then promote accep-and directions for future research and clinical tance only when thoughts are inaccurate. In theinnovations. First, there is a need for new case of the man with chest pains described ear-technologies to promote psychological accep- lier, for example, no acceptance-based therapisttance. Given the pervasiveness of psychological would suggest that he simply acknowledge andchange-oriented strategies in Western culture, accept the pain without first referring him for anthe notion of fully accepting one’s experience appropriate medical evaluation to rule out car-while simultaneously engaging in behavior that diac disease. We propose that the determinationis seemingly inconsistent with that experience of whether acceptance versus engagement withcan be counterintuitive. A range of clinical thoughts is indicated is best made on the strengthstrategies and techniques are needed to foster of one’s knowledge that (1) one has already sys-psychological acceptance. It is likely that there tematically evaluated a thought before, and/oris untapped clinical wisdom among both (2) one’s mind routinely emits this exact thoughtpracticing cognitive behavior therapists and without good cause. An example of a workablethose from other theoretical orientations that strategy along these lines would be to reach anwould be helpful in promoting acceptance. agreement with patients to undertake a thoroughSimilarly, the best methods of training practi- evaluation of a troubling thought once and onlytioners in acceptance-based technologies require once, after which the thought is simply noticedfurther development. Many leading innovators, and accepted without further elaboration.including Kabat-Zinn, Linehan, and Teasdale, In addition to clinical developments, thereall stress the importance of therapists cultivating remain a number of unresolved conceptualtheir own mindfulness practice (Lau & McMain, issues. For example, is acceptance best concep-2005). Likewise, Hayes incorporates various tualized as an overt behavior that can be directlyexperiential exercises in his training workshops assessed, as suggested by Cordova (2001), orwith the purpose of developing a deeper as a private experience that is only indirectlyappreciation of ACT principles. Although there reflected in overt behavior? An individual withis clear logic to the notion that such efforts will social anxiety disorder may attend a partybe helpful in therapists’ efforts to understand but may engage in a variety of covert ‘‘safetyand transmit acceptance-based strategies, the behaviors’’ that render her not fully engaged inimportance of such training strategies is not the experience. A purely behavioral assessmentknown empirically. of the topography of her behavior would erro- Second, the development of more explicit neously conclude that she was highly acceptingguidelines is needed in order to distinguish of her anxiety. The quality of one’s experiencewhen psychological acceptance is likely to be with respect to a distressing stimulus is alsohelpful, and conversely, when direct change unclear. Cordova (2001) argues that ‘‘genuine’’strategies are indicated. As discussed above, acceptance involves a ‘‘change in the stimulusthere are situations in which a certain level of function from aversive to more attractive’’ andattentional control and evaluation of the truth similarly as ‘‘ . . . change in stimulus function
  • 2 • PSYCHOLOGICAL ACCEPTANCE 13of a situation toward that which inclines the and terminological confusion (Zvolensky,person to seek or remain in contact’’ (p. 221). Feldner, Leen-Feldner, & Yartz, 2005).According to this analysis, if one remains in A review of the outcome research oncontact with an aversive stimulus without the acceptance-based CBTs is beyond the scopestimulus losing its aversive properties, one is of this chapter; several reviews of the litera-effectively in a state of hopeless resignation ture are now available (e.g., Brantley, 2005;rather than true acceptance. It is noteworthy ¨ Coelho et al., 2007; Hayes et al., 2006; Ost,that this perspective effectively requires that 2008). In general, the status of this body ofthe stimulus be experienced as less aversive evidence can be summarized as preliminaryto qualify as ‘‘genuine’’ acceptance. Yet it but promising. Acceptance-based methodsseems entirely plausible that one could learn tend to fare at least as well as traditionalto remain in psychological contact with an change-oriented approaches, although only aaversive stimulus without requiring that one’s handful of direct head-to-head comparisonsreactions to it necessarily change. For example, have been conducted to date (e.g., Forman,a patient with chronic pain may learn to accept Herbert, et al., 2007; Lappalainen et al., 2007).rather than fight his pain. This may or may not Clearly, more outcome research utilizing largerresult in a change in his pain perception, but it samples and more sophisticated methodological ¨ controls is needed (see Ost, 2008, for a detailedis not clear that the degree of perceived painshould distinguish ‘‘real’’ acceptance from mere discussion of methodological controls within published studies on ACT and DBT). Likewise,resignation. What seems important instead is much more psychotherapy process researchhis abandoning ineffective struggles with the is needed to evaluate the extent to whichpain and his simultaneously pursuing other psychological acceptance mediates changes inactivities that will enrich his life. acceptance-based models of CBT, as well as There also remains confusion about how the perhaps even in more traditional models ofconstruct of psychological acceptance differs CBT. Although initial studies are encouragingfrom related constructs such as mindfulness. (Hayes, Levin, Yadavaia, & Vilardaga, 2007),Some theorists view acceptance as a necessary much more work remains to be done.feature of mindfulness. Brown and Ryan (2003),for example, propose that mindful awarenessnecessarily involves a nonjudgmental, accepting CONCLUSIONstance toward one’s experience. However, thisperspective fails to acknowledge that acceptance The field of CBT has recently witnessed andoes not always accompany awareness, as increased interest in theoretical and techno-in the case of heightened awareness of one’s logical developments related to psychologicalphysiological arousal in panic disorder. This acceptance. Acceptance-based models of CBThas led other theorists to deconstruct the are quickly growing in popularity. Preliminaryconcept of mindfulness such that acceptance data not only support the efficacy of suchis only one aspect. For example, Herbert and approaches, but also support the conclusionCardaciotto (2005) argue that mindfulness is that changes in psychological acceptance maybest viewed bidimensionally as consisting of mediate more general changes produced by psychotherapy, although much more workongoing awareness of one’s experience and remains to be done with respect to both outcomenonjudgmental acceptance of that experience, and process. In addition, a number of theoreticaland that these two components are in fact con- and practical issues remain outstanding andceptually and empirically distinct (Cardaciotto, await further development.Herbert, Forman, Moitra, & Farrow, in press).This conceptual and terminological confusion Referencesstems in part from the fact that investigatorsare approaching these questions from diverse Abramowitz, J. S., Tolin, D. F., & Street, G. P. (2001).theoretical perspectives, resulting in conceptual Paradoxical effects of thought suppression:
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M., (1987). Fears, phobias, and rituals: Panic, V., Dalrymple, K., & Nolan, E. M. (2005). Social anxiety, and their disorders. New York: Oxford Uni- skills training augments the effectiveness of cog- versity Press. nitive behavior group therapy for social anxiety Marlatt, G. A. Witkiewitz, K., Dillworth, T. M., Bowen, disorder. Behavior Therapy, 36, 125–138. S. W., Parks, G. A., Macpherson, L. M., et al.Hope, D. A., Heimberg, R. G., & Bruch, M. A. (1995). (2004). Vipassana meditation as a treatment for Dismantling cognitive–behavioral group therapy alcohol and drug use disorders. In S. C. Hayes, for social phobia. Behaviour Research and Therapy, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness 33, 637–650. and acceptance: Expanding the cognitive–behavioralJacobson, N. S., Christensen, A., Prince, S. E., Cordova, tradition (pp. 261–287). New York: Guilford. J., & Eldridge, K. (2000). Integrative behavioral Orsillo, S. M., Roemer, L., & Barlow, D. H. (2003). 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  • 16 COGNITIVE BEHAVIOR THERAPY anxiety: Using acceptance and mindfulness Tacon, A. M., Caldera, Y. M., & Ronaghan, C. (2004). to enhance traditional cognitive-behavioral Mindfulness-based stress reduction in women approaches. In S. M. Orsillo & L. Roemer (Eds.), with breast cancer. Families, Systems, & Health, 22, Acceptance- and mindfulness-based approaches to 193–203. anxiety: Conceptualization and treatment (pp. 3–35). Teasdale, J. D. (1997). The transformation of meaning: New York: Springer. The interacting cognitive subsystems approach. In¨Ost, L. (2008). Efficacy of the third wave of behavioral M. Power & C. R. Brewin (Eds.), The transformation therapies: A systematic review and meta-analysis. of meaning in psychological therapies (pp. 141–156). Behaviour Research and Therapy, 46, 296–321. Chichester, UK: Wiley.Roemer, L., & Orsillo, S. M. (2002). Expanding our Wells, A. (2000). Emotional disorders and metacog- conceptualization of and treatment for general- nition: Innovative cognitive therapy. Chichester, ized anxiety disorder: Integrating mindfulness/ UK: Wiley. acceptance-based approaches with existing Wells, A. (2007). The attention training technique: The- cognitive-behavioral models. Clinical Psychology: ory, effects, and a metacognitive hypothesis on Science and Practice, 9, 54–68. auditory hallucinations. Cognitive and BehavioralSegal, Z. V., Teasdale, J. D., & Williams, J. M. G. Practice, 14, 134–148. (2004). Mindfulness-based cognitive therapy: Wenzlaff, R. M., & Wegner, D. M. (2000). Thought sup- Theoretical rationale and empirical status. In pression. Annual Review of Psychology, 51, 59–91. S. C. Hayes, V. M. Follette, & M. M. Linehan Witkiewitz, K., Marlatt, G. A., & Walker, D. (2005). (Eds.), Mindfulness and acceptance: Expanding the Mindfulness-based relapse prevention for alcohol cognitive–behavioral tradition (pp. 45–65). New and substance use disorders. Journal of Cognitive York: Guilford. Psychotherapy, 19, 211–228.Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Zvolensky, M. J., Feldner, M. T., Leen-Feldner, Mindfulness-based cognitive therapy for depres- E. W., & Yartz, A. R. (2005). Exploring sion: A new approach to preventing relapse. New basic processes underlying acceptance and York: Guilford. mindfulness. In S. M. Orsillo & L. RoemerShermer, M. (2002). Why people believe weird things. New (Eds.), Acceptance and mindfulness-based approaches York: Henry Holt. to anxiety: Conceptualization and treatmentSulloway, F. J. (1983). Freud: Biologist of the mind. New (pp. 325–357). New York: Springer. York: Basic Books.
  • 3 ANGER (NEGATIVE IMPULSE) CONTROL Brad Donohue, Kendra Tracy, and Suzanne GorneyAnger is an internal affective experience that populations who might or might not benefit.varies in its intensity and chronicity (Deffen- Anger and aggression can sometimes be a sidebacher, 1996). It may be experienced as a neg- effect of various biological processes, however,ative impulsive reaction to a specific stimulus so these factors should be considered beforein the environment (e.g., aggression in response focusing entirely on psychological approaches.to being kicked, swearing consequent of beingstruck in the thumb with a hammer, urges to usedrugs in response to an argument) or may persist ANGER MEASUREMENTover time or across situations. Problem-solvingskills deficits, maladaptive withdrawal, child and Anger can be measured via self-report, observa-spousal abuse, and increased risk for health tion, or physiologically. Widely used self-reportproblems such as essential hypertension and measures include the State-Trait Anger Expres-cardiovascular disease are all examples of prob- sion Inventory-2 (STAXI-2; Spielberger, 1999)lems often influenced by inappropriate manage- and the Novaco Anger Scale and Provocationment of anger (see, e.g., Deffenbacher, Demm, Inventory (NAS-PI; Novaco, 2003). The STAXI-2& Brandon, 1986; Deffenbacher, Oetting, et al., evaluates state anger, defined as the intensity of1996; Gentry, Chesney, Gary, Hall, & Harburg, anger at a particular point in time; trait anger,1982; Krantz, Contrada, Hill, & Friedler, 1988; defined as the frequency with which anger isNovaco, 1979; Schneider, Egan, Johnson, Drobny, experienced; and anger expression and anger& Julius, 1996). control, both of which can be either inwardly To assist in the remediation of anger and or outwardly expressed. A sixth-grade readingother negative impulsive disorders, several cog- level is required to complete the STAXI; how-nitive behavioral methods have been developed ever, normative data has been collected only forincluding thought stopping, relaxation training, individuals aged 16 years and older. The psycho-problem solving, and self-reward for perfor- metric properties of the STAXI-2 and its compo-mance of non-anger-associated behaviors. We nent subscales have been empirically validated,will briefly delineate each of these methods, with the exception of test-retest reliability. Theincluding their rationale and empirical support. NAS-PI consists of two scales (the Novaco AngerWe will conclude by describing an urge control Scale and the Provocation Inventory) that can beintervention that combines these methods in the administered together or separately, to individ-effective management of negative impulses that uals aged 9 to 84 years, and to individuals withare associated with behavioral misconduct and developmental difficulties, although the itemsimpulsive urges to use illicit drugs. may need to be read to the respondent in such a case. The Novaco Anger Scale consists of four subscales: Anger Regulation, defined as one’sRESPONSIVE POPULATIONS ability to control angry impulses or thoughts;AND CONTRAINDICATIONS Behavior, impulsive reactions or expressions of anger; Arousal, the intensity and duration ofThe state of the literature in anger manage- anger; and Cognitive, factors such as rumina-ment does not allow clear guidance for specific tion, hostility, or justification of angry thoughts. 17
  • 18 COGNITIVE BEHAVIOR THERAPYA Total anger score is provided, which indicates Other phrases or visual images (e.g., ‘‘cut it out,’’a person’s general predisposition toward anger. image of a red stop sign) may be used instead ofThe Provocation Inventory is used to identify ‘‘stop!’’ to mentally disrupt anger (Deffenbacher,situations that typically cause anger in a par- 1996). Thought stopping is conceptualized toticular individual (e.g., unfairness, disrespect, work because thought inhibition is reinforcedfrustration, etc.). The NAS-PI contains a validity by the arousal reduction that occurs each timeindex, to evaluate inconsistent responding, and the individual successfully stops an undesir-has demonstrated good internal and predictive able thought (Tyson, 1998). The procedure hasvalidity, as well as reliability. The NAS in par- demonstrated effectiveness in decreasing neg-ticular has been found to discriminate between ative thinking (Peden, Rayens, Hall, & Beebe,clinical and nonclinical samples with 94% accu- 2001; Peden, Rayens, & Hall, 2005). However,racy (Jones, Thomas-Peter, & Trout; 1999). it is important to note that thought stopping is Anger is associated with increased autonomic not a primary method of intervention. Rather,activity, thus physiological measures have been the procedure is used as an initial componentused as more objective evaluations of an individ- (Deffenbacher, 1996) because it does not alter theual’s level of arousal. Increased blood pressure, situation or environment or teach coping skills.heart rate, and skin conductivity are associatedwith higher levels of anger (Dimsdale, Pierce, RELAXATION TRAININGSchoenfeld, Brown, Zusman, & Graham, 1986;Everson, 1998; Montoya, Campos, & Schandry, Since anger is accompanied by physiological and2005; Suchday & Larkin, 2001) in children as well emotional arousal (Suinn, 1990), relaxation train-as adults (Hubbard, Parker, & Ramsden, 2004). ing may be initiated to teach individuals howPhysiological measurement is difficult to imple- to become aware of bodily tensions that oftenment during in vivo situations that involve anger. precede anger and may be used as cues to elicitHowever, these measures can be utilized during relaxation (Kendall et al., 1991). Relaxation proce-contrived scenarios in which the participant is dures vary, but they usually include some aspectprompted to imagine triggers or situations that of progressive muscle relaxation to assist in theare emotionally laden with anger or upset. Along early recognition of tension and subsequent reg-these lines, the participant can be taught to iden- ulation to a calm state of arousal (see Chaptertify physiological responses (e.g., heart beating 49, this volume). In this method, the individualfaster) that may precede troublesome behavior is taught to tense and relax each of the major(e.g., arguments, fist fights). muscle groups, thus allowing him- or herself to focus on feelings distinguishing tension fromTHOUGHT STOPPING relaxation. After reviewing all muscles, the indi- vidual is often instructed to imagine a relaxingThought stopping is a method that may be uti- scenario (i.e., resting on a warm beach; sittinglized to interrupt undesirable or unproductive in a remote forest). Tension-releasing exercisesthoughts that often lead to anger. The method is (e.g., instructing the individual to imagine ten-particularly effective when the level of arousal is sion leaving all the major muscle groups; Cahill,relatively weak (i.e., first recognition of the stim- Rauch, Hembree, Foa, 2003) and focused breath-ulus eliciting anger) (Tyson, 1998). As exempli- ing (e.g., practicing slow and rhythmic diaphrag-fied by Wolpe (1990), the procedure begins with matic breathing; Kendall et al., 1991) are alsothe patient closing his or her eyes and verbalizing popular relaxation exercise components that maya thought that has been associated with nega- be used in the reduction of anger. Particularlytive arousal or anger. The therapist consequently useful is the administration of this technique inshouts, ‘‘stop!’’ and then points out to the patient conjunction with an in vivo or visualization expo-that the thought has actually stopped. After sure intervention in which the client is exposedpracticing the termination of similar thoughts to an anger provoking situation, implementingin separate trials, the patient is encouraged to relaxation techniques as necessary (Gorenstein,practice the termination of thoughts subvocally. Tager, Shapiro, Monk, Sloan, 2007).
  • 3 • ANGER (NEGATIVE IMPULSE) CONTROL 19PROBLEM-SOLVING SKILLS TRAINING of anger, and self-praise has been shown to improve self-efficacy—that is, belief that angerAnger can be an intrapersonal problem, an can be sufficiently reduced (Deffenbacher, 1996;interpersonal problem, a community or societal Meichenbaum & Deffenbacher, 1988). Moreover,problem, or some combination of these, and Bandura, Reese, and Adams (1982) found thatproblem solving can be implemented in all these self-efficacy was related to physiological arousalcases (Chapter 45, this volume). Problem solving such that tasks regarded with high self-efficacyis a conscious, rational, purposeful activity resulted in no visceral reaction. Thus, it followsdirected at finding one or more solutions to a that if an individual has a strong belief inspecific problem (D’Zurilla & Nezu, 1991). For the ability manage arousal, the physiologicaleach problem scenario, the individual is taught arousal will also be controlled.to (1) make a brief, summative statement of theproblem; (2) generate potential solutions without URGE CONTROLcritique; (3) evaluate the good and bad aspectsof each solution; (4) choose one or more of the The urge control procedure employs componentssolutions; and (5) attempt the chosen solution(s). of each of the preceding anger control methodsSelf-instruction should be considered in the in sequence (see Chapter 67). The procedure wasimplementation of problem-solving strategies originally developed to assist adults and adoles-to help the individual initiate, implement, cents in preventing urges to use drugs and alco-and evaluate potential solutions (Daunic, hol (Azrin, McMahon, et al., 1994) and was laterSmith, Brank, Penfield, 2006; Meichenbaum modified to address all impulsive behaviors that& Deffenbacher, 1988). Problem-solving skills result in troublesome behavior, including thosetraining is an important component in the elicited from anger (Azrin, Donohue, Teichner,prevention of anger and aggression. For Crum, Howell, & Decato, 2001).instance, both juvenile and adult offenders have A step-by-step guide is presented inbeen found to evidence problem-solving skills Table 3.1. Consistent with the principles ofdeficits (Biggam & Power, 2002; Bourke & Van behavioral therapy, a rationale for treatmentHasselt, 2001). Social problem-solving strategies is provided to the client who is evidencinghave demonstrated efficacy in reducing anger problems associated with impulsive behaviors(Feindler, 1991; Sukhodolsky, Golub, Stone, or anger. For example, ‘‘Earlier you told meOrban, 2005), perhaps because in attempting you often do things that have resulted into review options available, the individual is trouble for you, such as getting angry andfocused on solving the problem and is thus punching other kids. Many people say theydistracted from thoughts that are associated do things like this because they react beforewith anger. they’ve had a chance to think about how the action will affect themselves or others. TheySELF-REINFORCEMENT also say anger makes it harder to prevent them from doing impulsive behaviors that willHostile or aggressive individuals experience get them in trouble. Tell me some impulsivelower levels of self-reinforcement than nonag- things you’ve done that later led to troublegressive individuals (Heiby & Mearig, 2002). for you or someone else [provide empathy].Therefore, it follows that individuals who have The technique you are about to learn is calleddifficulty in the management of their anger (as urge control because you will learn to controlwell as other negative behaviors) benefit from impulsive thoughts and feeling, such as anger,learning to reinforce themselves consequent that usually lead to trouble for you. You willto performing behaviors that terminate or learn to recognize these feelings and thoughtsreduce anger (negative impulses) or that are early, when they are not as strong. This shouldincompatible with anger (Meichenbaum & enable you to do other behaviors that willDeffenbacher, 1988). Indeed, positive reinforce- keep you out of trouble. Do you have anyment is commonly employed in the management questions?’’
  • 20 COGNITIVE BEHAVIOR THERAPYTABLE 3.1 Steps in Urge ControlFirst Session 1. Provide rationale. a. ‘‘Earlier, you said that you had done some spontaneous things that resulted in trouble for you, such as getting angry and yelling at others. Anger often starts out as a casual thought and grows in intensity. As the intensity of the anger grows, it becomes harder to prevent oneself from acting on negative impulses, such as aggressive behavior. The following technique is called the urge control procedure, and it will help you to learn how to control impulsive thoughts and feelings.’’ 2. Identify the most recent situation involving anger. 3. Model the following components of urge control: a. Stop! b. State one negative consequence for self and one for others if impulse is acted on. c. Relaxation, deep breaths. d. State four or more behavioral alternatives that are incompatible with anger. e. Imagine doing a behavior that is incompatible with anger. f. Imagine telling friends or family about doing the behavior, and imagine their positive responses. g. State positive things that will happen because the behavior is performed. 4. Reveal step(s) that helped decrease anger the most. 5. Reveal pre- and post-anger ratings. 6. Instruct client to perform urge control for a recent situation involving anger. 7. Instruct client to identify the component that helped decrease anger the most. 8. Instruct client to provide pre- and post- anger ratings. 9. Instruct client to provide ratings of each of the steps that were role-played.10. Instruct client to continue to role-play urge control trials, as needed.Future Sessions 1. Instruct client to use urge control in response to a situation involving anger. 2. Solicit client’s pre- and post-anger ratings. 3. Solicit which step was most helpful. 4. Solicit or provide feedback regarding the trial. The client is informed that recognizing and Therapist: You did a good job of identifying astopping impulsive thoughts or anger when thought that eventually led to hitting the boy in this situation. However, I want you to thinkthese thoughts first occur will greatly reduce hard. I’m sure you had a thought that broughtthe likelihood of engaging in negative impulsive you to the argument.behaviors. The client is instructed to disclose a sit- Youth: I started to think what a jerk he was foruation in which he or she experienced a negative asking my girlfriend if she’d like to talk withimpulsive behavior subsequent to anger and to him on the patio.identify the first thought associated with anger in Therapist: Excellent!that situation. As the following vignette demon- The therapist then models an urge control.strates, the therapist must sometimes assist the The first step of the urge control procedure is toclient in determining his or her first thought catch the anger-associated thought or image thatrelated to anger. preceded the troublesome impulsive behavior early in the response chain, and consequently Therapist: Tell me about the last time your anger terminate this thought or image by firmly stating led to your doing an impulsive or trouble- some behavior. I’m especially interested in the ‘‘stop’’ while muscles are tensed. Background thought that you had before you made plans to information associated with the situation should engage in the impulsive behavior. be stated with just enough detail to illuminate Youth: I was arguing with this guy, and I thought it the situation (e.g., ‘‘I’m in front of the mailbox. would feel good to let him have it, so I hit him. My friend tells me to give the old man’s mailbox
  • 3 • ANGER (NEGATIVE IMPULSE) CONTROL 21a bash with the bat I can feel the hatred for the old negative impulsive behaviors, (2) briefly check-man because he got me in trouble last week’’). ing to make sure the response is unlikely to The second step is to state at least one bring about anger or negative impulsive behav-negative consequence for getting angry and/or iors for self or others, or (3) reviewing positivedoing the undesired impulsive behavior, and consequences for self and others that may occurat least one negative consequence for friends, consequent to behaviors that are not associ-loved ones, or others who care about the client. ated with anger or negative impulsive behaviors.Use of perspective-taking skills has been shown During this exercise, it is important to provideto decrease anger arousal (Mohr, Howells, prompts to the client regarding additional alter-Gerace, Day, Wharton, 2007). Therefore, it native behaviors, how self and others wouldmakes sense that anger can be decreased after be positively affected by alternative behaviors,thinking about how negative consequences of what others would do for the client if alterna-anger affect others, especially those who are tive behaviors were performed, and how prob-loved, admired, or respected by the client, lem behaviors may continue to have negativeAlong these lines, negative consequences should consequences.be stated with affect reflecting despair, and After stating several behaviors that are incom-muscles should remain tense. Consequences patible with the behaviors associated with angermay be rotated (or changed) as trials progress. or impulsiveness, the client is encouraged to choose one option and describe doing the behav-Therapists should prompt detail regarding ior (e.g., I’m imagining walking toward Jackienegative consequences. and telling her I’d like to take her to get some- Stating the last negative consequence should thing to eat. I’m walking away from the guysignal the performance of a muscle review to and toward the car with Jackie. She is smilingassure that negative feeling states, and tension and telling me she’d love to get a big saladin muscles, are not present. Therapeutically, and she’s glad I didn’t start a fight with thatrelaxation techniques have been efficacious in guy.’’). When the client performs this step, theproducing positive change in the short and long therapist should provide prompts to elicit detail,term when dealing with anger (Deffenbacher, including questions as to how the client will suc-Oetting, Huff, & Cornell, 1996). Major muscles cessfully resolve difficult situations that are likelyshould be reviewed from head to toe. During to occur. Sometimes the client may be instructedthis review, if a muscle is tense, the client should to practice getting out of difficult interpersonaluse relaxing cue words until the muscle is no situations (e.g., ‘‘Show me how you would asklonger tense (e.g., My arms are getting more your girlfriend to leave. I’ll be her.’’).and more relaxed. I am imagining a band of The next step is to imagine telling a friendrelaxation around my arms. They feel relaxed, and/or family member about having performedcalm, more and more relaxed.’’) Deep, rhythmic the trouble-free alternative behavior. The recip-breaths should occur throughout the trial. Body ient should respond in a favorable manner,weight should be evenly distributed and posi- and positive feeling should be delineated. Fortioned in a relaxed state. Statements referring example, ‘‘I’m telling my mom that I could haveto the relaxed state of the body are acceptable fought the guy at the party, but instead I wentthroughout the relaxation period, which should to get something to eat with my girlfriend. Ascontinue until all muscle groups feel relaxed I’m telling her this, I feel good about myself. My(ideally about 5 to 10 seconds). If no tension or mom looks at me and tells me I’m doing a greatnegative feeling states are present, the client may job and that she’s proud of me. She also tellsbe instructed to only breathe deeply. me she’s been thinking about letting me have a The next step involves stating several behav- curfew extension because I’ve been acting veryiors that may be performed instead of getting responsible.’’angry or engaging in negative impulsive behav- The trial concludes when the client describesiors. These steps may include (1) stating several several pleasant outcomes and positive characteralternative actions that do not include anger or attributes. For example, ‘‘I’m really proud of
  • 22 COGNITIVE BEHAVIOR THERAPYmyself for going out to eat with my girlfriend problem behaviors in addition to anger manage-instead of fighting that guy. I’m going to have a ment. For instance, thought stopping has beengreat time with her and improve our relationship. shown to be effective in reducing the unwanted,I also liked how I avoided going near that guy. intrusive thoughts associated with depressionThat says a lot about the kind of person I am. I (Peden, Rayens, & Hall, 2005), chronic paincan usually hold my own in a fight but I can also (Degotardi, Klass, & Rosenberg, 2006), post-avoid them when I want. If I can keep my anger traumatic stress disorder (PTSD) (Foa, 1997),under control, I’m going to make my girlfriend obsessive–compulsive disorder (OCD) (Lam &and my parents proud, and I’ll be able to get Steketee, 2001), primary insomnia (Backhaus,more privileges at home and school.’’ Hohagen, Voderholzer, & Rieman, 2001), eating When clients practice the urge control pro- disorders (Cinciripini, Kornblith, & Turner,cedure for the first time, it may be necessary 1983), and overeating (Bonato & Boland, 1986).to state the situation and prompt the client to Thought stopping has also been applied in sportssubsequently state ‘‘stop’’ (e.g., ‘‘You’re at the psychology to decrease thoughts that negativelyparty. You hear the guy at the party ask your influence athletes’ performance (Sheard &girlfriend to go out on the patio. Go ahead and Golby, 2006). Relaxation training is a key featureyell ‘stop!’ ’’). Similarly, it may be necessary to in exposure and systematic desensitization inter-prompt the client to perform each component ventions targeting a broad range of anxiety-ladeninitially, and later decrease this assistance. problem disorders such as generalized anxiety After the client completes each trial, the ther- disorder and anorexia nervosa (Ayers, Sorrell, &apist asks the client to provide his or her rating Thorp, 2007; Goldfarb, Fuhr, & Tsujimoto, 1987;(0 = no anger, 100 = completely angry) of anger Stapleton, Taylor, & Asmundson, 2006).or desire to engage in the impulsive behav- Self-reinforcement is a component of manyior prior to performing the trial, and after the self-monitoring procedures that have beentrial is performed (i.e., pre- and posttrial urge applied to the treatment of depression (Rehmlevel). The client is prompted to critique his or & Rokke, 1988), social anxiety (Kocovski &her performance, and the therapist subsequently Endler, 2000), learning disorders (Graham,praises the client for making statements during Harris, & Olinghouse, 2007), and autismthe trial that reflected protocol adherence, includ- (Newman, Buffington, & Hemmes, 1996) toing suggestions or prompts to client regarding aid in increasing positive or adaptive behav-ways to improve performance in future sessions. iors. Poor problem-solving skills have beenThe number of trials performed depends on the linked to both externalizing and internalizingextent of the client’s troublesome behavior since disorders (D’Zurilla, Chang, & Sanna, 2003;last contact. Similarly, poor performance during Londahl, Tverskoy, & D’Zurilla, 2005). Indeed,trials necessitates additional trials per session. problem-solving skills training has been shown to be efficacious for a variety of problems in children including, but not limited to, anger andEVIDENCE-BASED APPLICATIONS aggression (Kazdin, 2000; Sukhodolsky, Golub, Stone, & Orban, 2005). This technique has alsoThe urge control procedure was originally been utilized with adults in the treatment ofdeveloped to prevent urges to use drugs and depression (Biggam & Power, 2002) and negativehas demonstrated efficacy in that area (Azrin, affect (Sahler, Fairclough, & Phipps, 2005).McMahon, & Donohue, 1994). This procedure Although the urge control components are wellhas also demonstrated efficacy in the prevention supported, it should be mentioned that none areof other types of impulsive problem behaviors, stand-alone therapies. Research suggests thatsuch as delinquency (Azrin, Donohue, et al., when they are combined with other therapeutic2001). The individual components of the urge techniques, they have an additive effect, leadingcontrol procedure; thought stopping, relaxation to more positive outcomes (Deffenbacher,training, problem-solving skills training, and Oetting, & DiGiuseppe, 2002; Tyson, 1998).self-reinforcement, have been applied to a host of Thus, the combination of behaviorally based
  • 3 • ANGER (NEGATIVE IMPULSE) CONTROL 23components in the urge control procedure CONCLUSIONSwork together to effectively reduce negativeimpulsive behaviors. Anger and impulse control problems are highly associated with devastating problem behaviors, including various disorders that areRESOURCES relevant to eating, substance abuse, conduct, and mood. Comprehensive evidence-basedFor the individual concerned about anger prob- intervention programs have been developed tolems, there are many resources available, both ameliorate these problems, and many of theseon the Internet and at the local bookstore. Web programs include components to specificallysites such as www.apa.org provide basic infor- address anger management and impulse controlmation about anger and offer links to scholarly problems. These programs are becomingarticles on the subject, in addition to supply- increasingly sophisticated and better integrateding anger management tips from experts in the into comprehensive psychological interventions,field (APA, 2008). The APA Help Center pro- thus enhancing efficacy.vides simple cognitive-behavioral strategies forpreventing violent, angry outbursts in children,adolescents, and adults (APA, 2004). Addition- Referencesally, e-therapy, in which clients communicate American Psychological Association. (2004). Dealingwith therapists via e-mail and teleconference, is with anger. Retrieved January 8, 2008 frombecoming increasingly popular. A simple inter- www.apahelpcenter.org/featuredtopics.net search will turn up dozens of sites that American Psychological Association. (2008). Con-connect clients with therapists; however, a major trolling anger before it controls you. Retrievedcaveat is that few e-therapy providers iden- January 8, 2008, from www.apa.org/topics/ controlanger.html.tify the type of degree their therapists possess Ayers, C. R., Sorrell, J. T. & Thorp, S. R. (2007).and whether or not they are licensed (Rabasca, Evidence-based psychological treatments for2000). An alternative resource for professionals late-life anxiety. Psychology and Aging, 22(1),in the field of psychology is the National Reg- 8–17.istry of Evidence-Based Programs and Practices Azrin, N. H., Donohue, B., Teichner, G., Crum, T.,(www.nrepp.samhsa.gov), which can be used Howell, J., & DeCato, L. (2001). A controlled eval-to identify evidence-based treatment programs uation and description of individual-cognitive problem solving and family-behavioral therapieswith a focus on violence prevention. This web in conduct-disordered and substance dependentsite includes several evidence-based programs youth. Journal of Child and Adolescent Substancethat chiefly target anger and associated negative Abuse, 11, 1–43.emotions. Azrin, N. H., McMahon, P. T., Donohue, B., Besalel, Although evidence supporting the use of bib- V., Lapinski, K., & Kogan, E. (1994). Behaviorliotherapy is mixed, the literature suggests that therapy for drug use: A controlled treatment out-in conjunction with therapy, or for those without come study. Behaviour Research and Therapy, 32(8), 857–866.significant problems, self-help books can be ben- Backhaus, J., Hohagen, F., Voderholzer, U., & Reimann,eficial (Mains & Scogin, 2003; Marrs, 1995). An D. (2001). Long-term effectiveness of a short-termadvantage of self-help books is that cutting-edge cognitive-behavioral group treatment for primarytherapies are available to the public in an easily insomnia. European Archives of Psychiatry and Clin-accessible form. Campbell and Smith (2003) offer ical Neuroscience, 251(1), 35–41.guidelines for therapists seeking to incorporate Bandura, A., Reese, L., & Adams, N. E. (1982).self-help books into therapy, including ways to Micro-analysis of action and fear arousal as a function of different levels of perceivedevaluate and select books. Books that are strongly self-efficacy. Journal of Personality and Socialfounded in research include: Act on Life Not on Psychology, 43, 5–21.Anger: The New Acceptance and Commitment Ther- Biggam, F. H., & Power, K. G. (2002). A controlled,apy (Eifert, McKay, Forsyth, & Hayes, 2006) and problem-solving, group-based interventionAnger Management for Dummies (Gentry, 2006). with vulnerable incarcerated young offenders.
