Guinther and Dougher (2013) PDF: From Behavioral Research to Clinical Therapy

Chapter 1 From Behavioral Research to Clinical Therapy Paul M. Guinther and Michael J. Dougher In this chapter, we provide an overview of the his- Historical Overview of CBA torica...

Chapter 1 From Behavioral Research to Clinical Therapy In this chapter, we provide an overview of the his- torical and conceptual development of clinical behavior analysis (CBA), characterize the transla- tional research most relevant to CBA, and describe the specific CBA therapies informing and informed by translational research. Although the term lational research is sometimes used in different ways (e.g., see Hake, 1982; Lerman, 2003; Mace, 1994; McIlvane, 2009), for our purposes we describe it as the investigation of the role of known behavioral principles in understanding more complex social and clinically relevant behav- ior as well as the identification of behavioral ciples that are necessary to account for complex human behavior. From this view, translational research is informed by both basic and applied research, thereby bridging the gap between basic findings and clinical applications at a faster than can be attained when relying on basic or applied research alone. When it comes to CBA, the preponderance of current translational research involves the mental analysis of verbal behavior and the behav- ioral processes that underlie it. In particular, informs and is informed by translational research on rule governance, the indirect acquisition and transformation of stimulus functions via derived stimulus relations, and relational responding. Before delving more deeply into the relevant lational research and the therapies that CBA, we begin with a historical and conceptual overview of CBA. DOI: 10.1037/13938-001 APA Handbook of Behavior Analysis: Vol. 2. Copyright © 2013 by the American Psychological Guinther and Dougher However, for all of its successes with these popu- lations, ABA remains limited in its applicability to the more traditional problems in clinical psychology and psychiatry, such as adult depression, anxiety disorders, and adjustment disorders (Dougher & Hayes, 2000; Kohlenberg, Tsai, & Dougher, 1993). The clinical problems faced by verbally competent adults often involve complex verbal processes that are not readily or adequately addressed by ABA’s direct contingency management procedures. In addition, therapists in typical outpatient settings have very limited access to or control over reinforce- ment contingencies outside the therapeutic context. Although Skinnerian psychology readily lent itself to application in the form of ABA, the extension of ABA to the treatment of traditional clinical problems was conceptually and practically limited (Kohlen- berg et al., 1993). Given the limitations of ABA, behaviorally ori- ented clinicians in the 1950s and 1960s who were interested in working with verbally competent adults in outpatient settings turned to or were part of the growing behavior therapy movement. Although behavior therapy shared with ABA an adherence to “empirically defined learning theory and conformity to well established experimental paradigms” (Franks & Wilson, 1974, p. 7), it was based on the methodological behaviorism of stimulus–response psychology (Mahoney, Kazdin, & Lesswing, 1974). In the late 1970s, behavior ther- apy went through a major change as stimulus– response theory merged with cognitive psychology. The change was not so much in terms of underlying philosophy, because both were essentially mechanis- tic and structuralistic (Dougher & Hayes, 2000), but rather in terms of a new mechanical metaphor, the computer, that guided theory and research. Mental- istic and mediational accounts of behavior change (e.g., Bandura, 1969) began to emerge and quickly grew into the cognitive–behavioral therapy (CBT) movement (Mahoney, 1974; Meichenbaum, 1977). Rather than grounding causality in operant and respondent contingencies, CBT views thoughts, feel- ings, and other mental or cognitive events as causal. Specifically, mental events are said to mediate the relation between the environment and behavior. Thus, the targets of intervention in CBT are the 4 never actually encountered. Likewise, individuals diagnosed with depression tend to selectively attend to and remember depressing events and often inter- pret seemingly neutral or even positive events tively. Clients’ behavior often seems to by rules, instructions, or inferences, even are in conflict with experience or with existing rein- forcement contingencies. Laboratory studies of sim- ple operant behavior provided little help for the clinician attempting to understand these complex sources of control. Fortunately, in the 1980s and 1990s a resurgence of behavior-analytic research on verbal behavior and cognition began to provide a nonmediational and functional account of the kind of complex behavior that is commonly seen in clinical contexts. Thus, although the conceptual foundations of CBA can be found in Skinner (1957), Ferster (1972a, 1972b, 1973), and Goldiamond (1974/2002), its empirical roots are equally planted in more recent areas of research. This is not to say that CBA eschews direct contingency management procedures, but given its focus on verbally competent clients in outpatient settings, its development was dependent on a more developed behavior-analytic understanding of verbal processes. Perhaps the first fully articulated behavior- analytic outpatient therapy was Israel Goldiamond’s constructional approach to therapeutic change (Goldiamond, 1974/2002; Schwartz & Goldiamond, 1975). The more modern CBA therapies include functional analytic psychotherapy for enhancing the impact of therapeutic relationships (Kohlenberg & Tsai, 1991); integrative behavioral couples therapy for increasing the quality of romantic relationships (Christensen, Jacobson, & Babcock, 1995; Jacobson & Christensen, 1996); dialectical behavior therapy for the treatment of borderline personality disorder and other severe problems (Linehan, 1993); behav- ioral activation therapy for the treatment of depres- sion (Kanter, Busch, & Rusch, 2009; Lejuez, Hopko, & Hopko, 2001; Martell, Addis, & Jacobson, 2001); and acceptance and commitment therapy (ACT) for the treatment of depression, anxiety, anger, and a variety of other quality-of-life concerns (Hayes, Stro- sahl, & Wilson, 1999; see Chapter 18, this volume). Although we describe each of these therapies in Guinther and Dougher talk to me” (B) and subsequently feel rejected (C). In therapy, that person may learn to replace his or her original distorted thought with a more appropri- ate alternative thought such as, “Or maybe these people are just shy” and subsequently feel curious rather than rejected. Presumably, repeated rational corrections of maladaptive thinking eventually lead to changes in the core structures presumed to be responsible for maladaptive thoughts (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979). At this point, the core structures cease to produce distorted cogni- tive products, emotional stabilization is thereby pro- moted, and treatment is deemed successful. Contrary to a pervasive misconception, radical behaviorists do not deny the existence of thoughts (Skinner, 1974). Instead, thoughts are seen simply as instances of private behavior that, despite their lack of intersubjective observability, are not funda- mentally different from public behavior. As such, behavior analysts consider thoughts to be dependent variables rather than independent variables or causes. Thus, an analysis of thoughts focuses on their environmental determinants and their relation to other behavior or, as Hayes and Brownstein (1986) put it, behavior–behavior relations. This does not mean that thoughts are considered unimportant or epiphenomenal. What it does mean is that there is no need in CBA to alter the occurrence or content of thought for a successful therapeutic outcome. With respect to their influence on other (i.e., behavior–behavior relations), a behavior- analytic view of thoughts (memories, inferences, conclusions, etc.) is that they are instances behavior in which the speaker and listener are in the same skin (e.g., Skinner, 1957). As with private events, radical behaviorism and methodological behaviorism have fundamental and substantial dif- ferences in their perspectives on verbal behavior. In line with its inherent mechanism and structuralism, methodological behaviorism focuses on language, or the structure or form of verbal behavior. In line with its functionalism, radical behaviorism defines verbal behavior functionally (Skinner, 1957; but Barnes-Holmes, & Roche, 2001) and is not particu- larly concerned with its form. Defined functionally, verbal behavior is behavior that is maintained by audience-mediated consequences. That is, rather 6 and conditioning. On the basis of the assumption of continuity of species, it was reasonably and widely assumed throughout the 1950s that any principles found to be applicable to nonhuman animals would be equally as applicable to humans. However, start- ing in the early 1960s, evidence slowly began to accumulate showing that human participants were not behaving in ways that would be predicted by animal models. An investigation by Kaufman, Baron, and Kopp (1966) illustrated some of these unique effects. In their study, three groups of participants were told that they would earn money according to a variable-interval, a variable-ratio, or a fixed- interval schedule of reinforcement. Participants in all three groups were then actually exposed to the same variable-interval schedule of reinforcement. The investigators found that participants’ response rates were substantially influenced by what they had been told, which outweighed the influences of the actual reinforcement contingencies. Such behavior in humans was perplexing. Unlike nonhuman ani- mals, humans in laboratory studies were shown to be more sensitive to instructions than to changes in programmed contingencies of reinforcement. Humans were also found to be quite susceptible to instructions in other investigations. For example, humans were found to be relatively insensitive to changes in programmed contingencies (e.g., Ader & Tatum, 1961; Barrett, Deitz, Gaydos, & Quinn, 1987; Buskist, Bennett, & Miller, 1981; Catania, Matthews, & Shimoff, 1982; Harzem, Lowe, & Bag- shaw, 1978; Matthews, Shimoff, Catania, & Sagvolden, 1977; Shimoff, Catania, & Matthews, 1981). Conversely, humans were often found to behave efficiently when provided with instructions about the operative schedule contingencies; this effi- ciency tended to develop more rapidly than when no