The constructivist perspective in cognitive therapy holds that

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Psychotherapy Theory Paper(Psychology Major Please)

For each theory discussed you will submit a paper with the following sections:

I. Brief 3 or more sentences summary of theory

II. Brief descriptions of major tenets of the theory (3 or more sentences per tenet)

III. Brief descriptions of common techniques of the theory (3 or more sentences per technique)

IV. Personal reflection/reaction to the theory (2 paragraphs)

V. Questions about the theory or its implementation (2 questions)

Electronic edition published 2014. ISBN: 978-1-4338-1620-8 (electronic edition).

Published by American Psychological Association 750 First Street, NE Washington, DC 20002 www.apa.org

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In the U.K., Europe, Africa, and the Middle East, copies may be ordered from American Psychological Association 3 Henrietta Street Covent Garden, London WC2E 8LU England

Cover Designer: Mercury Publishing Services, Inc., Rockville, MD

The opinions and statements published are the responsibility of the authors, and such opinions and statements do not necessarily represent the policies of the American Psychological Association.

Library of Congress Cataloging-in-Publication Data

Psychotherapy theories and techniques : a reader / edited by Gary R. VandenBos, Edward Meidenbauer, and Julia Frank-McNeil. — First edition. pages cm Includes bibliographical references. ISBN 978-1-4338-1619-2 — ISBN 1-4338-1619-9 1. Psychotherapy. 2. 

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Psychotherapy—Philosophy. 3. Psychotherapy—Methodology. I. VandenBos, Gary R., editor of compilation. II. Meidenbauer, Edward, editor of compilation. III. Frank- McNeil, Julia, editor of compilation. RC480.5.P785 2014 616.89'14—dc23

2013020747

British Library Cataloguing-in-Publication Data

A CIP record is available from the British Library.

First Edition

http://dx.doi.org/10.1037/14295-000

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http://dx.doi.org/10.1037/14295-000
CONTENTS

Preface

How to Use This Book With PsycTHERAPY, APA’s Database of Psychotherapy Demonstration Videos

Chapter 1.  Acceptance and Commitment Therapy Steven C. Hayes and Jason Lillis

Chapter 2.  Acceptance and Commitment Therapy Process Steven C. Hayes and Jason Lillis

Chapter 3.  Behavior Therapy Martin M. Antony and Lizabeth Roemer

Chapter 4.  Behavior Therapy Process Martin M. Antony and Lizabeth Roemer

Chapter 5.  Brief Dynamic Therapy Hanna Levenson

Chapter 6.  Brief Dynamic Therapy Process Hanna Levenson

Chapter 7.  Cognitive Therapy Keith S. Dobson

Chapter 8.  Cognitive Therapy Process Keith S. Dobson

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Chapter 9.  Cognitive–Behavioral Therapy Michelle G. Craske

Chapter 10.  Cognitive–Behavioral Therapy Process Michelle G. Craske

Chapter 11.  Constructivist Therapy Vittorio F. Guidano

Chapter 12.  Constructivist Therapy Process Greg J. Neimeyer

Chapter 13.  Emotion-Focused Therapy Leslie S. Greenberg

Chapter 14.  Emotion-Focused Therapy Process Leslie S. Greenberg

Chapter 15.  Existential Therapy Kirk J. Schneider and Orah T. Krug

Chapter 16.  Existential Therapy Process Kirk J. Schneider and Orah T. Krug

Chapter 17.  Family Therapy William J. Doherty and Susan H. McDaniel

Chapter 18.  Family Therapy Process William J. Doherty and Susan H. McDaniel

Chapter 19.  Feminist Therapy Laura S. Brown

Chapter 20.  Feminist Therapy Process Laura S. Brown

Chapter 21.  Gestalt Therapy Derek Truscott

Chapter 22.  Gestalt Therapy Process Uwe Strümpfel and Rhonda Goldman

Chapter 23.  Multicultural Therapy Lillian Comas-Díaz

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Chapter 24.  Multicultural Therapy Process Lillian Comas-Díaz

Chapter 25.  Narrative Therapy Stephen Madigan

Chapter 26.  Narrative Therapy Process Stephen Madigan

Chapter 27.  Person-Centered Therapy David J. Cain

Chapter 28.  Person-Centered Therapy Process David J. Cain

Chapter 29.  Psychoanalytic Therapy Jeremy D. Safran

Chapter 30.  Psychoanalytic Therapy Process Jeremy D. Safran

Chapter 31.  Rational Emotive Behavior Therapy Albert Ellis and Debbie Joffe Ellis

Chapter 32.  Rational Emotive Behavior Therapy Process Albert Ellis and Debbie Joffe Ellis

Chapter 33.  Reality Therapy Robert E. Wubbolding

Chapter 34.  Reality Therapy Process Robert E. Wubbolding

Chapter 35.  Relational–Cultural Therapy Judith V. Jordan

Chapter 36.  Relational–Cultural Therapy Process Judith V. Jordan

Chapter 37.  Schema Therapy Lawrence P. Riso and Carolina McBride

Chapter 38.  Schema Therapy Process Lawrence P. Riso, Rachel E. Maddux and Noelle Turini Santorelli

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PREFACE

Whether you are a student in a clinical training program or a seasoned practitioner, you may find it difficult to grasp the full range of psychotherapy theories or to become even partially acquainted with the plethora of associated techniques. My hope is that this book will be of assistance. This is a reader—a compendium of excerpts of previously published work. We chose to create this reader to provide access to some of the best writing the American Psychological Association (APA) has published on clinical theories and techniques in psychotherapy. The book surveys the great variety of orientations practiced today and provides not a complete explanation of each but rather a glimpse of these orientations at their richest—neither distilled into pat definitions nor tidily packaged into bullet points and takeaway phrases. Instead, short encounters with the best writing on each approach, afford the reader a look at the way psychotherapy is practiced today.

For every psychotherapeutic approach we have included an excerpt on theory and an excerpt on the therapeutic process. At the end of the excerpt on the therapy process we have included a list of techniques associated with that approach to therapy. Some of these techniques appear in the excerpts; others do not appear there. All are well-known interventions used by practitioners of the orientation in question.

In addition, we have provided guidance on where to find video examples of the techniques in our database of psychotherapy

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demonstrations, PsycTHERAPY. Although PsycTHERAPY is a product quite different from the individual videos in the APA Psychotherapy Video Series, it was created for the same purpose: training and educating psychotherapists. Just as the APA Psychotherapy Video Series has its companion books—from The Anatomy of Psychotherapy: Viewer’s Guide to the APA Psychotherapy Videotape Series to the more recent Exploring Three Approaches to Psychotherapy—this book may be considered as a companion to PsycTHERAPY.

Readers will find that viewing the video clips listed in the chapter appendixes will augment the glimpse into psychotherapy practice provided by the text excerpts. APA created its various psychotherapy video products because there is no better way to demonstrate the timing, the look, the feel of a technique than to capture it in video. In one way, the excerpts and the video clips may be seen as serving the same purpose. That is, just as we have captured a segment of our best writing on theory and technique in this book, we have also captured segments of our videos that best demonstrate some of the techniques for each of these theories. The technique lists are a road map to finding these video clips.

Psychotherapy Theories and Techniques may be enjoyed on its own, without the use of the videos, as an overview and introduction to the many psychotherapies that exist today. The technique lists will be useful in that they neatly identify the key techniques associated with each approach. Our recommendation is to use the book in combination with PsycTHERAPY by first reading the excerpts for each approach and then viewing all of the associated video clips. This will give a vivid introduction to each orientation—not a full one, not one meant to provide the background necessary to take up practice of the approach—but certainly enough of an introduction to get a good sense of what each of these orientations is about.

Observant readers will notice that many of the excerpts in this volume come from chapters in the APA Theories of Psychotherapy book series. If the writing intrigues you, I suggest going to the original books themselves to read more, as they provide a succinct introduction to the history, theory, and therapeutic process of the major approaches. Whatever further reading

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this volume inspires, my hope is that Psychotherapy Theories and Techniques: A Reader will provide a glimpse of the breadth, depth, and richness of psychotherapy as it is practiced today.

Gary R. VandenBos, PhD APA Publisher

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HOW TO USE THIS BOOK WITH PSYCTHERAPY, APA’S DATABASE OF

PSYCHOTHERAPY DEMONSTRATION VIDEOS

Psychotherapy Theories and Techniques: A Reader contains 38 chapters, each made up of an excerpt from previously published work from the American Psychological Association (APA). The chapters are paired up: The first chapter in each pair is an excerpt on a psychotherapy theory, and the second chapter is on psychotherapy technique. After the second chapter in each pair, there is an appendix of techniques associated with the approach discussed in that pair of chapters.

