(Specialty Competencies in Professional Psychology) Christine Maguth Nezu, Christopher R. Martell, Arthur M. Nezu - Specialty Competencies in Cognitive and Behavioral Psychology-Oxford University Pres

Specialty Competencies in Cognitive
and Behavioral Psychology

Series in Specialty Competencies in Professional Psychology
SE R I E S E D I T O R S
Arthur M. Nezu, PhD, ABPP, and Christine Maguth Nezu, PhD, ABPP
SE R I E S A D V I S O RY B O A RD
David Barlow, PhD, ABPP
Jon Carlson, PsyD, EdD, ABPP
Kirk Heilbrun, PhD, ABPP
Nadine J. Kaslow, PhD, ABPP
Robert Klepac, PhD
William Parham, PhD, ABPP
Michael G. Perri, PhD, ABPP
C. Steven Richards, PhD
Norma P. Simon, EdD, ABPP
T I T L E S I N T HE S E R I E S
Specialty Competencies in School Psychology
Rosemary Flanagan and Jeffrey A. Miller
Specialty Competencies in Organizational and Business Consulting Psychology
Jay C. Thomas
Specialty Competencies in Geropsychology
Victor Molinari (Ed.)
Specialty Competencies in Forensic Psychology
Ira K. Packer and Thomas Grisso
Specialty Competencies in Couple and Family Psychology
Mark Stanton and Robert Welsh
Specialty Competencies in Clinical Child and Adolescent Psychology
Alfred J. Finch, Jr., John E. Lochman, W. Michael Nelson III, and Michael C. Roberts
Specialty Competencies in Clinical Neuropsychology
Greg J. Lamberty and Nathaniel W. Nelson
Specialty Competencies in Counseling Psychology
Jairo N. Fuertes, Arnold Spokane, and Elizabeth Holloway
Specialty Competencies in Group Psychology
Sally Barlow
Specialty Competencies in Clinical Psychology
Robert A. DiTomasso, Stacey C. Cahn, Susan M. Panichelli-Mindel, and Roger K. McFillin
Specialty Competencies in Rehabilitation Psychology
David R. Cox, Richard H. Cox, and Bruce Caplan
Specialty Competencies in Cognitive and Behavioral Psychology
Christine Maguth Nezu, Christopher R. Martell, and Arthur M. Nezu
CHRIST INE M A G U T H N E ZU
CHRIST OPH E R R. M A RT E LL
ART H U R M . N E ZU
Specialty Competencies in
Cognitive and Behavioral
Psychology
3
3
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide.
Oxford New York
Auckland Cape Town Dar es Salaam Hong Kong Karachi
Kuala Lumpur Madrid Melbourne Mexico City Nairobi
New Delhi Shanghai Taipei Toronto
With offices in
Argentina Austria Brazil Chile Czech Republic France Greece
Guatemala Hungary Italy Japan Poland Portugal Singapore
South Korea Switzerland Thailand Turkey Ukraine Vietnam
Oxford is a registered trademark of Oxford University Press in

the UK and certain other countries.
Published in the United States of America by

Oxford University Press
198 Madison Avenue, New York, NY 10016
© Oxford University Press 2014

All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, without the prior
permission in writing of Oxford University Press, or as expressly permitted by law,
by license, or under terms agreed with the appropriate reproduction rights organization.
Inquiries concerning reproduction outside the scope of the above should be sent to the
Rights Department, Oxford University Press, at the address above.
You must not circulate this work in any other form and you must
impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data

Nezu, Christine M.
Specialty competencies in cognitive and behavioral psychology / Christine Maguth Nezu,
Christopher R. Martell, Arthur M. Nezu.
pages cm.—(Series in specialty competencies in professional psychology)
Includes bibliographical references and index.
ISBN 978–0–19–538232–7
1. Cognitive psychology. 2. Behaviorism (Psychology) 3. Psychologists.
4. Psychology—Practice. I. Martell, Christopher R. II. Nezu, Arthur M. III. Title.
BF201.N49 2011
153—dc23
2013028787
9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
To the competent and compassionate cognitive and behavioral
specialists who are devoted to easing human
suffering and improving people’s lives.
—Christine Maguth Nezu
To my life partner Mark Edward Williams, M.Div., MSW, Ph.D.,

who appreciates my dedication to psychology, my tendency to
agree to too many projects, and who has been there for me to
run ideas across, even in the midst of his own busy life.
—Christopher R. Martell
To the patients who have trusted in our competence

and struggled with the challenge of change.
—Arthur M. Nezu
THE SPECIALTY OF COGN I TI V E A N D BE HAV I ORA L P SYCHO L O GY
DEVELOPMENTAL TIMELIN E
1904 Pavlov wins Nobel Prize for Physiology.
1913 Radical behaviorism is launched by Watson.
1927 Backward conditioning developed by Mary Cover Jones.
1938 Joseph Wolpe develops systematic desensitization treatment based

upon reciprocal inhibition.
1950–1960 Behavioral psychologists explore the clinical relevance of learning

principles in South Africa, the United Kingdom, and the United States.
1960–1970 Clinical behavior therapy is established.
1962 Albert Ellis develops rational emotive psychotherapy (RET).
1969 George Kelly develops cognitive construct theory.
1970–1980 Expansion and inclusion of cognitive theories and positive psychology

to behavior therapy.
1980–1990 Construct of learning expanded to include schemas and implicit

learning.
1980–1990 Adaptation of Eastern influences of mindful meditation and awareness.
1987 American Board of Behavioral Psychology established.
1992 American Board of Behavioral Psychology recognized by the American

Board of Professional Psychology (ABPP).
1990–2000 Advances in neuroscience reveal emotional learning pathways

underlying conditioning models.
2000 Behavioral psychology recognized by Commission for the Recognition

of Specialties and Proficiencies in Professional Psychology (CRSPPP).
2000 American Board of Behavioral Psychology adopted its current name,

American Board of Cognitive and Behavioral Psychology, to reflect its
growth as a specialty in professional psychology.
2000 Academy of Cognitive and Behavioral Psychology adopts its new name
to reflect its growth as a specialty.
2000–present Increasing recognition of the common elements among cognitive

behavioral psychotherapies.
CONTENTS
About the Series in Specialty Competencies in

Professional Psychology ix
PA R T I History and Background 1

one Introduction 3
t wo Conceptual Foundations and Theories 9
three Scientific Research Foundations 39
PA R T I I Functional Competencies in Assessment 63

four Assessment in Cognitive and Behavioral Psychology 65
five Models of Cognitive-Behavioral Case Formulation 80
PA R T I I I Functional Competencies in Intervention 85

six Psychotherapeutic Interventions 87
seven Applied Behavioral Analytic Interventions 117
PA R T I V Other Functional Competencies 123

eight Consultation, Supervision, and Teaching 125
PA R T V Foundational Competencies 135

nine Interpersonal Interactions 137
ten Common Ethical and Legal Challenges in Cognitive
and Behavioral Practice 140
eleven Individual and Cultural Diversity 152
viii Contents
t welve Professional Identification 161
References 167
Key Terms 187
Index 189
About the Authors 199
About the Series Editors 201
ABOUT TH E SE RIE S IN SPE CIALT Y C O M PE T E N C I E S
IN PROFE SSIONA L PSY C H O LO G Y
This series is intended to describe state-of-the-art functional and founda-

tional competencies in professional psychology across extant and emerging
specialty areas. Each book in this series provides a guide to best practices
across both core and specialty competencies as defined by a given profes-
sional psychology specialty.
The impetus for this series was created by various growing movements
in professional psychology during the past 15 years. First, as an applied
discipline, psychology is increasingly recognizing the unique and distinct
nature among a variety of orientations, modalities, and approaches with
regard to professional practice. These specialty areas represent distinct
ways of practicing one’s profession across various domains of activities
that are based on distinct bodies of literature and often addressing differ-
ing populations or problems. For example, the American Psychological
Association (APA) in 1995 established the Commission on the
Recognition of Specialties and Proficiencies in Professional Psychology
(CRSPPP) in order to define criteria by which a given specialty could be
recognized. The Council of Credentialing Organizations in Professional
Psychology (CCOPP), an inter-organizational entity, was formed in reac-
tion to the need to establish criteria and principles regarding the types
of training programs related to the education, training, and professional
development of individuals seeking such specialization. In addition, the
Council on Specialties in Professional Psychology (COS) was formed in
1997, independent of APA, to foster communication among the estab-
lished specialties, in order to offer a unified position to the pubic regard-
ing specialty education and training, credentialing, and practice standards
across specialty areas.
Simultaneously, efforts to actually define professional competence
regarding psychological practice have also been growing significantly. For
example, the APA-sponsored Task Force on Assessment of Competence
x About the Series in Specialty Competencies in Professional Psychology
in Professional Psychology put forth a series of guiding principles for the

assessment of competence within professional psychology, based, in part,
on a review of competency assessment models developed both within (e.g.,
Assessment of Competence Workgroup from Competencies Conference;
Roberts et al., 2005) and outside (e.g., Accreditation Council for Graduate
Medical Education and American Board of Medical Specialties, 2000) the
profession of psychology (Kaslow et al., 2007).
Moreover, additional professional organizations in psychology have
provided valuable input into this discussion, including various associa-
tions primarily interested in the credentialing of professional psycholo-
gists, such as the American Board of Professional Psychology (ABPP), the
Association of State and Provincial Psychology Boards (ASPBB), and the
National Register of Health Service Providers in Psychology. This wide-
spread interest and importance of the issue of competency in professional
psychology can be especially appreciated given the attention and collabora-
tion afforded to this effort by international groups, including the Canadian
Psychological Association and the International Congress on Licensure,
Certification, and Credentialing in Professional Psychology.
Each volume in the series is devoted to a specific specialty and pro-
vides a definition, description, and development timeline of that specialty,
including its essential and characteristic pattern of activities, as well as its
distinctive and unique features. Each set of authors, long-term experts and
veterans of a given specialty, were asked to describe that specialty along the
lines of both functional and foundational competencies. Functional com-
petencies are those common practice activities provided at the specialty
level of practice that include, for example, the application of its science
base, assessment, intervention, consultation, and where relevant, super-
vision, management, and teaching. Foundational competencies represent
core knowledge areas which are integrated and cut across all functional
competencies to varying degrees, and dependent upon the specialty, in
various ways. These include ethical and legal issues, individual and cul-
tural diversity considerations, interpersonal interactions, and professional
identification.
Whereas we realize that each specialty is likely to undergo changes in
the future, we wanted to establish a baseline of basic knowledge and prin-
ciples that comprise a specialty, highlighting both its commonalities with
other areas of professional psychology, as well as its distinctiveness. We
look forward to seeing the dynamics of such changes, as well as the emer-
gence of new specialties in the future.
About the Series in Specialty Competencies in Professional Psychology xi
In writing this volume, we, in collaboration with our co-author

Christopher Martell, sought to meet the challenge of illustrating how com-
petencies within the continually growing specialty of cognitive and behav-
ioral psychology may be defined. With ever expanding scientific research
support for the wide range of cognitive and behavioral interventions, more
and more doctoral programs in clinical psychology have developed con-
centrations in this specialty area. As such, we (Nezu, Martell, and Nezu)
provide a needed bridge between these evidence-based interventions that
have become a hallmark of the specialty and the prominent cognitive,
behavioral, and emotional learning theories from which they have been
developed. Also of particular note are the chapters that illustrate the unique
ethical challenges that may arise for therapists who work from a cognitive
and behavioral perspective, as well as those that translate how multicul-
tural and interpersonal competencies specifically apply to the specialty.
Lastly, this volume provides a comprehensive overview of how the spe-
cialty area has emerged and offers a case formulation methodology as one
way to integrate the various aspects of cognitive and behavioral therapies
that include applied behavioral analysis, behavior modification, cognitive
therapy, and contemporary integrative cognitive behavioral approaches
to clinical problems. Those readers interested in obtaining an informed
understanding of past influences, extant scientific foundations, knowledge
about important professional issues, and an appreciation of the specialty’s
future directions, will find them all represented well in this single volume.
Arthur M. Nezu
Christine Maguth Nezu
This page intentionally left blank
PA RT I
History and Background

O NE
Introduction
The converging paths of the applied specialty of cognitive and behav-

ioral psychology can be traced back to the 1950s and the emergence of
behaviorism in the United States, the United Kingdom, Canada, and South
Africa (Antony & Roemer, 2011). Earlier scientific investigations of learn-
ing theory with animal models carried out by Pavlov, Thorndike, Hull,
Skinner, and later with human learning by Watson, as well as scores of
studies by other experimental psychologists, contributed heavily to the
foundations of the specialty. Although the various factors that contrib-
ute to cognitive and behavioral psychology’s evolution are numerous, the
approach was focused on applying a scientific method to understanding
and treating psychopathology. As a clinical approach, behavioral psychol-
ogy was directed toward understanding human behavior, increasing adap-
tive functioning, and modifying clinical behavior problems based upon the
application of theories of learning. An influential event in the develop-
ment of a behavioral specialty within professional psychology culture was
the Boulder Conference on Graduate Education in Clinical Psychology in
1949, which emphasized the concept of scientist-practitioner training in
psychology. During this conference and subsequent professional meetings,
an initial generation of behavior therapists sought to clinically demon-
strate this new and exciting field of applied research, which used learning
principles to understand the etiology and maintenance of problems in liv-
ing and to develop effective treatments for therapeutic change in order to
improve people’s lives.
In North America, behavioral treatments were heavily drawn from oper-
ant learning approaches based upon theories of Skinner (1953) and Hull’s
4 History and Background
drive reduction theory (1943), whereas the influence of respondent condi-

tioning was evident in the clinical research of Watson (Watson & Raynor,
1920), Jones (1924), and Mowrer (1948). In South Africa, Joseph Wolpe
was one of the first individuals to develop treatments based on the concept
of reciprocal inhibition, or pairing a previously learned, feared stimuli with
a relaxation response, known as systematic desensitization (Wolpe, 1958).
Beginning in the 1950s and 1960s, contributions from cognitive theo-
ries such as George Kelly’s personal construct theory (1955) and models
of information processing significantly expanded the concept of learning
to extend far beyond earlier conditioning theories (O’Donohue & Fisher,
2009). Several authors credit Albert Ellis as a major influence regarding the
incorporation of cognitive strategies into behavioral therapy (Antony &
Roemer, 2011). Ellis, who was influenced by his own training in both con-
ditioning theory and psychoanalysis, developed a treatment that he labeled
“rational emotive psychotherapy” (1962).
Contributions to contemporary cognitive and behavioral theory con-
tinued to expand regarding the role of cognitive mediators in learning.
Individuals who were instrumental to this advancement of the specialty’s
scope during that time included Donald Meichenbaum (1977), Marvin
Goldfried, Thomas D’Zurilla (Goldfried & D’Zurilla, 1971), and Michael
Mahoney (1974). In the time period extending from the 1970s to the
1980s, behavioral approaches to treatment incorporated concepts such
as Lazarus’ multimodal therapy (Lazarus, A., 1973) and Bandura’s social
learning theory (1976). Finally, Aaron Beck, a psychiatrist, advanced a
therapy approach based upon cognitive principles of change (Beck, 1976).
These are just a few examples of the many ways that behavior therapy
expanded to include the newly emerging paradigm of cognitive and behav-
ioral psychotherapy. Lazarus (2001) credits Cyril Franks with the actual
term cognitive-behavioral therapy, which illustrated the zeitgeist during
this time period to include cognitive-based approaches to psychotherapy
treatment, in addition to the conditioning-based approach that previously
had predominated behavioral interventions.
Later, during the 1980s and 1990s, the construct of learning was further
expanded to include phenomena such as implicit meaning structures or
schemas, through which people react to and interpret their world, often
outside conscious awareness (Goldfried, 2003; Young, 1994). The past two
decades have produced research that underscores the importance of emo-
tional activation (Gross & Thompson, 2007) as well as mindful aware-
ness of negative affective states (Hayes, Strosahl, & Wilson, 1999; Nezu,
Nezu, & D’Zurilla, 2013; Segal, Teasdale, & Williams, 2001; Roemer &
Introduction 5
Orsillo, 2002) as critical components of the cognitive-behavioral thera-

peutic process.
Finally, neuroscientific researchers have provided both animal and
human models of learning, using contemporary imaging methods in their
research. These studies have aided in the discovery of the presence of spe-
cific neural pathways involved in learning experiences with a strong emo-
tional component (LeDoux, 2000). This is a particularly exciting time in
the evolution of cognitive and behavioral psychology, because the field is
integrating its scientific foundations with more recent findings from brain
science and a return to the importance of emotional experience, first put
forward by William James (James, 1884), over a century ago. It is also a
time when competence in applying cognitive and behavioral interventions
within the specialty requires an integrated knowledge of a wide range of
physiologic phenomena, neuro-cognitive models, multicultural factors,
and theories of emotion with contemporary principles of learning.
Currently, there is an effort among leaders in this specialty to discern
the active ingredients that are common to the many interventions that fall
under the rubric of cognitive and behavior therapies (see Barlow, Allen,
& Choate, 2004; Task Force for Common Language in Psychotherapy
Procedures, 2010). This approach is focused on the investigation and
understanding of the most important “ingredients” across a wide range of
interventions that fall under the cognitive and behavioral rubric. From its
beginning as a specialty area of applied psychology, the unifying principle
in cognitive and behavioral psychology (and its associated psychotherapy
interventions) that has been present throughout its growth is the commit-
ment to a scientific approach. Specifically, the scientific approach is viewed
as the method for the identification and discovery of effective assessment
methods and treatments aimed at ameliorating human suffering and pro-
moting an increased quality of life.
The Path to Formal Recognition

Cognitive and behavioral psychology was initially recognized as a spe-
cialty by the American Board of Professional Psychology (ABPP) in 1992
(originally titled the American Board of Behavioral Psychology when first
incorporated in 1987 with support from the Association of Behavior and
Cognitive Therapies, which was then known as the Association for
Advancement of Behavior Therapy). Later, in 1994, the American Board of
Cognitive and Behavioral Psychology (ABCBP) adopted its current name to
reflect the growing breadth of the field and to be consistent with similar name
changes by organizations that promoted cognitive and behavioral thera-

pies around the world, including the Association for Behavioral and
Cognitive Therapies and the World Congress of Behavioral and Cognitive
Therapies. In 2000, the specialty was recognized by the Commission for
the Recognition of Specialties and Proficiencies in Professional Psychology
(CRSPPP), associated with the American Psychological Association (APA).
The commission reviews petitions for specialty recognition within pro-
fessional psychology and makes recommendations to the APA regarding
issues concerning psychology specialties and proficiencies. Additionally,
a representative from the specialty of cognitive and behavioral psychology
participates in the Council of Specialties (CoS), which is recognized by the
APA and the ABPP to meet and consider policies affecting specialization
in professional psychology.
Although there is no specific APA division that exclusively represents
the specialty of cognitive and behavioral psychology, many specialists
in this area are active in APA divisions dedicated to behavioral analysis
(APA Division 25), clinical psychology (Division 12, Section III, Society
for a Science of Clinical Psychology), and developmental disabilities
(Division 33). The post-licensure board certification process is admin-
istered by the American Board of Cognitive and Behavioral Psychology,
and fellowship membership for board-certified cognitive and behavioral
psychologists is offered through the American Academy of Cognitive
and Behavioral Psychology. Related multidisciplinary organizations that
represent physicians, social workers, and other mental health profes-
sionals include the Association for Behavioral and Cognitive Therapies,
the Behavior Analyst Certification Board, the Association for Behavior
Analysis, and the Academy of Cognitive Therapy. Cognitive-behavioral
psychologists are also very involved in the development of assessment and
treatment strategies that cross over to other areas of professional psychol-
ogy specialization, including (but not limited to) clinical, clinical child and
adolescent, clinical health, geropsychology, school, organization and busi-
ness consulting, couple and family, and rehabilitation areas.
Definition and Unique Characteristics of the Specialty

The specialty of cognitive and behavioral psychology emphasizes an
experimental-clinical approach regarding the application of behavioral
and cognitive sciences to understanding human behavior and develop-
ing interventions to enhance the human condition. Cognitive and behav-
ioral psychologists engage in research, education, training, and clinical
Introduction 7
practice regarding a wide range of problems and populations. The spe-

cialty’s distinct focus is twofold: (a) its heavy reliance on empiricism and
an evidence-based approach; and (b) its grounding in learning theories,
broadly defined, including classical (respondent) learning models, such
as associative and single stimulus conditioning, operant learning models,
social learning, and information-processing models (American Board of
Cognitive and Behavioral Psychology, 2010).
As indicated earlier, although cognitive and behavioral psychology is
theoretically rooted in early learning theories and behavior modification,
it has evolved over the years and has been informed by an emerging sci-
entific knowledge base in contemporary learning theory, neuro-cognitive
research, emotional and cognitive implicit learning models, and
information-processing theory, research, and practice.
With regard to education and training, cognitive and behavioral psy-
chology has not been associated with a specific, specialty-affiliated,
APA-accredited doctoral program. Over the years, simultaneous to its
emergence as a specialty, clinical, school, and counseling psychology train-
ing programs have historically included behavioral and cognitive courses,
as well as training experiences, such as supervised clinical practicum.
These included theories of learning, neuroscience, cognitive psychology,
and experimental analyses of behavior. Additionally, courses focused on
learning theories were typically included in training programs for educa-
tion, special education, clinical health, and behavioral economics.
Currently, there are four major subareas of the specialty that share their
theoretical foundations in learning theory and a common approach to
case conceptualization. These include applied behavior analysis, behavior
therapy, cognitive-behavior therapy, and cognitive therapy. Additionally,
there are many evidence-based therapeutic interventions and systems,
as well as individual therapy techniques that fall under each subarea. For
example, cognitive-behavioral therapy may include therapeutic inter-
ventions such as dialectical behavior therapy (DBT; Linehan, 1993) or
cognitive-processing therapy (CPT; Resick, Monson, & Chard, 2007); sys-
tems of psychotherapy such as problem-solving therapy (PST; D’Zurilla &
Nezu, 2007; Nezu, Nezu, & D’Zurilla, 2013) or behavioral activation
treatment (BA; Dimidjian, Barrera, Martell, Munoz, & Lewinsohn, 2011;
Jacobsen, Martell, & Dimidjian, 2001); and specific therapy techniques
such as virtual systematic desensitization (Rothbaum et al., 1995), expo-
sure and response prevention (ERP; Wilhelm & Steketee, 2006), cognitive
hypnotherapy (Dowd, 2000), or progressive relaxation training (Bernstein,
Borkovec, & Hazlett-Stevens, 2000). Moreover, learning occurs on both a
conscious and non-conscious level of awareness. Applied behavioral analy-

sis may include assessment systems such as functional analysis, or inter-
ventions such as token economies, time-out procedures, or differential
reinforcement of incompatible behavior (Kazdin, 2000). The construct of
“behavior” in the specialty of cognitive and behavioral psychology is very
broadly defined to include overt actions, as well as private phenomena, such
as cognitions, affect, emotional arousal, and physiological events (Dowd,
Chen, & Arnold, 2010). In summary, the definition of cognitive behav-
ior therapy is wide-ranging and has its historic roots in behavior therapy,
cognitive therapy, and experimental analysis of behavior, as well as con-
temporary learning approaches, physiologic psychology, neuro-cognitive
models, and research concerning multiculturalism and theories of emo-
tion. The specialty remains focused on clinical problems and clinical solu-
tions associated with learning.
As indicated in the preceding paragraphs, the actual knowledge base sub-
sumed under the rubric of cognitive and behavioral psychology is derived
from a wide range of experimental and applied research areas. Specifically,
the knowledge core that is common to all four subareas includes the full
spectrum of learning theories, theories of human development, biologi-
cal bases of behavior, neuro-cognitive aspects of behavior, affective aspects
of behavior, principles of measurement, ethics, case formulation, clinical
decision making, theories of individual differences regarding ethnic and
cultural diversity issues, and research methods, including both group and
single-subject experimental designs. Cognitive and behavioral psycholo-
gists are also concerned with how the various behavioral, cognitive, affec-
tive, biological, and social factors interact and impact each other (Dowd,
Chen, & Arnold, 2010); they assume a biopsychosocial view of human
physical and mental health and illness (Nezu, Nezu, & Rosessler, 2001) and
embrace a multicultural perspective.
Cognitive and behavioral psychologists serve a wide range of popula-
tions, including children, adolescents, adults, and older adults. Although
a focus on individual behavior is a hallmark of the specialty, cognitive and
behavioral therapies have been implemented successfully with couples,
groups, families, classrooms, and organizations, and in a variety of settings
(e.g., homes, schools, clinics, hospitals, workplaces, correctional facilities,
communities). More recently, cognitive and behavioral interventions have
become available through web-based Internet programs and treatments, as
well as through smart phone applications.
TWO
Conceptual Foundations and Theories
This chapter will focus on the influence of various conceptual and theoretic
factors that represent the core foundations of the specialty. These founda-
tions include the major learning theories that are traditionally invoked when
describing cognitive and behavioral conceptualizations of a particular clin-
ical problem or disorder (Nezu, Nezu, & Lombardo, 2006) and extend to
the recent integration of contemporary learning theory with findings from
developmental and interpersonal contexts (Mahoney & Lyddon, 1988;
Guidano & Liotti, 1983; Meichenbaum, 1977; Young, 1994), the neurosci-
ence of emotional, cognitive, and non-conscious learning (Damasio, 1999;
LeDoux, 2000; Murphy & Zajonc, 1993; Davidson & Begley, 2012), as well
as alternative philosophical, cultural, and spiritual traditions that impact
an individual’s learning experience (Hays, 2009; Nezu & Nezu, 2003).
These areas include the following broad categories: (a) associative and sin-
gle stimulus learning (also termed respondent, classical, or Pavlovian con-
ditioning); (b) instrumental learning (also termed operant conditioning or
Skinnerian conditioning); (c) two-factor theory, d) imitative learning (also
termed modeling or social learning theory); (e) information-processing the-
ories (including implicit and non-conscious information processing), and
(f) theories of emotion. Table 2.1 provides a brief summary of the major
theories.
Associative Learning
Learning by association, or the pairing of two events, can be traced back
to early experiments in classical conditioning. Classical conditioning, also
TA B L E 2 .1 Major Theories That Influenced the Specialty of Cognitive and Behavioral Psychology
THEO RY B R IEF DESC R IPT IO N NOT E D T H E ORI S T S F URT H E R R E A D I N G
Associative Learning Also termed classical conditioning, respondent conditioning, or Pavlovian conditioning; a form of learning in Pavlov, Watson & Raynor, Mary Rescorla & Wagner(1972);Barker
which a CS signals occurrence of a US. Cover Jones (2000)
Single Stimulus Learning A change in a response to a stimulus that does not involve association with another stimulus or event Thompson & Spencer Barker (2000)
such as reward or punishment (examples: habituation, sensitization).
Instrumental Learning Also termed operant conditioning, a form of learning in which an individual’s behavior is modified by Thorndike, Skinner Mittenberger (2012); Bayer, Wolf, &
its consequences. Risely (1968); Kazdin (2000)
Emotion Theories A subjective experience that includes physiologic, neurologic, and cognitive aspects. James, Darwin, Ekman, Levenson, Gross & Thompson (2007);Davidson
Davidson, LeDoux, Demasio & Begley (2012)
Two Factor Theory (Avoidance A motivational explanation of avoidance in which the first factor involves fear that is conditioned Mowrer Mower (1960)
Learning) to environmental cues that precede the occurrence of the aversive event. The conditioned fear
motivates the occurrence of an escape response, which terminates the CS, and serves to reinforce
the avoidance behavior.
Social Learning Theory Expanded concepts of learning to the social context, such that acquisition of behavior occurs through Bandura,Rotter Bandura & Walters (1963); Rotter
observation of models and expectation of reinforcing outcome (1982)
Personal Construct Theory Viewed humans as personal scientists who seek to explain events in their lives and employ “personal Kelly Kelly (1955)
constructs” to understand their experiences.
Learned Helplessness/ Learned helplessness developed as a theory to explain the condition of a human or animal that has Overmeier, Seligman Garber & Seligman (1980)
Attributional Theory learned to behave helplessly, failing to respond to opportunity for reinforcing consequences.Later
reformulated and expanded to include attributional processes.
Cognitive Behavioral Theories Cognitive and information processing in the form of schemas, beliefs, judgments, appraisals, Lazarus, Ellis, Beck, Michenbaum, O’Donohue & Fisher (2012); Beck
interpretations, and assumptions are primary determinants of one’s feelings and actions. Mahoney, Young (1995)
Relational Frame Theory Posits that early in the developmental process, humans learn to relate stimuli arbitrarily, which then Hayes Hayes, Barnes-Holmes, & Roche
becomes an operant response. The important tenet of RFT is that arbitrarily established relations will (2001); Ramnero and Torneke
alter stimulus functions, dependent upon social context. (2008)
Conceptual Foundations and Theories 11
known as Pavlovian or respondent conditioning, was initially based upon

the work of Ivan Pavlov, whose lifelong research in physiology and animal
research culminated with his studies of the psychic reflex and conditioning
(Pavlov, 1941). In the basic classical conditioning experimental paradigm,
a stimulus is made to elicit a response that was not previously associated
with that stimulus. Through repeated pairings of two stimuli, a conditioned
stimulus (CS) will come to elicit a response (referred to as the conditioned
response, or CR) that is similar to the unconditioned response (UR) origi-
nally elicited by an unconditioned stimulus (US). In humans, an example
of such a stimulus pairing is the experience of discomfort (CR) associated
with sound of a shrill dentist’s drill (CS). After repeated (or sometimes
single) pairings, the sound of the drill by itself (CS) may elicit physical
sensations of pain and discomfort (CR), because of the learned association
between the US and CS. Another example may be the pleasant association
or sexual arousal associated with a loved one’s perfume or cologne.
The strength of the learned association, or stimulus-stimulus learning,
depends upon many properties inherent in the learning situation, includ-
ing the intensity of either the unconditioned or conditioned stimulus, the
order of stimulus presentation, the time interval of the two stimulus pair-
ings, the degree of evolutionary preparedness present in a learned asso-
ciation (Garcia & Koelling, 1966) and many other potential properties of
the stimuli involved in the association (Barker, 2000). With regard to the
concept of evolutionary preparedness, for example, researchers Garcia and
Koelling (1966) revealed that associations between sound and visual cues
with shock (US) as well as a taste cue with a sickness-inducing chemical
(US) were made much more quickly than if either unconditioned stimuli
were associated with the other cue. Such research was important to under-
standing that there are stimuli in our environment that are likely to be
associated with various unconditioned stimuli when evolutionary adap-
tation and survival depended on it (for example, stimuli associated with
predators, heights, poisons, the unknown, or strangers). This evolution-
ary receptivity to learning of predictable associations is referred to as
preparedness. Repeated experiments have also documented that proper-
ties of one stimulus can prepare, block, overshadow, or enhance a specific
learning situation (Bouton, 2007). For example, in the situation previously
described in the chapter, if the sound of the dentist’s drill is very loud,
shrill, or unusual (intensity parameters), was introduced just prior to the
experience of pain (order and time parameters), and involved sound and
visual characteristics (vs. taste) then the learned association between the
dentist’s drill and pain is more likely to result in rapid learning. Among the
many factors that influence the strength of a learned association, an indi-

vidual’s learning history may also impact the association, such as the indi-
vidual’s prior exposure or experience with one of the stimuli that is being
paired (Bouton, 2007; Mineka & Zinbarg, 2006). For example, consider
the individual who has heard a dentist’s drill in several situations in which
a response of pain was not experienced. He or she would be less likely to
associate the sound of the drill with fear, arousal, or discomfort and the
specific association of the dentist’s drill and distress would be inhibited.
This phenomenon reflects a latent inhibition of associative potential based
upon the past experience of an individual.
Competent knowledge of classical conditioning therefore requires far
more than the understanding of the basic Pavlovian experiment that is
often described in introductory psychology texts. Rather, a more sophisti-
cated knowledge of the principles that impact the strength of the associa-
tion and a theoretic understanding of why one association is likely to be
learned, or resistant to change, and another not, is required for forming a
competent and learning-based case conceptualization of a clinical target.
Finally, an understanding of the possible long-term consequences of emo-
tional learning experiences is also a requirement for the clinician who spe-
cializes in cognitive and behavioral psychology, such as learning associated
with early life stress (for example, trauma or neglect during childhood).
For example, early painful or frightening experiences, which may be asso-
ciated with various external (or internal) stimuli may actually alter the
sensitivity and reactivity of the neuroendocrine system that mediates the
stress or fear response, such that later stress in life either engenders height-
ened emotional arousal or lowers the threshold for arousal (Gillespie &
Nemeroff, 2005; Nezu, Nezu, & D’Zurilla, 2013).
With regard to the scientific basis that supports the various aspects of
how associative learning occurs in both animal and human behavior, the
concept of extinction learning is also important. Just as repeated pairings
of a neutral stimulus with an unconditioned stimulus results in a learned
association of the two stimuli, extinction learning occurs when there is
repeated presentation of a previously conditioned stimulus (CS) in the
absence of the unconditioned stimulus (US). In such cases, after repeated
pairings, the conditioned stimulus no longer produces the previously con-
ditioned response (Pavlov, 1927). For example, an individual with a fear of
dogs who had previously been bitten by a dog and experienced the event
as painful and frightening would experience a reduction in fear response
after repeated exposure to a friendly and non-threatening dog. Years ago,
the extinction phenomenon was often inaccurately framed as a type of
“forgetting” of a conditioned response. Because extinction is a principle

that is common to many behavioral treatments, it is important to under-
score the findings that support extinction as a form of learning in its own
right. Studies that serve to underscore this point reveal that previously
extinguished conditioned responses can spontaneously recover and that
reconditioning occurs faster than initial conditioning. This strongly sug-
gests that extinction is not an erasure of the conditioned stimulus–uncon-
ditioned stimulus association but is stored as a second form of memory
(Santini, Muller, & Quirk, 2001). The notion that memory for extinc-
tion may be distinct from memory for initial fear conditioning has been
supported through research for decades (Rescorla & Heth, 1975, p. 2).
However, it was not until more recently, with technological advances, that
behavioral scientists have been permitted a closer look at both fear con-
ditioning and extinction learning at a more molecular level. As a result,
more information has been uncovered about the neural circuits involved
in both fear and extinction learning. Specifically, at the beginning of the
twenty-first century, through both animal research and human imag-
ing studies, research has provided a more carefully and comprehensively
mapped picture of the neural activity of both fear learning and extinction
learning. For example, contemporary research has shown that both fear
and extinction conditioning involve specific receptors in the amygdala and
associated brain pathways (LeDoux, 2000). This small, almond-shaped
subcortical area is now known to serve as a trigger for emotional reactions,
such as fear. Moreover, we now know that such emotional reactions are
initially triggered before we are even consciously aware that the reaction
is taking place. A full description is beyond the scope of this chapter; for
more information, the reader is referred to descriptions by LeDoux (2003)
and others (Damasio, 1999). However, the finding that emotional reactiv-
ity and fear conditioning occur beneath conscious awareness has signifi-
cant implications for cognitive and behavioral practice. As such, competent
applications of assessment and intervention require basic knowledge of
classical conditioning and extinction learning, as well as knowledge of the
neural pathways involved in emotional conditioning on intervention. An
important concept to underscore here is that the technology available for
contemporary neuroscientific studies such as brain imaging techniques
and animal research has permitted a better understanding of brain plas-
ticity (Cappas, Adres-Hyman, & Davidson, L. 2005; Davidson & Begley,
2012) and the promise of cognitive behavioral treatment to actually change
the way in which individuals process information. Understanding that our
day-to-day experiences are not only impacted by the way in which our
brains process information, but that the way in which our brains process
information can be impacted by our day-to-day experiences, provides an
exciting glimpse of the potential for cognitive behavioral interventions to
dramatically improve people’s lives.
The Ubiquity of Learning by Association in Everyday Life