  • 24 COGNITIVE BEHAVIOR THERAPY International Journal of Offender Therapy and sex, social class, obesity, and age. Psychosomatic Comparative Criminology, 46(6), 678–698. Medicine, 48(6), 430–436.Bonato, D. P., & Boland, F. J. (1986). A comparison D’Zurilla, T. J., Chang, E. C., & Sanna, L. J. (2003). of specific strategies for long term maintenance Self-esteem and social problem solving as predic- following a behavioural treatment program for tors of aggression in college students. Journal of obese women. International Journal of Eating Disor- Social and Clinical Psychology, 22, 424–440. ders, 5(5), 949–958. D’Zurilla, T. J., & Nezu, A. M. (1991). Problem-Bourke, M. L., & Van Hasselt, V. B. (2001). Social solving therapies. In K. S. Dobson (Ed.), Handbook problem-solving skills training for incarcerated of cognitive behavioral therapies (pp. 211–245). New offenders: A treatment manual. Behavior Modifica- York: Guilford Press. tion, 25(2), 163–188. Everson, S. A. (1998). Anger expression and inci-Cahill, S. P., Rauch, S. A., Hembree, E. A., & Foa, E. B. dent hypertension. Psychosomatic Medicine, 60(6), (2003). Effect of cognitive–behavioral treatments 730–735. for PTSD on anger. Journal of Cognitive Psychother- Feindler, E. L. (1991). Cognitive strategies in anger apy: An International Quarterly, 17(2), 113–131. control interventions for children and adolescents.Campbell, L. F., & Smith, T. P. (2003). Integrating In P. C. Kendall (Ed.), Child and adolescent therapy: self-help books into psychotherapy. Journal of Cognitive–behavioral procedures (pp. 67–97). New Clinical Psychology, 59(2), 177–186. York: Guilford Press.Cinciripini, P. M., Kornblinth, S. J., & Turner, Foa, E. B. (1997). Trauma and women: Course, predic- S. M. (1983). A behavioral program for tors, and treatment. Journal of Clinical Psychiatry, the management of anorexia and bulimia. 58(9) 25–28. Journal of Nervous and Mental Disease, 171(3), Gentry, W. (2006). Anger management for dummies. 186–189. Hoboken, NJ: Wiley Publishing, Inc.Daunic, A. P., Smith, S. W., Brank, E. M., & Penfield, Gentry, W., Chesney, A., Gary, H., Hall, R., & Harburg, R. D. (2006). Classroom-based cognitive–behavioral E. (1982). Habitual anger-coping styles: I. Effect on intervention to prevent aggression: Efficacy and mean blood pressure and risk for essential hyper- social validity. Journal of School Psychology, 44(2), tension. Psychosomatic Medicine, 44, 195–202. 123–139. Graham, S., Harris, K. R., & Olinghouse, N. (2007).Deffenbacher, J. L., Demm, P. M., & Brandon, A. D. Addressing executive function problems in writ- (1986). High general anger: Correlates and treat- ing: An example from the self-regulated strategy ment. Behavior Research and Therapy, 24, 481–489. development model. In L. Meltzer (Ed.), Execu-Deffenbacher, J. L. (1996). Cognitive-behavioral ap- tive function in education: From theory to practice proaches to anger reduction. In K. S. Dobson & (pp. 216–236). New York: Guilford Press. K. D. Craig (Eds.), Advances in cognitive-behavioral Goldfarb, L. A., Fuhr, R., & Tsujimoto, R. N. (1987). therapy. Thousand Oaks, CA: Sage. Systematic desensitization and relaxation asDeffenbacher, J. L., Oetting, E. R., & DiGiuseppe, R. A. adjuncts in the treatment of anorexia nervosa: (2002). Principles of empirically supported inter- A preliminary study. Psychological Reports, 60(2), ventions applied to anger management. Counsel- 511–518. ing Psychologist, (30) 2, 262–280. Gorenstein, E. E., Tager, F. A., Shapiro, P. A.,Deffenbacher, J. L., Oetting, E. R., Huff, M. E., Monk, C., & Sloan, R. P. (2007). Cognitive & Cornell, G. R. (1996). Evaluation of two –behavior therapy for reduction of persistent cognitive–behavioral approaches to general anger. Cognitive and Behavioral Practice, 14(2), anger reduction. Cognitive Therapy and Research, 168–184. 20(6), 551–573. Heiby, E. M., & Mearig, A. (2002). Self-control skillsDeffenbacher, J. L., Oetting, E. R., Thwaites, G. A., and negative emotional state: A focus on hostility. Lynch, R. S., Baker, D. A., Stark, R. S., et al. Psychological Reports, 90(2), 627–633. (1996). State-trait theory and the utility of the trait Hubbard, J. A., Parker, E. H., & Ramsden, S. R. (2004). anger scale. Journal of Counseling Psychology, 43(2), The relations among observational, physiologi- 131–148. cal, and self-report measures of children’s anger.Degotardi, P. J., Klass, E. S., & Rosenberg, B. S. Social Development, 13(1), 14–39. (2006). Development and evaluation of a Jones, J. P., Thomas-Peter, B. A., & Trout, A. (1999). cognitive-behavioral intervention for juvenile Normative data for the Novaco Anger Scale from fibromyalgia. Journal of Pediatric Psychology, 31(7), a non-clinical sample and implications for clinical 714–723. use. British Journal of Clinical Psychology, 38(4),Dimsdale, J. E., Pierce, C., Schoenfeld, D., Brown, A., 417–424. Zusman, R., & Graham, R. (1986). Suppresses Kazdin, A. E. (2000). Treatments for aggressive anger and blood pressure: The effects of race, and antisocial children. Child and Adolescent
  • 3 • ANGER (NEGATIVE IMPULSE) CONTROL 25 Psychiatric Clinics of North America, 9(4), of the American Psychiatric Nurses Association, 11(1), 841–858. 18–25.Kendall, P. C., Chansky, T. E., Friedman, M., Kim, R., Peden, A. R., Rayens, M. K., Hall, L. A., & Beebe, Kortlander, E., Sessa, F. M., et al. (1991). Treat- L. H. (2001). Preventing depression in high ing anxiety disorders in children and adolescents. risk college women: A report of an 18 month In P. C. Kendall (Ed.), Child and adolescent ther- follow-up. Journal of American College Health, 49, apy: Cognitive–behavioral procedures (pp. 67–97). 299–306. New York: Guilford Press. Rabasca, L. (2000). Self-help sites: A blessing or a bane?Kocovski, N. L., & Endler, N. S. (2000). Social anxiety, Monitor on Psychology, 31(4). self-regulation, and fear of negative evaluation. Rehm, L. P., & Rokke, P. (1988). Self-management European Journal of Personality, 14(4), 347–358. therapies. In K. S. Dobson (Ed.), HandbookKrantz, D., Contrada, R., Hill, D., & Friedler, E. of Cognitive-Behavioral Therapies. New York: (1988). Environmental stress and biobehavioral Guilford. antecedents of coronary heart disease. Journal of Sahler, O. J., Fairclough, D. L., & Phipps, S. (2005). Consulting and Clinical Psychology, 56, 333–341. Using problem-solving skills training to reduceLam, J. N., & Steketee, G. S. (2001). Reducing obses- negative affectivity in mothers of children with sions and compulsions through behavior therapy. newly diagnosed cancer: Report of a multisite Psychoanalytic Inquiry, 21(2), 157–182. randomized trial. Journal of Consulting and ClinicalLondahl, E. A., Tverskoy, A., & D’Zurilla, T. J. (2005). Psychology, 73(2), 272–283. The relations of internalizing symptoms to conflict Schneider, R. H., Egan, B. M., Johnson, E. H., Drobny, and interpersonal problem solving in close rela- H., & Julius, S. (1996). Anger and anxiety in bor- tionships. Cognitive Therapy and Research, 29(4), derline hypertension. Psychosomatic Medicine, 48, 445–462. 242–248.Mains, J. A., & Scogin, F. R. (2003). The effectiveness of Sheard, M., & Golby, J. (2006). Effect of a psychological self-administered treatments: A practice-friendly skills training program on swimming perfor- review of the research. Journal of Clinical Psychol- mance and positive psychological development. ogy, 59(2), 237–246. International Journal of Sport and Exercise Psychol-Marrs, R. W. (1995). A meta-analysis of bibliotherapy ogy, 4(2), 149–169. studies. American Journal of Community Psychology, Spielberger, C. D. (1999). State-trait anger expression 23(6), 843–870. inventory-2. Odessa, FL: Psychological Assess-Meichenbaum, D. H., & Deffenbacher, J. L. (1988). ment Resource, Inc. Stress inoculation training. The Counseling Psy- Stapleton, J. A., Taylor, S., & Asmundson, G. J. chologist, 16, 69–90. (2006). Effects of three PTSD treatments on angerMohr, P., Howells, K., Gerace, A., Day, A., & and guilt: Exposure therapy, eye movement Wharton, M. (2007). The role of perspective desensitization and reprocessing, and relaxation taking in anger arousal. Personality and Individual training. Journal of Traumatic Stress, 19(1), Differences, 43(3), 507–517. 19–28.Montoya, P., Campos, J. J., & Schandry, R. (2005). See Suchday, S., & Larkin, K. T. (2001). Biobehavioral red? Turn pale? Unveiling emotions through car- responses to interpersonal conflict during anger diovascular and hemodynamic changes. Spanish expression among anger-in and anger-out men. Journal of Psychology, 8(1), 79–85. Annals of Behavioral Medicine, 23(4), 282–290.Novaco, R. (1979). The cognitive regulation of anger Suinn, R. M. (1990). Anxiety management training: A and stress. In P. C. Kendall & S. Hollon (Eds.), behavior therapy. New York: Plenum. Cognitive-behavioral interventions: Theory, research, Sukhodolsky, D. G., Golub, A., Stone, E. C., & and procedures. New York: Academic. Orban, L. (2005). Dismantling anger controlNovaco, R. (2003). Novaco anger scale and provocation training for children: A randomized pilot study inventory. Los Angeles: Western Psychological of social problem-solving versus social skills Services. training components. Behavior Therapy, 36(1),Newman, B., Buffington, D. M., & Hemmes, N. S. 15–23. (1996). Self-reinforcement used to increase the Tyson, P. D. (1998). Physiological arousal, reactive appropriate conversation of autistic teenagers. aggression, and the induction of an incompat- Education and Training in Mental Retardation and ible relaxation response. Aggression and Violent Developmental Disabilities, 31(4), 304–309. Behavior, 3(2), 143–158.Peden, A. R., Rayens, M. K., & Hall, L. A. (2005). Wolpe, J. (1990). The practice of behavior therapy A community-based depression prevention inter- (4th ed.). Elsmford, NY: Pergamon. vention with low-income single mothers. Journal
  • ASSERTIVENESS SKILLS AND THE 4 MANAGEMENT OF RELATED FACTORS Melanie P. DuckworthAssertive behavior usually centers on making BEHAVIORAL, COGNITIVE–AFFECTIVE,requests of others and refusing requests made by AND SOCIAL FACTORS INFLUENCINGothers that have been judged to be unreasonable. ASSERTIVENESSAssertive behavior also captures the communi-cation of strong opinions and feelings. Assertive Given that assertive behavior occurs as a part of a broader interaction complex, the likelihoodcommunication of personal opinions, needs, and that an individual will engage in assertiveboundaries has been defined as communication behavior is a function of skill and performancethat diminishes none of the individuals involved competencies, reinforcement contingencies, andin the interaction, with emphasis on communica- motivational–affective and cognitive–evaluativetion accuracy and respect for all persons engaged factors. Behavioral explanations for the use ofin the exchange. passive or aggressive strategies rather than Assertiveness is conceptualized as the behav- assertive strategies emphasize opportunities forioral middle ground, lying between ineffective skills acquisition and mastery and reinforcementpassive and aggressive responses. Passiveness is contingencies that have supported the use ofcharacterized by an overattention to the opinions passive or aggressive behaviors over time.and needs of others and the masking or restrain- Behavioral conceptualizations for passivity oftening of personal opinions and needs. This over- emphasize early learning environments in whichattention to and compliance with the opinions passive responding may have been modeledand needs of others may serve as a strategy for (e.g., caregivers who were themselves anxious,conflict avoidance or maintenance of particular shy, or in some other way less than assertive) orsources of social reinforcement. Aggressiveness more assertive behavior punished (e.g., overlyoften involves the imposition of one’s opin- protective or dominating care givers). In theions and requirements on another individual. absence of opportunities for acquisition andImplicit in the discussion of assertiveness is the reinforcement of other interaction strategies, passive behavior persists.suggestion that assertive behavior is the univer- Important to any complete behavioralsally preferred behavioral alternative, and that conceptualization of passive behavior wouldassertive behavior necessarily leads to preferred be an evaluation of the reinforcement that isoutcomes. The degree to which assertive behav- associated with current displays of passiveiors are to be considered superior to either a pas- behavior, that is, how is passivity currentlysive or an aggressive stance is determined by the working for the individual? Behaviors that aresituational context. The success of assertiveness reinforced are repeated. Repeated engagementdoes not always lie in tangible outcomes (e.g., in passive behavior suggests repeated reinforce-request fulfillment). The success of assertiveness ment of such behavior. Passive respondingsometimes lies in the degree of personal con- may be reinforced through the avoidance oftrol and personal respect that is achieved and responsibility and decision making. With whatmaintained throughout the assertive exchange. amount of attention, positive or negative, 26
  • 4 • ASSERTIVENESS SKILLS AND THE MANAGEMENT OF RELATED FACTORS 27are passive responses met? The individual present these behaviors as falling into threeemploying passive strategies may need to mutually exclusive categories. Assertive behav-reconcile his or her ‘‘active’’ influence on ior is nuanced behavior, the tone, content, andsituations with the alleged passivity. appearance of which is determined by the per- Aggressive behaviors can be learned through ception of the social context and social demandsthe observation of aggressive models and rein- of a given moment. Certain social situationsforced through their instrumental effects. Even in require only gentle assertion of needs and desiresthe absence of overt goal attainment, aggressive while other situations require firm assertion ofbehaviors may be experienced as intrinsi- those needs and desires. On the first occasioncally reinforcing by virtue of the autonomic of your neighbor’s dog’s chewing through thedischarge associated with such behaviors. dividing fence, a communication that brings theAggressive behavior may serve as a socially neighbor’s attention to the damage might besanctioned interaction style (Tedeschi & Felson, sufficient to resolve the matter. On the fourth1994). Aggressive behavior may also be a occasion of the dog’s chewing through the divid-consequence of the absence of opportuni- ing fence, a communication indicating intent toties to acquire alternative social interaction bring the matter to the attention of the neighbor-strategies. hood association and/or animal control may be Motivational–affective factors are important warranted.to patterned displays of passive and aggressivebehavior. Although the affective experience ofanger is not sufficient to explain aggressive ASSESSMENTbehavior, feelings of anger do increase thelikelihood that the actions of others will be Assessment of assertiveness skills and perfor-experienced as aggressive and, thereby, elicit mance abilities should be broad enough to cap-aggressive behavior. Cognitive explanations for ture and distinguish among various explanationspassive and aggressive responding would posit for performance failure. Traditionally, a hierar-that outcome expectations are primary in deter- chical task analysis is used to determine themining the passive or aggressive response. The causal variable that accounts for the skill or per-passive individual may look to his or her history formance deficit (Dow, 1994). Initially, assertive-of failures in making or refusing requests in ness skills are evaluated in a nonthreatening (ordeciding whether to attempt the recommended less threatening) environment. Given that theassertive behavior. Outcome expectations may client demonstrates adequate assertiveness skillinterfere with adoption of the ‘‘new’’ assertive- in the nonthreatening environment, assertive-ness. Such outcome expectations must be ness skills are evaluated in the context of moremanaged if the likelihood of assertive respond- clinically relevant social situations. Given thating is to increase. The passive individual needs skills are adequately demonstrated in clinicallyto be cautioned regarding the imperfect relation- relevant social situations, other contributions toship between assertive responding and desired response failure are evaluated including affec-outcomes. Initially, assertive responses may not tive and cognitive variables that might mediatemeet with desired outcomes. It is the persistence the skill–performance relation. Behavioral mod-of the assertive response that will ensure that els of depression suggest that the pursuit ofthe probability of the desired outcome increases social interaction (and, thus, experience of rein-over time. In the short run, then, the measure of forcement) may be limited by negative affec-successful assertion may not be the occurrence tive experiences that are present throughoutof a desired outcome but the mere assertive the interaction (Lewinsohn, 1974). For example,communication of one’s opinions, needs or anxiety that is experienced during an assertivelimits. interaction may be insufficient to impair per- In an effort to assist individuals in discrimi- formance but may be sufficient to render thenating assertive behavior from passive behavior interaction a punishing rather than reinforcingand aggressive behavior, clinicians sometimes event.
  • 28 COGNITIVE BEHAVIOR THERAPYPRECONDITIONS FOR ASSERTIVENESS ASSESSMENT OF ASSERTIVENESS SKILLS AND PERFORMANCE ABILITIESAssertive behaviors presuppose the existence ofadequate social skills. An assertive communi- Assessment of skill sets and performance com-cation is measured not only by the content of petencies is necessary prior to skills training andthe verbalization but also by the accompany- throughout the skills acquisition and practiceing nonverbal behaviors. Appropriate posture process. Skills for behaving assertively are eval-and eye contact are essential in executing an uated through the use of self-report instrumentsappropriately assertive response. An appropri- as well as behavioral observation in simulatedately assertive posture would convey relaxed and natural settings.but focused attention, in contrast to an overlyrigid posture, which might convey either anxiety Questionnairesor obstinacy. Other important nonverbal behav-iors include facial expression and body move- Assertiveness skill evaluation and training oftenments and gestures. Affective displays should occurs in the broader context of social skill andbe congruent with the content of the assertive social competence. The self-report instrumentscommunication, not suggesting anxiety, false that purport to measure assertiveness range fromgaiety, or anger. Body movements that indi- actual measures of assertive behaviors to instru-cate nervousness and uncertainty (e.g., hand ments that assess related constructs such aswringing) should be avoided. Movements that social avoidance, self-esteem, and locus of con-convey anger or dominance (e.g., invasion of the trol. The most commonly used general measureother’s personal space) should also be avoided. of assertiveness skills is the Rathus Assertive-These nonverbal behaviors are included among ness Scale (Rathus, 1973). Other assertivenessbehaviors identified by Dow (1985) as relevant questionnaires have been designed to evaluateto socially skilled behaving. assertive behavior occurring in various profes- The content of the assertive communication sional (e.g., nursing) and clinical (e.g., date rapeis important in its clarity and form. The tone prevention, HIV/AIDS prevention, social anxi-and fluidity of the request or refusal are also ety treatment, and substance abuse relapse pre-important. Generally, the assertive request is vention) contexts.characterized by its reasonableness, its speci-ficity regarding actions required to fulfill therequest, and its inclusion of statements that con- Self-Monitoring Assignmentsvey the potential impact(s) of request fulfillment Self-monitoring of social behaviors performed infor both the individual making the request and the client’s natural environment is essential tothe request recipient. The tone in which the both assessment and treatment of potential skillsrequest is delivered should convey the impor- and performance deficits. Monitoring instruc-tance of the request; however, the tone should tions usually require that the client describenot imply some obligation on the part of the his or her social interactions with others alongrequest recipient to comply with the request. a number of dimensions. The client may beDow (1994) suggests that, in the context of a instructed to briefly describe interactions withrequest for behavior change, the potential for males versus females, acquaintances versus inti-a satisfactory outcome is maximized when the mate others, peers versus persons in authority,assertive communicator refrains from making and in structured versus unstructured interac-assumptions about the motivations driving oth- tions. Although real-world evaluation of skills isers’ behaviors, refrains from questioning others preferable, the office is the most common arenaregarding their motives, and interjects something for skills evaluation and practice. Therefore, it ispositive about the individual with whom they essential that the client provide detailed accountsare interacting. The content and tone of assertive of problem interactions and that the content andrefusals share the quality of being even-handed cues of the experimental arena be as consistentand unwavering. with that real world as possible.
  • 4 • ASSERTIVENESS SKILLS AND THE MANAGEMENT OF RELATED FACTORS 29BEHAVIORAL OBSERVATION library, an undergraduate seminar, a scheduled, on-campus extracurricular event). Other localBehavioral observation is considered the contact arenas are also acceptable for evaluationpreferred strategy for evaluating assertiveness of skills including coffee houses, dance clubs,skills and performance competencies. Usually, and the like.observations and evaluations of assertiveperformances are made in clinical or researchsettings rather than real-world settings. Clinic Role-Playingand laboratory settings provide contexts for In the clinical context, a ‘‘true’’ observation ofinformal observation (waiting room behaviors assertive behaviors is made through the useand behaviors engaged in by the client during of role-playing. Based on the client’s report ofthe clinical interview) and formal observation difficult interpersonal interactions, interaction(social interaction tasks and role-playing) of an opportunities that mimic these difficultindividual’s behavior. interpersonal interactions (to a lesser or greater degree) are engineered and the client’s use ofClinical Interview assertive behaviors observed. Typically, the therapist serves as the ‘‘relevant other’’ in suchIn the clinical setting, the client’s waiting room role play situations. Research participants orbehavior (i.e., his or her interactions with other clients are asked to display their skills repertoirepersons in the waiting room and with clinic staff) in the context of contrived interactions withis available for observation. Exchanges during the researcher/therapist or some confederate.initial assessment sessions also serve as data to In structuring the role play, the therapistbe used in establishing the presence or absence of aims to lessen the artificial quality of theverbal and nonverbal communication skills con- exercise and to strengthen the correspondencesidered essential to assertive displays as well as between the client’s performance in artificialcontextual factors that may influence the likeli- and natural settings. This is best achievedhood of assertive behaving and the mastery with through the use of dialogue and contextualwhich assertive behaviors are performed. cues that closely approximate the naturally occurring problematic interactions. Role playingSocial Interaction Tasks in Analogue Settings confederates and scenarios are often selected with relevant contextual factors in mind.In evaluating a client’s social skill and comfort,the therapist may enlist confederates to engagethe client in interactions that test the client’s abil-ity to initiate and participate in casual exchanges. ASSERTIVENESS TRAININGThese tasks are considered low-demand tasks.Usually, they do not contain any of the elements When it has been established that a skills deficitof identified problematic interactions. explains performance failure, it is often useful to begin at the beginning. Table 4.1 presents a detailed, step-by-step guide to the conduct ofSocial Interaction Tasks in Real-World Settings assertiveness skills training. Assertiveness train-Of course, the optimal arena for evaluating ing usually begins with a didactic presentationassertive behavior is the client’s natural envi- of (1) definitions of assertiveness, passivenessronment. As often as possible, the real-world and aggressiveness; (2) the rationale for the usecontext should be captured. For example, of assertive behavior; and (3) the basic contenta male client reporting difficulty initiating and procedural guidelines that govern assertivesocial interactions with female peers might behavior. In starting the practice of assertivenessbe observed in real world settings that are skills, the therapist always begins with a reviewfamiliar to him and that present opportunities of the more basic elements of assertive commu-for contact with female peers (e.g., the college nication and continues along a graded hierarchy
  • 30 COGNITIVE BEHAVIOR THERAPYTABLE 4.1 Key Components of an Assertiveness Training Protocol1. Presenting the rationale for assertiveness skills training. Assertive communication of personal opinions, needs and boundaries has been defined as communication that diminishes none of the individuals involved in the interaction, with emphasis placed on communication accuracy and respect for all persons engaged in the exchange. The success of assertiveness does not always lie in tangible outcomes (e.g., request fulfillment). The success of assertiveness sometimes lies in the degree of personal control and personal respect that is achieved and maintained throughout the assertive exchange. Assertive communication maximizes the potential for achievement of relationship goals in both professional and intimate contexts.2. Defining aggressive, passive, and assertive behaviors. The therapist follows the presentation of the rationale with descriptions of each of the three common form of communication: aggressive, passive and assertive communication. a. Aggressive communication of needs usually involves the goal of getting one’s needs met or having one’s opinion endorsed no matter the cost to the other individual or individuals participating in the exchange. Aggressive communication is often characterized by ‘‘shoulds’’ or ‘‘musts’’ or other language that suggests that the recipient is bound or required to meet the expressed need or agree with the expressed opinion. Aggressive communication is also characterized by nonverbal behaviors that are of the ‘‘in your face’’ quality. Aggressive communicators may ignore the boundaries of personal space, standing overly close to another individual. They may speak in loud, angry tones and in a number of other ways convey subtle pressure or even threat to the other individual or individuals participating in the communication exchange. b. Passive communication is problematic, not because of obvious demands placed on the recipient, but because passive communications often do not reflect the true needs or preferences of the speaker. Passive communications involve the use of acquiescent language. The passive communicator often responds to others’ statements of preferences and opinions with statements such as ‘‘if you think so’’ or ‘‘whatever you want is fine’’ or ‘‘no problem, I can take care of that.’’ In the short term, the passive communicator may be seen as ensuring the pleasure and happiness of the recipients of such behavior. The problems with passive communications are usually experienced over time. The passive communicator begins to resent the fact that their true needs and opinions aren’t being honored within these relationships. The recipient of passive communications may feel that the passive individual is only half-heartedly participating in the relationship and is avoiding responsibility for making important decisions within the relationship. c. Assertive communication ensures that the needs and opinions of the speaker are honestly expressed and owned by the speaker. Opinions are expressed as opinions rather than as statements of inarguable fact. This allows other participants in the exchange to comfortably express similar or opposing opinions. In communicator presents the request in a manner that is at the same time clear but respectful of the recipient’s right to refuse such a request. In refusing requests, the assertive communicator states the refusal clearly and unwaveringly while at the same time indicating appreciation for the other individual’s circumstances. Again, assertive communication has the goal of mutual respect.3. Reviewing content and procedural guidelines governing assertive behavior. The assertive request is characterized by its reasonableness, its specificity regarding actions required to fulfill the request, and its inclusion of statements that convey the potential impact(s) of request fulfillment for both the individual making the request and the request recipient. Imbedding request for behavior change between impact statements is referred to as ‘‘sandwiching.’’ In making a request for behavior change, then, the client would begin with a statement regarding the negative impact of the other’s current behavior, then suggest a specific and reasonable behavioral alternative, and end with a statement suggesting the positive impact of the proposed behavioral alternative for both parties. The behavior change request is sandwiched between the two impact statements.4. Provision of overview of assertiveness skills training package. Provide the client with an overview of the skill sets that comprise assertiveness skills training (i.e., nonverbal behavior as communication, giving and receiving compliments, giving and receiving criticism, and making and refusing requests). Suggest that the skill sets lie on a hierarchy, with practice of lower level skill sets being critical to the successful acquisition and performance of higher level skill sets. Explain that these general skills can be successfully applied across a variety of contexts.5. Specifying in-session tasks and homework assignments. In-session tasks will center around the introduction of particular skill sets, modeling of the behaviors import to the particular skill set being targeted, and practice of those skills in the context of role-plays. The client should be informed that self-monitoring of day-to-day interpersonal interactions will continue throughout assertiveness skills training. These real-world interactions will eventually serve as the setting for practice of assertive behavior.6. Modeling of assertive behavior. For the particular skill set being targeted, the verbal content of a sufficiently assertive response is delineated and the appropriately assertive delivery of that verbal communication is modeled by the therapist or confederate.7. In-session practice of assertive behavior. The client practices assertive behaviors in the context of in-session role-plays that are (increasingly) similar to the identified problematic interactions.
  • 4 • ASSERTIVENESS SKILLS AND THE MANAGEMENT OF RELATED FACTORS 31TABLE 4.1 (Continued) 8. Providing reinforcement and corrective feedback. The evaluation of the role-play performance should always begin with the solicitation of comments from the client. This strategy allows the therapist to (a) evaluate the client’s understanding of the verbal and nonverbal behaviors that comprise the assertive response, and (b) evaluate the accuracy and objectivity with which the client evaluates his or her performance. The client’s efforts and performance successes (however approximate) should be roundly reinforced by the therapist. Corrective feedback is provided by the therapist and/or confederate and instructions for further refinement of the assertive performance are provided. Videotaping role-plays is recommended to reduce recall burden and to provide specific, visual evidence for performance problems and performance gains over time. 9. Real-world practice of assertive behavior. Having practiced assertive behavior in the context of role-plays designed to simulate interpersonal interactions occurring in the client’s natural environment, the client begins to practice assertive behavior in the context of naturally occurring interpersonal interactions. The client provides a technical and affective evaluation of the assertive performance in the real-world situation.10. Establishing realistic performance expectations and acceptable schedules of reinforcement. Reinforcement and reiteration of reasonable performance goals is essential throughout the assertiveness skills training process. As the natural environ- ment becomes the practice arena, realistic expectations for performance success are outlined and obvious and regular self-reinforcement of successive approximations of the goal performance is mandated.of skill sets essential to assertive communica- in the therapeutic context and (2) suggest thattion across contexts. Traditionally, assertiveness the display of appropriately assertive nonver-training packages have identified several skill bal behavior is sometimes bound by context;sets as essential to assertive behaving, includ- that is, assertive nonverbal behaviors sometimesing using nonverbal behavior as communica- depend on how comfortable the person feels intion, giving and receiving compliments, giv- a given situation or with a given individual. Aing and receiving criticism, and making and review of nonverbal behaviors would be com-refusing requests. In addressing each of these pleted and instructions would be given that theskill sets, the therapist wishes to establish three client monitor and evaluate displays of appropri-things: (1) the presence and strength of a par- ately assertive nonverbal behaviors in the naturalticular skill in the client’s behavioral repertoire; environment.(2) the situations in which the client compe- The skills that characterize each level of thetently and reliably displays the particular skill; assertiveness hierarchy should be approached inand (3) the situations in which the client may be a similar manner. For example, if in the ongoingcalled upon to competently display the particular context of therapy the client has evidenced skill inskill. assertively requesting something of the therapist, The presence and strength of a particular this instance would be pointed to by the thera-assertive skill or skill set may be established for- pist and reinforced through praise. The therapistmally or informally. A client’s nonverbal behav- would then suggest that the display of eveniors are immediately observable by the therapist. well-established skills can be influenced by situa-In the context of the therapeutic exchange, the tions and persons. The various aspects of requesttherapist may observe nonverbal behaviors that making would be reviewed, real-world instancesare not at all consistent with the goals of assertive of successful and unsuccessful request makingcommunication. This would signal that, at least attempts would be solicited, and the client wouldwithin the context of the therapeutic exchange, be instructed to monitor and practice assertivedirect training and practice of assertive non- request making in the natural environment. Theverbal behavior are justified. When nonverbal therapist will structure in-session role-playingbehaviors have been observed to be sufficient in and homework assignments so that both morethis context, the therapist may feel uncomfortable common and less common request making situ-reviewing these more basic elements of assertive ations are encountered over the course of suchcommunication. In such situations the therapist practice.is encouraged to (1) acknowledge the appro- When the absence of assertive behaviorpriateness of the client’s nonverbal behavior is explained by affective or cognitive factors
  • 32 COGNITIVE BEHAVIOR THERAPYrather than a skills deficit, other strategies experimentation rather than a permanent changeare recommended as adjuncts to behavioral to the couple’s repertoire. In such situations,rehearsal of assertive behavior. Examples of the emphasis placed on overt reinforcement ofsuch strategies include relaxation training to satisfying aspects of current interactions can notreduce performance inhibiting anxiety or anger, be too strong.cognitive restructuring to challenge negative Assertiveness appears to be of differentialperformance predictions and overgeneral- utility in the context of domestic violence.izations regarding performance errors, and Some research suggests that battered womencognitive reframing with respect to performance are potentially at increased risk as a result ofgoals and measures of performance success. assertive behavior in the context of ongoing domestic violence (O’Leary, Curley, Rosenbaum & Clarke, 1985). However, assertivenessASSERTIVENESS IN SPECIFIC CONTEXTS training has been found to contribute to a woman’s decision to leave a violent relationshipWhen assertive behavior is routinely absent (Meyers-Abell, & Jansen, 1980). Research ad-in the context of a particular relationship or dressing male batterers suggests that batterersrelationship set, an evaluation of the relationship have assertiveness deficits that may contributehistory and implicit or explicit rules of the to there use of aggression and violence torelationship is appropriate. This information express their needs and manage the needsmay provide the therapist with clues as to the of their domestic partner (Maiuro, Cahn, &habit strength associated with the nonassertive Vitiliano, 1986). In the context of female sexualbehavior and the extent to which the pattern victimization, assertiveness training appears toof habitual responding is reinforced by others. empower women and reduce their exposure toA realistic appraisal of the benefits and deficits violence (Mac Greene & Navarro, 1998).of the relationship may need to be delineatedalong with an emphasis on the sufficiency of the Interactions Involving Business Associatesself. Business situations are often replete with indi- viduals skilled in the art of persuasion. Because ofInteractions Involving Intimate Others the high level of assertiveness that often charac-In the context of intimate relationships, the great- terizes business interactions, specific techniquesest challenge to assertive behaving is often the have been forwarded as helpful when making orlong interaction history that has been established. refusing some business request. These include:Nonverbal and verbal components of intimate the use of self-disclosure (suggestions of simi-exchanges may have become habitual and less larity in personal experiences or preferences aresubject to immediate reinforcement contingen- influential in ‘‘selling’’ an individual); repetitioncies. Intimate relationships are also unique with of request or request refusal (assuming a finiterespect to the sensitivity of topics that may number of arguments for or against a givenneed to be addressed. The assertiveness skills position, simple repetition of one’s position sug-forwarded for nonintimate interactions are appli- gests commitment to that stance and may wearcable to intimate interactions. Particular attention down the resolve of the other individual); andmay need to be given to acknowledging the singular focus (discussion of unrelated or tan-degree to which a new interaction style is being gentially related topics may serve to distract theforwarded. Sensitive behavior change requests participants from the critical topic).(or request refusals) may involve family tra-ditions, sexual behavior, or lifestyle behaviors. Interactions Involving Health Care ProvidersSensitive topics such as changes in the fre-quency or type of sexual activities should be There are obvious and subtle health implicationsaddressed in a manner that suggests an interest in associated with engaging in passive behavior
  • 4 • ASSERTIVENESS SKILLS AND THE MANAGEMENT OF RELATED FACTORS 33and aggressive behavior. Both forms of behav- control for the formerly aggressive individualior can result in unmet health care needs, either and loss of attachment figures for the formerlythrough nonarticulation of those needs (passive passive individual). In adopting an assertivebehavior) or through expression of those needs stance, individuals are not merely engaging inthat is experienced by the health care provider a simple display of a new behavior set. Theyas threatening or offensive (aggressive behav- are often realigning and reordering relationshipior) and, therefore, refused. Less obvious health priorities.implications of passive and aggressive behav-iors are those that are associated with the shifts Referencesin physiological arousal that often accompa-nies both passive and aggressive behavior. The Bruehl, S., Chung, O. Y., & Burns, J. W. (2006). Angerdeleterious effects of anger in (passive respond- expression and pain: An overview of findingsing) and anger out (aggressive responding) have and possible mechanisms. Journal of Behavioralbeen documented in the context of certain can- Medicine, 29, 593–606.cers (Penedo et al, 2006; White et al., 2007), Dow, M. G. (1985). Peer validation and idiographiccardiovascular disease (Kop et al., 2008; Smith analysis of social skill deficits. Behavior Therapy, 16, 76–86.& MacKenzie, 2006), and chronic pain (Bruehl, Dow, M. G. (1994). Social inadequacy and social skill. InChung, & Burns, 2006; Fernandez & Turk, 1995). L. W. Craighead, W. E. Craighead, A. E. Kazdin, Given both the obvious and subtle and M. J. Mahoney (Eds.). Cognitive and behavioralhealth-related effects of passive and aggressive interventions: An empirical approach to mental healthbehavior, assertive behavior is rendered problems (pp. 123–140). Boston: Allyn and Bacon.essential to both the pursuit of health care Fernandez, E., & Turk, D. C. (1995). The scope andand the maintenance of health. In the health significance of anger in the experience of chronic pain. Pain, 61, 165–175.care context, individuals present to health care Kop, W. J., Weissman, N. J., Bonsall, R. W., Doyle, M.,providers to obtain a service. Through the use Sretch, M. R., Glaes, S. B., et al. (2008). Americanof assertive behavior, an individual can be Journal of Cardiology, 101, 767–773.effective in requesting health care services, even Lewinsohn, P. M. (1974). A behavioral approach towhen the patient’s perception of best practice depression. In R. J. Friedman & M. M. Katz, (Eds.).requires more than the health care provider The psychology of aggression: Contemporary theorymight initially consider necessary. and research (pp. 157–178). Washington, DC: John Wiley & Sons. MacGreene, D., & Navarro, R. L. (1998). Situation -specific assertiveness in the epidemiology of sex-CONCLUSION ual victimization among university women: A progressive path analysis. Psychology of WomenIn establishing the effectiveness of an assertive Quarterly, 22, 589–604.response, we often consider the outcome that is Maiuro, R. D., Cahn, T. S., & Vitaliano, P. P. (1986).achieved. Although the ultimate goal of assertive Assertiveness deficits and hostility in domesti- cally violent men. Violence & Victims, 1, 279–289.communication may be to influence the behav- Meyers-Abell, J. E. & Jansen, M. A. (1980). Assertive-ior of others, the measure of assertiveness is the ness therapy for battered women: A case illus-extent to which personal opinions, needs, and tration. Journal of Behavior Therapy & Experimentalboundaries have been accurately and respect- Psychiatry, 11, 301–305.fully communicated and received. Competent O’Leary, K., Curley, A., Rosenbaum, A. & Clarke, C.performance of appropriately assertive behavior (1985). Assertion training for abused wives: Ais best predicted when sufficient attention has potentially hazardous treatment. Journal of Marital & Family Therapy, 11, 319–322.been given to the interpersonal context in which Penedo, F. J., Dahn, J. R., Kinsinger, D., Antoni, M. H.,the behavior is planned to occur. Very often, Molton, I., Gonzalez, J. S., et al. (2006). Journal oftreating professionals fail to acknowledge the Psychosomatic Research, 60, 423–427.consequences of assertive behavior that the client Rathus, S. A. (1973). A 30-item schedule for assessingwould consider negative (e.g., loss of perceived assertive behavior. Behavior Therapy, 4, 398–406.
  • 34 COGNITIVE BEHAVIOR THERAPYSmith, T. W., & MacKenzie, J. (2006). Annual Review of White, V. M., English, D. R., Coates, H., Lagerlund, Clinical Psychology, 2, 435–467. M., Borland, R., & Giles, G. G. (2007). Is cancerTedeschi, J. T., & Felson, R. B. (1994). Violence, aggres- risk associated with anger control and negative sion, and coercive actions. Washington, DC: Ameri- affect? Findings from a prospective cohort study. can Psychological Association. Psychosomatic Medicine, 69, 667–674.
