The most famous baby in the history of psychology is probably Little Albert. At the age of 11 months, Albert developed an intense fear of rats while participating in a classic study conducted by John B. Watson and Rosalie Rayner (1920). You would hope the researchers did something to reverse the effects of their ethically questionable experiment, that is, help Albert overcome his fear of rats. As far as we know, they did not. But could Albert have benefited from some form of behavior therapy?

LO 6 Outline the principles and characteristics of behavior therapy.

Using the learning principles of classical conditioning, operant conditioning, and observational learning (Chapter 5), behavior therapy aims to replace maladaptive behaviors with those that are more adaptive. If behaviors are learned, who says they can’t be changed through the same mechanisms? Little Albert learned to fear rats, so perhaps he could also learn to be comfortable around them.

EXPOSURE AND RESPONSE PREVENTION To help a person overcome a fear or phobia, a behavior therapist might use exposure, a technique of placing clients in the situations they fear—without any actual risks involved. Take, for example, a client struggling with a rat phobia. Rats cause this person extreme anxiety; the mere thought of seeing one scamper beneath a dumpster causes considerable distress. The client usually goes to great lengths to avoid the rodents, and this makes his anxiety drop. The reduced anxiety (and the satisfaction associated with it) will negatively reinforce his avoidance behavior. With exposure therapy, the therapist might arrange for the client to be in a room with a very friendly pet rat. After a positive experience with the animal, the client’s anxiety diminishes (along with his efforts to avoid it), and he learns the situation does not have to be anxiety-provoking. Ideally, both the anxiety and the avoidance behavior are extinguished. This process of stamping out learned associations is called extinction. The theory behind this response prevention technique is that if you encourage someone to confront a feared object or situation, and prevent him from responding the way he normally does, the fear response eventually diminishes or disappears.

A particularly intense form of exposure is to flood a client with an anxiety-provoking stimulus that she cannot escape, causing a high degree of arousal. In one study, for example, women with snake phobias sat in very close proximity to a garter snake in a glass aquarium for 30 minutes without a break (Girodo & Henry, 1976).

But sometimes, it’s better to approach a feared scenario with “baby steps,” upping the exposure with each movement forward (Prochaska & Norcross, 2014). This can be accomplished with an anxiety hierarchy, which is essentially a list of activities or experiences ordered from least to most anxiety-provoking (Infographic 13.2). For example, Step 1: Think about a caged rat; Step 2: Look at a caged rat from across the room; Step 3: Walk two steps toward the cage, and so on.

INFOGRAPHIC 13.2

INFOGRAPHIC 13.2

Credits: Pill bottle, Joe Belanger/Shutterstock; Pint of beer, Emin Ozkan/Shutterstock; Syringe, istockphoto/thinkstock

But take note: Working up the anxiety hierarchy needn’t involve actual rodents. With technologies available today, you could put on some fancy goggles and travel into a virtual “rat world” where it is possible to reach out and “touch” that creepy crawly animal with the simple click of a rat, er . . . mouse. Virtual reality exposure therapy has become a popular way of reducing anxiety associated with various disorders, including specific phobias.

SYSTEMATIC DESENSITIZATION Therapists often combine anxiety hierarchies with relaxation techniques in an approach called systematic desensitization, which takes advantage of the fact that we can’t be relaxed and anxious at the same time. The therapist begins by teaching clients how to relax their muscles. One technique for doing this is progressive muscle relaxation, which is the process of tensing and then relaxing muscle groups, starting at the head and ending at the toes. Using this method, a client can learn to release all the tension in his body. It’s very simple—want to try it?

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Once a client has learned how to relax, it’s time to face the anxiety hierarchy (either in the real world or via imagination) while trying to maintain a sense of calm. Imagine a client who fears flying, moving through an anxiety hierarchy with her therapist. Starting with the least-feared scenario at the bottom of her hierarchy, she imagines purchasing a ticket online. If she can stay relaxed through the first step, then she moves to the second item in the hierarchy, thinking about boarding a plane. At some point in the process, she might start to feel jittery or unable to take the next step. If this happens, the therapist guides her back a step or two in the hierarchy, or as many steps as she needs to feel calm again, using the relaxation technique described above. Then it’s back up the hierarchy she goes. It’s important to note that this process does not happen in one session, but over the course of many sessions.