instructions were provided (e.g., Baron, Kaufman, & Stauber, 1969; Turner & Solomon, 1962; Weiner, 1962). Humans were furthermore found to exhibit patterns of schedule performance that were system- atically different from those of nonhuman animals (e.g., Leander, Lippman, & Meyer, 1968; Lowe, Har- zem, & Hughes, 1978; Weiner, 1964, 1969), and humans were found to exhibit greater intersubject behavioral variability than nonhuman animals when exposed to the same programmed contingencies Guinther and Dougher folk psychology and CBT (e.g., Ellis’s [1962, 1970] ABC paradigm; Beck’s schema theory). In particular, the findings appeared to support the view that thoughts or cognition control adult human behavior to a greater extent than the environment. Indeed, some theorists (e.g., Brewer, 1974) inter- preted such findings to mean that neither classical nor operant conditioning had ever been conclusively demonstrated in adult humans. Others (e.g., Ban- dura, 1971, 1974) took such findings to mean that beliefs and expectancies were at least as important as reinforcement contingencies in controlling human behavior. Clearly, if behavior analysis was to continue to be a viable paradigm, it was going to have to deal with the fact that rules and instructions seemed to exert as much control over adult human behavior as programmed contingencies. This fact led to some very interesting conceptual issues and empirical research. In particular, behavior analysts had to develop a conceptually coherent account of verbal stimuli, including self-generated and covert verbal stimuli (e.g., beliefs, expectancies, reasons, cogni- tions), and how these stimuli come to exert control over behavior. ACT and aspects of other CBA thera- pies emerged, interestingly, in the investigation of these issues, in large part through the research efforts of clinicians who regularly observed the com- plex verbal behavior of adult outpatients. Rule following is operant behavior. An important experiment conducted by Galizio (1979) demon- strated that rule following is an operant. Recall that an operant response is a class of behavior affected by its consequences. In Galizio’s experiment, human participants tended to follow experimenter- provided rules as long as there were no negative consequences for doing so. For example, in one condition, participants followed instructions to respond quickly to avoid monetary losses. This was not the most efficient way to respond (slower responding would have avoided just as many losses), but it did work; nearly all losses were avoided. Rule following decreased in a differ- ent condition, however, when responding at the instructed pace was insufficient to avoid all losses. Galizio argued that experimenter-provided rules 8 maintained by the consequences specified by the rule. For example, supposing one is instructed to meet one’s sales quota to earn a bonus, then fol- lowing the rule (meeting the quota) is an example of tracking if the reinforcer (the bonus) is respon- sible for future rule following. The participants in Galizio’s experiment could be said to be tracking if they continued to follow the instruction to respond quickly to avoid losses because doing so was fol- lowed by a loss-free period. A second class of rule following is called pliance (Hayes Brownstein, Zettle, et al., 1986; Zettle & Hayes, 1982). Pliance occurs when one follows a rule because of one’s history of socially mediated conse- quences of being compliant or noncompliant. For example, when a parent instructs a child to do his or her homework, no natural consequence of the act is specified (e.g., boredom). Instead, if rule following occurs, it probably does so because of a history of socially mediated reinforcement for compliance (e.g., the child may be allowed a snack or access to a favored television program) and a history of socially mediated punishment for noncompliance (e.g., a time out or loss of privileges). Participants in Gal- izio’s study (1979) were likely predisposed to follow instructions because of such histories. Given that rule following can be maintained by social contingencies, one would expect that rule- governed insensitivity to otherwise trackable contin- gencies of reinforcement would vary across individuals as a function of the relative strength or potentiation of the social consequences for rule fol- lowing, differential histories of reinforcement for rule compliance, or both. In particular, individuals for whom pliance has been strongly reinforced (or for whom noncompliance has been punished) may be especially likely to follow rules even when rule following leads to decreased rates of reinforcement (Wulfert, Greenway, Farkas, Hayes, & Dougher, 1994). Such histories have been posited to underlie the rigid cognitive expectations (i.e., rules) of indi- viduals who compulsively attempt perfectionism and to avoid mistakes (Beck & Freeman, 1990). To see whether individual differences in trait rigidity would predict insensitivity to programmed contingencies, Wulfert et al. (1994) first assessed participants’ trait rigidity using a questionnaire that Guinther and Dougher generate and follow their own rules. To the extent that these self-rules lead to effective behavior, then rule generation and self-rule following would be reinforced. In addition to such track-based rein- forcement for generating and following self-rules, there are inherent consequences for complying with one’s own rules (self-pliance) just as there are for complying with rules provided by others (Hayes et al., 1999). Doing what one says one is going to do or what one thinks one should do has a long history of social reinforcement in most cultures and is con- sidered a desirable and admirable personal charac- teristic indicative of high intelligence (Wegner, 2002). Taken together, these two sets of reinforce- ment contingencies can establish a sense-making repertoire that is pervasive and leads individuals to generate rules and stick with them, even when they are not particularly effective. Persistent ineffective behavior is at least partly definitional of clinical disorders. Virtually all forms of cognitive therapy hold that adhering to ineffective rules underlies clinical disorders. CBT encourages clients to adopt or generate new rules that, if prop- erly constructed, could place clients in contact with actual contingencies (e.g., through the correction of cognitive distortions). How is CBA different? To answer this, we must first articulate how verbal stimuli influence behavior. That is, although studies such as Galizio’s (1979) have demonstrated that rules can be discriminative for the operant behavior of rule following, such studies have not fully illumi- nated how rules alter the functions of the elements of the contingencies they specify (see Dulany, 1968; Parrot, 1987; Schlinger, 1990, 1993; Zettle & Hayes, 1982). An articulation of function alteration via ver- bal processes will go beyond the prevalent assump- tion in mainstream psychology and the general culture that thoughts are causal. Behavior-analytic research examining how verbal stimuli influence behavior is sometimes not intuitive. However, this research has widened researchers’ understanding of the causal conditions under which cognitions come to exert stimulus control, thereby revealing thera- peutic alternatives to the CBT approach to rules and other cognitions. Research on the environmental determinants of function alteration via rules and cognitions, described in the following sections, 10 function, and investigators test to see if that func- tion is indirectly acquired by other members of the same class but not by members of the other classes. For example, Dougher, Augustson, Markham, Greenway, and Wulfurt (1994) used a matching-to- sample training procedure to establish two four- member classes consisting of unfamiliar figures (i.e., A1, B1, C1, D1 and A2, B2, C2, D2), in which the A stimuli were conditional for the selection of the B, C, and D stimuli (i.e., A–B, A–C, and A–D matching was directly reinforced for the Class 1 and Class 2 stimuli). After participants reached the matching-to- sample training criterion, they were given tests with- out feedback to determine whether the training had in fact established equivalence relations. Participants passed tests of symmetry (i.e., emergent B–A, C–A, and D–A matching was demonstrated with the Class 1 and Class 2 stimuli) and transitivity (i.e., emergent B–C, C–B, B–D, D–B, C–D, and D–C matching was demonstrated with the Class 1 and Class 2 stimuli), thereby demonstrating the formation of two equiva- lence classes (see Sidman, 1994; Sidman & Tailby, 1982). Next, a classical conditioning paradigm was used to directly alter the function of the B1 and B2 stimuli. B1 acquired a positive conditioned stimulus function because its presentation was followed with a mild electric shock. B2 acquired a negative condi- tioned stimulus function because it preceded a shock-free period. Skin conductance level served as the measure of conditioning. After this direct acqui- sition of stimulus functions by the B stimuli, skin conductance was measured when C1, D1, C2, and D2 stimuli were presented in the absence of shock (A1 and A2 stimuli were not presented because they had been directly related to the B1 and B2 stimuli, respectively, during the initial matching-to-sample training). For most participants, C1 and D1 elicited higher skin conductance levels than either C2 or D2, despite the fact that C1 and D1 had never been paired with electric shock. That is, C1 and D1 indi- rectly acquired the fear-eliciting function of B1 because of their common class membership, as pro- duced by arbitrary matching-to-sample training. In a similar study, Roche and Barnes (1997) demon- strated the transfer of sexual arousal through stimulus classes. These studies begin to offer an explanation for how events can acquire and lose Guinther and Dougher participants were presented with the B, C, and D stimuli from both classes in extinction (i.e., no shock was delivered even if participants failed to emit the avoidance response). Despite never having been paired with shock and not being included in avoidance training, both C1 and D1 evoked avoid- ance responding in all participants. As was the case with B2, neither C2 nor D2 evoked avoidance responding. In addition to the transfer of emotion-eliciting and avoidance-evoking functions among members of stimulus equivalence classes, investigators have demonstrated the transfer of a substantial number of other stimulus functions, including contextual stimulus control (Gatch & Osborne, 1989; Kohlen- berg, Hayes, & Hayes, 1991), conditional control (Roche & Barnes, 1996; Wulfert & Hayes, 1988), discriminative control (Barnes & Keenan, 1993; de Rose, McIlvane, Dube, Galpin, & Stoddard, 1988; Roche, Barnes-Holmes, Smeets, Barnes-Holmes, & McGeady, 2000), conditioned reinforcement and punishment (Greenway, Dougher, & Wulfurt, 1996; Hayes, Kohlenberg, & Hayes, 1991), ordinal control (i.e., first, second; Green, Sigurdardottir, & Saun- ders, 1991; Lazar 1977; Lazar & Kotlarchyk, Wulfert & Hayes, 1988), and instructional control (McGuigan & Keenan, 2002). Taken together, these studies have provided convincing evidence that a wide range of Pavlovian or operant functions can transfer between equivalent stimuli via derived stim- ulus relations. To return to our earlier question of how verbal stimuli affect behavior, a plausible explanation develops if one assumes that words and other verbal stimuli (whether spoken, written, drawn, thought, pictured, imagined, etc.) are in equivalence relations with corresponding events or objects (i.e., refer- ents). The research just cited has suggested that ver- bal stimuli can elicit emotions and evoke operant behavior when the stimuli directly or indirectly acquire the stimulus functions of their emotion- eliciting or operant-evoking referents. Words such as death, vomit, murder, torture, love, peace, and calm are all likely to have directly and indirectly acquired stimulus functions; they can elicit many of the same kinds of emotional reactions and evoke many of the same kinds of actions as their equivalent referents. 