  • 5 ATTRIBUTION CHANGE* Rebecca S. Laird and Gerald I. MetalskySince Beck first introduced cognitive behavior Unfortunately, there is a dearth of researchtherapy (CBT) for depression (1967; Beck, Rush, that attempts to dismantle and evaluate the com-Shaw, & Emery, 1979), there have been numerous ponents of a cognitive behavior program in orderstudies demonstrating its efficacy (for reviews to identify the active ingredients of successfulsee Dobson, 1989; Evans et al., 1992; Hollon, treatment outcome for depression (Harvey &Evans, & DeRubeis, 1990; Jacobson & Hollon, Galvin, 1984; Whisman, 1993). However, one1996). Beck’s CBT is based on the underlying the- impressive attempt to do this has been under-oretical rationale that an individual’s emotions, taken by Jacobson, Dobson, Gortner, and col-motivations, and behavior are largely deter- leagues (Jacobson et al., 1996; Gortner, Gollan,mined by the way in which he or she constructs Dobson, & Jacobson, 1998). These investigatorsthe world. Subjective thoughts, images, and feel- compared behavioral therapy with two cognitiveings are rooted in the enduring attitudes and behavior treatment packages that were based onassumptions, or schemas, that the individual Beck et al.’s (1979) CBT for depression. Theirdevelops from prior experience. Human expe- partial CBT program was designed to identifyrience is automatically filtered through these and modify automatic thoughts, including mal-cognitive structures, by which input is catego- adaptive attributions for negative life events.rized and evaluated. The complete CBT program included the tech- According to Beck et al. (1979), some niques utilized in the partial CBT program andindividuals develop maladaptive schemas that added several specific interventions that wereserve as vulnerability factors predisposing them designed to identify and modify core schemasto depression and other clinical disorders (Beck, underlying the kinds of cognitive distortions thatEmery, & Greenberg, 1985). Many subsequent were targeted in the partial CBT condition. This complete CBT condition included interventionsstudies have found compelling evidence for designed to modify attributional style (Peter-attributional style (Abramson, Seligman, & son & Villanova, 1988). Both CBT conditionsTeasdale, 1978; Metalsky & Abramson, 1981; included a behavioral activation component andNolen-Hoeksema, Girgus, & Seligman, 1992) consisted of 12 to 20 sessions. Individuals receiv-as one such risk factor for depression in ing treatment met criteria for major depres-children, adolescents, and adults (for reviews, sion according to the Diagnostic and Statisticalsee Andrews, 1989; Harvey & Galvin, 1984; Manual of Mental Disorders (3rd edition, revisedMetalsky, Laird, Heck, & Joiner, 1995; and [DSM-III-R], American Psychiatric Association,Peterson & Seligman, 1984). A depressogenic 1987).attributional style is the generalized tendency to Upon completion of either CBT condition,attribute negative life events to internal, stable, depressed participants showed a significantglobal factors. improvement in depressive symptoms. Anal- yses revealed that clinical improvement was accompanied by a significant decrease in∗The authors wish to acknowledge Tina Baeten, Eileen depressogenic attributions as well as a signif-Diller, Marvel Herlache, Holly Husting, Kris Hutchi- icant change in attributional style. The resultsson, and Carolyn Martin-Johnson for their invaluable persisted at 6-month and 2-year follow-upscontributions. (Gortner et al., 1998). It should be noted, 35
  • 36 COGNITIVE BEHAVIOR THERAPYhowever, that these studies did not include any adverse reactions that may impede the ther-complete tests of whether attributional style apy process.served as a mediator of the effect of CBT on Cognitive behavior therapy for depressionimprovement in symptoms (see Teasdale et al., is conducted within a framework of collabora-2001, for a discussion of this issue). tive empiricism. The therapist assumes an active, directive stance, joining with the client in a logical and empirical investigation of the client’s beliefs,WHO MIGHT BENEFIT FROM THIS TECHNIQUE attitudes, inferences, and assumptions. Therapy focuses on the present, examining the client’sCognitive behavior therapy that specifically thoughts and feelings as they occur during theincluded an attribution change component has session as well as in the client’s everyday life.been used successfully to treat depression in Therapist and client work together to establishboth individual and group outpatient settings specific treatment goals designed to ameliorate(Nixon & Singer, 1993), with children (Carlyon, depressive symptoms and any other problems1997), adolescents (Reynolds & Stark, 1987), that they agree to address.adults (Goldberg, Gask, & O’Dowd, 1989), and The therapist begins treatment by educat-married couples (Birchler, 1986). It may be used ing the depressed client about the theoreticalin conjunction with pharmacological treatment. rationale behind CBT, which Beck notes is a very important foundation for this therapeutic approach (Beck et al., 1979). Early therapy ses-CONTRAINDICATIONS sions focus on two major areas: (1) teaching the client to recognize and understand the connec-Research on therapeutic attribution retraining tions between his or her thoughts, feelings, andfor depression has not studied the efficacy behavior; and (2) training the client to identifyof this technique with hospital inpatients or the automatic thoughts that accompany negativethought-disordered individuals. This technique feelings and problematic behaviors. In particular,is not recommended for implementation with the client begins to observe the kinds of attribu-depressed patients who are actively psychotic. tions that he or she makes for negative life events. Interestingly, Addis and Jacobson (1996) The next phase of therapy involves teachingfound that the number and types of explana- the depressed client how to evaluate the evidencetions clients gave for their depression were for and against these maladaptive attributionssignificantly associated with treatment outcome. and other associated automatic thoughts. TheDepressed subjects who attributed their therapist teaches the client how to challenge hisdepression to negative childhood experiences or her cognitive distortions, and to substitutefailed to respond to CBT, whereas subjects more rational and reality-based ways of thinking.with external attributions for their depression In particular, the patient is encouraged to shiftappeared to benefit from CBT. from making internal, stable global attributions for negative life events to making more adaptive attributions. The client is encouraged to practiceHOW TO APPLY ATTRIBUTION CHANGE self-observation, hypothesis-testing techniques,TECHNIQUES: OVERVIEW and logical challenges to cognitive distortions in daily life, and to bring these data in for furtherBeck et al. (1979) note that CBT ought to take examination during therapy sessions.place in the context of a therapeutic relationship The final phase of therapy, conducted overcharacterized by warmth, accurate empathy, and eight sessions, involves helping the depressedgenuineness. Building trust and rapport are cru- client identify the maladaptive assumptions andcial ingredients when treating depressed clients attitudes (schemas) underlying his or her cogni-with CBT. It is also important to elicit client tive distortions. The client and therapist togetherfeedback regularly in order to check the client’s examine and evaluate his or her depressogenicunderstanding of the therapy and to assess for attributional style. Alternative core beliefs are
  • 5 • ATTRIBUTION CHANGE 37TABLE 5.1 Attribution Change Step by Step1. Perform client assessment.2. Educate the client about the rationale and techniques of CBT for depression.3. Teach the client to understand the connections between his or her thoughts, feelings, and behavior.4. Train the client to identify depressogenic attributions that are associated with negative feelings.5. Examine the evidence for and against those attributions. Substitute more rational, realistic thoughts for depressogenic attributions and other cognitive distortions.6. Identify underlying assumptions and core beliefs that compose the client’s depressogenic attributional style.7. Evaluate, challenge, and modify the client’s depressogenic attributional style.considered and the advantages and disadvan- cognitive theory of depression as well as the waytages of each are evaluated. The client is encour- in which CBT will be used to treat it.aged to practice evaluating his or her experienceaccording to the new attributional schemas thathave been consciously selected. Step 3 The client is encouraged to begin to apply theSTEP-BY-STEP PROCEDURES cognitive theory to his or her own situation. The therapist encourages the client to make connec-Step 1 tions between his or her own thoughts, feelings,As can be seen in Table 5.1, the therapist and behaviors.must make a thorough assessment of theclient’s depressive and other symptoms. Otherinformation gathered may include the client’s Step 4ability to identify and label feelings, the specific The client learns to identify automatic thoughtskinds of situations that are problematic, the link and images that are associated with negativebetween presenting complaints and depressive feelings and depressed behaviors. In particu-symptoms, and the kinds of thinking distortions lar, the client learns to identify and observeto which the client is subject. In particular, attributions that he or she makes for negativethe clinician is attuned to any of the client’s life events. The client is encouraged to keep astatements that illustrate a tendency to blame daily record of attributions and other automatichimself or herself or to assume personal thoughts together with the feelings, problematicresponsibility for adverse events, whether or not behaviors, and situations in which they occurthose events are under personal control. outside of therapy. The therapist is active in elic- Questionnaire data can supplement informa- iting client attributions for the negative eventstion gathered in a clinical interview. Jacobson he or she experiences.et al., (1996) administered the Beck Depres-sion Inventory (BDI; Beck, 1967; Beck, Steer, &Garbin, 1988), the Automatic Thoughts Ques- Step 5tionnaire (ATQ; Hollon & Kendall, 1980), andthe Expanded Attributional Style Questionnaire The client learns to evaluate the logical and(EASQ; Peterson & Villanova, 1988) to each client empirical validity of his or her attributions.before and after treatment. Information is also Together the therapist and client identify angathered about the client’s understanding of the attribution associated with negative affect. Theytherapy process and his or her therapy goals. review the situation that gave rise to this auto- matic thought, gathering and defining all of the factors associated with that event that wouldStep 2 be relevant in making a realistic and accurateThe therapist explains the theoretical rationale attribution of responsibility. These factors maybehind CBT. The client learns about Beck’s (1967) include a review of the relevant information
  • 38 COGNITIVE BEHAVIOR THERAPYavailable to the client at the time of the event, encouraged to explore how alternative core attri-the possible role of others in contributing to butions might be applied to life situations. Thethe adverse occurrence, the controllability of the therapist and client also subject these underlyingevent, and its significance to the client and others. attributional assumptions to the same kind ofThe client is encouraged to come up with alterna- logical and empirical scrutiny that they did thetive attributions and to consider the evidence for automatic thoughts and attributions in step 5.and against each of these competing hypotheses.Homework assignments may be given in orderfor the client to gather more information and to Further Readingevaluate the empirical evidence for and against Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G.depressogenic and more adaptive attributions. (1979). Cognitive therapy of depression. New York: The therapist may question the client about Guilford.the types of attributions that he or she would Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E.,make if someone other than the client were in Koerner, K., Gollan, J. K., et al. (1996). A compo-the client’s place. Does the client exhibit a dou- nent analysis of cognitive-behavioral treatmentble standard when assigning blame to self, but for depression. Journal of Consulting and Clinicalmake more realistic attributions for others? The Psychology, 64, 295–304. Metalsky, G. I., Laird, R. S., Heck, P. M., & Joiner, T. E. Jr.therapist may also challenge the client to con- (1995). Attribution theory: Clinical implications.sider whether responsibility in this situation is In W. O’Donohue & L. Krasner (Eds.), Theo-an absolute 100%, or whether it is more logical to ries of behavior therapy: Exploring behavior changeview responsibility as shared or partial (known (pp. 385–413). Washington, DC: American Psy-as deresponsibilitizing). chological Association. The client is thus enabled to gain a more objec-tive, balanced, and realistic view of his or her ownresponsibility in causing a negative event. The Referencesclient is then encouraged to generalize this reat- Abramson, L. Y., Seligman, M. E. P., & Teasdale, J.tribution process to other negative life situations (1978). Learned helplessness in humans: Critiquewith the therapist’s continued support. and reformulation. Journal of Abnormal Psychology, 87, 49–74. Addis, M. E., & Jacobson, N. S. (1996). Reasons forStep 6 depression and the process and outcome of cognitive-behavioral psychotherapies. Journal ofThe therapist goes on to identify more general Consulting and Clinical Psychology, 64, 1417–1424.patterns in the client’s depressogenic attribu- American Psychiatric Association. (1987). Diagnostictions, identifying the attributional schemas and statistical manual of mental disorders (3rd ed.,underlying the client’s habitual way of constru- rev.). Washington, DC: Author.ing negative life events. The downward arrow Andrews, J. D. W. (1989). Psychotherapy of depression:technique is useful here, wherein the therapist A self-confirmation model. Psychological Review,elicits the client’s explanations for his or her 96, 576–607. Beck, A. T. (1967). Depression: Clinical, experimental,problems, then generates hypotheses about and theoretical aspects. New York: Hoeber.various kinds of general patterns and concerns, Beck, A. T. (1976). Cognitive therapy and the emotionalultimately leading to the identification of the core disorders. New York: Meridian.beliefs comprising the client’s depressogenic Beck, A. T., Emery, G., & Greenberg, R. L. (1985).attributional style. Homework assignments Anxiety disorders and phobias: A cognitive perspective.enable the client to see whether these core beliefs New York: Basic Books.do in fact characterize his or her everyday Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York:experience. Guilford. Therapist and client then consider alternative Beck, A. T., Steer, R. A., & Garbin, M. G. (1988).attributional core beliefs and discuss the immedi- Psychometric properties of the Beck Depressionate and long-term advantages and disadvantages Inventory: Twenty-five years of evaluation. Clini-of holding each kind of belief. The client is then cal Psychology Review, 8, 77–100.
  • 5 • ATTRIBUTION CHANGE 39Birchler, G. R. (1986). Alleviating depression with jury’s returned its verdict, it’s time to present ‘‘marital’’ intervention. Journal of Psychotherapy the rest of the evidence. Journal of Consulting and and the Family, 2, 101–116. Clinical Psychology, 64, 74–80.Carlyon, W. D. (1997). Attribution training: Implica- Metalsky, G. I., & Abramson, L. Y. (1981). Attributional tions for its integration into prescriptive social style: Toward a framework for conceptualization skills training. School Psychology Review, 26, 61–73. and assessment. In P. C. Kendall & S. D. HollonDobson, K. S. (1989). A meta-analysis of the efficacy (Eds.), Assessment strategies for cognitive-behavioral of cognitive-behavioral therapy for depression. interventions (pp. 13–58). San Diego, CA: Aca- Journal of Consulting and Clinical Psychology, 57, demic Press. 414–419. Metalsky, G. I., Laird, R. S., Heck, P. M., & Joiner, T. E. Jr.Evans, M. D., Hollon, S. D., DeRubeis, R. J., Piasecki, (1995). Attribution theory: Clinical implications. J. M., Grove, W. M., Garvey, M. J., et al. (1992). In W. O’Donohue & L. Krasner (Eds.), Theo- Differential relapse following cognitive therapy ries of behavior therapy: Exploring behavior change and pharmacotherapy for depression. Archives of (pp. 385–413). Washington, DC: American Psy- General Psychiatry, 49, 802–808. chological Association.Goldberg, D., Gask, L., & O’Dowd, T. (1989). The Nixon, C. D., & Singer, G. H. (1993). Group cogni- treatment of somatization: Teaching techniques tive behavioral treatment for excessive parental of reattribution. Journal of Psychosomatic Research, self-blame and guilt. American Journal on Mental 33, 689–695. Retardation, 97, 665–672.Gortner, E. T., Gollan, J. K., Dobson, K. S., & Jacobson, Nolen-Hoeksema, S., Girgus, J. S., & Seligman, N. S. (1998). Cognitive–behavioral treatment for M. E. P. (1992). Predictors and consequences depression: Relapse prevention. Journal of Con- of childhood depressive symptoms: A 5-year sulting and Clinical Psychology, 66, 377–384. longitudinal study. Journal of Abnormal Psychology,Harvey, J. H., & Galvin, K. S. (1984). Clinical implica- 101, 405–422. tions of attribution theory and research. Clinical Peterson, C., & Seligman, M. E. P. (1984). Causal expla- Psychology Review, 4, 15–33. nations as a risk factor for depression: Theory andHollon, S. D., Evans, M. D., & DeRubeis, R. J. (1990). evidence. Psychological Review, 91, 347–374. Cognitive mediation of relapse prevention Peterson, C., & Villanova, P. (1988). An expanded attri- following treatment for depression: Implications butional style questionnaire. Journal of Abnormal of differential risk. In R. E. Ingram (Ed.), Psychology, 97, 87–89. Contemporary psychological approaches to depression Reynolds, W. M., & Stark, K. D. (1987). School-based (pp. 117–136). New York: Guilford. intervention strategies for the treatment of depres-Hollon, S. D., & Kendall, P. E. (1980). Cognitive sion in children and adolescents. Special Services self-statements in depression: Development of in the Schools, 3, 69–88. an automatic thoughts questionnaire. Cognitive Teasdale, J. D., Scott, J., Moore, R. G., Hayhurst, H., Therapy and Research, 4, 383–396. Pope, M., & Paykel, E. (2001). How does cognitiveJacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., therapy prevent relapse in residual depression? Koerner, K., Gollan, J. K., et al. (1996). A compo- Evidence from a controlled trial. Journal of Con- nent analysis of cognitive-behavioral treatment sulting and Clinical Psychology, 69, 347–357. for depression. Journal of Consulting and Clinical Whisman, M. A. (1993). Mediators and moderators of Psychology, 64, 295–304. change in cognitive therapy of depression. Psy-Jacobson, N. S., & Hollon, S. D. (1996). Cognitive behav- chological Bulletin, 114, 248–265. ior therapy vs. pharmacotherapy: Now that the
  • BEHAVIORAL ACTIVATION TREATMENT 6 FOR DEPRESSION Christopher R. MartellOver the past 10 years there has been a resur- cognitive profile throughout much of the 1980sgence of interest in behavioral treatments for and 1990s. The idea of increasing pleasant eventsdepression that were originally proposed in the alone, without cognitive interventions, was ques-early 1970s with the theoretical formulations of tioned (Hammen & Glass, 1975), and cognitiveC. B. Ferster (1973, 1981) and the applied work behavior therapy was seen as a psychosocialof Peter Lewinsohn and colleagues (Lewinsohn, treatment of choice for depression.1974; Lewinsohn, Biglan, & Zeiss, 1976; Lewin- A recent meta-analysis (Ekers, Richards, &sohn & Graf, 1973). The basic idea of the behav- Gilbody, 2007) suggests that behavioral treat-ioral theory of depression was that individuals ments are efficacious for treating depression.become depressed when there is an imbalance A component analysis of cognitive therapy forof punishment to positive reinforcement in their depression (Jacobson et al., 1996) demonstratedlives. According to Ferster (1981), when an indi- that depressed participants treated with behav-vidual responds primarily to deprivation and ioral activation alone improved as well as thosethe removal of an aversive, deprived state, he or subjects treated with a full cognitive therapyshe develops behaviors that function primarily treatment. Their results were maintained atas avoidance behaviors and there is little access follow-up (Gortner, Gollan, Dobson, & Jacobson,to positive reinforcement built into the behav- 1998). The results of the component analysisioral repertoire of the individual. Treatment for study opened the door for a larger study of thedepression would, therefore, consist of a process treatment of depression, which compared cogni-that would increase the individual’s access to tive therapy, behavioral activation, paroxetine,positive reinforcers. and pill placebo (Dimidjian, Hollon, Dobson, Following the analysis of Ferster, Lewinsohn et al., 2006). For moderately to severely de-and colleagues focused on increasing pleasant pressed clients, behavioral activation performedevents and pleasurable activities in order to as well as antidepressant medication and outper-treat depression (Lewinsohn & Graf, 1973). These formed cognitive therapy in the acute treatment.researchers developed the use of activity logs and Both behavioral activation and cognitive therapyactivity scheduling to help depressed patients were efficacious in the prevention of relapseincrease positive activities that would combat (Dobson, Hollon, Dimidjian, et al., in press).their lethargy and bring them into contact with Behavioral activation is a structured, behaviorpositive reinforcers. During this same time, cog- analytic approach that borrows heavily fromnitive therapy for depression was also being earlier behavioral formulations of depressionformulated (Beck, 1976) and utilized the activity (Jacobson, Martell, & Dimidjian, 2001; Martell,scheduling elements of Lewinsohn’s approach Addis, & Jacobson, 2001). Through functionalbut focused on changing the negative content analyses, client behavior is understood accordingof depressed patients’ beliefs. Cognitive therapy to its setting and consequences rather than thewas studied extensively and empirically vali- particular form it takes. The emphasis is, indeed,dated as a treatment for depression, and the on the function of a behavior rather than thefield of behavior therapy took on a distinctively form and the treatment is not just about getting 40
  • 6 • BEHAVIORAL ACTIVATION TREATMENT FOR DEPRESSION 41depressed clients to be more active. For example, has even been used with clients who maintainwhile chatting with a friend on the phone may a need for psychotropic medication (implying aformally appear to be a positive behavior for flaw in the machine). We would caution clini-a depressed individual, one must understand cians, however, from using this technique withthe contexts and consequences prior to coming depressed individuals who may be involved into such a conclusion. If chatting with the friend a domestic violence situation, where activatingserves to keep the individual from working on may expose them to greater harm from an abu-a project that is overdue, thus making her or sive partner. Clinicians should be cautious nothim more depressed, it functions as avoidance to encourage a client to engage in behavior thatand has negative consequences. The treatment is could result in any such harmful interpersonaltheory driven rather than protocol driven with interaction.a focus on targeting avoidance behavior as aprimary treatment goal with depressed clients. OTHER DECISIONS IN DECIDING WHETHER TO USE BEHAVIORAL ACTIVATIONWHO MIGHT BENEFIT FROM THIS TECHNIQUE The data suggest that BA alone, without evalua-Behavioral activation (BA) is currently a treat- tion of the content of clients’ thinking, works wellment for depression and has undergone eval- in the treatment of a major depressive episode.uation in that arena. A small pilot study has However, outside of the research setting, there issuggested that BA may be useful in the treatment no prohibition against using cognitive restructur-of veterans with posttraumatic stress disorder ing although recent investigations into methods(Jakupcak, Roberts, Martell, Mulick, Michael, for treating client rumination (see, e.g., Watkins,Reed, et al., 2006). The BA focus on avoidance Scott, Wingrove, Rimes, Bathurst, Steiner, et al.,places it in the realm of other exposure-based 2007) are more consistent with the behavioral for-treatments that have been used for the treat- mulation. Some clients maintain strong beliefsment of anxiety and other disorders. However, that their thinking is the problem. We wouldno data are yet available to demonstrate the recommend that, rather than arguing with autility of the approach in these areas. Partici- client, therapists incorporate the very behavioralpants in Jacobson’s lab met criteria for major aspects of BA with a cognitive conceptualization.depressive disorder and were screened out only The two treatments are complementary and pro-if there was presence of a thought disorder or vide a bridge for some clients (and therapists).active substance or chemical dependence. No For example, the context and consequences ofother comorbid disorders were excluded. There- clients’ thinking (where and when it occurs, andfore, the participant pool on which the treatment what effect it has on how the client feels andwas tested had at least an Axis I major depres- what he or she does next) can be incorporatedsive disorder, but could have had comorbid Axis into BA without focusing on the content.I or Axis II disorders (other than psychosis orsubstance dependence). HOW DOES THE TECHNIQUE WORK?CONTRAINDICATIONS OF THE TREATMENT At this time, we can only make assumptionsUnderstanding the possible contraindications of about the factors that make BA work. Primarily,this treatment requires clinical hypothesis rather the therapist takes the role of a coach, encour-than hard data. The treatment does not seem to be aging clients to become active even when theycontraindicated for most people suffering from feel as if they cannot possibly complete tasks ormajor depression. Although it is a context-based, get any pleasure from life. Because BA works tononpharmachological treatment that encourages help clients establish a regular routine, it breaksclients to look outward at their life context the destructive process of routine disruption thatrather than at hypothesized internal defects, it often accompanies depression (Ehlers, Frank, &
  • 42 COGNITIVE BEHAVIOR THERAPYKupfer, 1988). Activity in BA means getting There are several questions that the thera-engaged rather than just doing something for pist needs to ask about the depressive episodethe sake of being busy or living under a Calvinist that the client is experiencing. First, the thera-work ethic. pist should understand the client’s history and gather information about significant life events, positive or negative, that influence the client’sSTEP-BY-STEP PROCEDURES current life context. To do this, the therapist sim- ply need ask the client to recount such events,The treatment is based on the theory, described with questions like ‘‘What is your family like?earlier, that depression often results from What kinds of things have been good in yourchanges in a vulnerable individual’s life life? What has hurt you or has been distressing?’’that decrease the person’s access to positive It is also important, second, to understand howreinforcement. Basically, the treatment consists the client behavior during a depressive episodeof strategies that increase activity and block is different from his behavior at other times. Ask-avoidance so that the client can come in ing the client ‘‘What is your life like when youcontact with natural reinforcers in his or her are not depressed? Are there things that you areenvironment. In order to do this in a manner not doing now that you typically do when youthat is idiographic and not merely applying are not de pressed? What do you hope to accom-broad classes of pleasant activities that may or plish in you life? Are you taking steps towardmay not actually be reinforcing, the therapist accomplishing, these things?’’ can help to gatherneeds to do a good functional analysis. a picture of what problems the client may be experiencing. Gathering this information helps the thera-Conducting a Functional Analysis pist to develop a case conceptualization of theWhereas the laboratory provides much control client’s depression. We express the case concep-over conditions that can lead to accurate under- tualization in terms of the life events that maystanding of contingencies at work in the behavior have contributed to the depression by makingof organisms under study, the clinical setting the client’s life less rewarding, and we then lookdoes not provide the same level of control. When at how the client has tried to cope with the symp-we speak of functional analysis we are speak- toms of depression. Often the client’s attempts ating of the best hypotheses that the therapist and coping become problems in themselves, and weclient can develop about the antecedents, behav- refer to these as secondary problem behaviors. Foriors, and consequences that form elements of the example, the runner mentioned earlier might beclient’s repertoire contributing to depression. In coping with feelings of hopelessness and inade-BA we are interested in the function of the behav- quacy by engaging in a fervent exercise programior and not the form of the behavior. Therefore, the enables her to avoid dealing with issues withwe are less concerned with what popular opin- her significant other. We would call her exerciseion may be about a certain behavior (e.g., people regime a secondary problem. Even though wemay think that going for a run early in the morn- know exercise is good for depressed people ining is a good and healthy thing to do) that with general, with this particular client we wouldthe function of a particular behavior for particu- want to help her to address her issues with herlar person (e.g., the runner may actually be out partner and then institute exercise that is notearly in the morning because she does not want avoidance.to remain at home to have a discussion withher partner about having neglected to pay an Day-by-Day Analysisexpensive bill). Functional analysis is the heartof BA, and it will be conducted throughout the Since its earliest conception by Lewinsohn andtreatment. The first step, however, is to develop others, BA has made ample use of activity chartsgeneral case conceptualization from a behavior to help therapists understand the level of aanalytic perspective. client’s activity and to schedule pleasant events.
  • 6 • BEHAVIORAL ACTIVATION TREATMENT FOR DEPRESSION 43We continue to rely heavily on activity charts Try the behavior that I’ve chosen.in our work. We use activity charts for several Integrate any new activity into a regular routine,reasons. The therapist can use an activity chart remembering that trying a new behavior onlyto understand the following: once is unlikely to lead to significant change. Observe the outcome of the behavior: Does• The client’s current level of activity it affect mood, or does it improve a life• Restriction of the client’s affect situation?• Connections between the client’s activity and Never give up. Counteracting depression and mood avoidance takes continued work and tenacity• Mastery and pleasure ratings in the face of frequent disappointments.• How to help the client monitor avoidance behaviors• Guided activity The second acronym we use is TRAP, which• Steps the client is taking toward stated life stands for trigger, or some happening or event; goals response, usually the client’s emotional response to the trigger; and avoidance pattern, which is It does not matter what type of activity chart the typical avoidance response to the trigger.a therapist chooses to use with his or her clients. Once the client has identified a TRAP, we useAll that is important is that the chart include all the third acronym to help him or her get backthe hours in the day and provide room enough on TRAC (trigger, response, alternative coping).for the client to record what he or she did and The strategies of using activity charts and help-felt, and the intensity of the feeling, in each hour ing clients to recognize avoidance patterns andblock. modify their behavior make up the bulk of BA treatment.Techniques for Dealing with Client Avoidance Conceptualized as a contextual treatment, BA focuses on helping clients to change behaviorWe find it most important that clients continually in such a way as to bring them into contactbe vigilant of their avoidance behaviors. It is also with positive reinforcers in their natural envi-a basic tenet in BA that clients can choose to ronment. There is much less emphasis on skillsengage in activities that will possibly help them training than in other behavioral therapies. Theto feel better, or they can choose to continue toavoid and possibly remain depressed. Although model in BA is that therapists may conduct skillswe never tell clients that they are choosing to be training, but they are not required to. Whether todepressed, we do indeed suggest to clients that conduct skills training such as problem-solvingchoices made about specific behaviors can lead training will depend on the behavioral analysisto certain consequences. of each client. In clinical outcome trials of BA, While not required in the treatment, three therapists have used problem-solving trainingacronyms illustrate the concept of avoidance to or assertiveness training, but they have doneclients and help them to be aware of their patterns so in a fashion that anchors the training inand to modify behaviors. Using these acronyms the context of the client’s life. In other words,simplifies the explanation of complex ideas. The even in skills training, the BA therapist triesfirst is the acronym ACTION, which stands for not to teach a broad class of skills that can bethe following: applied by following rules; rather, the thera- pist debriefs specific incidents in the client’s lifeAssess my behavior: Is my current behavior and helps the client understand how he or she avoidant? How does this behavior serve me? might have changed an outcome by behavingChoose whether to activate myself and engage differently. In some cases the client may be plan- in behaviors that could help my depression ning a particular encounter, and the therapist in the long run, or to continue to avoid this would discuss options for achieving particular experience. outcomes.
  • 44 COGNITIVE BEHAVIOR THERAPYFINAL CONSIDERATIONS the acute treatment of adults with major depres- sion. Journal of Consulting and Clinical Psychology,The therapeutic stance in BA is always collab- 74(4), 658–670. Dobson, K. S., Hollon, S. D., Dimidjian, S.,orative. The therapist serves as a coach for the Schmaling, K. B., Kohlenberg, R. J., Gallop, R.,client. When the therapist is trying to help a et al. (in press). Randomized trial of behavioralclient develop a new skill, the therapist takes the activation, cognitive therapy, and antidepressantposition that his or her suggestions are hypothe- medication in the prevention of relapse andses to be tested rather than prescriptions from recurrence in major depression. Journal ofan authority figure. Behavioral activation thera- Consulting and Clinical Psychology.pists are working within a model that is quite Ekers, D., Richards, D., & Gilbody, S. (2007, Octo- ber). A meta-analysis of randomized trials ofdifferent from a medical model. Clients are seen behavioural treatment of depression. Psychologicalas individuals whose lives have somehow gone Medicine, 1(13) (forthcoming article, e-publicationawry rather than as patients with some defect at http://journals.cambridge.org).or flaw that must be modified. The therapist Ferster, C. B. (1973). A functional analysis of depres-works to help the client understand the areas of sion. American Psychologist, 28, 857–870.his or her life that are not working and to make Ferster, C. B. (1981). A functional analysis of behavioradjustments in behavior to enhance the workable therapy. In L. P. Rehm (Ed.), Behavior therapy for depression: Present status and future directionsaspects of life. (pp. 181–196). New York: Academic Press. In the treatment outcome studies conducted Gortner, E. T., Gollan, J. K., Dobson, K. S., & Jacobson,on BA to date from Jacobson’s laboratory, the N. S. (1998). Cognitive–behavioral treatment fortherapy has consisted of a 16-week protocol, with depression: Relapse prevention. Journal of Con-clients allowed up to 24 therapy sessions. Many sulting and Clinical Psychology, 66(2), 377–384.clients begin to show improvement in depres- Hammen, C. L., & Glass, D. R. (1975). Depression,sion scores within the first 10 sessions. However, activity, and evaluation of reinforcement. Journal of Abnormal Psychology, 54(6), 718–721.there are no clear data to suggest an optimal Jacobson, N. S., Dobson, K., Truax, P. A., Addis, M. E.,length of treatment. Researchers in a different Koerner, K., Gollan, J. K., et al. (1996). A compo-setting, conducting BA that primarily focused on nent analysis of cognitive–behavioral treatmentactivity scheduling, had successful results with for depression. Journal of Consulting and Clinicala 10-session protocol (Lejuez, Hopko, LePage, Psychology, 64(2), 295–304.Hopko, & McNeil, 2001). This would suggest that Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001).the treatment may be successful over a shorter Behavioral activation treatment for depression: Returning to contextual roots. Clinical Psychology:time period. Science and Practice, 8(3), 255–270. Jakupcak, M., Roberts, L. J., Martell, C., Mulick, P.,Further Reading Michael, S., Reed, R., et al. (2006). A pilot study of behavioral activation for veterans with posttrau-Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). matic stress disorder. Journal of Traumatic Stress, Behavioral activation treatment for depression: 19, 387–391. Returning to contextual roots. Clinical Psychology: Lejuez, C. W., Hopko, D. R., LePage, J. P., Hopko, Science and Practice, 8(3), 255–270. S. D., & McNeil, D. W. (2001). A brief behavioralMartell, C. R., Addis, M. E., & Jacobson, N. S. (2001). activation treatment for depression. Cognitive and Depression in context: Strategies for guided action. Behavioral Practice, 8, 164–175. New York: W. W. Norton. Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. M. Friedman & M. M. KatzReferences (Eds.), The psychology of depression: Contemporary theory and research (pp. 157–185). New York: JohnBeck, A. T. (1976). Cognitive therapy and the emotional Wiley & Sons. disorders. New York: New American Library. Lewinsohn, P. M., Biglan, A., & Zeiss, A. S.Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, (1976). Behavioral treatment of depression. In K. B., Kohlenberg, R. J., Addis, M. E., et al. (2006). P. O. Davidson (Ed.), The behavioral management Randomized trial of behavioral activation, cog- of anxiety, depression and pain (pp. 91–146). New nitive therapy, and antidepressant medication in York: Brunner/Mazel.
  • 6 • BEHAVIORAL ACTIVATION TREATMENT FOR DEPRESSION 45Lewinsohn, P. M., & Graf, M. (1973). Pleasant activities Watkins, E., Scott, J., Wingrove, J., Rimes, K., Bathurst, and depression. Journal of Consulting and Clinical N., Steiner, H., et al. (2007). Rumination-focused Psychology, 41, 261–268. cognitive behaviour therapy for residual depres-Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). sion: A case series. Behavior Research and Therapy, Depression in context: Strategies for guided action. 45, 2144–2154. New York: W. W. Norton.
  • 7 RESPONSE CHAINING W. Larry Williams and Eric BurkholderChaining refers to a set of procedures used to 2005), community skills (McDonnell, & Laugh-teach a task that consists of an ordered series of lin, 1989), and other complex skills (McWilliams,specific responses that must occur in a prede- Nietupski, & Hamre-Nietupski, 1990). Othertermined order to produce reinforcement. In the issues bearing on chaining have also beenbehavioral account, each step of this series pro- examined, including trainer preference forduces an outcome that serves both as a reinforcer chaining procedures (Walls, Zane, & Thvedt,for the response that produced it and as a dis- 1980), effects of conditions of reinforcement oncriminative stimulus for the next response in the chaining (Talkington, 1971), and teaching thesequence (Martin & Pear, 2007). The chain termi- effects of prompting and guiding proceduresnates with some principal outcome, product, or (Zane, Walls, & Thvedt, 1981).reinforcer. Three conventional methods have evolved for Chaining has been used by trainers in a teaching chains. Total task presentation involvesmyriad of professions dating back well over 100 teaching all of a chain’s component responsesyears (Crafts, 1929; Mountjoy & Lewandowski, on each teaching trial. Forward chaining teaches1984). In the basic literature, chaining has been the first response in the chain to some criterion,used to study such fundamental processes as then the first and second response, then the firstthe nature of conditioned reinforcement (Boren, three responses, and so on until the total chain1969; Boren, & Devine, 1968; Fantino, 1965; is acquired. Backward chaining teaches the lastJwaideh, 1973; Kelleher & Fry, 1962; Pisacreta, response in the sequence first, then the second1982; Thvedt, Zane, & Walls, 1984; Weiss, 1978). to last and the last responses, then the third toIn the applied literature, chaining has been last, second to last, and the last responses, and soshown to be a procedurally sound method of on, until the total chain is acquired. Which oneproducing a broad range of complex behaviors of these three variants has the highest level ofin a variety of populations, from teaching efficacy has not been satisfactorily answered, duecollege students to play golf (Simek, O’Brien, & to contradictory findings (Martin, Koop, Turner,Figlerski, 1994) to teaching disabled individuals & Hanel, 1981). It does seem clear that all threehow to engage in activities of daily living variants can be effective for teaching skills to a(Spooner, 1984). The literature related to persons wide range of populations.with intellectual disabilities is particularly wellelaborated, where chaining has been used toteach assembly-line tasks (Martin, Koop, Turner, WHO MIGHT BENEFIT FROM THIS TECHNIQUE?& Hanel, 1981; Spooner, 1984; Spooner, Spooner,& Ulicny, 1986; Weber, 1978); family-style Professionals and educators who work with pop-dining (Wilson, Reid, Phillips, & Burgio, 1984); ulations that need to learn complex activities orlanguage acquisition (Buckley & Newchok, populations that have displayed deficits in their2005); responding to a fire alarm (Cohen, 1984); ability to learn may benefit from the system-reducing escape behavior (Lalli, Casey, & Kates, atic application of this technique. As described1995); picture naming (Olenick, & Pear, 1980); earlier, this technique has been widely used toand treating total liquid refusal (Hagopian, teach a variety of skills to people with intellectualFarrell, & Amari, 1996), self-injurious behavior disabilities. The use of this technique is appro-(Hagopian, Paclawskyj, & Contrucci-Kuhn, priate for teaching any task that can be broken 46
  • 7 • RESPONSE CHAINING 47into smaller steps such as making coffee, tying discrete response), has a clear discriminativeshoes, making a bed, assembling electrical com- stimulus and is either directly reinforced byponents, or engaging in any of a wide variety of the trainer, leads to conditioned reinforcement,crafts, hobbies, sports, exercise, and vocational or both.and habilitation skills. Chaining may also beused for acquisition of complex verbal perfor-mances or for generating rules or strategies to COMPLETING AND VALIDATING A TASKguide other performances. ANALYSIS A task analysis breaks a complex activity intoHOW DOES THIS TECHNIQUE WORK? its component parts or units so that they can be individually shaped if they are not already in theChaining works by systematically establishing subject’s repertoire, or brought under appropri-a specific response in the presence of a spe- ate stimulus control within the chain if they arecific discriminative stimulus, itself the result of present already. Any task that results in a typicala specific prior response. As specific response outcome (e.g., taking a shower, making a bed)units are established, they are put together into can be broken into the essential response com-an ever-increasing sequence of responses until ponents rather easily. Consider, for example, thethe complete task is achieved. The completed task analyses in Figures 7.1 and 7.2.task is itself associated with a more significant Once a task has been broken into its compo-functional reinforcer, typically the functional nent parts, it needs to be validated prior to start-outcome of the task being taught (e.g., a pre- ing the teaching procedure. There are many wayspared sandwich, a loaded dishwasher, comple- of validating a task analysis (Cooper, Heron, &tion of a preflight check). The arrangement of Heward, 1987), including observing and pilotingthe responses and their outcomes is determined out the procedure, consulting experts or peopleby a task analysis. Before starting the teaching who are fluent in performing the task, or per-procedure, the task analysis should be vali- forming the task repeatedly. Regardless of whatdated (walked through and tried) and prompting method is used for the validation of the taskprocedures (additional material; instructional, analysis, each behavior to be taught should begestural, or physical aides) determined and spec- discrete and follow a clear, discriminative stim-ified as well as reinforcement criterion. Chaining ulus produced by either the initial instruction orworks because each link in the chain (i.e., each by the previous link in the chain. Enter shower Get wet Lather up Rinse off Leave shower Dry Off Turn on water Get soap Turn off Grab Body covered in suds water towel Note that each general response can itself be broken down into smaller responses each of which produce their own specific stimulus outcomes that signal another response. (For example there are many ways to “turn on water” such that some form of “getting wet” is the outcome serving as a prompt to pick up soap, resulting in prompting soap application, etc.) Indeed these are the individual differences in how we shower, but no one applies soap before being wet, nor dries off before turning off the water, etc.FIGURE 7.1 The sequence of chained responses in taking a shower. Each of the general responses below resultsin a specific outcome, which signals the next response. The necessary order is also well illustrated. Indeed, becauseof necessary pre-requisite conditions for some responses (e.g., being wet, being lathered with soap) this chainwould best be taught using a forward chaining or whole task presentation method.