The appendices contain not only the list of techniques but also information about where to find a video example of those techniques in PsycTHERAPY, APA’s premier database of psychotherapy demonstration videos. PsycTHERAPY contains hundreds of streaming videos of therapy demonstrations, each approximately 45 minutes long. All of the videos in PsycTHERAPY have been carefully tagged with metadata, making the videos findable by therapist, approach, therapy topic, and index terms. In addition, each video has been transcribed, and the transcripts may be searched as well. None of the videos appear in the APA Psychotherapy Video Series, but they were created in conjunction with that series.

The chapter appendices contain the following information for each technique as well as where to find it in PsycTHERAPY:

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1. Technique name 2. Video title: the video in which the technique appears 3. Video identifying number: A 12-digit number uniquely identifying the

video in PsycTHERAPY 4. Time at which technique occurs: The beginning and end times for when

exactly the technique is demonstrated in the video

To locate a technique in PsycTHERAPY, use the following steps:

1. Open PsycTHERAPY in your browser (http://psyctherapy.apa.org). 2. Accept the disclaimer terms. 3. Enter the video identifying number in the Quick Search box in the

upper right (alternatively, enter the video title in this search box). 4. Click “Go.” This will bring you to the search result page, where the

video should appear. 5. Open the video page. Click on the “Clips” tab above the transcript

pane. 6. A clip with the name of the technique will be provided here.

Rather than searching for the video for each technique, it may be easier to simply find the playlist associated with a given list of techniques. For each list of techniques, there is a playlist in PsycTHERAPY that collects all of the video clips of these techniques in one place. To locate a playlist of all of the technique demonstrations in an appendix, use the following steps:

1. Open PsycTHERAPY in your browser (http://psyctherapy.apa.org) and accept the disclaimer terms.

2. Click on “Playlists” in the blue navigation bar at the top of the screen. 3. There will be a featured playlist for every one of the approaches in the

Psychotherapy Theories and Techniques book. 4. Click on the playlist you are looking for (e.g., “Behavioral Therapy

Techniques”). 5. Click “Play All Items” or click on an individual title in the playlist to

go directly to that technique clip.

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http://psyctherapy.apa.org
http://psyctherapy.apa.org
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1 ACCEPTANCE AND COMMITMENT THERAPY

STEVEN C. HAYES AND JASON LILLIS

The goal of acceptance and commitment therapy (ACT) is the creation of psychological flexibility. The psychological flexibility model underneath ACT emphasizes six specific processes that promote psychopathology and needless human limitation, and six related processes that promote psychological health and human flourishing.

PSYCHOLOGICAL FLEXIBILITY

Psychological flexibility is the process of contacting the present moment fully as a conscious human being and persisting or changing behavior in the service of chosen values. That skill is argued to be composed of the following processes.

Cognitive Fusion Versus Defusion

If thinking is learned and regulated by arbitrary stimuli, it will always be difficult, if not impossible, to fully eliminate thoughts we do not like. There is no process called unlearning, and it is hard to eliminate all the cues for certain thoughts. Indeed, trying to do so creates such cues (Wenzlaff & Wegner, 2000). If a client with obsessive–compulsive

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disorder tries hard not to think of a disturbing image, for example, the frequency of that image is almost certain to increase, as all of the various distraction cues used become related to the very image being avoided and begin to evoke it.

In relational frame theory (RFT), some contextual cues regulate the emergence of relationships between events, but other cues regulate the functions of related events. ACT tends to emphasize interventions that change the functional context, not the relational context.

Suppose a person learns that another name for a favorite candy is “jumjaw.” Even a single exposure to that training could establish a mutual relation between these two events that may last a lifetime. But that is only half the story. It is possible to undermine the automatic functions of cognitive relations by altering the functional context. We do that in ordinary ways when we, for example, imagine tasting a jumjaw versus looking at one, but this insight from RFT can be used to clinical effect by changing the literal context of thoughts. Suppose a person is struggling with food urges that revolve around the thought “I want a jumjaw.” We might diminish the behavioral impact of that thought by saying it aloud in the voice of Donald Duck, or repeating the word jumjaw out loud until it loses all meaning, or noting that “I am having the thought I want a jumjaw” (this is called word repletion). These functional changes are arguably easier and more reliable than the difficult work of changing the occurrence of thoughts. ACT takes advantage of this insight and focuses particularly on the alternation of functional contexts that determine the behavioral impact of verbal/cognitive events.

Cognitive Fusion

Cognitive fusion (or what we will often just call fusion for short) is a process in which verbal events have a strong behavioral impact beyond other sources of regulation because they occur in a context of literal meaning. In some external situations, fusion with thought is not harmful to human functioning. A person trying to repair a broken bicycle needs to understand cognitively what is broken and how to fix it; being

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continuously aware of the process of thinking, in order to increase the psychological distance between the person and his or her thoughts, would likely not add to the effectiveness of this process. Suppose it is clear on inspection that a chain link is damaged. Thinking “I’m having the thought that the chain link is damaged,” would be of little help. The chain is damaged. Judgments about why it is damaged will likely help fix it.

That picture changes dramatically when the focus of what is being addressed is not amenable to problem solving. A person who is suffering is not like a bicycle with a broken chain. The emotions and thoughts being struggled with are historical. Some are deeply conditioned, and those aspects of history will not be changed. In such circumstances, ACT practitioners are likely to try to change the functions of experiences rather than their occurrence. Cognitive defusion is a classic method of that kind. We will examine this in a somewhat extended example.

Imagine a person who feels insecure, guilt-ridden, and self-critical. Decades earlier, her mother was very demanding and tried to motivate more attention from her daughter by using criticism and blame. Hayes (2009) shows a client in exactly that situation. We use another client as an example here. We refer to her throughout by the name “Sarah.” The transcript entries for Sarah in this volume are edited for clarity, space, and confidentiality, but the actual word-for-word interactions can be seen on the DVD.1

Sarah was seen by Steve Hayes in 2008. Sarah is in her early 60s and is returning to therapy. She has chronic health problems due to lung disease. She helps care for her elderly mother, and the relationship is very conflicted. Her mother has always been extremely demanding and critical:

Sarah: Her standards for “if you love me”—well, she has criteria. “If you love me, you’d ____.”

Therapist: Right, and then there is a list.

Sarah: And I can do nice things for her, and she notices them, but it’s still not enough. You should never say no. You should never say, “I’ve gotta go.” You should always be there to do whatever she wants.

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This is not a new pattern. It turns out that even as a young child, Sarah constantly heard, as she put it, “‘This should be this and this should be that.’” Sarah observes, “It impressed me that my mother was full of ‘shoulds.’” The pressure to conform and to serve her mother’s needs went all the way up to such judgmental and critical statements as, “and you call yourself a Christian.”

The result of this history is that it is hard to set reasonable limits without feeling bad about it:

Sarah: I feel bad if I’m not concerned about what my mother needs for her happiness. And so this is kind of painful. I go over here, “But I wanna be a good Christian, I wanna be, you know, good to my mother and love her,” but then I’m not responsible for making all of her moments happy. So it feels like a heavy burden.

Therapist: Yeah. Even as you say it, you kind of winced.

Sarah: And even, you know, I got caller ID so I can see when it was her. So that way if I didn’t think I could emotionally handle it, I just wouldn’t. But even now every time her name comes up on the caller ID, I have feelings. I feel overburdened.

Therapist: And sometimes when you don’t answer and she’s called?

Sarah: You know what? I don’t do that so much because I still do it to myself. Then I’m thinking, “Oh, what if this time it was something really important?” I’ve had to deal with a lot of guilt.

Fusion with judgment and self-criticism is extremely painful, but worse than that, it pulls for ineffective actions. Let’s apply the same mode of mind to this situation as one might apply to the broken bicycle. The indication that something is broken is the emotional result of the history we have been describing (e.g., “I feel a heavy burden” or “I feel a lot of guilt”). The broken link in the chain is like the negative self-judgment that leads to guilt and an inability to set reasonable limits. This pattern is

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historical—she was taught to do it. During the session, the client realized how she too often “goes with the shoulds”—directed at herself and her mother. In one of these moments, she declared, “That’s scary. The very thing you have hated in someone else, then you start becoming that.”

The problem is that, as the person tries to fix the “broken bicycle” of their own history, this very effort can amplify the thoughts and feelings this history produces. It is easy to end up in the paradoxical and unworkable situation of trying judgmentally to eliminate judgment (“I shouldn’t say should!”). Difficult thoughts can become even more central. Real behavior change can be put on hold while a war within is fought. Sarah knows this:

Therapist: If you start arguing with them logically, difficult thoughts and feelings can become even more central.

Sarah: I know! Isn’t that something?!

In an ACT model, the problem is not automatic thoughts. It’s that there is no distance between the person and predictions, judgments, and interpretations. Fusion itself is the problem. Fusion then restricts the ability to be moved by contact with direct experience. This exchange shows the process clearly:

Therapist: And when it’s happening, when these thoughts—these “should” thoughts—get going, are they up here, right on you? [Therapist holds his hand right in front of his face.] Or are they sort of out there? [Therapist holds his hand a couple of feet away from his face.]

