Introduction to Cognitive Behavioral Therapies
Behavioral Interventions in Cognitive Behavioral Therapy: Practical Guidance for Putting Theory
into Action (Farmer & Chapman (2016)
Chapter 1: Overview on cognitive behavior therapy
Cognitive Behavior Therapy (CBT) is a widely used treatment approach for psychological conditions
such as depression, anxiety disorders, personality disorders, substance abuse disorders, eating
disorders and couple’s distress. CBT is a broad concept, which represents a variety of therapeutic
approaches that highlight cognitive, behavioral, emotional, physiological and environmental factors in
relation to psychological disorders.
The cognitive perspectives differ in the degree to which they view the environment as a determinant of
action, thinking and emotion. The influential cognitive approach assumes that mood and behavior are
influenced by distorted and dysfunctional thinking and that inaccurate and biased forms of thinking are
common to all psychological disorders. For each disorder there is a unique set of thought distortions
and underlying beliefs (schemas). Therapeutic activities should promote realistic, accurate and
balanced thinking. The modification of thinking will produce changes in mood and behavior and
establish lasting therapeutic change. Schemas are cognitive structures that can predispose persons to
emotional and behavioral disorders and influence evaluation and interpretation of experiences.
In contrast, behavior theory and therapy avoid to ascribe mental concepts a causal role in behavior,
instead they place emphasis on the physical environment. According to the behavioral perspective,
thinking and emotional responding are examples of behavior.
Individuals who have psychological disorders or who display problematic behaviors are often
considered as deviant or abnormal because of the dominant role of ‘deviant’ or ‘defect’ models of
abnormality. Psychological disorders are often regarded as having maladaptive schemas and
underlying diseases or biological processes are presumed to underlie psychological syndromes. The
internal defect that the person has must be changed, removed or altered in some way to no longer be
disordered.
Behavior theorists and therapists do not search for internal causes of behavior. Instead, they are
primarily concerned about what a person does and the context where the behavior occurs. Culture
provides the context for referencing which behaviors are (ab)normal. Cultural norms and values can
change over time.
From a behavioral perspective normal and abnormal behavior is shaped by the same determinants. It is
assumed that there is nothing inherently defective or deviant about people who report emotional or
behavioral problems.
Psychological disorders from a behavioral perspective are defined by behavior, occurring both within
the individual (covert behavior such as thoughts) and as actions that can be observed by others (overt
behavior). The environment establishes the context of such behavior.
The three-term contingency concept of Skinner represents the basic unit of analysis within some forms
of behavioral therapy. It consists of 3 elements:
1. Antecedents of behavior: stimuli and conditions that set the occasion for behavior to occur
2. Behavior: anything a person does (overt and covert)
3. Consequences that follow behavior
Functionalism is a term based on the evolutionary theory of Darwin. The physical structure of a
species is determined by its associated function. Natural selection is selecting the most adaptive
physical structures with functional properties that are associated with the enhancement of gene fitness.
People are more likely to select functional behavior that produces reinforcing consequences.
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,Environmental determinism is the process of selection of variations in an individual’s behavior during
his/her lifetime. Cultural norms are also selected. Norms that proved to be most beneficial or enhance
fitness tend to be retained over time.
Contextual approaches in behavioral theories focus on how events and behavior are organized and
linked together in meaningful ways. Contextualism is about the context within behavior takes place
(also called the contextual flow in which behavior occurs).
In the assessment of clients, behavior therapies focus on the behavioral repertoire to see if it is
necessary to learn new alternatives and the context within which the problematic behavior occurs.
They are looking for internal and external factors that maintain problematic behavior. The motivation
to change is also important. Behavior therapists see motivation as a condition resulting from
environmental events and is changeable by manipulations of the environment.