In addition to the concept of how a learned association between a uncondi-
tioned stimulus and a previously neutral stimulus could elicit conditioned
responses, early experiments in classical conditioning also demonstrated
that associative learning occurs when a previously conditioned stimulus
is paired with a new conditioned stimulus. For example, early research
conducted by Staats, Staats, and Heard (1959), and continuing with con-
temporary research such as that conducted by Olson and Fazio (2002)
revealed that emotional responses may be reliably observed when people
read neutral nonsense syllables that are paired with words or pictures
containing strong emotional connotation through previous condition-
ing (e.g., words such as murder, grief, or pain, or conversely, joy, warmth,
or affection). This higher order conditioning process forms the basis for
human learning with regard to human biases and stereotypes, advertising
and propaganda, and the development of various clinical syndromes such
as anxiety reactions and addictions. Through higher order conditioning,
emotions such as fear, anger, and sadness, as well as various attitudes and
behavior and contextual cues (cues derived from the context or envi-
ronmental characteristics while the association was taking place) can all
become conditioned responses to stimuli (for example, words, situations,
or interactions with others) through their association with other previ-
ously conditioned stimuli, often below our conscious radar. The original
unconditioned stimulus (i.e., the original stimulus that elicited a pleasant
sensation, physiologic arousal, or pain) is no longer required. Thus, years
of research in associative learning have demonstrated that many common
emotional experiences that impact our everyday life, from attraction or
disgust to various stimuli, people, or environments, as well as the power of
marketing and commercials, stereotyping and prejudice, decision making,
and the presence of psychopathology, can be partially linked to this type
of conditioning. Classical conditioning continues to serve as an impor-
tant foundational principle for understanding behavioral and emotional
disorders. As an example, we discuss how such principles are useful to the
understanding of anxiety disorders.
Classical Conditioning and Anxiety Disorders

The first group of psychologists to rely on classical conditioning and
the laws governing associative learning to explain human psychopathol-
ogy focused their attention toward an explanation of anxiety disorders
and phobias (e.g., Eysenck, 1962; Watson & Raynor, 1920; Wolpe, 1958).
According to this view, anxiety reactions are seen as the result of higher
order conditioning of the autonomic nervous system to certain environ-
mental events and situations. Fear reactions are particularly associable, in
that many intense, fear-producing stimuli are available to be paired with
a wide range of environmental phenomena. For example, post-traumatic
stress disorder may result when individuals directly experience intense
aversive events such as war, rape, car accidents, child abuse, terrorism, or
natural disaster, or vicariously experience such events through observation
of others experiencing such events, or through film or news media. In such
situations, environmental stimuli such as sounds, smells, and visual cues
can all become conditioned stimuli as they are paired with one’s awareness
of internal stimuli (interoceptive events). Classical conditioning of auto-
nomic reactivity can be found to make at least a partial contribution to
the development of most anxiety disorders. These include specific pho-
bias, as well as obsessive-compulsive disorder, agoraphobia, social phobia,
and post-traumatic stress disorder. In addition, higher order or second-
ary classical conditioning can be identified as being involved in the etio-
pathogenesis of anger problems, depression, sexual disorders, and many
interpersonal difficulties. For example, various environmental cues, such
as a familiar song, a person’s name, or other stimuli, may come to be asso-
ciated with the experience of loss or a sad mood. In most cases, however,
in order to provide a full learning-based explanation of the disorder, addi-
tional types of learning should be posited to interact with classical condi-
tioning, incorporating a multifactor theory of conditioning, which will be
discussed later in this chapter.
Contemporary conditioning models (Mineka & Zinbarg, 2006) have
provided perspectives on the etiology and maintenance of anxiety disor-
ders that capture the complexity associated with individual differences in
the development and course of such clinical problems. These perspectives
add significant depth to earlier learning-based approaches, which were
based upon a single theory, and take into account more than one theory
as described above, as well as temperament vulnerabilities, early learning
experiences, short- and long-term outcomes, experiences of traumatic
events, and contextual variables. For example, Mineka and Zinbarg (2006)
describe a hypothetical case in which two individuals are both exposed to

a traumatic experience of a dog attack. In one case, the person was hiking
in the woods with her own pet dog when an unknown dog attacked her
and bit her on the wrist. She described herself as “terrified” when the attack
took place, and her bite wound became infected and very painful, requiring
medical treatment. In the other case, a person was also out for a walk when
three large growling dogs chased her to a fence. Although the victim of this
attack was also “terrified,” the dogs’ owner was described as intervening
and the person escaped without injury. These authors explain that in this
hypothetical example, the first person, although actually bitten, does not
go on to develop a phobia toward dogs, but the second person (who was
not actually physically injured) does develop a phobia. By providing this
example as well as others, Mineka and Zinbarg illustrate how the learn-
ing of different individuals, such as these dog attack victims, may differ
depending on many complex factors. These include vicarious conditioning
of fears and phobias, individual differences concerning temperament vul-
nerability, the impact of prior experiences, the impact of contextual vari-
ables during conditioning, the sense of control that one perceives, and the
impact of post-event variables.
Contemporary Classical Conditioning Models

and Psychosomatic Medicine
Although classical conditioning was historically associated with the
involuntary responses of the autonomic nervous system, as in the case of
reflexes and fear reactions, more recent models of classical conditioning
have focused on its role in the development of psychosomatic disorders
(Barker, 2001). Many studies support integrative explanatory models that
link classical conditioning of both the autonomic and central nervous sys-
tems with the neuroendocrine and immune systems and environmental
cues in such a way as to influence physiologic symptoms. This is an area
in which the specialty of cognitive and behavioral psychology significantly
overlaps with the specialty of clinical health psychology, especially where a
cognitive and behavioral specialist’s practice has evolved to focus on clini-
cal health populations. One major area in which classical conditioning is
associated with health applications is in studies associated with psychoneu-
roimmunology (Ader & Cohen, 1993). In a seminal experiment, initially
conducted by Robert Ader (Ader & Cohen, 1975), rats were classically con-
ditioned by giving them water that contained an immunosuppressant drug,
cyclophosphamide, as well as saccharine. Thus, the cyclophosphamide
was classically paired with saccharine. When the cyclophosphamide was

removed, the sweetened water alone actually suppressed the rats’ immune
systems, as if they had been injected with the powerful immunosuppres-
sant drug (cyclophosphamide). Some rats were so immune-compromised
that they died as a result of the sweetened water alone. It appeared to Ader
that the immune system could be classically conditioned. Ader and his
co-investigator Cohen (an immunologist) directly tested this hypothesis by
deliberately immunizing conditioned and unconditioned animals, expos-
ing these and other control groups to the conditioned taste stimulus, and
then measuring the amount of antibody produced. Their replicable results
revealed that conditioned rats exposed to the conditioned stimulus were
indeed immunosuppressed. In other words, a signal via the nervous sys-
tem (taste) was affecting immune function. This was one of the first scien-
tific experiments that demonstrated that the nervous system could impact
the immune system. Later, Ader and Cohen collaborated with David Felten
to compile the science supporting neuroendocrine-immune interaction
(1981) related to health. This hallmark publication, which ushered in the
multidisciplinary field of psychoneuroimmunology, is now in its fourth
edition (2007). Additional contemporary research, based on the founda-
tions of classical as well as additional learning principles, has revealed how
previously neutral stimuli can be linked with psychosomatic reactions in
a number of somatic problems. These include chronic fatigue syndrome
(Schmaling, Fiedelak, Katon, Bader, & Buchwald, 2003), hypoglycemia
(Stockhorst, de Friesa, Steingrueber, & Scherbaum, 2004), allergic reac-
tions, drug tolerance (Barker, 2001), medically unexplained symptoms
(Nezu, Nezu, & Lombardo, 2001), and pain (Turk & Wilson, 2013). Turk
and Okifugi (2003) describe a clinical example of a pain patient who expe-
rienced increased pain during physical therapy. Through a classical con-
ditioning paradigm, this patient came to associate a negative emotional
response to the presence of the physical therapist, the treatment room,
and other environmental cues associated with pain. Such negative emo-
tional reactions then led to increased muscle tension and worsening of the
pain, thus strengthening the association of physical therapy and pain. It is
important that individuals who provide cognitive-behavioral treatment or
consultation in medical or health settings are familiar with the learning
theories predominant in psychosomatic disorders.
Single Stimulus (Non-Associative) Learning

There are times when a relatively enduring change in a behavioral response
occurs that is not the consequence of an association of a US and a CS, or
higher order pairing of two CSs, but the result of an individual experienc-
ing a single stimulus. Two examples of this type of learning are habituation
and sensitization. Through habituation, although an individual initially
reacts and orients toward a stimulus, the repeated presentation of a stimu-
lus results in the stimulus becoming non-relevant and ignored. Common
phenomena may include familiar household sounds, such as traffic noise
for people accustomed to an urban environment. Sensitization occurs
when repeated presentations of a stimulus are very intense and do not
habituate easily. In such cases, the opposite effect can occur. Rather than
resulting in a reduced responsiveness, the individual becomes sensitized to
the stimulus and responds with a heightened or hypersensitive reactivity.
(Sensitization is used here to describe the phenomenon of a heightened
reactivity, both in the case of potentiation, or heightened reactivity to the
specific stimulus, as well as the more commonly used term of sensitiza-
tion, which refers to more generalized sensitivity to a range of stimuli.) The
process of sensitization may be a useful model in studying the underly-
ing causes of physical problems that involve reactive inflammation, such
as asthma, to environmental stimuli to which other individuals are not as
physically reactive, as well as psychological disorders that involve aspects
of hypersensitivity or hypervigilance to certain situations or stimuli. An
example of how both processes can occur simultaneously involve mothers
of small children in a nursery who, through a process of discriminative
learning, become sensitized to their own child’s cries, yet are habituated
and less responsive to the cries of other children.
One problem regarding habituation and sensitization as explanatory
theoretic constructs of psychopathological states is the difficulty in pre-
dicting how an individual will respond to any one specific stimulus. The
result of habituation or sensitization is dependent upon the intensity of
the stimulus, the nature of the stimulus, the background conditions, and
the individual’s prior history with the stimulus (Barker, 2001; Davis, 1974;
Overmeier & Seligman, 1967). Ultimately, in cases where an individual
experiences sensitization following presentation of a stimulus, they may be
more susceptible to further associative conditioning, as they may be more
physically reactive during the presentation of two stimuli, if one elicits a
reactive emotional response.
The learning principles of sensitization and habituation can be par-

ticularly helpful regarding a cognitive and behavioral understanding and
treatment of anxiety disorders. One example, with regard to the treat-
ment of phobias, is a procedure referred to as in vivo exposure. As part of
this treatment, the therapist accompanies phobic individuals as they are
placed in the presence of (i.e., are exposed to) the phobic stimuli repeat-
edly and are asked to refrain from avoidance or escape until the reactive
arousal is habituated. As with most learning-based explanations of a spe-
cific phenomenon, a full explanation also involves classical conditioning
(for example, the pairing of a neutral stimuli that, paired with a negative
emotional reaction, now elicits fear), as well as extinction learning (the
learning process actually involved in habituation). In other words, because
exposure-based interventions are essentially inhibiting a learned associa-
tion between two stimuli, there is a degree of extinction learning involved
in this process.
Neurosubstrates of Learning
As mentioned earlier in the chapter, over recent years there has been
an emerging research base that has contributed to a more sophisticated
understanding of the neurosubstrates of both fear and extinction learning.
Specifically, basic and translational research studies have implicated sub-
cortical structures, such as the amygdala and hippocampus, as indispens-
able for recognizing fear and important to fear conditioning (see LeDoux,
1996). LeDoux and others have reported that when a fearful memory
is triggered, the memory will be reconstructed or reconsolidated over a
several-hour time period. Exposing an individual to such a fear trigger and
creating a new learning experience in which a previously conditioned fear
stimulus is no longer associated with a negative event will result in extinc-
tion learning. These findings helped to provide an understanding of the
neural substrates involved in behavioral therapies that create new learning
experiences through habituation and extinction training.
Psychopharmacologic Enhancement of Extinction Learning

In recent years, there has also been a growing interest in a strong body of
evidence to suggest that the extinction of fear is mediated in a specific area
of the amygdala known as the N-methyl-D-aspartate (NMDA) receptor
(Norberg, Krystal, & Tolin, 2008). Moreover, there have been investigations
with drugs such as D-cycloserine (DCS) that may facilitate fear extinction
and exposure therapy by either enhancing NMDA receptor function dur-

ing the initial associative experience when fear memory is being consoli-
dated, or during extinction, when a fear memory is being triggered and
new associations are being formed. DCS, which is administered only at the
time of extinction training (and not to relieve symptoms of anxiety) has
been shown to enhance fear extinction/exposure therapy in both animals
and anxiety-disordered humans. It has been shown to be most effective
when administered a limited number of times and when given immediately
before or after extinction training/exposure therapy (Norberg, Krystal &
Tolin, 2008). A meta-analysis conducted by Norberg and colleagues (2008)
suggests that drugs such as DCS may be very useful targets for transla-
tional research regarding augmentation of exposure-based treatment via
compounds that impact neuroplasticity. Because of the drugs’ action spe-
cific to brain areas associated with classical conditioning of fear, it is not
surprising that subsequent research with the drug has not resulted in any
evidence of useful facilitation of operant or instrumental learning in either
the extinction or the conditioning context. Instrumental learning involves
a different learning process, and this foundational theory of cognitive and
behavioral psychology is discussed later in this chapter.
The Evolutionary Context of Classical Conditioning and Contemporary

Emotional Theories
Before leaving the topic of classical conditioning theory, it is impor-
tant to underscore the importance of learning theory to understand-
ing human emotional responses with particular regard to conscious and
non-conscious emotional learning experiences, and classical condition-
ing of emotion. Many contemporary theorists and researchers believe that
emotional learning occurs rapidly because we are evolutionarily prepared
for such emotions to be triggered for survival, mostly beneath our con-
scious awareness. However, in modern times, this may often go awry, and
many clinical problems can be tied to non-conscious classically conditioned
emotions that interfere with one’s goals, rather than to facilitate survival.
Contemporary theories of emotion are important because they highlight
the adaptive and informative nature of emotions (Stegge & Terwogt, 2007).
Although prevalent since the writings of Darwin (1872) and Freud
(1915), until recently, emotional theories have been loosely organized
(Gross & Thompson, 2007). However, beginning with early theories of
emotion (James, 1884), and continuing through to contemporary theories
such as Frijda’s (1988) theory of emotion and action tendencies, Ellsworth’s
(1994) review of the emotional theories, and Levenson’s (1999) theory of

the role of emotions in an interpersonal context, the importance of clas-
sical conditioning to everyday emotional experience and functioning is
impressive. For example, Levenson theorized that the human emotional
system consisted of a two-system design with each system contributing
differentially to the various intra- and interpersonal functions that emo-
tions serve. Several contemporary theorists view the core of the emotional
system as a remarkable and efficient processor that is both automatic and
adaptive (Zajonc, 1984). Contemporary theories of emotion and affective
scientific research have provided strong evidence for an emotional learn-
ing pathway, which is associative. As observed by neuroscientist Antonio
Damasio (1999), although the biologic and neurologic machinery for emo-
tions as an evolutionary gift to quickly teach us to avoid harmful stimuli
(such as poisonous creatures, strangers, or heights) is present, the inducers
are not part of the brain’s machinery; they are external to it. It is condition-
ing that results in learned reactivity (Damasio, 1999). He states, “the perva-
siveness of emotion in our development and subsequently in our everyday
experience connects virtually every object or situation in our experience,
by virtue of conditioning, to the fundamental values of homeostatic regula-
tion: reward/punishment, pleasure/pain, approach/withdrawal, good (sur-
vival) /evil (death)” (p. 58). If this evolutionary process allows for survival
behavior to deploy quickly, it must occur without the necessity of employ-
ing higher level cortical process that would slow down reaction to threat.
As a result, much of our emotional reactivity occurs beneath the radar of
our cognitive awareness.
Levenson also referred to a second system, or set of control mechanisms
that consist of a more recently evolved set of processes that are sensitive
to learning. Panksepp (1998) coined the term affective neuroscience to cap-
ture the content of an emerging field that was studying the neural mecha-
nisms of emotion and emotional learning, applied to areas of the brain far
removed from the primitive and non-conscious amygdala, hippocampus,
and limbic pathways described above. Our current understanding is that
the cortex also determines emotional states and moods. One of the ini-
tial studies that broadened this field occurred when the emotional cod-
ing systems of psychologist Paul Ekman (Ekman & Rosenberg, 1998) were
correlated with changes in the prefontal cortex (Davidson & Fox, 1982).
The theoretic foundations of emotional learning and conditioning theo-
ries provide us with a neuroscientific understanding of emotions, so cen-
tral to many cognitive and behavioral treatments. We now know that the
process of learning emotional regulation is complex. It may be automatic
or controlled, conscious or non-conscious; however, such regulation is a

critical concern of many psychotherapy interventions. It is essential that
the competent cognitive and behavioral psychologist remain informed of
this emerging area of research, as clinical investigators increasingly are
addressing the foundations of emotional learning in the development of
evidence-based interventions.
Whereas classical conditioning provides significant explanations of
human reactivity to their day-to-day-interactions, another foundational
learning theory that supports the cognitive behavioral understanding of
human challenges is instrumental learning. This form of conditioning is
focused less on conditioned reactivity, but on motivated behavior that is
maintained by reinforcement principles and is reduced through punish-
ment principles.
Instrumental Learning
Instrumental learning (also referred to as operant conditioning) occurs
through various types of reinforcement and punishment events that follow
behavioral responses, within specific situational contexts. Through oper-
ant conditioning, under various discriminating learning contexts, an asso-
ciation is made between a behavior and a consequence for that behavior.
The term operant conditioning was coined by the behaviorist B. F. Skinner;
this type of conditioning is thus occasionally referred to as Skinnerian con-
ditioning. As a behaviorist, Skinner believed that internal thoughts and
motivations could not be used to explain behavior. Instead, he suggested,
we should look only at the external, observable causes of human behavior
and used the term operant to refer to any “active behavior that operates
upon the environment to generate consequences” (1953).
Examples of Operant Conditioning

Cognitive and behavioral psychologists view all types of motivated behav-
ior, whether overt or covert, as partially rooted in the principles of operant
conditioning. This includes a full range of human activities, and can be
used to explain many examples of human behavior, such as a child com-
pleting homework to earn a reward from a parent or teacher, employees
finishing projects to experience an intrinsic sense of achievement, an indi-
vidual injecting a drug to decrease pain or withdrawal, a parent giving in to
the demands of a child whining for a later bedtime, an individual engaging
in a ritual of hand-washing to decrease anxiety, or an academic working

through the night to complete a paper in order to have her work published.
In all of these examples, the likelihood of reward or removal of unpleasant
events results in an increase in behavior; conversely, the likelihood of a
punishing/dissatisfying consequence or removal of a pleasant consequence
results in a decrease in behavior.
Although a full explanation and description of the substantial literature
base with regard to operant conditioning theory and the procedures on
which it is based is beyond the scope of this chapter, several pertinent prin-
ciples particularly important to the competency of cognitive and behav-
ioral specialists with regard to their work are described below. For a more
extensive description and discussion of the basic principles, applications,
and behavioral research methods, as well as a helpful guide toward the
acquisition of the conceptual and technical skills necessary to competently
apply behavioral analyses methods to foster socially adaptive behavior in
diverse individuals, see additional readings and texts by others who have
helped define the field (for example, Baer, Wolf, & Risely, 1968; Kanfer &
Grimm, 1977; Kazdin, 2000).
Because many instrumental learning principles have been applied to
so many areas of assessment and intervention, key conceptual competen-
cies with regard to operant conditioning are essential to understanding the
foundations of cognitive and behavioral practice. For example, key instru-
mental or operant principles have contributed to the development of effec-
tive assessment technologies such as applied behavior analysis, as well as
interventions such as increasing adaptive or rehabilitative behaviors, moti-
vational interviewing, behavior management strategies, self-control train-
ing, sports performance, health prevention, and coping skills training, and
these interventions require an advanced knowledge of the principles of
reinforcement and punishment. With regard to understanding how rein-
forcing consequences operate on behavior, it is important to differentiate
between positive and negative reinforcement. Knowledge of key concepts
in use of the principles of reinforcement and punishment to understand
and predict human behavior, as well as to develop strategies to improve
the quality of life for patients, is required. Therefore, in addition to the dis-
cussion of reinforcement and punishment that we provide in this chapter,
cognitive behavioral specialists should be familiar with important concepts
such as stimulus control and generalization, shaping, prompting, chaining,
and various strategies concerning the selection, scheduling, and amount of
reinforcing or punishing consequences that are part of an instrumentally
based intervention.
Positive reinforcers are favorable events or outcomes that are presented

following a behavior. In situations that reflect positive reinforcement,
a response or behavior is strengthened by the individual’s experience of
something pleasant, such as praise or a direct reward. The principle of
negative reinforcement involves the removal of unfavorable events or
outcomes after the display of a behavior. In these situations, a response is
strengthened by the removal of something considered unpleasant. In both
of these cases of reinforcement, the behavior increases.
Punishment, on the other hand, involves the presentation of an adverse
event or outcome that causes a decrease in the behavior it follows. It is
also useful to differentiate between the different forms of punishment.
Direct application of punishing consequences involves the presentation of
an unfavorable event or outcome in order to weaken the response it fol-
lows. Although the effectiveness of the use of direct application of punish-
ment has been shown to effectively suppress behavior in the behavioral
literature, there are several significant effects that can occur in learning
situations involving this type of punishment, in which an individual expe-
riences an unpleasant or painful consequence following a behavior. Such a
learning situation often involves emotional reactivity (associated with pain
or distress), behavioral retaliation, and although a specific target behavior
is decreased, new behavior in the situation will not be acquired without
specific positive reinforcement–based strategies added to a given interven-
tion for the purpose of building an individual’s adaptive behavioral reper-
toire (Miltenberger, 2008). An understanding of these additional collateral
consequences is important to understanding the emotional and behavioral
sequelae of individuals who received excessive or harsh punishment as
children with little reinforcement-based learning. Negative punishment,
also known as punishment by removal or “Punishment Type II,” occurs
when a favorable event or outcome is removed after a behavior occurs.
Similar to the principle involved in direct punishment that involves the
occurrence of an aversive consequence following a behavior, this type of
punishment principle also explains why a behavior decreases. In this case,
however, the unpleasant contingency involves removal of an experience
that the individual finds pleasant or favorable.
It is important to underscore that the principles of operant conditioning
have been extended to “behaviors” that include both overt behavior that is
easily observed by others, as well as more covert processes such as thoughts
and beliefs. For example, an individual attending a social event who expe-
riences the event as unsatisfying may experience thoughts of self-blame
or self-critical appraisals of his or her own social skills or desirability. The
punishing consequences of the unsatisfying time may be made worse

with catastrophic thoughts of self-blame. The combination may serve to
decrease motivation to attend all future social events. Conversely, if an
individual attending a social event were to experience the event as unsat-
isfactory, but also experienced thoughts such as “these events are usually
such fun, but in this case several uninteresting people were invited,” he or
she may be more likely to try another event in which different people were
in attendance. Self-blaming thoughts, or thoughts about the situational
factors that make this event unpleasant compared to other similar events,
also are maintained through processes of conditioning and the individuals’
learning histories. Most human situations, especially those involving some
form of interaction, such as parenting, friendships, romantic partner rela-
tionships, or work relationships, involve a complex interplay of reinforce-
ment and punishment principles at work.
Principles of instrumental conditioning provide one foundational the-
ory underlying depression—that of an imbalance of punishment to posi-
tive reinforcement in an individual’s life. The theoretic formulations of
C. B. Ferster (1973) and the clinically applied work of Peter Lewinsohn and
his colleagues (Lewinsohn, Biglan, & Zeiss, 1976) viewed depression as the
result of an individual having little access to positive reinforcement. The
rationale for this lack of access was ascribed to avoidant patterns result-
ing from individuals’ life experiences and is described in detail elsewhere
(Ferster, 1981). In Chapter 6, which provides an overview of cognitive
behavioral interventions, this theory will be discussed with regard to the
intervention known as behavioral activation.
In order to understand many clinical situations from this perspective of
instrumental learning, as well as to design learning-based psychotherapies,
it is necessary to have a competent working knowledge of how these prin-
ciples may interact in any given situation. It is also important that cognitive
and behavioral psychologists utilize effective methods for defining clinical
problems in observable terms and constructing individualized assessment
methods of what an individual experiences as reinforcing or punishing.
Consider the example of an individual who enjoys a high degree of stimu-
lation or social engagement as reinforcing versus an individual who places
high value on time alone. The motivational strength of social engagement
would be very different between two such individuals.
When relying on the principles of operant and classical conditioning,
cognitive and behavioral psychologists first attempt to understand clinical
phenomena through the lens of how and what learning occurred, and what
variables are contributing to the current maintenance of the clinical targets.
Later, the same principles are employed in the development of interven-

tions that essentially provide new learning experiences for the patient.
Competency in the concepts associated with these principles, such as
stimulus control, discrimination and generalization, shaping, prompting,
transfer of stimulus control, chaining, skills training, differential reinforce-
ment of alternative or incompatible behavior, habit reversal, token econo-
mies, behavioral contacts, and cognitive behavior modification methods,
are important concepts employed in instrumentally based assessment and
intervention in cognitive and behavioral practice.
Additional Learning Theories

Although classical and instrumental learning theories served as strong
foundations of the cognitive and behavioral assessment and interventions,
other learning theories expanded upon this knowledge and broadened the
scope of the specialty. This additional knowledge base helped move the
specialty forward.
For example, the psychologist Clark Leonard Hull, who was known
for his experimental studies on learning and for his attempt to give math-
ematical expression to psychological theory, developed a global theory
of learning. The theory was based partially on the principles of classical
conditioning as well as the principle of reinforcement conceptualized by
learning researchers such as Edward L. Thorndike, who preceded B. F.
Skinner. The theory attempted to explain behavior in terms of stimulus
and response, which became associated with each other in the learning
process, and Hull believed that drive states strengthened this association
(Hull, 1943). In other words, reinforcement in Hull’s theory was translated
as reduction in a physiological or psychological need. He proposed that
without drive, there could be no performance. Hull’s theory suffered fol-
lowing ongoing research concerning drive reduction and the evidence of
reinforcement through brain stimulation and learning in the absence of
drive reduction. However, he made a significant contribution to the sci-
entific foundation of learning theory in that he brought an awareness of
the complexity of behavioral conditioning and attempted to incorporate
many biological and psychological variables into one equation. His work
may have set the stage for Skinner, who focused more on environmental
determinism and observation of performance.
Mowrer’s two-factor theory of avoidance conditioning also provided
an opportunity to better understand the complexity of human behavior.
Cognitive and behavioral specialists continue to invoke two-factor the-

ory in order to integrate the major learning perspectives and understand
complex behavioral syndromes, as well as to develop effective treatment
plans. Mowrer’s theory (1960) focused on the interplay of classical con-
ditioning and operational contingencies to partially explain avoidance
conditioning. He believed that it may be necessary under some circum-
stances to extend the boundaries of the observable behavior and ana-
lyze the data that are not directly observable because stimuli from the
environment do not trigger the overt behavior directly, but through
more organismic factors such as thoughts and emotions. In contrast to
overt behavior, emotions and thoughts are not directly observable and
measurable. However, contemporary cognitive behavioral psycholo-
gists largely view these covert responses to function on the same prin-
ciples as overt behavior. Specifically, Mowrer’s experiments showed
that animals learn to fear previously neutral stimuli, such as a buzzer,
that have been paired with shock. After such classical fear condition-
ing, an animal’s subsequent escape when presented with the sound of
a buzzer is reinforced, as fear is decreased, thus increasing the escape
behavior through negative reinforcement or instrumental conditioning.
Two-factor theory provided a plausible explanation for maintenance of
phobias (Stampfl, 1987), as it underscored the point that avoidance can
be negatively reinforced by the reduction of fear while a conditioned
stimulus is not present. Subsequently, scientific evidence has supported
two-factor theory as an explanation of other psychological disorders
as well (Buck, 2010), including post-traumatic stress disorder (Foa &
Jaycoz, 1999). The theory also proved to be very successful in the therapy
of enuresis, and the provided basis for the development of bed-wetting
alarms. Two-factor theory also received some criticism from researchers
(Rachman, 1984), who postulated that avoidance in fear situations was
not motivated by a reduction of anxiety through negative reinforcement
but by positive feelings in safe places (positive reinforcement). This may
hold true in specific clinical situations, such as in the example of ago-
raphobia, where an individual may be motivated to search for signals
of safety. Although there is a rich literature to explore concerning the
various theoretic viewpoints in more detail, the point we wish to under-
score is that the competent cognitive and behavioral specialist must rec-
ognize the complexities of human behavior and evaluate an individual’s
behavioral challenges with respect to the interaction of different types of
learning.
Cognitive and Information Processing Theories

