Clinical Behavior Analysis: Where It Went Wrong, How It Was Made Good Again (PDF)

K O H L E N B E R T , B O L L I N G , K A N T E R & P A R K E R CLINICAL BEHAVIOR ANALYSIS: WHERE IT WENT WRONG, HOW IT...

K O H L E N B E R T , B O L L I N G , K A N T E R & P A R K E R CLINICAL BEHAVIOR ANALYSIS: WHERE IT WENT WRONG, HOW IT WAS MADE GOOD AGAIN, AND WHY ITS FUTURE IS SO BRIGHT. Robert J. Kohlenberg, Madelon Y. Bolling, Jonathan W. Kanter & Chauncey R. Parker University of Washington This paper traces the birth, quiescence and renaissance of clinical behavior analysis (CBA). CBA is the application of radical behaviorism to outpatient adult behavior therapy. It addresses the question of how talking in the consulting room helps the client outside of the office, in his or her daily life. The answer as formulated by CBA has led to exciting and significant developments with considerable promise for improving therapeutic interventions. A brief historical account of CBA is described that involves the interplay of three strands involving clinical applications of behaviorism: behavior therapy, applied behavior analysis, and the development of the Association for the Advancement of Behavior Therapy (AABT). These strands are traced through publications in Behavior Therapy from its inception to the present. We contend that there is a need in AABT and in behavior therapy in general for what CBA has to offer. As we see it, the major problems facing This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. the AABT membership with its current emphasis on cognitive therapy and empirically validated This document is copyrighted by the American Psychological Association or one of its allied publishers. treatments include the lack of a coherent theoretical base that can embrace all of the techniques used by behavior therapists. Now with all the behavioral procedures that have been developed, a horrendous question arises, "When do you use which procedure for what kind of person?" We conclude that far from being a thing of the past, CBA has a bright future in answering this question. Behavior analysis of the therapeutic situation offers a unique, coherent theoretical base that can embrace all techniques used by behavior therapists, including cognitive therapy strategies. Clinical behavior analysis (CBA) is including behavioral interpretations of terms defined as the application of radical behaviorism such as resistance, repression, and free (Skinner 1953, 1974) to answer the most basic association. Following this work, very little was question about outpatient adult behavior therapy published on CBA other than the insightful, but (or any other type of psychotherapy) largely ignored papers by Charles Ferster (1967, (Kohlenberg, Tsai & Dougher, 1993). Since 1972a, 1972b, 1972c, 1979). Neither Ferster nor outpatient treatment consists of verbal Skinner intended to devise new approaches to interchanges1 between client and therapist, the treatment in these writings. Instead they wrote question is this: what is the mechanism that in behavioral language, demonstrating a more explains how this talking helps the client outside useful way of describing, understanding, and in of the office in his or her daily life? In this Ferster’s case, teaching the change process. So, paper, we contend that CBA is an exciting, new, CBA got its start quite early in 1953 and then all and significant development that holds but disappeared until its reemergence in 1987 considerable promise for improving therapeutic with the publication of an edited book interventions. We also recognize that most (Jacobson, 1987). The Jacobson book contained behavior therapists are only superficially chapters by Hayes (1987) and Kohlenberg & familiar, if at all, with CBA and are not aware of Tsai (1987) that described in detail their its considerable potential as a highly effective approaches to using Skinnerian principles to treatment. There are several factors that account treat outpatient adults. We will refer to this for the relative invisibility of CBA, not least of hiatus as the quiescent period of CBA. The which is its mercurial appearance over the last reasons that behavior analysts did not pursue 46 years. CBA play a role in understanding the nature of its renaissance. THE BIRTH OF CBA In Science and Human Behavior (1953), CBA’s Quiescent Period Skinner gave an analysis of psychotherapy, Our historical account of CBA involves the interplay of three strands involving clinical 1 As we define it, verbal interchanges include making applications of behaviorism. These are behavior contracts, emotional expression, delivering rewards, etc. For therapy, applied behavior analysis, and the more on this broad conception of what is verbal, see Skinner development of the Association for the (1957). Advancement of Behavior Therapy (AABT). 