  • 48 COGNITIVE BEHAVIOR THERAPY Spread over Spread on Bed made, Top sheet Top sheet on Made Bed spread in hand pillows ½ of bed Tucked in ½ bed Smooth Spread up to Spread on Pillows on Top sheet on Top sheet on & adjust pillows end of bed bed all of bed bottom of bed Bottom sheet Tuck in top Tuck in New bottom and on, top sheet in of bottom bottom of top sheets, two hand sheet bottom sheet Find the pillows and 1 bed Bottom spread, one sheet mattress presumably Smooth the Tuck in sides of Place bottom with a cover bottom sheet bottom sheet sheet on bed “Make the bed” Note that as with the shower example, many variations and component responses can be added, depending on the learning level and abilities of the learner. Nevertheless, a definite sequence of events can be observed, each resulting in a situation or stimulus array that should prompt the next response (or set of component responses).FIGURE 7.2 Making a bed. Although a certain sequence of responses is involved, this task can be easily arrangedto be totally, partially, or not at all complete. As such, it is teachable in a backward chaining format,here the finalproduct of a ‘‘made bed’’ always is the product of a training session. In a backward chaining format training wouldstart with simply smoothing and adjusting the bed spread over the pillows. The rest of the bed would be alreadymade. The rest of the steps would then be introduced one at a time. The number of steps can be increasingly Forward Chainingrefined until they are (1) small and easily taught A forward chaining procedure teaches eachand (2) at the appropriate level for the learner. component response from the first to the finalThe ability of the learner, the behavioral charac- response in a forward sequential manner.teristics of the learner, and the exact environment For example, in chaining the skills from thethe skill will be taught in must be taken into con- validated task analysis for taking a shower, asideration when conducting a task analysis. In learner would be taught to turn on the waterthe examples shown in the figures, a learner and would be reinforced for doing so until hewould have to have the ability to use both armsand discriminate bedding materials from other or she displayed mastery (e.g., three consecutivematerials, in order to make use of the task anal- correct responses). Once the learner has demon-yses presented. For this reason, the exact steps strated mastery of step one, the second step ofand order of the steps in a task analysis may be getting oneself all wet would be introduced.different for two different learners, depending on Once this second step is introduced, the first stepthe constraints of the environment and the task. of simply turning on the water would no longer be reinforced; the learner would now have to turn on the water and get appropriately wet toDETERMINE WHAT CHAINING be reinforced by our trainer. The other behaviorsPROCEDURE TO USE in our chain would then be added systematically upon mastery of each, until all steps in ourThe trainer at this point has several different validated task analysis have been performed.options as to how to chain the behavior. Selecting An advantage of forward chaining is thatamong the most commonly used chaining proce- teaching trainers to use a forward chain is rel-dures depends upon the exact training situation atively simple, and most people are taught to(see Figure 7.3). engage in new tasks in a forward manner. These
  • 7 • RESPONSE CHAINING 49 Response Chaining 1. A Chain is an ordered series of specific responses that must occur in a predetermined order to produce its related functional reinforcement. SD1 R1 SD2 R2 S D3 R3 SR+ 2. Each response produces an outcome that serves as, 1) A conditioned reinforcer for that response, 2) As a discriminative stimulus (SD) for the next response, and 3) As a discriminative stimulus (S∇) for not engaging in that response. 3. A Task Analysis is conducted for the task to be taught which consists of breaking the task down into component response units based on the apparent or natural sequences that make up the task. Once produced it is important to validate the task analysis for accuracy, completeness and detail according to the skill level of the learner to be taught the chain. Forward chaining teaches the components separately and in the order R1 they occur in the chain. As each R1 R2 response is learned it is added to the R1 R2 R3 SR+ others. Backward Chaining teaches the last response in the chain first, then the R3 SR+ second last and so on. Each teaching trial involves the current response being R2 R3 SR+ taught and then the rest of the sequence already learned, and ends with the R1 R2 R3 SR+ chain’s natural reinforcer Total Task Presentation is a variation of Forward Chaining and teaches all of the R1 R2 R3 SR+ component responses on every teaching trial. That is, the whole chain is performed on every trial.FIGURE 7.3 Response Chaining.advantages can lead to staff’s using forward learner is engaging in the entire task of makingchaining and can decrease the need for staff the entire bed independently.supervision with this method of chaining (Wil- One advantage of backward chaining is thatson et al., 1984). right from the beginning of training, the learner’s performances result in obtaining or producingBackward Chaining the natural reinforcer for engaging in the chain, the made bed in our example. By teaching theBackward chaining involves teaching a learner last responses first, teaching any given preced-the final link in the chain first. For example, from ing step produces a change in the environmentour task analysis of bed making, smoothing the that functions as the discriminative stimulus forbedspread over the pillows is the final link. Thetrainer would arrange for the bed to be ‘‘made’’ the next step, which eventually is the last stepexcept for that final link. The learner would then that has already been followed by the ultimatebe taught to do that last step. Upon mastery reinforcer. Because of this repeated pairing, con-of smoothing the spread over the pillows, the ditioned reinforcement should occur (Skinner,next-to-last step (pulling the spread over the 1938), and this additional reinforcing functionpillows) would be added to the task and both should aid in the acquisition of the chain. Thereresponses would be practiced. The remaining are practical concerns, however, since the learnerresponses would then each be added until the is initially passive on all steps up to the final
  • 50 COGNITIVE BEHAVIOR THERAPYlink (Cooper, Heron, & Heward, 1987). Staff also Biesbrouck, 2006; Martin & Yu, 2000; Yu,sometimes have trouble avoiding confusion in Martin, & Williams, 1989) as well as otherusing backward conditioning due to its reverse factors such as motor dexterity, one mightstrategy. further break down component steps into even smaller units. The final components however must maintain clear stimulusTotal Task Presentation and response relationships with no sameTotal task presentation is a variant of forward stimulus presentations controlling differentchaining. This variant has the learner perform component responses.every step in the chain on every teaching trial. 2. Determine the types and arrangement of prompts.The trainer assists the learner on any step that The final response chain must be trained tohe or she cannot perform independently. This occur in the presence of a specific instructiontraining continues until the learner can perform or cue and then be performed such thatthe entire task independently at the mastery cri- each response sets the occasion for the next,terion. This is accomplished by prespecifying until the entire chain is completed. Thisprompts, including time between prompts, prior requires arranging for the fading of initialto the beginning of the training. For example, the interim instructions and prompts as thetrainer would initially use verbal prompts and component responses are acquired as largerhand-over-hand assistance for each step in mak- and larger units. For learners with languageing coffee, waiting 5 seconds between prompts and rule-governed skills (Ellen & Pate, 1986;until the learner either independently responds Hayes, 1989; Skinner, 1953), spoken, written,or is prompted to engage in the next behavior in self-reported, or pictorial aids can effectivelythe chain. As the learner begins to perform the guide the learner through the sequence in antask more independently, the prompts are faded independent fashion. For nonverbal learners,until the learner is engaging in the entire task interim instructions and prompts (gestural,independently. This procedure has been shown physical, etc.) may be required to establishto facilitate fast chain acquisition (Martin, et al., component responses and then gradually be1981; Spooner, 1984). Spooner (1984) suggests eliminated as the main overall instructionthat the fast rate of acquisition typically observed gains control over the ever-expanding chain.with this method may be accounted for by the 3. Use a modeling demonstration. Demonstrationpresentation of every stimulus–response link on of the entire task to the learner will often resultevery training trial, and may be worth the effort in much quicker acquisition of a chain, andand training time needed to engage in all steps reduce cumbersome training involving estab-during each teaching trial. lishment of partial chains and the gradual removal of the interim instructions for them as the appropriate sequence is established.Factors Related to the Effectiveness of Chaining 4. Training sequence and corrections. Begin train-Research and experience have shown several ing by providing the final instruction. If thefactors can influence the success of a chaining learner errs or stops responding, provide aprogram. momentum cue such as ‘‘keep going’’ that is not specific to the behavior to be engaged in1. Conduct a task analysis. Although there are but that will cue continuing to complete the numerous ways to break down a task into chain. If an error occurs, intervene with a cor- component responses of differing sizes, one rection procedure such as modeling the step should first conduct an analysis that leads to or instructional or gestural assistance until a series of responses that break along natural the learner completes the step. Then proceed lines of the task steps and which produce to the next step by providing the final chain characteristic clear situations or products. instruction again. Then, depending on the discrimination skill 5. Reinforcement. As in any behavior change level of the learner (Jackson, Williams & activity, one should use ample social praise
  • 7 • RESPONSE CHAINING 51 for progress toward the final target behavior. on use of mands in a student with autism. Research Praise should be given for completion in Developmental Disabilities, 26(1), 77–85. of individual responses and some larger Cohen, I. (1984). Establishment of independent responding to a fire alarm in a blind, profoundly reinforcer (such as an edible) provided when retarded adult. Journal of Behavior Therapy and the whole chain is completed, or when Experimental Psychiatry, 15, 365–367. larger units of the final chain are learned. Cooper, J. O., Heron, T. E., and Heward, W. L. (1987). Be cautious to not distract the learner from Applied behavior analysis. Englewood Cliffs, NJ: completing component responses because of Prentice Hall. well-intentioned but unnecessary reinforcing Crafts, L. (1929). Whole and part methods with statements or provision of reinforcers that non-serial reactions. American Journal of Psy- chology, 41, 543–563. stop the engagement in completing the DeLeong, I. G., & Iwata, B. A. (1996). Evaluation task (Gold, 1972). A stimulus preference of a multiple stimulus presentation format for assessment (see the relevant chapter in this assessing reinforcer preferences. Journal of Applied volume) (DeLeong & Iwata, 1996) should Behavior Analysis, 29, 519–533. be conducted to increase the chance that Ellen, P., & Pate, J. (1986). Is insight merely chaining?: supposed reinforcers are indeed reinforcers. A reply to Epstein. The Psychological Record, 36, Choice among several demonstrated rein- 155–160. Fantino, E. (1965). Some data on the discriminative forcers is a preferred method. stimulus hypothesis of secondary reinforcement.6. Prompt fading. Once a learner is engaging in Psychological Record, 15, 409–415. a component response, and especially when Gold, M. (1972). Stimulus factors in skill training component responses are beginning to occur of retarded adolescents on a complex assembly in their desired sequence, it is crucial not to task: Acquisition, transfer, and retention. Ameri- provide unnecessary additional instructions can Journal on Mental Deficiency, 5, 517–526. or cues. The objective is to have the natu- Hagopian, L., Farrell, D., & Amari, A. (1996). Treating total liquid refusal with backward chaining and rally occurring cues from the task itself guide fading. Journal of Applied Behavior Analysis, 29, performance. Failure to remove instructions 573–575. and interim prompts or assistance early on in Hagopian, L. P., Paclawskyj, T., and Contrucci-Kuhn, S. training can result in the learner’s ‘‘waiting’’ (2005). The use of conditional probability analysis for assistance and not trying to complete the to identify a response chain leading to the occur- task independently. rence of eye poking. Research in Developmental Disabilities, 26(4), 393–397. Hayes, S. (1989). Rule governed behavior: Cognition,Further Reading contingencies and instructional control. New York: Plenum.Cooper, J. O., Heron, T. E., and Heward, W. L. (1987). Jackson, M, Williams, W.L., & Biesbrouck, J. (2006). Applied behavior analysis. Englewood Cliffs, NJ: Conditional discrimination ability, equivalence Prentice-Hall. formation and mental retardation: ImplicationsMartin, G., Koop, S., Turner, G., & Hanel, F. (1981). for development in children with developmental Backward chaining versus total task presentation disabilities. Journal of Speech Language Pathology to teach assembly line tasks to severely retarded and Behavior Analysis, 1(1), 27–42. persons. Behavior Research of Severe Developmental Jwaideh, A. (1973). Responding under chained and Disabilities, 2, 117–136. tandem fixed-ratio schedules. Journal of the Exper- imental Analysis of Behavior, 19, 259–267. Kelleher, R., & Fry, W. (1962). Stimulus functions inReferences chained fixed-interval schedules. Journal of theBoren, J. (1969). Some variables affecting the supersti- Experimental Analysis of Behavior, 5, 167–173. tious chaining of responses. Journal of the Experi- Lalli, J., Casey, S., & Kates, K. (1995). Reducing escape mental Analysis of Behavior, 12, 959–969. behavior and increasing task completion withBoren, J., & Devine, D. (1968). The repeated acquisi- functional communication training, extinction, tion of behavior chains. Journal of the Experimental and response chaining. Journal of Applied Behavior Analysis of Behavior, 11, 651–660. Analysis, 28, 261–268.Buckley, S. D., & Newchok, D. B. (2005). Differential Martin, G., Koop, S., Turner, G., & Hanel, F. (1981). impact of response effort within a response chain Backward chaining versus total task presentation
  • 52 COGNITIVE BEHAVIOR THERAPY to teach assembly line tasks to severely retarded handicapped persons. Education and Training of persons. Behavior Research of Severe Developmental the Mentally Retarded, 75–21. Disabilities, 2, 117–136. Spooner, F., Spooner, D., & Ulicny, G. (1986). Compar-Martin, G. L., & Pear, J. J. (2007). Behavior modification: isons of modified backward chaining: Backward What it is and how to do it (8th ed). Upper Saddle chaining with leap-aheads and reverse chaining River, NJ: Prentice Hall. with leap-aheads. Education and Treatment of Chil-Martin, G. L., & Yu, D. (2000). Overview of research on dren, 9, 122–134. the assessment of basic learning abilities. Journal Talkington, L. (1971). Response-chain learning of men- on Developmental Disabilities 7(2), 10–36. tally retarded adolescents under four conditionsMcdonnell, J., & Laughlin, B. (1989). A comparison of of reinforcement. American Journal of Mental Defi- backward and concurrent chaining strategies in ciency, 3, 337–340. teaching community skills. Education and Training Thvedt, J., Zane, T., Walls, R. (1984). Stimulus functions in Mental Retardation, 230–238. in response chaining. American Journal on MentalMcWilliams, R., Nietupski, J., & Hamre-Nietupski, S. Deficiency, 88, 661–667. (1990). Teaching complex activities to students Walls, R., Zane, T., Thvedt, J. (1980). Trainers’ personal with moderate handicaps through the forward methods compared to two structured training chaining of shorter total cycle response strategies. American Journal of Mental Deficiency, 3, sequences. Education and Training in Mental 495–507. Retardation, 292–298. Weber, N. (1978). Chaining strategies for teachingMountjoy, P., Lewandowski, A. (1984). The dancing sequenced motor tasks to mentally retarded horse, a learned pig, and muscle twitches. Psycho- adults. American Journal of Occupational Therapy, logical Record, 34, 25–38. 32, 385–389.Olenick, D. L., & Pear, J. J. (1980). Differential reinforce- Weiss, K. (1978). A comparison of forward and back- ment of correct responses to probes and prompts ward procedures for the acquisition of response in picture-naming training with severely retarded chains in humans. Journal of the Experimental Anal- children. Journal of Applied Behavior Analysis, 13, ysis of Behavior, 29, 255–259. 77–89. Wilson, P., Reid, D., Phillips, J., & Burgio, L. (1984).Pisacreta, R. (1982). A comparison of forward and back- Normalization of institutional mealtimes for pro- ward procedures for the acquisition of response foundly retarded persons: Effects and non-effects chains in pigeons. Bulletin of the Psychometric Soci- of teaching family-style dinning. Journal of Applied ety, 20, 233–236. Behavior Analysis, 17, 189–201.Simek, T., O’Brien, R., Figlerski, L. (1994). Contracting Yu, D., Martin, G., & Williams, W. L. (1989). Expanded and chaining to improve the performance of a col- assessment for discrimination learning with the lege golf team: Improvement and deterioration. mentally retarded. American Journal on Mental Perceptual and Motor Skills, 78, 1099–1105. Retardation, 94, 61–169.Skinner, B. F. (1938). The behavior of organisms. New Zane, T., Walls, R., & Thvedt, J. (1981). Prompting and York: Appleton-Century-Crofts. fading guidance procedure: Their effect on chain-Skinner, B. F. (1953). Science and human behavior. New ing and whole task teaching strategies. Education York: Free Press. and Training of the Mentally Retarded, 125–135.Spooner, F. (1984). Comparisons of backward chaining and total task presentation in training severely
  • 8 BEHAVIORAL CONTRACTING Ramona Houmanfar, Kristen A. Maglieri, Horacio R. Roman, and Todd A. WardA behavioral contract is a written or oral outline specific responsibilities of the individu-agreement between a client(s) and a clinician, als involved (e.g., cost of the program to eachconsultant, or an instructor that specifies ex- individual in terms of time, effort, and money);pectations, plans, and/or contingencies for and (4) they ensure that all individuals arethe behavior(s) to be changed (Martin & Pear, committed to the project in that signatures are2007; Kirschenbaum & Flanery, 1984). In its obtained.classic form, behavioral contracts (sometimes The conceptual foundations of behav-also called contingency contracts) are written, ioral contracts are based on the basic princi-and specify a set of terms (i.e., the treatment ples of operant psychology (Murphy, 1988).plan) to be followed by the client, and related Most behavioral contracts are based on thepositive and/or negative consequences (Kidd & A-B-C approach to identify and modifyingSaudargas, 1988) to be carried out conditionally ‘‘antecedents’’ to the target behavior (A), theon compliance or noncompliance with the plan target ‘‘behaviors’’ (B), and the ‘‘consequences’’(Homme, 1970; Kidd & Saudargas, 1988; Mann, or reinforcers that shape and maintain behav-1972; Murphy, 1988; Petry, 2000; Welch, & iors (C). Since behavior is a function of itsHolborn, 1988). Behavioral contracting has been consequences, behaviors followed by positiveapplied to a wide variety of areas and settings or pleasant consequences are more likely tosuch as classroom behavior problems (Carns & recur than behaviors followed by negativeCarns, 1994; De Martini-Scully, Bray, & Kehle, consequences. Behaviors that are influenced by2000; Homme, 1970; Ruth, 1996), instructional a set of consequences can be changed either bydesign (Brooks & Ruthvan, 1984), addictive withholding those consequences or imposingbehaviors (Bigelow, Sticker, Liebson, & Griffiths, a new set of consequences. Accordingly, once1976; Mann, 1972; Vinson, & Devera-Sales, problem behaviors (e.g., noncompliance with2000), staff management (Azrin & Pye, 1989; medication regime, drug or alcohol abuse) andWelch & Holborn, 1988), delinquency (Stuart & their controlling consequences are identified,Lott, 1972), self-injurious behaviors (Heinssen, additional incentives (e.g., store vouchers,Levensky, & Hunter, 1995), family relationships prizes, cash) and loss of privileges can be(Blechman, Olson, & Hellman, 1976; Jacobson, implemented through behavioral contracting to1978), anorexia (Solanto, Jacobson, Heller, change the existing contingencies.Golden, & Hertz, 1994), weight loss programs Behavioral contracting has particular utility(Anderson, Mavis, Robinson, & Stoffelmayr, for clinicians in dealing with compliance with1993; Kirchenbum, Germann, & Rich, 2005), and treatment plans. Treatment noncompliancebedtime compliance (Robinson, & Sheridan, poses a major challenge to clinicians. Treatment2000). plans that are more acceptable to clients are The clear and mutually negotiated guidelines more likely to be followed than less acceptablein behavioral contracts serve four primary func- plans (Kolko & Milan, 1983) and thus treatmenttions (Martin & Pear, 2007): (1) they provide acceptability is a critical dimension of the effi-an agreement of goals; (2) they ensure that all cacy of a treatment plan (Kazdin, 1980; Yeatoninvolved individuals have an accessible refer- & Sechrest, 1981). The negotiation processence to monitor progress toward goals; (3) they involved in behavioral contracting can increase 53
  • 54 COGNITIVE BEHAVIOR THERAPYtreatment acceptability and compliance and for behaviors that can be monitored directly throughthat reason the use of negotiated contingencies observations (e.g., attendance to meetings) orand a focus on treatment process, not just by their permanent products (e.g., urine sam-outcome, are important participatory factors ples) are better suited to benefit from behavioralin design and implementation of behavioral contracts.contracts (Kirschenbaum & Flanery, 1984). Sincehow well the client does is directly related tohow well he or she follows the contract related ASSOCIATED CHALLENGEScontingencies, behavioral contracts should beviewed as a tool (Boudin, 1972) that facilitates According to Miller (1990), difficulties withtreatment compliance and treatment efficacy. behavioral contracts develop when contracts With regard to the consequential aspect of (1) are too restrictive or ‘‘parental,’’ (2) appeara behavioral contract, the extent to which new to be punishing or rejecting, (3) substituteconsequences compete and prevail over existing for therapy rather than enhance therapy, andconsequences is a function of three parameters: (4) are too rigid and do not allow for clientrelative magnitude or size, schedule of delivery, determination or client input. Further, variablesand latency (Petry, 2000). For instance, a conse- such as vagueness of the contract and thequence that immediately follows a behavior may therapist’s lack of vigilance to observe andbe more effective than a delayed consequence. monitor the client’s compliance with the contractLikewise, consequences that are delivered con- and implement the associated contingenciessistently and in small amounts tend to produce may participate in a contract’s ineffectivedesirable change. Thus, constructing contract implementation.terms should be preceded by an identification ofreinforcers. Although one can hypothesize aboutthe effectiveness of consequences in advance, STEP-BY-STEP PROCEDURESchange in behavior is the ultimate determinantof their influence. Accordingly, development and This section outlines a scenario that may be expe-implementation of a monitoring system is essen- rienced by a mental health professional whotial in evaluating compliance with treatment provides services in the area of family andcontingencies. marriage counseling. The example is used to illustrate the construction of an appropriate con- tract for a family receiving professional services.WHO MIGHT BENEFIT FROM THIS TECHNIQUE? Mr. and Mrs. Philbrick, who have been mar- ried for a little over 15 years, have soughtBehavioral contracting is a treatment that is uti- out professional advice regarding their maritallized in a variety of settings and for an even problems in addition to problems they are expe-greater number of target behaviors, including riencing with their daughter. Recently, Mike (theclassroom behavior, family-marital therapy, sub- father) has been spending more time at work andstance abuse, weight loss, smoking cessation, less time with the family. Rachel (the mother)and physical exercise, to name a few. However, feels that Mike isn’t home enough and that heas mentioned earlier, treatment noncompliance would rather be spending time with his friendsposes a major challenge for the success of behav- than with his family on the weekends. Conse-ioral contracts and in the selection of clients for quently, because Mike is not home during theuse of behavioral contracting variables such as week, communication between Mike and Rachelclient’s skills and repertoire needs to be consid- has declined considerably. Mike complains thatered. For example, a developmentally delayed or the time he does spend at home is spent arguingseverely mentally ill client must be able to moni- about family matters, specifically about money.tor the relevant contexts and their performances Rachel feels that she is the only one managingin them to make use of behavioral contracts as a the household and never has time to do thingstreatment tool. Additionally, clients who exhibit for herself.
  • 8 • BEHAVIORAL CONTRACTING 55 Mike and Rachel are also having trouble with • The behavioral contract should specifytheir 14-year-old daughter, Katy. She frequently short-term as well a long-term goalsignores her 10:00 curfew, sometimes coming (Kirschenbaum & Flanery, 1984). The client’shome around 1:00 in the morning. Katy had participation in setting his/her goals isalways been a good student, but recently her essential in determining reasonable andgrades have been starting to slip. Mike suspects obtainable goals (Lock et al., 1981; Ludwigthat Katy may be drinking or, worse, getting into & Geller, 1997). If treatment goals are toodrugs. Mike and Rachel have tried to discipline difficult, they will not be achieved, andKaty, but they report that nothing seems to be subsequently any attempts to obtain theworking. Rachel would like to spend more qual- goal will not be reinforced. This may resultity time with Katy and would like to see Mike in noncompliance with the treatment ordo the same. Katy complains that her parents termination of services altogether. Thus,are always arguing and she doesn’t want to be providing reinforcing consequences for thearound them. Both Mike and Rachel would like completion of each small step toward theto improve their marriage and their relationship end goal will increase treatment success.with their daughter as well. For those individuals who do not possess The first step in suggesting the most appro- the behavioral repertoire that is necessarypriate treatment is determining the family’s or to complete the end goal, the principle ofclient’s needs. Without a full assessment of the shaping may be utilized (Martin & Pear, 2007;client’s needs, determining the most appropri- Skinner, 1953). In other words, the contractate course of action will be difficult and may should specify relatively simple goals,result in targeting the wrong problem behaviors. initially ensuring that the client comes intoEqually important in determining the appro- contact with reinforcement. Once the clientpriate course of treatment is identifying the has achieved the desired level of behavior,client’s willingness to change his or her behavior systematic increases in goal difficulty should(Kirschenbaum & Flanery, 1984). Returning to be implemented. For example, it may bethe preceding example, both Mike and Rachel better to set a goal for a decrease in thehave expressed an interest in improving their number of arguments between the couplecurrent situation; however, it is unclear whether (e.g., decrease by 2) that gradually increasesKaty is committed to change as well. The initial than to start out with a very big goal at thedecision to seek professional help is typically a beginning (e.g., decrease by 10).good indicator of willingness to change; how-ever, identifying which behavior the individual • The behavioral contract must identify spe-is willing to change must be determined during cific target behaviors for change, as well asthe interview or assessment process. ones that will be supported in the natural Once it has been determined that a behavioral environment once change occurs. It is alsocontract is an appropriate technique to facilitate important that the contract specifies the con-treatment, the therapist should begin to construct ditions under which target behaviors occur,the written document. A well-written contract including times and dates. The more specificmust contain several essential pieces of informa- the contract, the easier it will be to follow. Thistion (See Table 8.1). The necessary components step is perhaps the most import aspect of thefor constructing a behavioral contract are as treatment process, but it can also be the mostfollows: challenging. Identifying target behaviors in some situations may be relatively obvious• The behavioral contract must clearly specify (e.g., weight loss), but in others, such as the goals of the treatment and use language family–marital interactions, it may be more that is geared to the client’s reading level. difficult to pinpoint critical behaviors that If the client(s) does not understand what is will result treatment success. For example, expected of him/her, the treatment will cer- if the goal is to decrease arguments about tainly not be followed. money, the defining conditions of that target
  • 56 COGNITIVE BEHAVIOR THERAPY (topographically and situationally) should be than on what he or she should avoid doing. clear. The most effective contracts should specify• Behavioral contracts should include a moni- both the reward for compliance and the con- toring system to ensure that the client is meet- sequence for noncompliance (Homme, 1970; ing his or her goals. Target behaviors that are Clark, Leukefeld, & Godlaski, 1999). Drawing selected should be objectively quantifiable, from the example above, an appropriate con- that is, sufficiently clear that another indi- tract contingency for Katy would be ‘‘I agree vidual can verify the completion of assigned to come home by my curfew for 3 weeks in a goals. The contract should also specify the row. In the event that I do come home by my person responsible for monitoring treatment curfew for 3 weeks in a row, I will spend one progress, how often the monitoring should Saturday a month shopping with my mother. occur, and by what method. Self-monitoring In the event that I do not come home by my (the client records his or her own behav- curfew, I will not be allowed to go shopping ior) may be utilized in some situations. For with my mother and I will not be allowed to instance, Kirchenbum, Germann, and Rich go out the following weekend.’’ An inappro- (2005) found that self-monitoring significantly priate contingency for Katy would be ‘‘If I do raised the likelihood that participants would not come home by my curfew, I will not be benefit from treatment than those that did not able to go out the following weekend and I self-monitor. Even so, practitioners should be will not spend one Saturday a month with my aware that reliability is a known problem, par- Mom shopping.’’ ticularly in areas, such as drug addiction, that are difficult to monitor (Petry, 2000). Clients To maximize the effects of rewards, they are particularly likely to lie when self-report should be delivered immediately, in frequent is linked to important consequences; thus, small amounts, and only when the desired in these areas, reinforcers should be deliv- behavior is achieved. The delivery of the ered based on the verification of products of reward can be systematically faded over time to behavior. In the area of drug use, for example, lessen the amount of effort and any additional it is better to reward screened clean urinaly- monetary costs associated with implementing sis data than to reward claims of abstinence. the contract. For example, a reward may initially In some conditions, self-monitoring can be be delivered each time the desired behavior less intrusive, less expensive, and more pro- occurs and eventually decreased according ductive of consistent behavior change than to a more manageable schedule over time. external monitoring, particularly when the If the desired behavior has not maintained goal is personally relevant and important after the reinforcement schedule has been (Kirschenbaum & Flanery, 1984). modified, the therapist should return to a• The behavioral contract must specify reward reinforcement schedule that has previously contingencies for compliance with treatment produced successful performance. goals in addition to consequences for non- compliance. The contingencies should focus • Finally, the negotiated behavioral contract on the positive. That is, the contract should should be agreed upon and signed by all focus on what the client should do rather involved parties.TABLE 8.1 Key Steps in Using Behavioral Contract1. Clearly specify the goals of the treatment and use language that is geared to the clients reading level.2. Specify short-term as well as long-term goals.3. Identify specific target behaviors for change.4. Include a monitoring system to ensure that the client is meeting his or her goals.5. Specify reward contingencies for compliance with treatment goals in addition to consequences for noncompliance.6. Be agreed upon and signed by all involved parties.
  • 8 • BEHAVIORAL CONTRACTING 57Behavioral Contract Example Katy Philbrick (daughter):The example below illustrates a family a. I agree to come home by my curfew 3contract between the Philbrick family and weeks in a row.Dr. Evans. b. I agree to spend one family night a week with the entire family. I agree notMike Philbrick (father): to argue with my Mom or Dad during this time.a. I agree to spend one family night a c. I agree to spend the evening two days week with the entire family. I agree not a week, Tuesday and Thursday, doing to argue with Rachel or Katy during this my homework with my dad. time. d. In the event that I do a through c, I willb. I agree to help Katy with her homework spend one Saturday a month shopping every week on Tuesday and Thursday. with my Mom. In the event that I doc. I agree to spend 1 hour a week on not do a through c, I will not spend one Sunday nights with Rachel discussing a Saturday a month shopping with my topic that she chooses that is not related Mom. to work, the house, or the kids.d. I agree to talk to Rachel about financial By signing below, you indicate that you matters for one hour on Monday nights agree to the terms stated above and agree only. to monitor the completion of your treat-e. In the event that I do a through d, I will ment goals. A written record of accom- spend one Sunday a month watching plished treatment goals must be turned in football with my friends. In the event to Dr. Evans every month during therapy that I do not accomplish a through d, sessions. I will not be allowed to watch foot- The behavioral contract will be moni- ball. tored and revised by Dr. Evans as treat- ment goals are achieved.Rachel Philbrick (mother): Datea. I agree to spend one family night a Family Members Negotiator week with the entire family. I agree not Mike Philbrick Dr. Evans to argue with Mike or Katy during this Rachel Philbrick time. Katy Philbrickb. I agree to take Katy shopping one Satur- day afternoon per month. In the event that Katy does not come home by her The behavioral contracting example utilized curfew, she will not be allowed to go in this chapter is designed to build structure shopping. and predictability into the family system.c. I agree to spend 1 hour a week on Sun- Many families tend to highlight the negative day nights with Mike discussing a topic behaviors of other family members and are that I choose that is not related to work, often unclear about the reciprocal interaction the house, or the kids. of members’ behaviors in the family unit.d. I agree to talk to Mike about financial Consequently, behavioral contracting provides matters for 1 hour on Monday nights initial restructuring of the family behaviors and only. their antecedents and consequences. In thise. In the event that I do a through d, I will context, the role of the family therapist is to (1) spend one Saturday a month out of the help the family design, initiate, and negotiate house doing an activity that I choose. contracts; (2) assist in the identification and
  • 58 COGNITIVE BEHAVIOR THERAPYmonitoring of specific problem behaviors and Heinssen, R. K., Levendusky, P. G., & Hunter,contingencies that are included in the contract; R. H. (1995). Client as colleague: Therapeuticand (3) eventually facilitate the development of contracting with the seriously mentally ill. American Psychology, 50, 522–532.less formal verbal contracts in the later stages of Homme, L. (1970). How to use contingency contract-therapy as written formal agreements become ing in the classroom (Rev. ed.). Champaign, IL.:less necessary. Research Press. Jacobson, N. S. (1978). Specific and nonspecific factors in the effectiveness of a behavioral approach to theFurther Reading treatment of marital discord. Journal of Consulting and Clinical Psychology, 46, 442–452.Homme, L. (1970). How to use contingency contract- Kazdin, A. E. (1980). Acceptability of alternative treat- ing in the classroom (Rev. ed.). Champaign, IL: ments for deviant child behavior. Journal of Applied Research Press. Behavior Analysis, 13, 259–273.Kirschenbaum, D. S., & Flanery, R. C. (1984). Toward Kidd, T. A., & Saudargas, R. A. (1988). Positive and a psychology of behavioral contracting. Clinical negative consequences in contingency contracts: Psychology Review, 4, 597–618. Their relative effectiveness on arithmetic perfor-Miller, L. J. (1990). The formal treatment contract in the mance. Education and Treatment of Children, 11, inpatient management of borderline personality 118–126. disorder. Hospital and Community Psychiatry, 41, Kirchenbum, D.S., Germann, J.N., Rich, B. H. (2005). 985–987. Treatment of morbid obesity in low-income ado- lescents: Effects of parental self-monitoring. Obe- sity Research, 13, 1527–1529.References Kirschenbaum, D. S., & Flanery, R. C. (1984). TowardAnderson, J. V., Mavis, B. E., Robinson, J. I., & Stof- a psychology of behavioral contracting. Clinical felmayr, B. E. (1993). A work-site weight man- Psychology Review, 4, 597–618. agement program to reinforce behavior. Journal of Kolko, D. J., & Milan, M. A. (1983). Reframing and Occupational Medicine, 35, 800–804. paradoxical instruction to overcome ‘‘resistance’’Azrin, N. H., & Pye, G. E. (1989). Staff management in the treatment of delinquent youths: A multiple by behavioral contracting. Behavioral Residential baseline analysis. Journal of Consulting and Clinical Treatment, 4, 89–98. Psychology, 51, 655–660.Bigelow, G., Sticker, O., Leibson, I., & Griffiths, R. Locke, E. A., Shaw, K. N., Saari, L. M., & Latham, (1976). Maintaining disulfiram ingestion among G. P. (1981). Goal setting and task performance outpatient alcoholics: A security deposit contin- 1969–1980. Psychological Bulletin, 90, 125–152. gency contracting program. Behavior Research and Ludwig, T. D., & Geller, E. S. (1997). Assigned versus Therapy, 14, 378–580. participative goal setting and response general-Blechman, E. A., Olson, D. H. L., & Hellman, I. D. (1976). ization: Managing injury control among profes- Stimulus control over family problem-solving sional pizza deliverers. Journal of Applied Psychol- behavior: The family contract game. Behavior Ther- ogy, 82, 253–261. apy, 7, 686–692. Mann, R. A. (1972). The behavior therapeutic use of con-Boudin, H. M. (1972). Contingency contracting as tingency contracting to control an adult behavior a therapeutic tool in the deceleration of am- problem: weight control. Journal of Applied Behav- phetamine use. Behavior Therapy, 3, 604–608. ior Analysis, 5, 99–109.Brooks, R. R., & Ruthven, A. J. (1984). The effects of Martin, G., & Pear, J. (2007). Behavior modification: contingency contracting on student performance What is it and how to do it. (8th ed.) Upper in a PSI class. Teaching of Psychology, 11, 87–89. Saddle River, NJ: Prentice Hall.Carns, A. W., & Carns, M. R. (1994). Making behav- Miller, L. J. (1990). The formal treatment contract in the ioral contracts successful. School Counseling, 42, inpatient management of borderline personality 155–160. disorder. Hospital and Community Psychiatry, 41,Clark, J. J., Leukefeld, C., & Godlaski, T. (1999). Case 985–987. management and behavioral contracting: Compo- Murphy, J. J. (1988) Contingency contracting in schools: nents of rural substance abuse treatment. Journal A review. Education and Treatment of Children, 11, of Substance Abuse Treatment, 17, 293–304. 257–269.De Martini-Scully, D., Bray, M. A., & Kehle, T. J. Petry, N. M. (2000). A comprehensive guide to the (2000). A packaged intervention to reduce dis- application of contingency management proce- ruptive behaviors in general education students. dures in clinical settings. Drug and Alcohol Depen- Psychology in the Schools, 37, 149–156. dence, 58, 9–25.
  • 8 • BEHAVIORAL CONTRACTING 59Robinson, K. E., & Sheridan, S. M. (2000). Using the Behavioral Therapy and Experimental Psychiatry, 3, mystery motivator to improve child bedtime com- 161–169. pliance. Child and Family Behavior Therapy, 22, Vinson, D.C., & Devera-Sales, A. (2000). Computer- 29–49. generated written behavioral contracts with prob-Ruth, W. J. (1996). Goal setting and behavior contract- lem drinkers in primary medical care. Substance ing for students with emotional and behavioral Abuse, 21, 215–222. difficulties: Analysis of daily, weekly, and total Welch, S. J., & Holborn, S. W. (1988). Contingency goal attainment. Psychology in the Schools, 33, contracting with delinquents: Effects of a brief 153–158. training manual on staff contract negotiation andSkinner, B. F. (1953). Science and human behavior. New writing skills. Journal of Applied Behavior Analysis, York: Free Press. 21, 357–368.Solanto, M. V., Jacobson, M. S., Heller, L., Golden, Yeaton, W. H., & Sechrest, L. (1981). Critical dimen- N. H., & Hertz, S. (1994). Rate of weight gain sions in the choice and maintenance of successful of inpatients with anorexia nervosa under two treatments: Strength, integrity, and effectiveness. behavioral contracts. Pediatrics, 93, 989–991. Journal of Consulting and Clinical Psychology, 49,Stuart, R. B., & Lott, L. A. (1972). Behavioral contract- 156–167. ing with delinquents a cautionary note. Journal of
  • BIBLIOTHERAPY UTILIZING COGNITIVE 9 BEHAVIOR THERAPY Negar Nicole JacobsBibliotherapy is defined in this chapter as the use Given these benefits, the use of bibliotherapyof written psychotherapeutic self-help materials by psychologists appears to be very popular.for the purpose of solving mental health prob- Starker (1988) surveyed 123 psychologists acrosslems. Bibliotherapy originally involved reading 36 states to analyze their use of bibliotherapy. Hefictional or religious stories and identifying with found that the practice of prescribing bibliother-a character as a means of gaining insight and apeutic materials was ‘‘widespread,’’ becauseexperiencing catharsis (Schrank & Engels, 1981). 97.7% of those surveyed prescribed self-helpHowever, when cognitive behavioral treatments materials at least regularly.(CBT) were developed and gained popularity The present chapter will review the demon-in the 1960s, many bibliotherapeutic materi- strated range of applicability of bibliotherapiesals evolved into treatment manuals based on utilizing CBT principles, discuss factors for cli-the principles of CBT (Papworth, 2006). Today, nicians to consider in deciding whether to uti-bibliotherapeutic materials are widely available lize bibliotherapy in their clinical practice, andto the lay public. The American Psychological provide recommendations in the use of biblio-Association (1989) has estimated that over 2000 therapy.self-help books are published each year, thoughthere is great variability in the quality of thesematerials. EVIDENCE-BASED APPLICATION Delivery of CBT principles in a bibliother-apeutic format has many advantages over The past couple of decades have shown atraditional psychotherapy. Advantages of bibli- proliferation of treatment outcome studiesotherapy include its demonstrated empirical involving bibliotherapy. The vast majoritysupport across a broad spectrum of problems of bibliotherapeutic materials that have(see below), cost effectiveness, widespread undergone empirical evaluation are basedavailability, and potential to reach populations on CBT techniques. These studies show thatwho would otherwise have difficulty accessing bibliotherapy has demonstrated a wide rangetraditional psychotherapy (Mains & Scogin, of applicability across psychological disorders,2003). Readers of bibliotherapeutic materials symptom severities, and levels of therapistcan take responsibility for their problems and assistance. As the scope of this chapter does notexercise control in managing their symptoms at allow for a thorough review of the research ona self-paced rate. Bibliotherapy can also afford bibliotherapy, a brief overview will be providedindividual readers privacy and help them avoid here and the interested reader will be referredthe stigma that is often associated with seeking to more detailed reviews of the bibliotherapymental health services through traditional psy- outcome literature (i.e., Apodaca & Miller, 2003;chotherapy. Furthermore, bibliotherapy can be Cuijpers, 1997; Den Boer, Wiersma, & Van Denutilized in a stepped-care model as a preventive Bosch, 2004; Gould & Clum, 1993; Gregory,intervention (Papworth, 2006) or for individuals Canning, Lee, & Wise, 2004; Hirai & Clum, 2006;with low levels of symptomatology. Jacobs & Mosco, in press; Mains & Scogin, 2003; 60
  • 9 • BIBLIOTHERAPY UTILIZING COGNITIVE BEHAVIOR THERAPY 61Marrs, 1995; McKendree-Smith, Floyd, & Scogin, a therapist showed significant improvement2003; Newman et al., 2003; Papworth, 2006; posttreatment and at a 3-month follow-up. TheScogin, Bynum, Stephens, & Calhoon, 1990). effectiveness of bibliotherapeutic approaches Bibliotherapeutic approaches for the treat- has also been demonstrated for other anxietyment of depression have been widely inves- disorders, such as panic attacks (Febbraro, 2005),tigated. Several meta-analyses have been panic disorder with agoraphobia (Sharp, Power,conducted to examine these numerous research & Swanson, 2000), and generalized anxietyfindings, with results that were mostly promising disorder (Bowman, Scogin, Floyd, Patton,for bibliotherapy. Scogin, Welsh, Hanson, Stump & Gist, 1997). However, bibliotherapy hasand Coates (2005) conducted a meta-analysis on differential effectiveness for different types offour treatment studies (Landreville & Bisson- anxiety disorders and levels of therapist contactnette, 1987; Floyd, Scogin, McKendree-Smith, involved in the treatment package (Mains &Floyd, & Rokke, 2004; Scogin, Hamblin, & Beut- Scogin, 2003; Marrs, 1995; Newman et al., 2003).ler, 1987; Scogin, Jamison, & Gochneaur, 1989) Bibliotherapy as a treatment modality has alsoemploying cognitive bibliotherapy for geriatric proven to be effective for a number of other psy-depression. Treatments utilized Burns’s Feeling chiatric disorders. In a meta-analysis of 22 studiesGood (1980) with minimal therapist contact. analyzing the effectiveness of bibliotherapy inData in all these studies indicated significant the treatment of problem drinking, Apodacaimprovement in depressive symptoms for and Miller (2003) found an overall effect sizebibliotherapy participants. In a meta-analysis of .80. Studies analyzing the effectiveness of bib-of six studies utilizing bibliotherapy to treat liotherapy for the treatment of eating disordersdepression, Cuijpers (1997) concluded that have found moderate effect sizes for bulimia andbibliotherapy was an effective treatment for binge-eating disorder (Bailer, et al., 2004; Carterunipolar depression and that bibliotherapy was & Fairburn, 1998; Carter, Olmstead, Kaplan,as effective as individual or group treatment. McCabe, Mills, & Aim´ , 2003; Cooper, Coker, & eIn another review of bibliotherapy studies Fleming, 2003; Ghaderi, 2006). A meta-analysisfor depression, McKendree-Smith, Floyd, and of bibliotherapies for sexual dysfunctions (vanScogin (2003) noted that bibliotherapy produced Lankveld, 1998) concluded that bibliotherapy foreffect sizes that were equivalent to average orgasmic disorders was found to be effective ateffect sizes found in traditional psychotherapy posttreatment but not at follow-up.studies. A meta-analysis conducted by Gregory,Canning, Lee, and Wise (2004) demonstrated theeffectiveness of bibliotherapy across adolescent,adult, and geriatric age groups. Numerous LIMITS OF BIBLIOTHERAPYstudies have demonstrated that improvementsgained from bibliotherapy at posttreatment are Despite the evidence base for bibliotherapiesmaintained at 2-year (Floyd, Rohen, Shackelford, described earlier, the vast majority of bibliothera-Hubbard, Parnell, Scogin, & Coates, 2006) and peutic materials lack empirical support. Concerneven 3-year (Smith, Floyd, Scogin, & Jamison, for the proliferation of self-help materials with-1997) follow-ups. out empirical evaluation has been addressed by The effectiveness of bibliotherapy for the a variety of researchers (i.e., Craighead, McNa-treatment of a variety of anxiety disorders has mara, & Horan, 1984; Glasgow & Rosen, 1978;also been demonstrated. In a meta-analysis Riordan and Wilson, 1989; Schrank & Engels,of self-administered treatments for anxiety 1981; Stevens & Pfost, 1982). Most notably, Rosendisorders, Newman, Erickson, Przeworski, and and colleagues have passionately and repeatedlyDzus (2003) noted a medium to large effect size given warning about the massive gap betweenoverall. Reeves and Stace (2005) found that adult the number of self-help programs available andsubjects with mild to moderate anxiety who the number of such programs evaluated for effec-utilized a cognitive-behavioral bibliotherapy tiveness, as well as the potential for iatrogenicpackage and had weekly coaching sessions with effects of such untested materials (i.e., Rosen,
  • 62 COGNITIVE BEHAVIOR THERAPYGlasgow, & Moore, 2003). Even when some bib- clients with internalizing coping styles moreliotherapeutic materials undergo empirical eval- successfully utilized bibliotherapy than thoseuation under research conditions, which involve with externalizing coping styles. In the depres-some level of therapist contact, Rosen (1987) has sion literature, some researchers have suggestedpointed out that the results do not always hold that bibliotherapy would be the most appropriateup under totally self-administered conditions, as treatment for those with mild to moderate levelswhen a reader buys a self-help book from a book- of depression and for those interested in the selfstore. Readers may not accurately self-diagnose management of chronic depression (i.e., Ander-and they may not properly apply the instructions son, Lewis, Araya, Elgie, Harrison, Proudfoot,of the self-help materials (Barrera, Rosen, & Glas- Schmidt, Sharp, Weightman, & Williams, 2005).gow, 1981). Rosen has criticized psychologists for Some studies (i.e., Newman, 2000 and Reevesmarketing untested materials and making exag- & Stace, 2005) have suggested that the followinggerated claims of effectiveness of these materials client characteristics could be contraindications(i.e., Rosen, 1987). Rosen and his colleagues have for use of bibliotherapy: presence of personalityalso provided clear recommendations to address disorders, emotional avoidance, high levels ofthese concerns (i.e., 1978 Task Force on Self-Help interpersonal distress, comorbid psychologicalTherapies; Rosen, 1981; Rosen, 1987) but they symptoms, and severe symptom severity. In thehave had to point out repeated failures by psy- depression literature, Mains and Scogin (2003)chologists to follow these recommendations (i.e., have noted that severe levels of depression, sui-Rosen, 1993; Rosen, 2004; Rosen, Glasgow & cidality, defensiveness, lack of learned resource-Barrera, 2007). fulness, and comorbidity are likely to reduce the effectiveness of self-administered treatments. Comorbidity includes factors such as psychosis,FACTORS TO CONSIDER WHEN alcohol or drug misuse, and high risk of harm toRECOMMENDING BIBLIOTHERAPY self or others. Clearly, bibliotherapy should not be offered to clients who are not able to read orTo date, no systematic research has been done comprehend the language used in the readingon specific indications or contraindications materials.for use of bibliotherapy. Campbell and Smith Several researchers have commented on other(2003) have suggested that providers may be factors that should be considered by cliniciansable to extrapolate from research matching when recommending bibliotherapy to theirclient characteristics to traditional types of psy- clients. Campbell and Smith (2003) recommendchotherapies (i.e., Beutler 1991) and they have that clinicians should consider both client andrecommended that cognitive behavioral thera- therapist characteristics. Client characteristicspists should exercise their clinical judgment in include reading levels and preferences, abilitydeciding whether to assign bibliotherapy and to understand self-help materials, demographichow to best match clients with bibliotherapy variables such as ethnicity and culture, and levelmaterials. of symptom severity. They also recommend Some researchers investigating the effective- that clinicians tailor self-help recommendationsness of self-help materials have discussed client to specific phases of treatment. They warncharacteristics that they have noted to help or clinicians to beware of use of bibliotherapyhinder bibliotherapy. For example, in research to intellectualize treatment or otherwise useanalyzing matching effects for treatment tech- the materials to divert attention away fromniques with various client characteristics, Beutler the therapy. Therapist considerations includeand colleagues (Beutler, Engle, Mohr, Daldrup, having the clinician be familiar with the self-helpBergan, Meredith, & Merry, 1991) observed that materials, ensuring that the recommendedself-administered treatments such as bibliother- reading be related to the client’s presentingapy produced better treatment outcomes for complaints, and making certain that theclients who were high in reactance and resis- recommended exercises in the bibliotherapytance. Campbell and Smith (2003) found that materials are feasible for the client in question.