Cognition is defined by Larsen and Buss (2009) as “a general term refer-
ring to awareness and thinking, as well as to specific, mental acts such as
perceiving, attending to, interpreting remembering, believing, judging,
deciding, and anticipating” (p. 369). These activities transfer environmen-
tal and sensory stimuli into mental representations and the way in which
these mental representations are manipulated; in other words, they are the
main activities involved in information processing. In a chapter focused
on cognitive approaches to understanding personality, Larsen and Buss
(2009) provide a history of cognitive approaches to understanding person-
ality, beginning with theories of Witkin’s “field dependence and field inde-
pendence” (Witkin et al., 1954), George Kelly’s cognitive construct theory
(1955), and culminating with later theories, such as Bandura’s social learn-
ing theory (1976), Rotter’s theory concerning locus of control (1982), and
Seligman’s theory of “learned helplessness” (1975). These and other cogni-
tive theories collectively provided a further intra-organism bridge between
environmental or sensory stimuli and observable behavior. These theo-
rists, who are discussed in the following paragraphs, established a scientific
foundation for the concept that how an individual processes information
in various contexts and situations may influence his or her learning expe-
riences. Although each of these theories is deserving of a separate volume
and a thorough description of these theories is beyond the scope of this
book, they are briefly surveyed and discussed below.
Witkin’s field dependence theory revealed that differences in percep-
tion, such as the tendency to locate hidden embedded figures in a draw-
ing with difficulty or ease, can provide one indication of an individual’s
general way of approaching new information or making a choice (Witkin,
1977). Additionally, the way in which people respond to interpersonal situ-
ations can also be predicted by their information processing style as “field
dependent vs. independent.” The theory provides a useful framework for
understanding these different processing styles and how each may be more
or less adaptive in different situations.
Bandura’s social learning research revealed the importance of percep-
tion and expectation of reinforcement with regard to the likelihood of an
individual imitating the observed behavior of others. Specifically, Bandura’s
research supported the presence of a “modeling effect” in human learn-
ing by which individuals learn from observing others engage in behav-
ior that is reinforced (see Bandura & Walters, 1963). Particularly with
regard to studies of aggressive behavior, his research demonstrated that
observational learning could result in behavioral acquisition of behavior

without the requirement of reinforced actual performance.
Bandura’s contributions were significant to the development of social
learning theory which proposed that people learn within a social context.
The concepts of modeling and observational learning are based upon the
idea that reinforcement is experienced by children during their develop-
ment through the acceptance and approval of influential models. This
perspective views the acquisition of new learning as dependent upon
observation and imitation of the actions of others, as well as whether or not
the behavior is rewarded and/or punished. Bandura proposed that obser-
vational learning can occur in the context of live models (actual people
who may demonstrate a behavior), verbal instructions from models, or
symbolically through the observation of media, such as movies, television,
or video games. Additionally, Bandura’s theory provided an understanding
of the contextual aspects of the learning situation that are likely to increase
the strength of a learning experience. Specifically, he proposed that the
modeling process necessarily involves attention (to the observed behav-
ior and its consequences), retention (memory of the learning experience),
reproduction (of the responses involved in the behavior), and motivation
(reinforcement for performance of the behavior).
The theory developed by George Kelly promoted the view that all indi-
viduals are motivated to understand their circumstances and seek to con-
trol and predict what will occur in their futures. He viewed humans as
personal scientists who seek to explain events in their lives and employ
“personal constructs” to understand their experiences. According to Kelly,
a construct has two extreme points, such as “happy-sad,” and people tend to
place others at either extreme or at some point between, and an individual’s
reality is construed through these constructs. Moreover, Kelly believed that
each individual has his or her own unique set of personal constructs, and
that individuals will experience anxiety when their personal construct sys-
tems fail them in their ability to adequately control or predict the events
in their lives.
Rotter’s social learning theory (1982) focused on an individual’s “locus
of control” and underscored the impact that peoples’ perception of respon-
sibility has concerning the events in their lives. The two major areas of
focus had to do with whether people tended to view responsibility as rest-
ing within themselves (internal), or due to external forces or fate (external).
Rotter suggested that the expected outcome of one’s behavior and antici-
pation of the degree of control one has over the outcome would have an
impact on the motivation of people to engage in that behavior. The theory
was important to the expansion of learning theory because it embraced the

idea that behavior is influenced by social context or environmental factors,
not psychological factors alone.
Related to this notion of perceived control, the foundational experi-
ments and theory of “learned helplessness” of Martin Seligman and J. B.
Overmeier (Overmeier and Seligman, 1967) provided an alternative view to
reinforcement theory when they and their colleagues discovered that ani-
mals, when subjected to inescapable shock, eventually became passive and
accepting of a situation despite having the opportunity to escape. Seligman
developed the theory further, finding learned helplessness to be a psycho-
logical condition in which a human being or an animal has learned to act
or behave helplessly in a particular situation—usually after experiencing
some inability to avoid an adverse situation—even when it actually has the
power to change its unpleasant or even harmful circumstance. This pro-
vided a new understanding of severe clinical depression and related mental
illnesses such that symptoms could possibly result in part from a perceived
absence of control over the outcome of a situation (Seligman, 1975). In later
years, alongside his colleagues, Seligman reformulated and extended his
theory of learned helplessness to encompass the importance of one’s attri-
butional style. Because learned helplessness sometimes remains specific to
one situation, but at other times generalizes across situations, it was pro-
posed that an individual’s attributional or explanatory style is the key to
understanding why people respond the way they do to different adverse
events. Specifically, people with a pessimistic explanatory style—which
perceives negative events as permanent (“this situation can never change”),
personal (“it’s all my fault”), and pervasive (“I’m a loser. I never do anything
right”)—are most likely to suffer from learned helplessness and depression.
Seligman worked with Abramson and others (Alloy, Peterson, Abramson,
& Seligman, 1984) to reveal how one’s attributional style would be likely to
result in continued hopelessness and helplessness due to a cognitive pattern
of viewing even positive circumstances as outside one’s control. Examples
of this style can be observed in many clinical problems such as depression,
domestic violence, or forced incarceration.
Michael Mahoney also emphasized the importance of cognitive media-
tors in learning and respect for the complexities of human behavior in a
well-known article that appeared in the American Psychologist in 1977. He
described what he referred to as a “cognitive revolution” that emphasized
an assimilation of behavioral techniques and both cognitive and affective
processes. He proposed a foundational cognitive-learning model that pos-
ited four major assertions: (1) that humans respond primarily to cognitive
representations rather than to the immediate environment per say; (2) that

cognitive representations are functionally related to learning processes;
(3) that most human learning is cognitively mediated; and (4) that feelings,
thoughts, and behaviors are causally interactive (Mahoney, 1977).
Donald Meichenbaum’s contributions to cognitive and information
processing theory are significant in that he highlighted the relevance
of cognition when he observed overt self-verbalizations that served as
important regulators of behavior in children. He proposed that overt
self-verbalizations become an internal dialogue in adults and medi-
ate behavior (see Meichenbaum, 1977). Finally, Arnold Lazarus, a South
African psychologist, significantly widened the scope of cognitive and
behavioral therapy to include cognitive aspects; some cognitive and behav-
ioral psychologists consider his 1971 text to be one of the first clinical
texts regarding cognitive behavioral psychotherapy. Lazarus promoted the
theory that in order to be effective, assessment and intervention should
be expanded beyond the consideration of cognitive and behavioral phe-
nomena to include physical sensations, visual imagery, interpersonal
relationships, and biologic factors. This culminated in an approach to psy-
chotherapy that he termed multimodal (Lazarus, 1989).
Albert Ellis and Aaron T. Beck were major contributors to the shift
in the specialty toward a theoretic focus on cognition in understanding
psychological and emotional symptoms and disorders. Ellis, originally a
psychoanalyst, posited that patients’ problems generally involve specific
distorted thinking patterns (e.g., an excessive use of “shoulds” and “musts,”
which he called absolutist thinking). Specifically, Ellis proposed that when
people are confronted with adversities that interfere with their goals and
purposes, they can choose to engage in functional or rational beliefs that
will result in healthy emotional behavioral consequences. Conversely, they
may also choose to focus on irrational beliefs that they have learned, which
result in distressful feelings and unhealthy behaviors. Because the theory
focused on the occurrence of adverse events (A), the beliefs that occur fol-
lowing these events (B), and the consequences of an individual’s belief ’s
(C), Ellis’s model of personal information processing, as well as other simi-
lar information processing models, is often referred to as an ABC model.
Ellis’s rational therapy, labeled rational emotive behavior therapy (REBT),
was developed to enable patients to recognize and dispute their distorted
thinking (see Ellis, 1977). Table 2.2 presents a list of common irrational
beliefs proposed by Ellis.
Aaron T. Beck, a psychiatrist and researcher, developed a theory that pro-
posed a cognitive model of depression (Beck, Rush, Emory, & Shaw, 1979),
TA B L E 2 . 2 Common Irrational Beliefs in REBT (Adapted from Ellis, 2003)
CHARACT ERIS T IC S OF IRRATIO N AL B ELIEFS EXAMPLES
Rigid and inflexible If I work hard, I should get exactly what I want.
Inconsistent with social reality I expect to be happy all the time.
Illogical My standards are harsher for me than for anyone else.
Prone to dysfunctional emotions vs. functional emotions Reactive with rage panic, depression vs. frustration, concern,
disappointment
Prone to dysfunctional behavior vs. functional behavior Reactive avoidance or compulsion vs. accepting of adversity
Demanding and “musturbatory” philosophies I must win the approval of others for my performances or else
I am no good.
Other people must treat me considerately, fairly, and kindly, and
in exactly the way I want them to treat me or it is terrible.
I must get what I want, when I want it; and I must not get
what I don’t want. It’s terrible if I don’t get what I want,
and I can’t stand it.
“Awfulizing” beliefs If I don’t do well, it is 100% bad.
If people don’t treat me well, they are bad. and should be
punished.
Beliefs that depreciate one’s human worth If I don’t have approval, I am a total failure.
which emphasized specific cognitive styles as a preexisting vulnerability to

the experience of this clinical syndrome. He suggested that this vulnerabil-
ity was associated with a particular cognitive schema or way of processing
information. Specifically, adopting a diathesis-stress model for depres-
sion, he proposed that vulnerability is associated with a “cognitive triad” in
which depressed individuals display negative automatic thoughts or cogni-
tions about the self, the world, and the future. Furthermore, he proposed
that depressed individuals experience cognitive processing distortions,
such as overgeneralization and dichotomous thinking (Beck et al., 1979).
For example, after performing poorly in a sporting event, an individual
prone to depression might experience the thought “I’m a total failure” This
would be an example of the distortion Beck referred to as “overgeneraliza-
tion” (Beck, Emery, & Greenberg, 1985). Table 2.3, partially adapted from
Larsen and Buss (2010), lists the major information-processing distortions
about one’s self, the world, and the future, with regard to depression.
Beck viewed other symptoms of distress, such as anxiety, as character-
ized by a sense of personal danger and proposed that anxious individu-
als also experience cognitive distortions. In the mid-1960s, Dr. Aaron
T. Beck developed “cognitive therapy” as a therapy that employs an
information-processing model to understand and treat psychopathological
TA B L E 2 .3 Cognitive Distortions Associated with Beck’s Cognitive Model of Depression
C O G N IT IO N S C O G N IT IO N S AB OUT COGNI T I ONS AB OUT

D ISTO RTI ON AB O U T T HE SELF T HE WO R LD T H E F UT URE
Overgeneralization: Holding extreme I struck out in the game. We find a way to lose Why bother playing?
beliefs on the basis of a single I can’t play baseball every game. I think I should
incident and applying it to at all. give up.
a different or dissimilar and
inappropriate situation.
Arbitrary Inferences: Drawing conclusions The people watching Everyone is laughing at All games are going to
about oneself or the world without the game think I’m our team. be very depressing.
sufficient and relevant information. a loser.
Personalizing: Relating external events It’s all my fault that Everyone always My team will never
to one another when no objective we lost. probably blames win because of my
basis for such a connection is me. playing.
apparent.
“Catastrophizing”: The process of My baseball playing I’ll never have dates Since I probably won’t
overestimating the significance of stinks. I have no because no one have dates, I better
negative events. talent for anything. will be attracted to avoid all chance of
someone with no rejection.
athletic ability.
Polarized Thinking: An “all-or-nothing,” I’m supposed to be If you lose one game, the If I get a hit in the game,
“good or bad,” and “either-or” perfect and not make season is over. things will be perfect.
approach to viewing the world. mistakes.
conditions. The theory emphasized the role of individuals’ views of them-

selves and their personal worlds as central to their behavioral reactions.
A common element of both Beck’s and Ellis’s theories is the constructivist
view that human learning involves an active attempt to construct mean-
ing in the world. Ellis and Beck, as well as other cognitive social theorists,
viewed learning as more active and self-directed than earlier conditioning
theories had proposed, and they built upon the theories developed earlier
by Kelly, Lazarus, Bandura, Lewinsohn.
Schema Theory
Related to Beck’s cognitive theory is the concept of schemas. As indicated
above, Beck referred to schemas as a broad and organizing principle that
can be helpful to the way in which people make sense of and process their
life experiences. Jeffrey Young developed cognitive schema theory (1990)
with the hypothesis that sometimes schemas are formed as the result of
toxic childhood experiences, often involving negative emotional learning

experiences. He proposed that such “maladaptive schemas” may lie at the
core of many personality disorders, because he believed that these sche-
mas may be superimposed on later life experiences, even when they are
no longer applicable. One example may be an individual who, through
early toxic learning experiences, anticipates that revealing any emotions
will be punished. Throughout his life, and later as an adult, this individual
may avoid getting close to people, or may overcompensate by engaging in
emotional outbursts, demanding the right to be heard. He defined a list
of “Early Maladaptive Schemas” that are described by Young, Klosko, and
Weishar (2003) as having the following characteristics:
• A broad and pervasive pattern or response style;

• Include memories, emotions, thoughts, and physical reactions;
• Relate to an individual and their relationships with others;
• Were initially learned in childhood/adolescence;
• Occur throughout one’s lifetime;
• Are significantly dysfunctional.
Young proposed that schemas develop when an individual’s core needs

are not met during childhood, and many schemas are so ingrained and
automatic that they tend to operate under an individual’s conscious radar.
He categorized 18 schemas under five broad areas of unmet emotional
needs that he termed “domains.” Based upon his theory, Young developed
schema therapy to allow patients to become aware of their maladaptive
schemas and the behavioral reactions to them that create distress. Table 2.4
contains a list of Young’s maladaptive schemas, and a brief description of
the cognitive, emotional and or interpersonal characteristics associated
with each maladaptive schema.
Rule-Governed Behavior and Relational Frame Theory

The term rule-governed behavior (RGB) was used by Skinner (1966) to
refer to behavior that was unique and essential to complex human abilities.
In brief, the concept was put forth that rules or instructions could serve as
antecedents that impacted behavior without the apparent occurrence of
environmental contingencies (Torneke, Luciano, & Salas, 2008). The tra-
ditional operant account of rule-governed behavior could not fully explain
how such complex verbal abilities and understanding of relations between
TA B L E 2 . 4 Maladaptive Schemas (Adapted from Young, Klosko, & Weishar, 2003)
MALAD A P T IV E S C HEM A S T YPIC AL CHAR AC T ER IST ICS
• Abandonment/Instability • The perceived instability or unreliability of those available for

support and connection.
• Mistrust/Abuse • The expectation that others will hurt, abuse, humiliate, lie, cheat,
manipulate or take advantage.
• Emotional Deprivation • The expectation that others will not meet one’s desire for reasonable emotional
support.
• Defectiveness/Shame • The feeling that one is defective, bad, unwanted, inferior, or invalid in
important respects or that one is unlovable to significant others if exposed.
• Social Isolation/ • The feeling that one is isolated from the rest of the world, different from other
Alienation people, and not part of a group or community
• Dependence/ • Belief that one is unable to handle one’s everyday responsibilities in
Incompetence a competent manner, without considerable help from others.
• Vulnerability to Harm/ • Exaggerated fear that imminent catastrophe will strike at any time
Illness and that one will be unable to prevent it (may refer to medical, emotional or
external catastrophe).
• Enmeshment/ • Excessive emotional involvement and closeness with one or more
Undeveloped Self significant others at the expense of full individuation or normal social development.
• Failure • The belief that one has failed, will fail, or that one is fundamentally inadequate
relative to one’s peers in areas of achievement.
• Entitlement/Grandiosity • The belief that one is superior to other people, entitled to special privileges; not
bound by the rules of reciprocity of normal social interaction.
• Insufficient Self-Control/ • Pervasive difficulty or refusal to exercise sufficient self-control and frustration
Self Discipline tolerance to achieve one’s personal goals. In milder form, there is an exaggerated
emphasis on discomfort avoidance.
• Subjugation • Excessive rendering of control to others because one feels coerced- submitting in
order to avoid anger, retaliation, or abandonment.
• Self-Sacrifice • Excessive focus on voluntarily meeting the needs of others in daily situations at the
expense of one’s own gratification.
• Approval-Seeking/ • Excessive emphasis on gaining approval, recognition, or attention from other
Recognition Seeking people, or on fitting in at the expense of developing a secure and true sense of self.
• Negativity/Pessimism • A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, conflict,
unresolved problems, potential mistakes, betrayal, things that could go wrong, etc.)
• Emotional Inhibition • The excessive inhibition of spontaneous action, feeling, or communication, usually
to avoid disapproval of others, feelings of shame, or loss of control
• Unrelenting Standards/ • The underlying belief that one must strive to meet very high internalized standards
Hypercriticalness of behavior and performance
• Punitiveness • The belief that people should be harshly punished for their mistakes; involves
a tendency toward anger, intolerance for those people who do not meet one’s
expectations or standards
Note: Copyright 2013 by Jeffrey Young. Unauthorized reproduction without written consent of the author
is prohibited. For more information, write to the Schema Therapy Institute, 561 10th Avenue, Suite #43,
New York, NY, 10036.
concepts are formed or modified over time. However, later developments

in relational frame theory (RFT) attempted to provide a comprehensive
understanding of psychological and behavioral problems across diverse
psychopathologies, incorporating both behavioral analytic principles and
research concerning the bidirectional nature of human understanding
of relation between stimuli. RFT was developed with an aim to integrate
diverse psychological phenomena including stimulus equivalence, nam-
ing, understanding, analogy, metaphor, and rule following. In short, RFT
posits that early in the developmental process, humans learn to relate stim-
uli arbitrarily, which then becomes an operant response. The important
tenet of RFT is that arbitrarily established relations will alter stimulus func-
tions, dependent upon social context. This is particularly important when
over time, humans have learned through various contexts to avoid negative
thoughts or feelings and to engage in experiential avoidance. Experiential
avoidance has been defined as the occurrence of deliberate efforts to avoid
and/or escape from private events such as affects, thoughts, memories, and
bodily sensations that are experienced as aversive (for a more complete
description of RFT, see Hayes, Wilson, Gifford, Follete, & Strosahl, 1996;
Wilson, Hayes, Gregg, & Zettle, 2001; Torneke, Luciano, & Salas, 2008).
The result of experiential avoidance has been described as paradoxical
because although control efforts are reinforced, the feared private events
increase. There is a considerable amount of data suggesting that destruc-
tive experiential avoidance, a uniquely human phenomenon, is central to
many psychopathology states (Hayes et al., 1996).
Theories of Emotion and Instrumental Conditioning

Although emotions are an important part of the human learning pro-
cess, particularly with regard to associative fear conditioning or avoid-
ance of unpleasant states, only recently have more comprehensive theories
emerged that actually map the neural pathways of various emotions, as
well as the pathways between emotional arousal and cognition. These
advances are particularly important to the specialty of cognitive behavioral
psychology because of the importance of understanding emotional arousal
that has been tied to various learning experiences, including instrumental
conditioning, as well as to classical conditioning and associative learning.
Particularly for theories and interventions that focus on early emotional
learning experiences that later provide barriers to relationships, such as
schema theory, or current coping with adversity (such as problem solving),
the emotional components of learning have strong relevance. With regard
to contemporary theories of emotional development and learning of emo-

tional regulation, theorists Gross and Thomson (2007) have elaborated a
theory of emotional regulation that reveals its complexity through the inte-
gration of evolutionary preparedness, early learning and developmental
experiences, situational context, attention, cognitive change, and response
modulation. Containing elements of many of the theories discussed thus
far, their theory illustrates, from an instrumental learning context, how a
given instance of emotional regulation may be either antecedent-focused
or response-focused.
Emotions also received attention in recent decades consistent with
the positive psychology movement. Within this movement, theories that
focused on the importance of positive emotional experiences as well as on
learning effective coping skills were viewed as important to the discovery
of ways to counter negative states such as depression. This focus on health
and resilience, rather than illness and psychopathology, has always had a
role in the cognitive and behavioral specialty, as illustrated by the work of
Goldfried and D’Zurilla (1971) or Meichenbaum (1977), and in the early
general psychological theories of Maslow (1968). In the late 1990s and the
decade that followed, the notion of a greater focus on positive psychology
through increasing positive emotion, engagement, and practicing valued
subjective experiences became popularized by Martin Seligman and his
colleagues (Seligman & Csikszentmihalyi, 2000; Seligman, Rashid, & Parks,
2006) and built upon the theoretic base of previous theoretic researchers,
as well as his own theory concerning optimism. Although historically, cog-
nitive and behavioral specialists have received criticism for providing less
attention on the primacy of emotion and more on the primacy of cognition
as the precursor of emotion (Greenberg, 2002), this view has shifted in
recent years. It is now commonly accepted among cognitive and behavioral
specialists that emotional processes have an independent function and can
impact conscious cognition. For example, Goldfried and Davidson (1976;
1996) emphasize the importance of emotion in the revised edition of their
text focused on clinical behavior therapy, and Nezu, Nezu, and D’Zurilla
(2013) have focused on the importance of emotion in informing people of
their goals.
Opponent Process Theory
Richard Solomon (1980) developed a theory of motivation that viewed
emotions as pairs of opposites (for example, fear-relief, pleasure-pain).
This theory, known as opponent-process, states that when one emotion is
experienced, the other is suppressed. For example, when frightened by

walking down a dark alleyway and seeing a figure in the dark, the emo-
tion of fear is experienced and relief is suppressed. If the fear-causing
stimulus continues to be present, after a while the fear decreases and the
relief intensifies. For example, if the “figure” is an inanimate statue, one’s
fear would decrease and relief that the perception was mistaken would
increase. If the stimulus is no longer present, then the first emotion disap-
pears and is replaced totally with the second emotion. In such a situation,
Solomon observed that in recognizing the statue, in addition to no lon-
ger being afraid, one might actually begin to laugh with relief and delight.
Solomon and Corbit (1974) analyzed the emotions present when skydivers
jump from planes. Beginners experience extreme fear as they jump, which
is replaced by great relief when they land. This is one theory that has been
used to explain several addictive behaviors. For example, if a drug initially
produces pleasurable feelings followed by a negative emotional experience
(“coming down”), the drug user may engage in greater drug use to avoid
the effects of withdrawal. Over time, however, as the levels of pleasure from
using the drug decrease, the levels of withdrawal symptoms from not tak-
ing the drug increase, thus providing motivation to use the drug despite a
lack of pleasure from it.
As the cognitive and behavioral specialists consider the various learn-
ing foundations that contribute to the specialty, it is predictable that the
competent specialist will seek to integrate the evidence-based theories that
have been a necessary part of his or her educational process, rather than
embrace a single theory that cannot explain the range of human learning
that will be encountered in his or her practice. Human behavior is rep-
resented by an integration of the rich theoretic foundations of the spe-
cialty, and competency requires an understanding of these foundational
concepts. Such knowledge informs effective interventions in cognitive and
behavioral practice.
THR E E
Scientific Research Foundations
Certainly the past decade has evidenced a coalescence among varying groups
of psychologists who have identified scientific knowledge and methods as a
basic core competency defining professional psychologists across various con-
ceptual and psychotherapy orientations. Such groups include, for example, the
Competencies Conference: Future Directions in Education and Credentialing
(e.g., Kaslow et al., 2004), the American Board of Professional Psychology (e.g.,
C. M. Nezu, Finch, & Simon, 2009), and the Assessment of Competencies
Benchmarks Workgroup (e.g., Fouad et al., 2009). Indeed, psychology is
definitionally characterized by the American Psychological Association as a
diverse discipline, grounded in science (American Psychological Association
website, 2013; italics are ours). However, the specialty of cognitive and behav-
ioral psychology has from its nascent days defined itself as being “insistent on
the empirical verification of its various interventions” (Nezu, Nezu, & Cos,
2007, p. 350). As such, support of this particular competency for psycholo-
gists would appear to be a high priority for this specialty.
In many ways, adherence to this competency for all professional psy-
chologists suggests that they be “scientifically minded.” Bieschke, Fouad,
Collins, and Halonen (2004), members of the Competencies Conference
Scientific Foundations and Research Competencies Workgroup, posited
that five subcomponents comprise the core competency of scientific prac-
tice. These include the following activities and responsibilities:
• Access and apply current scientific knowledge habitually and

appropriately;
• Contribute to the scientific knowledge base;
• Critically evaluate interventions and their outcomes;

• Practice vigilance about how sociocultural variables influence scientific
practice;
• Routinely subject one’s work to the scrutiny of colleagues, stakeholders,
and the public.
Adherence to these five areas, at the very least, requires knowledge of

both the content and methods of the research literature pertaining to the
vast array of cognitive and behavioral therapy procedures. This chapter
addresses these two foci in considering the scientific underpinnings of this
specialty in applied psychology.
The Scientific Basis of Cognitive and Behavioral Psychology

The research literature that provides for a sound scientific base of cognitive
and behavioral psychology is especially evident in the hundreds of psycho-
therapy outcome studies that directly test the efficacy of a given cognitive
and behavioral intervention. These interventions are typically based on
both theory and research underlying a given conceptualization of a par-
ticular disorder (see Chapter 2 for a description of the various theoretical
perspectives comprising this specialty and Chapters 6 and 7 for overviews
of the various types of interventions typically subsumed under a cognitive
and behavioral umbrella).
Since the early 1960s, in keeping with the continued increase in pop-
ularity and self-identified descriptor of one’s theoretical orientation as
being cognitive and behavioral in nature (Norcross & Karpiak, 2012;
Psychotherapy Networker, 2007), the literature has also flourished sub-
stantially in the outpouring of attention devoted to this approach to treat-
ment. The first scientific journal to appear devoted specifically to this area
was Behavioural Research and Therapy, whose inaugural issue was pub-
lished in 1963. Since then, at least 19 additional English-speaking jour-
nals devoted to cognitive and behavioral therapies have appeared (see
Table 3.1). Moreover, investigators of this orientation publish articles in a
variety of generalist periodicals as well, such as the Journal of Consulting
and Clinical Psychology and the Journal of Abnormal Psychology. Since a
summary, no matter how brief, of the burgeoning extant literature sup-
porting the efficacy of cognitive and behavioral interventions is far beyond
the scope of this chapter, we provide a sampling of this research by focus-
ing on the results of various meta-analytic studies.
Scientific Research Foundations 41
TA B L E 3.1 Cognitive and Behavioral (English-Language) Journals
• Behavior Modification (http://bmo.sagepub.com/)

• Behavior Therapy (http://www.journals.elsevier.com/behavior-therapy/)
• Behaviour Change (http://journals.cambridge.org/action/displayJournal?jid=BEC)
• Behavioural Research and Therapy (http://www.journals.elsevier.com/behaviour-research-and-therapy/)
• Behavioural and Cognitive Psychotherapy (http://journals.cambridge.org/action/displayJournal?jid=BCP)
• Child and Family Behaviour Therapy (http://www.tandfonline.com/toc/wcfb20/current)
• Cognitive and Behavioral Practice (http://www.journals.elsevier.com/cognitive-and-behavioral-practice/)
• Cognitive Behaviour Therapy (http://www.tandfonline.com/toc/sbeh20/current)
• Cognitive Therapy and Research (http://link.springer.com/journal/10608)
• European Journal of Behavior Analysis (http://www.ejoba.org/)
• International Journal of Behavioral Consultation and Therapy (http://www.baojournal.com/IJBCT/
IJBCT-index.html)
• International Journal of Cognitive Therapy (http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/jncx.
htm&sec=editorial_board&dir=periodicals/per_psych)
• Japanese Journal of Behavior Therapy (http://jabt.umin.ne.jp/e/activities/3-6journal.html)
• Journal of Applied Behavior Analysis (http://seab.envmed.rochester.edu/jaba/)
• Journal of Behavior Therapy and Experimental Psychiatry (http://www.journals.elsevier.com/
journal-of-behavior-therapy-and-experimental-psychiatry/)
• Journal of Cognitive and Behavioral Psychotherapies (http://jcbp.psychotherapy.ro/)
• Journal of Cognitive Psychotherapy (http://www.springerpub.com/product/08898391
#.UTpAGBy0J8E)
• Journal of Rational-Emotive and Cognitive-Behavior Therapy (http://www.springer.com/psychology/
journal/10942)
• The Behavior Therapist (http://www.abct.org/Members/?m=mMembers&fa=Journals
Periodicals#sec3)
• The Cognitive Behavior Therapist (http://journals.cambridge.org/action/displayJournal?jid=CBT)
ME TA- A N A LYS E S O F C OGN ITIV E

AND B E HAV I O R A L I N TERV EN TION S
A meta-analysis is a statistical procedure for systematically combining

relevant data from several selected investigations in order to ultimately
derive a single conclusion that has greater statistical power than any indi-
vidual study. This conclusion is statistically stronger than the analysis of
a single study as a function of increased numbers of study participants,
greater diversity among these individuals, and accumulated effects and
results. Essentially, researchers conducting a meta-analysis initially iden-
tify the relevant pool of studies related to a given topic (e.g., CBT for
panic disorder) and cull out only those that are methodologically sound,
particularly ensuring that randomization to conditions has occurred
and at least one comparison is available between that treatment and a
control condition. Rather than focus on the statistics related to a spe-

cific study, the relevant metric used in such an analysis is the effect size,
which in this context represents the magnitude of differences between
two or more groups (Rosnow & Rosenthal, 2008). As such, groups of
studies can be assessed for an average effect size in order to provide for
a general estimate of the efficacy of a given treatment (see Ferguson,
2009, for a guide for clinicians regarding how to interpret effect sizes).
Although meta-analyses are not infallible and devoid of limitations (for
example, Klein, Jacobs, & Reinecke, 2007, found that as methods of con-
ducting meta-analyses have become more standardized and rigorous,
over the past several years, differences in estimating the effect size over
time focusing on the same studies have become smaller), they do pro-
vide for a means of validly interpreting the meaning of a larger pool of
investigations.
Although an exhaustive review of the findings of those meta-analyses
that were conducted specifically to evaluate the efficacy of various cogni-
tive and behavior interventions is far beyond the scope of this chapter, we
do provide for a meaningful sampling. Table 3.2 provides a listing of several
meta-analyses that have been conducted during the past 15 years that have
evaluated the efficacy of cognitive and behavioral treatments for a wide
variety of clinical populations and psychological disorders. These include
anger, depression, anti-social behavior of children, attention-deficit/
hyperactivity disorder, worry/generalized anxiety disorder, adult anxiety
disorders, borderline personality disorder, dental anxiety, alcohol and drug
abuse, chronic fatigue syndrome, physical health problems, aggression,
insomnia, pain, suicidal behavior, and positive schizophrenia symptoms.
In general, results across these meta-analytic studies, which collectively
involve thousands of patients, strongly support the efficacy of cognitive
and behavioral approaches across a variety of problems, populations, and
specific interventions. As such, they represent a strong foundation in sup-
port of the scientific underpinnings of this particular applied psychology
specialty.
As noted previously, being a “scientifically minded” psychologist not
only requires that one is familiar with the content of the literature (e.g.,
which treatments are effective for a given disorder), but also the process of
how such findings were obtained. This latter issue involves one’s ability to
evaluate the scientific value of the literature, as well as potentially to con-
tribute to it. As such, we provide a primer of methods typically employed
by cognitive and behavioral researchers.
TA B L E 3.2 Meta-analyses of Cognitive and Behavioral Interventions for Treating a Wide Variety of
Disorders (All Effect Sizes Listed Are Significant Unless Specifically Stated)
AUTHO RS F OC US C O N CLU SIO N S
Beck & Fernandez Analysis of 50 studies of CBT in CBT produced a weighted effect size of .70.
(1998) treating anger
Bell & D’Zurilla (2009) Analysis of 21 samples of Mean effect size for PST was found to be .40.
problem-solving therapy (PST)
for treating depression
Beltman, Oude Voshaar, Analysis of 29 studies of CBT for CBT found to be superior as compared to control
& Speckens depression in people with a conditions (effect size = .83), but not when
(2010) somatic disease compared to other psychotherapies.
Bennett & Gibbons Analysis of 30 studies of CBT for Mean effect size was .48 at post-treatment and .66 at
(2000) children with anti-social behavior follow-up.
Butler, Chapman, Review of 16 meta-analyses Large effect sizes were found for CBT for: unipolar
Forman, & Beck depression, generalized anxiety disorder, panic
(2006) disorder, social phobia, post-traumatic stress
disorder, childhood depressive and anxiety disorders;
effect sizes for CBT for marital distress, anger,
childhood somatic disorders, chronic pain were in
moderate range.
Cuijpers, van Straten, Analysis of 16 studies of behavioral Mean effect size when BA compared to control
& Warmerdam activation (BA) for depression conditions = .87; nonsignificant when compared to
(2007) other psychological treatments.
Ekers, Richards, & Analysis of 17 studies of behavioral Behavioral treatment found to be superior to controls
Gilbody (2008) treatment of depression (mean effect size = .70), brief psychotherapy
(.56), supportive therapy (.75), and equal to
cognitive therapy (.08).
Fabiano, Pelham, Analysis of 174 studies of behavioral Behavioral treatments found to be highly effective
Coles, Gnagy, treatments of children with (between group studies = .83; pre-post
Chronis-Tuscano, & attention-deficit hyperactivity studies = .70; within group studies = 2.64; single
O’Connor (2009) disorder case studies = 3.78).
Gloaquen, Cottraux, Analysis of 78 cognitive therapy (CT) CT found to be effective for patients with mild to
Cucherat, & studies for depression moderate depression.
Blackburn (1997)
Hanrahan, Field, Jones, Analysis of 17 studies of cognitive CT found to be superior to control conditions (effect
& Davey (2013) therapy (CT) for worry in size = 1.81); weaker results when CT compared to
generalized anxiety disorder other forms of therapy.
Hendriks, Oude Analysis of 7 studies of CBT for CBT produced an effect size of .44 when compared to
Voshaar, Keijsers, late-life anxiety a waiting-list control or .51 when compared to an
Hoogduin, & van active control condition.
Balkom (2008)
Hofmann & Smits Analysis of 27 studies of CBT for CBT led to effect size of .73 for continuous anxiety
(2008) adult anxiety disorders measures; strongest effect sizes were for
obsessive-compulsive disorder and acute stress
disorder, weakest for panic disorder.
(continued)
Disorders (All Effect Sizes Listed Are Significant Unless Specifically Stated) (continued)
Kleim, Kröger, & Analysis of 16 studies of dialectical DBT found to be effective in reducing suicidal and
Kosfelder (2010) behavior therapy (DBT) for self-injurious behaviors.
borderline personality disorder
Kvale, Berggren, & Analysis of 38 studies of behavioral Behavioral treatment found to be highly effective (mean
Milgrom (2004) treatment of dental anxiety and effect size = 1.8).
phobia
Magill & Ray (2009) Analysis of 53 studies of CBT for Overall, CBT produced a small but significant treatment
adults diagnosed with alcohol- or effect (.15); effect was largest in marijuana studies
illicit-drug-use disorders (.51) and in studies where a no-treatment control
was the comparison condition (.79).
Malouff, Thorsteinsson, Analysis of 15 studies of CBT CBT produced an effect size of .48.
Rooke, Bhullar, & in treating chronic fatigue
Schutte (2008) syndrome
Malouff, Thorsteinsson, Analysis of 31 studies of Mean effect size of PST vs. no treatment = 1.37;
Schutte (2007) problem-solving therapy (PST) vs. treatment as usual = .54; and vs. attention
for various mental and physical placebo = .54; not more effective than other bona
health problems fide treatments (.22).
Powers, Zum, Vörding, Analysis of 18 studies of acceptance ACT found to be more effective than various control
& Emmelkamp and commitment therapy (ACT) conditions (mean effect size = .42), but not more
(2009) effective than other established treatments (.18).
Reger & Gahm (2009) Analysis of the effects of CBT for Effects sizes ranged from .49–1.14; small sample sizes
anxiety provided via computer or and other methodological concerns limit ultimate
internet; 19 studies conclusions.
Robinson, Smith, Analysis of 23 studies applying Mean effect size estimated to be .74.
Miller, & Brownell cognitive behavior
(1999) modification (CBM) to reduce
hyperactive-impulsive and
aggressive behaviors in children
and youth
Serketich & Duman Analysis of 26 studies of behavioral BPT found to be effective in the short-term in modifying
(1996) parent training (BPT) to modify child antisocial behavior at home and school and to
child antisocial behavior enhance parental personal adjustment.
Smith et al. (2002) Analysis of 21 studies evaluating No differences in magnitude between approaches were
either behavior therapy (BT) or found; BT resulted in a greater reduction in sleep
pharmacotherapy for persistent latency.
insomnia
Spek, Cuijpers, Analysis of internet-based CBT for Interventions for anxiety produced a large effect size
Nyklíček, Riper, depression and anxiety involved (.96) and a small mean effect size for depression
Keyzer, & Pop 13 studies (.27); authors suggest this difference may be a
(2007) function of differences in the amount of therapist
support provided.
Disorders (All Effect Sizes Listed Are Significant Unless Specifically Stated) (continued)
Sukhodolsky, Analysis of 21 published and 19 Mean effect size was found to be .67; skills training
Kassinove, & unpublished studies of CBT and multimodal approaches were more effective
Gorman (2004) for anger in children and in reducing aggressive behavior and improving
adolescents social skills; problem-solving treatments were more
effective in reducing subjective anger.
Tarrier, Taylor, & Analysis of 28 studies of CBT for Highly significant overall effect for CBT; not significant for
Gooding (2008) reducing suicidal behavior treating adolescents, if treatment was conducted in
groups, or if compared to another active treatment.
Tatrow & Montgomery Analysis if 20 studies of CBT for distress Effects sizes of .31 and .49 were found for CBT’s impact
(2006) and pain in breast cancer patients on distress and pain, respectively.
Walters (2000) Analysis of 17 studies of behavioral BSCT found to be effective in reducing both alcohol
self-control training (BSCT) for consumption and problem drinking; comparison with
problem drinkers traditional abstinence-control training not significant.
Zimmerman, Favrod, Analysis of 14 studies (N = 1,484) CBT showed significant reduction in positive symptoms;
Trieu, & Pomini of CBT to improve the positive higher benefit for patients with acute psychotic episode
(2005) symptoms of schizophrenia versus a chronic condition (effect size = .57 vs. .27).
spectrum disorders
Research Methods: The Randomized Controlled Trial