248  T H E B E H A V I O R A N A L Y S T T O D A Y V O L U M E 3 , I S S U E 3 , 2 0 0 2 Behavior therapy is the application of behavior change. It is important to point out that laboratory-based principles of learning (in the in these papers, the behavior changes that were early years) to human problems and a the goal of treatment were also observed during commitment to empiricism in evaluating the the session; we will elaborate on the significance effects of the treatment. Applied behavior of this later. There were, of course, equivalent analysis is more narrowly defined as the numbers of papers on desensitization and application of operant conditioning laboratory classical conditioning applications and it was not principles to treating and solving human unusual for individual papers to have references problems - in other words, the Skinnerian based to both. treatment approach. Although both are applications of Skinnerian operant principles to Given that applied behavior analysis real human problems, CBA is distinct from was a foundation of behavior therapy and had a applied behavior analysis in that it focuses on strong presence both in AABT and in its journal, This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. outpatient "talk" therapy, whereas applied it might well have continued playing a This document is copyrighted by the American Psychological Association or one of its allied publishers. behavior analysts pay very little attention to such substantial role. However in the 1980s and therapy. AABT is the dominant 1990s, through an unexpected, curious turn of professional/scientific organization to which events, applied behavior analysis became a behavior therapists belong and, with its journal, minor presence in the pages of Behavior Behavior Therapy, is the primary voice of Therapy (with the notable exception discussed behavior therapy. later in this paper) though AABT, with over 4000 members, had grown and prospered. Most In 1966, during CBA’s quiescent period, behavior analysts now belong to the Association AABT was established, and its journal, Behavior for Behavior Analysis and publish their work in Therapy, came into existence in 1969. Although another journal, the Journal of Applied Behavior CBA was quiescent, applied behavior analysis Analysis. Our explanation for this turn of events was not. In fact, applied behavior analysis is closely related to the quiescence and eventual played a very significant role in the development renaissance of CBA. of behavior therapy during these early years. Applied behavior analysis was considered one of First, behavior therapists became the two pillars of behavior therapy, the other increasingly interested in working with adults in being desensitization and classical conditioning the outpatient psychotherapy environment. based treatments. Applied behavior analysts, on the other hand, mainly worked in settings that differed from the During this period, behavior analysis typical psychotherapy office. Further, the kinds was in the mainstream of behavior therapy. of problems that applied behavior analysts dealt There was a virtual explosion of research on with were not typical problems of the adult behavior change techniques based upon operant outpatient such as depression, problems of the principles (e.g., Ayllon & Azrin, 1965; O'Leary self, difficulties in intimate relationships, and & Becker, 1967; Wolf, Risley, & Mees, 1964). existential anxiety. Instead the behavior analyst In the years 1970 to 1978, a casual tabulation of was extremely effective in treating problems the papers published in Behavior Therapy such as head banging, poor math performance, showed that about 40% of the empirical and hyperactive school children, tics, mutism, towel treatment papers referred to the operant terms hoarding, and lack of rudimentary self care skills contingency, reinforcement, extinction, or in hospitalized patients with schizophrenia. So, discriminative stimulus. Many of the published given the growing interest in adult outpatient graphs were cumulative records (a favorite of problems and the seeming inappropriateness of behavior analysts) that showed a baseline applied behavior analysis, behavior therapists condition, a reinforcement condition, and an became less interested in applied behavior extinction condition. These graphs showed how analysis. Even more telling, many applied the therapist's within-session actions (e.g., behavior analysts left the fold and turned to applications of reinforcement and punishment, cognitive therapy for guidance in doing office- shaping, exposure to feared stimuli) produced 249  K O H L E N B E R T , B O L L I N G , K A N T E R & P A R K E R based treatment (Hawkins, Kashden, Hansen & effective in devising treatments that addressed Sadd, 1992). the daily life problems of adult outpatients. The abandonment of the Skinnerian Thus we agree with Wulfert, in this approach in mainstream behavior therapy was series, that that particular form of the Skinnerian based on an unfortunate and misguided approach failed to meet an important need for assumption. The process was as follows: First it expanding the scope of behavior therapy. We was correctly concluded that applied behavior also agree that this failure set the stage for the analysis was effective for a wide variety of so-called "cognitive revolution," because problems ranging from self destructive cognitive therapy easily lent itself to office behaviors in severely disturbed children to treatment. problematic learning difficulties of children in classrooms. Second