  • 9 • BIBLIOTHERAPY UTILIZING COGNITIVE BEHAVIOR THERAPY 63PRACTICE RECOMMENDATIONS necessitate at least minimal therapist contact for the purpose of assessment and monitoring, doesSeveral researchers have offered a variety of not always generalize to such effectiveness whenrecommendations that should be used by clini- self-administered in real-world conditions.cians when assigning self-help books to clients. Finally, Mains and Scogin (2003) pointed out theKatz and Watt (1992) have likened recommen- variable data on effectiveness of bibliotherapydation of bibliotherapy to the prescription of for different disorders (as discussed above),psychotropic medications. As with medications, noting that overall there is good data forthey have suggested that self-help books be pre- bibliotherapeutic treatment of mild alcoholscribed after considering the patient’s problems, abuse, depression, and many anxiety disordersindividual characteristics of the patient, and the but unclear data with respect to habit controlpossible effects of the recommended treatment. problems. They suggested that clinicians shouldThey hypothesized that, as with medications, recommend bibliotherapies that have undergonecompliance to treatment would be most likely rigorous testing for efficacy, such as Feeling Goodin the context of a good therapeutic relationship (Burns, 1980) for the treatment of depression.and when the prescribing provider had a posi- Table 9.1 contains selected examples of excellenttive attitude toward the treatment. And, similar bibliotherapy materials, which are either basedto the prescription of a drug, they noted that on empirically supported techniques or haveproviders recommending bibliotherapy should themselves undergone empirical evaluation, foraddress patients’ expectations of the treatment a representative sample of psychiatric disorders.and discuss the potential problems a patient Because there is mixed data on the effec-could encounter when attempting to comply tiveness of bibliotherapies with varying levelswith the treatment. of therapist contact, the most conservative After reviewing the effectiveness of self- recommendation is to utilize bibliotherapy asadministered treatments, Mains and Scogin an adjunctive, as opposed to a totally self-(2003) developed a set of practice recommen- administered, treatment. Some researchers (i.e.,dations for the use of bibliotherapy. First, Pardeck & Pardeck, 1984) argue that cliniciansthey suggested that practitioners who recom- should offer guidance to clients at every stagemend bibliotherapy should monitor the client’s of the bibliotherapeutic process, includingresponse to and progress in the treatment, noting selection of the reading materials, reading andthat changes in symptomatology could necessi- comprehension of the self-help materials, andtate implementation of higher levels of treatment tying in the content with the overall therapeutic(as in a stepped-care model). Second, they rec- process. While little is known about the processommended that maintenance programs should variables accounting for change in bibliotherapy,be considered for clients who were progressing some authors (i.e., Hynes & Hynes-Berry, 1986)in the bibliotherapeutic treatment. Third, they contend that therapist contact, and not theurged clinicians to consider individual charac- content of the reading materials, is the essentialteristics of clients and to only recommend biblio- change agent involved in the effectiveness oftherapy to clients who would be good candidates bibliotherapy.(i.e., highly motivated, as discussed earlier).Fourth, they noted that self-administered treat-ments involving some level of therapist contactwere more effective than self-administered treat- CONCLUSIONments alone. However, they also pointed out thateven research involving minimal therapist con- Bibliotherapy is an excellent means of accessingtact would translate into no contact when used evidence-based cognitive behavioral techniquesby readers who buy the self-help materials in for the lay public, including populations whothe bookstore. And, as Rosen (1993) has pointed may not otherwise access mental health ser-out, bibliotherapy that has demonstrated vices due to barriers such as costs, transporta-effectiveness in research conditions, which tion problems, and/or stigmas associated with
  • 64 COGNITIVE BEHAVIOR THERAPYTABLE 9.1 Sampling of Bibliotherapy RecommendationsAnger Management• Novaco, R.W. (1975). Anger Control. Lexington, MA: Lexington Books.Anxiety Disorders• Antony, M. M., Craske, M. G., & Barlow, D. H. (2006). Mastering your fears and phobias (2nd ed.): Workbook. New York: Oxford University Press.• Barlow, D. H., & Craske, M. G. (2007). Mastery of your anxiety and panic (4th ed.): Workbook. New York: Oxford University Press.• Craske, M. G., Barlow, D. H. (2006). Mastery of your anxiety and worry (2nd ed.): Workbook. New York: Oxford University Press.• Foa, E. B., & Wilson, R. (1991). Stop obsessing!: How to overcome your obsessions and compulsions. New York: Bantam Books.• Hazlett-Stevens, H. (2005). Women who worry too much: How to stop worry and anxiety from ruining relationships, work and fun. Oakland, CA: New Harbinger.• Rothbaum, B., Foa, E., & Embree, E. (2007). Reclaiming your life from a traumatic experience: A prolonged exposure treatment program (workbook). New York: Oxford University Press.Child Management• Gordon, T. (1975). Parent effectiveness training: The tested way to raise children. New York: New American Library.• Patterson, G. R., & Gullion, M. E. (1976). Living with children. Champaign, IL: Research Press.• Webster-Stratton, C. The incredible years series.Depression• Burns, D. D. (1980). Feeling good: The new mood therapy. New York: Signet.• Lewinsohn, P. M., Munoz, R. F., Youngren, M. A., & Zeiss, A. M. (1986). Control your depression. New York: Prentice Hall.Eating Disorders• Agras, W. S., & Apple, R. (2007). Overcoming your eating disorder: A cognitive–behavioral therapy approach for bulimia nervosa and binge-eating disorder, guided self-help workbook. New York: Oxford University Press.Infertility• Jacobs, N. N., & O’Donohue, W. T. (2007). Coping with infertility: clinically proven ways of managing the emotional roller coaster. New York: Routledge.Marital Conflict• Gottman, J. M., Notarius, C., Gonso, J., & Markman, H. (1979). A couple’s guide to communication. Champaign, IL: Research Press.Pain Management• Lewandowski, M. J. (2006) The chronic pain care workbook: A self-treatment approach to pain relief using the behavioral assessment of pain questionnaire. Oakland, CA: New Harbinger.Sex Addiction• Penix-Sbraga, T., & O’Donohue, W. T. (2007). The sex addiction workbook: Proven strategies to help you regain control of your life. Oakland, CA: New Harbinger.Sexual Dysfunction• Heiman, J., LoPiccolo, J., & Palladini, D. (1987). Becoming orgasmic: A sexual and personal growth program for women. New York: Simon Shuster.• Zilbergeld, B. (1999). The new male sexuality: The truth about men, sex, and pleasure. New York: Bantam Books.
  • 9 • BIBLIOTHERAPY UTILIZING COGNITIVE BEHAVIOR THERAPY 65TABLE 9.1 (Continued)Sleep Disorders• Edinger, J. D., & Carney, C. E. (2008). Overcoming insomnia: A cognitive–behavioral therapy approach workbook. New York: Oxford University Press.• Hauri, P., & Linde, S. (1990). No more sleepless nights. New York: John Wiley Sons.Substance Use Disorders• Antonuccio, D. O. (1992). Butt out: A compassionate guide to helping yourself quit smoking, with or without a partner. Saratoga, CA: R&E Publishers.• Daley, D. C., & Marlatt, G. A. (2006). Overcoming your alcohol or drug problem: Effective recovery strategies (2nd ed.). New York: Oxford University Press.• Miller, W. R., & Munoz, R. F. (1982). How to control your drinking: A practical guide to responsible drinking. Albuquerque, NM: Prentice Hall.Weight Management• Beck, J. S. (2007). The Beck diet solution: Train your brain to think like a thin person. Birmingham, AL: Oxmoor House.TABLE 9.2 Key Points Regarding Bibliotherapy1. Bibliotherapy is defined as the use of written psychotherapeutic self-help materials for the purpose of solving mental health problems.2. Delivery of CBT principles in a bibliotherapy format has many advantages over traditional psychotherapy, including cost effectiveness, widespread availability, and potential to reach a broad spectrum of populations.3. Bibliotherapy has demonstrated empirical support across a wide range of mental health problems. However, the vast majority of bibliotherapy available to the lay public has not undergone empirical evaluation and there is wide variability in the quality of self-help materials.4. Clinicians wishing to assign self-help materials to their clients should exercise their clinical judgment and follow the practice guidelines discussed in this chapter.traditional psychotherapy. In addition to accessi- American Psychological Association Task Force onbility, bibliotherapy offers many advantages over Self-Help Therapies (1978). Task force report ontraditional psychotherapy, as described above. self-help therapies. Unpublished manuscript. Washington DC: American Psychological Asso-Studies evaluating bibliotherapy have demon- ciation.strated its empirical support across a broad range Anderson, L., Lewis, G., Araya, R., et al. (2005). Self-of mental health problems, cost effectiveness, help books for depression: How can practitionersand reader satisfaction. Table 9.2 provides a and patients make the right choice? British Journalsummary of some of the key points regarding of General Practice, 55, 387–392.bibliotherapy. Given these factors, it behooves Apodaca, T. R., & Miller, W. R. (2003). A meta-analysishealth care providers to recommend bibliother- of the effectiveness of bibliotherapy for alco- hol problems. Journal of Clinical Psychology, 59,apy as a treatment modality. 289–304. Bailer, U., de Zwaan, M., Leish, F., Strnad, A., Lennkh-Wolfsberg, C., El-Giamal, N., et al. (2004).References Guided self-help versus cognitive-behavioral group therapy in the treatment of bulimiaAmerican Psychological Association (1989). First nervosa. American Journal of Psychiatry, 160, annual golden fleece awards for do-it-yourself 973–978. therapies. Presentation at the annual meeting of Barrera, M., Rosen, G. M., & Glasgow, R. E. (1981). the American Psychological Association, New Rights, risks, and responsibilities in the use of Orleans, LA. self-help psychotherapy. In J. T. Hannah, R. Clark,
  • 66 COGNITIVE BEHAVIOR THERAPY & P. Christian (Eds.), Preservation of client rights for depression: A comparison of individual psy- (pp. 204–220). New York: Free Press. chotherapy and bibliotherapy for depressed olderBeutler, L. E. (1991). Predictors of differential response adults. Behavior Modification, 28, 297–318. to cognitive, experiential, and self-directed psy- Ghaderi, A. (2006). Attrition and outcome in self-help chotherapeutic procedures. Journal of Consulting treatment for bulimia nervosa and binge eating and Clinical Psychology, 59, 333–340. disorder: A constructive replication. Eating Behav-Beutler, L. E., Engle, D., Mohr, D., Daldrup, R. J., iors, 7, 300–308. Bergan, J., Meredith, K., et al. (1991). Predictors Glasgow, R. E., & Rosen, G. M. (1978). Behavioral bib- of differential response to cognitive, experiential, liotherapy: A review of self-help behavior therapy and self-directed psychotherapeutic procedures. manuals. Psychological Bulletin, 85, 1–23. Journal of Clinical and Consulting Psychology, 59, Gould, R. A., & Clum, G. A. (1993). A meta-analysis of 333–340. self-help treatment approaches. Clinical Psychol-Bowman, D., Scogin, F., Floyd, M., Patton, E., & Gist, L. ogy Review, 13, 169–186. (1997). Efficacy of self examination therapy in the Gregory, R. J., Canning, S. S., Lee, T. W., & Wise, treatment of generalized anxiety disorder. Journal J. C. (2004). Cognitive bibliotherapy for depres- of Counseling Psychology, 44, 267–273. sion: A meta-analysis. Professional Psychology, 35,Burns, D. D. (1980). Feeling good: The new mood therapy. 275–280. New York: Signet. Hirai, M., & Clum, G. A. (2006). A meta-analytic studyCampbell, L. F., & Smith, T. P. (2003). Integrating of self-help interventions for anxiety problems. self-help books into psychotherapy. Journal of Behavior Therapy, 37, 99–111. Clinical Psychology, 59, 177–186. Hynes, A. M., & Hynes-Berry, M. (1986). Biblio-Carter, J. C., & Fairburn, C. G. (1998). Cognitive– therapy—The interactive process: A handbook. behavioral self-help for binge-eatingdisorder: A Boulder, CO: Westview Press. controlled effectiveness study. Journal of Consult- Jacobs, N. N., & Mosco, E. (in press). Bibliotherapy ing and Clinical Psychology, 66, 616–623. as an adjunctive treatment. In W. T. O’DonohueCarter, J. C., Olmstead, M. P., Kaplan, A. S., McCabe, and N. Cummings (Eds.), Evidence-based adjunctive R. E., Mills, J. S., & Aim´ , A. (2003). Self-help for e treatments. New York: Academic Press. bulimia nervosa: A randomized controlled trial. Landreville, P., & Bissonnette, L. (1997). Effects of American Journal of Psychiatry, 160, 973–978. cognitive bibliotherapy for depressed older adults with a disability. Clinical Gerontologist, 17,Cooper, P. J., Coker, S., & Fleming, C. (1996). An 35–55. evaluation of the efficacy of supervised cognitive Mains, J. A., & Scogin, F. R. (2003). The effectiveness of behavioral self-help for bulimia nervosa. Journal self-administered treatments: A practice-friendly of Psychosomatic Research, 40, 281–287. review of the research. Journal of Clinical Psychol-Craighead, L., McNamara, K., and Horan, J. (1984). ogy/In Session, 59(2), 237–246. Perspectives on self-help and bibliotherapy: You Marrs, R. W. (1995). A meta-analysis of bibliotherapy are what you read. In S. Brown and R. Lent studies. American Journal of Community Psychology, (Eds.), Handbook of Counseling Psychotherapy (pp. 23, 843–870. 878–929). New York: John Wiley & Sons. McKendree-Smith, N. L., Floyd, M., & Scogin, F. R.Cuijpers, P. (1997). Bibliotherapy in unipolar depres- (2003). Self-administered treatments for depres- sion: A meta-analysis. Journal of Behavior Therapy sion: A review. Journal of Clinical Psychology, 59, & Experimental Psychiatry, 28, 139–147. 275–288.Den Boer, P. C. A. M., Wiersma, D., & Van Den Bosch, Newman, M. G. (2000). Recommendations for a R. J. (2004). Why is self-help neglected in the treat- cost-offset model of psychotherapy allocation ment of emotional disorders? A meta-analysis. using generalized anxiety disorder as an example. Psychological Medicine, 34, 959–971. Journal of Consulting and Clinical Psychology, 68,Febbraro, G. (2005). An investigation into the effec- 549–555. tiveness of bibliotherapy and minimal contact Newman, M. G., Erickson, T., Przeworski, A., Dzus, E. interventions in the treatment of panic attacks. (2003). Self-help and minimal contact therapies for Journal of Clinical Psychology, 61, 763–779. anxiety disorders: Is human contact necessary forFloyd, M., Rohen, N., Shackelford, J. A. M., Hubbard, therapeutic efficacy? Journal of Clinical Psychology, K. L., Parnell, M. B., Scogin, F., & Coates, A. 59, 251–274. (2006). Two-year follow-up of bibliotherapy and Papworth, M. (2006). Issues and outcomes associated individual cognitive therapy for depressed older with adult mental health self-help materials: adults. Behavior Modification, 30, 281–294. A ‘‘second order’’ review or ‘‘qualitativeFloyd, M., Scogin, F., McKendree-Smith, N., Floyd, meta-review.’’ Journal of Mental Health, 15(4), D. L., & Rokke, P. D. (2004). Cognitive therapy 387–409.
  • 9 • BIBLIOTHERAPY UTILIZING COGNITIVE BEHAVIOR THERAPY 67Pardeck, J. A. & Pardeck, J. T. (1984). An overview Scogin, F., Bynum, J., & Stephens, G., & Calhoon, of bibliotherapeutic treatment approach: Impli- S. (1990). Efficacy of self-administered treatment cations for clinical social work practice. Family programs: Meta-analytic review. Professional Psy- Therapy, 11, 241–252. chology: Research and Practice, 21, 42–47.Reeves, T., & Stace, J. M. (2005). Improving patient Scogin, F., Hamblin, D., & Beutler, L. (1987). Biblio- access and choice: Assisted bibliotherapy for mild therapy for depressed older adults: A self-help to moderate stress/anxiety in primary care. Jour- alternative. The Gerontologist, 27, 383–387. nal of Psychiatric and Mental Health Nursing, 12, Scogin, F., Jamison, C., & Gochneaur, K. (1989). Com- 341–346. parative efficacy of cognitive and behavioral bib-Riordan, R. J., & Wilson, L. S. (1989). Bibliotherapy: liotherapy for mildly and moderately depressed Does it work? Journal of Counseling and Develop- older adults. Journal of Consulting and Clinical Psy- ment, 67, 506–508. chology, 57, 403–407.Rosen, G. M. (1981). Guidelines for the review of Scogin, F., Welsh, D., Hanson, A., Stump, J., & Coates, do-it-yourself treatment books. Contemporary Psy- A. (2005). Evidence-based psychotherapies for chology, 26, 189–191. depression in older adults. Clinical Psychology:Rosen, G. M. (1987). Self-help treatment books and Science and Practice, 12, 222–237. the commercialization of psychotherapy. Ameri- Sharp, D. M., Power, K. G., & Swanson, V. (2000). can Psychologist, 42, 46–51. Reducing therapist contact in cognitive behaviourRosen, G. M. (1993). Self-help or hype? Comments therapy for panic disorder and agoraphobia in on psychology’s failure to advance self-care. Pro- primary care: Global measures of outcome in fessional Psychology: Research and Practice, 24(3), a randomized controlled trial. British Journal of 340–345. General Practice, 50, 963–968.Rosen, G. M. (2004). Remembering the 1978 and 1990 Smith, N. M., Floyd, M. R., Scogin, F., & Jamison, Task Forces on Self-Help Therapies. Journal of C. (1997). Three-year follow-up of bibliotherapy Clinical Psychology, 60(1), 111–113. for depression. Journal of Consulting and ClinicalRosen, G. M., Glasgow, R. E., & Barrera, M. (2007). Psychology, 65, 324–327. Good intentions are not enough: Reflections on Starker, S. (1988). Psychologists and self-help books: past and future efforts to advance self-help. In Attitudes and prescriptive practices of clinicians. P. L. Watkins & G. A. Clum (Eds.), Handbook American Journal of Psychotherapy, 42(3), 448–455. of Self-Help Therapies (pp. 25–39). Mahwah, NJ: Stevens, A. J., & Pfost, K. S. (1982). Bibliotherapy: Lawrence Erlbaum. Medicine for the soul? Psychology: A QuarterlyRosen, G. M., Glasgow, R. E., & Moore, T. E. (2003). Journal of Human Behavior, 19, 21–25. Self-help therapy: The science and business of van Lankveld, J. J. D. M. (1998). Bibliotherapy giving psychology away. In S. O. Lilienfeld, S. J. in the treatment of sexual dysfunctions: A Lynn, & J. M. Lohr (Eds.). Science and Pseudoscience meta-analysis. Journal of Consulting and Clinical in Clinical Psychology (pp. 399–424). New York: Psychology, 66, 702–708. Guilford.Schrank, F. A., & Engels, D. W. (1981). Bibliotherapy as a counseling adjunct: Research Findings. Personnel and Guidance Journal, 60, 143–147.
  • BREATHING RETRAINING AND 10 DIAPHRAGMATIC BREATHING TECHNIQUES Holly Hazlett-Stevens and Michelle G. CraskeBreathing retraining is a widely used technique treatment of panic disorder, breathing retrain-in a number of anxiety and stress reduction ing is combined with psychoeducation, cognitivetherapies. Slow and deep breathing from the restructuring, and interoceptive exposure (asdiaphragm (i.e., the abdominal muscle located well as in vivo exposure in the case of agorapho-underneath the lungs near the base of the ribs) bia) treatment components (Craske & Barlow,promotes a subjective state of relaxation as 2007). In these cases, breathing retraining is pre-well as physiological effects that are contrary sented early in treatment as an alternative copingto hyperventilation and autonomic nervous response to behavioral avoidance. Its utility issystem arousal. As a result, breathing retraining attributed to the reduction of hyperventilationoften is used to counteract the chronic anxiety sensations and symptoms that contribute to aseen in generalized anxiety disorder (GAD) and vicious cycle of fear responding found dur-the hyperventilation associated with sudden, ing panic attacks. In the treatment of GAD,unexpected fight-or-flight activation in panic breathing retraining is taught as a useful cop-disorder. In addition to these specific anxiety ing response whenever anxiety symptoms orreduction applications, breathing retraining worries are detected in the course of regularis useful as a general relaxation strategy and frequent anxiety level monitoring. Thus,for individuals interested in learning stress breathing retraining is presented in the contextmanagement techniques (Fried, 1993). of psychoeducation and frequent monitoring of Breathing retraining techniques typically general anxiety symptoms, and it is combinedbegin with a demonstration of hyperventilation, with progressive and applied relaxation training,which is followed by education about the cognitive restructuring, and imaginal exposurephysiology of overbreathing. The physiological techniques (Newman, 2000; Borkovec & Ruscio,effects experienced during initial hyperventi- 2001).lation induction are then contrasted with theslower heart rate, physical muscle relaxation,and other sensations that result from slow-paced WHO MIGHT BENEFIT FROM THIS TECHNIQUEabdominal breathing. Sometimes a cognitivemeditation component is added to promote Individuals with chronic anxiety symptoms,attentional focus on the deep breathing exercise. such as panic disorder and GAD, are most likelyAs individuals learn to engage in diaphragmatic to benefit from breathing retraining. Individualsbreathing with repeated practice, they are with these particular anxiety disorder diagnosesencouraged to apply this skill whenever they may chronically hyperventilate, thereby con-detect signs of anxiety or worry or when they tributing to somatic anxiety symptoms. Thus,encounter stressful situations. breathing retraining is used in panic disorder Breathing retraining has been investigated treatment to counteract hyperventilation, whichempirically as part of the larger cognitive behav- can trigger a panic attack, and therefore is usedioral treatment packages for panic disorder (with to help control and prevent panic attacks inor without agoraphobia) and for GAD. In the this population. In GAD cases, diaphragmatic 68
  • 10 • BREATHING RETRAINING AND DIAPHRAGMATIC BREATHING TECHNIQUES 69breathing is taught in order to promote a general is conducted to demonstrate the physiologicalstate of relaxation as well as a coping response effects of overbreathing. However, the techniqueto deploy when increased anxiety or worry is described presently is the same breathing tech-detected. nique used by physicians to teach respiratory However, individuals suffering from other patients how to breathe more effectively andanxiety disorders or from subclinical anxiety therefore is not always contraindicated for respi-symptoms may also benefit from the generalized ratory patients.relaxation and decreased arousal this techniqueprovides. Some research has suggested thatbreathing retraining can be effective when OTHER DECISION FACTORS WHEN DECIDINGit does not target physiology by providing TO USE THE TECHNIQUEa subjective sense of relaxation and feelingsof control (Garssen, de Ruiter, & Van Dyck, Certain individuals with panic disorder who1992). Furthermore, Fried (1993) suggested that enter treatment with strong convictions thata variety of stress-related behavioral medi- panic attack symptoms represent physical harmcine conditions, such as insomnia, hyperten- may use breathing retraining to avoid fearedsion, noncardiac chest pain, headache, and panic sensations. This practice can underminegastrointestinal distress, may also benefit exposure-related treatment efforts by maintain-from breathing retraining intervention. Novel ing irrational fears that such hyperventilationclinical applications continue to appear in the sensations are harmful. Therefore, such clientstreatment literature. For example, diaphrag- are discouraged from using their breathingmatic breathing combined with minimized retraining skills in this way and are instructedswallowing effectively treated complaints of to use diaphragmatic breathing only as achronic belching in a case of aerophagia, or general relaxation strategy rather than as aexcessive air swallowing (Cigrang, Hunter, & response to panic attack episodes. ExperiencedPeterson, 2006). Finally, breathing retraining therapists working with clients reporting highmay be a useful stress management tool for anxiety sensitivity (i.e., fear of anxiety-relatedseverely mentally ill psychiatric populations sensations) sometimes refrain from teachingseeking ways to reduce general tension and such clients breathing retraining for this reason.anxiety (Key, Craske, & Reno, 2003). In his review of this empirical literature, Tay- lor (2001) concluded that while hyperventilation often may not play a strong role in panic attacks,EVIDENCE-BASED APPLICATIONS the subjective relaxation and control effects of breathing retraining identified by GarssenBreathing retraining is indicated for the follow- et al. (1992) still may hold value for some panicing conditions: patients. In these cases, Taylor encouraged clinicians to teach breathing retraining only• Panic disorder (with or without agoraphobia) when patients understand that breathing• Generalized anxiety disorder techniques assist with unpleasant but harmless• Stress-related health conditions sensations. Other cognitive behavioral tech- niques of interoceptive exposure and cognitive restructuring are needed to teach patients thatCONTRAINDICATIONS OF THE TECHNIQUE feared sensations are indeed harmless.Individuals with medical conditions affecting therespiratory system, such as chronic obstructive HOW DOES BREATHING RETRAINING WORK?pulmonary disease (COPD) or asthma, shouldfirst consult with their physician before breathing Breathing retraining teaches individuals how toretraining is attempted. This caveat is particu- reduce the shallow chest breathing associatedlarly relevant because induced hyperventilation with chronic hyperventilation by engaging in
  • 70 COGNITIVE BEHAVIOR THERAPYdeep diaphragmatic breathing. This intentional at approximately three times the normal rate.shift to slower and deeper breaths produces a The client then begins to overbreathe with thehost of physiological effects consistent with a therapist. Oftentimes, the therapist will need tostate of relaxation. Learning to breathe prop- encourage the client to maintain speed and toerly allows for optimal levels of oxygen intake, exhale hard because the client may reduce thethereby preventing an imbalance of oxygen and level of effort after a few breaths. The clientcarbon dioxide in the blood and the myriad of should try to continue for 60 to 90 seconds, butresulting physical sensations resulting from the should be allowed to stop in the case of excessivebody’s attempt to compensate for such an imbal- distress.ance. As discussed earlier, an alternative view After this demonstration, the client is askedoffered by Garssen et al. (1992) posits that breath- to sit down, close his or her eyes, and to breatheing retraining induces a subjective relaxation very slowly, pausing at the end of each breath.response by presenting a credible explanation After the client begins to relax, this exercise is dis-for threatening anxiety symptoms and promot- cussed in detail, beginning by asking the client toing feelings of self-control. identify each physical sensation brought on by the voluntary hyperventilation. When treating clients with anxiety, such symptoms are dis-STEP-BY-STEP PROCEDURES1 cussed regarding their similarity with familiar anxiety-related sensations. In the case of panicSee Tables 10.1 and 10.2 for an overview of key disorder or recurrent panic attacks, similarityelements. Breathing retraining typically begins to the physical symptoms of a panic attack iswith a demonstration of how hyperventilation highlighted even if the emotional aspects of theaffects physiology. The client is asked to stand exercise differ because the client can identifyand to voluntarily hyperventilate by breathing the cause of the sensations. When working withvery quickly and deeply as if blowing up a panic disorder individuals, it is important toballoon. Exhalations should be very hard andforced so that the air is taken all the way downto the lungs. The therapist first demonstrates 1. These procedures are based on the manual entitledthis for the client by taking three to four deep Mastery of your anxiety and panic, 4th ed. (Craske &breaths while exhaling as forcefully as possible Barlow, 2006).TABLE 10.1 Key Elements of Breathing Retraining• Conduct the voluntary hyperventilation exercise to demonstrate the effects of overbreathing.• Describe the physiology of hyperventilation and explain the rationale for deep, diaphragmatic breathing.• Teach the client how to engage in deep breathing and give corrective feedback.• Assign homework practice exercises.• Review client’s progress with the home practice, giving feedback to help overcome any difficulties.TABLE 10.2 Key Elements Specific to Panic Disorder• After the voluntary hyperventilation exercise, these effects are systematically compared to feared panic attack sensations.• Discussion of hyperventilation physiology includes identification of which effects might be misinterpreted as dangerous during a panic attack.• Initial breathing practices are only conducted at scheduled times in a relaxed setting.• After breathing retraining skills have been developed in the relaxed practice setting, brief practice sessions are conducted in stressful settings.• After breathing retraining skills are mastered in stressful settings, brief practice sessions are conducted in response to physical anxiety cues.• Clients are reminded not to use breathing retraining skills when purposefully confronting feared sensations or situations during exposure-based treatment exercises.
  • 10 • BREATHING RETRAINING AND DIAPHRAGMATIC BREATHING TECHNIQUES 71compare each physical effect of the hyperventi- means we are taking in more oxygen than nec-lation to the client’s panic symptoms and note essary, less oxygen actually gets to certain areasany similarities. This exercise can then be used of our brain and body. This causes two groupsto launch a discussion of the role of hyperventi- of symptoms. First are symptoms produced bylation in panic attacks. the slight reduction in oxygen to certain parts of The therapist then provides the rationale for the brain, including dizziness, light-headedness,breathing retraining and a brief explanation of confusion, breathlessness, blurred vision, andthe physiology resulting from hyperventilation. feelings of unreality. Second are symptoms pro-This information is crucial when treating panic duced by the slight reduction in oxygen to certaindisorder because it will help correct mistaken parts of the body, including increase in heartbeatbeliefs that such symptoms are harmful. This to pump more blood around, numbness and tin-presentation of information should be explained gling in the extremities, cold and clammy hands,in terms that the client can understand, and and sometimes stiff muscles. Also, hyperventi-the amount of detail should be tailored to each lating can produce a feeling of breathlessness,client’s individual needs. Typically, the thera- sometimes extending to feelings of choking orpist begins by explaining that the body needs smothering, so that it actually feels as if there isoxygen in order to survive. Whenever a person not enough air.inhales, oxygen is taken into the lungs and then Hyperventilation also causes other effects.carried around the body, where it is released for First, the act of overbreathing is hard physicaluse by the body’s cells. The cells use the oxy- work. Hence, the person may feel hot, flushed,gen in their energy reactions and then release and sweaty. Because it is hard work, prolongedcarbon dioxide (CO2 ) back to the blood, where periods of hyperventilating will often causeit is transported to the lungs and eventually tiredness and exhaustion. In addition, peopleexhaled. The balance between oxygen and car- who overbreathe often breathe from their chestbon dioxide is very important and is maintained rather than their abdomen; it is the latter that ischiefly through an appropriate rate and depth of really intended for breathing, as the diaphragmbreathing. The appropriate rate of breathing, at muscle serves this purpose and is locatedrest, is usually around 10–14 breaths per minute. underneath the lungs. When chest muscles areHyperventilation is defined as a rate and depth primarily used for breathing, they become tiredof breathing that is too much for the body’s needs and tense because they are not well equipped forat a particular point in time. Although breathing breathing, resulting in chest tightness or evenis controlled automatically, breathing can also be severe chest pains. However, hyperventilation isput under voluntary control. Consequently, the not always obvious, especially with mild over-non-automatic factors of fear and stress cause breathing for a long period of time. Therefore,increased breathing because the muscles need many people are chronic hyperventilators butmore oxygen in order to fight or flee from dan- are unaware that such sensations may be theger. If the extra amount of oxygen is not used result of their breathing. Learning to breatheup at the rate at which it is brought in (as when at an appropriate rate and depth can thereforethere is no actual running or fighting going on), reduce these sensations and promote feelingsthen the state of hyperventilation results. of relaxation. When treating clients with panic The most important effect of hyperventila- disorder, it is important to emphasize thattion is to produce a drop in carbon dioxide such hyperventilation is not dangerous. Increasedthat the amount of carbon dioxide is low in respiration is central to the fight-or-flight fearproportion to the amount of oxygen. This imbal- response, and thus its purpose is to protectance leads to constriction of certain blood vessels the body from danger. Hyperventilation isaround the body, and the blood going to the brain merely the body’s natural way of compensatingis slightly decreased. Not only does less blood for such increased respiration in the absencereach certain areas of the body, but the oxygen of the physical exertion normally involvedcarried by this blood is less likely to be released with behavioral fight or flight. Therefore, itto the tissues. Hence, although overbreathing is important for the panic disorder client to
  • 72 COGNITIVE BEHAVIOR THERAPYidentify panic-related feared sensations that breather, this may feel artificial and causemight be the consequence of overbreathing. feelings of breathlessness. That is a natural The next step is to teach a specific exercise response; just remember that you are gettingto learn control over breathing. Typically, the enough oxygen and the feelings of breathless-therapist will model diaphragmatic breathing by ness will decrease the more you practice. Ifplacing one hand on his or her chest and the other you find it very hard to keep your chest still,hand on his or her abdomen and monitoring the lie on the floor, flat on your stomach (i.e., fac-movement of each. The client also attempts this ing the floor) with your hands clasped underwhile attending to the movement of each hand. your head. This will make it easier to breatheThe client should try to isolate breathing from from the abdomen. Once you have done thatthe abdomen such that only that hand moves.During this process, the therapist encourages several times and feel comfortable breathingthe client and gives corrective feedback until from the abdomen, practice the exercise againthe client learns to breathe slowly (8–10 breaths while in a seated position.per minute) yet smoothly and easily from the 3. Keep your breathing smooth and fluid. Don’tabdomen. gulp in a big breath and then let it out all at In the case of panic disorder or other chronic once. When you breathe out, let the air escapehyperventilators, the therapist may first instruct equally over the whole time you are breathingthe client to breathe at his or her normal pace. out. Think of the air as oozing and escapingThe client would then attempt to reduce the rate from your nose or mouth rather than beingof his or her breathing after one to two weeks suddenly released. It does not matter whetherof regular practice. This can be accomplished by you breathe through your nose or your mouthmatching the pace or breathing to counting and as long as you breathe slowly and smoothly.gradually slowing the counting to a rate near The nose is easier for this because it is a smaller10 breaths per minute. Sometimes it is helpful to opening.pause between each step, before exhaling, and 4. Start to count on your inhalations. That is,before inhaling. The therapist then explains that regular home when you breathe in, think the word ‘‘one’’practice is crucial to learning breathing retraining to yourself, and as you breathe out, think theskills, and this exercise should be practiced at word relax. Think two on your next breath inleast twice a day for at least 10 minutes each and relax on the breath out. Think three ontime. The following instructions are given: your next breath in and relax on the breath out. Continue this up to around ten and then1. Find a quiet, comfortable spot where you will go backwards to one. not be disturbed, and allow yourself a few 5. Focus only on your breathing and the words. seconds to calm down. This can be very difficult, and you may never2. Concentrate on taking breaths right down to be able to do it perfectly. You may not get your stomach. There should be an expan- past the first number without other thoughts sion of the abdomen with every breath in coming into your mind. When this happens, (inhalation). The abdomen is sucked back in do not get angry or give up. Simply allow with every breath out (exhalation). If you are the thoughts to pass through your mind and having trouble taking the air down to your bring your attention back to the numbers. stomach, try to push your stomach out just 6. When you first begin to count your breaths, before you inhale so that there is a space for the air to fill. Be sure to place one hand on you may become breathless or a little dizzy your chest and the other hand on your stom- and begin to speed up your breathing. This ach, as the movement should come almost should subside once you get used to the entirely from the lower (abdominal) hand. exercise. If it becomes too uncomfortable, stop Try to limit the amount of movement from the for a short while and calm down, then begin upper (chest) hand. If you are normally a chest again.