The gold standard approach to evaluate the efficacy of psychotherapy inter-
ventions is the randomized controlled trial (RCT), also referred to as a
randomized clinical trial (Nezu & Nezu, 2008a). RCTs represent a “true”
experiment, in that this type of study is designed such that participants are
randomly allocated or assigned to an experimental condition (i.e., the treat-
ment of interest) or to a condition against which the outcome (i.e., depen-
dent variable) is compared. Because participants are randomly assigned to
these two (or more) differing conditions or groups, it can be determined
whether differences in outcome (e.g., improvements in self-esteem) occur
differentially depending on one’s group assignment. As such, it is said that
the investigator is able to “manipulate” the independent variable (i.e., differ-
ent conditions). The major goal of an RCT is to provide reliable and valid
evidence that a given treatment has a given effect or outcome. RCTs allow
investigators to be able to answer questions such as: Does cognitive therapy
“cause” (lead to) a significant decrease in depression? Does exposure ther-
apy “cause” a decrease in anxiety symptoms? Does problem-solving therapy
improve one’s ability to cope more effectively with life stress? In other words,
RCTs help to determine the presence and strength of a causal relationship
between a specific treatment approach and a given outcome.
According to Shadish, Cook, and Campbell (2002), determining whether

a causal relationship exists requires that the investigator demonstrates that
(a) the cause precedes the effect (i.e., that improvement occurs only after
the implementation of a treatment); (b) the cause was related to the effect
(i.e., that the outcome is a function or consequence of the treatment); and
(c) no other plausible explanation can be identified that can explain the
reason that the given effect occurred except for the cause (i.e., that the
specific outcome was directly a consequence of the specific intervention).
Whereas the first condition tends to be easily met, especially if one can
establish that no prior treatment existed across study participants, the sec-
ond two requirements become difficult to meet given the exigencies and
challenges usually associated with any research endeavor with humans. To
a large extent, what investigators need to accomplish regarding these lat-
ter two conditions involves overcoming threats to validity. Validity, in this
context, involves the degree to which an investigator’s conclusions, based
on the data he or she obtained from an RCT, can be considered accurate
and veridical.
T H R E AT S T O VA LI D I T Y
In conducting any type of research, an investigator needs to be concerned

about maximizing four different types of validity: internal validity, exter-
nal validity, construct validity, and statistical conclusion validity (Cook &
Campbell, 1979; Nezu & Nezu, 2008b). Internal validity involves the degree
to which one can eliminate alternative plausible explanations regard-
ing whether X truly led to Y (e.g., Did Treatment A “cause” a decrease in
anxiety?). External validity is defined as the degree to which this associa-
tion can be generalized to other populations, settings, and factors beyond
that which was contained in a single study (e.g., Does this reduction in
anxiety occur for people in general?). Construct validity addresses the gen-
eralizability of a given operational definition (e.g., Was Treatment A as
implemented in this study truly representative of Treatment A?). Statistical
conclusion validity focuses on one’s ability to apply certain statistical ana-
lytic tools to determine the relationship between X and Y (e.g., Was there a
sufficient number of participants to be able to actually detect a difference?).
For each of these types of validity dimensions, various issues can arise
that serve to threaten or challenge one’s ability to establish strong design
properties. In designing and/or evaluating an RCT, it is important to know
what these threats are and how to handle them appropriately. Table 3.3 pro-
vides a brief overview of the more common types of threats that can arise
TA B L E 3.3 Threats to Validity and Possible Solutions
B RI EF DESC R I PT I ON
TH REAT O F THR EAT POTEN TI AL R E ME DIE S
I NTERNAL VA L IDITY
Temporal Precedence Ambiguity regarding “which Exclude participants with recent prior psychotherapy
comes first” experience if relevant to current research question.
Selection Existence of significant Carefully select participants knowing their backgrounds.
differences between groups Randomly assign to condition by blocking on relevant
prior to random selection demographic characteristics (e.g., gender, age,
ethnicity).
Statistically analyze impact of systematic prior
differences.
History Presence of an event that occurs Ensure that the experience of all participants across
during the course of the conditions are equivalent during implementation
study that can provide for of RCT.
an alternative explanation of Randomly assign participants to conditions.
the results Statistically analyze impact if event does occur.
Maturation Presence of various “natural Select participants carefully with this threat in mind.
growth” processes internal Randomly assign participants to conditions.
to subjects that may be Include adequate control conditions.
responsible for change
Regression to the Mean General tendency of extreme Ensure that all DVs have strong test-retest reliability.
scores to regress to Include multiple measures when screening and selecting
distribution mean participants (i.e., do not rely on single measure to
“diagnose” caseness).
Include adequate control groups.
Attrition Significant and/or differential Foster motivation for continued participation.
loss of participants over time Ensure that treatment condition(s) do not radically
differ from control conditions regarding
attrition-related factors (e.g., amount of attention
provided to controls).
Consider alternative control condition instead of the
“no-treatment” control.
Testing and Instrumentation Untoward effects emanating from Choose testing protocols that have minimal effects on
assessment issues subsequent performance.
Conduct quality control checks on instruments (e.g.,
continued calibration) and assessment procedures
(e.g., rater drift).
Include adequate control conditions to assess impact
of testing.
EX TERNA L VA L IDITY
Sample Characteristics Limited ability to generalize to Ensure that study sample includes adequate representation
other individuals across important subject characteristics (e.g., gender,
SES, ethnicity, comorbidity).
(continued)
TA B L E 3.3 Threats to Validity and Possible Solutions (continued)
Setting Characteristics Limited ability to generalize to Ensure that all aspects of the study (e.g., physical
other settings setting, therapists, research assistants) represent
“universal” variables of interest.
Testing Effects Reactions of participants due to Include additional measures beyond self-report inventories
(a) awareness that they are to control for self-report biases.
being tested, (b) pretest Consider using unobtrusive measures.
sensitization, or (c) timing of Time assessments in clinically meaningful ways (e.g.,
testing length of follow-up should be based on understanding
of course of disease rather than convenience).
CO NSTRUC T VA L IDITY
Inadequate Explication of Constructs of interest are not Be specific in describing all constructs (e.g.,
Constructs operationally defined well or avoid jargon and ambiguous labels).
adequately Ensure that all operational definitions of constructs
adequately represent the entire construct of
interest.
Confounding Constructs Constructs are confused with Ensure that the construct of interest truly is the correct
others construct that you want to investigate.
Singular Definitions Using only one operation or Use multitrait-multimethod approach when operationally
method to define a construct defining all constructs (e.g., use more than one
therapist).
Participant Reactivity Unwanted reactions of subjects Choose control groups that will minimize this threat
(e.g., a no-treatment control can lead to
subject demoralization or compensation).
Include adequate attention-placebo control conditions
that are likely to be perceived as potentially
effective.
Include “manipulation checks” to assess whether
participants across conditions rated the conditions
(and therapists) equivalently.
Experimenter Expectancies Effects of an experimenter’s “Blind” all research personnel as much as ethically
unintentional biases possible.
Request that all research personnel be “on guard.”
Include treatment integrity protocol to analyze such
effects.
Treatment Diffusion Aspects of one condition are Use different therapists to implement differing conditions.
inadvertently provided to a “Blind” all assessors, research personnel, etc., as much as
control or other condition possible to study hypotheses.
Conduct treatment integrity assessment to evaluate the
presence of this threat.
Keep subjects in differing conditions separate.
TA B L E 3.3 Threats to Validity and Possible Solutions (continued)
STATI STIC A L C ONC L US ION VALIDIT Y
Low Statistical Power Low power limits one’s ability to Have adequate number of participants.
detect differences when they Include robust treatments.
do exist Decrease variability in implementing RCT.
Family-Wise Error Conducting multiple statistical Be conservative in the number of tests conducted.
tests Use Bonferroni correction when conducting multiple
tests.
Unreliable Measures Use of unreliable assessment Only use reliable tests; strong test-retest reliability is
procedures and tests important for repeated measures assessments.
Unreliability of Treatment RCT is variably implemented Select, train, and supervise therapists, assessors, and
Implementation across subjects, conditions, research assistants with goal of ensuring consistent
or settings and reliable performance.
Use detailed, but flexible, training, therapy, and
assessment manuals as guides.
Include treatment integrity protocol as major guide to
guard against this threat.
Participant Heterogeneity Increased heterogeneity leads to Delineate and adhere to appropriate inclusion and
increased unwanted variability exclusion criteria regarding subject selection.
Randomly assign to conditions using methods (e.g.,
blocking) that adequately distribute variability across
conditions.
From Nezu & Nezu (2008a). Reprinted with permission.
regarding each of the four types of validity dimensions, as well as recom-

mended research strategies to help overcome such challenges or to “control
for” potential sources of bias that can influence the dependent variable. To
a large extent, controlling for such threats requires that the investigator
ensure that all study participants are equivalent regarding any and all vari-
ables that may influence the dependent variable(s), with the exception of
differences related to being in different conditions. If the results at the end
of treatment indicate that those individuals in the experimental condition
experienced substantial change in the hypothesized direction in compari-
son with those persons in the control group(s), then a strong case can be
made for the efficacy of the treatment under investigation. On the other
hand, if various threats to validity are not adequately controlled for, despite
any significant differences in outcome between the two groups that may
occur, the ability of the investigator to claim that such a difference was
actually due to the treatment is severely compromised.
CONT R O L C O N D I T I O NS
Within an RCT outcome design, an investigator can include various

types of control conditions in order to compare differences in outcome.
Such control groups are crucial to such a research endeavor in order to
ensure that alternative explanations can be adequately ruled out as pos-
sible reasons that such differences occurred. For example, in what is
generally termed a pre-post design, participants are evaluated before and
after treatment is conducted, but no comparison group is included (and
therefore randomization to conditions does not occur). Whereas these
individuals may experience a variety of positive changes, in the absence
of an adequate control group, it is difficult to determine whether any of
the threats to internal validity as noted in Table 3.3 (e.g., regression to the
mean) served to influence or “cause” such improvement. Various control
conditions have been applied in psychotherapy outcome research, includ-
ing (a) no-treatment control, (b) waiting-list control, (c) attention-placebo,
(d) treatment-as-usual, and (e) comparable treatment control.
No-treatment control Participants randomly assigned to this condition are

evaluated similarly to those individuals who receive treatment (i.e., before
and after treatment). This type of comparison group sufficiently controls
for many major threats to validity, such as the effects of testing, history,
and maturation. However, it does not adequately eliminate other plausible
explanations, such as novelty or the possibility that any contact with a pro-
fessional (in contrast to the specific treatment under investigation) may
have led to improvement. In addition, individuals in this condition have
little to look forward to, knowing that no treatment would be forthcoming.
As such, hope and motivation can serve as possible reasons that persons
receiving treatment fared better.
Waiting-list control (WLC) To eliminate the concern about differences in

motivation and expectations between treated and no-treatment control
participants, persons allocated to a WLC are told that they will be receiv-
ing treatment, albeit after a period of waiting. The length of time between
pre- and post-testing is equal to that of the treated condition. However, after
post-test assessment, WLC members are provided treatment. Whereas the
WLC does enhance motivation, additional problems exist. For example, the
wait may be too long. As such, some individuals may seek treatment else-
where, but not divulge such information to the investigator for fear that they
may be excluded from the study or may be prohibited from receiving treat-
ment in the future. In this instance, the WLC no longer serves as a control
condition. Further, other individuals who wish not to wait may simply leave
the study, thus leading to differential attrition between the treated and con-
trol conditions, potentially presenting another source of bias.
Attention placebo In order to control for the amount of time, attention,

therapist contact, and expectations generally associated with being assigned
to the experimental condition (i.e., the treatment under study), investiga-
tors have included a condition that is parallel to it, minus the active ingre-
dients of the treatment per se. This is similar to a “drug placebo” condition
whereby participants do not know whether the medication they are receiv-
ing is the active drug or an inert “sugar pill.” However, although control-
ling for time and activity, often in the past investigators have not devised
the placebo condition to adequately control for participants’ expectations
or sense of being helped. In other words, differential treatment outcome
between the experimental condition and the attention placebo may still
not be a function of the specific causal effects of the therapy; rather, par-
ticipants might perceive (rightly or wrongly) that they are not receiving a
“bona fide” treatment if the placebo falls short of appearing as a legitimate
treatment approach. Therefore, in order for this control condition to effec-
tively serve as such, it must be construed by participants as meaningful.
Treatment as usual Often the type of patients that an investigator is inter-

ested in studying are already receiving some form of treatment that can-
not be reasonably stopped. A typical example involves medical patients
who are receiving treatment for their illness, such as cancer, diabetes, or
chronic pain. In addition to chemotherapy, radiation, or surgery, for exam-
ple, a person diagnosed with cancer is likely to be involved in multiple
programs at the treating hospital (e.g., peer support groups, meetings with
social work staff, consultations with clergy). To request that such indi-
viduals cease such activities in order to best evaluate the unique impact
of a given psychosocial intervention would border on the unethical, as
well as being impractical. Therefore, one means of evaluating the efficacy
of a cognitive-behavioral intervention, for instance in order to decrease
comorbid depression or anxiety, would be to add such a treatment above
and beyond treatment as usual. This would be compared to a condition
whereby participants continue to receive both the medical and adjuvant
treatments that they would normally undergo (i.e., treatment as usual, or
TAU). The research question then becomes one of whether adding the
cognitive-behavioral intervention to TAU serves to enhance/decrease the
dependent variable(s) of interest.
Comparable treatment Comparing two (or more) bona fide treatments

at the same time provides for an optimal set of conditions in that both
can serve as controls for each other, providing that both involve similar
amounts of time, activities, and other essential treatment ingredients. If
one fares better than the other, it is unlikely that this might be due to other
non-treatment-related factors, such as differential participant expectations.
T R E AT M E N T O U T C O M E D ES IGN S
In order to best inform cognitive-behavioral practice, as well as further

the evidence base of this field of applied psychology, investigators have
employed a variety of research designs to ask a variety of research questions
(Nock, Janis, & Wedig, 2008). These include (a) treatment efficacy design,
(b) dismantling studies, (c) constructive design, (d) parametric design,
(e) treatment moderator studies, and (f) treatment mediator design.
Treatment efficacy The basic hypothesis put forth by this design is to

determine whether a given treatment “works”—in other words, whether
the treatment has a causal impact on a given set of dependent variables or
outcome. Typically, the basic design is to evaluate changes in the depen-
dent variable from before treatment to after treatment has been imple-
mented and then to compare such changes to those that may or may not
have occurred for individuals in a control condition (e.g., waiting-list con-
trol, WLC). To enhance the validity of such a design, as in all the other
types of experimental designs, the investigator needs to adequately address
the various threats to validity previously described. An example of such a
study was conducted by Stice, Rohde, Shaw, and Marti (2012), who evalu-
ated the efficacy of a prevention program that targeted both eating disor-
der symptoms and unhealthy weight gain in young women as compared
to an educational brochure control condition. Results indicated that indi-
viduals receiving the prevention program displayed significantly greater
reductions in body dissatisfaction and eating disorder symptoms, as well
as greater increase in physical activity, as compared to control participants.
Dismantling studies This type of design allows the investigator to ask a

question that helps to determine which components of a treatment pro-
tocol are necessary and sufficient to be effective. Also termed a compo-
nent analysis, such a study helps to isolate the unique contributions of the
various components of an intervention after it has initially been found to
be efficacious. An example is a dismantling study conducted by Nezu and
Perri (1989). Nezu (1986) had previously found problem-solving therapy
(PST) to be an effective intervention for treating major depressive disorder

among a community sample of adults. PST for depression was conceptual-
ized as containing two major treatment components: one that focused on
enhancing one’s positive problem orientation (i.e., the cognitive-affective
set of beliefs and attitudes about problems in living and one’s sense of
self-efficacy in handling such problems); and one that addressed a per-
son’s actual problem-solving coping skills. The Nezu and Perri study
sought to determine whether taking away the problem-orientation treat-
ment component would reduce the overall efficacy of PST. Results found
that participants who received the entire PST intervention fared signifi-
cantly better than patients who received an intervention focused only on
problem-solving skills training, suggesting that both components contrib-
ute significantly and uniquely to positive outcome.
Constructive design Similar to the dismantling design, a constructive (also

referred to as an additive design) is invoked after a given treatment has
been found to be efficacious. In this case, an investigator may be interested
in answering the question of whether adding a treatment component to the
intervention may be beneficial. Participants in this type of study are randomly
assigned to either a given treatment or a condition where another component
has been added to that treatment. A relevant example is provided by Nock
and Kazdin (2005), who added a brief participation enhancement interven-
tion to parent management training. Individuals who received both com-
ponents were found to report higher treatment motivation, attended more
sessions, and were significantly more adherent to the treatment procedures as
compared to those persons receiving only the parent management training.
Parametric design Investigators using this type of design are interested

in determining whether changes in various aspects or parameters of a
given intervention, or the manner in which it is delivered, can enhance
its efficacy. Whereas the content remains the same between the interven-
tion and its modified version, they can differ in such dimensions as overall
length of treatment, the number of sessions, differing treatment settings, or
methods of delivering the intervention. An example is provided by Perri,
Nezu, Patti, and McCann (1989), who tested the hypothesis that a behavior
therapy obesity treatment protocol could be improved by lengthening the
duration of treatment. The two conditions involved a standard protocol of
20 weekly sessions and an extended treatment of 40 weekly sessions. The
content of each intervention was identical, but the treatment procedures
were introduced in a more gradual manner in the extended condition.
Participants receiving the extended protocol were found to experience sig-

nificantly greater mean weight losses at 40- and 72-week evaluations as
compared to individuals in the standard treatment.
Treatment moderator A moderator is a variable that changes the strength

or direction of the relationship between two other variables. With regard
to treatment outcome studies, a moderator variable would involve a factor
that influences the strength or direction of the association between treat-
ment and outcome. The moderator in this context would be assessed at
baseline in order to determine its effects on outcome. Such studies help
to enhance our understanding of whether certain treatments may be
more efficacious for certain people and/or under certain circumstances,
thus helping to make more effective treatment decisions. For example,
Wolitzky-Taylor, Arch, Rosenfield, and Craske (2012) evaluated various
potential moderators of traditional cognitive-behavioral therapy (CBT) as
compared to acceptance and commitment therapy (ACT) for the treatment
of anxiety disorders. Results indicated that CBT fared better than ACT for
those patients reporting moderate levels of anxiety sensitivity at pretreat-
ment, whereas ACT outperformed CBT for those individuals with comor-
bid mood disorders. As such, baseline anxiety sensitivity and comorbid
mood disorders were found to serve as treatment moderators.
Treatment mediators These types of studies attempt to better understand

the mechanisms or processes by which a treatment leads to improvement
or change. Not only does this enhance our basic scientific understanding
of how a given treatment works, but can also eventually improve the effi-
ciency and efficacy of therapeutic interventions (Nock et al., 2008). An
example of a study that tested a specific treatment mediator is recently
provided by Goldin et al. (2012) who focused on the treatment of social
anxiety disorder. Specifically, they examined whether changes in cognitive
reappraisal self-efficacy (i.e., the belief that one can effectively engage in
cognitive reappraisal when desirous of regulating one’s negative emotions)
mediated the effects of individually administered CBT on social anxiety
symptoms. Compared to a waiting-list control condition, CBT resulted in
greater increases in cognitive reappraisal self-efficacy and greater decreases
in social anxiety. More important, the self-efficacy beliefs were found to
mediate the effects of CBT on social anxiety symptoms.
STAND A R D I ZE D GU I D ELIN ES
A recent phenomenon in the history of published research is the attempt

to standardize reporting guidelines in order to enhance clarity, reduce bias,
and improve the quality of the research itself. One of the most widely rec-
ognized set of guidelines related to treatment outcome is the CONSORT
(Consolidated Standards of Reporting Trials) Statement (Trudeau,
Mostofsky, Stuhr, & Davidson, 2008). Originating from an international
movement in medicine, by 1997, over 70 medical journal editors endorsed
it (Moher, 1998). In 2003, the American Psychological Association (APA)
adopted the CONSORT principles and encouraged its editors to use such
guidelines when evaluating the quality of a paper submission. The CONSORT
group continues to refine these guidelines, as well as adopting them for
specific applications (see CONSORT website, www.consort-statement.org,
for the latest guidelines, as well as relevant resources).
In 2008, the APA published a new set of guidelines, entitled JARS
(Journal Article Reporting Standards) that built on those posited by
the CONSORT group, but attempted to broaden its focus by address-
ing all types of research designs, including RCTs (APA Publications and
Communications Board Working Group on Journal Article Reporting
Standards). Many editors of journals that typically report RCTs have
already adopted the JARS guidelines, such as the Journal of Consulting
and Clinical Psychology (Nezu, 2011). Whereas both sets of guidelines aid
researchers in their reporting of RCTs in a more clear and comprehensive
manner, they also go far in helping them to actually design and conduct
them as well. As such, we strongly recommend that either approach rep-
resents a useful tool when evaluating and designing treatment outcome
studies. Table 3.4 provides a listing of the major methodology topics or
areas that the JARS, for example, directs investigators to address when
reporting (designing) an RCT.
A particularly useful aspect of such guidelines is the inclusion of a chart
that provides for a short-hand, visual representation of the flow of par-
ticipants through various stages of an intervention trial. Figure 3.1 is an
example of such a chart, provided by the CONSORT Statement website. By
including such a chart, the reader has the ability to quickly determine, for
example, how many participants were initially assigned to different treat-
ments, how many remained in treatment, and how many were included in
the statistical analyses.
Research Designs: Single Case Designs

In addition to group RCTs, cognitive and behavioral investigators have fre-
quently employed single case, or N of 1, designs to assess the causal relation
between a given intervention and a given outcome with a given individual.
Indeed, it was the early behaviorists who developed and refined single
TA B L E 3. 4 Sample of Research Design Issues Addressed by the JARS Guidelines
• Participant Characteristics (e.g., eligibility and exclusion criteria)

• Sampling Procedures (e.g., sampling method, settings and locations, percentage of sample approached that
participated)
• Sample Size, Power, and Precision (e. g., how sample size was determined, explanation of interim analyses and
stopping rules)
• Measures and Covariates (e.g., methods used to collect data, training of data collectors)
• Experimental Manipulations/Interventions (e.g., details of interventions, method of intervention delivery, level of
training of intervention deliverer, setting, number and duration of sessions, time span, activities to enhance compliance)
• Units of Delivery and Analysis (e.g., how participants were grouped during delivery, description of the smallest unit
analyzed)
• Participant Flow (total number of groups, flow of participants through each stage of the study)
• Treatment Fidelity (evidence of whether the treatment was delivered as intended)
FIGURE 3 . 1 Sample CONSORT Diagram
Enrollment Assessed for eligibility (n= )
Excluded (n= )
♦ Not meeting inclusion criteria (n= )
♦ Declined to participate (n= )
♦ Other reasons (n= )
Randomized (n= )
Allocation
Allocated to intervention (n= ) Allocated to intervention (n= )
♦ Received allocated intervention (n= ) ♦ Received allocated intervention (n= )
♦ Did not receive allocated intervention ♦ Did not receive allocated intervention
(give reasons) (n= ) (give reasons) (n= )
Follow-Up
Lost to follow-up (give reasons) (n= ) Lost to follow-up (give reasons) (n= )
Discontinued intervention (give reasons) (n= ) Discontinued intervention (give reasons) (n= )
Analysis
Analysed (n= ) Analysed (n= )
♦ Excluded from analysis (give reasons) (n= ) ♦ Excluded from analysis (give reasons) (n= )
case designs that were quantitative in nature, rather than purely descrip-
tive, which was the typical approach in clinical investigations during the
first half of the twentieth century (Barlow, Nock, & Hersen, 2009). In fact,
various single case designs have become synonymous with an experimen-
tal analysis of behavior approach, which then enables intensive study of
the individual (see Chapter 7). Although not the exclusive domain of that
segment of this specialty known as applied behavior analysis, single case
designs were originally associated with helping to evaluate the relation-
ship between more operant types of interventions on behavior (see Barlow
et al., 2009, for a historical overview of the origins of single case designs).
The advantage of a single case design, which focuses more on a
within-subject perspective, over group RCTs, which focuses heavily on
between-subject analyses, is threefold. First, when done properly, it can
provide for an intensive analysis of an individual, rather than address-
ing global differences represented by groups. Second, it is less expensive,
both financially and regarding resources, as compared to even a small
RCT. Thus, it can provide meaningful pilot data that support confirma-
tion or disconfirmation of a hypothesis prior to expending large amounts
of resources. Third, it is a very useful design when applied to individuals
who represent a very small group of patients (e.g., those suffering from a
rare disease). The major disadvantage of single case designs is the limited
ability to generalize to larger populations. In this next section, we will
briefly describe some of the major single case research designs.
A- B D E S I GN S
The A-B design represents the simplest of the single-case approaches.

Essentially, a target behavior is operationally defined and specified and
repeated measurement of this behavior is taken during the baseline (A) and
intervention (B) stages of the investigation. Sufficient baseline data need
to be obtained in order to obtain a “true” pretreatment assessment. At a
predetermined point, the treatment phase is introduced and changes (or
lack of) are observed and recorded regarding the targeted behavior (i.e.,
dependent variable). If changes in the dependent variable are identified,
it can be interpreted that the treatment “caused” the change. However, as
noted with regard to RCTs, various threats to validity can also rear “their
ugly heads.” For example, it is possible that simultaneous with the intro-
duction of the B phase, an event occurred outside of the investigation that
might have “caused” the change in behavior, which an A-B design does not
adequately control for (which is similar to the threat of “history” in group
designs, see Table 3.3).
A- B- A D E S I GN S
To overcome some of the limitations of the A-B design, researchers have

employed an A-B-A design, often referred to as a withdrawal approach, as
the third stage of the design is to withdraw the intervention after obtain-
ing both baseline data (A) and changes (or lack of) in the target behavior
related to the introduction of the intervention (B). Conceptually, one can
determine whether it is the intervention under investigation that is caus-
ally related to outcome if the dependent variable changes (i.e., improves),
in comparison to the baseline, after the intervention is introduced, but
changes back again (i.e., deteriorates) after it is withdrawn. If this pat-
tern occurs, it is highly likely that treatment in such a case is the variable
responsible for the fluctuations in the target behavior. However, two con-
cerns remain with this design. First, if the dependent variable does not
change when treatment is withdrawn, one possible explanation is that the
improvement persisted despite the withdrawal of treatment (i.e., the behav-
ior was maintained by other variables). Second, it may be unethical to leave
the patient or client under study without treatment after it is withdrawn.
A- B- A- B D E S I GN S
This type of single case design, often referred to as a reversal design, is

perhaps the most popular method and provides features to help overcome
the ethical concerns and methodological limitations of the A-B-A design.
As can be seen in Figure 3.2, there are two treatment phases, thereby end-
ing the study with the individual continuing to receive care. Moreover, two
occurrences of the potential effects due to treatment are included, thereby
providing a more powerful evaluation of the treatment impact (i.e., B to
A and then A to B). In Figure 3.2, an increase in behavior is observed dur-
ing the first treatment phase (sessions 4–8), which then reverses back to
baseline when treatment is withdrawn (sessions 9–11), and increases once
again when treatment is re-introduced (after session 12).
MU LT I P LE B A S E LI N E D ES IGN S
Despite the methodological rigor that an A-B-A-B design can provide

when conducting single case studies, additional concerns remain. The
possibility of maintenance or generalization of the initial treatment effects
still exists, thus compromising the supposed close association between
changes in the behavior and the introduction/withdrawal of treatment.
Further, although the A-B-A-B design does end where the individual is
receiving care, perhaps for ethical or certain clinical reasons, withdrawing
FIGURE 3 . 2 Reversal Design

Reversal Design
18 A B A B
16
14
12
Behaviors
10
8
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Sessions
treatment during any phase is undesirable. Given these concerns, inves-

tigators frequently turn to multiple baseline designs to overcome these
limitations.
This type of methodology involves a protocol whereby treatment is
introduced at varying times to different individuals (e.g., differing stu-
dents), behaviors (e.g., aggressive and cooperate behaviors), or settings
(e.g., school and home). The strength of this design “comes from dem-
onstrating that change occurs when, and only when, the intervention is
directed at the behavior, setting, or subject in question” (Barlow et al.,
2009, p. 202). Figure 3.3 provides for a visual representation of a multiple
baseline approach that involves three different participants (i.e., John,
Ralph, and Paul). Baseline data collection begins at the same time for
all three individuals, but treatment is temporally introduced at differing
times. More specifically, for John, treatment is introduced at session #6,
with baselines continuing for Ralph and Paul. For Ralph, the interven-
tion is presented at session #11 and baseline data collection for Paul is
continued. Last, Paul receives treatment at session #16, while data con-
tinue to be collected for John and Ralph. According to Figure 3.3, it can
be concluded that treatment is effective in that it served to increase the
frequency of a targeted behavior only after it was introduced across the
three individuals.
Multiple baseline designs can also be used for a single individual where
treatment is introduced at different times for two or more differing target
behaviors. In addition, it can also be employed to evaluate the effects of
treatment across two or more settings. Barlow et al. (2009) suggest employ-
ing at least three baselines, regardless of whether focusing on three dif-
ferent participants, behaviors, or settings, as such a practice increases the
overall strength of the design.
FIGURE 3 . 3 Multiple Baseline Design

BASELINE INTERVENTION
25
20
15
10
JOHN
0
1 6 11 16 21
20
18
16
14
FREQUENCY
12
10
8
6
4 RALPH
2
0
1 6 11 16 21
20
18
16
14
12
10
8
6
4
PAUL
2
0
1 6 11 16 21
SESSIONS
How Research Serves as a Bridge Between Theory and Practice:

Problem-Solving Therapy as an Example
Any given specialty in applied psychology, including cognitive and
behavioral psychology, comprises both various theoretical and concep-
tual underpinnings (see Chapter 2) that describe certain frameworks
within which to better understand human behavior (both “normal” and
pathological), as well as different treatment interventions (Chapters 6
and 7) that are geared to help foster improved human functioning and
well-being. Within a cognitive and behavioral perspective, it can easily be
said that scientific research endeavors serve to provide a two-way bridge
that connects both areas, hopefully with the goal of not only obtaining
an increased valid understanding of human nature, but also to enhance
the efficacy and effectiveness of the clinical change strategies them-
selves. In the last section of this chapter, we focus on problem-solving
therapy, one of the many cognitive and behavioral interventions that
have a strong evidence base in support of its efficacy as a brief illustra-
tion of this process.
As will be described in more detail in Chapter 6, contemporary
problem-solving therapy (PST) is a cognitive-behavioral clinical inter-
vention that is geared to enhance one’s ability to cope effectively with
both minor (e.g., chronic daily problems) and major (e.g., traumatic
events) stressors in order to attenuate extant mental health and physi-
cal health problems. The major treatment goals of PST include (a) adop-
tion of an adaptive worldview or orientation toward problems in living
(e.g., optimism, positive self-efficacy, acceptance that problems are com-
mon occurrences in life); and (b) the effective implementation of specific
problem-solving behaviors (e.g., emotional regulation and management,
planful problem solving).
Historically, PST began as a cognitive and behavioral intervention when
D’Zurilla and Goldfried published a seminal article in 1971 that proposed
a theoretical model of how to solve or cope with real-life problems in liv-
ing. A major gist of this paper was to articulate one aspect of “positive
mental health” (i.e., the ability to deal with day-to-day stressors) in con-
trast to it being viewed solely as “the lack of psychopathology.” This model
was based on a comprehensive survey and review of a wide range of top-
ics in the literature, including abnormal psychology, creativity, cognitive
problem solving, education, and industry/business. Their prescriptive
model of problem solving consisted of two components: (a) general ori-
entation (later re-labeled problem orientation), and (b) problem-solving
skills. General orientation was defined as the set of relatively stable

cognitive-emotional schemas that reflect a person’s general awareness and
appraisals of problems in living, as well as his or her own problem-solving
ability. Problem-solving skills referred to the set of cognitive-behavioral
activities by which a person attempts to discover or develop effective “solu-
tions” or ways of coping with real-life problems (e.g., defining a problem,
generating creative alternative solutions, making decisions as to which
alternatives should be carried out, and implementing a solution plan and
evaluating the outcome).
Subsequent research emanating from this theoretical model initially
involved several lines of inquiry: (a) whether training in specific problem-
solving skills actually led to more effective problem solving (e.g., Nezu &
D’Zurilla, 1979, 1981); (b) whether effective problem solving in real life
served to buffer the negative effects of stress (e.g., Nezu & Ronan, 1985,
1988); and (c) whether a clinical intervention based on this model could be
effective in enhancing well-being and reducing psychopathology, for exam-
ple, depression (e.g., Nezu, 1986; Nezu & Perri, 1989). Positive answers to
such research questions then led to revisions and refinements of both the
underlying theory (D’Zurilla, Nezu, & Maydeu-Olivares, 2004) and ther-
apy (Nezu, Nezu, & D’Zurilla, 2007), as well as additional research ques-
tions (e.g., can PST be effective for a variety of psychological disorders?
Can it be useful in preventing pathology among vulnerable individuals?
Can it be provided in various ways, such as over the Internet and via video-
conferencing?). Again, predominantly positive answers to such questions
continue to lead to further refinements of the theory and therapy, demon-
strating the interdependence among theory, research, and clinical practice
(Nezu, Nezu, & D’Zurilla, 2013).
PA RT I I
Functional Competencies
in Assessment
FO UR
Assessment in Cognitive and

Behavioral Psychology
Introduction
During the early history of behavior therapy there was a significant schism
between two approaches to assessment: that which used traditional psy-
chological tests (measuring personality characteristics, intelligence,
and aptitude) and behavioral assessment. A detailed description of the
methodological and theoretical assumptions between these two assess-
ment traditions is covered in detail in a landmark article by Goldfried
and Kent (1972). Most notably, these authors underscored the viewpoint
that in behavioral assessment an individual’s response to an assessment
served as an actual sample of observable behavior that occurred, or in the
case of observations under analogue conditions, was likely to occur under
similar real-life situational circumstances. In contrast, traditional testing
involved higher levels of inference in which an individual’s test response
purportedly measured a hypothetical construct that was ultimately
used to explain and predict one’s behavior (Goldfried & Kent, 1972). In
other words, traditional assessment was often employed to diagnose or
to uncover an underlying vulnerability or mental illness. This schism in
assessment continued for many years, creating an often overgeneralized
theoretical disagreement regarding assessment of internal or environ-
mental factors.
66 Functional Competencies in Assessment
The Current Status of Behavioral Assessment

Assessment procedures that fall under the umbrella of cognitive and behav-
ioral psychology include a large array of evaluation tools. These include the
historic methods of behavioral psychology, referred to as applied behavior
analysis (also referred to as functional analysis of behavior), as well as many
other ways to directly observe overt behavior, and sample a full range of
human cognition, emotion, and social interactions. Assessment tools cover
a range of methods, such as specific situational observational tests, ana-
logue and role-play observational methods, self-report of behavior, cogni-
tion, and emotions, various diaries and journals, structured interviews and
questionnaires, subjective ratings of pain and distress, imaging technolo-
gies, and physiologic measures. Although behavioral assessment makes
much less use of nomothetic, trait-based measures, psychological testing
and clinical neuropsychological evaluation test results are often used to
better understand enduring schemas, perceptions, beliefs, and values, as
well as to understand preferred learning and information-processing styles
to identify learning strengths and weaknesses. While cognitive and behav-
ioral psychologists diagnose patients using the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV; American Psychiatric Association,
2000), the use of diagnoses are more focused on increasing communication
with other professionals, health care or insurance systems, and conducting
research regarding evidence-based assessment and treatment. There is a
distinct historic trend in cognitive and behavioral practice not to embrace
DSM diagnostic categories as reified constructs, but to respect the DSM
as a categorization system. For a more complete discussion of the chal-
lenges of integrating the use of the DSM and behavioral assessment proce-
dures, the reader is referred to two special series that appeared in both the
Journal of Consulting and Clinical Psychology (Follette & Houts, 1996) and
Behavioral Assessment (Follette & Hayes, 1992) during the 1990s.
Characteristics of Behavioral Assessment

According to Steven Haynes (Haynes & O’Brien, 2000), the overarching
goal of behavioral assessment is to increase the validity of clinical judg-
ments, particularly judgments about the clinical case formulation. In
order to achieve this goal, a clinician has the task of selecting assessment
strategies and instruments that are most likely to provide information
concerning the variables associated with the reason for which therapy is
undertaken. Rosen and Proctor (1981) refer to these reasons for which
Assessment in Cognitive and Behavioral Psychology 67
therapy is undertaken as “ultimate outcomes.” These ultimate outcomes or

goals of treatment will be discussed further in the following chapter that
discusses case formulation.
In order to make effective decisions concerning each individual case,
assessment information needs to be synthesized and integrated. Haynes,
as well as other clinical authors, has suggested a “funnel” approach to
assessment (Haynes & O’Brien, 2000). This begins by using broadly
focused assessment instruments to scan many life domains and areas
of possible challenges and strengths, as well the full range of biological,
social, familial, interpersonal, health, cultural, and spiritual factors. This
broadly focused assessment may include surveys of symptoms or prob-
lems across a wide range of areas, structured, semi-structured, or open
clinical interviews, and clinical questionnaires. It is helpful at this initial
stage of assessment to gain as much information as possible in order to
reduce biased-search strategies or judgmental errors, so common to the
diagnostic process in both psychology and medicine (Groopman, 2007;
Kahnemann, Slovic, & Tversky, 1982; Nezu, Nezu, & Lombardo, 2004). As
a clinician begins to discern hypotheses concerning possible target areas,
a more focused assessment can obtain a closer view of these areas, as well
as the possible functional relationships that contribute to the maintenance
of an individual’s areas of life difficulty. As an example, an individual may
seek treatment for “low self-esteem” or “depressed and anxious mood.”
The cognitive-behavioral specialist would consider the wide range distal
or historic factors that may have been salient to the development of various
affective, cognitive, or learned behavioral characteristics that contribute
to the current dysfunctional system. Developing hypotheses concerning
the way these factors interact, the functional relations among them, the
strengths that serve to buffer negative circumstances or stressors, and the
intra- and interpersonal consequences of the individual’s behavioral rep-
ertoire provides a basis for an understanding, rather than simply describ-
ing their reasons for seeking help (Eells, Lombart, Kendjelic, Turner, and
Lucas, 2005).
In addition to the superordinate goals of behavioral assessment, Haynes
and O’Brien list the stepped goals of behavioral assessment as selection
of assessment strategies, determining whether consultation or referral are
appropriate, development of a case formulation, design of an intervention,
evaluating therapy process and progress, prediction of behavior, informed
consent, and nonclinical goals such as theory or assessment method devel-
opment, development of causal models, and adding to the literature con-
cerning various diagnostic groups (2000, p. 65).
Therefore, the various assessment strategies described below are

designed to aid the clinician in answering these questions with maximal
effectiveness, as well as to develop an explanatory model of a patient’s cur-
rent difficulty, through a case formulation.
Evolution of Behavioral Assessment

Behavioral assessment procedures were drawn from the various models of
learning that formed the scientific foundations for the specialty (described
in Chapter 3). These include the instrumental learning principles of
Thorndike and Skinner, as well as applied practitioners such as Baer, Wolf,
and Risly, who among others translated these principles into the tech-
nologies associated with applied behavior analysis as a distinct method
of assessment. Other behavioral tests, such as those assessing behavioral
avoidance, were an outgrowth of early scientific foundations regarding
associative learning and classical conditioning principles that were laid
down by individuals such as Pavlov and his students and were trans-
lated to human models of psychopathology by Watson, Jones, and later
Joseph Wolpe. Social-cognitive theories of information processing pro-
duced many measures associated with self-report. Interactions between
individuals such as romantic partners, or children and adolescents and
their caregivers, are often observed through coded observational systems
(Gottman & Notarius, 2000; Robinson & Eyberg, 1981). Finally, assess-
ment of the neurosubstrates of emotion and mood through measurement
of both biologic markers (Gur, Gur, Resnick, Skolnick, Alavi, & Reivich,
1987) and imaging technology (Goldapple et al., 2004), have taken their
place among the more recent assessment methodologies important to the
cognitive-behavioral psychologist. Cognitive-behavioral psychologists use
all of these assessment strategies to a greater or lesser degree, based upon
their particular training, area of focus, and access to technology. Many cli-
nicians integrate these strategies to draw information about the various
contributions that the individual, social, and cultural learning one has expe-
rienced over a lifetime may make, including their impact on one another,
in ultimately constructing any given person’s “story” or individualized case
formulation. In addition to identification of an individual’s strengths or
vulnerabilities in each of these areas, one of the most important clinical
tasks presented by assessment is to construct learning-based explanation
that may help cognitive and behavioral clinicians to understand, predict,
and ultimately change a challenging mental health problem by creating a
new learning experience for the patient. Such an individualized approach
to treatment is a hallmark of cognitive-behavior therapy and has its early

roots in behavioral analysis. Here is where our overview of behavioral
assessment tools will begin.
Behavioral Analysis
Applied behavior analysis focuses on objectively defined, observable behav-
iors and social significance; its goals are to improve the behavior under
study while demonstrating a reliable relationship between the procedures
employed and behavioral improvement. It uses the methods of science—
description, quantification, and analysis. Baer, Wolf, and Risly (1968) pub-
lished a description of the dimensions in applied behavior analysis that
remain an important part of the methodology of functional analysis of
behavior to this day. In this early work, the authors helped to define the
field as well as the criteria by which research in applied behavior analysis
would be judged. It is among the most widely cited papers in this area and
continues to serve as a standard to guide applied behavioral analysis, and
describes the following characteristics of the study of behavior. According
to these authors, the study of behavior must be applied (e.g., socially sig-
nificant), behavioral (e.g., measurable), and analytic (i.e., demonstrate the
functional relations between manipulated events and the behavior of clini-
cal or research interest). Additionally, the methods should be technological
(all procedures clearly identified and described), conceptually systematic
(with regard to the relevant principles of learning from which they are
derived), effective (offer a means of practical improvement with regard to
the intervention designed from assessment), and should display some gen-
erality (that the resulting intervention leads to relatively enduring behavior
change over time or situations).
Specifics of Behavioral Analysis

Although the full scope of historic development and intricacies of applied
behavioral analyses will not be covered here, we have distilled, from vari-
ous sources and clinical case reports, several important aspects of compe-
tent implementation of an applied behavioral analysis method. Specifically,
it should include the following components:
1. A target problem or area for observation should be identified and its

relevance to an individual’s quality of life described.
2. An operational definition of the target problem should be developed

that reflects the central features of the construct being observed.
Operational definitions should meet several criteria: objectivity
(observable characteristics), clarity (unambiguous wording, so it can
be read, repeated, and paraphrased by observers), and completeness
(delineation of boundary conditions concerning what responses
should be included and excluded in those responses). For example, let’s
assume that one wanted to measure a patient’s complaint of “feeling
angry.” Feeling angry is not observable and is a subjective experience.
One could measure, however, the number of times that an individual
shouts, criticizes, or uses profanity toward someone else. These actions
are observable. One could not reliably conclude that the individual was
“angry” in terms of a universal definition or apart from a description
of the individual’s subjective experience. What is important in defining
behavior for the purpose of a functional analysis is that observable
behavioral components are described that define “anger” relative to the
individual of interest and the behavior that is the target of change.
3. An understanding of possible physical, genetic, or biologic factors that
may be contributing to maintenance of the target behavior of interest
should be described.
4. Hypotheses concerning possible maintaining factors drawn from
learning theory should be considered and the clinical observation
designed to determine what factors are currently contributing to
maintenance of the behavior.
5. Behavioral analysis methods may involve several different contexts
for the assessment, including clinical situations, natural settings,
educational settings, as well as others. The assessment should be
relevant to the setting in which the problem occurs.
6. Confidence in the reliability of one’s observation, mostly through
inter-rater agreement, should be assessed and reported in any clinical
application of applied behavioral analysis with a sound method of
determining inter-observer agreement used.
7. The assessment must include a survey of salient potential tangible,
social, or intrinsic reinforcers that are relevant to the individual being
assessed. Reinforcers can be ascertained through interview, historic
report, observation of high frequency behaviors, tangible items,
activities, or social interaction in which an individual engages, if given
the free choice.
8. A behavioral analysis is designed to provide a learning-based

explanation for the etiology, selectivity (hypotheses concerning
how this person developed the target problem), and maintenance
(regardless of original etiological function, why the problem continues
to occur) of the target behavior.
9. After observing the target behavior of interest, a functional analysis
is employed to help to identify the current conditions that are
maintaining the behavior. Information obtained through observational
assessment, often by varying the conditions to demonstrate the
function of the behavior, is then used to guide the intervention by
direct alteration of the conditions that sustain behavior. The basic
formula for a functional assessment is the ABC observation (Bijou,
Peterson, & Ault, 1968). With the understanding that all behavior
occurs in a certain context, and that behavior will increase or decrease
according to the consequences that follow, the three-term ABC
contingency provides an opportunity to: view antecedent contexts
(A), in which a behavioral response (B) is likely to happen, because
of the reinforcing consequences (C) that have followed, or is less
likely to occur because of either lack of reinforcement or because of
aversive consequences. This is particularly important when working
with undesirable behaviors that the patient or someone in the patient’s
life wishes to change. The goal of ABC observation is to record the
immediate antecedents and consequences of a behavior under typical
conditions.
There are many interventions that have been shown to systematically

change the contingencies of a target behavior, such that it is no longer rein-
forced, or that an alternative behavior is learned through reinforcement.
What is important is that a description of the recommended treatment
should logically flow from the learning-based explanation of the behav-
ior obtained through functional analysis. An effective intervention plan
should provide for new learning opportunities for a patient. These may
include ways to increase the likelihood of a patient learning new associa-
tions or functional contingencies, inhibition of a patient’s previous asso-
ciations through extinction learning, reduction or extinction of patient
behaviors that have been previously reinforced, or fostering the patient’s
learning of new skills or adaptive behavior. Although applied behavior
analysis consists of a specific methodology to apply to the direct observa-
tion of overt behavior, the principles of functional analysis (understanding
the learning principles involved in maintenance of the target behavior) are
used throughout the specialty of cognitive and behavior therapy and are
extended to cognition, emotional reactivity, and interpersonal interactions.
Other Measures of Overt Behavior

Separate from the specific applied behavior analysis procedures, there are
other commonly used measures of observable behaviors that constitute an
important part of a comprehensive assessment. These include observation
of interview behavior, interpersonal interactions, and specific tests that have
been designed to observe overt behavior under structured conditions, such as
behavioral avoidance within specific situational contexts, eating or drinking
behavior, activity schedules, or sleep behavior. Determination of what behav-
iors to observe, in what context, using what strategies, and the frequency or
duration of observation is made by the clinician based upon each individual
case and the relevance of such measures to the behavior of interest.
Behaviors can belong to the same response class, although the behaviors
may actually look quite different (Umbreit, Ferro, Liaupsin, & Lane, 2007).
An individual having a “tirade”—the response class—may shout, pound his
fist on a table, shake his head from side to side, and stamp his foot. None of
these behaviors looks the same as the others. However, they are all part of the
same response class, and if the goal was to reduce the number of “tirades”
that the individual experienced in a given week, assuming it was a relatively
frequent behavior, all of the behaviors that make up the entire response class
would need to be addressed. One would be unlikely to consider a successful
intervention to be one that reduced the number of times the individual shook
his head from side to side while the individual still maintained the same level
of shouting (perhaps including a number of obscenities) and continued (at the
same or increased rate) fist pounding and foot stomping. The therapist would
consider all components of the response class in his or her measurement.
Another important aspect regarding what is to be measured is whether
one is measuring discrete behaviors, such as tapping one’s foot, repetitive
checking or hand washing, or a behavior that occurs continuously over a
period of time, such as avoidance of all social contact. When developing a
behavioral observation strategy, it is important to measure behavior that is
relevant and applicable to the real world.
One means of employing direct observation that is applicable to the real
world in self-referred, individual psychotherapy situations is to directly
observe an individual (or group) engaged in the activity (or activities)
that they wish to modify. For example, Craske and Barlow (2006) refer
to examples of therapist-directed in vivo (real-life environment) exposure,
with patients who experience panic. These clinical researchers point out
that patients can be “taught to drive in a relaxed position at the wheel and
to walk across a bridge without holding the rail” (p. 10). Accompanying a
patient to a real-world, in vivo setting can also provide useful, direct obser-
vation for assessment. By observing a patient (e.g., a patient with a fear of
driving because of fear of panic), one can understand much more about the
various components of the anxiety response and the circumstances elicit-
ing the response than by simply gathering details from the patient’s report.
For example, one of the authors worked with a patient who had developed
a fear of driving through tunnels. The patient reported in session that there
was a feeling of “total anxiety” when driving through a tunnel but could
not state anything specific. The therapist accompanied the patient driving
through an actual tunnel and observed that upon approaching the tunnel
the patient gripped the steering wheel of the car more tightly, began to
breathe in a rapid, shallow fashion, and sat forward in an extremely rigid
position—considered to be preparatory safety behaviors elicited by the
stimulus of the tunnel. All the while, the patient reported feeling slightly
dizzy and experiencing perceptual distortions from the lights in the tun-
nel. The direct observation was an essential component of the assessment
to operationalize the “total anxiety” reported in the therapist’s office and
to begin to develop a strategy for modifying the patient’s behavior in the
actual setting. When the patient was able to breathe normally rather than
hyperventilating, to relax the grip on the steering wheel, and to sit back in
a typical driving position, there was a reported reduction in the sensations
of dizziness and perceptual distortion. At that point, repeated exposure
to tunnels, initially accompanied by the therapist and then as homework,
became an important part of the therapy.
Extending Behavioral Assessment to Covert Processes

Over the past few decades, cognitive and behavioral psychologists have
also included the identification of thoughts and emotions as part of a
behavioral assessment. While thoughts cannot be observed by someone
other than the person thinking them, both conscious and non-conscious
thoughts and emotional reactions are learned and maintained (or extin-
guished) through the same processes as overt behaviors. Thus, the use of
patient self-monitoring and patient self-reports have found their place
within the behavioral assessment literature. While covert behaviors can be
measured, they are susceptible to subjective factors and therefore may be
less reliable than direct observation.
As indicated in the previous paragraph, self-report is ubiquitous to cog-

nitive and behavioral assessment. This may take the form of symptom ques-
tionnaires and inventories that assess thoughts, feelings, behaviors, family
or social/cultural/sexual/medical experiences, life history questionnaires,
or questionnaires that help to identify long-held beliefs or schemas. It is
important to underscore the commitment to evidence-based assessment
and intervention that defines a cognitive and behavioral approach when
selecting self-report measures. Rather than being guided by the self-report
measures that one is familiar with regarding a specific clinical problem
or that one may have been exposed to during a training experience, it is
important to consider a range of clinical assessment tools and to use the
one that best matches the information that one wants to obtain. For exam-
ple, with regard to depression and anxiety, the Association for Behavioral
and Cognitive Therapy (ABCT) published a clinical assessment guide
for each of these problem areas, in which many empirically derived mea-
sures were provided (Nezu, Ronan, Meadows, & McClure, 2000; Antony,
Orsillo, & Roemer, 2001). These resources allow cognitive and behavioral
clinicians to become familiar with a wide range of tools from which an
optimal choice can be made concerning assessment.
Standardized tests also represent a form of self-report, when the test taker
is asked to identify items that she views as descriptive of herself, such as the
Millon Clinical Multiaxial Inventory III (MCMI-III; Millon & Bloom, 2008),
or the Minnesota Multiphasic Personality Inventory (MMPI-II; Butcher,
Dahlstrom, Graham, Tellegen, & Kaemmer, 2001). Such measures may pro-
vide normative information concerning Axis I and Axis II syndromes, as
well as the breadth of problem areas that a patient may be experiencing.
It is important to remember that, although the patient may be viewed
as a personal expert who is in the best position to describe how he or she
thinks, feels, or reacts, it is difficult for people to remove all forms of bias
with regard to such questions. Bias may be self-serving and overly positive
or may be self-critical and magnify vulnerabilities. Several standardized
tests have specific scales built into them in order to identify possible biases
that may be present in a patient’s self-report. This can be helpful in iden-
tifying people for whom self-report may be insufficient in conducting an
accurate assessment.
Structured and Semi-structured Interviews

Structured and semi-structured interviews provide the cognitive and
behavioral specialist with additional standardized ways to clarify diagnostic
impressions, identify the presence of a particular syndrome or several

comorbid syndromes, and often help to identify the specific aspects of a
diagnostic syndrome on which to focus. With regard to clarifying diag-
nosis or identifying comorbidity, one example that helps to illustrate this
point may be the Clinician-Administered Post Traumatic Stress Disorder
Scale (CAPS; Blake et al., 1995) The CAPS is a 30-item structured inter-
view that corresponds to diagnostic criteria (DSM-IV; APA 2000) for
PTSD. Widely considered to be the “gold standard” in trauma-related, dis-
order assessment tools, it provides a structured interview format and can
be used to make a current or lifetime diagnosis of PTSD. In addition to
assessing the 17 PTSD symptoms, questions target the impact of symptoms
on social and occupational functioning, improvement in symptoms since
a previous CAPS administration if relevant, overall response validity of the
person being interviewed, overall PTSD severity, and frequency and inten-
sity of five associated symptoms (guilt over acts, survivor guilt, gaps in
awareness, depersonalization, and derealization). For each item, standard-
ized questions and probes are provided. As part of the trauma assessment
(Criterion A), a Life Events Checklist (LEC) is used to identify traumatic
stressors experienced. The CAPS is just one example of many structured
and semi-structured interviews that can be useful in focusing on areas in
need of change.
With regard to identifying specific aspects of a diagnostic syndrome on
which to focus, another example that may be useful is to consider the assess-
ment of an individual who is likely to meet diagnostic criteria for borderline
personality disorder (BPD). In this case, a structured or semi-structured
interview might reveal that while two individuals meet the diagnostic crite-
ria for BPD, one individual engages in significant non-suicidal self-injury,
while another has volatile arguments with his partner, marked by dramatic
emotional dysregulation. The cognitive-behavioral specialist would funnel
down their further assessment by concentrating direct observation, self- or
other report, or standardized tests by concentrating on the clinical target
or area of interest.
Physiologic Assessment
In addition to assessment through direct observation in real life or ana-
logue settings, clinical interview, self-report, clinical ratings, and structured
and semi-structured interviews, additional assessment methodologies that
have been traditionally associated with other specialties serve as important
sources of information for the cognitive-behavioral specialist who seeks to
develop a biopsychosocial case formulation to guide evidence-based treat-

ment. These are briefly discussed below.
Measures of the Autonomic Arousal

Physiologic measures provide an important component of assessment, par-
ticularly when physiologic arousal, sexual arousal, brain injury or impair-
ment, or metabolic processes such as hormone changes and immune
functioning are relevant to patient symptoms or behavior. For example,
when assessing anxiety disorders, physiologic assessment of autonomic
nervous system arousal may provide an important comparison with both
subjective self-report of arousal and observation of behavior through
behavior avoidance tests or ABC analyses of specific anxiety symptoms.
These include measurements of heart rate (HR), blood pressure (BP), elec-
trodermal responses such as galvanic skin response (GSR), and stress hor-
mone levels, such as cortisol, a common measure of stress reactivity.
Physiologic measures are often a component of cognitive and behavioral
assessment, particularly when mood or personality challenges occur in
reaction or simultaneously with a stress-related medical conditions, such
as heart disease, obesity, autoimmune disorders, asthma, irritable bowel
disease, or cancer. In such assessment situations, the role of various behav-
iors, thoughts, and emotional phenomena to neuroendrocrine changes and
physical inflammation may have significant implications for treatment.
Brain Imaging
Assessment through brain imaging is increasingly important to cogni-
tive and behavioral research, in that imaging studies have shown that
cognitive-behavioral therapy interventions seem to affect clinical recovery
in syndromes such as depression and anxiety by modulating the function-
ing of specific sites in the brain. While brain imaging is rarely a tool used by
cognitive and behavioral practitioners in day-to-day settings, the increas-
ing use of assessment though brain imaging in research is revealing brain
changes that are associated with cognitive and behavioral interventions.
This provides important information for specialists to communicate to
their patients as a means of instilling hope that learned habits of informa-
tion processing are not hard-wired or impossible to change. Rather, they
are more similar to well-worn paths that can be reduced in intensity while
new paths are forged, through new learning experiences.
Sleep Studies
Sleep medicine is a rapidly growing field, and with increasing evidence
for the efficacy of nonpharmacological interventions, cognitive and behav-
ioral assessment is earning its place in the assessment and treatment of
sleep disorders. In addition to other cognitive and behavioral measures,
specialists are likely to incorporate physiologic measures such as a “sleep
study” or polysomnography in their overall assessment. This consists of
a test that records a variety of body functions during sleep, such as the
electrical activity of the brain, eye movement, muscle activity, heart rate,
respiratory effort, air flow, and blood oxygen levels. Polysomnography is
used to diagnose the presence of comorbid conditions, such as sleep apnea,
that can contribute to insomnia and require attention in the development
of a treatment.
Physiologic Assessment of Sexual Functioning

Physiologic assessment employed by cognitive and behavioral psycholo-
gists has included the use of measures of sexual functioning such as phallo-
metric assessment or penile plethysmography. Measures of sexual arousal
may be useful in the assessment of sexual dysfunction, but have been more
typically used in the assessment of sexually deviant responses. This infor-
mation provides specific areas of learning with regard to extinction of
deviant associations such as preferential sexual arousal to children, as well
as new learning, such as sexual arousal toward adults.
Use of Standardized Tests in Behavioral Assessment

Psychological tests with a strong evidence base, such as intelligence and
achievement tests, specialized tests for individuals with sensory deficits,
personality tests (such as the MMPI and the MCMI discussed previously),
and neuropsychological tests, are often integrated with cognitive-behavioral
assessment as a way of determining the presence of individual strengths
and vulnerabilities that can impact a learning situation. For example, if
considering a relaxation or stress management intervention to increase
distress tolerance for an individual with specific learning disabilities, test-
ing may reveal that learning how to relax one’s body with abstract verbal
instructions or visualization may be very difficult. In such a situation, pro-
viding the individual with technology such as biofeedback may provide a
more concrete, direct, and practical way to teach these new skills.
Culturally Relevant Behavioral Assessment

Because a functional analysis is focused on what an individual does in par-
ticular contexts and the discovery of the environmental and behavioral
factors that maintain or extinguish behaviors, it is useful across many set-
tings. However, it is an error to think that clinicians do not need to consider
culture when conducting this or other types of behavioral and/or cognitive
assessment. Advising clinicians regarding the practice of culturally sensitive
cognitive-behavioral assessment, Okazaki and Tanaka-Matsumi (2006) have
observed that studies show cultural variations in multiple areas of self-report
with regard to (a) normative levels of self-reported happiness and distress,
(b) the importance of perceived norms regarding happiness and distress,
(c) retrospective judgments of one’s past affective states, and (d) the desir-
ability of consistency between one’s emotions and identity across situations.
The authors further caution that because of these variations, there is a need
for care when using self-report scores in assessment. Citing Cohen and Gunz
(2002), Okazaki and Tanaka-Matsumi provide examples of cultural differ-
ences that would certainly affect direct answers to questions, but would also
impact the way a clinician might interpret a simple behavioral observation
made during an assessment or therapy session. Specifically, Cohen and Gunz
found that Asian Canadians were more likely than European Canadians to
have third-person memories of personal events. They describe the difficulties
that an Asian-Canadian patient would face if, after telling a story about the
little child who got accidentally locked in a barn, the clinician assumed that
the patient was either dissociating from emotion when telling a traumatic
story, was demonstrating an odd psychotic presentation, or was describing
an event that may be reportable to child protective services!
An engaging book, entitled Addressing Cultural Complexities in
Practice: A Framework for Clinicians and Counselors, as well as a follow-up
book focused on cultural competence for cognitive and behavioral spe-
cialists, authored by Dr. Pamela Hays (2001), provides a useful framework
for assessment that integrates multicultural factors using the acronym
ADDRESSING. This provides an assessment framework that cues cog-
nitive and behavioral specialists to better recognize cultural influence
throughout the assessment process. The areas indicated by the acronym
include age and generational influences, developmental and acquired dis-
abilities, religion, ethnic and racial identity, socioeconomic status, sexual
orientation, indigenous heritage, national origin, and gender. The acronym
can be used to maintain a strong multicultural focus throughout all phases
of the assessment process.
As indicated at the beginning of this chapter, cognitive and behavioral

assessment assumes a funnel approach to consider many different fac-
tors that are relevant to past learning, current maintenance of challeng-
ing problems, assessment of strengths, and development of new learning
experiences to improve patients’ lives. An individualized case formulation
approach allows clinicians to draw upon rich resources of evidence-based
theories and to integrate them within a systems-oriented approach. The
next chapter will provide information concerning the various case formu-
lation models associated with the specialty.
FIVE
Models of Cognitive-Behavioral
Case Formulation
As the overarching field of cognitive and behavioral therapies continues

to grow, the number of specific evidence-based treatments that address
the same or similar clinical problems also increases. Cognitive and behav-
ioral clinicians are often faced with the dilemma of which treatment or set
of techniques they should implement in any given case. Because compe-
tent cognitive and behavioral practice often involves treating people with
comorbidities from an individualized approach and in a multicultural con-
text, it is important for therapists to have a model to guide their decision
making during the assessment and treatment process. In combination with
what Barlow and colleagues (Barlow, Allen, & Choate, 2004) refer to as a
“unified treatment approach,” which involves distilling the common ele-
ments across effective treatments, a case formulation model may provide
the next important wave for cognitive and behavior therapy—specifically,
one in which assessment culminates in an integrated view of the most
salient targets for change uniquely applied to any one individual. This is
referred to as an idiographic approach and focuses on each individual’s
unique clinical assessment and comorbid areas in need of change to guide
a “best match” of techniques from various evidence-based interventions to
achieve the ultimate outcomes for which therapy was undertaken (Rosen
and Proctor, 1981; Nezu, Nezu, & Cos, 2007).
Case formulation provides clinicians with a competent synthesis and
integration of the many current assessment methods and measures avail-
able to them in their practice. Competent assessment in general has been
described as a dynamic paradigm (Eells, 2007) that involves multiple
Models of Cognitive-Behavioral Case Formulation 81
methods, is culturally competent, employs consultation, reveals an aware-

ness of cognitive biases and common judgmental errors, employs a
decision-making method to select tools, and employs a case formulation
process to guide treatment (Fouad, Grus, Hatcher, Kaslow, Hutchings,
Smith, Madson, Collins, & Crossman, 2009). Eels has defined case for-
mulation as a “hypothesis” about the causes, precipitants, and main-
taining influences of a person’s psychological problems (cognition and
emotion), interpersonal problems, and behavioral problems. Moreover,
a case formulation allows the cognitive and behavioral specialist to orga-
nize complex and contradictory information about an individual, identify
therapy-interfering events, accept what each patient may bring to treat-
ment, develop a blueprint for guiding treatment, and identify markers for
change. Last, it is a structure by which a therapist can better understand and
empathize with a patient and share a collaborative approach to treatment.
Case Formulation Research

Until recently, very little was known about inter-rater reliability or predic-
tive validity concerning therapy process and outcome with regard to the
case formulation process, and there are equivocal opinions about its impact
in the literature (Tarrier & Calam, 2002). With regard to inter-rater reli-
ability, one problem rests in extant biases of a clinician’s information pro-
cessing. More recent research has shown that reliability and validity of case
formulation is increased when there is a focus on relationship interactions
expressed in psychotherapy, when patient report is augmented with clinical
judgment, when levels of inference remain close to observable statements
or behaviors, when the formulation is broken down into components that
can be measured, and when a diversity of viewpoints is taken into account
(Eells, Lombart, Kendjelic, Turner, & Lucas, 2005). Flitcroft, James, and
Freeston (2007) offer an explanation about why reliability among different
clinicians’ clinical formulations may be low. Specifically, they attribute this
phenomenon to the existence of several different explanatory viewpoints
held by clinicians conducting an assessment. These include a focus on
situation-specificity, functionality of problem behaviors or clinical targets,
or trait features. The results of their research may partially explain why
reliability in case formulation has been equivocal.
In Tarrier’s (2006) overview of the historical origins of the case formu-
lation approach and its role on clinical practice and research, the author
argued that treatment based on individual case formulations should not be
precluded from clinical trials, as this represents therapy in the real world.
In this review of the literature with regard to both reliability and efficacy of
case formulation, the author points out that in the past, studies have been
underpowered and potentially suffer from a Type II error. With regard to
suggestions for competent case formulation in evidence-based practice
settings, Tarrier and Calam (2002) underscore that assessment should be
soundly based upon empirical evidence and hypothesis testing and not on
mere speculation. Last, they provide several suggestions for cognitive and
behavioral clinicians. They underscore the importance of the conceptual-
ization of a dysfunctional systems approach in the maintenance of clinical
problems. They also advise that the historical background of a clinical prob-
lem should be described in terms of individualized vulnerabilities and an
epidemiological evidence base. Finally, these authors describe and discuss
the importance of the social behavioral context and recommend that it be
emphasized in a case formulation (Tarrier & Calam, 2002; Tarrier, 2006).
In summary, the more recent research regarding case formulation has
suggested modifications to its process that can improve accuracy and util-
ity (Flitcroft, James, & Freeston, 2007; Mumma & Mooney, 2007; Tarrier
& Calam, 2002), has investigated when it is most likely to improve patient
care (and when it is not helpful) to consider a change from a manual-
ized treatment to a case formulation model (Schulte & Eifert, 2002), and
has demonstrated how training in case formulation can improve skills
(Kendjelic & Eels, 2007).
With a current zeitgeist in the specialty that recognizes the challenge
of assessment and treatment of individuals with complex problems and
histories, there are several models that provide a method to developing a
case formulation. They include models by Nezu and Nezu (Nezu, Nezu, &
Cos, 2007), Persons (Persons, 1989; Persons & Tompkins, 2006), Kuyken,
Padesky, and Dudley (2009), Linehan and her colleagues (Koerner, 2007),
Haynes (Haynes & O’Brien, 2000), and Tarrier (2006).
Overview of Cognitive-Behavioral Case Formulation Models