12 important to provide an overview here to illustrate its translational and clinical relevance. To respond to a relation or to respond relation- ally is to respond to one stimulus in terms of another. Most organisms can learn to respond to physical relations among stimuli, as when a rat learns to enter the brighter or darker of two runways or a pigeon learns to peck the brighter or darker of two keys, regardless of their absolute brightness (see Reese, 1968; Skinner, 1953). Relational responding, however, can also be established with arbitrary rela- tions among stimuli, for example, when humans learn that a name is equivalent to an object (e.g., the word cup and a cup), that the numeral 10 is greater than the numeral 5, or that the word white is the opposite of the word black. These relations are arbi- trary in that they are defined by social convention rather than by the physical features of the stimuli. A critically important feature of RFT is that arbitrary relational responding as typically seen in humans is itself hypothesized to be a contextually controlled generalized operant class that emerges as a result of extensive formal and informal multiple-exemplar training over several years and in many contexts (Luciano, Becerra, & Valverde, 2007). That is, responding relationally is differentially reinforced in certain contexts or in the presence of certain cues, and over time, those contextual cues come to occa- sion relational responding. As a naturalistic example of the learning history thought to be responsible for arbitrary relational responding, a child presented with a relatively small cat and a large dog is asked, “Which of these is big- ger?” and is reinforced for picking the physically larger dog. The child is then asked, “Which of these is smaller?” and is reinforced for picking the physi- cally smaller cat. Later, the child may be presented with a relatively small toy car and a larger ball, asked again to identify which is bigger and which is smaller, and reinforced for the appropriate selection. After many such instances of reinforced responding in the context of the words bigger and smaller, the child comes to occasion the correct selection between any two stimuli. The words bigger and smaller can then be used to condition arbitrary rela- tionships, as when a child is reinforced for picking a dime over a nickel when asked, “Which is bigger?” Guinther and Dougher is, the function will transform into punishment in accordance with the relational frame of opposition To reiterate, by definition the transfer formation of stimulus functions results from ing in the behavior of arbitrarily applicable relational responding. However, exactly which trary stimulus relations will influence behavior, exactly which functions will transfer or be trans- formed, can be brought under contextual control (Dougher, Perkins, Greenway, Koons, & 2002; Wulfert & Hayes, 1988), permitting degree of behavioral flexibility with regards tional responding. Roche and Barnes (1997) conducted an early lab- oratory investigation of function transformation in accordance with stimulus relations other than equivalence. They began by replicating the Dougher et al. (1994) finding that members of a stimulus equivalence class could indirectly acquire eliciting functions, in this case showing a transfer of the arousing functions of filmed sexual stimuli. Skin resistance, measured by polygraph, served as the dependent measure. With respect to nonequivalence relations and the transformation of stimulus func- tions, Roche and Barnes implemented a training procedure resembling Steele and Hayes’s (1991) procedure for establishing a network of same and opposite relations among various experimental stim- uli (see Figure 1.1). During pretraining, participants learned to respond to the nonarbitrary relations same and opposite in the presence of arbitrary same (S) and opposite (O) contextual stimuli, respectively (the actual contextual stimuli were repeated charac- ters: !!!!!! and %%%%%%). For example, given S as a contextual stimulus, a short line as a sample, and short, medium, and long lines as comparisons, par- ticipants were reinforced for selecting the short line. In contrast, given this same problem but with O as a contextual stimulus, participants were reinforced for selecting the long line. The S and O contextual stim- uli then were used to train a set of arbitrary relations between five other stimuli (i.e., A1 same B1, A1 same C1, A1 opposite B2, and A1 opposite C2). After suc- cessful direct training, several derivable relations were tested and shown to be derived (i.e., B1 same C1, B2 same C2, B1 opposite C2, and B2 opposite C1; see Figure 1.1). Next, a counterbalanced 14 transformation of the B2 punishing function in accord with the relation of opposite. More recent studies using comparable proce- dures (Dymond, Roche, Forsyth, Whelan, & Rho- den, 2007, 2008) have shown the transformation of avoidance and nonavoidance functions in line with the relations same and opposite. As in earlier stud- ies, a relational network was first established in which A1 was the same as B1 and C1 but was the opposite of B2 and C2 (see Figure 1.1). In the sig- naled avoidance task that followed, participants learned to press a button in the presence of B1 to prevent the presentation of aversive images and sounds; presentations of B2 were followed by the presentation of nonaversive images and did not lead to avoidant responding. Thereafter, participants engaged in avoidance responding in the presence of C1 but not in the presence of C2, demonstrating the transformation of avoidance and nonavoidance functions. In a follow-up investigation, Roche, Kanter, Brown, Dymond, and Fogarty (2008) first replicated their demonstration of a network transformation of avoidance (B1 to C1, not C2) and nonavoidance (B2 to C2, not C1) functions. They then disabled the avoidance response button and presented the exper- imental stimuli in extinction. In a direct extinction group (n = 9), the response button was disabled and presentations of B1 and B2 ceased to be fol- lowed by images or sounds. In a derived extinction group (n = 9), the response button was disabled and presentations of C1 and C2 were not followed by images or sounds. After the extinction phase, all participants were exposed to all four stimuli, and avoidance responses were recorded in extinction. In the direct extinction group, only one participant did not avoid B1, whereas two participants did not avoid C1. Within the indirect extinction group, five partic- ipants did not avoid B1, whereas eight participants did not avoid C1. If these surprising results are rep- licable, they raise a question for further translational research on extinguishing avoidance behavior: Are there circumstances in which derived exposure (e.g., talking about a feared event) could produce therapeutic gains that are comparable or even supe- rior to direct exposure (e.g., being in the presence of a feared event)? Guinther and Dougher skin conductance response to the A stimulus and higher skin conductance responses to the C stimu- lus than they did to the directly conditioned B stim- ulus. All participants reported that they expected to receive a larger shock to C than to B, despite the fact that C had never been paired with shock. One par- ticipant became so alarmed at the presentation of the C stimulus that she tried to remove the shock electrodes from her arm, fearing that the shock would be too severe. These results demonstrated that, along with their discriminative functions, the fear-eliciting functions of A and C stimuli had been transformed in line with their respective relation to the B stimulus. Roche and Dymond (2008) reported similar results with sexually arousing stimuli. Verbal Behavior and the Clinical Relevance of RFT According to Hayes et al. (2001), “The primary pragmatic purpose of the analysis of derived relations... is an analysis of the development of verbal rules (e.g., through thinking, reasoning, and problem-solving), and the use of verbal formulae to guide behavior” (pp. 104–105). As mentioned, rules often allow for greater prediction and control of events, and the generation, derivation, and following of rules may therefore be reinforced as operant behav- ior (Hayes et al., 2001). At the same time, people’s social environments often require and reinforce the formulation of complete and coherent narratives about their actions and the events in their lives. Skinner (1953, 1974) suggested that this verbal behavior is the basis of the development of self- awareness. Social demands for coherent narratives about one’s own behavior require discrimination of oneself from the rest of the environment and that the narratives one generates fit with culturally acceptable explanations. To respond to such ques- tions as “Where are you going?” or “How do you feel?” or “What do you intend to do tomorrow?” the responder must first be able to discriminate him- or herself from other objects and events in the environ- ment. A fundamental assumption of both ACT and RFT is that networks of derived stimulus relations play a critical role in this process and give rise to an abstracted, reified, and