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N. J. Smelser and Paul B. Baltes (editors) 2001 International Encyclopedia of the Social & Behavioral
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L. M. Drummond
Behavior Therapy: Psychological
Perspectives
A new way of treating psychopathology, called behavior therapy, emerged in the 1950s. In its initial form
this therapy was restricted to procedures based on
classical and operant conditioning. Therapists who
employ operant conditioning as means of treatment
often prefer the term `behavior modification.' Over the
years many writers have broadened the scope of
behavior therapy beyond conditioning to include any
attempt to change abnormal behavior, thoughts, and
feelings by applying the research methods used and the
discoveries made by experimental psychologists in
their study of both normal and abnormal behavior.
Over a number of years people in the clinical field
—among them Joseph Wolpe and Arnold Lazarus in
South Africa, H. J. Eysenck in Great Britain and B. F.
Skinner, Albert Bandura, Albert Ellis, and Aaron T.
Beck in the United States—began to formulate a new
set of assumptions about dealing with clinical problems. Although there are areas of overlap, it is helpful
to distinguish four theoretical approaches in behavior
therapy- -counterconditioning and exposure, operant
conditioning, modeling, and cognitive behavior therapy.
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Behavior Therapy: Psychological Perspectives
1.
Counterconditioning and Exposure
Counterconditioning is relearning achieved by eliciting a new response in the presence of a particular
stimulus. A response (R,) to a given stimulus (S) can
be eliminated by eliciting a new response (R 2) in the
presence of that stimulus. For example, in an early and
now famous demonstration in 1924, Mary Cover Jones
successfully treated a young boy's fear of rabbits by
feeding him in the presence of a rabbit. The animal was
at first kept several feet away and then gradually
moved closer on successive occasions. In this way the
fear (R,) produced by the rabbit (S) was replaced by
the stronger positive feelings evoked by eating (R 2 ).
The counterconditioning principle, deriving from
earlier work by Pavlov and Guthrie, forms the foundation of an important behavior therapy technique,
systematic desensitization, developed by Joseph
Wolpe (1958). A person who suffers from anxiety
works with the therapist to compile a list of feared
situations, starting with those that arouse minimal
anxiety and progressing to those that are the most
frightening. Over a number of sessions and sometimes
with the help of taped at-home practice, the person is
also taught to relax deeply. Step-by-step, while relaxed, the person imagines the graded series of anxietyprovoking situations. The relaxation tends to inhibit
any anxiety that might otherwise be elicited by the
imagined scenes. The fearful person becomes able to
tolerate increasingly more difficult imagined situations
as he or she climbs the hierarchy over a number of
therapy sessions. Reduction of fears in real life usually
follows.
Wolpe hypothesized that counterconditioning
underlies the efficacy of desensitization: a state or
response antagonistic to anxiety is substituted for
anxiety as the person is exposed gradually to stronger
and stronger doses of what he or she fears. Some
experiments (Davison 1968) suggest that counterconditioning accounts for the efficacy of the technique,
but a number of other explanations are possible (see
Social Cognitive Theory and Clinical Psychology). Most
contemporary theorists attach importance to exposure
per se to what the person fears; relaxation is then
considered a useful strategy to encourage a frightened
individual to confront what he or she fears, rather than
a response that is substituted for the maladaptive
anxiety. Whatever its mechanism of action, systematic
desensitization and other exposure techniques have
been shown to be effective in reducing a wide variety of
fears, from specific phobias like fear of snakes and
closed spaces to more complex fears such as social
anxiety and agoraphobia (see Psychological Treatments, Empirically Supported).
Another type of counterconditioning, aversive conditioning, also played an important historical role in
the development of behavior therapy. In aversive
conditioning, a stimulus attractive to the patient is
paired with an unpleasant event, such as a drug that
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produces nausea, in the hope of endowing it with
negative properties. For example, a problem drinker
who wishes to stop drinking might be asked to smell
alcohol while he or she is being made nauseous by a
drug. Aversive techniques have been employed to
reduce smoking and drug use, and the socially inappropriate attraction that objects have for some people,
such as the sexual arousal that children produce in
pedophiles.