Sarah: No, they’re right up there on me.

Therapist: They’re right up on you.

Sarah: Almost like I can’t breathe.

Therapist: Almost like you can’t . . . Oh, yeah.

Sarah: And when I’m talking to her on the phone like that she can be telling me something interesting and I still don’t wanna talk to her. I mean I don’t hate her, but her voice and her

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mannerisms annoy me.

The effects of fusion as seen in this case are typical. Fusion feeds a problem-solving mode of mind, but treating our inner life that way turns life from a process to be experienced into a problem to be solved.

Defusion

In ACT, therapy itself is viewed as a different context for verbal/cognitive events; the goal is to establish a verbal community that changes how the client interacts with or relates to thoughts, feelings, and bodily sensations. The main goal is to undermine the excessive literal quality of evaluations and judgments and to relate to them instead as merely aspects of ongoing experience. That is the essence of defusion. Exercises, metaphors, and other methods are used to help the client to be able to see that a thought is more like a coffee cup than a lens; that is, it is something one can look at, not merely look from. In that posture, thoughts need not regulate actions other than mere noticing. They can, if they are helpful, or not, if they are not. The issue is workability toward a goal, not literal “truth.”

Let’s return to Sarah and show a method for how thoughts can be looked at, not from.

Therapist: So let’s just see if we could sort of take some of that burden off without having to take off the programming. Like, let’s just look at how easy it is to get things programmed. If you’ve got this judgmental critical streak going, sometimes you probably even hear these words in your mother’s voice, and I bet you they are so deeply in your head that . . .

Sarah: You’re right.

Therapist: Okay, so let’s just see how fast it happens. I’m gonna give you three numbers to remember. If you remember them, the people who are doing this filming, they’re giving me money, and if you remember them a week from now I’ll give you $10,000. Here are the numbers—1, 2, 3. Now if I come

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back and say, “What are the numbers?” what are you gonna say?

Sarah: The numbers are 1, 2, 3.

Therapist: Oh! Good for you; $10,000. So if I say, “What are the numbers?” you’ll say?

Sarah: 1, 2, 3.

Therapist: There’s no $10,000. I fibbed. [laughter] If I came back next week, do you suppose you could remember those?

Sarah: I think so.

Therapist: Next month?

Sarah: Probably.

Therapist: It’s even possible, possible, next year?

Sarah: Yes.

Therapist: What if a very old man who is bald came up on your deathbed and said, “Sarah, what are the numbers?” Is even that possible?

Sarah: It’s possible.

Therapist: I’ve said it twice. Your mother said these judgmental things to you a hundred times.

Sarah: Daily.

Therapist: They will never leave your head. There’s no place for them to go. When you’re interacting with her, this voice shows up. What are the numbers?

Sarah: 1, 2, 3.

Therapist: And if I get angry with my mother, then I’m . . .

Sarah: Bad. Oh, I see what you are saying! That’s why that guilt and judgment just keep coming up!

The What Are the Numbers? exercise is a classic ACT cognitive

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defusion method. When the person sees how easy it is to program a human mind, conditioned thoughts take on less literal meaning. Having “1, 2, 3” come to mind (perhaps even for life!) means nothing about Sarah other than that she has a history. This is experientially obvious after this exercise. Yet Sarah is taking “I’m bad” literally, as if it means that there is something wrong with her and that something needs to be changed. By metaphorical extension, she now sees that it too could say nothing more about her than that she has a history. In such a moment, the thought “I’m bad” is being looked at, not looked from.

There are hundreds of specific ACT defusion methods such as the What Are the Numbers? exercise. We have already mentioned word repletion, adding “I am having the thought that ___” before difficult thoughts, saying thoughts in unusual voices, or distilling difficult thoughts down to a word and saying it out loud a number of times. The point is not to ridicule thoughts but rather to be able to notice thought as an ongoing process in the moment. Defusion methods can rapidly reduce the believability and distress produced by thoughts. Some well-researched defusion methods are as short as 30 seconds long (e.g., Masuda et al., 2009).

A common objection to our arguments about defusion versus content change in thinking is that if deliberate change or elimination is difficult, unreliable, or risky, traditional cognitive restructuring should not work or should even be harmful. In fact, there is little evidence that cognitive restructuring is an effective component of traditional cognitive behavior therapy (for a review of that evidence, see Longmore & Worrell, 2007). But why isn’t it harmful? Some studies suggest that it is (Haeffel, 2010), but we expect it is usually neutral because detecting and trying to change thoughts can do both positive and negative things. It contains an elementary distancing component that arguably has a defusion effect (noticing your thoughts is a key facet of defusion, an argument similar to that being made by mindfulness researchers in cognitive therapy; see Segal, Teasdale, & Williams, 2004). In addition, thinking about how to change thoughts can encourage greater cognitive flexibility just by

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generating multiple cognitive variants to consider. Indeed, ACT sometimes uses this process by encouraging clients to formulate their self-narrative in several different ways as a defusion method (Hayes, Strosahl, & Wilson, 1999). ACT theory suggests that negative effects from cognitive restructuring would come from consequences such as greater entanglement with difficult thoughts, increased cues for them, greater chance of thought suppression, or amplification of a neurotic self-focus. These unintended effects would vary with the skill of the clinician (skilled cognitive therapists are trained to avoid most of them) and the propensity of individuals to engage in them. Thus, some individuals would benefit, some would be harmed, and on the whole it would be a wash.

REFERENCES

Haeffel, G. J. (2010). When self-help is no help: Traditional cognitive skills training does not prevent depressive symptoms in people who ruminate. Behaviour Research and Therapy, 48, 152–157. doi:10.1016/j.brat.2009.09.016

Hayes, S. C. (2009). Acceptance and commitment therapy [DVD]. Washington, DC: American Psychological Association.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York, NY: Guilford Press.

Longmore, R. J., & Worrell, M. (2007). Do we need to challenge thoughts in cognitive behavior therapy? Clinical Psychology Review, 27, 173–187. doi:10.1016/j.cpr.2006.08.001

Masuda, A., Hayes, S. C., Twohig, M. P., Drossel, C., Lillis, J., & Washio, Y. (2009). A parametric study of cognitive defusion and the believability and discomfort of negative self-relevant thoughts. Behavior Modification, 33, 250–262. doi:10.1177/0145445508326259

Segal, Z. V., Teasdale, J. D., & Williams, J. M. G. (2004). Mindfulness-based cognitive therapy: Theoretical rationale and empirical status. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 45–65).

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New York, NY: Guilford Press.

Wenzlaff, R. M., & Wegner, D. M. (2000). Thought suppression. Annual Review of Psychology, 51, 59–91. doi:10.1146/annurev.psych.51.1.59

Excerpted from Acceptance and Commitment Therapy (2012), from Chapter 3, “Theory,” pp. 41–50. Copyright 2012 by the American Psychological Association. Used with permission of the authors. 1The DVD, which can be purchased at http://www.apa.org/pubs/books/, is titled Acceptance and Commitment Therapy and is copyrighted by the American Psychological Association. It is important to note that the client’s name and other identifying information have been changed here to protect her confidentiality. The reader who watches the DVD may notice some discrepancies.

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2 ACCEPTANCE AND COMMITMENT THERAPY

PROCESS

STEVEN C. HAYES AND JASON LILLIS

DEFUSION

Have you ever had the thought deep down that you’re a horrible person or there is something really wrong with you? Perhaps you came by that thought honestly; maybe somebody told you that, your dad screamed it at you, or you derived it on the basis of painful and traumatic events in your life. It is possible that this thought will be with you from time to time for the rest of your life, at times powerfully so, and could be triggered by just about anything that happens to you. Trying to get it out of your mind means you have to focus on it. It means you have to treat it as important. As you do so, you make it more central, you connect it to more events, and you devote more life moments to it. As a result, you might actually make it more frequent, amplifying its impact on your behavior. Treating thoughts literally is called cognitive fusion, and it is a primary target of acceptance and commitment therapy (ACT).

Imagine being in a place where you can have whatever thoughts you have, more as you might watch the dialogue in a movie or a play. You can have the thought, “There’s something wrong with me,” and, without having to change or get rid of it, you can determine its impact on your life.

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As you experience that thought with perspective, awareness, and curiosity, that is what you are doing. That is the goal of defusion work.

Fusion is so pervasive that the signs of it are often hard to notice. There may be a loss of your sense of being present, like in a daydream; a sense of being caught up in your thoughts, as though your mind were working overtime; a sense of busyness, comparison, and evaluation. Maybe you’re often looking to the future or thinking about the past, as opposed to being connected to the now; there may be a sense of struggling to clarify things. Conversely, defusion contains a sense of lightness, flexibility, presence, consciousness, and playfulness. There is a sense that you have the freedom to direct your behavior without the dominance of certain thoughts. Defusion is simply seeing your thoughts as thoughts, so that what you do is determined more by your choices and less by automatic language processes.