The following features are assessed and evaluated in the behavioral assessment:
− Antecedents of problematic behavior: internal or environmental cues, verbal rules
− Consequences of problematic behavior: short-term, long-term, positive or negative reinforcing
− The client's learning history as it relates to current problematic behaviors
− Current behavioral repertoire: emotions (appropriate responses, overly reactive), thoughts
(evaluations of self, world and future), overt behaviors (skill deficits, coping and problem-
solving skills) and physiological sensations or responses (associations with catastrophic
outcomes)
− Motivation for change: behavior consistent with values and goals
General characteristics of behavioral interventions are:
− Empirical orientation: the use of empirically supported intervention strategies and ongoing
assessments of the client's behaviors targeted for change
− Therapist-client collaboration
− Active orientation: client is actively encouraged to work on his problem areas
− Flexible approach: continuous evaluations and testing of the hypotheses
− Emphasis on environment-behavior relations: describing the actions of clients, their thoughts,
emotions and physical sensations within the context in which they occur
− Time-limited and present focus: focus on current situation rather than the past
− Problem and learning focus
− Emphasis on change and acceptance processes
In the late 1800s and early 1900s Ivan Pavlov and his colleagues studied reflexive and conditioning
processes. Respondent or classical conditioning is that environmental stimuli yield a reflexive, innate
(unlearned) response. For example, when a rubber hammer is struck right below the kneecap
(unconditioned stimulus, UCS), a reflexive kneejerk response follows (in this case an unconditioned
response, UCR).
A neutral stimulus object or event will come to acquire certain stimulus properties over time when
repeatedly paired or associated with the UCS. This neutral stimulus becomes a conditioned stimulus
(CS). The CS will excite a response (conditioned response, CR) under some circumstances that seem
quite similar to the UCR produced by the UCS.
Generalization is the process of CRs who often occur in the presence of stimuli that are similar to the
CS. When the CS is presented several times without the UCS the conditioned response disappears
(extinction).
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,Classical conditioning is most obvious in conditioned emotional responses (trauma related stimulus
cues). The traumatic event is the UCS and it elicits different reflexive or unlearned responses (UCR)
such as fear. Individuals with PTSD have strong emotional responses (CR) to events or objects (CS)
that are similar to those that were present at the time of the traumatic event.
Thorndike’s theory (the law of effect) implies that the consequences of behavior influence the learning
process and associated behaviors. Skinner refined this theory and came up with the operant theory of
behavior. Operant means that behavior is selected and shaped over time by the consequences that such
behavior produces. Human behavior is the result of phylogenetic processes (Darwin) and cultural
selection processes.
It was not until the early 1960s that therapeutic interventions based on behavioral principles began to
have widespread influence. There were some earlier efforts, for example the work of Mary Cover
Jones in 1924. She found that a child's fear of an animal could be decreased through
counterconditioning methods. Earlier efforts did however not result in an immediate impact on clinical
research and practice.
The beginning of behavior therapy took place in the late 1950s. Wolpe published the first treatment
procedure based on reciprocal inhibition. According to Wolpe, anxiety and neurotic states could be
reduced or eliminated by pairing the experience of anxiety with an inconsistent feeling.
Eysenck introduced the term behavior therapy and published a book with different treatment methods
(e.g. desensitization, aversion therapy), based on the Pavlovian learning theory. Behavior modification
is the change of behavior through learning principles.
In the 1970s CBT became firmly established. Bandura came up with the social learning theory, later
termed as the social cognitive theory. He elevated symbolic cognitive processes to determinants of
behavior. Whether or not certain behavior will be demonstrated is influenced by the individual’s belief
about his/her ability to perform the behavior.
Cognitive therapy focuses on identifying the client’s idiosyncratic way of thinking and changing
thought processes through rational examination. Automatic thoughts, processing biases, core beliefs
and schemas are used to explain variations in emotion and behavior and central treatment targets.
A new generation of CBT represents a theoretical evolution with many new approaches such as
acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT), which emphasize
factors like emotion and language. These new cognitive behavior therapies focus on the context rather
than the modification of the physical environment. The new generation of CBT deals with the range of
human experience more broadly.
Chapter 2: What are the principles, goals and structure of initial assessment sessions?
The behavioral assessment approach focuses on the person, the clinically relevant behaviors and the
environmental factors that influence and maintain those behaviors. This approach is based on
theoretical principles. One key principle is that behavior varies in relation to the antecedent conditions
that induce behavior and the consequences of the behavior. In contrast to other approaches, behavioral
assessments are idiographic or person centered.