Aversion therapy has been controversial for ethical
reasons. A great outcry has been raised about inflicting
pain and discomfort on people, even when they ask for
it. For example, in its early days, aversion therapy was
used to try to change the sexual orientation of
homosexuals. But in the late 1960s, gay liberation
organizations began to accuse behavior therapists of
i mpeding the acceptance of homosexuality as a legitimate lifestyle. Currently, aversion therapy is rarely
used as the only treatment for a particular problem.
2.
Operant Conditioning
Several behavioral procedures derive from operant
conditioning, an analysis of overt behavior in terms of
the conditions under which it occurs and the consequences that it elicits from the environment (see
Autonomic Classical and Operant Conditioning; Behavior Analysis, Applied). Much of this work has been
done with children, perhaps because a great deal of
their behavior is subject to the oversight and control of
others. Treatment typically consists of altering the
consequences of problem behavior. For example, if it
was established that the problem was motivated by
attention seeking, the treatment might be to ignore it.
Alternatively, the undesired behavior could be followed by time-out, a procedure wherein the person is
banished for a period of time to a dreary location
where positive reinforcers are not available.
Making positive reinforcers contingent on behavior
is used to increase the frequency of desirable behavior.
For example, a socially withdrawn child could be
reinforced for playing with others. Similarly, positive
reinforcement has been used to help children with
autistic disorder develop language, to remediate learning disabilities, and to help children with mental
retardation develop necessary living skills. Other
problems treated with these methods include bedwetting, aggression, hyperactivity, disruptive classroom behavior, and tantrums (Kazdin and Weisz
1998).
2.1
The Token Economy
An early example of work within the operant tradition
is the token economy, a system in which tokens (such
as poker chips or stickers) are given for desired
Behavior Therapy: Psychological Perspectives
behavior and can later be exchanged for pleasing items
and activities. Ayllon and Azrin (1968) set aside an
entire ward of a mental hospital for a series of
experiments in which rewards were provided for
activities such as making beds and combing hair, and
were not given when behavior was withdrawn or
bizarre. The patients, who averaged 16 years of
hospitalization, were systematically rewarded for their
ward work and self-care with plastic tokens that could
later be exchanged for special privileges, such as
listening to records, going to the movies, renting a
private room, or enjoying extra visits to the canteen.
The life of each patient was as much as possible
controlled by this regime.
The rules of a token economy—the medium of
exchange, the chores and self-care rewarded and by
what number of tokens, the items and privileges that
tokens—ar can be purchased and for how many
carefully established and usually posted so that the
patients can understand what the payoff is for behaving in a particular way. These regimes have
demonstrated how even markedly regressed adult
hospital patients can he significantly helped to achieve
more normal functioning by systematic manipulation
of reinforcement contingencies. The role of cognitive
factors, discussed below, was not formally acknowledged in the early operant conditioning work.
Token economy work demonstrates the positive
i mpact of directing staff attention to rewarding selfcare and recreational behaviors, and on the acquisition
of social skills, in contrast to the more typical situation
in which patients get attention more when they are
acting maladaptively and sometimes dangerously. The
beneficial effects of carefully constructed token economies have been shown to be markedly superior to
routine hospital management, including antipsychotic
drugs (Paul et al. 1997).
3.
Modeling
Modeling has also been used in behavior therapy (see
Social Cognitive Theory and Clinical Psychology). For
example, people can reduce their unrealistic fears by
watching both live and filmed encounters in which
others gradually approach and successfully confront
the things they are afraid of. Modeling is also part of
the treatment for children with autistic disorder,
helping them develop complex skills. Films depicting
actors having pleasurable sex have been used to help
sexually inhibited people overcome their discomfort
with sexuality and learn sexual techniques (see Sex
Therapy, Clinical Psychology of).
