COGNITIVE BEHAVIOR THERAPYApplying Empirically Supported Techniques in Your Practice Second Edition Edited by William O’Donohue Jane E. Fisher John Wiley & Sons, Inc.
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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:
14 COGNITIVE BEHAVIOR THERAPY A meta-analysis of controlled studies. Clinical Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, Psychology Review, 21, 683–703. K. B., Kohlenberg, R. J., Addis, M. E., et al. (2006).Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, Randomized trial of behavioral activation, cog- J. S. (1989). Behavioral treatment of panic disorder. nitive therapy, and antidepressant medication in Behavior Therapy, 20, 261–282. the acute treatment of adults with major depres-Bishop, S. R. (2002). What do we really know about sion. Journal of Consulting & Clinical Psychology, 74, mindfulness-based stress reduction? Psycho- 658–670. somatic Medicine, 64, 71–83. Dobson, K. S. (1989). A meta-analysis of the efﬁcacyBongar, B. M., & Beutler, L. E. (Eds.) (1995). Comprehen- of cognitive therapy for depression. Journal of sive textbook of psychotherapy: Theory and Practice. Consulting and Clinical Psychology, 57, 414–419. New York: Oxford University Press. Eifert, G. H., & Forsyth, J. P. (2005). Acceptance andBorkovec, T. D. (1994). The nature, functions, and ori- commitment therapy for anxiety disorders. Oakland, gins of worry. In G. C. L. Davey & F. Tallis (Eds.), CA: New Harbinger. Worrying: Perspectives on theory, assessment, and Eifert, G. H., & Heffner, M. (2003). The effects of accep- treatment (pp. 5–34). New York: Wiley. tance versus control contexts on avoidance ofBorkovec, T. D., Alcaine, O. M., & Behar, E. panic-related symptoms. Journal of Behavior Ther- (Eds.). (2004). Avoidance theory of worry and apy & Experimental Psychiatry, 34, 293–312. generalized anxiety disorder. In R. G. Heimberg, Farmer, R. F., & Champman, A. L. (2008). Behavioral C. L. Turk, & D. S. Mennin (Eds.), Generalized interventions in cognitive behavior therapy: Practical anxiety disorder: Advances in research and practice guidance for putting theory into action (chapter 10). (pp. 77–108). New York: Guilford. Washington, DC: American PsychologicalBrantley, J. (2005). Mindfulness-based stress reduction. Associaton. In S. M. Orsillo & L. Roemer (Eds.), Acceptance Forman, E. M., Hebert, J. D., Moitra, E., Yeomans, and mindfulness-based approaches to anxiety: Concep- P. D., & Geller, P. A. (2007). A randomized tualization and treatment (pp. 131–145). New York: controlled effectiveness trial of acceptance and Springer. commitment therapy and cognitive therapy forBrown, K. W., & Ryan, R. M. (2003). The beneﬁts of anxiety and depression. Behavior Modiﬁcation, 31, being present: Mindfulness and its role in psycho- 772–799. logical well-being. Journal of Personality and Social Forman, E. M., Hoffman, K. L., McGrath, K. B., Her- Psychology, 84, 822–848. bert, J. D., Brandsma, L. L., & Lowe, M. R. (2007).Cardaciotto, L., Herbert, J. D., Forman, E. M., Moitra, A comparison of acceptance- and control-based E., & Farrow, V. (in press). The assessment of strategies for coping with food cravings: An ana- present-moment awareness and acceptance: The log study. Behaviour Research and Therapy, 45, Philadelphia Mindfulness Scale. Assessment. 2372–2386.Clark, D. M., Ehlers, A., Hackmann, A., McManus, Folette, V. M., Ruzek, J. I., Abueg, I. I. (1998). Cognitive F., Fennell, M., Grey, N., et al. (2006). Cognitive behavioral therapies for trauma. New York: Guilford. therapy versus exposure and applied relaxation Goldfried, M. R., & Davison, G. C. (1994). Clinical in social phobia: A randomized controlled trial. behavior therapy. New York: John Wiley & Sons. Journal of Consulting and Clinical Psychology, 74, Hayes, S. C. (in press). Climbing our hills: A begin- 568–578. ning conversation on the comparison of ACT andCoelho, H. F., Canter, P. H., & Ernst, E. (2007). traditional CBT. Clinical Psychology: Science and Mindfulness-based cognitive therapy: Evaluating Practice. current evidence and informing future research. Hayes, S. C. (2001). Psychology of acceptance and Journal of Consulting and Clinical Psychology, 75, change. In N. J. Smelser & P. W. Baltes (Eds.), 1000–1005. International encyclopedia of the social and behav-Cordova, J. V. (2001). Acceptance in behavior therapy: ioral sciences (pp. 27–30). Oxford, UK: Elsevier Understanding the process of change. The Behavior Sciences. Analyst, 24, 213–226. Hayes, S. C. (2004). Acceptance and commitment ther-Craske, M. G., & Barlow, D. H. (2008). Panic dis- apy and the new behavior therapies: Mindfulness, order and agoraphobia. In D. H. Barlow (Ed.), acceptance, and relationship. In S. C. Hayes, Clinical handbook of psychological disorders (4th ed., V. M. Follette, & M. M. Linehan (Eds.), Mindfulness pp. 1–64). New York: Guilford. and acceptance: Expanding the cognitive-behavioralDeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, tradition (pp. 1–29). New York: Guilford. R. C., Young, P. R., Salomon, R. M., et al. (2005). Hayes, S. C., Bissett, R., Korn, Z., Zettle, R. D., Rosen- Cognitive therapy vs. medications in the treat- farb, I., Cooper, L., et al. (1999). The impact of ment of moderate to severe depression. Archives acceptance versus control rationales on pain tol- of General Psychiatry, 62, 409–416. erance. The Psychological Record, 49, 33–47.