In the subsections that follow, we discuss examples of cognitive fusion processes and techniques designed to address these processes in an attempt to change the context in which thoughts occur. There are hundreds of defusion methods in the ACT literature—these are just a few examples.

Ubiquity

Thoughts are ubiquitous; they are always hanging around. Sometimes they are big or small, loud or soft, good or bad, scary, happy, strange, and so on. But they are there, and they often pull us out of the present moment. It can be useful to simply call this process out and get it in the room. You might consider naming your mind and the mind of your client, noting that there are “four of us” in the room. Or you might refer to the mind as a “word-generating machine” that is constantly churning out thoughts, commenting on everything, judging, having opinions, causing a ruckus. The natural tendency is to look at the world from our thoughts. Defusion allows us to look at our thoughts rather than from them.

Watching your thoughts without involvement is inherently defusing. Many mindfulness exercises fit the bill. The Thoughts on Clouds exercise

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is an example:

I’d like you to close your eyes and simply follow the sound of my voice. Try to focus your attention on your breathing, and notice as each breath enters and exits your nose or mouth. . . . And now I want you to imagine sitting in a lush field. . . . Notice the trees and foliage, see the blue sky, try to become aware of your surroundings and really see yourself there. . . . And now I want you to lie down and look up to the sky and notice that there are clouds moving at a steady pace across the sky. . . . See if you can focus your attention on your thoughts, and as you become aware of a thought, put it on a cloud and watch it float across the sky. . . . Try to put each thought you have on a cloud and watch it as it goes by. . . . If you notice that you are no longer viewing the clouds from afar, but rather are caught up in a thought, gently bring yourself back to the field, lying down, gazing up at the clouds, and put each thought, one by one, on a cloud.

When you debrief this exercise, it is a good idea to check in with the client about his or her general experiences first. If the client was unable to perform the exercise, some more basic mindfulness training might be needed. Assuming the client was able to follow the exercise, you might want to discuss the experience of watching thoughts versus being caught up in thoughts. Typically clients are able to watch their thoughts for a while but then get caught up in a sticky thought (something personal or with emotional valence) or a process thought (e.g., “Am I doing this right?”), or perhaps worries about the future or past. This distinction is key because you are trying to teach the client to be able to notice the process of thinking. Nobody is able to do this all the time, nor would that be desirable; rather, it is important to be able to catch oneself entangled in thought, so that fusion or defusion can be used on a basis of workability rather than automaticity.

Literality

Swimming in a stream of thoughts, as we often do, we tend to

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experience our thoughts as being literally true. ACT calls this the context of literality, and it can contribute greatly to suffering. We become like a person so lost in a movie that the threats to the characters seem like personal threats: each sudden sound eliciting a startle, each creak on the stairs evoking an urge to flee. We are like that with our mental sounds and creaks because we’ve forgotten that they are in large part echoes of moments gone by.

If we treat thoughts as literal, then we must be invested in their content. For example, if you have the thought “I am a horrible person,” and you take that thought to be literally true, then it makes sense that you would do anything to try and not have that thought or change that thought in some way to make it possible for you to exist in the world and not be a horrible person. However, if you can step back from the screen and notice that there is a “you” and there is also a thought, maybe there is some room there for you to just have that thought as it is, without struggle.

ACT uses a variety of techniques to undermine the literality of thoughts. For example, clients might be asked to imagine that their negative thoughts (e.g., “I’m a failure,” “I can’t do anything right”) are like a radio station that can’t be shut off—it’s bad news radio, all bad news all the time! They can also imagine a barrage of negative thoughts as pop- up ads from hell. They can’t get a spam blocker for these! Another method is to have clients say their thoughts in silly voices, or say them very slow or very fast, or in the voice of themselves as children. Thoughts can be distilled into a single word and said rapidly aloud for 20 to 30 seconds.

It is important not to use these methods to ridicule thoughts. You can explain it to the client like this:

When you start seeing thoughts the way you would see things like a billboard or a pop-up ad or radio voice, or when you change how you interact with thoughts by speaking them slowly or singing them, or having a puppet say it to you, it gives you just a little space to look at them and use what is useful in them. It’s like stepping away from the computer screen. Then maybe this thought is also just a thought, and not necessarily anything that you have to do anything about, and certainly not something that you have to turn over your

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life to.

Automaticity

Say whatever words come to mind when I give you these partial phrases: “Only the good die . . . [young]” or “A picture is worth . . . [a thousand words]” or “Blondes have more . . . [fun].” These words come as a package in our history. If the words are painful (try this one: “I pretend to be a good person but deep down I’m _____”), we might try to erase them, but all we are doing is adding to them. Try it with any of these statements and you will notice that another word appears and you are initially pleased because it is not ____ [put in the forbidden word], until you realize that “___ is not ___” is yet another relation. There is no healthy eraser. This can be exactly like what is going on with clients. It can help to see how this game is impossible to win:

Therapist: Tell me, as a child did you believe in Santa Claus?

Client: Sure. We put cookies out and everything, I’d write a wish list.

Therapist: Do you still believe in Santa Claus?

Client: Of course not, but it’s fun for the kids.

Therapist: Yeah. And when you see a rainbow reaching the ground, what’s over there?

Client: [chuckles] A pot of gold.

Therapist: Funny, everyone says that. Not a pile of gold, not a pot of silver, but a pot of gold. Ever gone digging for it?

Client: [laughs] No.

Therapist: Back to Christmas for a moment. When you walk through the toy store in mid-December, what do you see?

Client: Santa, all the Christmas stuff, elves, reindeer.

Therapist: And what does that make you think of?

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Client: Santa’s toy factory at the North Pole.

Therapist: Now you don’t believe in this stuff, right? But it still comes up. And when you see a rainbow, what pops up in your mind?

Client: A pot of gold.

Therapist: Where did these thoughts come from?

Client: I suppose we’re told this stuff when we are kids, by our parents, other people.

Therapist: And this idea, you haven’t done well enough in your life, that you’ve failed as a person. Where did that come from?

Client: I don’t know, same place, I guess, stuff I’ve heard, stuff I’ve put together over the years.

Therapist: Yeah. And tell me, how would we get rid of the thought of a pot of gold, or the elves?

Client: Don’t know, I guess we don’t.

Therapist: So what about this other stuff—I’ve failed. . . . I’m not good enough, nothing I do is ever quite good enough, and all the dozens of variations?

A classic ACT technique is the What Are the Numbers? exercise we described in the case of Sarah in the chapter on the theory behind ACT. If clients get a sense of the point, the exercise itself can be used as a form of communication: Why should we take our own thoughts so seriously, when they may be nothing more than conditioned events? How silly is it that we are at the whim of their showing up at any time? The point is not to convince clients that their thoughts are wrong, or useless, or silly, but to offer a context in which they can notice that thoughts can be automatic. Maybe your client needn’t give such importance to those thoughts or engage in a struggle to change or get rid of them but, rather, can make room for them and let them be, while choosing to live his or her life.

This was done later in the work with Sarah, when discussing her

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anger and frustration with her mother (it is also worth noting that she is now spontaneously using more defused language as the result of the previous defusion interventions):

Therapist: It’s something almost like “I’m bad for feeling that.”

Sarah: Yeah. That’s it. I think that’s the bottom line. I mean all the other sentences come but the bottom-line sentence is “and that means, I’m bad.”

Therapist: OK, [offering a tissue] so here comes “I’m bad.” What are the numbers?

Sarah: 1, 2, 3.

Therapist: And if I get angry I’m . . . ?

Sarah: Bad.

Therapist: OK, here we go. We’ll just let that be there like that [laying the tissue on her knee]. Is that your enemy? Does that have to change before you can be there with yourself and allow yourself to feel what you feel even when your mind says you can’t? It’s just your conditioning. What are the numbers?

Excerpted from Acceptance and Commitment Therapy (2012), from Chapter 4, “The Therapy Process,” pp. 81–86. Copyright 2012 by the American Psychological Association. Used with permission of the authors.

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APPENDIX 2.1: ACCEPTANCE AND COMMITMENT THERAPY TECHNIQUES

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3 BEHAVIOR THERAPY

MARTIN M. ANTONY AND LIZABETH ROEMER

Reviews of behavior therapy often focus more on the techniques than on the theory underlying them. However, to conduct behavior therapy skillfully, one must understand the conceptual basis and intention of the specific techniques, beginning with the overarching goals of behavior therapy.