In an analogous fashion, some behavior therapists
use role-playing in the consulting room. Particularly
with patients who lack social skills, therapists demonstrate patterns of behaving that might prove more
effective than those in which the patients usually
engage and then have the patients practice them. In his
behavior rehearsal procedures, Lazarus (2000) demonstrates exemplary ways of handling a situation and
then encourages patients to imitate them during the
therapy session. For example, a student who does not
know how to ask a professor for an extension on a
term paper might watch the therapist portray a
potentially effective way of making the request. The
clinician would then help the student practice the new
skill. Similar procedures have helped patients with
schizophrenia acquire social skills to allow them to
deal more effectively with others, and with nonpsychotic patients to encourage greater assertiveness.
4.
Cognitive Behavior Therapy
There is nothing either good or bad, but thinking
makes it so.
(Hamlet, Act II, Scene 2)
The mind is its own place, and in itself
Can make a Heav'n of Hell, a Hell of Heav'n.
(Paradise Lost, line 247)
Behavior therapy initially eschewed any appeal to
cognitive processes (Wolpe 1958), perhaps as part of
efforts to distinguish it from insight-oriented therapies
like psychoanalysis and its many variations, as well as
humanistic and existential approaches. But it became
increasingly apparent in the mid to late 1960s that
an empirically-based understanding of therapeutic
change would be inadequate without formal inclusion of cognitive variables (Bandura 1969, Davison
1966, London 1964) (see Social Cognitive Theory and
Clinical Psychology).
One of the ways cognition entered into behavior
therapy was via research on modeling. The question
was how the observation of a model is translated into
changes in overt behavior. In his original writings on
modeling, Bandura asserted that an observer could
somehow learn new behavior by watching others.
Given the emphasis that much of experimental psychology places on learning through doing, this attention to learning without doing was important. But
it did not delineate the processes that could be
operating. A moment's reflection on the typical modeling experiment suggests the direction that theory and
research have taken.
The observer, a child, sits in a chair and watches a
film of another child making a number of movements,
such as hitting a large, inflated plastic doll in a highly
stereotyped manner, and hears the child in the film
uttering peculiar sounds. An hour later the youngster
is given the opportunity to imitate what was earlier
seen and heard. The child is able to do so, as common
sense and folk wisdom would predict. How can we
understand what happened? Since the child did not do
anything of interest in any motoric way while watching
the film, except perhaps fidget in the chair, it would not
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Behavior Therapy: Psychological Perspectives
be fruitful to look at overt behavior for a clue.
Obviously, the child's cognitive processes were engaged, including the ability to remember later on what
had happened. Data such as these led some behavioral
researchers and clinicians to include cognitive
variables in their analyses of psychopathology and
therapy.
4.1 Approaches to Cognitive Behavior Therapy
Cognitive behavior therapy (CBT) applies theory and
research on cognitive processes to alter cognition in
the interests of effecting favorable change in emotions
and behavior (see Cognitive Theory: ACT). CBT has
become a blend of the cognitive and behavioral
perspectives. Cognitive behavior therapists pay attention to private events—thoughts, perceptions, judgments, self-statements, and even tacit (unconscious)
assumptions—and have studied and manipulated
these processes in their attempts to understand and
modify overt and covert disturbed behavior. But they
do not neglect the behavioral factors reviewed above
that influence emotion, cognition, and overt behavior
(Bandura 1969).