The model by Nezu and Nezu focuses on the clinician’s information pro-
cessing and advocates a problem-solving approach to clinical decision
making, including adoption of a multicausal and systemic worldview.
The Nezu and Nezu model of case formulation does not view cognitive,
emotional, biologic, historic, or current functional factors as primary, but
underscores the importance of integrating and understanding all of these
factors and their functional relations as contributory to understanding
a person’s individual “story.” Person’s model (1989), which was initially
Models of Cognitive-Behavioral Case Formulation 83
aligned with a traditional cognitive therapy approach, has evolved to

focus more on conditioning theories and emotion (Persons & Thompkins,
2006). Koerner (2007) has focused a case formulation model on the spe-
cific approach to assessment for clinicians theoretically grounded in
dialectical behavior therapy (DBT; Linehan, 1993) for patients with bor-
derline personality disorder (BPD). Haynes and Williams (2003) follow a
functional analytic systems framework and quantify the potential strength
of functional relationships between hypothesized etiological factors and
psychological problems. Kuyken, Padesky, and Dudley (2009) integrate
collaborative empiricism and identification of strengths with functional
analysis, and Tarrier and Calam (2002) propose a probabilistic model in
which idiographic characteristics of a patient’s life and experience were
identified through various vulnerability and risk factors.
The Common Ground of Cognitive-Behavioral

Case Formulation Models
Rather than attempt to distill the various nuance of differences among
all of these case formulation models, it may be most useful here to limit
the focus on this topic to discerning the similarities among the models.
Tracy Eells (2006) has accomplished this succinctly with the following
points. First, all cognitive and behavioral case formulation models assume
a multiple-causal hypotheses perspective. This is an important point,
because regardless of the efficacy studies to support any one specific treat-
ment for a particular problem, no one treatment is effective for every indi-
vidual with the same diagnosis. This is because no one etiological factor
explains its presence in every individual. Additional, individual factors
such as temperament, social and cultural development, strengths and/or
comorbidities make every person unique. Second, all of the case formu-
lation approaches listed above place an emphasis on functional analysis
as a way to understand what may be triggering or maintaining a prob-
lem. Third, all of the models above emphasize the need for positive treat-
ment goals, such as the development of skills, as part of a constructional
approach to intervention. Finally, all of the models underscore the ubiquity
of cognitive errors and human decision-making bias, and therefore include
strategies to reduce biases in clinical judgment. Competent cognitive and
behavioral specialists adopt a systematic approach to conducting assess-
ment and integrating the results of assessment into a meaningful explana-
tion of the likely etiologic, triggering, and maintaining factors regarding
the symptoms for which people seek help. When the explanation involves
areas in which positive and practical coping skills, self-assessment, and

self-reinforcement can be integrated with other cognitive and emotional
experiential learning, specific areas in which new skills can be taught are
identified. Therefore, cognitive-behavioral intervention is not a series of
random techniques used whenever a therapist thinks they might be help-
ful. Rather, the approach assumes a strategic functional focus on the fac-
tors that appear to be maintaining clinical symptoms of distress. As such,
it can reduce the effectiveness of cognitive and behavioral interventions
when clinicians operating from other theoretic viewpoints attempt to “use
a little cognitive behavior therapy” with other interventions without a full
understanding of how one treatment might impact the other. Integrating
ideas and techniques from various theoretical orientations is acceptable
when done in the context of a careful case conceptualization, and the
cognitive-behavioral specialist can integrate methods, techniques, or ideas
from other specialties that have empirical support, such as clinical neuro-
psychology, or couple and family approaches.
PART III
Functional Competencies
in Intervention
SIX
Psychotherapeutic Interventions
Introduction
The challenge in describing cognitive and behavioral interventions and
clinical strategies that are required for competent practice is to provide
an overview of intervention competencies without the appearance that the
specialty consists of a menu of techniques applied to specific problems.
While it is certainly the case that a variety of techniques have been studied
in their application to certain types of clinical problems, the selection of
strategies and techniques must be based on an individualized assessment,
often employing a careful case conceptualization, as discussed in the previ-
ous chapter, and including elements from established and researched proto-
cols for particular disorders. For example, consider the presence of anxiety
symptoms as presenting challenges for an individual who is also experi-
encing depression and problems with his romantic partner. Following a
case formulation of the ways in which various factors may be operating
with regard to the individual’s difficulties in functioning, the interven-
tion will inevitably include some form of an exposure-based strategy with
regard to the anxiety, regardless of the other treatment strategies that are
integrated in the overall treatment. This is because of the strong research
evidence base to support exposure-based interventions. Simultaneously,
strategies aimed at the thoughts and behaviors associated with depression
will likely be considered, as well as those interventions focused on partner
relationships that have been shown either to have or hold promise of sci-
entific evidence. Evidence-based interventions can be defined as effective
in reducing symptoms of the disorder that they are designed to treat, are
goal oriented, often involve teaching new skills, are usually time limited,
88 Functional Competencies in Intervention
and often have demonstrated lasting or generalized effects, with reduced

likelihood of relapse.
The hallmark of the cognitive-behavioral specialty is to use the scien-
tific evidence as a guide to developing effective interventions. However,
the distinction between behavioral and cognitive interventions is often
blurred. To some extent, the emphasis on behavioral or cognitive expla-
nations for treatment depends on the theoretical leanings of the thera-
pist/researcher and his or her interpretation of the literature. Consider
an example of a therapist working collaboratively with a patient in cog-
nitive therapy to test the patient’s belief that “if I go out of my way to
introduce myself to people, they will be unfriendly.” The patient may
carry out an experiment to gather evidence for or against the belief
by intentionally introducing himself to people over a week. When the
patient returns to therapy and reports that, in fact, many people were
very reciprocal and friendly, the experiment would be said to have
been successful in helping the patient to change the belief. Should an
improvement in mood follow, the cognitive therapist could determine
that the change in belief improved the mood. However, it is also possible
that the patient’s mood improvement was the result of having been posi-
tively reinforced by friendly people and having experienced a feeling of
enjoyment and relief. Theoretically, this could occur even though belief
change was not the mechanism of action. In other words, the belief may
remain the same, “people are generally unfriendly,” yet the patient had a
good interaction, anxiety was reduced, and the approach behavior was
reinforced through both positive and negative reinforcement. From a
behavioral perspective, behavior change can be seen to have occurred
and anxiety ameliorated through exposure and reinforcement contin-
gencies, and the patient may still hold the belief that people are not
likely to reciprocate if he goes out of his way to engage them socially,
despite this one situation.
In another situation, a behavioral intervention such as exposure with
response prevention may have been utilized to help a patient face a
fear of rodents. In this situation, the fearful patient goes repeatedly to
a pet store and looks at a variety of rodents, eventually taking the step
to hold a white rat, and through repetitions of this procedure, the fear
decreases significantly. From a conditioning perspective, we would say
that the patient habituated to the stimulus as a result of the continual
exposure to the feared stimulus (the rodents) without the associated
fear response. However, it is also possible that the exposure allowed
the patient to develop a new belief regarding rodents. Had the patient
Psychotherapeutic Interventions 89
originally believed that rodents were dangerous and would bite, and she
then saw that some of them were cute, and that the white rat actually
snuggled into her hand, the patient may now have a newly learned belief
that “tamed rodents are cute and cuddly.” Was it behavioral habituation
or belief change that reduced the fear? The mechanism of change in
cognitive-behavioral interventions is complex and involves the interplay
of temperament, evolutionary preparedness, emotional reactivity, and
various types of conditioning. Thus, it is difficult to talk about cognitive
interventions and behavioral interventions as separate from one another.
For the most part, clinicians will use a combination of behavioral and
cognitive techniques to achieve desired outcomes, and many behavioral
techniques are focused on emotional learning. Depending on the train-
ing and background of the therapist, he or she may focus more on one
type of intervention strategy or another, or may explain the mechanism
of change from a conditioning, information-processing, or emotional
framework. The assumption is that behaviors, thoughts, and feelings all
are important factors and collectively account for the amelioration of dif-
ficulties through learning.
The remainder of this chapter will provide a brief overview of the variety
of interventions developed within the specialty of cognitive and behavioral
psychology and, in some cases, will provide brief examples of situations
in which they would be useful. Recently, Moses and Barlow (2006) pro-
posed a unified treatment protocol for treating emotional disorders. They
point out that key components in the treatment of most emotional disor-
ders include cognitive reappraisal, changing action tendencies associated
with the emotional disorder, preventing emotional avoidance, and facili-
tating emotional exposure. While more research on the unified protocol
is necessary, the components proposed by Moses and Barlow provide a
nice overall picture of the behavioral and cognitive techniques consistently
found in many treatments. It is also important for the competent cogni-
tive and behavioral specialist to remain mindful that while some interven-
tions represent comprehensive systems of psychotherapy in which all of
these key components are included, other interventions comprise specific
techniques or strategies that have been shown to target one of these key
component areas.
It is important to remember that the treatments we describe in the
chapter represent neither an exhaustive list nor even the “best” interven-
tions. Rather, they represent a glimpse as to the variety and core princi-
ples of change that currently define the specialty. Some of the treatments
described have historical significance, but are no longer recommended
because the data have supported alternative interventions, which have

greater efficacy under most circumstances. Given the limited space
available in this book, the reader is advised to rely on other sources for
a more exhaustive description of each treatment, as well as a more com-
plete list of treatments. For example, the web-based project referred
to as the Common Language in Psychotherapy (http://www.common
languagepsychotherapy.org/), the task force led by Dr. Isaac Marks, main-
tains a list of psychotherapy procedures that constitutes an ecumenical
lexicon of psychotherapy procedures. Therapists from around the world
describe operationally what they do with clients, including a discussion of
the overlaps and differences across procedures used in varying approaches.
The purpose of the project is to have a description of what therapists do (not
why they do it) in plain language, and includes a short Case Illustration.
The growing list already includes over one hundred procedures from many
therapy approaches, with entries coming thus far from Australia, Canada,
France, Germany, Israel, Italy, Japan, Netherlands, Sweden, Switzerland,
the United Kingdom, and the United States. Other handbooks and vol-
umes are readily available for cognitive and behavioral psychologists to
become familiar with the wide range of psychotherapeutic technology
that has been developed. Classic texts on behavior therapy include those
by Goldfried and Davison (1976), Walker, Hedberg, Clement, and Wright
(1981), and O’Donohue, Fisher, and Hayes (2003). In a comprehen-
sive project published by Oxford University Press, the upcoming Oxford
Library of Psychology will include a handbook of cognitive and behavioral
therapies (Arthur M. Nezu and Christine M. Nezu, Eds., in press), and will
contain in-depth information about many of the strategies discussed in
this chapter, as well as many others. Finally, because of the important con-
cept of actual reinforcement for performance of behavior, we suggest that
those interested in more in-depth training in any one area should attend
continuing education workshops or trainings in order to glean “hands-on”
competency in the intervention.
In the remainder of the chapter we provide examples of interventions
that have their origins in learning and conditioning theories, those that
have as a main feature the facilitation of emotional exposure, and those
involving change of action tendencies. We will discuss a range of interven-
tions that represent the application of learning theories to reduce suffering
and increase skills to improve the quality of life. Following the exposition
of techniques that have their hallmark in basic learning theory, we will
present interventions that have their origins in information-processing
theory and will reflect how the specialty expanded in the 1970s to add a
strong social-cognitive focus. Last, we will discuss the influence in the last
two decades to include the importance of affect regulation and targeted
avoidance of negative thoughts and emotions, in what has been commonly
referred to as the “third wave” of cognitive-behavioral intervention. In this
section we will describe how contemporary cognitive-behavioral interven-
tions incorporate mindful acceptance and awareness of negative emotions
and thoughts as important clinical targets, in addition to conditioning and
information-processing theory.
These new developments, which are underscored by both neuroscien-
tific studies of implicit learning and emotional memory, as well as tradi-
tional spiritual philosophies of Eastern traditions, include techniques that
provide training in which patients learn to focus on acceptance of negative
emotions and thoughts as part of human reality, using mindfulness as a
way to ameliorate suffering, boost the effects of learning-based interven-
tions, and create a sense of inner peace.
Not every individual technique has been tested empirically across a
wide range of populations or individuals with comorbid clinical symp-
toms. Some cognitive and behavioral therapies include components of
treatment procedures that have individually been shown to be effective, or
may be part of a manualized treatment package that has been extensively
researched. We will discuss treatment manuals and a few examples of such
protocols at the end of the chapter.
As with all therapies, behavioral and cognitive therapies are most effec-
tive in the context of empathy and a strong relationship with patients, their
families, or even with direct-care staff who work with severely disabled
patients. Lazarus (1997) noted that this has always been the case in behav-
ior therapy in that the reinforcing nature of the relationship is considered
an essential motivation for treatment.
Interventions Originating from Learning and Conditioning Theories

Fear, worries, anxiety, and the unpleasant states associated with these
emotional experiences seem to represent the “common cold” of behav-
ioral syndromes. As we have illustrated in previous chapters, they are
learned and they are common. Without treatment they are often chronic
in nature, and have been the focus of many cognitive and behavioral
interventions. Several of these intervention components or systems are
highlighted below.
SY ST E M AT I C D E S E N S I T IZ ATION
Historically, behavioral techniques were first used in the treatment of

phobias. Learning by “reciprocal inhibition” (Wolpe, 1958) was one of the
first reported behavior therapy techniques. In this approach, patients were
taught relaxation procedures and, with the help of the therapist, developed
a fear hierarchy of situations that would cause the least amount of subjec-
tive fear to situations that would cause the most. The therapist would then
ask the patient to imagine a fear-producing situation and to continue imag-
ining the situation for five seconds after their anxiety began to rise, and
then they would practice relaxation. They would continue this procedure
until the patient could imagine the situation with no reported increase in
anxiety and then move up to a situation that was higher on the hierarchy,
that is, one that would produce a stronger fear response (Wolpe, 1990).
By progressively moving up a hierarchy of imagined situations, patients
were exposed in vitro to that which they had previously avoided. Wolpe’s
systematic desensitization was an early treatment requiring patients to face
feared stimuli in order to reduce the fear. Systematic desensitization is no
longer the treatment of choice for specific phobias. A review by Choy, Fyer,
and Lipsitz (2007) found only modest results of systematic desensitization
in the acute treatment of phobias, whereas in vivo exposure—having the
patient directly face the feared object—had better results, although this
approach frequently resulted in higher treatment dropout rates. These
authors also found that cognitive therapy and exposure therapies using
virtual reality were helpful in some specific phobias such as claustrophobia
and fear of flying. Öst (1989) has demonstrated that exposure therapy in
one continuous 3-hour session can be effective for treatment of phobias,
and a one-session treatment has been used to treat a variety of phobias
(e.g. Öst, Brandberg, & Alm, 1997;) Haukebø, Skaret, Öst, Raadal, Beg,
Sunberg, & Kvale, 2008).
The role of avoidance in psychological disorders has been a focus of
attention in behavior therapy for decades. Bandura (1969) highlighted the
self-reinforcing nature of avoidance. Escaping or avoiding an aversive situ-
ation is more likely to occur in the future because the relief that occurs
negatively reinforces it. As discussed in Chapter 2, while many emotional
responses to a variety of situations are classically conditioned, the response
of the individual, including escape and avoidance responses, are often
maintained by the consequences that follow through operant conditioning.
Thus, many of the behavioral procedures require that the patient directly
face situations that may be feared. Alternatively, procedures may be used
to reduce behaviors that result in escape from negative affect. Additionally,

human beings are voluntarily prepared to learn fear quickly as a mecha-
nism of survival, and the fear response is inextricably linked to the stress
response. The stress response creates a sudden and dramatic shift that cre-
ates changes in our physiologic, immunologic, endocrine, cardiovascular,
brain, and behavioral functioning. Cognitive and behavioral specialists
require a basic knowledge of the stress response, because in order to help
patients confront fears, change beliefs or behavior, and learn new adaptive
skills to change physiologic arousal, it is important to have effective tools
for patients to use to improve their ability to manage this response when
learning to approach (vs. avoid) feared situtaions. What follows are a few
examples.
PR OG R E S S I V E R E LA XATION TRA IN IN G (P RT)
We have already mentioned relaxation procedures, which can be taught in

numerous contexts. Patients can practice progressive relaxation training
(Jacobson, 1928) wherein they alternate between tensing specific muscles
and then letting go of the tension. Bernstein, Borkovec, and Hazlett-Stevens
(2000) recommend starting with 16 muscle groups, beginning with the
dominant hand and arm, tensing the lower arm and hand first, then the
bicep, moving to the non-dominant hand and arm and doing the same.
Then the face is broken down into three sections, forehead, central face
(where the patient squints eyes and wrinkles the nose), and lower face. The
next area is the neck, then the chest, shoulder and upper back. Training
then moves to the abdomen and to the legs and feet. The therapist uses
his or her voice intentionally as part of the treatment, increasing the vol-
ume, speed, and tension of the voice when giving the signal to tense the
muscles and then changing the voice to a slower, softer tone when giving
the cue to relax. The patient should also let go of the tension in the mus-
cles immediately upon the cue, not gradually. Homework is an essential
component of PRT, and patients are asked to practice in an appropriate
setting twice per day. The number of muscle groups used in training is
reduced as the patient gains competence, and variations on the procedures
include differential relaxation training, whereby the individual relaxes
muscles that are not engaged during particular activities. For example,
when using a computer at a desk, the muscles in the legs and feet are not
required in the task, and can be relaxed with practice in differential relax-
ation. Examples of problems for which progressive relaxation training has
empirical support as part of the treatment include specific phobia, social
phobia, generalized anxiety disorder, headache, depression, chronic pain,

and insomnia. Bernstein et al. (2000) provide a listing of the problems, the
type of relaxation used, the therapy for which it is a treatment component,
and references to the empirical literature.
Relaxation training typically also includes breathing retraining. When
individuals are experiencing negative emotional arousal, improper breath-
ing can create physiological sensations such as lightheadedness that are
disturbing and evoke greater distress. It is common for patients with panic
disorder to hyperventilate when they become fearful, creating an imbal-
ance of carbon dioxide (CO2) that results in many of the internal phys-
ical sensations that the individual interprets as a sign of a heart attack,
going crazy, or dying. Breathing retraining consists of teaching a patient
to breathe from the diaphragm rather than from the chest and to slow the
pace of the breathing. Anyone trained either to play a wind instrument or
trained to sing properly will be familiar with the difference between dia-
phragmatic breathing and chest breathing. For children and adolescents,
diaphragmatic breathing is often referred to as “belly breathing.” It can be
hard for some patients to differentiate between breathing from the chest
and breathing from the diaphragm. Teaching patients to watch whether
their chest or their abdomen is extended when they are breathing can assist
them in developing the skill of diaphragmatic breathing. Patients also may
simply put one hand on the chest and one hand on the belly and feel which
is moving. A simple measured breathing procedure is to breathe on a four
by four count. Breathing from the diaphragm, one inhales through the nos-
trils slowly and then exhales slowly through the mouth. Foa, Hembree and
Rothbaum (2007, p. 42) recommend that the patient use the word “calm”
or “relax” as they exhale, and then hold the breath for a slow count of 4
before inhaling again. The sequence is then repeated 10–15 times.
AU T OG E N I C T R A I N I N G
Autogenic training, first introduced in the early twentieth century by

Schultz as an aspect of self-hypnosis according to Yurdakul, Holttum, and
Bowden (2009), is another form of relaxation that does not consist of tens-
ing or relaxing muscles. It is now considered a behavioral procedure with
demonstrated efficacy in the treatment of anxiety (Yurdakul, Holttum, &
Bowden, 2009). In autogenic training, the individual imagines his or her
body feeling heavy and warm. Rather than imagining one’s entire body
feeling heavy or warm, one starts with a particular area of the body until
one experiences success feeling relaxed in that particular area. The proto-
col used at the Royal London Homeopathic Hospital consists of eight or
nine weekly sessions with standard exercises in which patients are taught
six phrases, one per session, such as “my right arm is heavy” or “my fore-
head is cool” (Yardakul, et. al, 2009, p. 404). The procedure also includes
repeating a phrase such as “I am afraid” repeatedly until it no longer
has meaning, an exercise that the authors point out is similar to those
used in an acceptance-based intervention developed decades later with
interventions such as acceptance and commitment therapy (ACT; Hayes,
Strosahl & Wilson, 1999) and Metacognitive Therapy (Wells, 2009), which
will be discussed later in the chapter. In some cases, biofeedback can be
used in order to provide a visual aid to patients about their level of relax-
ation. Autogenic training, as a form of self-hypnosis, or self-instructed
relaxation, is considered by many to be a forerunner of biofeedback.
B I OFE E D B A C K
Biofeedback is a process that helps an individual to learn how to modify his

or her physiologic activity for purposes of managing stress and improving
health and overall performance. The methods involve the use of physiologic
devices to measure internal activities such as brain waves, heart functions
(e.g., blood pressure, heart rate variability), breathing, muscle activity, tem-
perature, and skin conduction to provide “feedback.” Presentation of this
information is often integrated with learning ways to change or focus on
new ways of thinking, or managing feelings that support desired physiologic
changes. Over time, the changes can be obtained without the use of instru-
ments because the body has essentially learned how to achieve physiologic
changes without the equipment (Association for Applied Psychophysiology
and Biofeedback, AAPB, retrieved from website, 2011).
VI SU ALI ZAT I O N
Many cognitive and behavioral specialists have used visualization as

a technique to help people to relax and to reduce their level of arousal.
Visualization is the conscious and intentional creation of impressions that
use all of your senses (seeing, hearing, smelling, touching, emotional expe-
rience) for the purpose of creating a positive image of calmness and tran-
quillity (Nezu & Nezu, 2003). Frequently referred to as traveling to one’s
“safe place” in many visualization instructions, an individual is guided
through the use of instructions by the therapist, an audio product, or
covert self-instruction to create a positive and peaceful image on which
to focus when experiencing negative emotional reactions, or a sense of
hopelessness.
Relaxation techniques are frequently part of many integrated cogni-

tive and behavioral interventions. They are often included in cognitive
and behavioral interventions for many health-related problems, such as
chronic pain, inflammatory and autoimmune disorders, cardiovascular
disorders, as well as insomnia. This is because the stress response and
conditioned reactivity to stressors is implicated in these types of medical
problems (Stowell, McGuire, Robles, Glaser, & Kielcolt-Glaser, 2003). For
example, patients who experience insomnia may find relief by practicing
these techniques at bedtime. Empirical evidence supports the use of PRT
for insomnia, and some clinical trials have also supported the use of bio-
feedback (Taylor & Roane, 2010).
Relaxation procedures are also part of many treatments focused on anx-
iety disorders and interventions that target many fear-inducing situations
and stimuli. For example, patients who are afraid of flying may practice
relaxation skills during take-off and landing. Socially anxious individuals
often find it helpful to relax prior to meeting someone new or giving a
public address. Lastly, relaxation procedures, integrated with other strat-
egies such as cognitive restructuring and problem-solving training, have
been helpful in treatment focused on anger management (Deffenbacher,
Oetting, & DiGiuseppe, 2002).
The key to success with relaxation procedures is structured practice that
produces habits that can be implemented in situations that have previously
been associated with distress.
Decisions regarding the use of relaxation techniques require a consideration
of balance with the benefits of techniques focused on exposure. For example,
it is possible that some patients may use relaxation techniques as a method for
avoiding fear, when exposure to the fear is also a necessary part of treatment.
In other words, patients may be motivated to learn a relaxation technique in a
similar way to having a tranquilizer on hand “just in case.” Avoidance of nega-
tive affect or aversive experiences occurs in many psychological disorders.
For this reason, many behavioral treatments focus on reduction of avoidance
behavior. While there is often a rationale for beginning slowly and teaching
patients to manage strong emotion through relaxation, ultimately patients
require new learning through confrontation of fearful stimuli.
E X POS U R E T R E AT M E N T
Exposure is perhaps the most frequent principle used to treat psychologi-

cal disorders when avoidance is a prominent feature. Exposure techniques
in some form are useful across many diagnostic areas in the treatment
of post-traumatic stress disorder (PTSD), obsessive-compulsive disorder

(OCD), and anxiety disorders in general. Avoidance behaviors maintain
conditioned connections between environmental cues and anxious feel-
ings, flashbacks, and other symptoms. Exposure therapy allows new learn-
ing to take place. Two exposure procedures, prolonged exposure (PE)
for treatment of PTSD or exposure with response prevention (ERP) for
treatment of OCD, have demonstrated efficacy in the treatment outcome
literature.
In all instances of exposure, the patient is in control of the situation by
willingly encountering the feared image, memory, or actual situation. It
is intentional. This is an important factor in exposure; otherwise, there
would be examples of people overcoming fears in situations of inescap-
able or unintended exposure, when such situations have been shown
not to reduce fear in the long term. Few claustrophobic individuals, for
example, overcome their fear of small places following being stuck in an
elevator for a prolonged period of time. In fact, such situations have been
shown to make the problem worse. Cognitive and behavioral specialists
work with patients to set up a hierarchy of feared situations, beginning
with situations that evoke very little fear and moving incrementally to the
most feared situations. Exposure can be through imagery in vitro (mean-
ing that it is simulated in session) or in vivo (meaning that it occurs in the
actual situation). Some in vivo exposure can take place in the clinical set-
ting, for example, when a patient who has a phobia of social conversation is
engaged in a conversational role play during a session. At other times, the
exposure will take place outside the clinical setting when the therapist is
not present. Studies in neuroscience have provided specific mechansisms
by which extinction learning occurs (LeDoux, 1996).
PR OL O N GE D E XP O S U RE (P E)
PE has strong empirical support in the treatment of PTSD (Powers,

Halpern, Ferenschak, Gilihan, & Foa, 2010). A particular protocol of PE
in the treatment of PTSD following assault and rape (Foa, Rothbaum,
Riggs, & Murdock, 1991) consists of the following procedures. Sessions
were 90 minutes long and patients were asked to relive the assault by
imagining it as vividly as possible and recounting it to the therapist for 60
minutes of the session. The narratives were tape-recorded and the patient
was instructed to listen to the tape at least once daily between sessions.
Additional in vivo homework was agreed upon between patient and thera-
pist, during which the patient would face a feared or avoided situation that
was judged by both therapist and patient to be safe. PE allows for emotional
processing of the traumatic memory to ameliorate the PTSD symptoms
(Foa, Hembree, & Rothbaum, 2007). General procedures of PE include
psycho-education, breathing retraining, in vivo exposure and prolonged
exposure to imagined scenes of the trauma (Foa et al., 2007).
In some cases, the therapist will collaborate with the patient to develop
a hierarchy of in vivo situations that the patient avoids and will assign
exposure to a safe situation that the patient rates as moderately distressing.
Once the patient is in a moderately anxiety-producing situation and has
stayed until fear is reduced somewhat, the next situation on the hierarchy
should be less frightening. In this fashion, the patient works up the hier-
archy, but by the time there have been repeated successful exposures to
lower level fear situations, the “most feared” situation will actually be less
frightening. Knowing this often helps patients to move forward with expo-
sure. When they first enter therapy, thinking that they will have to actually
face their worst fear can be overwhelming, and some patients will choose
not to engage in exposure at this point. When they are assured that each
situation will become less frightening or anxiety provoking as they repeat-
edly face the situations lower on the hierarchy and then move up, they will
more readily engage in treatment. In vivo exposure is used as homework,
following imaginal exposure to the traumatic event in session, and review
of the audiotaped account of the assault event. Similar procedures have
been used with Vietnam veterans with PTSD (for example, Keane et al.,
1989) with good results.
E X POS U R E WI T H R E S P ON S E P REV EN TION (ERP )
ERP is similar to PE and is often used in the treatment of obsessive com-

pulsive disorder (OCD) and other anxiety disorders. Foa, Liebowitz,
Kozak, Davis, Campeas, Franklin and colleagues (2005) found that ERP
was more effective than control, and was equally effective when used alone
or in combination with clomipramine, and that the combination of clo-
mipramine did not improve the treatment of OCD. Both imaginal and in
vivo exposure is part of the treatment, and graduated exposure from less
feared to most feared situations is treated as exposure occurs; ritual behav-
iors are blocked so that patients do not utilize compulsive rituals as safety
behaviors. In reviewing studies that provided optimal examples for evalu-
ation of ERP with OCD, Franklin and Foa (1998) concluded that studies
to be included as using adequate systematic exposure would involve con-
frontation of an obsession-evoking stimuli for 90 minutes or longer, for
at least a once a week frequency initially, for a duration of 15–20 sessions.
The optimal treatment also included ritual prevention through patients’

voluntarily refraining from engaging in rituals immediately after exposure.
ERP assignments were to be conducted by the patients between sessions.
Learning theory provides an understanding of how treatments for panic
disorder may require a specific type of exposure. Mineka and Zinbarg
(2006) provide an explanation of how interoceptive conditioning (one’s
own bodily sensations), as well as exteroceptive conditioning to stimuli
from the external environment, plays an important role in the development
of PD. For instance, if physical sensations, which are present during panic
(e.g., heart beating quickly), are paired with a full-blown panic attack (e.g.
very high levels of panic), then low levels of these internal sensations can
become conditioned stimuli for experiencing a panic attack in the future.
Exposure to internal physiological cues for panic, referred to as interocep-
tive exposure (Barlow, 1988) helps patients to build tolerance for sensa-
tions that are experienced as aversive, and that are often misinterpreted
as indicating that there is something dangerous occurring. Interoceptive
exposures may include activities such as having a patient hyperventilate to
create a sensation of dizziness, breathe through a straw to mimic shortness
of breath, run in place to increase heart rate. Patients continue to practice
the exposure until their anxiety level decreases. There may also be a cogni-
tive effect in exposure as the individual’s expectation of a negative outcome
is disproven by engaging in the behaviors in a safe environment.
As we indicated earlier in this chapter, the procedural tools in cognitive
and behavioral interventions focused on fear conditioning and avoidance
behavior, as well as anger arousal, are based upon a combination of clas-
sical and instrumental conditioning theories, as well as social learning
theory and information processing. The strategies for intervention in the
following section also employ these principles but have a greater focus
on information processing. These interventions are designed to help
individuals change the way that their beliefs and attitudes influence their
emotions and behaviors. Such interventions are often integrated with
those based upon reducing fear and anger arousal, as well as avoidance
behavior.
Interventions Originating from Information-Processing Theory