GOALS OF BEHAVIOR THERAPIES

The overarching goal of behavior therapies is to help clients develop flexible behavioral repertoires that are sensitive to environmental contingencies and are maximally effective for the individual (e.g., Drossel, Rummel, & Fisher, 2009). From a behavioral perspective, a wide range of clinical problems are seen as evidence of habitual, stuck patterns of responding that have developed over time because of associations and contingencies in the environment (which can also include the internal environment, e.g., physical sensations, thoughts, imagery) that maintained these patterns in a given context. Therapy is therefore focused on identifying the factors that are currently maintaining the difficulties in question and on intervening to reduce problematic behaviors and responses and increase more flexible, adaptive behaviors and responses. A central

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focus is on broadening behavioral repertoires and encouraging alternative, adaptive repertoires that will enhance well-being and functioning, rather than on symptom reduction (Drossel et al., 2009). That is, the intent is to help clients engage in a range of behaviors that are likely to help them function in their lives rather than solely to reduce their anxiety or depressive symptoms.

An initial goal, therefore, is the careful assessment and analysis of presenting problems to determine the contexts in which they occur, the stimuli that trigger their occurrence, and the consequences that maintain them. This functional analysis helps the client and the therapist to see the ways in which problematic patterns of responding emerge in response to specific cues and are maintained by specific consequences. It also helps to determine whether problematic responses can be understood as resulting from learned associations, reinforcing consequences, or skills deficits, which will have implications for intervention. This analysis also helps to determine how multiple problems interact so that treatment targets can be chosen that will optimize positive outcomes by influencing more than one presenting problem. Although people often think of cues and contingencies as explaining only overt, simplistic behavior problems, such as phobias, these same models can be used to understand more complex patterns of responding, such as those that underlie relationship difficulties. For instance, a client who presents for treatment because of relationship concerns might first be asked to monitor when concerning interactions with a partner occur. Functional analysis may reveal that the client has developed a habit of responding to perceived instances of rejection (which take the behavioral form of the client’s partner being focused on something else or seeming distant) by feeling hurt and vulnerable. The client may habitually respond to these feelings by expressing anger through criticism or storming out of the room, behaviors that are reinforced by the initial reduction in hurt and vulnerability that the client experiences. However, these behaviors increase the partner’s tendency to withdraw, thus perpetuating the problematic cycle of interaction. This analysis provides several potential targets for intervention: the client’s

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learned emotional response to the partner’s behavior and the client’s behavioral responses to feeling hurt and vulnerable. If the couple were in treatment together, a functional analysis of the partner’s behavior would also be conducted, providing additional targets for intervention.

In behavior therapy, the therapist and client collaboratively set specific treatment goals and the therapist shares with the client the model of how these goals will be met. Therapy is active in that the client engages in exercises both within and between sessions designed to develop and strengthen new learning and new patterns of responding and to weaken old, habitual ways of responding. Given the emphasis on new learning, practice is an essential part of treatment, requiring the client to actively engage with the treatment. Actively engaging means that it is essential that the client agree with the rationale for and goals of treatment. Therapists need to be sensitive to indications that the conceptualization and plan make sense to the client. As in all treatments, the therapist should be attuned to and familiar with both general cultural views that may affect how a client views health, clinical problems, and goals for treatment and the specific perspective of a client and his or her family. These perspectives should all shape the developing conceptualization and plan.

Behavior therapy is flexible and iterative. Therapists and clients are continually evaluating the impact of interventions and the continued relevance of stated goals. Alterations are made to treatment plans on the basis of the effects of interventions, the feasibility of specific interventions for a given individual, and changing external circumstances. The scientific basis of behavior therapy makes continual hypothesis testing an explicit characteristic of this approach to treatment. The findings from a functional analysis are always treated as a working hypothesis, and ongoing assessment and reflection are used to reevaluate and revise these models and intervention plans in order to promote optimal functioning for the individual.

Thus, the goals of behavior therapy are idiographic and are determined and refined collaboratively in the therapeutic relationship. An overarching goal of flexible, adaptive functioning is consistent across

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clients and presenting problems, but the specifics of what this will look like for a given individual depend on the context and what is most important to the client. Behavior therapists are careful not to assume that they know what is optimal functioning for an individual, but instead aim to help the individual examine his or her life to determine what will be optimal for her or him.

KEY CONCEPTS IN BEHAVIOR THERAPIES

Behavior therapy is a broad category that encompasses a wide range of intervention strategies, as well as variability in theoretical emphases. Behavior therapists incorporate various behavioral approaches (e.g., cognitive, mindfulness based) to differing degrees. Also, because behavior therapists emphasize the importance of scientific inquiry, theories that underlie these approaches are constantly being refined on the basis of scientific study and discovery. However, several shared theoretical assumptions characterize therapy based in the behavioral tradition. In this chapter, we provide an overview of these theoretical assumptions and also discuss some of the points of disparity among behavior therapists.

Theory plays an important role in behavior therapies that is often overlooked. The importance that behaviorists (and cognitive behaviorists) place on empirical study has led to the development of numerous manualized treatments that can be subjected to careful, controlled evaluation to examine the efficacy of a specific approach. Although this approach has many advantages, one disadvantage is that it can give the impression that behavior therapy is a collection of techniques rather than a coherent way of understanding human behavior and optimizing human functioning. An emphasis on technique can leave clinicians who are implementing interventions at a loss when aspects of a specific strategy do not fit well with a given client. A clear understanding of the theory underlying specific strategies helps therapists to flexibly implement treatments, responding to individual clients’ needs while remaining consistent with the underlying model of the treatment. For instance,

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strategies can be adjusted so that they are more culturally consistent for a given client while still corresponding to the intervention’s initial intent. For example, relaxation imagery that incorporates other people may be more resonant for individuals who identify themselves in relation to others than solitary images that are more commonly used, leading these individuals to practice using imagery more regularly and benefit more from treatment (La Roche, D’Angelo, Gualdron, & Leavell, 2006).

All Behavior Serves a Function

A central assumption of behavior therapists is that problematic patterns of behavior happen for a reason. That is, even behaviors that seem to be destructive or clearly harmful to an individual, such as substance dependence, deliberate self-harm, or an abusive relationship, make sense in the context of an individual’s learning history. In the context of behavior therapy, the term behavior applies to a wide range of client responses, including thoughts, physiological responses, emotional responses, and covert behaviors as well as overt behaviors. Using a behavioral conceptualization, even responses that seem irrational, such as extreme anxiety in response to apparently nonthreatening cues or guilt and shame in response to apparently benign interpersonal exchanges, happen because of biological predispositions and prior learning experiences that have shaped a client to have certain types of responses to particular stimuli. In this way, puzzling behaviors can actually be explained and understood because of previous learning experiences (which we describe in more detail shortly).

Thus, a central goal in behavior therapies is to determine the potential function of presenting problems. This determination serves several purposes in therapy. First, as the therapist and client work together to understand why the client is repeatedly having responses or engaging in behaviors that she or he sees as problematic, these puzzling responses begin to make more sense and seem less baffling. More important, the client often experiences a reduction in self-blame and criticism as a result

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of this increased understanding of why she or he is responding in this way. For instance, clients with a long-standing history of anxiety often experience relief when the fight-or-flight response, paths to learning fear, and the natural but fear-maintaining response of avoidance are explained to them. Although this understanding alone is often not enough to alter responding, it does often help to reduce the criticism, judgment, and shame that can exacerbate anxious responding and further interfere with relationships and general functioning.

Although the validation that comes with a behavioral conceptualization is likely an active ingredient in behavior therapies, a more important goal is the identification of targets for intervention and strategies that will promote new learning that is more adaptive and growth enhancing. An understanding of principles of learning (described more fully in the next section) is an important foundation in developing intervention strategies that will most efficiently lead to robust new learning.

BEHAVIOR IS LEARNED; NEW BEHAVIOR CAN BE LEARNED THROUGH EARLY CUE DETECTION AND PRACTICE

Behavior therapies are based on an assumption that individuals have learned to respond and act in the ways they habitually respond and act through identifiable principles of learning. Behavior therapies evolved from experimental research that detailed these learning principles. Modern behavior therapies are similarly informed by newer developments in experimental research that have identified complexities in principles of learning (e.g., Bouton, Mineka, & Barlow, 2001; Craske et al., 2008). An in-depth discussion of these principles and complexities is beyond the scope of this book (see Bouton, Woods, Moody, Sunsay, & García- Gutiérrez, 2006; Craske & Mystkowski, 2006; O’Donohue & Fisher, 2009), but we provide a summary so that therapists can use these principles to guide implementation of behavior therapies.

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Learning Through Association

Both humans and animals learn to associate stimuli that frequently appear together. Classical conditioning refers to the process through which a previously neutral stimulus becomes associated with a stimulus that evokes certain responses (either aversive or appetitive). Through being repeatedly paired with an unconditioned stimulus (US) that naturally evokes a given response, the conditioned stimulus (CS) becomes a cue for the US and elicits similar or related responses. This process is clearly evolutionarily adaptive in that organisms learn that the presence of certain stimuli indicates that a threat is likely to appear or that something desirable is likely to appear, and respond accordingly. Once a stimulus has been conditioned, it can lead to new learning by being paired with another previously neutral stimulus, which will in turn come to be associated with the CS and elicit similar or related responses.1 Through this process of higher order conditioning, more stimuli come to be associated with undesirable or desirable events. Also, through stimulus generalization, stimuli that are similar to the CS also become learned cues, so that eventually a broad range of stimuli are associated and evoke similar responses. For instance, a learned fear of a bright red shirt might lead an individual to respond with anxiety or fear to anything red in the environment.