4.1.1 Beck's cognitive therapy. The psychiatrist
Aaron Beck is one of the leading cognitive behavior
therapists. He developed a cognitive therapy for depression based on the idea that depressed mood is
caused by distortions in the way people perceive life
experiences (Beck 1976). For example, a depressed
person may focus exclusively on negative happenings
and ignore positive ones. Beck's therapy aims to persuade patients to change their opinions of themselves
and the way in which they interpret life events. For
example, when a depressed patient expresses feelings
that nothing ever goes right, the therapist uses
Socratic strategies to help the person identify
counter-examples. The general goal of Beck's therapy is to provide patients with experiences, both inside
and outside the consulting room, that will alter their
negative schemas, their general beliefs about themselves and their environment. This therapy has shown
its value, particularly in alleviating depression
(DeRubeis et al. 1999), but elements of Beck's
approach can be found as well in effective cognitive–
behavioral interventions for such problems as bulimia
nervosa, panic disorder (see especially Barlow et al.
2000), social phobia, and generalized anxiety disorder (see Clinical Psychology: Manual-based Treatment; Cognitive Therapy; Psychological Treatments,
Empirically Supported).
4.1.2 Ellis's rational–emotive behavior therapy.
Albert Ellis is another leading cognitive behavior
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therapist (see Behavior Psychotherapy: Rational and
Emotive). His principal thesis is that sustained
emotional reactions are caused by internal sentences
that people repeat to themselves and that these selfstatements reflect sometimes unspoken assumptions—
irrational beliefs—about what is necessary to lead a
meaningful life. In Ellis's rational emotive behavior
therapy (REBT) (Ellis 1962), the aim is to eliminate
self-defeating beliefs through a rational examination
of them. Anxious persons, for example, may create
their own problems by making unrealistic demands
on themselves or others, such as, '1 must win love
from everyone.' Ellis proposed that people interpret
what is happening around them, that sometimes
these interpretations can cause emotional turmoil,
and that a therapist's attention should be focused on
these beliefs rather than on historical causes or,
indeed, on overt behavior.
Ellis used to list a number of irrational beliefs that
people can harbor, such as the assumption that they
must be thoroughly competent in everything they do.
More recently, he has shifted from a cataloguing of
specific beliefs to the more general concept of
`demandingness,' that is, the musts or shoulds that
people impose on themselves and on others. Thus,
instead of wanting something to be a certain way, feeling disappointed, and then perhaps engaging in some
behavior that might bring about the desired outcome,
the person demands that it be so. It is this unrealistic,
unproductive demand, Ellis hypothesizes, that creates
the kind of emotional distress and behavioral dysfunction that bring people to therapists, and that
should be altered in order to create a more realistic,
less absolutistic approach to life's demands. Research
supports the value of REBT in alleviating a wide range
of anxiety-related problems, including interpersonal
performance anxiety, test anxiety, anger, and depression; and it may also be of use in a preventive way by
teaching children that their self-worth is not utterly
dependent on their endeavors.
4.1.3 Behavioral medicine. A wide range of cognitive–behavioral strategies have been applied with
success in a field called `behavioral medicine,'
defined as the study and application of empirically
supported techniques for the prevention and amelioration of physical problems (see Behavioral Medicine).
For example, relaxation training has been found effective in reducing blood pressure in borderline hypertension, possibly by lessening the anger that patients
experience when frustrated or provoked (see Hypertension: Psychosocial Aspects). Cognitive and behavioral interventions are useful also in encouraging
people, even older adults, to alter their lifestyle in
ways that contribute to better health and even to
help cancer patients cope with their illnesses and with
the pain associated with the treatment of them. There
is ever-increasing appreciation of the importance of
Behavior Therapy. Psychological Perspectives
psychological factors in encouraging people to adopt
healthier lifestyles, adhere to sometimes difficult treatment regimens, and to cope with negative emotions
that, if unchecked, can exacerbate the course of
a physical illness as well as affect the success of a
medical intervention (see Self-efficacy and Health).
4.2
Conceptual Issues in Cognitive Behavior
Therapy
Some criticisms of CBT should be noted. The concepts
on which it is based (e.g., schema) are somewhat
slippery and not always well-defined. Furthermore,
cognitive explanations of psychopathology do not
always explain much. For example, that a depressed
person has a negative schema tells us that the person
has a pessimistic outlook on things. But such a pattern
of thinking is actually part of the diagnosis of
depression. What is distinctive in the cognitive paradigm is that the thoughts are given casual status; that
is, the thoughts are regarded as causing the other
features of the disorder, such as profound sadness.
Left unanswered is the question of where the negative
schema came from in the first place, and to what extent
it creates negative emotion and maladaptive behavior
rather than being only a correlate of them.
Is the cognitive point of view basically different and
separate from the behavioral paradigm? Much of the
preceding discussion suggests that it is. But the
growing field of cognitive behavior therapy gives one
pause, for its workers study the complex interplay
of beliefs, expectations, perceptions, and attitudes on
the one hand, and overt behavior on the other. For
example, Albert Bandura (1977), a leading advocate of
the cognitive viewpoint, argues that different therapies
produce improvement by increasing people's sense of
self-efficacy, a belief that they can achieve desired
goals. But, at the same time, he argues that changing
behavior through behavioral techniques is the most
powerful way to enhance self-efficacy.
Therapists such as Ellis and Beck emphasize direct
alteration of cognitions through argument, persuasion, Socratic dialogue, and the like to bring about
i mprovements in emotion and behavior. Complicating
matters still further, Ellis, Beck, and their followers
also place considerable importance on homework
assignments that require clients to behave in ways in
which they have been unable to behave because they
are hindered by negative thoughts (see Cognitive Therapy). Indeed, one study failed to find added benefit
from the cognitive components of Beck's cognitive
therapy (CT) as compared with the behavioral components alone (Jacobson et al. 1996). Ellis even changed
the label for his approach from rational-emotive
therapy to rational-emotive behavior therapy in order
to highlight the importance of overt behavior. Therapists identified with cognitive behavior therapy work
at both the cognitive and behavioral levels, and most
of those who use cognitive concepts and try to change
beliefs with verbal means also use behavioral procedures to alter behavior directly.
This issue is reflected in the terminology used to
refer to people such as Beck and Ellis. Are they
cognitive therapists or cognitive behavior therapists?
The latter term is preferred by behavior therapists
because it denotes both that the therapist regards
cognitions as major determinants of emotion and
behavior and that he or she maintains the focus on
overt behavior that has always characterized behavior
therapy. Nonetheless, Beck, even though he assigns
many behavioral tasks as part of his therapy, is usually
referred to as the founder of cognitive therapy (CT),
and Ellis's rational-emotive therapy (RET) used to be
spoken of as something separate from behavior
therapy.
5.
Concluding Comment
Towards the end of the twentieth century, the increasing role of managed care in the United States—
entering the picture much later than in other Western
countries—made mental health professionals more
aware of the need to employ the best-validated and
most efficient interventions available. This greater
level of accountability is having a revolutionary effect
on who gets treated, for how long, and at what cost.
Not all patients are helped with behavioral and
cognitive-behavioral procedures, and the data are not
fully available as to what kinds of problems respond
better to such approaches than to others (such as
psychoanalytically oriented, humanistic/existential,
or drug and other somatic therapies). An advantage of
the approaches reviewed in this article is that they
possess a high degree of accountability: procedures are
clearly spelled out, links to the science of behavior
change are a defining characteristic, and evaluations
of outcome are routine. These features of behavioral
and cognitive therapies would seem to bode well for
the continuing development of more and better interventions, to the benefit both of the science and the
profession as well as the communities that are served.
See also: Behavior Therapy: Psychiatric Aspects;
Behavior Therapy with Children; Cognitive and
Interpersonal Therapy: Psychiatric Aspects; Cognitive Therapy; Operant Conditioning and Clinical
Psychology
Bibliography
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Bandura A 1969 Principles of Behavior Modification. Holt,
Rinehart & Winston, New York
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Behavior Therapy: Psychological Perspectives
Bandura A 1977 Self-efficacy: Toward a unifying theory of
behavioral change. Psychological Review 84: 191-215
Barlow D H, Gorman J M, Shear M K, Woods S W 2000
Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial.