transcendent sense of self. 16 resulting statements such as “I feel depressed” do not occur in isolation. Once said, “I,” which to be a real entity, is placed in an equivalence tion with “depressed,” which, by virtue culture in which depression is considered an equivalence relation with “bad.” Through natorial entailment, “I” is then equivalent which, via function transformation, has the to elicit other negative private events and alter the functions of otherwise reinforcing activities (Dougher & Hackbert, 1994). Many clients attempt to solve such problem in the ways they have successfully solved other prob- lems in their lives. In particular, one often forced problem-solving strategy is to remove the determinants of the problem. Coupled with a history of reinforcement for attributing the self and private events, “I am depressed” rally leads to the conclusion that “I have of this depression” and other related rules can’t do anything else until I don’t (Hayes et al., 1999, 2001). At an extreme, a rule requiring the elimination of depressive feeling entail an elimination of the self as a viable (i.e., suicide). Attempts to eliminate feelings ness or depression can take many forms, but these attempts are often not very helpful or healthy, cisely because the actions that are likely the depression, such as engaging in productive, ued activities, are contradicted by self-generated rules or are depotentiated as reinforcers by the events that cause the depression in the first (Dougher & Hackbert, 1994). In other words, depressed individuals just do not feel like in previously reinforcing activities. Instead, may attempt experiential avoidance (e.g., through social withdrawal, excessive sleeping, self-medica with alcohol or drugs) or spend time trying (ruminate) their way out of the problem. Paradoxi- cally, because of the equivalence relations words and their referents and the attendant of functions, attempting to verbally control events only makes them more likely to occur (see also Wegner, 1994), and one may be better off accepting private experiences rather than to alter their occurrence (Hayes et al., 1999; see Chapter 18, this volume). Guinther and Dougher total control approach is neither pragmatic nor ethical. Instead, a constructional therapist attempts to influ- ence client behavior only insofar as it helps clients bring their behavior under their own control and helps them achieve their own goals. More important, the objectives of a construc- tional treatment agreement are to be framed in positive rather than negative terms (Goldiamond, 1974/2002; Schwartz & Goldiamond, 1975; see also Delprato, 1981; Fleming, 1984). Using the U.S. Constitution as an analogy, Goldiamond (1974/2002) noted that the framers sought to ensure domestic tranquility, not prevent unnecessary vio- lent revolts. More literally, CBA therapists seek to ensure valued activity, not prevent undesirable thoughts and behavior. Framing outcomes in nega- tive terms is what Goldiamond referred to as an eliminative approach. Under an eliminative approach, patients were often diagnosed according to their socially undesirable patterns of behavior, with successful treatment defined in terms of the elimination of those behavioral patterns. The gen- eral problem with an eliminative approach is that there are typically many ways to eliminate an unwanted behavior, but there is no guarantee that it will be replaced by desirable or more effective behavior. For example, under an eliminative approach, the successful treatment of stuttering would be defined as its elimination (or reduction). Sedation, punishment, and even surgical removal of the tongue and larynx would all eliminate stuttering, but none would be expected to result in more fluent speech. Indeed, one far too frequently used therapy of the 1960s for the treatment of disturbing behav- iors was frontal lobotomy, a surgical procedure that was highly successful at eliminating behaviors but far less effective at constructing effective repertoires. In contrast, a constructional approach to stutter- ing entails promoting fluid speech. In the case of depression, it amounts to switching from the goal of eliminating depressive thoughts and feelings to the goal of promoting valued, personally meaningful activity. The latter is important; a therapist could unilaterally impose a positively framed construc- tional program, but there would be no guarantee that this program would reflect the client’s values. Thus, the construction of therapeutic outcomes 18 The third commonality among CBA therapies is that they tend to emphasize experience and experi- ential learning over rules and rule governance. Cli- ents are encouraged to set aside their verbal defenses and justifications for their actions in favor of direct evaluation of whether their actions are leading to valued outcomes. An important aspect of this pro- cess is clients’ discrimination of the actual results of their own rule following. As such, CBA therapists do not seek to specifically develop better rules (thoughts, beliefs) for the client to live by. Instead, therapy focuses on helping clients experientially evaluate their customary ways of behaving, includ- ing their ways of thinking, in terms of whether they facilitate or detract from valued outcomes. The fourth commonality is that CBA therapies encourage clients to accept experiences and situa- tions that cannot be changed, that is, for which there can be no effective action. Especially within ACT (Hayes et al., 1999; cf. Martell et al., 2001), this acceptance includes the painful or negative thoughts, emotions, or memories that inevitably arise as humans interact in the world. It should not be interpreted as reflecting a cynicism or pessimism about the human condition or a kind of Nietzschean no-pain, no-gain philosophy. Rather, it is more in line with Zen Buddhist teachings; although pain is inevitable, suffering is the result of verbal distortions of the world and people’s beliefs that the world should be different than it is. Human suffering is exacerbated by struggling against what is and attempting to control what cannot be controlled. Among the CBA therapies, ACT (see Chapter 18, this volume) has the most developed perspective on acceptance. On the basis of basic laboratory research on rule governance, transformation of function, and RFT, ACT makes a convincing case that negative private experiences acquire a disproportionate amount of control over behavior and that because of the nature of verbal processes (relational frames), the very act of trying to avoid these experiences nec- essarily exacerbates them and detracts from valued living. For this reason, learning to accept private events and see them for what they really are (i.e., verbal events) instead of what they appear to be (i.e., the real condition of the world) is a key element of therapy. Guinther and Dougher treating depression after a breakup (Ferro García, Valero Aguayo, & Vives Montero, 2006), exhibition- ism (Paul, Marx, & Orsillo, 1999), and chronic pain and fibromyalgia (Vandenberghe & Ferro, 2005; Vandenberghe, Ferro, & Furtado da Cruz, 2003; see also Queiroz & Vandenberghe, 2006). FAP- enhanced cognitive therapy (see Kohlenberg & Tsai, 1994) has been shown to be effective for the treat- ment of depression (Gaynor & Lawrence, 2002; Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002), as has FAP-enhanced ACT (Dougher & Hackbert, 1994); FAP-enhanced behavioral activation also shows promise in the treatment of relationship dis- tress (Manos et al., 2009). Other investigations are beginning to reveal the active components of FAP (Busch et al., 2009; Kanter, Schildcrout, & Kohlen- berg, 2005; Kohlenberg et al., 2002), indicating that in vivo work leads to improved interpersonal func- tioning. Thus, across differing treatments and clini- cal issues, FAP shows promise as a widely applicable and effective interpersonal approach to therapy. Integrative Behavioral Couple Therapy The use of behavioral principles in treating couples was originally developed in the form of behavioral marital therapy (Jacobson & Margolin, 1979), or what is now called traditional behavioral couple therapy (TBCT; see Christensen et al., 1995). With more than 20 randomized clinical trials of TBCT’s efficacy, it is the most widely studied treatment for marital distress (see Baucom, Shoham, Mueser, Dai- uto, & Stickle, 1998; Christensen & Heavey, 1999; Jacobson & Addis, 1993; Shadish & Baldwin, 2005). Despite this impressive level of empirical scrutiny, one of the pioneers of TBCT, Neil Jacobson, was not fully satisfied with its reported clinical significance (see Christensen et al., 1995). Impressed with increasing reports of success for acceptance-based therapies, Jacobson and his colleague, Andrew Christensen, explored whether TBCT could be made more effective by including techniques for fostering acceptance. This gave rise to what is now called inte- grative behavioral couple therapy (IBCT; Christensen et al., 1995; Jacobson & Christensen, 1996, 1998). Jacobson and Christensen (1996) reasoned that people engage in romantic relationships because of the reinforcement inherent in them. Relationship 20 counteract reinforcement erosion. For example, each partner may make a list of the other partner’s wants, discuss their lists with each other and the therapist to plan behaviors around these wants, and then try some of the behaviors to see whether they increase happiness or satisfaction in the other part- ner. Second, clients are given communication skills training, including speaking and listening skills, which can help counteract the polarization process. The therapist may instruct and model extensively during the initial shaping of communication and reduce his or her level of involvement over time. Finally, problem-solving training may be used to help couples define and communicate problems, generate potential solutions in the form of alternate behaviors, evaluate and negotiate the alternatives, and implement and evaluate planned change. In addition to these change strategies, IBCT includes strategies for promoting emotional accep- tance of aspects of the other person that cannot be changed (Christensen et al., 1995; Jacobson & Christensen, 1998), the idea being that closer rela- tionships can be built on acceptance when change is not possible. Most couples will have problems that cannot be changed, and IBCT therefore stresses that emotional acceptance strategies are as important, or even more important, than behavioral change gies (Christensen et al., 2004). Moreover, acceptance may change the context of a relationship such that behavioral change is more likely, paradoxically