A client, Monique, can be used to illustrate these principles. Monique presented for therapy reporting that she was anxious and uneasy in social situations. A functional analysis, including monitoring of her symptoms and exploration of specific incidents of anxiety during the previous week, revealed that she responded with physiological arousal and anxious thoughts when she interacted with people who looked or sounded critical. She described her father as extremely critical when she was growing up and stated that he would often turn his attention to other people or walk away after he had criticized her for something. In this example, this withdrawal of attention and affection from a parent was a US that would have naturally elicited fear in a child. Its pairing with criticism from her father led Monique to respond to her father’s criticism with anxiety

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because she anticipated the removal of his attention and affection. Gradually, these associations generalized, and she came to have similar responses to any instances of perceived criticism, leading her to feel anxious in a broad range of social situations.

People are particularly prone to learning threatening cues because it is evolutionarily adaptive to identify markers for potential harm and danger so that individuals can avoid this harm or danger. In addition, some individuals are probably biologically predisposed to learn threat more easily and robustly and are therefore more prone to anxiety (e.g., Lonsdorf et al., 2009). Prior experiences with threat, or modeling of fear behavior by significant role models, may also make it more likely that an individual will easily learn to fear cues, and those responses will generalize (Mineka & Zinbarg, 2006). Biology, prior experiences, and modeling likely play a role in other kinds of learning, such as the reinforcing properties of alcohol and drugs (e.g., Enoch, 2007).

Initial models of associative learning identified the conditions under which learned associations (to CSs) could be extinguished such that an organism no longer responded to the CS as though it were associated with the US. Further study has indicated that the term extinction is a misnomer because associations are not, in fact, unlearned. Instead, new, competing, nonthreatening associations are learned. So, in the case of fear conditioning, repeated exposure to the CS in the absence of the US will lead to a new, nonthreatening association to the CS, such that fear is no longer the predominant response. Extinction can therefore be thought of as inhibitory learning (Craske et al., 2008) in that an association that inhibits the previous association is learned. Rescorla and Wagner (1972) noted that learning is an adjustment that occurs when there is a discrepancy between the outcome that is expected and the outcome that occurs. So extinction trials promote new learning in that the expected association does not occur, so that the CS comes to be associated with “not US” instead of the US.

Bouton et al. (2006) reviewed the literature that suggests that conditioned associations, as well as conditions that are likely to make extinction or inhibitory learning more robust, are not unlearned. Animal

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research has demonstrated that even after extensive extinction of fearful associations, the continued presence of these associations is demonstrated by (a) a renewal effect, in which a learned association to a CS returns when the CS is presented in a different context from the extinction trials; (b) spontaneous recovery, in which a learned association to a CS returns after the passage of time; (c) reinstatement, in which a learned association to a CS returns after the US is presented alone and the CS is presented later; and (d) rapid reacquisition, in which an association to a previously extinguished CS is learned much more rapidly in new conditioning trials. All of these phenomena suggest that a learned fearful association is maintained despite successful extinction. Bouton et al. interpreted these findings as evidence that extinction learning is context specific, which makes sense from an evolutionary standpoint—people learn cues for fear easily, and generalize them, yet learning of inhibitory responses to feared stimuli is more context specific. This serves an important survival function in that individuals will not prematurely learn that a given stimulus is safe simply because it was safe in a specific context. However, it makes it more likely that learned fears will recur, making it important for therapists to address relapse prevention in therapy, so that clients are prepared for these recurrences and are able to continue to approach feared stimuli to promote more robust extinction learned across multiple contexts. Researchers have also suggested that the presence of retrieval cues during extinction trials will help extinction (or inhibitory learning) generalize to novel contexts (Craske et al., 2008).

Although associative learning is often described in terms of learned associations to external stimuli, there is also extensive evidence that organisms learn associations to internal stimuli as well (for an extensive review of this literature in the context of panic disorder, see Bouton et al., 2001). As a result, people’s own internal sensations can become threat cues, leading them to respond with anxiety, which strengthens the cue, potentially leading to a spiral of anxiety or panic. From a behavioral perspective, thoughts can also become associated with a US. As such, thoughts or memories of a traumatic event can elicit posttraumatic

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responses, even in the absence of the event itself. Thoughts can also have appetitive associations, so that a thought of a drink can lead to a powerful conditioned response of craving for an individual addicted to alcohol. Because these internal cues are beyond people’s instrumental control (they cannot avoid thoughts of drinking or anxious sensations completely), these associations are particularly likely to lead to clinical problems. As such, learning new associations to these cues is often an important target of treatment (as is learning not to respond to them behaviorally).

REFERENCES

Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological Review, 108, 4–32. doi:10.1037/0033-295X.108.1.4

Bouton, M. E., Woods, A. M., Moody, E. W., Sunsay, C., & García-Gutiérrez, A. (2006). Counteracting the context-dependence of extinction: Relapse and tests of some relapse prevention methods. In M. G. Craske, D. Hermans, & D. Vansteenwegen (Eds.), Fear and learning: From basic processes to clinical implications (pp. 175–196). Washington, DC: American Psychological Association. doi:10.1037/11474-009

Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5–27. doi:10.1016/j.brat.2007.10.003

Craske, M. G., & Mystkowski, J. L. (2006). Exposure therapy and extinction: Clinical studies. In M. G. Craske, D. Hermans, & D. Vansteenwegen (Eds.), Fear and learning: From basic processes to clinical implications (pp. 217–233). Washington, DC: American Psychological Association. doi:10.1037/11474-011

Drossel, C., Rummel, C., & Fisher, J. E. (2009). Assessment and cognitive behavior therapy: Functional analysis as key process. In W. T. O’Donohue & J. E. Fisher (Eds.), General principles and empirically supported techniques of cognitive behavior therapy (pp. 15–41). Hoboken, NJ: Wiley.

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Enoch, M. (2007). Genetics, stress, and risk for addiction. In M. Al’Absi (Ed.), Stress and addiction: Psychological and biological mechanisms (pp. 127– 146). San Diego, CA: Elsevier. doi:10.1016/B978-012370632-4/50009-7

La Roche, M. J., D’Angelo, E., Gualdron, L., & Leavell, J. (2006). Culturally sensitive guided imagery for allocentric Latinos: A pilot study. Psychotherapy: Theory, Research, Practice, Training, 43, 555–560. doi:10.1037/0033-3204.43.4.555

Lonsdorf, T. B., Weike, A. I., Nikamo, P., Schalling, M., Hamm, A. O., & Öhman, A. (2009). Genetic gating of human fear learning and extinction: Possible implications for gene-environment interaction in anxiety disorder. Psychological Science, 20, 198–206. doi:10.1111/j.1467- 9280.2009.02280.x

Mineka, S., & Zinbarg, R. (2006). A contemporary learning theory perspective on the etiology of anxiety disorders: It’s not what you thought it was. American Psychologist, 61, 10–26. doi:10.1037/0003-066X.61.1.10

O’Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive behavior therapy. Hoboken, NJ: Wiley.

Rescorla, R. A. (1988). Pavlovian conditioning: It’s not what you think it is. American Psychologist, 43, 151–160. doi:10.1037/0003-066X.43.3.151

Rescorla, R. A., & Wagner, A. R. (1972). A theory of Pavlovian conditioning: Variations in the effectiveness of reinforcement and nonreinforcement. In A. H. Black & W. F. Prokasy (Eds.), Classical conditioning II: Current research and theory (pp. 64–99). New York, NY: Appleton Century Crofts.

Excerpted from Behavior Therapy (2011) from Chapter 3, “Theory,” pp. 15–24. Copyright 2011 by the American Psychological Association. Used with permission of the authors. 1Initially, this learning process was thought to involve learning a response to a stimulus because that stimulus had been associated with another stimulus that automatically elicited that response. However, an extensive body of research has demonstrated that an association is learned between the previously neutral stimulus and the US and that associations are also learned regarding the context in which these pairings take place (Rescorla, 1988). In addition, conditioning can result in a different response to the CS than the response to the US, one that is preparatory for the potential occurrence of the US and matched to the properties of the CS (Rescorla, 1988). Although classical conditioning continues to often be described in terms of learning responses, the term learned associations is a technically more accurate description of this

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type of learning.