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Beck A T 1976 Cognitive Therapy and the Emotional Di orders.
International Universities Press, New York
Davison G C 1966 Differential relaxation and cognitive restructuring in therapy with a 'paranoid schizophrenic' or 'paranoid
sound and empirically validated, and (3) application
of such principles and procedures to adjustment
Olendick problems of children and adolescents' (
1986). Presented here is an overview of the historical
roots of child behavior therapy, an explication of key
concepts underlying the approach, and examples of
classic and contemporary uses of behavior therapy
with children.
state.' Proceedings of the 74th Annual Convention of the
American Psychological
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Davison G C 1968 Systematic desensitization as a counterconditioning process. Journal of Abnormal Psychology 73:
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DeRubeis R J, Helfand L A, Tang T Z, Simons A D 1999
Medications vs. cognitive behavioral therapy for several
depressed outpatients: A mega-analysis of four randomized
comparisons. American Journal of Psychiatry 15: 1007-13
Ellis A 1962 Reason and Emotion in Psychotherapy. Lyle Stuart,
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Consulting and Clinical Psychology 66: 19-36
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G. C. Davison
Behavior Therapy with Children
Child behavior therapy, including behavior modification and cognitive therapy, consists of a group of
diverse but related scientifically-based approaches to
the assessment and treatment of children experiencing
behavioral and emotional difficulties. Although contemporary behavior therapy with children is characterized by a plurality of viewpoints, techniques, and
theoretical rationales, a distillation of these differing
perspectives reveals several common features that
define the essence of child behavior therapy. These
features include `(1) principles of behavioral psychology, most notably principles of learning, (2) use of
strategies or procedures that are methodologically
1.
Historical Roots
The historical roots of child behavior therapy can be
traced to the work of John B. Watson, a key figure in
the rise of behaviorism in America during the early
1900s. Watson, who rejected the trends of the time
emphasizing mentalistic causes of behavior, maintained that learning processes were the basis of all
human behavior. In perhaps the first historical antecedent to modern behavior therapy, one of Watson's
students, Mary Cover Jones, applied classical conditioning principles to alleviate a young boy's intense
fear of rabbits, by rewarding an incompatible response
to fear, and using successive approximations to introduce the rabbit (Jones 1924) (see Classical Conditioning and Clinical Psychology).
With the exception of a few isolated examples, such
as the classic `bell and pad' method of treating
nocturnal enuresis (bedwetting) (Mowrer and Mowrer
1938), there was a lag of some 30 years before interest
in behavioral approaches in the treatment of children
re-emerged in psychology. This resurgence was precipitated in large part by discontent with psychoanalysis, the prevailing therapeutic model of the day.
Institutional settings in which developmentally delayed children often resided provided the ideal, tightly
controlled environments in which to evaluate emergent behavioral treatments. In most cases, early behavioral techniques were developed in animal laboratories by experimental psychologists with the objective
of demonstrating the utility of applying specific
learning principles to rather circumscribed child behavioral symptoms (Mash 1998).
During the 1960s, behavior therapy relied primarily
upon operant conditioning procedures, the principles
of which had been pioneered by B. F. Skinner in the
1940s (see Operant Conditioning and Clinical Psychology. These approaches were used successfully with
developmentally delayed children in institutional settings. Lovaas and Simmons (1969), for example, were
able dramatically to improve the behavior of autistic
children by applying operant learning principles to
manipulate the environmental antecedents and consequences of behavior. In the 1960s and 1970s, behavior
therapy was extended to school settings where it was
applied to classroom misbehavior. Through this work
it was found that ignoring disruptive behavior, while
reinforcing positive behavior through praise (or atten-
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Copyright © 2001 Elsevier Science Ltd. All rights reserved.
International Encyclopedia of the Social & Behavioral Sciences
ISBN: 0-08-043076-7