it was clear that the kinds The Renaissance This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. of problems that applied behavior analysis was This document is copyrighted by the American Psychological Association or one of its allied publishers. used for all had one thing in common, namely Unfortunately, the fact that problematic the focus on actual within-session occurrences client behavior actually occurs in the office was of the client's problematic behavior and overlooked by most behavior analysts. One improvement. That is, in order to use operant reason for this oversight was that behavior techniques, the therapist had to observe the analysts were focusing their efforts in other problematic behavior directly, deliver the settings. They were doing very well with the rewards and punishments, and actually see the populations in institutions such as school behavior change. Third, it was assumed that classrooms, mental hospitals and even whole most of the problems presented by outpatient communities. But Behavior Therapy stopped adults, such as "difficulties in intimate publishing this kind of work because the relationships" or "depression," or "anger" readership had more interest in office treatment, occurred only outside the therapy session in their so cognitive therapy papers appeared with daily life and could not be observed and increasing frequency. We suspect that those reinforced directly by the therapist during applied behavior analysts who didn’t embrace typical office treatment. This last assumption, the cognitive perspective, left AABT and joined we believe, was erroneous. the Association for Behavior Analysis, published in their own journal (The Journal of In addition to this erroneous conclusion, Applied Behavior Analysis) and more or less there were other barriers that deterred behavior abdicated their role in outpatient treatment to therapists from using Skinnerian based methods cognitive therapists. for outpatient adults. Some applied behavior analysts themselves uncritically accepted the This situation set the stage for a erroneous conclusion and, as discussed by renaissance of clinical behavior analysis. How Hawkins et al. (1992), became cognitive did we get back on track? From our perspective, therapists. Others inappropriately used operant the watershed event in this whole clinical techniques with adults that further added to the behavior analysis area was Steve Hayes’ work prevailing misconception that behavior analysis (Hayes, 1987; Zettle & Hayes, 1982;). He took had little to offer in the adult treatment arena. Skinner's Verbal Behavior (1957) and applied it For example there were procedures such as to outpatient individuals while investigating the contracting, e.g., “I'll fine you a nickel if you underlying principles with corresponding don't do this and that kind of behavior or if you laboratory work. For the first author, weren't nice to your wife”, or only paying Kohlenberg, Hayes’ work was an eye opener, attention to a client with depression if they were because early in his own career during the smiling, or asking a husband to earn points for 1970s, he was a radical behaviorist at heart, but taking out the garbage that could be redeemable was unable to use Skinnerian principles when for sex with his wife. So, during the early years doing outpatient treatment. At that time, it was of behavior therapy and continuing till just difficult to conceptualize outpatient treatment in recently, applied behavior analysts were not very Skinnerian terms because the framework wasn’t 250  T H E B E H A V I O R A N A L Y S T T O D A Y V O L U M E 3 , I S S U E 3 , 2 0 0 2 there. Then Steve Hayes’ work changed that. of behavior therapy there was almost no interest There were many other contributors who added in theory. Now with all the behavioral to this, but it was a concentrated effort on his procedures that were developed, a horrendous part that made the critical difference. This question arose, "When do you use which symposium that is gathered here today is a direct procedure for what kind of person?" result of Hayes’ application of radical behavioral principles to outpatient treatment. Now there is In fact, this is a big question for all a way for behavior analysts to start talking about therapies, and we behavior analysts are actually what goes on in a talk therapy situation. in a good position to answer it. There is nothing in a behavior analytic approach that rules out Behavior therapists abandoned applied any procedure. We can do anything. We might behavior analysis and the idea of using the conceptualize it in different terms than a Skinnerian approach, as we said, due to an cognitive therapist might, but basically we can This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. erroneous conclusion that problems presented by embrace every treatment procedure that AABT This document is copyrighted by the American Psychological Association or one of its allied publishers. outpatient adults do not occur in the therapy has ever had presented at conventions or session. We do not think that the therapy published in their journal. We can fit it into a environment actually differs significantly from