being more effective than direct attempts at inducing behavioral change (Jacobson & Christensen, 1996). As mentioned, TBCT’s efficacy has been well established (see Baucom et al., 1998; Christensen & Paul M. Guinther and Michael J. Dougher Historical Overview of CBA CBA is a branch of applied behavior analysis (ABA) distinguished by the types of clients and clinical problems addressed, the mode of therapeutic inter- vention, and the settings in which therapy is typi- trans- cally conducted (Dougher & Hayes, 2000). We should note that we are speaking here of the clinical applications of ABA. ABA is also used extensively in a variety of other contexts including educational set- tings, organizations and industry, and athletic per- formance enhancement. Within clinical contexts, ABA typically involves using direct contingency prin- management to address the problems faced by, for example, children and other individuals with brain injury, autism, or other developmental disabilities. Such ABA populations tend to be treated in environ- ments in which a great deal of control exists over pace reinforcement contingencies, such as residential treatment settings, schools, and hospitals. These features of ABA can be traced back to its emergence in the early 1960s, when psychologists with devel- experi- opmental and experimental backgrounds began applying B. F. Skinner’s operant psychology to the CBA problems faced by institutionalized patients and children in educational or therapeutic settings (see Volume 1, Chapter 4, this handbook). The success of direct contingency management procedures in such settings helped behavior analysts carve out a niche trans- that has carried through to the present day, espe- constitute cially with respect to the ABA treatment of children with autism and other developmental disabilities. Translating Principles Into Practice, G. J. Madden (Editor-in-Chief) 3 Association. All rights reserved. mental structures and processes (e.g., schemata, beliefs, expectancies, cognitive distortions) consid- ered responsible for maladaptive behaviors and psychological suffering. The adoption of this mentalistic–meditational orientation appeared to overcome the limitations of ABA (Kohlenberg et al., 1993). First, it made the locus of behavioral causality portable. That is, the problem of limited access to extratherapy contingen- cies became mute; the target of intervention was now the client’s mind, which was present in the therapy session. Clients could carry mental changes made within session out into their daily lives. In addition, the inherent mentalism of CBT accorded well with the mentalistic view of behavior widely held by members of Western cultures. Specifically, many clients enter therapy with the belief that if they can change their ostensibly problematic thoughts and feelings, then they can lead happier lives (Dougher & Hayes, 2000; Kohlenberg et al., 1993). Moreover, empirical studies of CBT were reporting good outcomes, especially with depression and anxiety disorders, which enhanced the appeal of CBT’s mentalistic approach. As CBT gained in prominence, ABA was further relegated to circum- scribed settings and populations, and its application in outpatient settings diminished. While CBT gained prominence over ABA, CBA was slowly taking form and beginning to grow. Unlike ABA, CBA is directly concerned with the same kinds of clinical problems and treatment set- tings as CBT. CBA takes as its focus an accounting of the behavioral processes governing publicly observable behavior and the covert behavior that makes up cognition. CBA is different from CBT in its epistemological foundation—radical behavior- ism, which is philosophically incompatible with the methodological behaviorism of CBT. Thus, CBA rejects the mentalistic and mediational causal models of CBT. One problem facing clinical behavior analysts was that the experimental analysis of behavior tended to focus on relatively simple operants rather than the kinds of complex behavior, especially ver- bal behavior, common in clinical contexts. As an example of the latter, clients frequently report strong fear reactions to stimuli or events they have From Behavioral Research to Clinical Therapy greater detail later in this chapter, we turn first to a conceptual overview of CBA and then to a discus- sion of relevant translational research. nega- be controlled Conceptual Underpinnings of CBA when they As previously noted, CBA is based on the philoso- phy of radical behaviorism. A more complete description of CBA’s defining characteristics can be found in Dougher and Hayes (2000). Our focus here is on the radical behavioral treatment of private events (i.e., perceiving, thinking, feeling, remember- ing) and their role in a science and technology of behavior. A central problem presented by private events is that, by definition, they are not publicly or intersubjectively observable, which makes them dif- ficult to study scientifically. The methodological behaviorist’s approach to this dilemma is to treat private and public events differently. Specifically, private events are considered mental or cognitive as opposed to overt observable behavior, which is con- sidered to be physical. Mental events are defined operationally and studied indirectly by inferring their existence from publicly observed responses to environmental manipulations. Methodological behaviorism has been adopted by most of main- stream psychology (Hayes & Brownstein, 1986) and is particularly characteristic of cognitive psychology, which infers the properties of causal mental struc- tures (e.g., schemata) and their associated processes (e.g., memory retrieval) from their products (e.g., reported thoughts, feelings, and overt behaviors; see Hollon & Kriss, 1984, for a discussion of cognitive structures, processes, and products). Insofar as it is based on the assumptions and principles of cognitive psychology, CBT is directed toward changing those cognitive structures and pro- cesses thought to be responsible for feelings and behavior. For example, much of CBT is based on the ABC paradigm (Ellis, 1962, 1970), in which it is conceived that antecedent environmental events (A) lead to thoughts (B) that then cause subsequent actions or emotions (C). Accordingly, replacing a maladaptive thought with an appropriate new thought leads to a new and more preferable emotion or action. For example, a person at a party (A) may have the distorted thought, “No one here wants to 5 than working directly on the environment, verbal behavior are stimuli that act on listeners (including the self as listener), whose reactions serve as con- trolling consequences. From this view, thoughts are verbal behavior that may influence other behavior through their stimulus functions, although this stimulus control is caused by environmental contingencies. This radical behavioral view of private events and verbal behavior has important clinical implications, both in terms of specific CBA interventions and in terms of therapeutic objectives and outcomes. As already mentioned, private events are not seen as causes and, therefore, are not the specific targets of therapy. However, although CBA does not specifi- cally target private events, they are not ignored. Instead, the focus is on altering the conditions that give rise to these private events and their functions; attempts are made to alter the function of thoughts and feelings so that they are no longer discrimina- tive for maladaptive behavior. This fundamental dif- ference between CBA and CBT runs parallel to their differing research bases. Grounded in the experi- mental analysis of behavior rather than in main- stream methodological behaviorism, the various CBA therapies are all informed by empirically derived behavioral principles and recent laboratory- based research findings. We turn now to a discus- sion of some of these findings. behavior Translational Research Relevant to CBA of verbal Although the entire body of research that consti- tutes the experimental analysis of behavior informs CBA therapies, research on verbal behavior is particularly relevant because it provides a behavior- analytic account of language and cognition. Rele- vant to this account is research on rule governance, the indirect acquisition and transformation of stim- ulus functions via derived stimulus relations, and relational responding. see Hayes, Rule Governance A long-standing tradition within the experimental analysis of behavior is the use of nonhuman animal studies to illuminate the basic principles of behavior From Behavioral Research to Clinical Therapy (e.g., Lippman & Meyer, 1967; Lowe, 1979). Inves- tigations into the sources of these differences con- verged on verbal processes, particularly those involved in instructional control (see Baron & Galizio, 1983, for a review), also known as rule- governed behavior (Skinner, 1966, 1974). Instructions and rules are verbal stimuli that specify antecedent, behavioral, and consequent components of operant contingencies (Skinner, 1966, 1974). They can be presented by others or be self-generated. As examples, a participant in a human operant conditioning experiment may fol- low the written instructions “Every two minutes, you can press the button in order to earn points,” or a person may follow the self-spoken rule “After each meal, I should brush my teeth to avoid cavi- ties.” That is, accurate rules tell people how to go about behaving in ways that are likely to produce desirable results (i.e., acquiring reinforcers or avoiding punishers). However, following rules that specify a relation among an antecedent, behavior, and consequence is sometimes incompatible with effectively responding to operative contingencies (e.g., Catania et al., 1982; Galizio, 1979). For exam- ple, a person who sweeps his or her bedroom floor on an hourly basis because of the rule that “cleanli- ness is next to godliness” (i.e., sweep on the hour so as to maintain piety and avoid sin) may not connect with the fact that it would take considerably longer than an hour for the floor to become dirty or that cleanliness is, in fact, not a path to godliness. Like- wise, if a person generates and follows the rule “If I leave the house, something terrible will happen to me,” staying in the house will be negatively rein- forced by the absence of terrible events. The avoid- ance of these verbally described terrible events may also increase the probability of generating and fol- lowing other potentially maladaptive rules. Instruc- tions and rules are clearly tied to both adaptive and maladaptive behaviors and are, therefore, of special interest to clinical behavior analysts. Initially, how behavior