The medical model approach evaluates the presence of behavioral and physiological signs of diseases.
This approach is most used for psychiatric diagnoses. Behavioral approaches to assessment are
distinguished from the medical model and other approaches by a unique set of goals and features.
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,There are 5 general goals of behavioral assessment:
1. Clarification of client’s problem and identification of associated behaviors
2. Evaluation of functional impairments
3. Identification of factors that maintain problematic behavior
4. Collaborative development of a formulation of the client's problems and development of a
therapeutic intervention plan
5. Evaluation of the effectiveness of the treatment
There are several features that distinguish behavioral approaches from more traditional approaches:
− Analyzing the whole person in interaction with the environment (context)
− Each individual is recognized as unique, and therefore also the treatments
− Behavior is situation specific. External influences are important
− Behavior itself is the focus of therapy and construct or diagnostic labels are avoided
− Client’s problems are defined in behavioral terms
− Therapy focuses on the development of effective behavior and competencies
The chances of dropping out of therapy are high in the first few sessions, therefore the initial contacts
with the client are important. It is important that the therapist creates a warm and collaborative
therapeutic relationship and provides realistic expectations about the therapy.
Therapy is enhanced when the therapist shows genuineness, respect, warmth, acceptance, validation
and empathy. Other important behaviors for therapists are appropriate demeanor (e.g. sympathetic and
interested), facial expressions, eye contact and easily understood communication.
Ideally, the therapist and client work together in developing and maintaining a context in which issues
can be constructively addressed as they emerge. The therapist has to keep in mind that this relationship
itself can facilitate behavior change.
CBT is an action-oriented therapy, so the client should be active and share responsibility in carrying
out the therapy. The therapist can facilitate this through continuous checking in with the client by
asking questions such as if the client wants to add something and by using 'we' to convey that therapist
and client work in a team.
The therapist’s theoretical orientation influences initial sessions and the selection of areas to talk about
that are relevant for the case formulation. A case formulation is a hypothesis about the causes,
precipitants, and maintaining influences of a client's psychological, interpersonal, and behavioral
problems.
Firstly, it is useful for the therapist to listen for a period of time and let the client tell his/her reasons
for coming to therapy, this gives insight in how the client organizes thoughts and explains the events
of his/her life. After this period of free speech, the therapist needs to make several inquiries to clarify
and assess the problem area. More serious and severe behaviors are addressed first.
Behavioral assessors will often collect information about the behavior clients display. There are
assessments that are primarily concerned with how people behave. It is however also important to
know why people behave the way they do.
Before the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition
(DSM-III), semi-structured diagnostic interviews came up. These were used for identifying groups of
which members were similar based on symptom presentation. Since the publication of the DSM-III,
numerous diagnostic interviews have been developed that assess single disorders, a group of related
disorders or several distinct classes of psychiatric disorders.
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,Just like the diagnostic categories, psychological constructs are often defined in terms of groupings of
behaviors that are endorsed by or evident for an individual.
Self-report measures are easy to complete, brief and focused on particular problem areas.
Questionnaire assessments are focused on the clients score referenced to those from a larger normative
sample. Cut scores are used to indicate an extreme score. Someone familiar with the client often
completes checklists and rating scales. They indicate the severity of behavioral problems and suggest
specific behavioral targets.
Problematic behaviors can be categorized within 2 broad categories:
1. Behavioral excesses: when a person displays certain behaviors that are excessive in terms of
frequency, intensity or duration. The behaviors are associated with distress and impaired
functioning. Excessive behaviors are maintained by positive and negative reinforcements,
especially among persons who display strong avoidance and escape behavior
2. Behavioral deficits: when persons do not demonstrate adequate behavior in different contexts
or do not display flexibility when circumstances are changing. There are 2 reasons for
behavioral deficits: (1) past environments failed to model, shape or reinforce the behaviors
and (2) absent behaviors have been learned and are part of someone’s repertoire, but they
appear deficient because they have been negatively reinforced or have been extinguished
Coping behaviors are important to assess because they show how a person responds to adversity.