AVERSION THERAPY Exposure therapy focuses on extinguishing or eliminating associations, but there is another behavior therapy aimed at producing them. It’s called aversion therapy. Seizing on the power of classical conditioning, aversion therapy seeks to link problematic behaviors, such as drug use or fetishes, to unpleasant physical reactions like sickness and pain (Infographic 13.2). The goal of aversion therapy is to get a person to have an involuntary—and unpleasant—physical reaction to an undesirable behavior, so that the behavior eventually becomes a conditioned stimulus to the conditioned response of feeling bad. A good example is the drug Antabuse, which has helped some people with alcoholism stop drinking, at least temporarily (Cannon, Baker, Gino, & Nathan, 1986; Gaval-Cruz & Weinshenker, 2009). Antabuse interferes with the body’s ability to break down alcohol, so combining it with even a small amount of alcohol brings on an immediate unpleasant reaction (vomiting, throbbing headache, and so on). With repeated pairings of alcohol consumption and physical misery, drinkers are less inclined to drink in the future. But aversion therapies like this are only effective if the client is motivated to change and comply with treatment.

LEARNING, REINFORCEMENT, AND THERAPY Another form of behavior therapy is behavior modification, which draws on the principles of operant conditioning, shaping behaviors through reinforcement. Therapists practicing behavior modification use positive and negative reinforcement, as well as punishment, to help clients increase adaptive behaviors and reduce those that are maladaptive. For behaviors that resist modification, therapists might use successive approximations by reinforcing incremental changes. Some will incorporate observational learning (that is, learning by watching and imitating others) to help clients change their behaviors.

One common approach using behavior modification is the token economy, which harnesses the power of positive reinforcement to encourage good behavior. Token economies have proven successful for a variety of populations, including psychiatric patients in residential treatment facilities and hospitals, children in classrooms, and convicts in prisons (Dickerson, Tenhula, & Green-Paden, 2005; Kazdin, 1982). In a residential treatment facility, for example, patients with schizophrenia may earn tokens for socializing with each other, cleaning up after themselves, and eating their meals. Tokens can be exchanged for candy, outings, privileges, and other perks. They can also be taken away as a punishment to reduce undesirable behaviors. Critics contend that token economies manipulate and humiliate the people they intend to help (you might agree that giving grown men and women play money for good behavior is degrading). But, from a practical standpoint, these systems can help people adopt healthier behaviors.

TAKING STOCK: AN APPRAISAL OF BEHAVIOR THERAPY Because of their focus on observable behaviors occurring in the present moment, behavior therapies offer a few key advantages over insight therapies. Behavior therapies tend to work fast, producing quick resolutions to stressful situations, sometimes in a single session (Ollendick et al., 2009; Öst, 1989). And reduced time in therapy typically translates to a lower cost. What’s more, the procedures used in behavior therapy are often easy to operationalize (remember, the focus is on modifying observable behavior), so evaluating the outcome is more straightforward.

Behavior therapy has its drawbacks, of course. The goal is to change learned behaviors, but not all behaviors are learned (you can’t “learn” to have hallucinations). And because the reinforcement comes from an external source, newly learned behaviors may disappear when reinforcement stops. Finally, the emphasis on observable behavior may downplay the social, biological, and cognitive roots of psychological disorders. This narrow approach works well for treating phobias and other clear-cut behavior problems, but not as well for addressing far-reaching, complex issues arising from disorders such as schizophrenia.

LO 7 Outline the principles and characteristics of cognitive therapy.

Dr. Foster has identified his client’s maladaptive thoughts and is beginning to help her change the way she views her world and her relationships. This is the basic goal of cognitive therapy, an approach advanced by psychiatrist Aaron Beck (1921–).

BECK’S COGNITIVE THERAPY Beck was trained in psychoanalysis, but he opted to develop his own approach after trying (without luck) to produce scientific evidence showing that Freud’s methods worked (Beck & Weishaar, 2014). Beck believes that patterns of automatic thoughts are at the root of psychological disturbances. These distortions in thinking cause individuals to misinterpret events in their lives (Table 13.2).

Beck identified a collection of common cognitive distortions or errors associated with psychological problems such as depression (Beck, Rush, Shaw, & Emory, 1979). One such distortion is overgeneralization, or thinking that self-contained events will have major repercussions in life (Prochaska & Norcross, 2014). For example, a person may assume that just because something is true under one set of circumstances, it will be true in all others (I have had difficulty working for a male boss, so I will never be able to work effectively under a male supervisor). Another cognitive distortion is dichotomous thinking, or seeing things in extremes (I can either be a good student, or I can have a social life). One goal of cognitive therapy then is to help clients recognize and challenge these cognitive errors.