As discussed in the initial chapters, the specialty of cognitive and behav-
ioral psychology followed an evolution of theory, assessment, and interven-
tion, and particularly during the 1960s and 1970s, an emerging interest in
the development of techniques that targeted the modification of cognitions
and were rooted in information-processing theory. The development of

techniques that targeted the thinking habits that resulted in negative states,
such as depression and worry, led to effective clinical interventions. As
described in Chapter 2, which discussed the theoretic foundations of the
specialty, early writings by Albert Ellis, the developer of rational emotive
behavioral therapy (REBT) and by Aaron T. Beck, a pioneer of cognitive
therapy (CT), described the focus of their respective treatments on chang-
ing distortions in thinking (Beck, 1976; Ellis, 1962). From both of these
perspectives, the belief of the philosopher Epictetus—that people are not
moved by events but by what they think about events—serves as a guide to
treatment, and differentiates the cognitive therapies from early behavioral
techniques, particularly from classical conditioning and operant proce-
dures. Whereas previous behavioral treatments had underscored the impact
of conditioning and the environment on emotional experience, Beck and
Ellis stressed the intervening factors of meaning. Thus, both Beck and Ellis
broadened the “Antecedent stimulus—Conditioned response” connec-
tion to an “A-B-C” formulation: “Antecedent stimulus—Belief about the
stimulus event—Conditioned response.” To the cognitive therapist, there
is always an intervening belief or interpretation that determines the emo-
tional or behavioral response of the patient. Further refinements of both
REBT and CT have incorporated behavioral elements, and very few cog-
nitive therapy treatments are absent some form of behavior change tech-
nique (Beck, Rush, Shaw, & Emery, 1979; Persons, 2008). REBT and CT
are treatments in their own right, but there are numerous other individu-
als, Bandura, Meichenbaum, Goldfried, and Lazarus, for example, whose
names have been associated with understanding the cognitive as well as
behavioral elements of emotional disorders. As we indicated previously,
not all cognitive-behavioral therapists consider themselves to be either
REBT therapists or cognitive therapists, even though they use cognitive
strategies that are typically associated with these two therapies. Because
several cognitive-behavioral treatment protocols make use of ideas first
developed by Ellis and Beck, a basic understanding of their approaches is
an important factor in therapist competence. These strategies are woven
into treatment following assessment and formulation, and they are incor-
porated into treatment protocols for specific disorders.
R AT I ON A L E M O T I V E B EHAV IOR THERA P Y (REB T)
Ellis and Harper (1975) suggested eleven irrational beliefs that are con-
nected with emotional disorders. These beliefs provide rigid demands that
one is always loved, others are always considerate, things that are feared
are to be avoided, and so forth. Ellis and Bernard (1985) summarized three
major irrational beliefs that incorporate many of the beliefs that people
hold. These are: believing that one must do well and win approval, other-
wise one is “a rotten person”; that one must be treated by others consider-
ately in exactly the way one desires to be treated or else “society and the
universe should severely blame, damn, and punish them for their incon-
siderateness”; and the belief that one must get everything one wants easily
and virtually never get what one does not want (Ellis & Bernard, 1985,
p. 11). For additional discussion regarding REBT theory, see Chapter 2
and Table 2.2. The authors stated, “The main sub-goals of RET consist of
helping people to think more rationally (scientifically, clearly, flexibly); to
feel more appropriately; and to act more functionally (efficiently, undefeat-
ingly) in order to achieve their goals of living longer and more happily”
(p. 5). REBT is not a value-free therapy and is based on an existential/
humanistic philosophy that stresses the importance of individuals reach-
ing their highest potential, or “self-actualizing.”
COG N I T I V E T HE R A P Y TEC HN IQUES
Cognitive therapy, as it has developed based on Beck’s work, endorses

the premise that emotional reactions to various environmental stimuli
are mediated by conscious and, more recently, non-conscious meaning
attached to the stimulus (Beck, 1976). Human beings have active brains,
and we are continually interpreting and evaluating situations. From early
childhood we develop unique ways of viewing ourselves and the world
around us. Through this learning process we learn schematic represen-
tations of ourselves and the world that are stable across situations. For
more discussion of the the theory underlying this therapy approach, see
Chapter 2 and Table 2.3. Also referred to as core beliefs, these cognitive
schemata tend to be absolute. J. S. Beck (1995) refers to core beliefs as “the
most fundamental level of belief; they are global, rigid, and overgeneral-
ized” (p. 16). J. S. Beck places core beliefs into two basic categories: helpless
core beliefs and unlovable core beliefs. She has suggested that therapists
help patients to identify core beliefs, look at the historical evidence that
seems to support the core beliefs, and use cognitive restructuring to change
the beliefs to more accurately reflect reality. Often one’s core beliefs are
tied to early emotionally laden learning experiences. In modifying a core
belief, several strategies have been found to be effective, including the use
of metaphor, looking at extreme examples of the patient’s core belief about
self to which she or he then is compared, and helping patients to use a

worksheet to develop a new core belief, finding evidence for and against
the old core belief as well as for and against the new core belief.
When core beliefs are connected to early emotional learning experiences
and occur on a more non-conscious level, one cognitive therapy approach takes
the view that intensive therapeutic work may be indicated to change pervasive
ways of perceiving and processing the world and one’s self-concept, known as
schemas. Jeff Young (1990) described 18 maladaptive schemas that fall under
four domains of thinking. In a popular press book for patients, Young and
Klosko (1993) refer to schemas as “life traps.” Young’s schema-focused cogni-
tive therapy identifies the ways in which schemas are maintained and how the
patient learns to compensate for his or her schemas. For more discussion and
a list of maladaptive schemas, see the discussion in Chapter 2 and Table 2.4.
Cognitive-behavioral techniques such as guided empiricism and behavioral
experiments, as well as emotional imagery and re-parenting techniques, are
used to challenge and change maladaptive schemas.
As people negotiate their way through life, they also adhere to condi-
tional rules and beliefs. These are referred to as underlying assumptions.
Underlying assumptions are less absolute than core beliefs and schemas,
and they are often expressed as “if-then” (Padesky & Greenberger, 1995).
A patient who assumes that “if I work hard and am kind to others, then
I will be rewarded” will behave according to this rule. Thus he or she will
maintain a strong work ethic and, perhaps, be a very amiable, helpful per-
son. Such assumptions may become rigid and demanding. If the patient’s
belief about hard work and kindness is more accurately stated as “if I work
hard and am kind to others, I must be rewarded” and there is little room
for disputation of this rule, the patient will be distressed when the world or
other people do not provide the expected rewards. The patient may become
distressed, for example, when after having done volunteer service for a
nonprofit organization at great personal expense, she is overlooked for an
award or public recognition. In this situation, either the belief must change
or the information will be assimilated into the belief structure. Should the
belief change, the patient may become less rigid. The “must” would become
a “may.” On the other hand, if the patient maintains the rigid belief, the
organization may be blamed for having made a bad or, at the very least,
inconsiderate decision, and she may experience anger and resentment.
Cognitive theory supports the concept that people see the world through
the filter of their core beliefs and act according to their assumptions. Because
this involves a process of interpretation of events, it is often the case that
interpretations are inaccurate or biased to confirm deeply held beliefs. It can
be as if people are unable to see disconfirming evidence. Rather than encour-

aging patients to think positive thoughts or randomly pulling out worksheets
during the course of therapy to help patients change their thinking, cognitive
therapists help patients identify the times when their thinking is biased or
distorted and find more accurate and broader ways of thinking. These more
stable narratives influence interpretations of a wide variety of situations
as they occur. When a situation occurs, we have thoughts about the event
sequences that are automatic, based on our learning history and in keeping
with strongly held core beliefs. People typically are not aware of these auto-
matic thoughts. They are experienced simply as the way the world is.
Because automatic thoughts are congruent with core beliefs and underly-
ing assumptions, they are often the key to recognizing these other cognitive
structures. It is not surprising that cognitive therapists such as Dr. Judy Beck
(1995) suggest that therapists develop a cognitive case conceptualization,
beginning with noting patterns in automatic thoughts. Strategies that are
core to cognitive therapy are focused on identifying automatic thoughts.
This is most easily facilitated when thoughts are clearly associated with a
specific event (Persons, 2008); when cognitive distortions can be identified
(Beck, Rush, Shaw, & Emery, 1979; Burns 1980); and when using techniques
for recognizing underlying assumptions and core beliefs or schemas. The
goal of all of these cognitive therapy strategies includes working collabora-
tively with patients to change their thinking and beliefs in order to improve
mood or to shift behavior patterns. Throughout the treatment, therapists
make use of the following strategies to accomplish this change.
Guided discovery used throughout cognitive therapy Once patients have

identified their automatic thoughts, underlying assumptions, or core
beliefs, the focus is then on modifying those beliefs that increase distress,
prevent adaptive behavior, or cause interpersonal problems. The overarch-
ing goal of the cognitive techniques used in CT is to change maladaptive
beliefs through guided discovery. Once the beliefs have been identified,
they can be evaluated. Although therapists can be creative and use a variety
of techniques to change negative beliefs, it is important to keep the princi-
ples of CT in mind. The particular case conceptualization for a patient and
awareness of the empirical literature helps therapy remain goal-focused
and structured. Changing maladaptive beliefs is accomplished through
cognitive reappraisal, one of the trans-diagnostic approaches identified by
Moses and Barlow (2006) in their unified protocol. Cognitive reappraisal
means that the patient recognizes that his or her thoughts do not always
represent reality and can look for alternative explanations.
Socratic dialogue in cognitive reappraisal Cognitive therapists have

emphasized the need to use Socratic questioning and to ask open-ended
questions to assist patients in forming their own conclusions. Frequent
summarization of those conclusions is critical to success. Therapists can
ask many types of questions, but several have nearly become standard and
can be useful for most therapists practicing this approach.
Looking for the evidence Whenever patients state a thought or belief, a

basic question that can be asked of them is “Where is the evidence that
this is true?” Therapist and patient can then list evidence that supports
a particular thought or belief, as well as evidence that does not support
the belief. As they review the evidence, the patient can then construct
an alternative to the original belief, based on the evidence. Cognitive
therapists have always been clear that they are not emphasizing posi-
tive thinking but are trying to help patients to consider events realis-
tically and flexibly, with a broader and balanced perspective. Thus, in
some cases the evidence may suggest that a patient’s automatic thought
is accurate.
Assessing the utility of a given thought Even when a thought is true, it

may not be useful to dwell on it. Some patients ruminate and brood over
a particular thought. For example, evidence may support the thought “My
boss is angry with me because I made a mistake on last week’s report.”
However true, dwelling on this fact may do nothing for the patient except
make her or him anxious or dysphoric. Brooding or ruminating about
these thoughts usually does not result in a reasonable plan. Often, rumi-
nating over a thought such as the one in the example also leads to further
distortions and catastrophic thinking.
Developing coping strategies When evidence suggests that a thought is

accurate and there is a possibility of a negative outcome, it is then impor-
tant to teach the patient to assess the likelihood that certain events will
create difficulty. When there is a high likelihood that a worst-case scenario
will occur, a patient can benefit from articulating strategies for coping.
Therapists can ask, “If this occurs, what does it mean about you (a way to
check on underlying assumptions and schemas)? If this occurs, what can
you do to lessen the impact?” This helps patients to recognize when they
are making a problematic situation worse by using it to support a distorted
schema, and it teaches patients to take ameliorative steps rather than being
stuck in a ruminative process.
All of these strategies for cognitive restructuring occur through a dia-

logue with the therapist during the session. Patients are directed to practice
these skills on their own, using thought records or other methods for find-
ing evidence and articulating alternative beliefs to automatic thoughts as
between session homework.
Use of behavioral experiments for hypothesis testing A powerful method

for helping patients to think in a more balanced fashion is to help them
develop behavioral experiments to test their beliefs. Behavioral experi-
ments are particularly helpful in testing underlying assumptions (Padesky
& Greenberger, 1995). Rouf and colleagues (Rouf, Fennell, Westbrook,
Cooper, & Bennett-Levy, 2004) suggest that behavioral experiments serve
three purposes: elaborating a formulation, testing negative cognitions,
and constructing and testing new perspectives. There are different types
of behavioral experiments, active experiments, observational experiments,
and surveys (Rouf et al., 2004). Active experiments involve the patient
doing something to directly test a hypothesis, and may occur in vivo or in a
simulation or role-play. An active experiment may be used to test a hypoth-
esis, such as “if I make a complaint to the barista about my coffee drink,
I will be told that the mistake was mine”; the patient would intentionally
complain about a drink and see if the hypothesis was correct. One can also
test one hypothesis against another. Rouf et al. (2004) provide an example
of a panic patient, after developing an alternative explanation to palpita-
tions, can test hypothesis A “a heart attack” with hypothesis B “an anxiety
reaction.” An active experiment can also be used to test a new hypoth-
esis, such as “when I assert myself, people will treat me with respect.” The
patient may role-play with the therapist or, ideally, test the hypothesis in
the real world. Patients can also observe others to see if their hypotheses
are true. For example, a patient who had the belief “I can’t talk to anyone at
work because they’ll think I’m stupid” spent several lunch hours observing
others and listening to the kinds of topics they talked about. This patient
discovered that, in a setting with many highly educated professionals, the
most frequent topics of lunch conversation were movies, the antics of chil-
dren, and gossip about someone else. The patient recognized that he had
believed that he needed to have important topics for conversation, and the
observational experiment provided new evidence that even very bright
people make small talk. In a survey, a patient who believes she is the only
person who feels uncomfortable during the first 30 minutes of a social gath-
ering can ask several friends what they experience when they first arrive at
parties. In this case, the therapist would need to work collaboratively with
the patient to identify friends who are outgoing, as well as friends who
tend to be introverted and shy, in order to get an accurate representation.
There is always something to be learned by a behavioral experiment, and
they should be set up to be fail-proof. When a patient with a particularly
negative hypothesis reports that the hypothesis was demonstrated to be
accurate, the therapist would then work collaboratively to help the patient
develop ways to cope, to test the hypothesis in a variety of settings for pos-
sibly different results, or would see if something that the patient did actu-
ally contributed to the predicted negative outcome. For example, someone
who is afraid that others will ask her what she means if she comments at a
meeting may actually speak so softly that others have to ask her to repeat
herself, thus fulfilling her prediction.
There are variations in emphasis on the role of cognition and in the
conceptualization of cognition. These range from the consideration of
cognitions as separate structures best understood by principles that differ
from overt behaviors to understanding cognition as private behavior that
develops and is maintained through the same processes as overt or public
behaviors. At the core of practicing competent cognitive therapy is that
the practitioner works in a fashion that is consistent with his or her under-
standing of cognition and in keeping with current research. For example,
although a therapist may be successful in reducing the number of nega-
tive self-statements that a patient produces, she would be remiss if she did
not consider the schemas underlying a patient’s negative self-statements
or automatic thoughts and include modification of the schemas to help a
patient break out of the pessimistic mode that he or she is in.
Integrated Treatments with Behavioral, Emotional, and Cognitive Components

Most protocols and systems of psychotherapy within the cognitive and
behavioral specialty include both overt behavioral and cognitive change
in their interventions, with greater or lesser emphasis on one or the other.
For example, Beck’s cognitive therapy of depression (Beck, Rush, Shaw, &
Emery, 1979) included a number of behavioral techniques, such as activity
scheduling, that were to be used as part of the treatment. Beck, Freeman,
and Davis (2006) suggest that the more depressed the patient, the more
behavioral the therapy, and that as the patient becomes more energized
and engaged, the cognitive interventions would then take precedence.
Cognitive-processing therapy (CPT) for post-traumatic stress disorder
(Resick & Schnicke, 1992) is an evidence-based treatment for PTSD and is
based upon a cognitive therapy protocol that has been demonstrated to be
effective for remediating PTSD symptoms and depression resulting from

a range of traumatic events. In CPT, individuals learn about their PTSD
symptoms, through psychoeducation. Next, the treatment focuses patients
to become more aware of thoughts and feelings, and pinpoints ways in
which people who have experienced trauma attempt to make sense of, or
process, the event. An example would be a victim of a crime who thinks to
himself, “I should have known that this would happen and been better pre-
pared.” The treatment then helps individuals learn how to pay attention to
these thoughts and the feelings associated with them. They are taught how
to think about or process the trauma that occurred in their life in a differ-
ent way. This is often accomplished through writing about it or talking to
a therapist about it. The treatment involves exposure to memories and rec-
ollections of the trauma, but also includes a cognitive restructuring com-
ponent that helps individuals to become “unstuck” in their beliefs about
the event. The treatment provides an opportunity to learn new skills and
to understand the changes in their beliefs. Learning new skills is another
overlapping aspect among effective cognitive and behavioral intervention
strategies.
L E AR NI N G N E W S K I LL S
At the same time that other cognitive and behavioral therapies were
being developed to weaken conditioning to negative or emotionally
distressful stimuli, other interventions were developed out of a positive
psychology movement in which the abilities observed in people who
were resilient to stressful circumstances were researched and interven-
tions were developed to teach these types of social or coping skills as
part of a treatment program. These included self-instructional training
(Meichenbaum, 1977), social skills training (Bellack, Mueser, Gingerich,
& Agresta, 2004), and rational problem-solving training (D’Zurilla &
Goldfried, 1971).
Contemporary problem-solving therapy (PST) first emerged during
this period with the seminal article by D’Zurilla and Goldfried (1971) that
described a prescriptive model of training for individuals who present
with significant deficits in their ability to cope effectively with problems
encountered in daily living. Since that time, researchers and clinicians all
over the world have applied variations of this model to a wide variety of
psychological and health problems and clinical populations (see D’Zurilla
& Nezu, 2007, and Nezu, D’Zurilla, Zwick, & Nezu, 2004, for overviews
of this literature base). The development of this model over the next few
decades is covered in the following section, on cognitive and behavioral

interventions as examples of the current trends in the specialty.
Recent Developments in Cognitive and Behavioral Therapies

Intellectual curiosity and research will inevitably bring about change over time.
This has been true in the history of cognitive-behavioral psychotherapy and
continues to be so. Reference is often made to several paradigm shifts in cog-
nitive and behavioral interventions that are considered three major “waves”
in the behavioral tradition. These waves are not necessarily temporally based,
although there were significant shifts in popularity over time. Initially, in what
is considered the first wave, behavior therapies developed from respondent
and operant conditioning theories. Because there was an emphasis on observ-
able behavior, modification of thinking and other “mental” processes was not
a primary concern, and some considered them inappropriate targets for a
true behavioral technology. In many ways, Albert Bandura’s research in social
learning theory provided an important bridge between purely behavioral
approaches and extensions into considering self-efficacy, a cognitive concept,
and beliefs as phenomena of interest. As the work of Bandura, Lazarus, Ellis,
Beck, Meichenbaum, Mahoney, and others influenced the practice of behav-
ior therapy, there was a shift in focus on the impact of beliefs on emotion and
behavior. This is sometimes referred to as a “cognitive revolution” in behavior
therapy, which is now considered a second wave.
Often referred to as a “third wave” within the specialty are interven-
tions that are characterized by therapies that incorporate and extend the
behavioral theories, but have a distinct focus on balancing change tech-
niques with strategies for helping patients accept and make room for nega-
tive emotional states. In other words, many contemporary cognitive and
behavioral interventions incorporate the value of individuals learning to
be aware of their thoughts simply as thoughts without necessarily making
attempts at restructuring thinking. Rather than talk about a “third wave”
as we discuss important new methodologies developed in the past few
decades, we refer to them as contemporary approaches for several reasons.
First, the notion of a wave implies a washing away of what has come before,
and this is neither how science, nor how these newer approaches work.
Second, Beck (1976) refers to the humanistic psychotherapy movement
that had been dubbed a “third force” between psychoanalysis and behav-
iorism in the mid-twentieth century, and the idea of a “third wave” in cog-
nitive and behavioral therapy may be confusing. Third, while there have
been significant innovations among contemporary behavior therapies,
elements of these new approaches have been present in the cognitive and
behavioral literature for a long time. For example, one concept that is com-
mon among those associated with a third wave is the concept of acceptance
of negative thoughts and feelings. However, in 1986, from a specifically
cognitive therapy point of view, Beck and Emery encouraged patients with
anxiety to be “AWARE” when they were anxious. AWARE stood for accept-
ing the anxiety, watching emotions and rating the intensity as it changes as
they accept the anxiety, as well as watching the thoughts that occur, acting
constructively despite the thoughts, repeating the above, and expecting the
best. There are other examples of clinical interventions that have included
a mindful component of acceptance and non-judgmental observation
of negative feeling states, such as those developed in relapse prevention
(Marlatt & Marques 1977), dialectical behavior therapy (Dimeff & Koerner,
Eds, 2007), problem-solving therapy (Nezu, Nezu, & D’Zurilla, 2013), and
acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 1999).
While these contemporary behavioral approaches are noted by their
emphasis on the acceptance of negative emotion, the idea of accepting
anxiety has been implicit in most treatments for anxiety, as the “fear of
fear” has been a target. It will become clear through this chapter that some
of these theories and therapies are consistent with behavior therapy as it
has been practiced for decades, and some offer more radical departures
from what would be considered traditional. The concepts that contem-
porary therapies share in common, to a greater or lesser extent, are the
importance of the therapeutic relationship as an essential part of therapy;
the promotion of acceptance; and the application of mindfulness practice.
These therapies also place less emphasis on directly changing maladaptive
thoughts. Rather than describe each treatment in detail, after a brief intro-
duction to the therapies that are usually associated with contemporary
behavior therapies, we will describe the concepts that represent innovation
or departure from traditional cognitive and behavioral techniques, but are
now integrated into more complex systems of psychotherapy. These con-
temporary approaches probably share more similarities than differences,
and many include the characteristics that we discussed earlier as suggested
by Barlow in adopting a unified approach.
ACCE P TA N C E A N D C OMMITMEN T THERA P Y (A C T)
ACT (Hayes, Strosahl, & Wilson, 1999) is a contextual therapy that incor-
porates mindfulness. Harris (2009) suggests that there are six “core pro-
cesses” of ACT: contacting the present moment; defusion (or watching
thoughts but not buying into them); acceptance or “making room for pain-
ful feelings, sensations, urges, and emotions” (p. 9); self as context, or being
aware of the observing self; values; and committed action (see also Hayes,
Luoma, Bond, Masuda, & Lillis, 2005). ACT incorporates a behavioral the-
ory of verbal behavior and cognition, known as “relational frame theory,”
which was discussed in Chapter 2 (Hayes, Barnes-Holmes, & Roche, 2001).
The intervention has an existential emphasis on helping people to have
highly valued lives despite the pain and suffering that is a part of life for
everyone at some point in time. To date there have been limited compari-
sons of ACT with other cognitive-behavioral treatments, although ACT
has been used with a variety of patient problems and may work across a
broad range of disorders (Hayes et al, 2005).
B E H AV I O R A L A C T I VAT ION (B A )
BA (Martell, Addis, & Jacobson, 2001; Martell, Dimidjian, & Herman-Dunn,

2010) is a contemporary therapy that was developed for the treatment of major
depressive disorder. This approach is based squarely on a behavioral theory of
depression that is associated with traditional behavior therapy—specifically,
that not enough environmental reinforcement or too much environmental
punishment can contribute to depression—and the goal of the intervention is
to increase reinforcement in an individual’s life. BA’s incorporation of accep-
tance and view of rumination as behavior rather than changing beliefs has
occasioned its inclusion among the contemporary behavior therapies. This
approach is sometimes referred to as contemporary BA (Hopko, Lejuez,
Ruggiero, & Eifert, 2003) or “BA-II” (Kanter, Callaghan, Landes, Busch, &
Brown, 2004) but in actuality it is not a great departure from tradition, and
has emerged as an empirically supported treatment that has evolved from
the “pleasant events scheduling” of Lewinsohn and colleagues (Lewinsohn &
Graf, 1973; Lewinsohn & Libet, 1972; Lewinsohn, Youngren, & Grosscup,
1979). While not called “BA”, the work of Lewinsohn and colleagues is usu-
ally considered the original clinical application of this approach (Dimidjian,
Barrera, Martell, Muñoz, & Lewinsohn, 2011). Hopko and colleagues have
developed a brief behavioral activation treatment that has been supported by
several single-subject design experiments (Hopko, Lejuez, LePage, Hopko, &
McNeil, 2003; Lejuez, Hopko, LePage, Hopko, & McNeil, 2001).
CONT E M P O R A RY P R OB LEM-S OLV IN G THERA P Y (P S T)
Social problem solving (SPS) is the process by which individuals attempt

to identify, discover, or create adaptive means of coping with a wide variety
and range of stressful problems, both acute and chronic, encountered dur-
ing the course of living (D’Zurilla & Nezu, 2007). More specifically, social
or interpersonal problem solving reflects the process whereby people direct
their coping efforts at altering the problematic nature of a given situation,
their reactions to such problems, or both. Rather than representing a sin-
gular type of coping behavior or activity, SPS represents the multidimen-
sional meta-process of ideographically identifying and selecting various
coping responses to implement in order to adequately match the unique
features of a given stressful situation at a given time (Nezu, 2004).
PST is a cognitive-behavioral and integrated cognitive, emotional, and
behaviorally focused intervention that teaches individuals a series of adap-
tive problem-solving strategies geared to foster their ability to cope effec-
tively with stressful life circumstances in order to reduce psychopathology
and negative physical symptoms. This approach is based on the notion that
what is often conceptualized as psychopathology and behavioral difficul-
ties is a function of ineffective coping with life stress. Research addressing
differences between effective and ineffective problem solving, the role of
social problem solving as a moderator of the stress-distress relationship,
and the efficacy of PST interventions have all supported the intervention
and are described in several texts in detail (Nezu, Nezu, & D’Zurilla, 2013).
Originally based upon the development of positive psychological coping
skills described in the previous section of this chapter (i.e., problem-solving
training), over the years PST has emerged as a comprehensive system of
psychotherapy and has been effectively applied to differing clinical popu-
lations, problems, and methods of treatment implementation. The clinical
components of PST include several foci that the authors often refer to as
“tool kits,” each of which is directed toward a possible barrier to effective
problem solving under stress. These barriers included cognitive overload,
emotional dysregulation, negative thinking, poor motivation, and ineffec-
tive problem-solving strategies. The intervention incorporates therapeutic
strategies aimed at information processing, mindful awareness of negative
arousal, decreased avoidance of negative emotions, cognitive and behav-
ioral skills development, skills to increase emotional regulation, and spe-
cific planful or rational problem-solving skills to make needed life changes
consistent with one’s values and life goals.
D I AL E C T I C A L B E H AV I O R THERA P Y (D B T)
Though DBT was originally developed as a treatment for chronic

para-suicidal behavior, Linehan (1993) has extended its development as a
behavioral treatment for borderline personality disorder. A contemporary

cognitive-behavioral approach, it is an excellent example of the integration
of empirically based behavioral techniques such as problem solving, social
skills training, and chain analysis, applied creatively with a difficult-to-treat
population. The particular focus of this population’s “therapy-interfering”
behaviors is often associated with intense challenges in emotional regula-
tion. The intervention applies functional analytic principles to understand,
predict, and ultimately change patients’ therapy-interfering behavior. DBT
also has provided the addition of mindfulness techniques, the notion of
“radical acceptance,” and the interpersonal nature of the therapeutic rela-
tionship. These ideas extended DBT beyond traditional behavior therapy.
The treatment is packaged in such a way that it follows a comprehensive
protocol, including a number of cognitive-behavioral therapy techniques,
with less emphasis on cognitive restructuring and greater emphasis on val-
idation and teaching skills for managing strong negative emotion.
FU NCT I O N A L A N A LYTIC P S Y C HOTHERA P Y (FA P )
FAP (Kohlenberg & Tsai, 1993) emphasizes the therapeutic relationship in

behavior therapy. The FAP therapist is encouraged to be aware of clinically
relevant behaviors (CRBs) that occur in session, and to assess the function
of such behaviors. Depending on the context in which they occur, similar
behaviors can serve a different function for the same patient at different
times. For example, a socially anxious patient who finds assertiveness very
difficult may angrily say to a therapist who is late for a session, “I really think
you’re being inconsiderate of my time by starting late!” While therapists
typically experience patient’s anger as somewhat aversive, a patient who
struggles with assertiveness may actually be demonstrating an in-session
improvement in behavior. On the other hand, if the same patient is only
direct when angry, but otherwise lets everything pass, the anger expressed
during the complaint about the therapist being late may be problematic.
FAP has not been studied as a stand-alone treatment. An FAP-enhanced
cognitive therapy protocol was compared with standard cognitive therapy
(Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002) and, while not differ-
ing significantly from CT in depression outcomes, the addition of FAP was
superior in improving interpersonal functioning as reported by participants.
MI ND FU LN E S S - B A S E D C OGN ITIV E THERA P Y
The practice of being fully present to momentary experience is used

in many of the contemporary approaches to behavior therapy such as
DBT (Linehan, 1993) and acceptance and commitment therapy (ACT;

Hayes, Strosahl, & Wilson, 1999), as well as having been an essential
skill in cognitive-behavioral addictions treatments (Marlatt & Marques,
1977). Mindfulness has been used in stress reduction and pain man-
agement (Grossman, Nieman, Schmidt, & Walach, 2004). Recently, a
mindfulness-based cognitive therapy for depression has been developed
(Segal, Williams, & Teasedale, 2002) and has been applied in the treatment
of anxiety disorders (Orsillo & Roemer, 2011; Roemer & Orsillo, 2006).
Mindfulness-based cognitive therapy is used for relapse prevention, and
studies have been providing a growing evidence base for a wide range of
additional clinical problems. It remains to be seen whether mindfulness
and acceptance strategies will be more effective than cognitive reappraisal
strategies (Hofmann, Heering, Sawyer, & Asnaani, 2009), although data
have been promising for the use of these strategies as additional tools
for clinicians. In acceptance-based approaches that incorporate mind-
fulness, such as ACT, the focus of treatment is on training a willingness
to experience thoughts, feelings, and bodily sensations without trying to
avoid or change them. This may include discussing the consequences of
non-acceptance in a patient’s life, and encouraging a contact with the pres-
ent, both within themselves and in their environment. Patients are encour-
aged to practice acceptance particularly when distressing experiences
impede engagement in what ACT therapists refer to as “valued action”
(Hayes, Strosahl, & Wilson, 1999).
ME TAC O GN I T I V E T HE RA P Y
Metacognitive therapy (Wells, 2009) is based upon the view that people
may experience distress such as anxiety and depression because their meta-
cognitions cause a pattern of responding to inner experiences that main-
tain their distressful emotion and strengthen negative ideas. The pattern,
which Wells refers to as cognitive attentional syndrome (CAS), consists of
the way in which patients react to worry, rumination, and fixed attention.
Such reactions are often defining features of psychological disorders and
are difficult to control, as Wells has indicated; many patients report that
they feel that they have lost control over their thoughts and behaviors as
their thinking and attention becomes fixed in patterns of brooding and
dwelling on the self and threatening information.
Because proponents of metacognitive therapy view CAS as controlled
by metacognitions, they propose that it is necessary to remove the CAS by
helping patients develop new ways of controlling their attention, new ways
of relating to negative thoughts and beliefs, and by modifying metacog-

nitive beliefs that give rise to unhelpful thinking patterns. This approach
has been developed into specific ways of understanding and treating dis-
orders such as generalized anxiety disorder, post-traumatic stress dis-
order, obsessive-compulsive disorder, social anxiety, depression, and
health-anxiety (Wells, 2005; 2009).
There are many different interventions that might additionally be
included in this chapter, and we have not intentionally excluded any inter-
ventions from this summary. Rather, we have attempted to capture exam-
ples of the various ways in which cognitive and behavioral specialists have
applied their knowledge of learning theory to clinical interventions that
can improve lives. In providing these brief descriptions, we have attempted
to reveal the breadth and different foci of the many evidence-based cogni-
tive and behavioral therapeutic strategies that have been developed over
the past 75 years. We end the chapter with our remarks about the plethora
of treatment manuals that have been developed within the specialty of cog-
nitive and behavioral psychological research, along with a summary of the
current zeitgeist within the specialty.
A Word about Treatment Manuals

The past three decades have witnessed the increased use of published pro-
tocols for cognitive and behavioral treatment. Many of these manuals were
used in carefully controlled studies that isolated specific clinical problems
and were closely followed and monitored for adherence during the clinical
efficacy trials in which they were tested. In some cases, the treatments were
also monitored for therapist competency in delivering the treatment, as
well as for nonspecific therapy factors such as those associated with a ther-
apeutic alliance. Within the specialty there are differing schools of thought
with regard to the use of manuals. There are individuals who believe that
the efficacy of the manual speaks for itself and recommend its use by a
therapist who is competent in general therapy or counseling skills when
the relevant clinical target is a focus of treatment. Other therapists believe
that adaptation of effective interventions and manuals is required, since no
two people are alike and a manual is not a “one size fits all.” This philosophy
considers that the same clinical problems or challenges may have different
functions for different people based upon their individual characteristics,
strengths, and supports, as well as comorbidity. These clinicians tend to
focus on a case formulation approach in which effective interventions
serve as a rich toolbox to draw from when developing a treatment plan,
often combining different techniques. The suggestion of these authors is to

consider a manual-driven treatment in the limited number of cases when
there is a specific problem to address without any idiosyncratic features or
other treatment barriers.
There are many “manualized” treatments that can be used when patients
present with a particular and single problem. One of the most widely used
treatment manuals is the Mastery of Your Anxiety and Panic program
(MAPS; Craske & Barlow, 2007). This protocol includes both behavioral
and cognitive interventions. MAPS begins with education about the nature
of anxiety, including both psychosocial and biological components, how to
record panic and anxiety episodes, and the cyclical nature of panic and ago-
rophobic avoidance. The patient and therapist then collaborate to develop
a hierarchy of feared situations. Patients are then taught breathing skills,
cognitive restructuring, and exposure to feared situations as well as intero-
ceptive exposure (i.e., exposure to the physiological sensations associated
with panic, such as increased heart rate, shortness of breath). Maintenance
of gains and relapse-prevention strategies are also an integral part of the
MAPS protocol.
Similarly Hope, Heimberg, and Turk (2006) developed a manual for
the treatment of social anxiety that also includes the identification of situ-
ations that provoke anxiety and education regarding the nature of social
anxiety and a cognitive-behavioral conceptualization of the problem.
Patients in this protocol are taught how to identify and modify automatic
thoughts. A hierarchy of feared social events is created, and exposure
within session and in vivo is undertaken. The protocol includes exposure
to specific fears that are often experienced by socially anxious patients,
including making small talk, public speaking, and engaging in activities
(e.g., eating) in front of other people. Attention is given to recognizing
and modifying core beliefs. This program also concludes with relapse pre-
vention strategies.
Manuals for treatment protocols have been developed for many disor-
ders. Such protocols are available for the cognitive-behavioral treatment
of insomnia (Edinger & Carney, 2008); cognitive therapy of depres-
sion (Gilson, Freeman, Yates, & Freeman, 2009); prolonged exposure for
post-traumatic stress disorder (Foa, Hembree, & Rothbaum, 2007), PST
for depression (Nezu, Nezu, & Perri, 1989; Nezu, Nezu, & D’Zurilla, 2013),
cognitive and behavior therapy for anger problems (Kassinove & Tafrate,
2002), and cognitive-behavior therapy for adult ADHD (Safren, Perlman,
Sprich & Otto, 2005) are just a few of the 75 or more examples of the range
of problems for which therapists can use a treatment manual.
More recently, Barlow and colleagues have published a manual for their
unified treatment protocol for trans-diagnostic use (Barlow, Farchione,
Fairholme, Ellard, Boisseau, Allen, & Ehrereich-May, 2011) that includes
motivational enhancement techniques, cognitive reappraisal, avoidance
modification, and exposure modules. Therapists can use a manual as the
entire course of therapy for a patient with a particular problem, or, based
on the case conceptualization, may identify co-occurring problems and
address one problem at a time using the treatment manuals.
Summary
There is far more that can be said about cognitive and behavioral interven-
tions than can be included in one chapter, or perhaps in one volume. The
techniques used by cognitive and behavioral specialists exemplify work that
is firmly grounded in theory, clearly identified in methodology, and tested
in the research laboratory. As the overarching field of cognitive and behav-
ioral therapies continues to grow, the number of specific evidence-based
treatments, often addressing the same or similar clinical problems, has
dramatically increased as well. As such, clinicians frequently have relevant
and important questions about which treatment(s) to implement with a
given individual or set of individuals. Because clinical practice involves
treating patients often with comorbidities and within a social/cultural sys-
tem, it has been suggested than an overzealous treatment allegiance to a
particular approach, or even to a specific manual, may potentially lead to
ineffective outcomes or even iatrogenic effects. Because many of these cog-
nitive and behavioral therapy interventions have been found to be equally
effective, we believe that the notion of conceptual, procedural, and meth-
odological overlap can be addressed through the use of a case formulation
approach (described in Chapter 5) that matches an individual’s therapeutic
needs with strategies that can carry the most potential for change, given
the many factors that must be considered in a given case and context.
SE VE N
Applied Behavioral Analytic Interventions
As mentioned in Chapter 4, which included a description of applied behav-

ioral analysis as an assessment methodology, there are many interventions
that have been shown to systematically change the contingencies of a target
behavior, such that it is no longer reinforced, or an alternative behavior is
learned through reinforcement. It bears repeating that the recommended
treatment should logically flow from the learning-based explanation of the
behavior obtained through functional analysis. Unfortunately, as the tech-
nology of strategies based upon applied behavior analyses grew in effec-
tiveness and popularity, interventions were often prescribed without the
benefit of an individualized assessment of the individual for whom it was
intended. This shortcut significantly compromises the effectiveness of the
interventions that were developed through functional analysis, and com-
petent intervention requires a sound behavioral assessment and functional
analyses to precede the use of the following interventions.
An effective intervention plan should provide for new learning oppor-
tunities for a patient. These may include ways to increase the likelihood of
a patient learning new associations or functional contingencies, inhibition
of a patient’s previous associations through extinction learning, reduction
or extinction of patient behaviors that have been previously reinforced, or
fostering the patient’s learning of new skills or adaptive behavior.
Examples of Strategies to Increase Adaptive Behavior