Therapists focus on developing, strengthening and maintaining alternative and adaptive coping skills
such as:
− Problem-solving skills: assisting the client to find effective solutions to problems that arise
− Social skills: requisite for developing and maintaining social relationships and for obtaining
reinforcement from others
− Mindfulness skills: several skills or abilities that foster a full awareness in the moment.
Examples of behavior patterns that are antithetical to mindfulness are rumination, worry and
dissociation
− Self-regulation skills: skills for exercising self-control in areas as emotions, thoughts,
impulses, attention and bodily sensations
− Acceptance, self-validation and tolerance skills
Evaluating the impairments in functioning is important because of several reasons:
1. It indicates the severity of the client’s problem and helps determining a customized therapy
2. The nature of impairment can be relevant for the emphasis of therapy interventions
3. Psychological disorders are partly defined by the presence of behavioral patterns associated
with subjective distress or functional impairment
It is useful to compare a person’s current functioning with how well he/she had functioned in the past.
This personal functioning evaluation suggests a level of impairment and it could clarify which skills
are already present.
Social relations can protect individuals against the development of psychological disorders and
enhance health. When assessing family and social relations, it is important to distinguish whether
current problems in these areas are due to avoidance tendencies, deficits in social skills, suppression of
social behavior by the environment or a low rate of positive reinforcement.
The first signs of impairment can be seen in response to demands for day-to-day living in places such
as school or work. This part of life is often filled with demands for performance and pressure that
performance is evaluated.
It can be useful to review a person’s legal history because it can reveal the presence of psychological
conditions that were not visible at first sight. When someone has a history of substance abuse, bipolar
disorder and antisocial behaviors it is more likely that there will be legal difficulties.
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, Reports of risk factors have priority over the regular treatment, because it is important to ensure the
safety of clients and their environment. Exploring protective factors such as reasons for living is also
important.
Behavioral interviews are used by the therapist to gather information about the development of a
behavioral case formulation. The focus of such interviews is on the designation of the client's problem
areas, an identification of specific behavioral patterns related to these areas, an exploration of possible
precipitants and maintaining factors associated with these patterns, and an investigation into the
possible commonalities across these areas.
During the behavioral interview, the therapist adopts an active approach. The therapist develops, tests,
and refines the case formulation as the client provides new information.
Functional analysis of behavior focuses on the conditions under which behaviors are most prevalent.
There are 4 important components: antecedent stimuli, person variables, behavior and consequences.
There are 3 types of antecedents that set the occasion for behavior:
− Discriminative stimuli (SD): events or situations that elicit the behavior and predict
reinforcement or punishment
− Establishing operations (EO)/motivational operations: factors changing the reinforcing or
punishing properties of other environmental events. Internal events (e.g. thoughts, emotional
states) are common Eos
− S-delta: situations or circumstances in which the behavior does not take place
Behavior that is influenced by verbal rules is called rule-governed behavior. For example, a person
who is afraid of speaking in public can have a verbal rule such as: “If I speak in front of a public, I will
be evaluated negatively” and because of this rule this person will avoid public speaking.
To maintain (problematic) behavior there are 2 types of reinforcement:
− Positive reinforcement: behavior resulting in the application of something that increases the
likelihood of the behavior in future similar situations
− Negative reinforcement: when behavior results in the removal of an aversive event that
increases the likelihood of the behavior in future similar situations
Both types of reinforcement maintain behavioral excesses.
To decrease the likelihood of behavior in future similar situations there are 2 types of punishment:
− Positive punishment: when behavior results in the application of an aversive event that
decreases the likelihood of the behavior in similar situation
− Negative punishment: when behavior results in the removal of a reinforcing event that
decreases the likelihood of the behavior in the future
Extinction is another type of process that results in a reduction of behavior. This occurs when behavior
is frequently performed without being followed by reinforcing consequences.
There are 2 other important considerations regarding the consequences of behavior:
1. The definition of what constitutes a reinforcer or punisher is solely determined by the effect it
has on future behavior. A reinforcer is an operation that increases behavior frequency or
intensity. A punisher is an operation that decreases a behavior over time. These effects can be
different for different persons
2. Consequences of problematic behavior are short-term or immediate versus long-term or
delayed. Short-term consequences maintain problematic behavior and long-term consequences
make them problematic
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