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4 BEHAVIOR THERAPY PROCESS

MARTIN M. ANTONY AND LIZABETH ROEMER

EXPOSURE-BASED STRATEGIES

In the context of behavior therapy, the term exposure refers to the repeated and systematic confrontation of feared stimuli (Moscovitch, Antony, & Swinson, 2009). Many behavior therapists consider it to be an essential component of behavioral treatment for most anxiety disorders, as well as for certain related conditions. It has long been established in research with animals and humans that repeated exposure leads to a reduction in fear responding. Habituation is often cited in the literature as a mechanism to explain how exposure works, although the pattern of change seen in exposure is not consistent with what one might expect after habituation (Moscovitch et al., 2009). For example, in habituation (as it is typically defined) no new learning occurs, and there is a full reinstatement of the response after a short break; neither of these is true in the case of exposure (Tryon, 2005). Rather, models relying on the occurrence of new inhibitory associative learning or extinction seem to explain the effects of exposure much better than habituation models (for reviews, see Moscovitch et al., 2009; Tryon, 2005).

The contemporary behavior therapy literature typically refers to three types of exposure: in vivo exposure, imaginal exposure, and interoceptive exposure. In vivo exposure involves exposure to external situations and

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objects in real life (e.g., entering social situations to reduce anxiety around other people, practicing driving to overcome a fear of driving), while minimizing any forms of avoidance, such as distraction. It is a standard component of evidence-based treatments for specific phobias, social anxiety disorder, agoraphobia, obsessive–compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and other problems in which an individual has an exaggerated fear of some external object or situation. Typically, the difficulty of exposures is increased gradually across sessions, although some forms of exposure therapy involve confronting the most frightening stimuli right from the start (a process sometimes referred to as flooding).

Imaginal exposure involves exposure in imagination to thoughts, memories, imagery, impulses, and other cognitive stimuli and is most often used in evidence-based treatments for OCD (e.g., exposure to obsessional thoughts of stabbing a loved one) and PTSD (e.g., exposure to a feared traumatic memory). Imaginal exposure may involve having the client describe a feared stimulus aloud or in writing or having the client listen to a verbal description of the feared stimulus, either in the form of an audio recording or described out loud by the therapist. The therapist encourages the client to imagine the stimulus vividly, with all of her or his senses, to maximize the new associative learning that takes place (i.e., the nonfearful associations to the range of conditioned stimuli present).

Interoceptive exposure involves purposely experiencing feared physical sensations until they are no longer frightening. It is used most often in the treatment of panic disorder. Examples of commonly used interoceptive exposure exercises include breathing through a straw to induce breathlessness, spinning in a chair to induce dizziness, and hyperventilation to induce breathlessness and dizziness.

Exposure may involve other stimuli as well. For example, exposure to visual stimuli in photos or on video is often used in the treatment of blood and needle phobias (Antony & Watling, 2006) and fears of certain animals, such as snakes, spiders, bugs, and rodents (Antony & McCabe, 2005). Exposure using computer-generated stimuli in virtual reality is also

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increasingly being used for the treatment of certain phobias and other anxiety disorders (Parsons & Rizzo, 2008).

Because behavioral models for disorders have begun to focus particularly on the role of avoidance of emotions (e.g., Barlow, Allen, & Choate, 2004; Mennin & Fresco, 2010) in maintaining difficulties, explicit exposure to emotional responses (which has always been a part of exposure-based treatment) has been proposed as an effective intervention. Therapists might ask clients to imagine emotional situations or view emotionally evocative film clips to reduce avoidance of their own emotional responses.

GUIDELINES FOR EFFECTIVE EXPOSURE

A number of factors have been found to affect outcomes after exposure-based treatments. First, exposure seems to work best when it is predictable (i.e., the client knows what is going to happen and when it is going to happen) and when it is under the client’s control (i.e., the client controls the intensity and duration of the practice; see Antony & Swinson, 2000). Second, exposure works best when sessions are prolonged. Two- hour exposures have been found to be more effective than 30-minute exposures (Stern & Marks, 1973). However, contrary to previous assumptions, it may not be necessary for fear to decrease in any particular exposure session for a client to show improvement across sessions (Craske & Mystkowski, 2006). Third, exposure seems to work best when practices are not too spread out, particularly early in treatment (Foa, Jameson, Turner, & Payne, 1980). A number of other variables can influence the outcomes of exposure, including the extent to which the context of exposure is varied and the extent to which safety behaviors (e.g., distraction) are used during exposure practices (for a review, see Abramowitz, Deacon, & Whiteside, 2011; Antony & Swinson, 2000).

EXPOSURE HIERARCHIES

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Before starting exposure therapy, the therapist and client typically develop an exposure hierarchy, which is subsequently used to guide exposure practices. The hierarchy usually includes 10 to 15 situations. Each item is rated in terms of how much fear it would typically generate and how likely the client would be to avoid the situation, using a Likert- type scale (e.g., ranging from 0 to 100, where 0 = no fear or avoidance and 100 = maximum fear and avoidance). Ratings are used to determine the order of items, such that the most difficult items are at the top of the list and the less difficult items are at the bottom. Table 4.1, “Exposure Hierarchy for Social Anxiety Disorder,” includes an example of an exposure hierarchy for an individual with a diagnosis of social anxiety disorder.

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TABLE 4.1. Exposure Hierarchy for Social Anxiety Disorder

RESPONSE PREVENTION

Response prevention refers to the inhibition or blocking of a learned behavioral response to a stimulus, with the goal of breaking the association between the stimulus and the response (Nock, 2005). The process may be facilitated by physically preventing the unwanted behavior (e.g., turning off the main water source so a client with OCD cannot wash his or her hands) or using reinforcement for not engaging in the unwanted behavior (e.g., complimenting a client for his or her success at refraining from nail biting).

Response prevention is most often discussed in the context of treating OCD, in which it is also referred to as ritual prevention. Compulsive rituals are believed to have the same functions as safety behaviors, avoidance, and escape—namely, to prevent the occurrence of harm and to reduce fear, anxiety, and distress. Compulsions are also thought to help

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maintain fear of relevant obsessional thoughts, situations, and objects. Therefore, along with exposure to feared stimuli, individuals with OCD are typically encouraged to prevent their compulsive rituals.

In addition to the treatment of OCD, response prevention is used to reduce the occurrence of safety behaviors in other anxiety-based disorders and to reduce problematic impulsive behaviors (e.g., hair pulling in trichotillomania).

REFERENCES

Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2011). Exposure therapy for anxiety: Principles and practice. New York, NY: Guilford Press.

Antony, M. M., & McCabe, R. E. (2005). Overcoming animal and insect phobias: How to conquer fear of dogs, snakes, rodents, bees, spiders, and more. Oakland, CA: New Harbinger.

Antony, M. M., & Swinson, R. P. (2000). Phobic disorders and panic in adults: A guide to assessment and treatment. Washington, DC: American Psychological Association. doi:10.1037/10348-000

Antony, M. M., & Watling, M. A. (2006). Overcoming medical phobias: How to conquer fear of blood, needles, doctors, and dentists. Oakland, CA: New Harbinger.

Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35, 205–230. doi:10.1016/S0005-7894(04)80036-4

Craske, M. G., & Mystkowski, J. L. (2006). Exposure therapy and extinction: Clinical studies. In M. G. Craske, D. Hermans, & D. Vansteenwegen (Eds.), Fear and learning: From basic processes to clinical implications (pp. 217–233). Washington, DC: American Psychological Association. doi:10.1037/11474-011

Foa, E. B., Jameson, J. S., Turner, R. M., & Payne, L. L. (1980). Massed vs. spaced exposure sessions in the treatment of agoraphobia. Behaviour Research and Therapy, 18, 333–338. doi:10.1016/0005-7967(80)90092-3

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Mennin, D. S., & Fresco, D. M. (2010). Emotion regulation as an integrative framework for understanding and treating psychopathology. In A. M. Kring & D. M. Sloan (Eds.), Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 356–379). New York, NY: Guilford Press.

Moscovitch, D. A., Antony, M. M., & Swinson, R. P. (2009). Exposure-based treatments for anxiety disorders: Theory and process. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 461–475). New York, NY: Oxford University Press.

Nock, M. K. (2005). Response prevention. In M. Hersen & J. Rosqvist (Eds.), Encyclopedia of behavior modification and cognitive behavior therapy: Vol. 1. Adult clinical applications (pp. 489–493). Thousand Oaks, CA: Sage.

Parsons, T. D., & Rizzo, A. A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39, 250–261. doi:10.1016/j.jbtep.2007.07.007

Stern, R., & Marks, I. (1973). Brief and prolonged flooding: A comparison in agoraphobic patients. Archives of General Psychiatry, 28, 270–276.

Tryon, W. W. (2005). Possible mechanisms for why desensitization and exposure therapy work. Clinical Psychology Review, 25, 67–95. doi:10.1016/j.cpr.2004.08.005

Excerpted from Behavior Therapy (2011) from Chapter 4, “The Therapy Process,” pp. 59–63. Copyright 2011 by the American Psychological Association. Used with permission of the authors.