analysts were to account for findings that human laboratory behavior appeared to be more susceptible to instructions and self-generated rules than to programmed contingen- cies was unclear. Such perplexing findings appeared to lend credence to the mentalistic underpinnings of 7 would be followed only as long as rule following did not result in punishing consequences. A second characteristic of an operant is that its emission can be controlled by antecedent stimuli signaling the likelihood of response-contingent rein- forcement or punishment. In Galizio’s (1979) exper- iment, human rule following came under antecedent stimulus control. When an orange light was on, the experimenter-provided rules were accurate, and fol- lowing them resulted in the efficient avoidance of monetary losses. However, when a purple light was on, the instructions were inaccurate and following them resulted in periodic losses. Participants were not instructed about the meaning of these lights, but they quickly followed the rules only when the orange light was on, thereby demonstrating stimulus control of rule following as an operant. Finally, Galizio (1979) hypothesized that rule fol- lowing was a generalized operant. That is, rule fol- lowing is an operant that generalizes to different contexts that in some way resemble those in which rule following has been reinforced in the past. For example, if rule following has been reinforced in the presence of one’s parents while at home, this behav- ior is likely to generalize to rules given by the same parents at the grocery store. When following other people’s rules (e.g., aunts and uncles, teachers, police officers) is also reinforced, the operant is likely to generalize to still other adults. By the time human participants enter an experiment such as the one arranged by Galizio, they have an extensive history of reinforcement for following rules that have been provided by authority figures such as experimenters. Given this history, it should not be surprising that participants conform to experimenter-provided instructions (see Milgram, 1963, for an extreme and troubling example of control by experimenter instructions). Classes of rule following. Not long after Galizio (1979) demonstrated that rule following was an operant, Zettle and Hayes (1982) suggested that rule following could be usefully classified on the basis of the type of consequences that maintain it. One category of rule following is tracking (Hayes, Brownstein, Zettle, Rosenfarb, & Korn, 1986; Zettle & Hayes, 1982). Tracking is rule following that is From Behavioral Research to Clinical Therapy measured constriction, inhibition, conservatism, intolerance of ambiguity, and perseverative tenden- cies (Rehfisch, 1958a, 1958b); the questionnaire was known to correlate with measures of social anxiety. Next, participants were given a task with either accurate instructions (i.e., depending on the status of the signal light, press the button at different rates to earn points) or minimal instructions (i.e., press the button to earn points). At the beginning of the task, points were delivered contingent on button presses, but then an extinction schedule was imposed in which responses were no longer fol- lowed by points. Although accurate instructions generally resulted in perseveration after the switch to extinction, this effect was especially pronounced among participants whose answers to the question- naire suggested high trait rigidity. Even in the mini- mal instructions condition, trait-rigid participants were more likely to continue pressing the button during extinction. Thus, highly rigid individuals appeared to be especially prone to pliance, even in the face of discrepant feedback. In sum, insensitivity to programmed contingen- cies of reinforcement arranged in human operant experiments appears to be a product of two types of rule-following behavior. First, insensitivity may occur because of a history of reinforcement for tracking: Following rules has generally led to a host of naturally occurring reinforcers. Because of this history, track-based rule following generalizes to the human operant laboratory and precludes behavior that would be more efficient than the behavior spec- ified by inaccurate experimenter-provided rules (e.g., Baron & Galizio, 1983; Galizio, 1979; Hayes, Brownstein, Zettle, et al., 1986; Joyce & Chase, 1990). Second, contingency insensitivity may result from pliance or the differential sensitivity to the social consequences for following rules and instruc- tions (e.g., Barrett et al., 1987; Hayes, Brownstein, Haas, & Greenway, 1986; Hayes, Brownstein, Zettle, et al., 1986; for a review, see Hayes, Zettle, & Rosen- farb, 1989). Although investigated in the context of human operant experiments, tracking and pliance presumably account for the rule-following behavior exhibited by clients. More important, a history of reinforcement for rule following would naturally lead individuals to 9 provides much of the empirical foundation for the alternative therapeutic approaches used by CBA therapists. Equivalence Relations and the Transfer of Stimulus Functions Stimulus equivalence is a behavioral phenomenon that emerges from certain natural conditions and laboratory arrangements (Sidman, 1994; Sidman & Tailby, 1982). Roughly speaking, equivalent stimuli are those that, despite their physical dissimilarity, mean the same thing. That is, they are functionally interchangeable or do the same things. Otherwise distinct stimuli can acquire common functions in many different ways, including through direct Pav- lovian conditioning, through direct operant condi- tioning, and through stimulus generalization (see Catania, 1998; Donahoe & Palmer, 2004). What is particularly interesting about equivalent stimuli is that they can acquire functions indirectly, in the absence of direct conditioning or generalization. For example, for most English speakers, the word araña is not emotionally arousing. However, when told that araña is Spanish for spider, araña may acquire an eliciting function. That is, by establishing an equivalence relation between the words spider and araña, araña may indirectly acquire the functions of the word spider. More generally, words stand in an equivalence relation with the events in the world they reference or stand for, and by that we mean they take on many of the functions of their referents and vice versa. This is how rules can alter the func- tions of the elements of the contingencies they spec- ify and how words can make people laugh, cry, cringe, or fall in love. Although stimulus equivalence is of interest in its own right (a discussion of stimulus equivalence and the methods used to study it can be found in Volume 1, Chapter 16, this handbook), its clinical relevance is most apparent in demonstrations of the transfer of functions among stimuli that are mem- bers of the same stimulus equivalence class (see Dougher, 1998). Laboratory studies of equivalence- based transfer of function typically start by using matching-to-sample procedures to train and test some number of stimulus equivalence classes. A subset of one of the classes is then given a new From Behavioral Research to Clinical Therapy emotion-eliciting functions in the absence of direct training. They also suggest that explanations for this kind of phenomena go beyond the basic Pavlovian or operant contingency. In a second experiment, Dougher et al. (1994) demonstrated that the effects of extinction can also indirectly transfer among members of stimulus equivalence classes. As in their first experiment, two four-member stimulus equivalence classes were established and tested. Next, all of the Class 1 stim- uli except A1 (i.e., B1, C1, and D1) directly acquired positive conditioned stimulus (CS+) function by preceding mild electric shock. In Class 2, B2, C2, and D2 directly acquired negative conditioned stim- ulus (CS−) function by preceding shock-free peri- ods. As expected, this procedure resulted in greater skin conductance responses to all of the Class 1 stimuli than to any of the Class 2 stimuli. The func- tion of B1 was then directly altered by presenting B1 in extinction (without shock) for six trials. To deter- mine whether the new CS− function of B1 would indirectly transfer to C1 and D1, all of the Class 1 and Class 2 stimuli (again, except the A stimuli) were presented individually. Consistent with an indirect transfer of B1’s CS− function to same-class stimuli, no difference in skin conductance elicitation between the two stimulus classes was found after extinction of B1. In a final condition, B1 was recon- ditioned as a CS+ by preceding shock, and all of the stimuli were again presented to see whether this reconditioning would transfer to C1 and D1. The results confirmed that it did. Continuing this line of research, Augustson and Dougher (1997) found that operant avoidance behavior can be occasioned by members of a stimu- lus equivalence class even when only one member of the class has directly acquired response-evoking stimulus function. In their experiment, two four- member stimulus equivalence classes were trained and tested (as described earlier), and B1 was estab- lished as a CS+ using mild shock. Next, participants learned that they could avoid the shock that fol- lowed B1 if they pressed the space bar on a com- puter keyboard a set number of times within a set time period. No shock followed presentations of B2 (CS−), so no avoidance responses were required. After avoidance was reliably occasioned by B1, 11 This is why a novel, poem, or slogan can move peo- ple to tears, make them laugh, or spur them to action. This is why repeating the word calm can induce a state of relaxation and why thinking about death can induce fear in some and relief in others, even in the absence of any direct experience with death. The equivalence relations between words and their referents may also explain why clients fre- quently cry when relating painful past experiences or feel better after having talked about them (see Pennebaker, 1997, for a review). Talking about emotionally painful events (CS+) in a neutral envi- ronment (CS−) may promote extinction of the elic- iting functions of those events. Equivalence relations may also explain how rules and instructions can alter the operant functions of relevant stimuli. For example, the rule “Turn right at the corner to reach your destination” alters the function of the actual corner such that it becomes discriminative for the behavior of turning right. In sum, these findings begin to provide a behavior-analytic account of cog- nitively mediated stimulus functions and how indi- viduals come to respond both appropriately and inappropriately in novel contexts. 