  • 10 • BREATHING RETRAINING AND DIAPHRAGMATIC BREATHING TECHNIQUES 73 Individuals with panic disorder are reminded breathing at the appropriate rate, they arethat they are learning to decrease physical feel- encouraged to do brief practice sessions inings that may trigger panic attacks and that occur more demanding environments. Stressfulduring panic attacks. These clients are warned settings, such as at work or while stuck inagainst using this technique to cope with anxiety traffic, are identified as good opportunitiesearly on to avoid frustration. However, despite to practice their breathing retraining skills.this therapist instruction not to attempt breathing Once slow diaphragmatic breathing has beenretraining to combat panic sensations, panic dis- effectively applied in these situations, even moreorder clients often will try to apply this technique challenging situations involving feared anxietyduring a panic attack before developing ade- cues are attempted. However, panic disorderquate skill. When such attempts are reported, the clients should be strongly discouraged fromtherapist can respond to client disappointment using breathing retraining skills to avoid panicand discouragement by reminding the client that sensations during the course of interoceptivebreathing control involves a skill that develops or in vivo exposure treatment. Any thoughtsonly with practice, instructing the client only to about catastrophic consequences that couldpractice slow breathing in relaxed settings until result from failure to control breathing inthis skill has developed, and addressing fears anxiety situations are subjected to cognitiveof panic sensations with cognitive restructuring restructuring.techniques. These clients may also benefit fromtracking levels of concentration on the breathing Further Readingand counting and the ease of breathing using apractice journal. Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and panic: Therapist guide (4th ed.). New In subsequent therapy sessions, the therapist York: Oxford University Press.reviews the home practices with the client. Fried, R. (1993). The role of respiration in stressPotential problems are identified and corrected. and stress control: Toward a theory of stressFor example, was the client getting enough as a hypoxic phenomenon. In P. M. Lehrer &air into the abdomen? If not, the stomach R. L. Woolfolk (Eds.), Principles and practicescan be pushed out slightly before inhaling. of stress management (pp. 301–331). New York:Were symptoms of anxiety experienced during Guilford Press. Fried, R. (1987). The hyperventilation syndrome: Researchpractice? This is probably due to breathing a and clinical treatment. Baltimore, MD: Johns Hop-little fast or becoming anxious about breathing kins University Press.while attending to it. This reaction usuallydiminishes with practice. If the client expressesdifficulty concentrating on the counting after Referencesfrequent practice, then it may help to make Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapyan audiotape on which the client records his for generalized anxiety disorder. The Journal ofor her voice counting at the appropriate rate. Clinical Psychiatry, 62, 37–45.Some clients will say that they have no trouble Cigrang, J. A., Hunter, C. M., & Peterson, A. L. (2006). Behavioral treatment of chronic belching due tobreathing at 8–10 breaths per minute and this aerophagia in a normal adult. Behavior Modifica-is how fast they usually breathe. In this case, tion, 30, 341–351.they may not be chronic hyperventilators but Craske, M. G., & Barlow, D. H. (2006). Mastery of yourmay still overbreathe during times of stress or anxiety and panic: Therapist guide (4th ed.). Newpanic. This technique may still be of benefit York: Oxford University Press.as a method of somatic control. Clients with Craske, M. G., & Barlow, D. H. (2007). Panic disorderpanic disorder may use breathing retraining and agoraphobia. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-stepout of desperation as a method of avoiding treatment manual (4th ed.) (pp. 1–64). New York:the experience of panic. This fear of panicking Guilford Press.should be subjected to cognitive restructuring or Fried, R. (1993). The role of respiration in stressreminders that panic is not harmful. After clients and stress control: Toward a theory of stresswith panic disorder master slow diaphragmatic as a hypoxic phenomenon. In P. M. Lehrer &
  • 74 COGNITIVE BEHAVIOR THERAPY R. L. Woolfolk (Eds.), Principles and practices Newman, M. G. (2000). Generalized anxiety disorder. of stress management (pp. 301–331). New York: In M. Hersen & M. Biaggio (Eds.), Effective brief Guilford Press. therapies: A clinician’s guide (pp. 157–178). SanGarssen, B., de Ruiter, C., & Van Dyck, R. (1992). Diego, CA: Academic Press. Breathing retraining: A rational placebo? Clinical Taylor, S. (2001). Breathing retraining in the treatment Psychology Review, 12, 141–153. of panic disorder: Efficacy, caveats and indica-Key, F. A., Craske, M. G., & Reno, R. M. (2003). tions. Scandinavian Journal of Behaviour Therapy, Anxiety-based cognitive-behavioral therapy for 30, 49–56. paranoid beliefs. Behavior Therapy, 34, 97–115.
  • 11 CLASSROOM MANAGEMENT Steven G. Little and Angeleque Akin-LittleManaging behavior in the classroom in order if followed, should help the teacher maintainto increase student learning has always been order in the classroom. The chapter is writ-of concern to teachers and education personnel ten for teachers, classroom consultants such as(Lewis, Romi, Qui, & Katz, 2005). Additionally, school psychologists, child clinical psychologists,recent years have witnessed an increased focus social workers, behavioral specialists, etc. andon children’s behavior in school as a result of the assumes a basic understanding of the principlestragic events in locations such as Red Lake, Min- of applied behavior analysis and behavior modi-nesota, and Littleton, Colorado. In spite of the fact fication. The chapter will present both proactivethat little reported violence involving children and reactive procedures that can be combined toand youth are reported in schools (Heaviside, provide a comprehensive approach to classroomRowand, Williams, & Farris, 1998; Henry, 2000) management.and criminal activity in schools has decreasedyearly for more than a decade (Dinkes, Cataldi,Kena, & Baum, 2006), student classroom behav- CLASSROOM RULESior is still of great concern to teachers, parents,and the general public (Brown & Beckett, 2006). An essential element of any classroom manage-Behaviors that are disruptive to the classroom ment program is a set of firm, but fair, classroomsuch as inattention, overactivity, and noncompli- rules (Malone & Tietjens, 2000; McGinnis, Freder-ance are the most common complaint of teach- ick, & Edwards, 1995; Rademacher, Callahan, &ers (Goldstein, 1995). With prevalence rates of Pederson-Seelye, 1998; Wilke, 2003). While rulesattention-deficit hyperactivity disorder (ADHD) are necessary for effective classroom manage-estimated to be as high as 20% of the population ment, they alone are not sufficient to reduce rates(Coleman & Webber, 2002), rates of conduct dis- of problem behavior in the classroom (Gettinger,order and oppositional defiant disorder both as 1988). Classroom rules must be integrated withhigh as 16% (American Psychiatric Association, a comprehensive behavior management plan.2000), and the growing trend toward educating However, rules are the first place to start inall children in the regular classroom (Little & effective classroom management.Akin-Little, 1999), the need for empirically val- In helping a teacher develop a set of classroomidated approaches to classroom management is rules there are certain assumptions that need toevident. be conveyed to the teacher. First and foremost is There is no one specific technique that can be the idea that good classroom rules are the back-called classroom management. Rather, there are a bone of classroom management. With rules innumber of techniques and procedures that can be place, other classroom management techniquesfollowed to help teachers better manage the class- will be much easier to implement. There shouldroom. The exact techniques that are implemented also be a minimum expectation for behavior fordepend on the ecology of the classroom, the level every student in the classroom. All studentsof involvement of the psychologist in the school should be expected to follow the rules, evenand classroom, the type of disruptive behav- special education students. Once rule excep-ior, and the severity of the problem behaviors. tions are made, a double standard exists andFor the purpose of this chapter, classroom man- rules become worthless. Next, it is essential thatagement is defined as a set of procedures that, students understand the resulting consequences 75
  • 76 COGNITIVE BEHAVIOR THERAPY(both positive and privilege loss) of the rules. • Measurable. Rules describe behavior that isTo accomplish this it is advisable to have the measurable. That is, behavior must be able toteacher, during the first 2 weeks of school, ran- be counted and quantified in some way fordomly selecting students to read a rule, discuss monitoring purposes.why the rule is important, and explain what • Posted. The rules should be publicly postedwill happen if the rule is followed or not fol- in a prominent place in the classroomlowed. To demonstrate that the teacher is fair, (e.g., in front of the classroom, near the door).students should be allowed to question the util- The lettering should be large and blockity or fairness of a rule during these discussion printed.periods. It is also important that students know • Consequences. Following the rules should bethat rules cannot be questioned at other times, connected to consequences. Spell out whatespecially when a rule is broken. Further, the happens positively if students follow theteacher makes the final decision and that should rules, and what they lose if they do not followbe clearly stated at the onset. Finally, the teacher the rules.should post the classroom rules in a visible • Compliance. A compliance rule should alwaysspot in the classroom before the first day of be included. Classroom behavior will corre-school. spond to the posted rules. If you want to There are a number of characteristics that improve compliance in the classroom, a rulehave been found associated with good rules such as ‘‘Do what your teacher asks immedi-(McGinnis et al., 1995; Rhode, Jenson, & Reavis, ately’’ should be included.1993; Wilke, 2003). These include: ENHANCING CLASSROOM ENVIRONMENT• Number. The number of rules should be kept to a minimum, with five rules considered Keeping with the initial focus of this chapter on the maximum. Compliance is greatest when proactive classroom management techniques, students can readily recall all of the rules. a number of factors dealing with the classroom• Simplicity. The wording of rules should be environment need to be considered. While kept as simple as possible and should convey consequent stimuli are frequently the focus of exactly what behavior is expected. Pictures or classroom management techniques, antecedent icons depicting the rules may help younger stimuli are equally important and need to be students understand the rules. considered. Recognize that unstructured time in• Positive. Keep the wording of the rules posi- the classroom makes disruptive behavior more tive if at all possible. Most rules can be stated likely. If possible, 70% of classroom time should in a positive manner; some rules cannot. How- be devoted to academic activities (Wehby, ever, the majority of classroom rules should Symons, Canale, & Go, 1998). If students are be positive. It is much better to have rules that engaged in interesting academic activities, convey the behavior that is expected of the disruptive behavior will be less likely. This students rather than a list of don’ts. does not mean, however, that the teacher needs• Specific. The rules should be very specific. to be actively teaching 70% of the day. The The more ambiguous the rules are, the more utilization of strategies such as peer tutoring difficult they are to understand. If there are and cooperative learning help make this a loopholes in the rules, students will find them. more realistic goal. In order for sufficient Operational definitions of expected behavior time to be devoted to academic activities, are the best. an antecedent-based approach to classroom• Observable. The rules should describe behav- management is recommended. Strategies to ior that is observable. The behavior must be consider include: (1) proximity, (2) high rates observable so that the teacher can make an of opportunities to respond, (3) high-probability unequivocal decision as to whether or not the requests (behavioral momentum), and (4) choice rule has been followed. making. Physical proximity of the teacher
  • 11 • CLASSROOM MANAGEMENT 77to students helps curtail disruptive behavior Providing students with choice in activitiesand refocus a student to instructional tasks. has also been found to increase the fre-Shores, Gunter, and Jack (1993) reported that quency of appropriate behavior. Incorporatingmovement of a teacher in a classroom may be student-identified preferred activities or stimulione of the most effective means of managing into the existing instructional tasks can resultstudent behavior. Teacher movement around in decreasing the aversive nature of the taskthe classroom allows the teacher to respond and allows students to exert more control inquickly, improves the quality of teacher–student their daily lives (Dunlap et al., 1994). Shogren,interactions, allows better maintenance of dis- Faggella-Luby, Bae, and Wehmeyer (2004)ruptive students, and increases the opportunity conducted a meta-analysis of choice makingfor the teacher to provide positive feedback to interventions and found they were effective instudents. reducing undesirable behaviors and sustaining Research has indicated that classrooms with treatment effects.higher rates of academic instruction tend to be In addition, consider the following sugges-those with the lowest level of problem behavior tions regarding structuring the classroom space:(Gunter & Denny, 1998). To accomplish this it isbest to focus on improving the rate at which stu- • Place disruptive students in the front of thedents are given opportunities to actively respond classroom near the teacher, but not separatedto instruction. This can be accomplished by the from rest of class. Do not place a disrup-teacher’s increasing the amount of instructional tive student next to the teacher’s desk fac-talk, providing prompts for correct responding, ing the classroom. That is placing a majorgiving students adequate time to respond, and source of positive reinforcement (peer atten-providing positive feedback for correct respond- tion) directly in front of the disruptive stu-ing. Sutherland and Wehby (2001) report that dent.incorporating higher levels of active respond- • Do not let two disruptive students sit next toing by students leads to fewer opportunities for each other.inappropriate behavior and increases appropri- • Disruptive students need more frequent rein-ate behavior in the classroom. forcement for appropriate behavior than other Another proactive technique is to increase the students. Having them close to the teacherfrequency of high-probability request sequenc- makes this easier to accomplish.ing prior to the delivery of a low-probability • If there are a group of difficult students inrequest. Teacher requests can be placed into the classroom, have the most difficult ones sittwo categories: high-probability requests (i.e., close to the teacher and spread the others out.those that students are likely comply with) and It is best to place students who tend to behavelow-probability requests (i.e., those for which appropriately next to disruptive students.students that have a history of noncompliance). • Students should have only relevant materialsHigh-probability request sequencing involves on their desk. Relevant material includes onlyproviding a series of high-probability requests the material necessary for completion of theprior to the delivery of a low-probability request. current assignment.To work, the low-probability request needs • Do not place easily distracted students nearto be delivered within 5 seconds of the last the window or other location where distrac-high-probability request, the high-probability tion is likely.requests need to be varied and randomized, • Having the teacher move around the class-and the high-probability requests must have room frequently is one of the best proactivean established history and be easily embedded strategies. Walking around lets the teacherwithin the context of an activity. Known as more easily detect problems before they esca-behavioral momentum, these techniques have late. It also allows the teacher to subtly rein-been found to be effective at increasing the force students (e.g., a touch on the shoulder,frequency of low probability behavior (Mace & leaning down to look at their work, sayingBelfiore, 1990; Nevin, Mandell, & Atak, 1983). ‘‘good job’’) and check on academic progress.
  • 78 COGNITIVE BEHAVIOR THERAPYREINFORCEMENT STRATEGIES TABLE 11.1 Suggestions for Natural Positive ReinforcementAppropriate classroom behavior is maintained • Access to lunchroom snack machines (students suppliesfor many students in the classroom by naturally money)occurring reinforcers such as positive attention • Omit certain assignmentsfrom the teacher, grades, or self-reinforcement • Be first in line (to anything)that results from task completion. These natu- • Run film projector or video player for class • Be team captainrally occurring reinforcers may not be sufficient • Serve as class or office messenger or aideto maintain all desirable behaviors in all stu- • Care for class petsdents however. It is frequently necessary to • Sharpen class pencilslook for more powerful reinforcers. Teachers • Choose activity or game for classshould use caution in selecting and using posi- • Sit by a friendtive reinforcers, however. Reinforcers should be • Pass out paper • Time with favorite adult or peerage appropriate and the use of ‘‘natural’’ rein- • Decorate the classroomforcers is encouraged whenever it is possible • Tutor in class, or with younger students(see Table 11.1). The student’s level of function- • Extra portion at lunching should also be considered when selecting • Use of class walkman or tape recorderreinforcers (e.g., Don’t send a student for unsu- • Extra recess or break time • Use of magic markers and/or art suppliespervised free time in the library when he/she • Free time to use specific equipment/suppliesusually gets into trouble when unsupervised.). • Visit the school library (individual or group)It is very important that the teacher does not • Give the student a place to display workuse partial praise statements such as, ‘‘I’m glad • Water class plantsyou finished your work—finally!’’ as statements • Help custodiansuch as these may not be viewed as reinforcing Key Element of Classroom Managementto the student, but, rather, punishing. 1. Rules The use of touch (e.g., pat on the back or shoul- 2. Classroom Environmentder) as an adjunct to verbal praise may increase a. Proximitythe potency of the reinforcement. In spite of b. High Rates of Opportunities to Respondpossible hesitancy to use touch, it is poten- c. High-Probability Requests (Behavioral Momentum),tially powerful in its ability to comfort and quiet d. Choice Making 3. Positive Reinforcementbut may need to be used cautiously because of 4. Effective Command Givingcultural considerations (Halbrook & Duplechin, 5. Response Cost Procedures1994). Token reinforcers are generalized con- 6. Group Contingenciesditioned reinforcers that are exchangeable fora reinforcer of value to a student (Alberto &Troutman, 2006). They have been used effec- Giving Effective Commandstively in both regular and special education Barkley (1997) provides guideline to parents inclasses. Finally, school–home notes consist of the area of effective command giving. Chang-teachers evaluating student behavior daily and ing the manner in which commands are givenproviding parents with feedback. Parents can may effectively reduce the frequency of problemthen implement consequences based on the eval- behaviors and increase student compliant behav-uation (Jurbergs, Palcic, & Kelley, 2007; Kelley, ior. While Barkley’s list was designed for parents,1990). Parents have an important role in their it can easily be adapted for use with teachers inchildren’s education, and home–school commu- the classroom. The following list summarizesnication has been shown to lead to better educa- effective command giving strategies for teach-tional outcomes (Christenson & Conoley, 1992). ers and is adapted from those given by BarkleyOne way to facilitate such a relationship is to (1997) and Forehand and McMahon (1981):involve both parent and teacher in home-basedinterventions for classroom problems (Kelley, • Mean it.—Never issue a command you do not1990). intend to follow through to its completion.
  • 11 • CLASSROOM MANAGEMENT 79• Never issue a command as a question or favor. Therefore, if punishment is the initial recommen- —The command should be stated simply, dation, it may strengthen the teacher’s existing directly, and in an unemotional manner. bias in favor of punishment and lower the accept-• Do not yell. Getting you upset may be rein- ability of reinforcement-based procedure. Also, forcing to the student. Try to maintain your it is important to understand each student for composure. whom punishment will be used, because in some• Give the student time. When giving a com- cases the intention to punish a behavior results mand allow 5 to 10 seconds for the student to in the behavior being inadvertently reinforced respond before (1) giving the command again, (e.g., removal of student from class for disrup- or (2) giving a new command. tive behaviors when the function of the problem• Avoid nagging. Issue a command only twice, behavior was to avoid doing academic work). then follow through on the preplanned con- Additionally, even in those localities where cor- sequence. The more you ask, the less likely poral punishment is legal, it is not recommended they are to comply. as an effective behavior management technique.• Give only one or two commands at a time. Too For a detailed discussion of this and other impor- many commands can confuse the student. tant issues see Hyman and Snook (1999). Alberto• Deliver the command while maintaining eye con- and Troutman (2006) offer the following hierar- tact. This helps ensure that the student is chy of procedures for behavior reduction from paying attention to the teacher. least intrusive to most intrusive.• Be descriptive. Telling the student specifically to ‘‘pick up the paper around your desk and Level I Strategies of differential reinforcement stack your books’’ is much better than giving a. Differential reinforcement of low-rate a vague instruction such as ‘‘clean up your behavior (DRL) desk.’’ b. Differential reinforcement of other behav-• Make more start requests than stop requests. ‘‘Do’’ ior(s) (DRO) requests are better than ‘‘Don’t’’ requests. c. Differential reinforcement of incompatible• Verbally reinforce compliance.—It is easy to for- behavior (DRI) get to socially reward a student when he/she d. Differential reinforcement of alternative complies with your request. behavior(s) (DRA) Level II Extinction (terminating reinforcement)Reductive Procedures Level III Removal of desirable stimuliThere are times when even the most proactive a. Response-cost proceduresteacher must follow through with a negative con- b. Time-out proceduressequence for an inappropriate behavior. Remem-ber, however, that the worst time to select a Level IV Presentation of aversive stimulipunishment is during an episode with a stu- a. Unconditioned aversive stimulident. In instances such as these the teacher may b. Conditioned aversive stimulibe tempted to use a punishment that is too c. Overcorrection proceduressevere for the behavior. Maag (2001) believesthat educators may adopt the use of punish- The most logical reductive techniques fromment because it is easy to administer, it works this list for classroom use include response-costquickly to suppress behavior, and encourage- and overcorrection. Response cost, defined as ament of punishment (i.e., discipline) is part of procedure for ‘‘reducing inappropriate behav-our cultural ethos. It is important that psychol- ior through withdrawal of specific amounts ofogists working in the schools recognize these reinforcer contingent upon the behavior’s occur-issues when suggesting behavioral interventions rence’’ (Alberto & Troutman, 2006, p. 422), isto teachers. It is also important to recognize a versatile procedure with few negative sidethat some educators may evidence disdain for effects. It is particularly adaptable to a tokenreinforcement-based techniques (Axelrod, 1996). reinforcement system in which students can earn
  • 80 COGNITIVE BEHAVIOR THERAPYtoken reinforcers for appropriate behaviors and to some students and not to others. This notlose tokens for misbehavior. Response cost pro- only makes the program easier to manage butcedures can also be implemented without a token also should reduce backlash because classmateseconomy system being in place in the classroom. are not separated into reinforcer ‘‘haves’’ andA teacher who ‘‘fines’’ a child with the loss of ‘‘have-nots’’ (Cashwell, Skinner, Dunn, & Lewis,free time or recess would be an example of a 1998). Because students are attempting to earnresponse cost procedure. reinforcers as opposed to avoid punishment, Overcorrection involves penalizing an unde- these programs can also be fun (Skinner & Wat-sirable behavior by having the student perform son, 2000). Finally, when everyone or no onesome other behavior (Kazdin, 2001). Alberto and receives access to positive consequences, stu-Troutman (2006) describe two types of over- dents are not provided with information regard-correction. Restitutional overcorrection consists ing their peers’ performance and all students,of correcting the environmental effect of the as opposed to only a portion, get to celebratestudent’s misbehavior, not only to its original successes (Skinner, Pappas, & Davis, 2005).condition but to a better condition. For example,if a student is caught writing on his/her desk,the teacher may require the child to not only Further Readingerase/clean their writing, but all writing on the Alberto, P. A., & Troutman, A. C. (2006). Applied behav-desk. This can be a particularly effective form ior analysis for teachers (7th ed.). Upper Saddleof punishment for vandalism, littering, or other River, NJ: Pearson Prentice Hall.behavior that has a clear environmental out- Rhode, G., Jenson, W. R., & Reavis, H. K. (1993).come. Positive-practice overcorrection is cited The tough kid book: Practical classroom managementmuch more frequently in the psychological lit- strategies. Longmont, CO: Sopris West.erature and consists of repeatedly practicing theappropriate behavior, sometimes in an exagger-ated or overly correct form. It has been found to Referencesbe effective in reducing the incidence of a variety Alberto, P. A., & Troutman, A. C. (2006). Applied behav-of behaviors including pica (Myles, Simpson, & ior analysis for teachers (7th ed.). Upper SaddleHirsch, 1997) and bruxism (Watson, 1993). While River, NJ: Pearson Prentice Hall.not technically reductive in nature, it has also American Psychiatric Association (2000). Diagnostic andbeen used successfully with a variety of aca- statistical manual of mental disorders, 4th ed., (Text Revision). Washington, DC: Author.demic behaviors such as mathematics fluency Axelrod, S. (1996). What’s wrong with behavior analy-(Rhymer, Dittmer, Skinner, & Jackson, 2000) and sis? Journal of Behavioral Education, 6, 247–256.oral reading (Singh & Singh, 1986). Barkley, R. A. (1997). Defiant children: A clinician’s manual for assessment and parent training, 2nd ed. New York: Guilford.Group Contingencies Brown, L. H., & Beckett, K. S. (2006). The role of theA final consideration in developing classroom school district in student discipline: Building con- sensus in Cincinnati. Urban Review, 38, 235–256.behavior management programs are interdepen- Cashwell, C. S., Skinner, C. H., Dunn, M. S., & Lewis,dent group contingencies. When interdependent J. (1998). Group reward programs: A humanisticgroup contingencies are used, reinforcers are dis- approach. Humanistic Education and Development,tributed to every member of the group contingent 37, 47–53.upon the group meeting some criteria (Litow Christenson, S. L., & Conoley, J. C. (1992). Home-school& Pumroy, 1975). They have several advan- collaboration: Enhancing children’s academic andtages. Teachers can implement one program for social competence. Silver Springs, MD: National Association of School Psychologists.the entire class rather than an individual pro- Coleman, M. C., & Webber, J. (2002). Emotional andgram for each member of the class. The entire behavioral disorders: Theory and practice (4th ed.).group either earns or doesn’t earn the reinforce- Boston: Allyn and Bacon.ment; therefore teachers do not have to monitor Dinkes, R., Cataldi, E. F., Kena, G., & Baum, K. (2006).each student’s performance and give reinforcers Indicators of school crime and safety: 2006 (NCES
  • 11 • CLASSROOM MANAGEMENT 81 2007-003/NCJ 214262). U.S. Departments of Edu- Maag, J. W. (2001). Rewarded by punishment: Reflec- cation and Justice. Washington, DC: U.S. Govern- tions on the disuse of positive reinforcement in ment Printing Office. schools. Exceptional Children, 67, 173–186.Dunlap, G., dePerczel, M., Clarke, S., Wilson, D., Mace, F. C., & Belfiore, P. (1990). Behavioral Wright, S., White, R., & Gomez, A. (1994). Choice momentum in the treatment of escape-motivated making to promote adaptive behavior for stu- stereotypy. Journal of Applied Behavior Analysis, 23, dents with emotional and behavioral challenges. 507–514. Journal of Applied Behavior Analysis, 27, 505–518. Malone, B. G., & Tietjens, C. L. (2000). Re-examinationForehand, R. L., & McMahon, R. J. (1981). Helping the of classroom rules: The need for clarity and spec- noncompliant child: A clinician’s guide to parent ified behavior. Special Services in the Schools, 16, training. New York: Guilford. 159–170.Gettinger, M. (1988). Methods of proactive classroom McGinnis, J. C., Frederick, B. P., & Edwards, R. (1995). management. School Psychology Review, 17, Enhancing classroom management through pro- 227–242. active rules and procedures. Psychology in theGoldstein, S. (1995). Understanding and managing Schools, 32, 220–224. children’s classroom behavior. New York: John Myles, B. S., Simpson, R. L. & Hirsch, N. C. (1997). Wiley & Sons. A review of literature on interventions to reduceGunter, P. L., & Denny, R. K., (1998). Trends and issues pica in individuals with developmental disabili- in research regarding academic instruction of stu- ties. Autism, 1, 77–95. dents with emotional and behavioral disorders. Nevin, J. A., Mandell, C., & Atak, J. R. (1983). The Behavioral Disorders, 24, 44–50. analysis of behavioral momentum. Journal of theHalbrook, B., & Duplechin, R. (1994). Rethinking touch Experimental Analysis of Behavior, 39, 49–59. in psychotherapy: Guidelines for practitioners. Rademacher, J. A., Callahan, K., & Pederson-Seelye, Psychotherapy in Private Practice, 13, 43–53. V. A. (1998). How do your classroom rules mea-Heaviside, S., Rowand, C., Williams, C., & Farris, E. sure up? Guidelines for developing an effective (1998). Violence and discipline problems in U. S. pub- rule management routine. Interventions in School lic schools: 1996–1997. (NCES 98-030). Washington and Clinic, 33, 284–289. D.C.: U.S. Department of Education, National Rhode, G., Jenson, W. R., & Reavis, H. K. (1993). Center for Education Statistics. The tough kid book: Practical classroom managementHenry, S. (2000). What is school violence? An inte- strategies. Longmont, CO: Sopris West. grated definition. Annals of the American Academy Rhymer, K. N., Dittmer, K. I., Skinner, C. H., & of Political and Social Science, 567, 16–29. Jackson, B. (2000). Effectiveness of a multi-Hyman, I. A., & Snook, P. A. (1999). Dangerous schools: component treatment for improving mathematics What we can do about the physical and emo- fluency. School Psychology Quarterly, 15, 40–51. tional abuse of our children. San Francisco: Jossey- Shogren, K. A., Faggella-Luby, M. N., Bae, S. J., Bass. & Wehmeyer, M. L. (2004). The effect ofJurbergs, N., Palcic, J., & Kelley, M. L. (2007). choice-making as an intervention for problem School-home notes with and without response behavior: A meta-analysis. Journal of Positive cost: increasing attention and academic perfor- Behavior Interventions, 6, 228–237. mance in low-income, ADHD children. School Shores, R. E., Gunter, P. L., & Jack, S. L. (1993). Psychology Quarterly, 22, 358–379. Classroom management strategies: Are they set-Kazdin, A. E. (2001). Behavior modification in applied ting events for coercion? Behavioral Disorders, 18, settings (6th ed.). Belmont, CA: Wadsworth/ 92–102. Thomson Learning. Singh, N. N., & Singh, J. (1986). A behavioralKelley, M. L. (1990). School-home notes: Promoting remediation program for oral reading: Effects children’s classroom success. New York: Guil- on errors and comprehension. Educational ford. Psychology, 6, 105–114.Lewis, R., Romi, S., Qui, X., & Katz, Y. J. (2005). Skinner, C. H., & Watson, T. S. (2000). Randomized Teachers’ classroom discipline and student mis- group contingencies: Lotteries in the classroom. behavior in Australia, China, and Israel. Teaching The School Psychologist, 54, 21, 24, 32, 36–38. and Teacher Education, 21, 729–741. Skinner, C. H., Pappas, D. N., & Davis, K. A. (2005).Litow, L., & Pumroy, D. K. (1975). A brief review of Enhancing academic engagement: Providing classroom group oriented contingencies. Journal opportunities for responding and influencing of Applied Behavior Analysis, 8, 431–447. students to choose to respond. Psychology in theLittle, S. G., & Akin-Little, K. A. (1999). Legal and Schools, 42, 389–403. ethical issues of inclusion. Special Services in the Sutherland, K. S., & Wehby, J. H., (2001). Explor- Schools, 15, 125–143. ing the relation between increased opportunities
  • 82 COGNITIVE BEHAVIOR THERAPY to respond to academic requests and the aca- Wehby, J. H., Symons, F. J., Canale, J. A., & Go, demic and behavioral outcomes of students with F. J. (1998). Teaching practices in classrooms for emotional and behavioral disorders: A review. students with emotional and behavioral disor- Remedial and Special Education, 35, 161–171. ders: Discrepancies between recommendationsWatson, T. S. (1993). Effectiveness of arousal and and observations. Behavioral Disorders, 24, 51–56. arousal plus overcorrection to reduce nocturnal Wilke, R. L. (2003). The first days of class: A practical bruxism. Journal of Behavior Therapy and Experi- guide for the beginning teacher. Thousand Oaks, mental Psychiatry, 24, 181–185. CA: Corwin Press.