theoretical structure and solve the problem of the client’s daily life environment. On the deciding which procedure to use. The idea that contrary, we contend that most people's daily behavior analysis offers an integrative treatment life problems are the same kinds of problems approach is very compelling. There really isn't that occur in-vivo, during office treatment. In any other theory or theoretical approach that can daily life, our problems have to do with relating embrace every procedure, from cognitive to other people, and therapy requires the client interventions to free association. Kohlenberg & and therapist to relate to one another. Tsai (1994), who used CBA to embrace Functionally speaking, the way you know psychoanalytic and cognitive therapy whether a client-therapist environment is the procedures, demonstrated the integrative same or different from the environment on the possibilities of this approach. outside is whether or not it evokes the same kinds of problems the client reports having The Bright Future for CBA outside of therapy. And in fact, if therapists take a functional view of client behavior, they see There has been a recent spate of reports that the same kinds of client problems actually showing that medication is better than do happen in the office as in daily life. That's psychosocial treatment for a variety of disorders because the therapy situation is part of daily life: such as depression. If medication is in fact it’s not separate from the natural world. That better, then it's not a problem. But many of us being the case, the behavior analyst who's used think that psychosocial treatments could be to working with behavior as it occurs in a better and are preferable in the long run. Now classroom or Skinner box, actually has the same what's the solution to the problem? We must opportunity to do something with on-going develop more powerful treatments. Again, client behavior in the outpatient therapy office. looking at the last two 1997 issues of Behavior Therapy, the innovative treatments with promising futures that were mentioned the most A Grand Theory for Behavior Therapy came from the behavior analytic tradition. We contend that there is a need in AABT and in behavior therapy in general for We're in a position to offer something what CBA has to offer. As we see it, the major new to the field. One strategy for doing that is to problems facing the AABT membership with its build upon something that's already there. This current emphasis on cognitive therapy and is fairly easy to do if you look at the integrative empirically validated treatments include the lack power of behavioral analysis referred to above. of a coherent theoretical base that can embrace As a case example, we have done a behavioral all of the techniques used by behavior therapists analysis of cognitive behavior therapy for (Branch, 1987). During the rapid growth period depression and have come up with some very 251  K O H L E N B E R T , B O L L I N G , K A N T E R & P A R K E R promising improvements that should enhance 1.8 efficacy. One such improvement is based on the 1.7 notion that maximum change occurs when improvements in the client's behavior are 1.6 Use of the therapist client relationship reinforced as they occur, within the therapist- 1.5 client relationship. For example, a client who feels isolated because s/he always needs to 1.4 appear strong, competent and in control, 1.3 happens to admit a fear or a weakness to the 1.2 therapist. If the therapist responds honestly that s/he feels closer to the client as a result of this 1.1 CT disclosure, that this may help the client to risk 1.0 FECT making such a disclosure with selected others 4 8 12 16 This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. outside of therapy, consequently feeling less Session This document is copyrighted by the American Psychological Association or one of its allied publishers. isolated. In other words, an in-session, directly Figure 1. Use of the therapist client relationship in sessions 4, 8, observable client behavior (admitting a 12, and 16 for clients receiving either Cognitive Therapy (CT, weakness to the therapist) occurred and was n=15) or the functionally-enhanced Cognitive Therapy (FECT, immediately reinforced2. We have been n=23). The use of the therapist client relationship was measured by trained raters using the Therapist In-vivo Strategies Scale conducting an NIMH treatment development (Parker, Bolling, & Kohlenberg, 1996) on videotapes of therapy study to find out if these in-vivo enhancements sessions from the NIMH treatment development study. High could be implemented. Although the study is scores indicate more use of the client-therapist relationship. not yet completed, preliminary results indicate that experienced cognitive therapists can learn Behavior analysis can even help with how to do the enhanced treatment. As shown in problems that are perplexing to cognitive Figure 1, therapists doing the enhanced therapists regarding such issues as cognitive treatment with clients with depression make structures, cognitive products, and automatic much more use of the therapist-client thoughts, specifying exactly how they differ and relationship as an in-vivo example of their daily how to change them (Kohlenberg & Tsai, 1991). life problems. We have some very good solutions to these questions that are based on distinctions between rule-governed and contingency-shaped behavior. So, not only can we improve treatment but we can also help cognitive therapy and make some friends. We agree with Wulfert that we need to reach out, offer something, and learn something, rather than just being critical of our AABT brothers and sisters. Our study on enhancing cognitive behavior therapy has shown what a good treatment cognitive therapy is and how difficult it is to do properly. We employed experienced cognitive behavior therapists and have learned to appreciate what they do. It is actually a very good treatment: it's easy to undersell cognitive therapy if you don't see it in action and appreciate how difficult it is to do properly. Although behavior analysis was out of the picture till very recently we think the current status is good, based on certain bits of evidence. 2 Technically, the event is not known to be reinforcing until First of all, Steve Hayes is the president of we can observe future occurrences of the client behavior in AABT and a behavior analyst. Not only that, question. 252  T H E B E H A V I O R A N A L Y S T T O D A Y V O L U M E 3 , I S S U E 3 , 2 0 0 2 but Neil Jacobson, a recent radical behavioral Ferster, C.B. (1979). A laboratory model of psychotherapy. In P. convert, chided the audience in his 1991 AABT Sjoden (Ed.), Trends in behavior therapy. New York: Academic Press. presidential address that AABT wasn’t Hawkins, R.P., Kashden, J., Hansen, D.J., & Sadd, D.L. (1992). behavioral anymore and had ignored functional The increasing reference to "cognitive" variables in behavior analysis. Secondly, if you look at AABT therapy: A 20-year empirical analysis. The Behavior programs, you'll find there are more and more Therapist, 15, 115-118. behavior analysts actually presenting at AABT. Hayes, S.C. (1987). A contextual approach to therapeutic change. Third, more evidence can be found in the last In N. S. Jacobson (Ed.), Psychotherapists in clinical practice: two issues of the 1997 Behavior Therapy. These Cognitive and behavioral perspectives (pp. 327-387). New issues were devoted to an assessment of the last York: Guilford Press. 30 years and the future of AABT and behavior Jacobson, N. S. (Ed.). (1987). Psychotherapists in clinical practice: Cognitive and behavioral perspectives. New York: Guilford therapy. Interestingly enough, they were edited Press. by two behavioral analysts, Rob Hawkins and Kohlenberg, R.J., & Tsai, M. (1987). Functional analytic This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. John Forsyth, good evidence that clinical psychotherapy. In N. S. Jacobson (Ed.), Psychotherapists in This document is copyrighted by the American Psychological Association or one of its allied publishers. behavior analysis once again has a strong clinical practice: Cognitive and behavioral perspectives (pp. presence in AABT. Some may not like the idea 388-443). New York: Guilford Press. that we are using "influencing AABT or being in Kohlenberg, R.J., & Tsai, M. (1991). Functional analytic AABT" as a measure of the health of CBA. But psychotherapy: A guide for creating intense and curative given the size and influence of AABT, it's a therapeutic relationships. New York: Plenum. meaningful measure. Fourth, if you look Kohlenberg, R.J., & Tsai, M. (1994). Functional analytic through those last two 1997 issues of Behavior psychotherapy: A behavioral approach to treatment and integration. Journal of Psychotherapy Integration, 4, 175- Therapy, it's remarkable how much attention is 201. being given to behavior analysis by mainstream Kohlenberg, R.J., Tsai, M., & Dougher, M.J. (1993). The behavior therapists. References to Kohlenberg dimensions of clinical behavior analysis. The Behavior & Tsai and Hayes are frequent. That's evidence Analyst, 16, 271-282. that clinical behavior analysis is more present O'Leary, K.D., & Becker, W.C. (1967). Behavior modification of than it has been since the very early years. So an adjustment class: A token reinforcement program. our assessment is that the current status of CBA Exceptional Children, 33, 637-642. is good and our future is bright. Parker, C.R., Bolling, M.Y., & Kohlenberg, R.J. (1996). Therapist in-vivo strategy scale. 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Rule governed behavior: A Psychiatry, 4 (2), 101-111. potential theoretical framework for cognitive-behavioral therapy. In P. C. Kendall (Ed.), Advances in cognitive Ferster, C.B. (1972b). An experimental analysis of clinical behavioral research and therapy (Vol. 1). New York: phenomena. The Psychological Record, 22, 1-16. Academic Press. Ferster, C.B. (1972c). Psychotherapy from the standpoint of a behaviorist. In J. D. Keehn (Ed.), Psychopathology in animals: Research and clinical implications. New York: Author Note: Address editorial correspondence to: Robert J. Academic Press. Kohlenberg, Director of Clinical Training, Department of Psychology 351635, University of Washington, Seattle, WA. 98195-1635. Email: [email protected] 253