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APPENDIX 4.1: BEHAVIOR THERAPY TECHNIQUES

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5 BRIEF DYNAMIC THERAPY

HANNA LEVENSON

The integrative view of time-limited dynamic psychotherapy (TLDP) intertwines three substantive approaches that have complex, overlapping historic and clinical perspectives, each one pertaining to a different focus of the clinical work. The first leg of this theoretical stool is attachment theory, which provides the motivational rationale for the therapy. From attachment theory, one can answer the questions “Why do people behave as they do?” “What is necessary for mental health, and how does mental illness occur?” The second support comes from interpersonal–relational theory, which forms the frame or platform for the therapy. “What is the medium in which the therapy occurs?” The third leg emphasizes the experiential–affective component, which is concerned with the process of change. “What needs to shift for change to occur?” When I am working clinically, I experienced these three perspectives as inseparable and reinforcing one another—all contributing to support a stable base from which to do therapy.1 In the next section each component will be examined so that the reader can better understand my current perspectives on the theory and practice of TLDP.

ATTACHMENT THEORY

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Attachment in Infancy

Attachment theory maintains that infants manifest an instinctive behavioral repertoire (the attachment behavioral system) in the service of maintaining physical closeness to caregivers. From an attachment perspective, we are hardwired to gravitate toward “older and wiser” others particularly during times of stress or threat. Moreover, we are genetically programmed to solicit attention from our caregivers on whom we are dependent because our very existence depends on this vital bond. Infants’ ability to elicit such attention is then maintained through a mutual feedback loop in which caregivers (usually initially mothers) are socially reinforced by their infants for engaging in attentional behaviors (e.g., the infant’s steady gaze reinforces the mother’s cooing and staring back, which then encourages the infant to fixate on her face and engage in smiling behaviors that again results in more rapt attention from mother). There is ample research to indicate that some of an infant’s ability to imitate the social behavior of another (e.g., stick out one’s tongue after seeing the mother stick out her tongue) and to respond to social cues from a caregiver is not learned and is already available in the infant’s behavioral repertoire just a few hours after birth (Meltzoff & Moore, 1977).

The literature on attachment theory and its application to understanding human development is enormous and spans nearly 40 years (Obegi & Berant, 2008). John Bowlby’s classic trilogy on attachment, separation, and loss (1969, 1973, 1980) highlighted the importance of the emotional quality of early childhood for understanding psychopathology. Through observations, consultations, and the empirical/theoretical literature that existed at the time, Bowlby concluded that

the young child’s hunger for his [sic] mother’s love and presence is as great as his hunger for food, and that in consequence her absence inevitably generates a powerful sense of loss and anger. . . . Thus we reached the conclusion that loss of mother-figure, either by itself or in combination with other variables yet to be clearly identified, is capable of generating responses and processes that are of the greatest interest to psychopathology. (1969, p. xiii)2

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Bowlby noticed that infants had a large repertoire of behaviors to keep their mothers close and interactive. He believed the infant had acquired this behavioral repertoire gradually over the course of evolution; those infants who could connect had a better chance of passing on their DNA to future generations. “Bowlby viewed the human infant’s reliance on, and emotional bond with, its mother to be the result of a fundamental instinctual behavioral system that, unlike Freud’s sexual libido concept, was relational without being sexual” (Mikulincer & Shaver, 2007, p. 7, emphasis added).

Attachment Patterns

While attachment originally pertained to an infant’s proximity seeking, Bowlby later wrote of how the attachment needs and behaviors continue throughout the life cycle, with adults turning to other adults, especially in times of stress. As he stated in his treatise on healthy human development, A Secure Base (1988), “All of us, from the cradle to the grave, are happiest when life is organized as a series of excursions, long or short, from the secure base provided by our attachment figure(s)” (p. 62, emphasis added). We probably have no stronger example of this in modern times than when so many people in the Twin Towers on 9/11, when faced with a certain, horrific death, reached for their cell phones for the sole purpose of making contact with loved ones.

The analysts called Bowlby a behaviorist (the ultimate condemnation, no doubt) because of his interest in animal research and in observing the actual behavior of children. But quite to the contrary, the behaviorists would have nothing to do with his ideas. During this time, John Watson, for example, was cautioning parents not to reward crying children with attention. “Never hug and kiss them . . . never let them sit in your lap. If you must, kiss them once on the forehead when they say goodnight” (Watson, 1928, as quoted by Lewis, Amini, & Lannon, 2001, p. 71).

Ainsworth, an American colleague of Bowlby’s, developed an experimental procedure to assess the attachment patterns of infants called

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the “Strange Situation” (Ainsworth, 1969). In this situation, infants came with their mothers into a room with a one-way mirror. The infants would spend some time in the room with their mothers, an experimenter, and a variety of toys. At some point the mother would leave the child alone with the experimenter who recorded the child’s behavior. When the mother came back a short time later, the child’s behavior was again noted. Infants who were classified as secure were able to use their mothers as a home base as they explored their new surroundings. When their mothers left, they were obviously distressed, but they were able to be soothed by her return and resume constructive play. Children who were classified as avoidant exhibited little visible distress when their mothers left and did not greet her upon her return. They seemed more interested in the toys, but their play was not particularly creative.3 These children were thought to have deactivated their attachment system. The children labeled as anxious– ambivalent looked distressed even when they entered the room with their mothers. When their mothers left, they cried and were visibly angry. At reunion, these children were not able to be comforted and remained hyperaroused, unable to return to their play activities.

Internal Working Models

Bowlby’s formulations about the significance of internal working models help therapists understand how patterns of attachment might be maintained over time.4 He postulated that “an internal psychological organization with a number of highly specific features, which include representational models of the self and of attachment figure(s)” (1988, p. 29), develops over time and is built up through a series of experiences with caregivers throughout one’s early life. Thus the child not only has an internalized set of expectancies about how he or she will be treated by others, but also an internalized model of how one sees, feels about, and treats one’s self that is a reflection of how one has been treated by others.

Bowlby postulated that a securely attached child (i.e., a child who has been responded to by caregivers in a contingent, helpful, and loving

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manner whether distressed or contented) comes to expect that there are no aspects of the self that cannot be noticed, responded to, and dealt with. However, children who are not securely attached (i.e., who have been responded to sporadically, noncontingently, inadequately, or inappropriately) learn that when they are under threat, they cannot count on others to keep them safe.

Insecurely attached children get a quadruple whammy. First, they have models of self and/or others that are negative; second, they also have considerable difficulty self-correcting these harmful internalized models because of difficulties cognitively and emotionally perceiving disconfirmatory incoming information; third, since their working models or templates are derived and perpetuated out of awareness, they continue to be at their mercy. I am reminded of the saying that a fish has no idea of water. So it is with working models. They have an enormous impact on our lives, but we take them for granted as the way life is. Wachtel (2008) points out a fourth way insecurely attached children are affected. The stability of their internal working models persists in part because the ongoing interactions with the very people who gave rise to these experiences also persist (e.g., parents who were harsh toward their child as an infant are harsh when the child is a toddler and harsh when the child is an adolescent).

Adult Attachment

How does one understand the relevancy of attachment theory for adults? As Bowlby stated, attachment is significant from “cradle to grave,” but by the time people are adults, they normally do not need the proximity to another human being to survive. Adults feel secure when their attachment figures have confirmed “that (a) they are loved and lovable people, and (b) they are competent or have mastery over their environment” (Pietromonaco & Feldman Barrett, 2000, p. 167). Over the years, this builds up a sense of felt security that individuals internalize and carry with them throughout the life span (Stroufe & Waters, 1977).

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Shaver and Mikulincer (2008) delineate the three critical functions necessary for a person to reach adult attachment figure status: (a) this person is sought out at times of stress, or this person’s undesired leaving creates distress and protest; (b) this person creates a “safe haven” because he/she is a source of comfort, protection, or security; and (c) this person provides a “secure base” from which the adult can explore the world, take risks, and pursue self-development. Bowlby (1969/1982) acknowledged that a variety of people, personages (like God), or even institutions could be seen as attachment figures. In addition, the mental representations of these central figures (or of oneself) also can be a source of felt security and comfort. In a series of ingenious studies (see Shaver & Mikulincer, 2008), it has been demonstrated that activation of mental representations of attachment figures (e.g., asking people to visualize the faces of such figures) promotes a positive feeling, reduces painful or hurt feelings, and fosters empathy. (As a mini-experiment right now, the reader could take a moment and imagine seeing the face of someone who has provided comfort and security. Are you aware of having more positive feelings and an increased sense of well-being?)

Mary Main, a student of Ainsworth’s, developed the Adult Attachment Interview (AAI; Main, Kaplan, & Cassidy, 1985) to explore the mental representations of adults’ attachment as children to their parents. The AAI asks people to respond to specific questions about their relationships with their parents when they were young. For example, “Could you give me five adjectives or phrases to describe your relationship with your mother during childhood?” Those