  • 12 COGNITIVE DEFUSION Jason B. Luoma and Steven C. HayesCognitive defusion involves a change in the nor- action. While Cognitive Therapy attempts tomal use of language and cognition such that the reduce the believability and behavioral impactongoing process is more apparent and the normal of negative thoughts disputation and test,functions of the products of thinking are broad- defusion attempts to accomplish similar aimsened. The normal state of living is such that we through relentless emphasis on seeing thoughtssee the world as structured by our thoughts—we as thoughts. As such, thoughts are not so muchdo not notice that we our thinking influences how hypotheses to be tested (as in cognitive therapy)it appears to be. One purpose of cognitive defu- as they are habitual constructions to be noticedsion is to help people become more aware, in an and integrated into a pattern of living well.ongoing manner, of this ubiquitous process of This expanded technique was named cognitivestructuring the world through thought, so that defusion both in order to avoid the dissociativethey might relate to thinking and the world in connotations of the term distancing, and toa more flexible responsive manner even with- emphasize the more comprehensive character ofout changing the form or frequency of specific the process involved.thoughts. The purpose of cognitive defusion is to help Cognitive defusion is a descendant of cognitive clients who are caught up in the content ofdistancing, a technique that dates back to the ori- their own thinking to ‘‘defuse’’ from the literalgins of cognitive therapy. Cognitive distancing meaning of thoughts and instead become moreencourages clients to detect their thoughts, and aware of thinking as an active, ongoing, process.to see them as hypotheses rather than objective Cognitive defusion is based on a functional con-facts about the world. Distancing was described textual theory of language and cognition calledas a ‘‘first, critical step in cognitive therapy’’ relational frame theory (Hayes, Barnes-Holmes,(Hollon & Beck, 1979, p. 189) because it enables & Roche, 2001). According to this view, thoughtsclinicians to teach clients to analyze, test, dispute, work the way they do because of the context,and alter negative thoughts through traditional both current and historical, in which they arecognitive techniques. Thus, cognitive distancing experienced. The theory suggests that normal,is conceptualized as a preparatory step: nec- common contexts of cognitive control and ratio-essary but not sufficient to produce profound nal analysis that are directly aimed at changingchange. the form or occurrence of particular patterns of A contextual psychotherapy originally thinking may exacerbate the behavior regulatorytermed Comprehensive Distancing (Hayes, 1987), functions of problematic thinking, rather thanwas one of the first to attempt to alter the weaken them. Thus, defusion attempts to alterfunctions of negative thoughts by the use of this social/verbal context so that people are lessextended and elaborated forms of cognitive pushed and pulled by their own idiosyncraticdistancing. Later, this therapy was renamed ways of thinking and are free to make choices inAcceptance and Commitment Therapy (ACT; accordance with their values. While this chapterHayes, Strosahl, & Wilson, 1999) when it is written in a less technical style, more technicalexpanded beyond a more narrow focus on accounts of defusion that are closely linked todefusion to include other elements such as terms from behavior analysis and relation frameacceptance, mindfulness, values, and committed theory are available (Blackledge, 2007). 83
  • 84 COGNITIVE BEHAVIOR THERAPY In recent years a number of related concepts such as Muto, Tada, and Sugiyama (2002), whoand procedures have emerged within empirical tested the impact of physicalizing and ‘‘leavesclinical traditions that have similar goals, such on the stream’’ (see Table 12.1).as mindfulness procedures (e.g., Linehan, 1993;Segal, Williams, & Teasdale, 2001) and the useof metacognitive strategies (Wells, 2000). While WHO MIGHT BENEFIT FROM THIS TECHNIQUEit is clear that these concepts are related, theexact dividing lines are unclear. In this chapter Cognitive defusion can be applied to any clientthe use of cognitive defusion in ACT will be problems that are exacerbated by entanglementemphasized. with cognitive events. The preliminary data show that these procedures can rapidly alter the functions of these events. For treatment-EVIDENCE FOR THE EFFECTIVENESS resistant clients who have failed in previousOF COGNITIVE DEFUSION courses of cognitive behavior therapy, cognitive defusion holds out the promise of reducingData for the impact of cognitive defusion the negative behavioral impact of harmfulcomes from several sources. Indirect evidence thoughts without having first to alter the form,comes from the body of research supporting frequency, or situational sensitivity of thosethe effectiveness of ACT, a therapy which thoughts.typically includes a strong focus on the processof defusion. Outcome evidence is now availableacross a range of behavioral problems, including CONTRAINDICATIONS OF THE TECHNIQUEpsychosis, chronic pain, workplace stress,obsessive compulsive disorder, social anxiety, The primary contraindication is treatment incon-drug abuse, nicotine addiction, depression, sistency. Cognitive defusion is aimed at under-coping with physical illness, and others (Hayes, mining the excessive literality of thinking itself.Luoma, Bond, Masuda, & Lillis, 2006). Changes Cognitive defusion thus does not combine wellin defusion related measures have also been with approaches specifically aimed at testing,shown to mediate outcomes in ACT interven- disputing, arguing, suppressing, or controllingtions in studies on depression (Zettle & Hayes, cognitive events, since all of these are heav-1987), counselor burnout and stigma (Hayes, ily focused on the literal meaning of thoughtsBissett et al., 2004), and two studies on psychotic (e.g., the adequacy of evidence for truth claims).behavior (Bach & Hayes, 2002; Gaudiano & Clients with ‘‘brittle’’ cognitive systems can beHerbert, 2006). Successful mediation in these agitated by the very idea of simply noticingstudies means that the changes seen in outcome thoughts without agreement or disagreement.variables occurred because of changes seen in Such clients (e.g., those with some obsessivedefusion. disorders) tend to present difficulties for most Studies examining the impact of a partic- forms of therapy, however, including traditionalular psychotherapy technique in isolation are forms of cognitive therapy, and furthermore canquite rare, but there are experimental analogue sometimes improve through the use of defusionstudies of defusion. One recent study examined procedures.the impact of a common defusion technique,rapidly repeating a word until it loses its mean-ing, as compared to control-focused techniques OTHER DECISIONS IN DECIDING WHETHERsuch as distraction (Masuda, Hayes, Sackett, & TO USE COGNITIVE DEFUSIONTwohig, 2004). Results showed that the defusiontechnique reduced both discomfort and believ- Cognitive defusion can be an important supple-ability of targeted thoughts more rapidly than ment to a number of other therapy approachescontrol conditions. Other studies of defusion and techniques. It may be particularly well com-techniques have reached similar conclusions, bined with other techniques that attempt to
  • 12 • COGNITIVE DEFUSION 85TABLE 12.1 Some Examples of Cognitive Defusion Techniques‘The Mind’’ Treat ‘‘the mind’’ as an external event; almost as a separate personMental appreciation Thank your mind; show aesthetic appreciation for its productsCubbyholing Label private events as to kind or function in a back channel communication‘‘I’m having the thought that’’ Include category labels in descriptions of private eventsCommitment to openness Ask if the content is acceptable when negative content shows upJust noticing Use the language of observation (e.g., noticing) when talking about thoughtsWord repetition Repeat a difficult thought until you can hear it as a soundPhysicalizing Label the physical dimensions of thoughtsPut them out there Sit next to the client and put each thought and experience out in front of you both as an objectOpen mindfulness Watching thoughts as external objects without use or involvementFocused mindfulness Direct attention to nonliteral dimensions of experienceSound it out Say difficult thoughts very, very slowlyArrogance of word Try to instruct nonverbal behavior and respond to each attempt ‘‘how do I do that?’’Thoughts are not causes ‘‘Is it possible to think that thought, as a thought, and do x?’’Choose being right or choose being alive If you have to pay with one to play for the other, which do you choose?There are four people in here Open strategize how to connect when minds are listeningMonsters on the bus Treating scary private events as monsters on a bus you are drivingWho is in charge here? Treat thoughts as bullies; use colorful languageTake your mind for a walk Walk behind the client chattering like minds do, while client choose where to walkAnd what is that in the service of? Step out of content and ask this questionOK, you are right. Now what? Take ‘‘right’’ as a given and focus on actionLeaves on a stream Watch thoughts like leaves floating by on a streamWhy, why, why? Show the shallowness of causal explanations by repeatedly asking ‘‘why’’Create a new story Write down the normal life story, then repeatedly integrate those same facts into other storiesCarry cards Write difficult thoughts on 3 × 5 cards and carry them with youCarry your keys Assign difficult thoughts and experiences to the clients keys. Ask the client to think the thought as a thought each time the keys are handled, and then carry them from therechange one’s relationship to or functions of correction is not desirable due to time constraints,thoughts and feelings (i.e., second-order change) past treatment failures with these approaches, orsuch as acceptance and mindfulness meditation comparative data.(see Chapters 2 and 40 in this volume). It isalso easily integrated with techniques that targetdirect change (i.e., first-order change) of overt HOW DOES THE TECHNIQUE WORK?behavior, such as behavioral activation, behav-ioral rehearsal and modeling, social skills train- Thoughts have much of their impact throughing, and stimulus control strategies (see Chapters altering the way in which we perceive the world,63 and 65 in this volume). It should be used without our noticing the process of thinkingwhen the clinician has determined that interven- itself. The world simply occurs as it does, struc-tion is needed to reduce the impact of a client’s tured behind the scenes by thought. Experien-thoughts, but the more lengthy and perhaps tially, it is as if the world as directly perceiveddifficult process of cognitive disputation and and the world as thought about become fused
  • 86 COGNITIVE BEHAVIOR THERAPYinto one world. Defusion is in part based on by the context in which they occur. In cognitivethe premise that if we can catch, in flight, this defusion, rather than trying to directly changeact of structuring our world through thought, the content or frequency of these private events,then perhaps we can relate to thinking in a more the therapist targets the context that relates themflexible, practical, and workable manner. to undesirable overt behavior so as to induce More technically, thoughts alter the functions greater response flexibility. The classic defusionof current situations because thoughts are mutu- technique of repeating a word rapidly can helpally related to other events. For example, when clarify this point. When a person rapidly saysyou think of a lemon, some of the reactions a word or phrase over and over again for aproduced by an actual lemon occur, at least in minute or two, two things typically happen:weakened form. For example, you may ‘‘see’’ a The word temporarily loses most of its mean-lemon and your mouth may water. This process ing and the sound of the word itself will emergeis helpful in most contexts. For example, a person more dominantly (it is common for clients to saythinking about how to fix a car can usefully go that they never realized the word sounded likethrough the steps cognitively, seeing each step that). The technique works best with one-syllablein his or her mind, before actually dismantling words (e.g., ‘‘milk’’), but also works with two- orthe car. Because many contexts are of this kind, three-syllable phrases (e.g., ‘‘I’m bad’’) if morepeople can come to interact with the world as time is spent repeating them. In this example ascognitively organized without noticing that they in all examples of defusion techniques, the wordare constantly organizing it. Verbal/cognitive or phrase is still present but a non-literal contextconstructions come to substitute for direct con- is created that diminishes its normal symbolictact with events. functions and increases its more direct functions In clinical situations, however, this kind of (in this example, its auditory functions). Statedcognitive fusion is often unhelpful and confin- another way, defusion techniques teach clients toing. When a panic disordered client imagines think thoughts as thoughts, not so much throughhow they might be trapped and socially humili- logical argument or direct instruction as throughated in a particular situation they are seemingly changes in the context of language and cognitiondealing with the problem of being trapped, just itself, so as to make responding more fluid andas the mechanic is seemingly dealing with a car. functional.If the literal functions of that thought dominate As a result, the literal functions of problematicover all other possible functions, the issue may thoughts are less likely to dominate as a sourcebecome how to avoid public situations so as toavoid being trapped, and not any of a thousand of influence over behavior and more helpful,other possible responses. Commonly, consider- direct, and varied sources of control over actionable clinical attention is given to such negative can gain ground. A large body of literature showsthoughts and experiences with the intent of that when individuals respond to stimuli in thegetting rid of them. However, a number of environment based on verbal rules, insensitivitystudies demonstrate that attempts to suppress, to the direct contingencies in the environmenteliminate, or alter negative thoughts and feel- may result and the range of behaviors availableings may result in paradoxical effects, at times may be excessively narrowed. Individuals mayactually increasing the frequency, intensity, and continue to apply the same ‘‘logical’’ solutionbehavioral regulatory powers of these experi- even when that solution is not working in aences. Furthermore, because these thoughts can particular context.be automatic and well established, altering them The contexts that are targeted by defusioncan be painstaking even when successful. Finally, techniques include those that establish literalthis process can narrow the behavioral focus even meaning itself, such as in the repeated wordmore to the undesirable thought, when that very example, but also contexts that encourage peo-narrowness is part of the problem. ple to generate verbal reasons to justify their Emotions and thoughts achieve their power behavior, to control private events, or to be rightnot only by their form or frequency, but also about their explanations for actions. Cognitive
  • 12 • COGNITIVE DEFUSION 87defusion acts in part through establishing con- the mechanics of how to swim down the min-texts in which sense-making is not supported, utest detail of how exactly to hold one’s hand,such as paradox, confusion, meditative exercises, how to kick one’s feet, and so on. However, inexperiential exercises, metaphor, and undermin- order to actually learn how to swim, one needs toing sense-making language conventions. Instead, get in the water and practice. This can be shownclients are encouraged to focus on opportuni- by asking the client to instruct the therapist in aties that the current environment affords and motor behavior, as in the following vignette:the workability of specific cognitive events infostering effective action in that environment. Therapist: I’d like you to tell me how to stand up. Can you do that? Client: Sure. You just lean forward, put your handsSTEP-BY-STEP PROCEDURES on the side of the chair and push up. Therapist: Okay, how do I do that?Cognitive defusion techniques can be broken Client: Just shift your weight forward and flex yourdown into three major groups. First, clients are arm muscles to move them over to the sides ofintroduced to the concept that language may not the chair.hold all the answers: that there may be other Therapist: How do I do that?more flexible ways of knowing that are beyond Client: You just tell your legs to move.verbal knowing. Second, thoughts and emotions Therapist (speaking to his legs): Move legs . . .are objectified through various metaphors, lead- they’re not moving. [brief pause] You see what’sing to greater distinction between thought and happening here? Minds don’t know how to dothinker, emotion and feeler. Third, various lan- this. They don’t know how to stand up. Lotsguage conventions and experiential exercises are of things we know how to do don’t happenintroduced to differentiate ‘‘buying a thought’’ through conscious thought. Like this example,from ‘‘having a thought,’’ with the goal of teach- when did you learn how to walk?ing clients to evaluate thoughts based on their Client: Oh, I don’t know. I guess I was about a yearfunctional utility, rather than their literal ‘‘truth.’’ old. Therapist: Yeah, you learned how to walk even before you could talk. And then only later didTHINKING VERSUS EXPERIENCE your mind come in and try to claim it for itself. What if there are things that we need to do in‘‘Verbal knowing rests atop non-verbal knowing this therapy that you can’t learn through yourso completely that an illusion is created that mind, but only through practice or experience?all knowledge is verbal’’ (Hayes et al., 1999,pp. 153–154). Cognitive defusion begins theattack on clients’ confidence in conscious thought OBJECTIFYING THOUGHTby demonstrating its limits. The repeated wordexercise (usual at first done with an arbitrary The natural sense of distance between self andword such as milk) is often one of the earliest. object often disappears when those objects areClients are first encouraged to notice all of the thoughts because the literal functions of thoughtperceptual functions of the word (e.g., what milk become so dominant. People tend to act as if atastes like) and then after a minute or two of thought is an adequate substitute for experience.saying the word rapidly out, to notice how these Objectifying thoughts can help people handlefunctions have changed. This exercise quickly their thoughts in more flexible and practicalpulls back the curtain of literality and reveals ways, in much the same way that external objectsthe illusion language and cognition create. can be handled in multiple ways, depending on The limits of language can also be illus- the purpose present in the moment.trated by examining how one learns any new Certain language conventions are helpfulskilled activity, such as a sport or hobby. For in that regard. ACT therapists often reactexample, one could listen to a description of all to thoughts in playful ways, such as saying
  • 88 COGNITIVE BEHAVIOR THERAPY‘‘Well, thank your mind for that thought’’ Eventually, you go back to placating theor congratulating clients for making dismal passengers, trying to get them to sit way in thecognitive connections (e.g., Client: ‘‘So then I back again where you can’t see them. . . . Prettythought I’d completely blown it.’’ Therapist: soon, they don’t have to tell you, ‘‘turn left’’—you‘‘Ah, very nice. Beautiful.’’) as if in appreciation know as soon as you get near a left turn thatfor how creative minds can be. Another verbal the passengers are going to crawl all over you.convention has to do with labeling the type of In time you may get good enough that you cantalk clients are engaged in, rather than respond- almost pretend that they’re not on the bus ating to the content of what the thought is literally all. . . . However, when they eventually do showabout. The therapist can, as an unelaborated up, it’s with the added power of the deals thataside, simply label client talk by type (e.g., you’ve made with them in the past.‘‘Evaluation. Very good,’’ or ‘‘Okay. Feeling.’’), Now the trick about the whole thing is that therather than engaging in the content of the power the passengers have over you is 100% basedconversation. Eventually, clients can be taught to on this: ‘‘If you don’t do what we say, we’re comingdo this with their own talk, labeling evaluations up and we’re making you look at us.’’ That’s it.as evaluations and feelings as feelings. For It’s true that when they come up from the backexample, a client might verbalize the thought they look as if they could do a whole lot more. . . .‘‘I’m worthless.’’ The client may be taught to say, The deal you make is you do what they say so they‘‘I’m having the evaluation that I’m worthless.’’ won’t come up and stand next to you and make you More extended metaphors can objectify look at them. The driver (you) has control of the bus,thoughts as well. An ACT metaphor is the but you trade off the control in these secret dealspassengers on the bus metaphor, which compares with the passengers. In other words, by trying tothe relationship between a person and his or get control, you’ve actually given up control! Nowher thoughts to that of a person and with bullies notice that even though your passengers claim theytrying to take control of his or her life (Hayes can destroy you if you don’t turn left, it has neveret al., 1999): actually happened. These passengers can’t make you do something . . . you are just making deals Suppose there is a bus and you’re the driver. On this with them (pp. 157–158). bus we’ve got a bunch of passengers. The passen- gers are thoughts, feelings, bodily states, memories, Later in therapy, this metaphor can be reintro- and other aspects of experience. Some of them are duced when clients bring up troubling thoughts, scary, and they’re dressed up in black leather jackets feelings, or behaviors that they feel are getting and they have switchblade knives. What happens is in the way of moving toward their valued goals. that you’re driving along and the passengers start A therapist might say, ‘‘so what passenger is threatening you, telling you what you have to do, bothering you now?’’ where you have to go. . . . The threat they have over Another defusion exercise that can help you is that if you don’t do what they say, they’re clients distinguish between themselves and the going to come up from the back of the bus. content of their minds is to have clients write It’s as if you’ve made deals with these passen- personally troubling thoughts cards. These gers, and the deal is, ‘‘You sit in the back of the bus cards can then be carried around by clients as and scrunch down so that I can’t see you very often, homework, literally allowing them to carry their and I’ll do what you say pretty much.’’ Now, what troubling thoughts as objects and still perform if one day you get tired of that. . . . You stop the their daily activities. bus, and you go back to deal with the mean-looking passengers. But you notice that the very first thing you had to do was stop. Notice now, you’re not A THOUGHT IS A THOUGHT IS A THOUGHT driving anywhere, you’re just dealing with these passengers. And they’re very strong. They don’t Cognitive defusion presents clients experien- intend to leave, and you wrestle with them, but it tially with the distinction between looking at just doesn’t turn out very successfully. the world as thought presents it (i.e., buying
  • 12 • COGNITIVE DEFUSION 89a thought) and looking at the world while to become fused with thoughts, to see them assimultaneously being aware of the process being literally true, as well as the tendency forof thinking and being aware of the response people to cling to and defend their own verbalalternatives present and choosing one of many constructions, can serve to restrict and narrowalternatives (i.e., having a thought). This is often behavior and inhibit movement towards valueddone through a variety of meditative and mind- life goals. Cognitive defusion loosens the gripfulness exercises, such as by having clients, eyes that excessive literality can hold on behaviorclosed, imagine a stream with leaves floating by so that more flexible and functional behaviorson it and placing each new thought that comes can emerge. Cognitive defusion can open up aup on one of the leaves. Inevitably the stream world of possible behaviors that may allow anstops, or people lose the exercise when a thought individual to move in a direction that is more incomes along (e.g., ‘‘Am I doing this right?’’) that line with his or her chosen values.is not being looked at but is being looked from. Further ReadingFOCUS ON THE FUNCTIONAL UTILITYOF THOUGHTS Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experientialAll of the techniques in cognitive defusion are approach to behavior change. New York: Guilford.tied together by a common focus on the func- Luoma, J. B., Hayes, S. C., & Walser, R. (2007). Learn-tional utility of thinking. Thoughts are not to be ing Acceptance and Commitment Therapy: A skills training manual for therapists. Oakland, CA: Newevaluated according to their literal truth or coher- Harbinger (includes DVD).ence with a network of understanding, but ratherby their workability. In any given situation, theprimary question the therapist and client should Referencesask is whether buying a thought would movethe client towards a life in line with his or her Bach, P., & Hayes, S. C. (2002). The use of Acceptancechosen values, or whether it moves the client in and Commitment Therapy to prevent the rehos-some other direction. pitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Various language practices and verbal con- Psychology, 70(5), 1129–1139.ventions can serve to keep the client focused on Blackledge, J. T. (2007). Disrupting verbal processes:the workability of thoughts. For example, when a Cognitive defusion in Acceptance and Commit-client begins to describe reasons to justify behav- ment Therapy and other mindfulness-based ther-ior, the therapist can ask questions like (Hayes apies. The Psychological Record, 57, 555–576.et al., 1999, p. 164): Gaudiano, B. A., & Herbert, J. D. (2006). Acute treatment of inpatients with psychotic symptoms• ‘‘And what is that story in the service of?’’ using Acceptance and Commitment Therapy: Pilot results. Behaviour Research and Therapy, 44(3),• ‘‘Is this helpful, or is this what your mind 415–437. does to you?’’ Hayes, S. C. (1987). A contextual approach to therapeu-• ‘‘Have you told these kinds of things to your- tic change. In N. Jacobson (Ed.), Psychotherapists in self or to others before? Is this old?’’ clinical practice: Cognitive and behavioral perspectives• ‘‘If God told you that your explanation is (pp. 327–387). New York: Guilford. 100% correct, how would this help you?’’ Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001).• ‘‘Okay, let’s all have a vote and vote that you Relational Frame Theory: A post-Skinnerian account of human language and cognition. New are correct. Now what?’’ York: Springer-Verlag. Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlen- berg, B. S., Fisher, G., et al. (2004). The impact ofCONCLUSION Acceptance and Commitment Training and multi- cultural training on the stigmatizing attitudes andVerbal understanding is very adaptive in many professional burnout of substance abuse coun-situations. However, the tendency for people selors. Behavior Therapy, 35(4), 821–835.
  • 90 COGNITIVE BEHAVIOR THERAPYHayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., negative thoughts: examining the impact of a & Lillis, J. (2006). Acceptance and Commitment ninety year old technique. Behaviour Research and Therapy: Model, processes and outcomes. Therapy, 42(4), 477–485. Behaviour Research and Therapy, 44(1), 1–25. Muto, T., Tada, M., & Sugiyama, M. (2002). Accep-Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). tance rationale and increasing pain tolerance: Acceptance and Commitment Therapy: An experiential Acceptance-based and FEAR-based practice. approach to behavior change. New York: Guilford. Japanese Journal of Behavior Therapy, 28, 35–46.Hollon, S. D., & Beck, A. T. (1979). Cognitive therapy of Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001). depression. In P. C. Kendall & S. D. Barlow (Eds.), Mindfulness-based cognitive therapy for depression: Cognitive-behavioral intervention: Theory, research, A new approach to preventing relapse. New York: and procedures (pp. 153–203). New York: Academic Guilford. Press. Wells, A. (2000). Emotional disorders and metacognition:Linehan, M. M. (1993). Cognitive-behavioral treatment Innovative cognitive therapy. New York: John Wiley of borderline personality disorder. New York: & Sons. Guilford. Zettle, R. D., & Hayes, S. C. (1987). Component andMasuda, A., Hayes, S. C., Sackett, C. F., & Twohig, process analysis of cognitive therapy. Psychologi- M. P. (2004). Cognitive defusion and self-relevant cal Reports, 64, 939–953.
  • COGNITIVE RESTRUCTURING OF THE 13 DISPUTING OF IRRATIONAL BELIEFS Albert EllisCognitive restructuring and the disputing of dys- same time, I pointed out that thinking, feeling,functional or irrational beliefs of people who and behaving are holistically integrated andhave emotional and behavioral disturbances date interactionally influence each other. Therefore,back to ancient times, particularly to early Asian, I hypothesized that effective therapy includesGreek, and Roman philosophers, who took a many techniques and had better be—as Arnoldconstructivist view of humans. Several of these Lazarus indicated 15 years later—multimodalthinkers held that people have a considerable (Ellis, 1957, 1958, 1962; Lazarus, 1971). I was notdegree of agency or free will and that therefore, the first therapist to use what became knownwhen their main goals and desires are thwarted as cognitive behavior therapy (CBT), since aby adverse conditions, they have some choice of few practitioners—such as Herzberg (1945) andreacting in a rational (self-helping) or irrational Salter (1949)—had employed aspects of it previ-(self-defeating) manner. The idea that people’s ously. But I seem to have been the main therapistemotions are significantly connected with their to create systematic cognitive restructuring,modes of thinking was nicely summed up by which I called disputing irrational beliefs, andEpictetus, a stoic philosopher, in the first cen- which I will describe in this chapter. After I hadtury A.D. He succinctly stated that people are promoted its use in several articles and books,disturbed not by the events that happen to them it also began to be employed by several otherbut by their view of these events. therapists who presented their own versions Nineteenth- and early twentieth-century of it—such as Beck (1967) and Meichenbaumpsychologists largely based their treatment (1977)—so that now it has become one of themethods on this constructivist theory, as shown most popular techniques of CBT.in the writings of Janet (1898), Dubois (1907), Today, important aspects of cognitiveCou´ (1923), and Adler (1927). Even Freud e(1922/1960) pointed out that the small voice of assessment and cognitive restructuring are used,reason can ultimately overcome the powerful overtly or tacitly, by a great many differentvoice of irrationality. His emphasis, however, kinds of therapists. Thus, psychoanalysis delveson the overpowering influence on unconscious, into clients’ unrealistic and illogical beliefs andoften repressed, thinking and feeling led somehow induces them to change these fortherapists to largely abandon dealing with healthier ideas and feelings. A few analysts,their clients’ irrational thinking; by the time especially Karen Horney (1950), have clearlythe 1950s arrived they were replacing cognitive demonstrated the ‘‘tyranny of the shoulds,’’ andrestructuring with emotional and behavioral some philosophers—especially Alfred Korzyb-techniques of therapy. ski (1933/1991) described the self-defeating In 1955, however, I started to do rational overgeneralizing and other thinking difficultiesemotive behavior therapy (REBT) and to that people use to make themselves, asforcefully favor cognitive restructuring and Korzybski said, ‘‘unsane.’’ REBT and CBTthe disputing of irrational client beliefs. At the pioneered in specifically showing clients their 91
  • 92 COGNITIVE BEHAVIOR THERAPYdysfunctional beliefs and how to dispute them how they are to be integrated with REBT’sand replace them with healthier philosophies. cognitive methods (Ellis, 2001a, 2001b, 2002). REBT and CBT present an A-B-C theoryof neurotic disturbance. When people are WHO MIGHT BENEFIT FROM THIS TECHNIQUEconfronted with adversities (As) that interferewith their goals and purposes they can choose to Cognitive restructuring or the disputing of IBshave functional or rational beliefs (RBs) that will may help psychotherapy clients who are con-encourage them to create healthy emotional and vinced by their therapist or by themselves thatbehavioral consequences (Cs). But they can also (1) their emotional–behavioral dysfuctioning ischoose to have irrational beliefs (IBs) that help partly the result of their irrational, unrealistic,produce unhealthy feelings and behaviors (Cs). and illogical thinking; (2) they can construc-Being constructivists (both innately and by social tively change their IBs to RBs and will thenlearning), and having language to help them, function significantly better; (3) their irrationalthey are also able to think about their thinking, and dysfunctional thinking includes strong emo-and even think about thinking about their tional and behavioral components; (4) if theythinking. Therefore, they can therapeutically persist in emotionally (strongly) feeling againstchoose to change their IBs to more rational and behaviorally (actively) acting against their(self-helping) beliefs. dysfunctional beliefs, they will automatically Since people’s thoughts, feelings, and actions and unconsciously create an effective new philos-reciprocally and sometimes powerfully affect ophy that will tend to make them less disturbedeach other, people can also simultaneously and keep them from seriously disturbing them-use—by themselves and with therapists’ selves in the future. Most Axis I individuals candirection—a number of emotional and behav- considerably benefit from this technique, andioral methods to improve their disturbed many Axis II individuals can obtain less, butfunctioning. Therefore, REBT and CBT practi- still considerable, benefit from persistently andtioners emphasize techniques of helping clients forcefully using it.to change their dysfunctional cognitions, but atthe same time they encourage clients to modify CONTRAINDICATIONStheir handicapping feelings and desires. Onlythe main aspects of cognitive restructuring and Some individuals with obsessive–compulsivethe disputing of IBs that I largely use in my own disorder (OCD) and other severe thoughtpractice of individual and group therapy will be disorders may take cognitive restructuringdescribed in this chapter (see Table 13.1 for the and the disputing of IBs to extremes and maykey elements of cognitive restructuring). I have become so absorbed in analyzing and changingdescribed many of the emotional and behavioral their beliefs that they sidetrack themselves fromtechniques elsewhere and have emphasized other useful techniques of therapy. IndividualsTABLE 13.1 Key Elements of Cognitive Restructuring• Show clients the ABCs of REBT and CBT. Show them how As alone do not lead to their disturbed Cs, but that they personally contribute to their Cs by engaging in strong and persistent beliefs (Bs) about their As. Thus, A → B = C.• Particularly show clients that when they disturb themselves (at point C) they have powerful RBs that largely consist of flexible preferences as well as strong IBs that largely consist of absolutistic, rigid musts, shoulds, and other demands.• Show clients how to think, feel, and act against their rigid IBs with a number of cognitive, emotive, and behavioral techniques, which interrelate to each other.• Show clients how to specifically dispute their IBs (1) realistically and empirically, (2) logically, and (3) juristically or pragmatically. Particularly show them how to change their rigid, absolutistic demands on themselves, other people, and world conditions to flexible, workable preferences.• Show clients that when they actively and persistently dispute (D) their IBs they can create an effective new philosophy (E) that includes strong rational coping statements that can help them to feel better, get better, and stay better.
  • 13 • COGNITIVE RESTRUCTURING OF THE DISPUTING OF IRRATIONAL BELIEFS 93who are rigidly convinced that changing their 4. Prone to produce dysfunctional feelings (e.g.,IBs cannot have any effect on their feelings may depression, panic, and rage) rather thanrefuse to try to do so or may waste their time and functional feelings (e.g., disappointment,energy by trying only halfheartedly. People with concern, and frustration) when the client’sabysmal self-deprecation may severely blame goals and purposes are thwarted.themselves for trying to use this technique and 5. Prone to lead to dysfunctional behavioral con-failing. Clients with abysmal low frustration sequences (e.g., serious avoidances and com-tolerance may find it too hard to try and may pulsions) instead of functional consequencesgive up on it. (e.g., not avoiding or compulsively dealing with adversities). 6. Demanding and musturbatory philosophies,OTHER FACTORS IN DECIDING WHETHER especially (a) ‘‘I absolutely must do well atTO USE THIS TECHNIQUE all times!’’ (b) ‘‘You absolutely must treat me considerately and fairly at all times!’’ andEven when it appears that clients are unlikely (c) ‘‘Life conditions absolutely must be fairto benefit from cognitive restructuring, it can be and favorable!’’used if the therapist thinks that they will not 7. Awfulizing and terribilizing beliefs, such asbe harmed or too sidetracked when they try it. ‘‘I must do well at important tasks, and it’sWhen the disputing of IBs is not very effective, terrible—almost 100% bad—if I don’t!’’ andtherapists may still find that it provides use- ‘‘Living conditions must be satisfactory, andful information on how else their resistant clients it’s awful if they aren’t!’’may benefit. Clients may be able to distract them- 8. Beliefs that depreciate human worth, such asselves from their problems and obtain palliative ‘‘If I don’t perform well and please significantrelief, even when cognitive restructuring itself is others, as I absolutely must, I am a total failurenot very effective. and am thoroughly unlovable!’’ Clients are taught the A-B-Cs of REBT theory and practice, which follow in the next section.HOW DOES THIS TREATMENT WORK?First, clients are educated by their therapist The A-B-Cs of REBTto acknowledge the four requisites mentioned Clients are taught how to distinguish their RBsabove: that dysfunctional thinking significantly from their IBs, to find the specific IBs of theircontributes to emotional disturbance; that they unhealthy feelings and behaviors (C’s), and thencan constructively change this thinking and to actively and forcefully dispute (D) their IBs.function better; that their IBs include strong Thus, their goal (G) is to lead a functional andemotional and behavioral elements; and that reasonably happy life, in spite of the adversitiesthey can, by cognitive restructuring, distinctly (As) that occur, but their IBs about A’s help createimprove themselves and make themselves less their dysfunctional feelings (such as panic anddisturbable. depression) at C (consequences). They are also Second, clients are specifically shown the shown that they often have secondary symptomsdifferences between rational (self-helping) and of disturbance. Thus, when they feel depressedirrational (self-defeating) beliefs. According to (C) about failing a test (A), they tend to have thethe theory of REBT, IBs that accompany distur- IB that ‘‘I must not fail, and it shows that I am anbances are: inadequate person when I do!’’ But they secon- darily take their depressed feeling (C) and make1. Rigid and extreme, instead of flexible. it into a new adversity (A): ‘‘Oh, I see that I am2. Inconsistent instead of consistent with social severely depressed.’’ Then they have an RB about reality. this secondary A (‘‘I don’t like being depressed;3. Illogical or nonsensical instead of logical. I wish I weren’t’’), which leads them to have
  • 94 COGNITIVE BEHAVIOR THERAPYthe healthy C of feeling sorry and disappointed question is ‘‘Where will it get me if I keepabout A. But they also have an IB about A (‘‘I demanding, instead of preferring, that I abso-must not be depressed!’’), which produces a sec- lutely must do well at test-taking and at winningondary disturbance, self-deprecation about their people’s approval for doing well?’’ The answerdepression, at C. to this question might be ‘‘It will most probably The REBT of cognitive restructuring or dis- get me anxious and depressed. Then I will hardlyputing of clients’ IBs shows them how to strongly do well at test taking or almost anything else!’’(emotionally) and persistently (behaviorally) Another pragmatic question could follow: ‘‘Also,argue with their IBs in an empirical, logical, where will it get me if I keep demanding that Iand pragmatic manner. Each of these argument not be depressed about test-taking? The answertypes is illustrated in the following sections. might be, ‘‘It will help make me depressed about my depression, and again less likely to do wellEmpirical or Realistic Disputing of Irrational Beliefs at other tests.’’This technique proposes an answer or effectivenew philosophy (E) for each empirical question. Changing Musturbatory Demands to PreferencesFor example, for the empirical question, ‘‘Where REBT holds that when clients have goals, values,is the evidence that I absolutely must perform and preferences, they usually react to adversi-well at all times and must not fail this test?,’’ the ties by feeling healthily sorry and disappointed,answer or E might be ‘‘There is no evidence that but that when they have absolutistic, rigid insis-I must not fail, although it would be preferable if I tences that they absolutely must do well, mustsucceeded.’’ Likewise, for the empirical question, be treated properly by others, and must live with‘‘Why must people like me for doing well at conditions that are satisfactory, they then maketests?,’’ the answer might be ‘‘Obviously, they themselves anxious, depressed, raging, compul-don’t have to. I would like them to like me, but sive, and avoiding. Thus, REBT shows clientsthey can choose not to do so.’’ how to keep their goals and desires but not raise them to unrealistic and illogical demands. InLogical Disputing of Irrational Beliefs addition to empirically, logically, and pragmat-This technique calls IBs into dispute through ically disputing clients’ demands and helpinglogical questioning. For example, the logical them change them to preferences, it uses manyquery ‘‘Does it logically follow that, because I other cognitive, emotional, and behavioral tech-very much want to take tests well and win the niques. Some other forms of cognitive restruc-approval of others, I absolutely have to do so?’’ turing that clients learn through REBT includemight evoke this answer: ‘‘No, it doesn’t follow the following:that no matter how much I want to do well, Iabsolutely have to do so.’’ Likewise, the logical 1. Working out rational coping statements—question, ‘‘Although it is highly preferable for new RBs—and learning how to stronglypeople to like me and for me to like myself for (emotively) repeat them many times untilbeing a good test taker, does it follow that this is they act on them.necessary?,’’ might lead to this answer: ‘‘No, it is 2. Using positive visualization to hopefully envi-great if they like me for that reason, but I can be sion their acting on efficacious and functionalhappy and can always accept myself as a person behaviors.whether or not I do well and whether or not people 3. Working on cost–benefit analyses of theirlike me.’’ disturbed thoughts, feelings, and actions, to motivate them to see how harmful they are and how useful it will be to change them.Pragmatic or Heuristic Disputing 4. Doing cognitive homework, especially fillingof Irrational Beliefs out regularly REBT self-help forms.Pragmatic questioning is another technique with 5. Modeling themselves after the therapist, afterwhich to dispute IBs. An example of a pragmatic people they know, and after other people
  • 13 • COGNITIVE RESTRUCTURING OF THE DISPUTING OF IRRATIONAL BELIEFS 95 they learn about who have successfully References changed their dysfunctional beliefs, feelings, Adler, A. (1927). Understanding human nature. New and behaviors when assailed by grim A’s. York: Greenberg.6. Reading and listening to REBT and CBT Beck, A. T. (1967). Depression. New York: Hoeber- books, pamphlets, tapes, lectures, courses, Harper. and workshops. Cou´ , E. (1923). My method. New York: Doubleday- e7. Recording their own therapy sessions and Page. Dubois, P. (1907). The psychic treatment of nervous disor- playing them back several times. ders. New York: Funk and Wagnalls.8. Learning and using REBT’s philosophy Ellis, A. (1957). Outcome of employing three techniques of unconditional self-acceptance, uncondi- of psychotherapy. Journal of Clinical Psychology, 13, tional other-acceptance, and unconditional 334–350. life-acceptance (Ellis, 2001a, 2001b, 2002, Ellis, A. (1958). Rational psychotherapy. Journal of Gen- 2003). eral Psychology, 59, 35–49.9. Using practical problem-solving and self- Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. management techniques when afflicted with Ellis, A. (2001a). Feeling better, getting better, staying A’s in their lives. better. Atascadero, CA: Impact Publishers. Ellis, A. (2001b). Overcoming destructive thinking, feeling and behaving. Amherst, NY: Prometheus Books. Ellis, A. (2002). Overcoming resistance: A rational emotiveCONCLUSION behavior therapy integrative approach. New York: Springer.Rational emotive behavior therapy and (to Ellis, A. (2003). Anger: How to live with it and without it.some extent) many forms of CBT hypothesize New York: Citadel Press.that if clients are made fully aware of their Freud, S. (1960). Jokes and their relation to the unconsciousspecific IBs and are strongly (emotively) and (James Strachey, Ed. & Trans.). London: Rout- ledge & Kegan Paul. (Original work publishedactively (behaviorally) helped to change their 1922).unrealistic, illogical, and disturbance-creating Herzberg, A. (1945). Active psychotherapy. New York:absolutistic demands into healthy preferences, Grune & Stratton.they will often considerably reduce their Horney, K. (1950). Neurosis and human growth. Newdisturbed feelings and behaviors. They can do York: Norton.this by empirically, logically, and heuristically Janet, P. (1898). Neuroses et idee fixes [Neuroses anddoing cognitive restructuring, along with fixed ideas]. Paris: Alcan. Korzybski, A. (1991). Science and sanity. Concord,using various other emotive-evocative and CA: International Society for General Semantics.active-behavioral methods. (Original work published 1933). Lazarus, A. A. (1971). Behavior therapy and beyond. NewFurther Reading York: McGraw-Hill. Meichenbaum, D. (1977). Cognitive-behavior modifica-Ellis, A. (2001a). Feeling better, getting better, staying tion. New York: Plenum. better. Atascadero, CA: Impact Publishers. Salter, A. (1949). Conditioned reflex therapy. New York:Ellis, A. (2001b). Overcoming destructive thinking, feeling Creative Age. and behaving. Amherst, NY: Prometheus Books.Ellis, A. (2002). Overcoming resistance: A rational emotive behavior therapy integrative approach. New York: Springer.
  • COGNITIVE RESTRUCTURING: 14 BEHAVIORAL TESTS OF NEGATIVE COGNITIONS Keith S. Dobson and Kate E. HamiltonThe power of self-observation of behavior has to review historical phenomena or to conductbeen recognized for a long time, and even has interviews with significant figures from thebeen the basis of developmental models of per- past, to determine whether or not the client’ssonality (Bem, 1970). Some have argued that the memory accurately portrays what the otherability to behave, and to accurately perceive one’s person believes occurred. Also, in the case ofactions and consequences, are hallmark features delusions, there is some evidence that evenof good mental health (Beck, Rush, Shaw, & the process of developing behavioral tests ofEmery, 1979). Conversely, negative cognitions delusional thinking can significantly underminehave been recognized as features of many dif- the potency of those delusions (see Kingdonferent forms of psychopathology, and cognitive & Turkington, 2005). Our perspective is thatbehavioral therapy has developed a large num- the flexibility of behavioral tests of negativeber of models and techniques to change these cognitions is limited largely by the clinician andnegative cognitions (Dobson, 2001). the client’s imagination. Behavioral tests are one of the most potent The specific efficacy of behavioral tests oftechniques to challenge negative thoughts in clin- negative cognitions has not been evaluated.ical practice, and they can be applied to most However, a dismantling study has examinedproblems that involve negative thinking. For the comparative efficacy of cognitive behavioralexample, negative cognitions that involve pre- therapy for depression and its two majordictions about the future, or statements about the components: (1) behavioral activation and (2)self, can be operationalized as hypotheses subject behavioral activation with automatic thoughtto empirical investigation. It is then possible to modification. The results of this study suggestgenerate behavioral tests of these negative cog- that cognitive behavioral therapy was nonitions. We describe the process of conducting more effective than its components eitherbehavioral tests of negative cognitions, and then at termination or during a 2-year follow-upprovide four clinical examples from the domains period (Gortner, Gollan, Dobson, & Jacobson,of anxiety, depression, marital dysfunction, and 1998; Jacobson et al., 1996). A more recent trialnegative self-schemas (see Table 14.1 for the key that examined the efficacy of a more purelytechniques). behavioral activation therapy of depression has There are few cognitions that cannot be used revealed similar results (Dimidjian, et al., 2006;to address this technique, although cognitions Dobson, et al, in press).that are ideally suited to behavioral testinginclude negative predictions, negative attribu-tions, negative conclusions and generalizations, HOW TO USE BEHAVIORAL TESTS TO COUNTERand global self-assessments. In contrast, some NEGATIVE THINKINGof the more difficult types of cognitions put toa behavioral test are memories and delusions. There are three main phases to the use ofEven in the instance of negative memories, behavioral tests of negative thoughts. First, thehowever, it may be possible to devise strategies client and therapist must agree that the negative 96
  • 14 • COGNITIVE RESTRUCTURING: BEHAVIORAL TESTS OF NEGATIVE COGNITIONS 97TABLE 14.1 Key Elements of Behavioral Tests of data gathering about the role of the thought, isNegative Cognitions needed before the behavioral test is attempted.1. Identify the negative cognition and its role in maintain- A second critical element of behavior tests of ing the problem behavior. negative cognitions is the behavioral test itself.2. Operationalize the problem behavior and generate a The behavior in question must be clearly spec- behavioral test. ified in order for a behavior test to work well,3. Review the outcome of the behavioral test with respect and the cognition that is being targeted by the to the original negative cognition. behavioral test must also be well identified. This specification is important to reduce the possibil- ity that the client will engage in a half-heartedthought in question is important and that it attempt with the behavior and then draw theplays a contributing or maintaining role in negative conclusion that this type of behaviorthe client’s overall problem. For example, the test does not work. Behavioral recordings suchtendency to perceive threat in many situations as audiotapes, written descriptions of the test,is a negative cognition that perpetuates anxiety. dysfunctional thought records, or other methodsA distressed wife who perceives that her might be employed by the therapist and client ashusband does those things that she wants only aids to ensure that the behavior test is conductedbecause she nags him has a negative cognition in the way it was intended.that perpetuates marital distress. Thus, the The third, and critical, aspect of the behav-first part of developing a behavioral test is ior test of cognitions is the review process.working with the client sufficiently to ensure Having engaged in a behavioral assignment orthat he/she recognizes the critical role of the experiment, the therapist and client must eval-negative cognition in the current problem, and uate the conclusions that the client now drawsthat he or she concurs that an evaluation of, or about himself/herself, in contrast to the previ-change to, this cognition may be therapeutically ous cognitions. For example, if the client hadimportant. In many instances, clients only get made a negative prediction, such as in the caseto this perspective once they have begun to of anxiety disorders, his/her actual experiencesexamine their negative thoughts over a period need to be contrasted with those expectationsof time, or when other related techniques, such in order to ensure that the next time theseas the dysfunctional thought record, are used expectations are present the client can remem-(J. Beck, 1995), so the critical issue at this early ber that these have been invalidated in thestage is to have them agree in principle to the past. Likewise, the depressed client who canexamination of the thought, rather than agree more realistically evaluate negative cognitionsthat it is erroneous or faulty at the outset. through behavioral assignments needs to see the Once a client has come to the perspective that role of his or her negative thinking in his or herhis or her thought is worthy of evaluation, the depression, in order to understand that behav-therapist can suggest the possibility of a behav- ioral tests can meaningfully undermine negativeioral test of that thought. Often, such suggestions cognitions and depression more generally. Thus,are put in the form of ‘‘experiments,’’ ‘‘assign- while simple ‘‘behavioral activation’’ in depres-ments,’’ or ‘‘tasks,’’ with which the client and sion may have a salutary effect on depressiontherapist can work collaboratively, in the spirit (Dimidjian et al., 2006), our perspective is thatof truly understanding the role of these thoughts. the client’s perception of that behavior may beA critical factor in this process is to ensure that the critical ingredient for lasting change.the client agrees that this thought, at least inprinciple, can be modified through a behavioraltest. If the client maintains that his/her particular EXAMPLES OF BEHAVIORAL TESTS TO COUNTERcognition is absolute or, incontestable, or perhaps NEGATIVE THINKINGthat the therapist doesn’t understand if he or shesuggests that it can be changed, then clinical wis- After the client and therapist are convinced thatdom suggests that more preparatory work and the cognition is clinically important, and the
  • 98 COGNITIVE BEHAVIOR THERAPYclient has accepted that the test of the thought quickly returns to normal without a catastrophicmay yield important clinical information, the outcome. Over time, the behavioral test can betherapist is in a position to develop a behav- exaggerated to the point that the client may beior test. The nature of the actual test will vary, willing to undertake activities that he or shedepending on the clinical problem, and for this previously would have found too risky.reason we provide four illustrative examples for Behavioral tests of negative, anxiety-relatedthe reader. cognitions are extremely powerful in modifying those predictions (Deacon & Abramowitz, 2004). It can be argued that without behavioral testsPanic Disorder of these negative cognitions, successful treat-It is now fairly well accepted that panic- ment of most anxiety-related disorders is notdisordered clients generally have a critical possible. Contemporary behavior therapy of allcognition that involves the idea that if they expe- the anxiety disorders involves exposure to therience the symptoms they associate with panic fear- provoking stimulus or situation, with cog-they may either be severely injured or even die nitive restructuring attendant to behavioral tests(Antony & Swinson, 2000). For example, a client (see Table 14.2 for the key elements of cognitivewho monitors his heart rate may believe that restructuring). Thus, this area probably repre-if his heart rate and/or blood pressure exceed sents the most widely accepted behavioral testsa certain value, he is likely to have a cardiac of negative cognitions.arrest or stroke and be critically injured or die.Therefore, the cognitive behavioral treatment Depressive Cognitionsof panic disorder typically involves a directbehavioral test of this critical negative cognition. Depressed clients characteristically make nega-The manner in which the test is conducted tive assessments of themselves, others, and theis to first have the client accept in principle world in general (Beck et al., 1979). These ‘‘cog-that this may only be a negative catastrophic nitive distortions’’ can take many and variedprediction, and to accept that evaluation of this forms, but their characteristic feature is thatcognition’s role in panic is warranted. Once the they typically reflect diminution of the client’sclient accepts these premises, the behavioral test self-worth or his or her status in the world. Foris to have the client engage in an activity that example, a depressed executive may believe thatproduces panic-like symptoms, but in a way that she can ‘‘never’’ get her work completed, andis structured so that the panic does not actually she may berate herself for her lack of accom-occur. For example, the client may be instructed plishment, even while maintaining that even ifto walk up and down a flight of stairs in order to she were successful in the completion of heraccelerate his or her heart rate; however, when work assignments, it would be of little conse-he or she stops the exercise, the heart rate will quence anyway. Behavioral tests are a potentiallyTABLE 14.2 Elements of Cognitive Restructuring• Show clients the logic of Cognitive Behavior Therapy (CBT). Show them that events alone do not lead to their disturbed reactions, but that they contribute to these consequences through negative thoughts, beliefs and predictions.• Show clients that when they disturb themselves they have strong negative thoughts that largely consist of absolutistic, rigid musts, shoulds, predictions, and other ideas.• Show clients how to think, feel, and act against their negative thoughts with cognitive and behavioral techniques, which interrelate to each other.• Show clients how to specifically dispute their negative thoughts: (1) realistically and empirically, (2) logically, and (3) juristically or pragmatically. Particularly show them how to change their rigid, absolutistic demands on themselves, other people, and world conditions to flexible, workable preferences.• Show clients that when they actively and persistently dispute negative thoughts with behavioral evidence they can create a new thought that is based on experiential evidence, and that will include strong rational coping statements that can help them to get and stay better.