1986; Other Stimulus Relations and the Transformation of Functions Although equivalence relations are particularly rele- vant for discussions of how verbal stimuli affect human behavior, several stimulus relations other than equivalence can also alter stimulus functions and influence behavior. These include opposition and difference (Roche & Barnes, 1996, 1997; Steele & Hayes, 1991; Whelan & Barnes-Holmes, 2004), more than and less than (Berens & Hayes, 2007; Dymond & Barnes, 1995; O’Hora, Roche, Barnes- Holmes, & Smeets, 2002; Reilly, Whelan, & Barnes- Holmes, 2005; Whelan, Barnes-Holmes, & Dymond, 2006), before and after (O’Hora, Barnes-Holmes, Roche, & Smeets, 2004), and many others. Rela- tional frame theory (RFT; Hayes et al., 2001) was developed on the assumption that a more compre- hensive theory of verbal behavior would result from a more general account of stimulus relations and what is called arbitrarily applicable relational responding (details follow). A complete account of RFT is beyond the scope of this chapter, but it is From Behavioral Research to Clinical Therapy In addition, the child also learns that if one of two stimuli is called bigger, then it can be derived that the other is called smaller. Similarly, if trained that a nickel represents a certain value (e.g., $0.05 worth) and told that a nickel is smaller than a dime, one can derive that a dime has a larger value (i.e., more than $0.05 worth) despite its smaller physical size. When an arbitrary stimulus relation has been established with two or more stimuli, RFT proposes that those stimuli participate in a relational frame. Relational frames are defined by three characteristics (Hayes et al., 2001). The first is mutual entailment. That is, given any relation, x, between stimuli A and B, there is an entailed relation, y, between B and A. Symmetry in equivalence relations is an example of mutual entailment. Given A = B, then the symmet- ric relation B = A is entailed. In relations other than equivalence, mutual entailment involves asymmetri- cal relationships. Given A < B, then the asymmetri- cal relation B > A is entailed. The second defining characteristic of relational frames is combinatorial mutual entailment. Given a relation, r, between stimuli A and B, and another relation, x, between B and C, then there is an entailed relation, y, between A and C and an entailed relation, z, between C and A. Transitivity in equiva- lence relations exemplifies combinatorial mutual entailment. Given A = B and B = C, then A = C and C = A are entailed. Similarly, given A < B and B < C, then A < C and C > A are entailed. The final defining characteristic of relational frames is transfer or transformation of functions. The term transfer characterizes relational frames of equivalence, and the term transformation character- izes relational frames other than equivalence. For example, if A is a reinforcer and it is arbitrarily established that A is the same as B, then the rein- forcing function of A will be indirectly acquired by B without alteration. That is, the function will trans- fer as reinforcement in accordance with the rela- tional frame of equivalence. However, the functions that are indirectly acquired via relations other than equivalence vary depending on the specific type of relation that has been applied. For example, if A is a reinforcer and it is arbitrarily established that A is the opposite of B, then the reinforcing function of A will be indirectly acquired by B with alteration. That 13 . or trans- engag- arbi- and Chiasson, a high to rela- Figure 1.1. Based on a popular training preparation (e.g., Dymond et al., 2007, 2008; Roche & Barnes, 1997; Roche et al., 2008; Steele & Hayes, 1991; Whelan & Barnes- Homes, 2004), the figure shows a relational network consisting of directly trained (solid lines) and derived (dashed lines) relation- ships, where S and O represent same and opposite relations, respectively. classical conditioning procedure paired B1 and B2 with sexual and nonsexual film clips. When B1 pre- ceded a sexual film clip, its sexually arousing func- tion was indirectly acquired by C1, which was the same as B1 through two same relations (i.e., B1 same A1 same C1). In addition, when B2 was paired with a sexual clip, its arousing function was indi- rectly acquired by C2, which was the same as B2 through two opposite relations (B2 opposite A1 opposite C2). This combinatorially entailed trans- formation of function occurred despite the fact that the tests for transformation (i.e., elicitation of a sex- ual response) were conducted in the absence of the S and O contextual stimuli. Thus, the eliciting func- tions were transformed in accord with a network of derived and arbitrarily applied relations. Using similar training procedures (see Figure 1.1), Whelan and Barnes-Holmes (2004) established B2 as a punisher, after which C2 functioned as a pun- isher and C1 functioned as a reinforcer. The rein- forcing function of the C1 stimulus emerged even though no member of the relational network had been directly established as a reinforcer. Thus, C1’s reinforcing function emerged through the From Behavioral Research to Clinical Therapy In another study of the transformation of stimu- lus functions via relations other than equivalence, Dougher, Hamilton, Fink, and Harrington (2007) demonstrated the transformation of discriminative and eliciting functions in accord with the relations less than and greater than. First, relational functions were established for three visual forms labeled A, B, and C by reinforcing across multiple training trials selections of the physically smallest, medium, or largest of three comparisons in the presence of sam- ples A, B, and C stimuli, respectively. On each trial, one of the samples would appear at the top of the computer screen along with three visual compari- sons across the bottom that varied in size but were otherwise identical. New comparison arrays were presented across trials, but regardless of the array, selections of the smallest comparison were rein- forced when A was the sample, selections of the medium comparison were reinforced when B was the sample, and selections of the largest comparison were reinforced when C was the sample. This train- ing was intended to establish the comparative rela- tions A < B < C among the samples. After successful training, the B stimulus was pre- sented for 30 seconds, and participants were instructed to press the space bar on the computer keyboard at a steady rate. They were also told that the stimulus presented on the computer screen would sometimes change and to “press the bar at a rate that you think is appropriate for each symbol you see.” After a steady state of button pressing in the presence of the B stimulus was attained, partici- pants were then presented with the A and C stimuli while their response rates were recorded. Without further instruction and for all eight participants, presentations of the A and C stimuli occasioned slower and faster responding, respectively, than the B stimulus. Thus, the discriminative functions of the A and C stimuli were transformed in line with their respective relations to the B stimulus. In the next phase of the experiment, the B stimu- lus acquired a CS+ function by following it with a mild electric shock; skin conductance served as the dependent measure. After this direct conditioning, the A and C stimuli were presented without instructions, and skin conductance levels were recorded. Six of eight participants showed lower 15 A detailed description of these processes is beyond the scope of this chapter (see Hayes, 1984, and Barnes-Holmes, Stewart, Dymond, & Roche, 2000, for a more thorough accounting), but the important implication here is that most typically developing individuals are encouraged by their verbal commu- nity (culture) to act as if the self is a real entity. Fur- thermore, people are taught that the self roughly corresponds to their thoughts and feelings, which are treated as causes of behavior. Taken together, the sense of self as a real entity and the tendency to explain behavior by appeal to private experience can be problematic and contribute to clinical problems. As mentioned in our earlier discussion of rule governance, rule following can be maladaptive, especially if one has a strong history of reinforce- ment for pliance and when rule following precludes contact with discrepant actual contingencies and consequences. Hayes et al. (1999, 2001) argued that one particularly troublesome domain of maladaptive rules includes those that promote the avoidance of private experience or emotional avoidance. The rules promoting this experiential avoidance can take many forms but are largely rooted in cultural pre- scriptions that certain thoughts and feelings are good and others are bad. Very few individuals would argue with the classification of depression, sadness, anxiety, insecurity, fear, regret, and remorse as bad, and many sources of information, including parents, friends, popular media, and mental health profes- sionals, articulate and support that view. Most men- tal health professionals clearly see these emotions as undesirable, and most therapies are aimed at getting rid of them. In contrast, from a CBA and especially an ACT perspective, experiential avoidance is the source of many clinical problems. The human tendency to constantly verbalize (think) and problem solve as people interact with the environment around them extends to the world of private events, and people’s verbal behavior with respect to these private events can itself become problematic. The trouble starts with a simple fact of life: Negative thoughts and feelings are inevitable. Living in a complex world without encountering frustration, failure, loss, sadness, fear, worry, insecu- rity, incompetence, and so forth is unimaginable. As people encounter such inevitabilities, however, From Behavioral Research to Clinical Therapy CBA Therapies is assumed The existing CBA therapies, although differing in rela- domain of application and degree of emphasis on of living in a the role of verbal processes in the development and bad, is in treatment of clinical disorders, share core philo- combi- sophical assumptions about the origins of human to “bad,” suffering, the means by which quality of life can be potential improved, and the goals or objectives of therapy. perhaps One commonality among the CBA therapies is a events or focus on constructing effective repertoires rather than eliminating unwanted private events. The over- arching objective is to help clients lead rich and val- ued lives. A formal explication of this position can rein- be found in