Beck suggests that cognitive schemas underlie these patterns of automatic thoughts, directing the way we interpret events. The goal is to restructure these schemas into more rational frameworks, a process that can be facilitated by client homework. For example, the therapist may challenge a client to test a “hypothesis” related to her dysfunctional thinking. (“If it’s true you don’t work effectively under male bosses, then why did your previous boss give you that highly sought-after promotion?”) Client homework is an important component of cognitive therapy. So, too, is psychoeducation, which might include providing resources that help clients understand their disorders and thus adopt more realistic attitudes and expectations.

Beck’s cognitive therapy aims to dismantle or take apart the mental frameworks harboring cognitive errors and replace them with beliefs that nurture more positive, realistic thoughts. Dr. Foster calls these mental frameworks “paradigms,” and he also tries to create a more holistic change in thinking. “I tell people that thoughts, behaviors, and words come from beliefs, and when a belief is not working for you, let’s change it,” he says. “To modify a belief doesn’t mean all or none,” he adds, “but when we outgrow a belief, that’s a wonderful time for transformation.”

ELLIS’ RATIONAL EMOTIVE BEHAVIOR THERAPY The other major figure in cognitive therapy is psychologist Albert Ellis (1913–2007). Like Beck, Ellis was trained in psychoanalysis but was disappointed by its results, so he created his own treatment approach: rational emotive behavior therapy (REBT). The goal of REBT is to help people identify their irrational or illogical thoughts and convert them into rational ones. An REBT therapist uses the ABC model to understand a client’s problems. Point A represents an Activating event in the client’s life (“My boss fired me”); point B stands for the irrational Beliefs that follow (“I will never be able to hold a steady job”); and point C represents the emotional Consequences (“I feel hopeless and depressed”). Therapy focuses on addressing point B, the irrational beliefs causing distress. If all goes well, the client successfully reaches point D: Disputing flawed beliefs (“Losing one job does not spell the end of my career”), and that leads to point E: an Effective new philosophy (“I am capable of being successful in another job”), a mature and realistic perspective on life (Ellis & Dryden, 1997; Figure 13.2).

According to Ellis, people tend to have unrealistic beliefs, often perfectionist in nature, about how they and others should think and act. This inevitably leads to disappointment, as no one is perfect. The ultimate goal of REBT is to arrive at self-acceptance, that is, to change these irrational thoughts to realistic ones. This often involves letting go of the “I shoulds” and “I musts,” what Ellis called “musturbatory thinking” (Prochaska & Norcross, 2014, p. 266). Through REBT, one develops a rational way of thinking that helps reduce suffering and amplify enjoyment: “The purpose of life,” as Ellis was known to say, “is to have a $&%#@ good time” (p. 263). Ellis took a hard line with clients, forcefully challenging them to provide evidence for their irrational ideas and often shocking people with his direct manner (Kaufman, 2007, July 25; Prochaska & Norcross, 2014).

As Ellis developed his therapy throughout the years, he realized it was important to focus on cognitive processing as well as behavior. Thus, REBT therapists focus on changing both cognitions and behaviors, assigning homework to implement the insights clients gain during therapy. Because Ellis and Beck incorporated both cognitive and behavior therapy methods, their approaches are commonly referred to as cognitive behavioral therapy. Both are action-oriented, as they require clients to confront and resist their illogical thinking.

TAKING STOCK: AN APPRAISAL OF COGNITIVE THERAPY There is considerable overlap between the approaches of Ellis and Beck. Both are short-term (usually no more than about 20 one-hour sessions), action-oriented, and homework-intensive. In some instances, cognitive therapy has been found to be more successful than relaxation and exposure therapy in treating certain disorders, such as social phobia and generalized anxiety disorder (Clark et al., 2006; Dugas et al., 2010). If you compare the effectiveness of Beck’s and Ellis’ approaches, you will find some studies showing greater support for Beck’s cognitive therapy. But this advantage is only apparent with certain client characteristics and problems, such as pathological gambling and chronic pain (Prochaska & Norcross, 2014).

In some cases, cognitive models that focus on flawed assumptions and attitudes present a chicken-and-egg problem. People experiencing depression often have distorted beliefs, but are distorted beliefs causing their depression or is depression causing their distorted beliefs? Perhaps it is a combination of both.

All the therapies we have discussed thus far involve interactions among people. But in many cases, interpersonal therapy is not enough. The problem is rooted in the brain, and a biological solution may also be necessary.

Question 1

1. behavior

2. person-centered

3. humanistic

4. psychodynamic

Question 2

Question 3

Question 4

1. Behavior

2. Psychodynamic

3. Exposure

4. Rational emotive behavior