  • 14 • COGNITIVE RESTRUCTURING: BEHAVIORAL TESTS OF NEGATIVE COGNITIONS 99effective method to counter depressive cogni- The wife could be encouraged to elaborate hertions, however. If this client can evaluate her prediction of how her husband will not do thesenegative thoughts systematically, and in particu- things unless he is nagged. The husband couldlar her idea that completing her housework is of discuss the effect nagging has on him, whichminimal benefit, the therapist and the client can is most likely that he resents it and feels thatwork together to develop a behavioral examina- he does not get the credit he deserves when hetion of these thoughts. Thus, the therapist and actually engages in the things his wife wants.client could systematically consider the various Both partners then need to agree that the wifetasks that are part of her work assignments, and will experiment with not nagging, on the under-they could develop a behavioral plan for the standing that if the husband cares for her andsuccessful completion of these various tasks. As is honestly motivated to do these things, theythe client gradually completes these tasks, her will occur ‘‘spontaneously.’’ Hopefully, the hus-sense of accomplishment and mood can be eval- band will recognize his opportunity to reduceuated. Depending on the client’s current level his partner’s negative behavior and will chooseof depression, these activities can be planned in to engage in the desired activity without sucha graduated fashion, so that the chances of the prompting. In such a case, this behavioral testclient’s experiencing success in a gradual fashion of the effect of lack of complaining can pro-are maximized. vide powerful information that the husband is more motivated in contributing to the relation- ship than the wife first believed. It could alsoMarital Distress enhance the husband’s sense of efficacy in theOne of the characteristic negative thoughts in relationship, and thus overall contribute to mar-many distressed couples is that the partner is not ital harmony.truly committed to the success of the relationshipand engages in positive activities only because of Schema Change Therapythe threat of negative consequences if that activ-ity is not done. Thus, a wife may believe that her A final example of behavior tests of negative cog-husband engages in social activities only because nitions can be seen in the recent emphasis in cog-she insists, and that if she did not mention these nitive behavior therapy on schema change therapyactivities and did not ‘‘remind him’’ of the need (Young, Klosko & Weishaar, 2003). Increasingly,to do these activities, they may never happen at therapists are interested in the identification ofall. The paradox of such negative expectations general beliefs that clients have about themselvesfor the partner may lead the wife to nag or to or how the world generally operates, and to testconstantly remind her husband of social obliga- these beliefs behaviorally. For example, if a clienttions, and then to make negative attributions like comes to believe that he is a ‘‘social loser,’’ this‘‘He only did this because I nagged him,’’ even general belief can be put to a behavioral test. Inif the husband might have in any event engaged order to perform such a test, the therapist andin the desired behavior. Thus, even if the hus- client first need to agree that holding this belief isband were to honestly desire social relations, important to the client, and might, for example,and if he might even engage in these without limit his social attainment.prompting, her behavior does not allow for this The therapist and client need to agree thatpattern to be recognized. If this pattern can be this thought is refutable, if sufficient contraryindentified in a distressed relationship, it lends evidence can be gathered, and then they need toitself nicely to a behavioral test of the negative develop a behavioral test. To do so, it is importantcognition. In order to do a behavior test of this to first operationalize the belief—‘‘What is atype of thought, it is first necessary for both the social loser?’’—and to work with the client towife and the husband to see the pattern of nega- develop a method to potentially invalidate thistive thoughts that lead to nagging behavior and self-construction. Often, the therapist will ask thethat, in effect, are reinforced by either compli- client a questions such as ‘‘What would it takeance or noncompliance with the social activity. for you not to believe you are a social loser?’’
  • 100 COGNITIVE BEHAVIOR THERAPYor ‘‘How would you know you are no longer a a review process to evaluate the conclusionssocial loser?’’ This question will help the client be that the client draws regarding the negativeconcrete about the activities he or she associates cognition, in the face of the new behavioralwith being a social loser, and will help to generate evidence they have gathered. Self-observationbehavioral tests of this construct. For example, through behavioral tests offers a potent meansif one of the criteria that the client enunciates to challenge and modify the maladaptiveis that he rarely has a date on the weekend cognitions associated with a broad range ofevenings, the therapist and client could generate clinical problems.the assignment of getting the client a date, so thathe can evaluate his social identity. References Another useful behavior test of a general Antony, M. M., & Swinson, R. P. (2000). Phobic disordersbelief is the ‘‘as if’’ technique (J. Beck, 1995). In and panic in adults: A guide to assessment and treat-the as-if technique, a general self-schema that the ment. Washington, DC: American Psychologicalclient has adopted is first identified, and some Association Press.other more positive alternative is then devel- Beck, A. T., Rush, A. G., Shaw, B. F., & Emery, G.oped. For example, if the client’s self-schema is (1979). Cognitive therapy of depression. New York:that he or she is ‘‘unlovable,’’ an alternative of Guilford.‘‘being loved’’ could be generated. The impli- Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.cations of holding the alternative belief would Bem, D. (1970). Beliefs, attitudes, and human affairs.be discussed at length with the client, and then, Oxford, England: Brooks/ Cole.if appropriate, the client could be encouraged to Deacon, B. J., & Abramowitz, J. S. (2004). Cognitivebehave ‘‘as if’’ he or she is capable of being loved. and behavioral treatments for anxiety disorders: AHaving done so, the client then evaluates how review of meta-analytic findings. Journal of Clinicalthe adoption of this alternative way of being Psychology, 60, 429–441.(both cognitively and behaviorally) affects his Dimidjian, D., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., et al. (2006).or her sense of self and emotional valuing. For Randomized trial of behavioral activation, cog-many clients, such behavioral tests are powerful nitive therapy, and antidepressant medication inmethods to demonstrate to them that they have the acute treatment of adults with major depres-the potential to be different than they have other- sion. Journal of Consulting and Clinical Psychology,wise been. Even if they are not fully successful in 74, 658–670.the development of an alternative sense of self, Dobson, K. S. (2001). Handbook of cognitive-behavioralthese tests can be important milestones in the therapies (2nd ed.). New York: Guilford. Dobson, K. S., Hollon, S. D., Dimidjian, S., Schmaling,path to the evaluation of a range of possibilities K. B., Kohlenberg, R. J., Gallop, R., et al. (2008).that exist for the client. Randomized trial of behavioral activation, cog- nitive therapy, and antidepressant medication inSUMMARY AND CONCLUSIONS the prevention of relapse and recurrence in Major Depression. Journal of Consulting and Clinical Psy-We have described how behavioral tests can chology, 76, 468–477. Gortner, E. T., Gollan, J. K., Dobson, K. S., & Jacobson,be used to undermine a variety of negative N. S. (1998). Cognitive-behavioral treatment forcognitions seen in clinical practice, ranging from depression: Relapse prevention. Journal of Con-specific predictions through to global negative sulting and Clinical Psychology, 66, 377–384.self-assessments. We have emphasized three Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E.,main phases of behavior test implementation. Koerner, K., Gollan, J. K., et al. (1996). A compo-The first phase involves the identification of the nent analysis of cognitive-behavioral treatmentkey negative cognition and its importance in for depression. Journal of Consulting and Clinical Psychology, 64, 295–304.the maintenance of problem behavior. Having Kingdon, D. G., & Turkington, D. (2005). Cognitiveachieved this objective, the therapist and client Therapy of Schizophrenia. New York: Guilford.collaboratively operationalize the problem Young, J. E., Klosko, K. S., & Weishaar, M. E. (2003).behavior and generate an appropriate behavior Schema therapy: A practitioner’s guide. New York:test. Finally, the therapist and client engage in Guilford Press.
  • COMMUNICATION/PROBLEM-SOLVING 15 SKILLS TRAINING Pamella H. Oliver and Gayla MargolinCommunication training historically has been PROPOSED MECHANISMS OF EFFECTan integral component of behavioral maritaltherapy and continues to be a fundamental Many therapeutic treatments for distressed fam-procedure utilized in contemporary forms of ily members include communication training.therapy for marital or couple distress (Jacobson Often families do not apply the basic listening& Christensen, 1996), prevention programs for and problem-solving skills presented here to thecouples (Braukhaus, Hahlweg, Kroeger, Groth, difficult, conflictual issues of their relationships.& Fehm-Wolfsdorf, 2003; Floyd, Markman, Many have never used such skills. Others, whoKelly, Blumberg, & Stanley, 1995; Hahlweg & may be skilled communicators in some situa-Markman, 1988), and parent training programs tions, dispense with good listening and problemor interventions (Dishion & Kavanaugh, 2003; solving when such skills are most needed,Forgatch, & DeGarmo, 1999; Kazdin, 2005). Com- that is, in moments of frustration and anger.munication training involves the practice and Instead, these family members either withdrawenactment of two sets of skills— speaker/listener from the interaction or resort to bombardingskills and problem-solving skills. These skills others with the same ill-stated point. Thus, theare components of many efficacious treatments, rationale for this procedure is derived from twointerventions or programs. For this chapter we models. One is a skills deficit model, the otherfocus on the specifics of using communication a stimulus–response model. Communicationtraining in marital or couples therapy with the skills training is basically a skills orientedrecommendation that these same techniques approach. The training is sometimes prescribedcan be adapted for use with children and to counteract family members’ lack of basicfamilies in a variety of interventions. Based on interpersonal skills with which to negotiatesocial learning theory, behavior marital therapy conflict. In contrast, the stimulus–responsefocuses on improving couples’ interaction model assumes that although family membersthrough skills training and through changing possess communication skills in general, theyconditions in the environment that establish do not use effective communication behaviorand maintain behavioral patterns. Jacobsonand Margolin (1979), the traditional treatment in the particular context of relationship tension.manual for behavior marital therapy, provides a From this perspective, communication trainingdetailed description of communication training is used as a means of stimulus control. That is,as well as a description of other elements communication training provides a structure toof therapy such as behavior exchange. The circumvent the family’s well-developed patternssteps of communication training are also that preclude using effective communication andprovided in other, generally more recent, problem-solving skills. Whether the destructivemanuals for therapists (Epstein & Baucom, behavioral patterns are seen as etiologic or2002; Jacobson & Christensen, 1996) and for as maintaining the problems, the therapeuticclients (Christensen & Jacobson, 2000; Forgatch objective is twofold: to learn and practice any& Patterson, 2005; Gottman, Notarius, Gonso, necessary skills, and to utilize the structured& Markman, 1976; Notarius & Markman, procedures in such a way that the context of1993). conflict is fundamentally changed. 101
  • 102 COGNITIVE BEHAVIOR THERAPY A third model describing a proposed rapidly escalating conflict or frustrated with-mechanism of effect is through a construc- drawal. Such patterns generally are fueled whentive, positive environment. Because parents one person, feeling misunderstood, repeats andfrequently are the ones facilitating change reiterates the same information. The other per-toward the goal of reducing child or adolescent son, feeling attacked, defends or counterattacksproblem behavior, parents’ abilities to relate to by responding to one small segment of infor-their children are important, particularly their mation. The goal of practicing speaker/listenersupportive communications and limit-setting skills is to interrupt such ritualized patterns bycommunications. The general goal of increasing building in steps that guarantee family mem-parents’ positive emotional connection to the bers accurately receive each other’s messages.child can be enhanced through communication Instructions that insert additional steps in fam-skills of initiating contact and showing interest ily communication dramatically slow down the(Liddle, Rodriguez, Dakof, Kanzki, & Marvel, communication process and thereby interrupt2005). Beyond developing a more positive well-rehearsed patterns. The additional stepsaffective interaction between parents and change the fundamental nature of the communi-children, communication interventions also cation and promote different expectations aboutare used to foster a constructive environment the purpose of the interaction. When success-for structured problem-solving (Forgatch & fully enacted, these changes allow participants toPatterson, 2005). figure out and articulate what they truly want to say and to ensure that the partner has accurately received the message.COMMUNICATION SKILLS TRAINING In addition to imparting new skills,PROCEDURES speaker/listener skills training also creates a stimulus situation that triggers the enactmentCommunication training falls into two general of constructive speaker and listener behaviorsskill sets: speaker/listener skills to generate rather than angry or divisive behaviorsunderstanding and problem-solving skills. As (Margolin, 1987). The enactment of theseWeiss (1978) noted, communications often behaviors results in a greater closeness andfall apart when one person simply wants to intimacy despite the fact that the partners do notbe understood and the other person starts to necessarily resolve the problem. This process ofproblem solve. Speaker/listener skills result in using problem discussions to enhance closenessunderstanding and validation of a partner’s is similar to the processes of ‘‘empathic joining’’perspective. These skills are an important goal (Jacobson & Christensen, 1996) or ‘‘building ain themselves as well as a preliminary step to joint platform’’ (Wile, 1993).problem solving. Productive problem solvingoccurs only when partners fully understand one STEP-BY-STEP PROCEDURESanother’s viewpoint. Problem-solving skills lead FOR SPEAKER/LISTENER SKILLSto changes in the way partners handle a givensituation. However, issues that do not require For the purposes of training and practice, thean action-oriented response need not progress speaker and listener roles are clearly defined.to the problem-solving phase. One partner, the speaker, introduces a topic that she or he wants to discuss, and the other partner, the listener, is to demonstrate that she or heFUNCTION OF SPEAKER/LISTENER SKILLS understands what is being said.The goal of practicing speaker/listener skills is The Listener’s Roleto facilitate the accurate sending and receivingof messages. A common pattern in distressed The therapist defines and demonstrates four sep-couples and families is that communication falls arate skills of increasing complexity that demon-into highly ritualized patterns, characterized by strate accurate listening (Jacobson & Christensen,
  • 15 • COMMUNICATION/PROBLEM-SOLVING SKILLS TRAINING 1031996; Jacobson & Margolin, 1979). Parroting, the is particularly distressing. According to Wilemost straightforward skill, requires the listener (1993), spouses’ seemingly out-of-proportionsimply to repeat back verbatim what the partner anger often stems from feeling unentitled tohas said. Paraphrasing requires the listener to very reasonable and normal reactions. Differentrephrase, in her or his own words, the content of dimensions of the process of expressing the core,the communication. Reflection requires the lis- underlying feelings associated with a problemtener to discern the emotion behind the speaker’s have been described as leveling (e.g., Gottman,message and to verbally check out that emotional et. al, 1976) or as disclosing ‘‘soft’’ as opposed tointerpretation with the speaker. Validation con- ‘‘hard’’ emotions (Jacobson & Christensen, 1996).veys to the speaker that her/his perspective is For the listener to accurately restate theunderstandable. Thus, the speaker’s statement, speaker’s message, that message needs to‘‘I can’t believe you didn’t call your mother to be stated succinctly. Thus, an important rolelet her know we’d be late for dinner,’’ could be for the therapist is to interrupt statementsrepeated back in those exact words, paraphrased that are too long and to cue the listener toas ‘‘You wanted me to call my mother letting her restate what has been said thus far. Thisknow we’d be late,’’ reflected as ‘‘You’re angry process of chunking speaker statements intoat me for not calling my mother and maybe also manageable units provides the speaker withembarrassed that we delayed her dinner party,’’ essential feedback about what portions ofor validated as ‘‘It makes sense that you’d be her/his statement have been received, therebyangry at me if you thought I had made the reducing the tendency for speakers to repeatcall.’’ It is important to note that none of these the same message. Moreover, listeners can beresponses require the listener to agree with the encouraged to restate part of the speaker’sspeaker. statement but to raise questions if another part These four listener skills are introduced is still confusing. Only when the speaker hassequentially. A new skill is introduced only finished stating her or his complete point andwhen the previous skill has been mastered. The the listener has demonstrated understandingtherapist actively directs the back-and-forth of the entire message does the listener presentcommunication, prompting the listener’s re- her/his perspective. At that point, speaker andstatement, and asking the speaker if the listener roles reverse. There is no guarantee inlistener’s statement was correct. If the listener this process that the new speaker will not comewas not correct, the entire process is repeated. across as angry and defensive but at least sheThe communication is thus slowed down or he has accurately heard the original speaker’sconsiderably by building in checks for clarity point of view.and accuracy before a reply can be given. As contrasted with the equal status between two adult partners, the differential status between parents and children is reflected inThe Speaker’s Role somewhat different practices of speaker/listenerAt the same time that one partner is practicing roles. Some basic ‘‘do’s’’ and ‘‘don’ts’’ still applylistening skills, the other is practicing expressive (e.g., see Forgatch & Patterson, 2005). Behaviorsskills. Expressive skills are as important to be encouraged include: staying focused on theas listening skills in fostering productive speaker, attempting to understand the other’scommunication. Frequently, a speaker begins perspective, and using active listening skills.to present a concern without fully knowing or Behaviors to be discouraged include: beingacknowledging what makes that situation upset- defensive, criticizing the speaker, and lecturingting. Accurate expressiveness, or being able to or giving advice.state what is truly on one’s mind, often evolvesthrough the communication process. Through The Therapist’s Roleclarification and feedback from the listener, be itthe partner or the therapist, the speaker gains fur- As described earlier, the therapist plays an activether understanding about why a given situation role to maximize the likelihood of success in
  • 104 COGNITIVE BEHAVIOR THERAPYspeaker/listener skills training. The therapist should be documented in writing to help keepmodels both speaker and listener behaviors, and the process on track and to avoid disagreementsencourages, prompts, and reinforces the part- about the specifics of the agreed-upon plan.ners’ efforts in this process. Most importantly,the therapist monitors and interrupts the pro-cess when it is not working to bring it back to STEP-BY-STEP PROCEDURES FORa more productive course. Some instructions for PROBLEM-SOLVING SKILLS FOR COUPLEScommunication training include extensive lists of Defining the Problemrules. Certainly, it is important for the therapistto demonstrate and prompt ways for partners Problem definition is the most important andto express strong feelings without provoking most difficult step in problem solving. It is thean immediate counterattack. However, the pri- most important because it sets up a frameworkmary objective of speaker/listener skills training for thinking about and approaching the problem.should not be overshadowed by undue attention It is the most difficult because it requires trans-directed to a list of communication rules. The lating one person’s complaint into a nonblam-overriding goal is to create an atmosphere of ing relationship issue. It also requires balancingmutual respect and openness so that spouses can the specificity and generality of the problemget their most difficult and controversial points definition—specificity so that participants knowacross to one another. what problem is being addressed, and generality so that they do not solve a small manifestation of a larger issue.FUNCTION OF PROBLEM-SOLVING SKILLS Ideally, problem definition acknowledges the role of both people and the consequences ofProblem-solving skills training is designed to the problem for both spouses. When those com-provide spouses and family members with ponents are included, spouses find it easier toa strategy for examining and responding to collaborate with brainstorming solutions. How-situations that they want to change but are ever, in generating the problem definition, it isin disagreement about how to change. Thus, common for spouses to revert to a pattern inproblem-solving skills are used when the family which one partner complains or criticizes andmembers feel ‘‘stuck’’ because each is entrenched the other partner defends her or his behav-in her or his own position that is different from, ior. This situation is best managed by: (1) notif not diametrically opposed to, the other’s defining problems when either spouse is angry;position. The steps involved in problem-solving (2) reminding spouses to state the problem inskills are threefold. The first is to define the a way that is easiest for the partner to hear;problem in a manner that is noninflammatory (3) employing listener/speaker skills as needed;and incorporates the role of both people, thereby and (4) making sure that spouses do not side-increasing the motivation of both to want to track from one problem to another (Jacobson &solve the problem. The second is to generate a Margolin, 1979).broad array of solutions to the problem, thereby Particularly when couples are first learningincreasing the likelihood that the partners will problem-solving skills, the therapist needs tofind some set of solutions upon which they play an active role to ensure that spouses definecan agree. The third is to craft a carefully the problem in a way that opens up creativeconsidered plan of action that can be put into and constructive possibilities for addressingeffect quickly and, in subsequent sessions, can the problematic issue. For example, the initialbe monitored and modified. Proposed solutions complaint of a wife who comanaged a businessare construed as ‘works in progress’. Even if with her husband was that the husband wassuccessful, they generally need to be updated obsessed with the business. This complaintand revised as the problem starts to resolve directed toward the spouse was translatedand/or as circumstances change. The content into the mutual issue that the couple had noof each phase of the problem-solving session relationship time apart from their business
  • 15 • COMMUNICATION/PROBLEM-SOLVING SKILLS TRAINING 105dealings. The redefinition of this problem behaviors practiced in session and extendopened up possibilities for new solutions the behaviors to a new topic. When learningtoward reserving special relationship time as speaker/listening behaviors, family memberswell as making sure that mutual business issues typically are asked to set aside a half-hour oncewere adequately dealt with in a timely fashion. or twice during the week with each person alternately taking the role as speaker and as listener. Similarly, once the family membersBrainstorming Solutions have practiced problem solving with theOnce the partners and the therapist have agreed therapist on several different issues, they canon a problem definition, the brainstorming pro- be asked to try the same procedures at home.cess begins. The primary rules of brainstorming For the first such assignment, the therapistare that: (1) any idea, no matter how outrageous, may want the complete problem definitionis worthy of mention, and (2) no evaluation of in the session and then have the clients doideas takes place until the entire list is generated the brainstorming and problem solution atand rated. As a result of these rules, partners are home.less inhibited in presenting their ideas and they It is generally advised that the topics selectedstay focused on the one problem under discus- for homework practice of speaker/listener skillssion (Jacobson & Margolin, 1979). Each solution or of problem-solving skills should be less con-is written down until a list of 10–20 solutions is flictual than those addressed in the session.generated. Having family members tape-record their com- munication skills homework is a good way forRating Brainstormed Solutions the therapist and clients to review homeworkStill without discussion, spouses independently practices. As with all between-session assign-rate each suggestion (1 = suggestion is good; ments, the therapist must fully debrief the home-2 = suggestion may be worthy of consideration; work during the next session. Ultimately, the3 = suggestion is bad). Each item rated as a 3 by goal is for the family to recognize when theyboth spouses is immediately removed from the need to use communication skills and to thenlist. Each item with a 1–1 or a 1–2 combination employ the skills on their own.is discussed to develop a plan based on one ormore of these ideas. EVIDENCE-BASED APPLICATIONSDeveloping and Revising the Plan Research on the efficacy and effectiveness ofThe initial plan should incorporate suggestions communication skills training is embeddedthat can be put into effect within the next week, in empirical research on behavioral maritalwith the possibility of revision or incorporating therapy, prevention training, and parentingother steps in future weeks. A problem solution interventions. Baucom and colleagues (Baucom,thus is reevaluated and revised until the prob- Shoham, Mueser, Daiuto, & Stickle, 1998) havelem is solved or a long-range solution is in place. determined, based on more than 20 published,What makes this process of problem solving very controlled treatment outcome investigations,rewarding to spouses is that they discover mul- that behavioral marital therapy is an ‘‘efficacioustiple mutually acceptable solutions to a problem and specific intervention’’ (Chambless & Hollon,that previously seemed unsolvable. 1998) for maritally distressed couples. Similarly, a recent meta-analysis indicates behavioral marital therapy is significantly more effectiveGENERALIZABILITY than no treatment for distressed couples (Shadish & Baldwin, 2005). Research on theFollowing each session of communication skills efficacy of communication and problem-solvingtraining, family members are given a homework skills training for committed couples has beenassignment to practice and consolidate the established (Braukhaus et al., 2003; Kaiser,
  • 106 COGNITIVE BEHAVIOR THERAPY Communication Training Listener/Speaker Skills Listener behaviors: Repeat verbatim Paraphrase Reflect Validate Speaker behaviors: Make succinct statements Clarify and express accurate feeling statements Problem-Solving Skills Define problem in mutual non-blaming language Brainstorm and then rate problem solutions Develop plan to be enacted in stated time period Implement plan Review implementation and revise planHahlweg, Fehm-Wolfsdorf, & Groth, 1998) behavioral marital therapy. These studies havewith intervention couples having significantly reported positive consumer ratings (Baucommore positive communication and less negative et al., 1998). Dropout rates are estimated to becommunication than the control couples. low, as suggested by a 6% attrition rate found byWith respect to the long-term effects of Hahlweg and Markman in their meta-analysiscommunication skills training in particular, of behavioral marital therapy studies (1988).a component analysis of behavioral marital Improved parent–child communicationtherapy indicated that after 6 months the generally has been examined in the context ofcommunication skills training component comprehensive programs to change children’sshowed superior maintenance of treatment behavior or to improve family functioninggains over the behavioral exchange component around difficult issues. Parenting programs,(Jacobson, 1984). However, a subsequent such as Adolescent Transitions Program2-year follow-up indicated no differential (Dishion & Kavanagh, 2003), based on thebenefit of either component, and approximately Patterson (1982) ecological model of antisocial30% of couples who had improved in ther- behavior and coercive family interaction pat-apy later relapsed (Jacobson, Schmaling, & terns, have empirical evidence that interventionHoltzworth-Munroe, 1987). Although research groups of at-risk adolescents in treatment hadoverall indicates that couples appear to benefit less negative engagement and a significantfrom communication training, there is a small reduction in home problem behavior after aset of women who demonstrate a decrease in program focused on parent–teen relationshipmarital satisfaction across time if, as a result skills. These relationship skills includedof an intervention, they have been extremely communication skills, problem-solving skills,positive and rarely negative in communication and negotiating. Based on similar models,(Baucom, Hahlweg, Atkins, Engl, & Thurmaier, there is extensive empirical evidence of the2006). These findings indicate the importance efficacy of programs that utilize componentsof the expression of both negative and positive of communication skills and problem solving.communication. A sample of these are a program for divorcing In addition to questions of efficacy, a limited mothers and their young sons (Forgatch &number of studies also have investigated the DeGarmo, 1999), Incredible Years parenteffectiveness, or real-life generalizability of intervention program for young children
  • 15 • COMMUNICATION/PROBLEM-SOLVING SKILLS TRAINING 107with conduct problems (Webster-Stratton & Dishion, T. J., & Kavanagh, K. (2003). The AdolescentReid, 2003) and Parent Management Training Transitions Program: A family-centered preven-(Kazdin, 2005) for children and adolescents with tion strategy for schools. In J. B. Reid, J. J. Snyder, & G. R. Patterson (Eds.), Antisocial behavior in chil-aggressive and antisocial behavior. dren and adolescents: A developmental analysis and model for intervention (pp. 257–272). Washington, DC: American Psychological Association.SUMMARY Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples: A contextualCommunication skills training sets up the struc- approach. Washington, DC: American Psychologi-ture and expectation that family members will cal Association.listen to each other and approach problem solv- Floyd, F. J., Markman, H. J., Kelly, S., Blumberg, S. L., & Stanley, S. M. (1995). Preventive interventioning in new ways. Interaction behaviors to be and relationship enhancement. In N. S. Jacobsonenacted are shaped with the therapist initially & A. S. Gurman (Eds.), Clinical handbook of coupledoing much modeling and reinforcing and fam- therapy (pp. 212–226). New York: Guilford.ily members gradually doing the steps more Forgatch, M. S., & DeGarmo, D. S. (1999). Parentingindependently. Although the steps of communi- through change: An effective prevention programcation skills training are spelled out in several for single mothers. Journal of Consulting and Clini-manuals, the timing and sequencing are left to cal Psychology, 67, 711–724.the therapist’s judgment. Toward the goal of Forgatch, M. S., & Patterson, G. R. (2005). Parents and adolescents living together. Part 2: Family prob-optimizing each person’s likelihood of success at lem solving (2nd ed.). Champaign, IL: Researcheach therapeutic stage, the therapist uses her or Press.his judgment with respect to when to introduce Gottman, J., Notarius, C., Gonso, J., & Markman, H.communication skills training, how to pace the (1976). A couple’s guide to communication. Cham-training, whether to begin the training on more paign, IL: Research Press.or less serious problems, whether to combine Hahlweg, K., & Markman, H. J. (1988). Effectivenesscommunication training with other intervention of behavioral marital therapy: Empirical status of behavioral techniques in preventing and alle-procedures, and whether to introduce communi- viating marital distress. Journal of Consulting andcation skills in a formal, educational manner or Clinical Psychology, 56, 440–447.to work them in seamlessly as needed in ongoing Jacobson, N. S., & Christensen, A. (1996). Integrativediscussions of the couple’s or family’s problems. couple therapy: Promoting acceptance and change. New York: W. W. Norton. Jacobson, N. S., & Margolin, G. (1979). Marital therapy:References Strategies based on social learning and behaviorBaucom, D. H., Hahlweg, K., Atkins, D. C., Engl, J., exchange principles. New York: Brunner/Mazel. & Thurmaier, F. (2006). Long-term prediction of Jacobson, N. S. (1984). A component analysis of behav- marital quality following a relationship education ioral marital therapy: The relative effectiveness program: Being positive in a constructive way. of behavioral exchange and communication/ Journal of Family Psychology, 20, 448–455. problem-solving training. Journal of ConsultingBaucom, D. H., Shoham, V., Mueser, K. T., Daiuto, and Clinical Psychology, 52, 295–305. A. D., & Stickle, T. R. (1998). Empirically sup- Jacobson, N. S., Schmaling, K. B., & Holtzworth- ported couple and family interventions for marital Munroe, A. (1987). Component analysis of distress and adult mental health problems. Journal behavioral martial therapy: 2-year follow-up and of Consulting and Clinical Psychology, 66, 53–88. prediction of relapse. Journal of Marital and FamilyBraukhaus, C., Hahlweg, K., Kroeger, C., Groth, T., & Therapy, 13, 187–195. Fehm-Wolfsdorf, G. (2003). The effects of adding Kaiser, A., Hahlweg, K., Fehm-Wolfsdorf, G., & booster sessions to a prevention training program Groth, T. (1998). The efficacy of a compact for committed couples. Behavioural and Cognitive psychoeducational group training program for Psychotherapy, 31, 325–336. married couples. Journal of Consulting and ClinicalChambless, D. L., & Hollon, S. D. (1998). Defining Psychology, 66, 753–760. empirically supported therapies. Journal of Con- Kazdin, A. E. (2005). Parent management training: sulting and Clinical Psychology, 66, 7–18. Treatment for oppositional, aggressive, and anti-Christensen, A., & Jacobson, N. S. (2000). Reconcilable social behavior in children and adolescents. New differences. New York: Guilford. York: Oxford University Press.
  • 108 COGNITIVE BEHAVIOR THERAPYLiddle, H. A., Rodriguez, R. A., Dakof, G. A., Kanzki, E., randomized controlled trials. Journal of Consulting & Marvel, F. A. (2005). In J. L. Lebow (Ed.), and Clinical Psychology, 73, 6–14. Handbook of clinical family therapy (pp. 128–163). Webster-Stratton, C., & Reid, M. J. (2003). The Incred- Hoboken, NJ: John Wiley & Sons. ible Years Parents, Teachers, and Children Train-Margolin, G. (1987). Marital therapy: A cognitive– ing Series: A multifaceted treatment approach behavioral–affective approach. In N. S. Jacobson, for young children with conduct problems. In (Ed.). Psychotherapists in clinical practice: Cognitive A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based and behavioral perspectives (pp. 232–285). New psycho-therapies for children and adolescents (pp. York: Guilford. 224–240). New York: Guilford.Notarius, C., & Markman, H. (1993). We can work it out: Weiss, R. L. (1978). The conceptualization of marriage Making sense of marital conflict. New York: G. P. from a behavioral perspective. In T. J. Paolino & Putnam’s Sons. B. S. McCrady (Eds.). Marriage and marital ther-Patterson, G. R. (1982). Coercive family process. Eugene, apy: Psychoanalytic behavioral and systems theory OR: Castalia. perspectives. New York: Brunner/Mazel.Shadish, W. R., & Baldwin, S. A. (2005). Effects of Wile, D. (1993). After the fight: A night in the life of a behavioral marital therapy: A meta-analysis of couple. New York: Guilford.
  • 16 COMPLIANCE WITH MEDICAL REGIMENS Elaine M. Heiby and Maxwell R. FrankIn past decades, many medical regimens modification techniques that are described inand public health advisories have involved other chapters of this volume. Variables corre-prescribing individuals to modify their daily lated with compliance that are not subject tohabits (O’Donohue, Naylor, & Cummings, modification, such as demographics and person-2005). Research has suggested that more than ality considerations, are not addressed.one-half of all deaths in the United States The prescription to modify health-relatedhave behavioral determinants (Levant, 2005; behavior commonly involves little more than aMcGinnis & Foege, 1993). Important health health care provider’s verbal recommendationareas that have been emphasized within the (Dyer, Levy, & Dyer, 2005). It is self-evidentcontext of prior intervention and research efforts that if such prescriptions are made withouthave included diet, exercise, and plaque control prior consideration of the individual’s capac-regimens; use of safety helmets, seat belts, and ity to comply with the prescription, non-safer sexual practices; as well as adoption of adherence is more likely to occur. For example,routine cancer screening habits (e.g., for testic- has the physician assessed the patient’s prac-ular, cervical, and breast cancers). Additional tical understanding of the prescription beingimportant components of preventive health made? Do environmental conditions exist in themedicine include smoking cessation, medication patient’s life such as may be necessary to succeedcompliance, and the various self-monitoring with the recommended behavior change? It isactivities associated with diabetes management. variables such as these that may play a role in Less than half of the population is initially whether the patient leaves the doctor’s officecompliant with instructions to make a behav- and is successful in following through withioral change—and this figure diminishes rapidly the behavior change. Some prescribed changesover time, particularly for preventive regimens seem fairly simple—such as taking a once-daily(Christensen, 2004; Myers & Midence, 1998). medication for hypertension that is inexpensiveNumerous theories have proposed situational and free of troublesome side effects. Other healthand behavioral targets for enhancement of com- regimens, however, will involve the adoptionpliance, stimulating a large body of research of far more complex skills— for example,identifying correlates of compliance. At this time, instructing the newly diagnosed patient withhowever, most of the theoretical literature is diabetes how to make sweeping changes in hisdisunified and has failed to successfully inte- or her diet, engage in a wide variety of routinegrate empirically supported aspects of prior the- monitoring behaviors (such as blood glucoseories. Subsequently, no standardized assessment testing), get regular physical exercise, and startdevice for risk of noncompliance and no empiri- taking self-administered injections that are notcally supported treatment or prevention package only frequent, but are commonly painful as well.have been developed (e.g., as argued by Cramer,1991). Therefore, this chapter will provide guide-lines for enhancement of compliance that are MAJOR THEORIES OF COMPLIANCEbased on consideration of what situational fac-tors and behavioral competencies have been Two prominent theories of compliance are pri-related to compliance and are subject to estab- marily descriptive, process-oriented approaches:lished environmental engineering and behavior the transtheoretical model of behavior change 109
  • 110 COGNITIVE BEHAVIOR THERAPY(e.g., DiClemente, 1993) and the relapse pre- prevention and intervention technique that isvention model (Marlatt, 1985). The former has expected to enhance compliance.encouraged the view that long-term strategies Facilitating conditions, discriminative stim-are needed to maintain healthy habits and uli, and consequences have implications forexamines the paths individuals may take in the techniques involving environmental engineer-behavior change process. The latter model rec- ing, such as contingency contracting andognizes that a range of coping skills are needed stimulus control. Language–cognitive variablesto maintain healthy habits and that these skills are conducive to techniques involving changesinclude unspecified cognitive, emotional, and in knowledge and information processing, suchinstrumental behaviors. In addition, we have as bibliotherapy and cognitive restructuring.assessed four theories of compliance that are Verbal–emotional variables may respond best toprimarily explanatory models that have helped techniques involving manipulation of cognitionsidentify concrete targets for behavioral change: that elicit affect, such as self-management and(1) the theories of reasoned action and planned attribution change. Emotional–motivationalbehavior (Fishbein & Ajzen, 1975; Ajzen, 1985); variables are conducive to techniques that(2) social cognitive theory (Bandura, 1991); (3) change affective conditioning, such as exposuremodified social learning theory (Wallston, 1992); and systematic desensitization. And finally,and (4) the health belief model (Rosenstock, sensorimotor variables may respond best to operant techniques, such as shaping and social1991). While each major compliance theory skills training. In total, assessment of a wideenjoys some empirical support, none provides a range of situational factors and the behavioralcomprehensive framework to guide the clinician repertoires related to compliance would provideabout what to assess in order to identify targets the clinician with additional direction regardingfor enhancement of compliance. what intervention may be effective given the The health compliance model (HCM; Heiby current environmental circumstances and prior& Carlson, 1986; Heiby, 1986) is a cognitive learning history of a particular individual.behavioral approach to complia