Israel Goldiamond’s constructional or alter approach to therapy (Goldiamond, 1974/2002; Schwartz & Goldiamond, 1975; see also Delprato, causation to 1981; Fleming, 1984; Layng, 2009), which was per- natu- haps the first outpatient therapy based primarily on to get rid behavior-analytic principles and assumptions. such as “I Israel Goldiamond (1919–1995) first developed his feel depressed” constructional approach with an eye toward protect- ing the constitutional and human rights of individuals can living under institutional control (Goldiamond, solution 1974/2002; Schwartz & Goldiamond, 1975). Within of sad- institutions such as prisons and mental hospitals, the prevailing ideology of the time was that the purpose of pre- the institution was to establish total control over the to alleviate lives and behaviors of those who were institutional- val- ized, an approach that Goldiamond (1974/2002) believed precluded the freedom to assent or dissent to treatment. Therapeutic objectives in these institutions place tend to focus on eliminating socially undesirable behavior, where power differentials allow the institu- engaging tion, as opposed to patients, to determine which they behaviors are desirable and undesirable. Goldiamond argued that this total control approach to mental ting health treatment is not only ethically problematic but to think is also antithetical to the social purpose of ostensibly therapeutic agencies. Alternatively, the needs of soci- between ety and the rights of clients are usually better met transfer through a sort of constitutional allegiance between private therapists and clients, in which those behaviors consti- tuting therapeutic outcomes are agreed on by both therapist and client rather than dictated by the thera- struggling pist. This emphasis on respecting client autonomy is especially relevant in outpatient settings, in which a 17 should be informed by the client’s values, not the therapist’s. By focusing on valued, personally mean- ingful activity as a therapeutic outcome, the con- structional approach fulfills the ethical responsibility of social institutions and professionals to provide therapeutic services while respecting and promoting clients’ autonomy (Goldiamond, 1974/2002). Although Goldiamond (1974/2002; Schwartz & Goldiamond, 1975) reported case examples of the successful use of a constructional approach, the approach represents a philosophical assertion of what it means for an outcome to be therapeutic and is therefore not subject to empirical verification. Rather, a constructional approach has been used successfully whenever treatment helps a client engage in behaviors that are consistent with the cli- ent’s values, thereby improving the client’s quality of life by definition. In addition to being rooted in a constructional approach and client values, CBA therapies are either based on or are consistent with the philosophy of radical behaviorism and its modern elaboration, functional contextualism (see Gifford & Hayes, 1999; Hayes, 1993; Pepper, 1942; Skinner, 1953, 1974; Vilardaga, Hayes, Levin, & Muto, 2009). That is, when CBA therapists conduct a behavioral analysis, public and private behaviors are understood to be a function of their current and historical contexts, and a behavioral analysis is said to be true or valid to the extent that it leads to effective action with respect to the achievement of specified goals. The inherent monism and nonmentalism of radical behaviorism (see Dougher & Hayes, 2000) leads behavior analysts to eschew explanations of behavior that rely on organismic states, traits, predispositions, thoughts, beliefs, expectancies, or attitudes as sources of causa- tion (see Hayes & Brownstein, 1986). The inherent pragmatism of radical behaviorism requires behav- ioral theories and explanations to be cast in terms of identifiable and manipulable environmental determi- nants. As we tried to make clear earlier, however, this does not mean that behavior analysts ignore private or verbal events or their roles as links in complex chains of behavior. Instead, an adequate explanation of behavior cannot stop with private events and must explain both the occurrence of private events and their influence on other behavior. From Behavioral Research to Clinical Therapy Functional Analytic Psychotherapy One of the first verbally based outpatient therapies based on behavior-analytic principles and assump- tions is functional analytic psychotherapy (FAP). Developed by Robert Kohlenberg and Mavis Tsai (1991), FAP is based on the assumption that the problems faced by verbally competent outpatient adults are mostly interpersonal, and the context of the therapy relationship is an ideal place to observe, understand, and shape clients’ interpersonal behav- ior. Clients miss sessions, have insights, pick fights, express appreciation, fear disclosure, avoid certain topics, lie, cry, relate, dissociate, and otherwise engage in myriad behaviors that therapists can directly observe, functionally analyze, and conse- quate. Thus, the basic premises of FAP are that the therapeutic relationship involves contingencies that can be used to decrease the frequency of problem- atic behavior and increase the frequency of desirable behavior in vivo and that these changes may then generalize to other interpersonal relationships (Kohlenberg & Tsai, 1991). Although usable as a stand-alone treatment, FAP is more commonly used as a therapeutic adjunct to other primary treatments (Kohlenberg & Tsai, 1991). However, FAP assumes that an exclusive focus on the primary treatment may result in thera- pists missing opportunities to better understand the functional effects of their clients’ behavior as it occurs in session and to shape client behavior directly. In this sense, FAP resembles the direct con- tingency management procedures of ABA but is spe- cifically tailored to the context of outpatient therapy. Much of the research to support the efficacy of FAP consists of case studies (see Ferro García, 2008). FAP-enhanced therapy has been conducted with clients with anxiety disorders (Carrascoso López, 2003; Kohlenberg & Tsai, 1998), personality disorders (Callaghan, Summers, & Weidman, 2003; Holmes, Dykstra, Williams, Diwan, & River, 2003), and chronic pain (Queiroz & Vandenberghe, 2006). Vandenberghe (2007) argued that FAP is also well suited to facilitate exposure-based treatments for posttraumatic stress disorder and obsessive– compulsive disorder (see also Kohlenberg & Tsai, 1998; Kohlenberg & Vandenberghe, 2007). Further investigations have examined the use of FAP in 19 difficulties, then, can arise when relationships lose their reinforcing functions or develop aversive func- tions. One way this occurs is through reinforcement erosion, which is essentially habituation to the rewarding aspects of a relationship. Relationship dif- ficulties can also arise from changes in the life cir- cumstances of one or both partners, such as having children, loss or change of a job, increasing work stress, or financial difficulties. Incompatibilities that arise from such changes can lead a couple to vilify each other’s differences and to withhold gratification from each other in a polarization process (Jacobson & Christensen, 1996), further reducing the reinforc- ing qualities of a relationship. A functional analysis of a given couple’s polarization process allows the clinician to sort topographically distinct problem behaviors into functional response classes, which helps to identify the underlying theme of the cou- ple’s primary conflict (Jacobson & Christensen, 1996). After the problem theme is identified, the partners are in a better position to collaborate on finding solutions that reduce polarization, promote each other’s needs, and improve the quality of their relationship (Berns, Jacobson, & Christensen, 2000). As opposed to targeting particular behavioral topographies (as advocated by TBCT), IBCT change strategies are directed toward placing clients in con- tact with contingencies that will reduce the fre- quency of the functional class of problematic behaviors identified by the theme. For example (see Berns et al., 2000), initiating sex may serve the func- tion of promoting intimacy for one couple, but that same topography could be a means of domination for another couple. For the first couple, initiations of sex could alter the frequency of behaviors from a functional response class associated with attempts to achieve intimacy, whereas modifications of this topography would not benefit the latter couple in their attempts to achieve greater intimacy. Given its more functional orientation, IBCT is more clearly aligned with modern CBA than is TBCT. Change strategies are common to both TBCT and IBCT (Christensen et al., 1995; Jacobson & Chris- tensen, 1996; Jacobson & Margolin, 1979). First, behavioral exchange procedures are used to encour- age couples to increase the number of reinforcing behaviors in their relationships, which can help From Behavioral Research to Clinical Therapy trial (RCT) of 21 couples experiencing clinically sig- nificant marital distress. Although statistical analy- ses were not reported, descriptive analyses showed that 64% of TBCT couples had improved or recov- ered by the end of therapy, whereas 80% of IBCT couples had improved or recovered. Christensen et al. (2004) conducted a large RCT with 134 mod- erately to severely distressed couples, concluding that TBCT and IBCT were equally as efficacious by the end of treatment; 60% of TBCT and 69% of IBCT couples were still reporting significant improve- ments at 2-year follow-up (Christensen, Atkins, Yi, Baucom, & George, 2006). Doss, Meng Thum, Sevier, Atkins, and Christensen (2005) examined the 2004 RCT data and concluded that both thera- pies worked according to their differing theoretical mechanisms of change (see also Cordova, Jacobson, & Christensen, 1998). That is, TBCT decreased tar- geted damaging behaviors and increased targeted helpful behaviors to produce relatively quick thera- peutic gains, whereas IBCT gradually increased the amount of acceptance for behaviors that could not be changed easily. Thus, although IBCT tends to outperform TBCT, the available research would sug- gest that IBCT and TBCT are equally efficacious but qualitatively distinct therapies. strate- Dialectical Behavioral Therapy Marsha Linehan developed dialectical behavioral therapy (DBT) during the 1980s while investigating the use of CBT for the treatment of parasuicidal cli- ents (Linehan, 1993). More recently, however, DBT has come to be most closely associated with the treatment of borderline personality disorder. Duri

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