2 • PSYCHOLOGICAL ACCEPTANCE 15Hayes, S. C., Levin, M., Yadavaia, J. E., & Vilardaga, Lappalainen, R., Lehtonen, T., Skarp, E., Taubert, E., R. V. (2007, November). ACT: Model and processes Ojanen, M., & Hayes, S. C. (2007). The impact of of change. Paper presented at the Association CBT and ACT models using psychology trainee for Behavioral and Cognitive Therapies, Phila- therapists: A preliminary controlled effectiveness delphia. trial. Behavior Modiﬁcation, 31, 488–511.Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Larimer, M. E., Palmer, R. S., & Marlatt, G. A. (1999). Lillis, J. (2006). Acceptance and commitment ther- Relapse prevention: An overview of Marlatt’s apy: Model, processes and outcomes. Behaviour cognitive–behavioral model. Alcohol Research & Research and Therapy, 44, 1–25. Health, 23, 151–160.Hayes, S. C., & Pankey, J. (2003). Acceptance. In Leigh, J., Bowen, S., & Marlatt, G. A. (2005). Spiritu- W. O’Donohue, J. E. Fisher, & S. C. Hayes (Eds.), ality, mindfulness and substance abuse. Addictive Cognitive behavior therapy: Applying empirically sup- Behaviors, 30, 1335–1341. ported treatments in your practice (pp. 4–9). Hobo- Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. ken, NJ: John Wiley & Sons. (2004). The effects of acceptance versus suppres-Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). sion of emotion on subjective and psychophysi- Acceptance and commitment therapy: An experiential ological response to carbon dioxide challenge in approach to behavior change. New York: Guilford. patients with panic disorder. Behavior Therapy, 35,Hayes, S. C., & Strosahl, K. D. (Eds.). (2005). A practical 747–766. guide to acceptance and commitment therapy. New Lau, M. A., & McMain, S. F. (2005). Integrating mindful- York: Springer Science. ness meditation with cognitive and behaviouralHayes, S. C., Wilson, K. W., Gifford, E. V., Follette, therapies: The challenge of combining acceptance- V. M., & Strosahl, K. (1996). Emotional avoidance and changed-based strategies. Canadian Journal of and behavioral disorders: A functional dimen- Psychiatry, 50, 863–869. sional approach to diagnosis and treatment. Linehan, M. M. (1993a). Cognitive–behavioral treat- Journal of Consulting and Clinical Psychology, 64, ment of borderline personality disorder. New 1152–1168. York: Guilford.Herbert, J. D., & Cardaciotto, L. (2005). An acceptance Linehan, M. M. (1993b). Skills training manual for treat- and mindfulness-based perspective on social anx- ing borderline personality disorder. New York: iety disorder. In S. M. Orsillo & L. Roemer (Eds.), Guilford. Acceptance and mindfulness-based approaches to anx- Longmore, R. J., & Worrell, M. (2007). Do we need to iety: Conceptualization and treatment (pp. 189–212). challenge thoughts in cognitive behavior therapy? New York: Springer. Clinical Psychology Review, 27, 173–187.Herbert, J. D., Gaudiano, B. A., Rheingold, A., Harwell, Marks, I. 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). Inte- couple therapy: An acceptance-based, promising grating acceptance and mindfulness into exist- new treatment for couple discord. Journal of Con- ing cognitive-behavioral treatment for GAD: A sulting and Clinical Psychology, 68, 351–355. case study. Cognitive and Behavioral Practice, 10,Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., 222–230. Koerner, K., Gollan, J. K., et al. (1996). A compo- Orsillo, S. M., Roemer, L., Lerner, J. B., & Tull, nent analysis of cognitive-behavioral treatment M. T. (2004). Acceptance, mindfulness, and for depression. Journal of Consulting and Clinical cognitive-behavioral therapy: Comparisons, Psychology, 64, 295–304. contrasts, and applications to anxiety. InKabat-Zinn, J. (1990). Full catastrophe living: Using the S. C. Hayes, V. M. Follette, & M. M. Linehan wisdom of your body and mind to face stress, (Eds.), Mindfulness and acceptance: Expanding the pain, and illness. New York: Delacorte Press. cognitive-behavioral tradition (pp. 66–95). NewKohlenberg, R. J., & Tsai, M. (1991). Functional analytic York: Guilford. psychotherapy: Creating intense and curative Orsillo, S. M., Roemer, L., & Holowka, D. (2005). therapeutic relationships. New York: Plenum. Acceptance-based behavioral therapies for
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