Increasing adaptive behavior is the focus of treatment when a particular
adaptive skill is not present in an individual’s repertoire because it has not
previously been learned. This may take the form of a behavioral skill, such
as a child learning to tie a shoelace or an adult learning to tie a sailing knot,
or a more complex, cognitive-behavioral skill, such as a child learning to
read or an adult learning to regulate his emotional arousal. Many interven-
tions have been developed and tested through both group and case designs
that can be used to effectively teach new behavior. An extensive descrip-
tion of these strategies is beyond the scope of the book and only a few
examples are provided below. Those individuals who wish to extend their
competencies to focus on interventions derived from behavioral analysis
principles will require more extensive texts, such as those by Barker (2000),
Kazdin (2000), Mittenberger (2012), or Ramnerö and Törneke (2008).
Shaping and Prompting

Shaping refers to training and reinforcing successive approximations to an
ultimate target behavior. The procedure is used to establish a new topogra-
phy or a new dimension of a more complex behavior (Mittenberger, 2012).
It involves identifying a series of steps that can be reinforced, until the ulti-
mate target behavior is reached. For example, in teaching a child how to
make a bed, a series of steps are identified in which each approximation
of the behavior can be reinforced and can serve as motivation to continue
the training procedure until the child is able to complete the complex task
of making her bed. Another common procedure to teach new behavior
involves the use of prompts. A prompt can be provided verbally, physically,
or environmentally, to increase the likelihood that one will engage in the
correct behavior at the correct time. One example of prompting may occur
if an individual is learning to use various breathing techniques and a brace-
let with the words “breathe when anxiety increases” is placed on her wrist.
Contingency Management
When a relationship exists between a specific response and a consequence
such that the consequence is presented if (and only if) the behavior occurs,
it is referred to as a contingency. In such cases, the consequence is said to be
contingent on the response (Kazdin 2000; Miltenberger, 2012). Although
contingencies may be pleasant (positive) or unpleasant (punishing), the
establishment of contingencies is a basic part of teaching new behavior,
or modifying existing behavior. For example, contingency management
strategies are an important part of any intervention to increase behav-
ior. As such, reinforcing consequences are viewed as an important part of
Applied Behavioral Analytic Interventions 119
motivation. Because direct access to salient reinforcement is not always

available, the use of token economies has become a frequently used contin-
gency management system, in which conditioned reinforcers called tokens
can be given as a consequence of performing a specific desired behavior
and later exchanged for back-up reinforcers (Miltenberger, 2012).
Examples of Strategies to Decrease Challenging Behavior

Many clinical referrals to cognitive and behavioral specialists who focus
their work on interventions associated with applied behavior analysis are
often expected to develop effective interventions for decreasing challeng-
ing, problematic, or dangerous behavior. Such behavioral referrals take
many forms and may involve parents seeking help with reducing tantrums
in their child, or a clinician who wishes to decrease suicidal risk, or a cor-
rectional system requesting behavioral consultation for reducing aggres-
sion among residents. The strategies discussed below have been employed
for decades with particular regard to decreasing the incidence of behavior
that either impedes patients’ learning process or places them in a position
of risk to themselves or others.
Punishment
Punishment is defined by its effect on the behavior that it follows as a con-
sequence. Specifically, Miltenberger (2012) defines punishment as “the
process by which a behavior is followed by a consequence that results in
the future reduced probability of the behavior.” An important clinical and
ethical consideration with regard to punishment-based procedures is that
because of the distress and negative affect that is associated with an indi-
vidual experiencing a negative, unpleasant, or painful consequence, most
behavioral clinicians, trainers, and writers provide important guidelines
and caveats with regard to the use of punishment-based procedures. These
include specifying that the behavior or response—not the individual—is
being punished and to make it a practice not to use punishment strate-
gies without a programmed use of reinforcement-based strategies in con-
junction with the punishment procedure, in order to teach new behavior.
This is because punishing a response decreases or suppresses it, but does
not provide a systematic learning opportunity for new behavior. A simple
example of using punishment in conjunction with reinforcement-based
contingencies might include punishing a child with a brief time-out fol-
lowing disruptive classroom behavior and at the same time providing a
token contingency management procedure for on-task school behavior,

which can be later exchanged for back-up reinforcers.
Most clinical uses of punishment follow a principle of removal of a posi-
tive consequence (for example, a child being required to have a time-out
from playtime, or an adult receiving a parking ticket, which removes
money, for parking illegally). In contrast to procedures based upon pun-
ishments that involve a removal of positive consequences, the use of pain-
ful or aversive consequences that are contingent upon occurrence of the
target behavior, while certainly effective in suppressing behavior, carry a
host of moral, ethical, legal, and practical characteristics that have resulted
in very infrequent use. Early behavioral treatments did incorporate very
short-term use of punishing consequences such as restraint or aversive
stimulation in situations where behavioral suppression was required
because the intensity and frequency of the behavior served as an extreme
barrier to an individual’s ability to learn new skills, or it posed a signifi-
cant danger to the individual patient (for example, extensive self-injury)
that threatened his or her survival or basic quality of life (Nezu, Nezu, &
Gill-Weiss, 1992).
Problems with punishment are discussed extensively in books and
manuals focused on the techniques of applied behavior analysis. However,
competent cognitive and behavioral specialists should have a rudimentary
awareness of the problems inherent in applying unpleasant or aversive
punishment to reduce or suppress behavior. These include (a) the likeli-
hood that punishment can trigger aggression; (b) the individual receiv-
ing punishment may associate the individual providing the punishment
with the punishment itself, through classical conditioning; (c) the use
of punishment may serve as a behavioral model, effectively teaching the
individual being punished to become one who punishes via aggressive
acts; and (d) the use of several punishments, such as spanking, hitting,
or yelling in “real life” are often applied when the punisher is aroused and
frustrated and not as a systematic consequence based upon a functional
analysis. In such a case, the punisher may be reinforced by the act because
it decreases his or her own arousal. Finally, punishment carries ethical and
legal restrictions and liabilities, the laws of which vary from state to state
(Miltenberger, 2012).
Punishment procedures that are more commonly used involve the
removal of a positive experience or as a consequence to a target response, in
order to decrease the response. These include time-out procedures and dif-
ferential reinforcement of alternative and incompatible behavior. Time-out
refers to “time out from positive reinforcement,” in which a person loses
Applied Behavioral Analytic Interventions 121
access to positive reinforcers for a brief period of time. Typically, the per-
son is removed from a reinforcing environment in a time-out procedure.
Although time-out procedures may seem straightforward and simple,
whether they are applied to a tantruming child being directed to a corner
chair, or a violent inpatient being placed in a solitary room, there are many
considerations for implementing time-out procedures. Competency in
administering time-out requires supervised experience in carrying out the
procedure, managing patients’ non-adherence to requests, and knowledge
of the literature regarding the optimal settings in which to implement the
procedure or the duration of the time-out procedure to be used.
Differential reinforcement of alternative or incompatible behavior is
actually a positive reinforcement technique that many clinicians prefer as
a means of decreasing unwanted behavior. Specifically, differential rein-
forcement of alternative behavior (DRA) provides reinforcement for a
functionally equivalent or competing behavior to the behavior that is the
target to be reduced. The result is that the alternative or competing behav-
ior is increased and the target behavior is reduced because it is no longer
reinforced (Kazdin, 2000; Miltenberger, 2012; Nezu, Nezu, & Gill-Weiss,
1992). Differential reinforcement of incompatible behavior (DRI) is a type
of DRA that actually replaces the problem behavior. For example, if indi-
viduals on a hospital unit are aggressive or threatening toward one another,
a DRI procedure might provide specific and motivating reinforcement to
the individuals for respectful and socially skilled communication, which
would replace the problematic behavior.
There has been a rich and strong literature that was built over the last
50 years regarding behavior modification procedures that were developed
through careful behavioral observation and functional behavioral analy-
sis. Because of the impressive success of clinical procedures for remedi-
ating even profound and horrific behavior such as extreme aggression
and self-injury (Foxx, 1996), behavior modification procedures became
clinically popular in many different settings. However, it is important to
remember that competency in administering such interventions should
include a completion of requisite coursework regarding relevant learning
theories, readings, and supervised practicum experience specifically in
applied behavioral analysis, in order to maximize the effectiveness of the
techniques employed and reduce the likelihood of collateral learning that
would be detrimental to the person receiving treatment.
PA RT I V
Other Functional Competencies

E IG H T
Consultation, Supervision, and Teaching
Consultation
Because of the historic focus that cognitive-behavioral psychologists
have placed on measured changes in overt behavior as well as the empiri-
cal support that has accumulated with regard to cognitive-behavioral
interventions, they are frequently consulted with regard to changing
problematic behavior in many different contexts. This specialty often
overlaps with other specialties with regard to the clinical evidence
base that has been developed with specific populations. For example, a
cognitive-behavioral psychologist may be consulted on a hospital inpa-
tient unit to help develop strategies to improve management of challeng-
ing patient behaviors. These may range from treatment non-adherence
behaviors for outpatient settings as well as disruptive, withdrawn, or
non-participatory behavior during stays on a medical or psychiatric
inpatient unit. These consultations extend to many different psychiatric,
medical, and behavioral-health settings such as rehabilitation hospitals,
nursing homes, drug and alcohol treatment programs, and hospice envi-
ronments. In such cases, there is often integration or overlap with other
American Board of Professional Psychology (ABPP) specialties such as
clinical psychology, clinical health psychology, clinical neuropsychology,
and rehabilitation psychology.
When cognitive and behavioral specialists are consulted with regard
to assessment or treatment of non-adherence with medical requirements,
mood disorders, or coping challenges concerning chronic illness popula-
tions such as individuals who struggle with cancer, heart disease, diabetes
126 Other Functional Competencies
management, or other problems, they frequently overlap with specialties of

clinical psychology, clinical health psychology, couples and family psychol-
ogy, and clinical neuropsychology. As such, they may be consulted as part
of an integrated care team.
The unique contributions of the cognitive and behavioral special-
ist in these circumstances may involve adapting effective interventions
for pain and stress management, depression, and anxiety that is associ-
ated with an illness experience. As one example, distressed patients with
cancer were shown to experience reduced depression associated with
cancer-related problems following a problem-solving therapy (PST) inter-
vention and to sustain the improvement over time (Nezu, Nezu, Felgoise,
McClure, & Houts, 2003). When treatments such as these are delivered in
a group format, there is also overlap with the specialty of group psychol-
ogy. It is possible in these situations that the group format itself may be
an effective component of the intervention in addition to the content of
the intervention itself. Additionally, cognitive and behavioral interventions
may be combined with other mind/body approaches. For example, stress
management and interventions based upon mindful meditation and yoga
have been very helpful to patients with various cardiac-related conditions
(Ditto, Eclache, & Goldman, 2006; Jayasinghe, 2004).
The incorporation of cognitive and behavioral interventions have
become ubiquitous with regard to their integration into health care set-
tings and are often viewed as adjunctive to traditional Western medical
treatments because they can improve life quality and mood, and can help
people to cope with, or adapt to, physical problems. Examples of such
interventions include anger management, biofeedback, cognitive ther-
apy, cognitive-behavioral therapy, guided imagery, lifestyle modification,
mindfulness meditation, problem-solving therapy, relaxation training,
stress management, and psycho-education, as well as other psychologi-
cal interventions such as emotional disclosure, hypnosis, and supportive
group counseling (Astin, Beckner, Soeken, Hochberg, & Berman, 2002;
Astin, Shapiro, Eisenberg, & Forys, 2003; Kabat-Zinn, 1982).
When such interventions are employed to reduce psychological distress
(e.g., anxiety and depression), to manage stressful situations, or to treat
a range of other behavioral and interpersonal disorders, physicians seek
the consultation of cognitive-behavioral psychologists with the recogni-
tion that these treatments have been well-tested and thus are considered
as best practices (Epp & Dobson, 2010). However, when the focus of such
therapies is on the reduction of actual medical symptoms and disease,
their use is often viewed by physicians as alternative or complementary
Consultation, Supervision, and Teaching 127
mind/body interventions, because they have not been traditionally pre-

scribed or employed in the culture of Western medicine. For example, in a
recent review (Astin et al., 2002), the authors claim that despite significant
emerging evidence during the past several decades of the direct influence
of psychosocial factors on both physiologic function and health outcomes,
the Western medical culture has yet to fully embrace a biopsychosocial
model of health and illness. These authors review the literature and con-
clude that there is considerable evidence on which to base a realistic opti-
mism concerning the effectiveness of therapies that fall under the cognitive
and behavioral umbrella within the context of an integrative care model. In
a similar manner, the potential effectiveness of cognitive-behavioral treat-
ments regarding many medically unexplained symptoms has also been
suggested (A. M. Nezu, Nezu, & Lombardo, 2001). This is particularly rel-
evant with regard to the large percentage of individuals who seek medi-
cal care each year from their primary care physicians in cases where there
exists no known biomedical explanation for symptoms.
School settings represent environments where consultation is frequently
sought for ways to improve attention, reduce behavioral problems or dis-
ruptive behavior, and create more effective learning environments. It is not
uncommon for psychologists trained in the specialty of school psychology
to also have a strong background in a subset of cognitive and behavioral
specialty areas, such as applied behavioral analysis or functional family
therapy approaches. Where school psychologists are not trained in cogni-
tive and behavioral procedures, they may seek collaborative consultation
with a cognitive and behavioral specialist to augment their work. This rep-
resents another intersection of cognitive and behavioral psychology with
other specialties.
Correctional facilities and other forensic rehabilitative settings fre-
quently seek consultation with a behavioral specialist. Behavioral inter-
ventions based upon applied behavioral analysis have been employed in
such settings in the form of token economies or other reinforcement-based
contingency management programs, and cognitive-behavioral therapies
have been applied to various criminogenic behavioral targets. In addi-
tion to contingency-based behavioral interventions, cognitive-behavioral
interventions have been shown to be effective in such settings (Andrews,
Zinger, Hoge, Bonta, Gendreau, & Cullen, 1990). Additionally, cognitive
and behavioral psychologists have also worked with forensic psychologists
in consultation regarding their behavioral expertise related to victims, per-
petrators, and jurors. Two interventions that have a very strong evidence
base regarding the emergence of post-traumatic stress disorder (PTSD) in
individuals who have been victimized by crime include strategies devel-

oped within the specialty, such as cognitive-processing therapy (CPT)
and prolonged exposure (PE; National Center for Posttraumatic Stress
Disorder, 2012). For more information on these interventions, the reader
is directed to Chapter 6 in this volume.
Because of the powerful and evidence-based observational technolo-
gies developed by cognitive and behavioral specialists, their expertise in
learning and behavior change has also been sought by the military, police,
and public safety, to help law enforcement officers cope with critical inci-
dents and anger management (Novaco, 1977). Cognitive and behavioral
psychologists have developed assessment and treatment techniques that
are effective for stress-related disorders that are often associated with the
life experience of first responders. As such, the specialty also may intersect
with the specialty of police and public safety psychology.
Behavioral psychologists have been consulted in many private sector
areas, such as advertising and political campaigns, with regard to condi-
tioning theories and associative learning (Gorn, 1982). Even the leisure
industry has consulted with cognitive and behavioral psychologists with
regard to how best to train animals, control crowds, maintain attention, or
sell souvenirs.
Cognitive and behavioral psychologists who competently provide con-
sultation to other psychology specialties, as well as other disciplines and
the private sector, follow several important heuristics to increase the suc-
cess of their consultation experience; these are consistent with competen-
cies in consultation services developed by a consensus task force (Fouad
et al., 2009) and are listed below.
1. Recognize situations in which consultation is appropriate.
As the preceding paragraphs indicate, cognitive and behavioral spe-

cialists may be consulted for many different reasons. Most of these con-
sultation requests are reasonable and relevant. However, there are times
when another professional may be unfamiliar with the specialty, and in
such cases, discussion and agreement concerning the goals of the consul-
tation require further negotiation. In such cases, the consultation ques-
tion or request may need to be clarified or modified. For example, one of
the authors was consulted by a gastroenterologist who was seeking rec-
ommendations for behavioral relaxation strategies that would reduce the
need for anesthesia administered during colonoscopy procedures. Such
procedures are prescribed for patients once every 5 to 10 years for most
patients, and the investment of a patient’s time, energy, and cost to prepare
for an anesthesia-free colonoscopy was not outweighed by the frequency
with which it would be used. However, after negotiation with the gastroen-
terologist, it was determined that the cognitive and behavioral consultant
might be very helpful in reducing fears and myths that are often associated
with the procedure, including fears concerning the use of anesthesia.
2. Provide effective advice, feedback, and recommendations.
When providing feedback or advice to colleagues, other providers, or

systems regarding cognitive and behavioral psychology, it is important to
do so informed by a scientific evidence base, and to also be specific and
practical in advice or instructions. This often involves employing a case
formulation approach that may incorporate the need and identification of
additional interventions than those for which the specialist is initially con-
sulted. For example, when one of the authors was contacted by an attorney
for a family to provide individual therapy for a developmentally disabled
young adult with non-suicidal self-injury who was in danger of losing his
job placement, it was important to provide the patient and his family with
a user-friendly description of what family system factors appeared to be
maintaining the self-injury behavior as part of the behavior analysis that
was conducted. This required a compassionate and tactful discussion with
the parents regarding how the family would need to change in order to best
help the patient. Additionally, based upon a review of the relevant literature,
it was important to focus the patient and his family on ways to increase his
psychological resilience, as well as to modify the family factors contribut-
ing to maintenance of the self-injurious behavior, through adjunct family
training sessions. Indeed, it is important to apply the relevant literature to
the consultation situation, and to provide appropriate psycho-education
to consultees concerning cognitive and behavioral interventions, with the
recognition that this is the very reason for which consultation is sought.
3. Implement interventions that meet the goals of the consultation

request.
Finally, there are situations in which the choice of intervention might

be very different if a consultation is sought, versus a situation in which
an individual seeks treatment on his own. For example, a urologist made
a consultation request to one of the authors with regard to a patient with
prostate cancer, low back pain, and significant marital difficulties. The
request focused on providing the patient with strategies specifically for
improved pain management. Although the cognitive and behavioral spe-

cialist believed that the stress of the patient’s marriage and other interper-
sonal or long-held schemas were also factors that were important areas
of potential intervention, the initial focus on pain relief and stress man-
agement reinforced the confidence that the urologist had in continuing to
make such referrals.
Supervision and Teaching

For cognitive and behavioral specialists, it is a tradition of this specialty that
a written exam or scholarly article is not always an accurate approximation
of actual behavior. Therefore, professional activities involving supervision
and training are more effective when they are competency-based and make
use of strategies geared to shape the behavior of a trainee.
In addition to didactics, behavioral observation, modeling, role-play,
guided practice, and the use of audio- and videotape are all important tools.
There is a common philosophy among cognitive and behavioral specialists
that actually demonstrating how to interview, assess, intervene, and con-
sult is an important part of clinical teaching and supervision. Additionally,
because training is viewed as a critical learning experience, reinforcement
is seen as a key training strategy.
Cory Newman (2010) has described supervision competencies in cogni-
tive and behavioral therapies in terms of both foundational and functional
competencies. With regard to foundational aspects of supervisory compe-
tency, he indicates that a “high level” of professional functioning is required
in which supervisors possess significant skills in diagnosis, responsibility
for patient care and records, and communications skills in order to provide
clear, concise, and sensitive feedback to their supervisees. He additionally
underscores the importance of cultural awareness and insight regarding how
such factors not only influence patient care but supervisory relationships as
well. A final point discussed by Newman concerns the importance of rec-
ognizing the power differential inherent in the supervisory relationship and
the impact of each supervision on a trainee’s future career. As such, he states
that supervisors must rise to the occasion by “creating, communicating, and
sustaining a safe, growth-enhancing climate in which their supervisees can
learn optimally to conduct therapy more and more competently.”
A challenging balance for supervisors is that an important part of their
task is to identify problem areas that need to be addressed while devel-
oping effective learning experiences to remediate a trainee’s difficulties.
This duty of supervision is a weighty one, in that protection of the public
is an important continual goal (Kaslow, Rubin, Forrest, et al., 2007). The

challenges inherent to the process of supervision have not yet been fully
resolved by the specialty. As indicated by Reiser and Milne (2012), there
is a dearth of reliable tools for assessing the competencies of supervisors.
Moreover, these authors cite several surveys that suggest very limited use
of supervisory training that involves the use of videotapes, ratings scales,
or other standardized measures of supervision competence. They addi-
tionally propose that a wide-ranging assumption exists that any adequate
clinician can be an adequate supervisor. This does not appear to be a satis-
factory approach to training individuals how to supervise.
However, during the past decade there has been significant attention
focused on the aspirational goal of defining supervision competencies
more carefully. Although developed for the entry-level psychologist, the
competencies defined by Falender and colleagues (2004) provide a useful
rubric by which to list the competencies that should be present with regard
to the cognitive and behavioral specialty. These are adapted from sugges-
tions provided by these authors and are listed in bullet form below.
Competency Areas of Knowledge

• Across areas being supervised, such as assessment, applied behavior
analysis, psychotherapy, and so forth;
• Models and theories of the specialty;
• Developmental process for the psychological trainee;
• Ethics and legal issues regarding supervision;
• Evaluation, process, and outcome;
• Diversity in all its forms.
Competency Areas of Skills

• Supervision modalities;
• Relationship skills;
• Awareness of multiple roles of supervisor and supervisee;
• Promotion of growth and self-assessment in trainee;
• Self-assessment;
• Ability to assess learning needs;
• Ability to encourage feedback;
• Teaching and didactics;
• Ability to set boundaries;

• Flexibility;
• Scientific thinking.
Competency Areas of Professional Values

• Responsibility for patient and supervisee;
• Respect for supervisee;
• Sensitivity to diversity;
• Balance between support and challenging;
• Empowering supervisees;
• Commitment to lifelong learning;
• Balance between clinical and training needs;
• Ethical principles;
• Commitment to science;
• Knowing one’s own limitations.
Competency Areas Regarding the Recognition of the Social Context

• Diversity;
• Ethics and legal issues;
• Developmental process;
• Knowledge of the expectations present in the system within which
supervision is conducted;
• Creation of climate that fosters honest feedback.
Competency Areas of Training in Supervision Competencies

• Coursework in supervision;
• Supervision of supervision involving observation (videotape or
audiotape).
Documentation of Demonstration of Supervision Competencies

• Successful completion of course in supervision;
• Verification of previous supervision with documentation of readiness
to supervise independently;
• Evidence of direct observation;

• Documentation of supervision experience that directly reflects
diversity;
• Documented supervisory feedback;
• Self-assessment and identification of areas in need of consultation.
Several authors have highlighted the importance in supervision of

teaching trainees how to conceptualize cases (Eells, Lombart, Kendjelic,
Turner, & Lucas, 2005; Newman, 2010; Tarrier, 2006). Finally, it is impor-
tant to provide help to trainees to allow them to access resources that will
familiarize them with a full range of conceptual and technical skills, and
will afford them opportunities for practice. One useful way of doing this is
to provide specific feedback of their case presentations (Petti, 2008).
Many cognitive-behavioral specialists have underscored the importance
in supervision of addressing the emotional reactions of trainees to their
patients as well as supervisors to their trainees and their trainees’ patients.
This is encompassed by the area of self-assessment, self-knowledge, and
self-care. Although a problem-solving framework was identified by a con-
sensus panel in 2004 regarding supervision competencies in professional
psychology in general, Nezu, Saad, and Nezu (2000) suggested the use of a
problem-solving framework as a heuristic when identifying and address-
ing therapist and supervisor reactivity to an assessment or therapy situa-
tion. We believe that this provides a framework for supervisors and trainees
to use in identifying and resolving the inevitable emotional reactions that
occur on the part of the therapist, by using a planful problem-solving
approach. Cognitive and behavioral specialists in training may face numer-
ous obstacles to discussion and exploration of their emotional reactions
to patients. Supervisory strategies for overcoming these obstacles with the
goal of facilitating discussion and ultimately furthering the trainee’s pro-
fessional development can be guided by the use of problem-solving prin-
ciples. Moreover, it serves as a useful heuristic for how to teach trainees to
supervise others in the future.
Teaching Competency
With regard to teaching competencies in the specialty, not all specialists
require such competencies in the traditional sense of classroom teaching.
However, clinical supervision and even clinical work requires competencies
in teaching skills. Ultimately, since much of what cognitive and behavioral
specialists do in their day-to-day work, with regard to patient care, con-

sultation, and supervision, is to provide new learning experiences, their
role is often that of teacher; thus the competencies involved in effective
teaching or training of new skills are necessary and theoretically consis-
tent with their specialty. In addition to providing information, it is impor-
tant to make use of the strategies that were developed within the specialty
with regard to demonstration, guided instruction, prompting, shaping and
fading, and to apply such concepts to the teaching and training situation.
Fortunately for cognitive and behavioral specialists, the strong evidence
base for the interventions that have been developed for patient populations
can be adapted for teaching as well. Ultimately, the pedagogical process
of increasing motivation and eagerness to learn, guiding and encouraging
rather than doing and rescuing, and finally reinforcing successive approxi-
mations are all competencies required by the teaching process.
PA RT V
Foundational Competencies
NINE
Interpersonal Interactions
The cognitive and behavioral specialty carries with its history a strong
foundation of scientific theory and a strong empirical basis for many
cognitive and behavioral psychotherapies under its specialty umbrella.
Although the specialty has maintained this exemplary reputation for its
well-defined and empirically supported therapy tools, it has occasionally
received unfair criticism from those unfamiliar with the specialty who
tend to view cognitive-behavioral techniques as very limited because of
a perceived inattention to the therapy relationship and to the importance
of the therapist’s interpersonal skills. In fact, the therapeutic relationship
is of central importance to the cognitive-behavioral specialty (Gilbert &
Leahy, 2007).
As Cory Newman underscored in a recent article concerning com-
petencies in cognitive and behavioral therapy interventions (Newman,
2010), there is compelling and recent evidence that the foundational com-
petencies involved in building the therapeutic alliance during treatment,
the functional competencies of case formulation, and the therapy inter-
ventions being implemented may interact in compelling and unexpected
ways. For example, he cites an outcome study of a cognitive-behavioral
intervention by Strauss (Strauss, Hayes, Johnson, Newman, Barber,
Brown, & Beck, 2006) for patients with avoidant personality disorder and
obsessive-compulsive personality disorder, where the most favorable out-
comes tended to occur in participants who experienced significant alliance
strains with their therapists but then resolved them favorably and com-
pleted the treatment protocol (Strauss et al., 2006). Additionally, he cited
evidence that patients who are depressed and who learn the specific skills
138 Foundational Competencies
commonly included in cognitive-behavioral therapies—and as a result of

using them, experience relief—often find that their therapeutic relation-
ship improves as a result (DeRubeis, Brotman, & Gibbons, 2005; Barber,
Connolly, Crits-Christoph, Gladis, & Siqueland, 2009).
The popularity of functional analytic psychotherapy (FAP; Kanter,
Tsai, & Kohlenberg, 2012) reveals how cognitive and behavioral specialists
have focused on the importance of interpersonal interactions as an essen-
tial area of assessment and intervention over recent years. The treatment
was developed by Kohlenberg and Tsai at the University of Washington. It
is based upon a behavior analytic, functional, and contextualistic approach
to human behavior, initially introduced by the research of B. F. Skinner.
The treatment, rather than assuming a mechanistic view of behavior,
assumes a primary role of the functions and interactions of interpersonal
behavior. This results in psychotherapy relationships that are frequently
more intense and personal than are typically expected by those unfamiliar
with cognitive-behavioral treatments. This treatment provides an under-
standing of how to apply instrumental behavioral principles to the context
of clinically relevant behavior. Its focus on emotion and relational inter-
vention provides cognitive-behavioral psychologists with a translation
of traditional concepts such as transference and counter-transference to
learning-based phenomena.
These few examples of recent advances in the understanding of the
therapist’s interpersonal interactions as part of therapy underscore the
importance of competencies in interpersonal functioning for the spe-
cialty. Although cognitive-behavioral psychologists have traditionally
not required graduate students, interns, or other trainees to engage in
individual psychotherapy, the specialty recognizes the importance of
self-awareness, self-reflection, and how a psychologist’s own verbal and
physical behavior can communicate approval, disagreement, avoidance,
distancing, or disgust, just as these reactions are so readily observed in
their patients. As such, it is important for cognitive and behavioral special-
ists to engage in peer supervision, consultation, and feedback, and to learn
how to identify their own interpersonal communications, especially those
that may be unintended but that reflect habituated ways of responding to
various social, environmental, and emotional interpersonal stimuli.
In addition to self-awareness, self-reflection, and receiving feedback
non-defensively from patients, specialists require competencies regard-
ing their knowledge and abilities to interact collegially and collaboratively
with other health care professionals or colleagues in different disciplines
(Newman, 2010). One area where this type of relationship may exist
Interpersonal Interactions 139
with some frequency is in collaborations with a prescribing psychiatrist.

Newman (2010) refers to this competency as requiring communication in
a mutually enlightening and constructive manner. This may be challenging
to accomplish when two disciplines may have very different approaches
to treatment. For example, an exposure-based approach to the treatment
of anxiety disorders may view a patient’s experience of discomfort as an
important part of her new learning experience. A prescribing physician
may be focused on reducing the discomfort associated with various fears
and may communicate to a patient that such discomfort should be removed
through medication. In such cases, differences of opinion, frustration, and
even antagonistic dialogue between professionals may occur. Whatever
the causal factors, the patient is likely to suffer as a result. It is important
to adopt a competent interpersonal style, balancing assertive communica-
tion with openness to other opinions, a respect for the approaches of other
disciplines, and a rational view that reduces the tendency to personalize
a collegial disagreement. These skills are rarely taught as part of graduate
training. However, the cognitive and behavioral principles that are part of
so many interventions can be applied to one’s self-knowledge and plans
for problem solving challenging communications with other professionals.
Practitioners in other disciplines with whom psychologists frequently
interact include physicians in medical specialties other than psychiatry
(such as primary care or internal medicine), nurses, and social workers.
Each discipline is part of its own culture, and the competencies that a spe-
cialist has acquired with regard to multiculturalism (see Chapter 11) can
be directed toward the culture of these other disciplines as well.
TE N
Common Ethical and Legal Challenges

in Cognitive and Behavioral Practice
All psychologists are expected to follow the Ethical Principles of

Psychologists and Code of Conduct (American Psychological Association,
2002) that was revised in 2002 and adopted for use in June 2003. The
American Psychological Association (APA) ethics code provides a set of
General Principles that are aspirational and that are to be used to inform
ethical decision making in clinical care. There are five principles: benefi-
cence and non-maleficence; fidelity and responsibility; integrity; justice;
and respect for peoples’ rights and dignity. In this chapter we will review
each of these principles briefly, and throughout we will relate specific ethi-
cal dilemmas that are particularly relevant to cognitive and behavioral psy-
chology. In addition to the five general principles, the 2002 Ethics Code
also provides ethical standards that cover ten major areas of psychologi-
cal practice and which are enforceable by ethics boards and state licensing
boards. The standards provide specific heuristics for psychologists to fol-
low with regard to (1) resolving ethical issues; (2) practicing within one’s
level of competence; (3) dealing with human relations that include con-
cerns over discrimination, harassment, non-exploitative relationships and
so forth; (4) maintaining privacy and confidentiality; (5) advertising and
making public statements; (6) keeping records and setting fees; (7) work-
ing in educational and training environments; (8) conducting research and
publishing; (9) conducting assessments; and (10) conducting therapy.
While psychologists are expected to follow the standards, there is a fair
degree of “gray area” that requires the psychologist to remain adherent
to the ethical principles when making professional decisions rather than
Common Ethical and Legal Challenges in Cognitive and Behavioral Practice 141
simply following clear-cut rules that do not easily generalize to all situa-
tions. Several of the standards are particularly relevant to cognitive and
behavioral psychology and will be addressed in this chapter. When this
chapter does not address particular ethical standards, however, the reader
should not interpret such an omission to suggest that the standards are
not important or that they are not relevant. It is up to the individual psy-
chologist to be conversant with and to abide by the ethical standards of the
profession. Our focus on specific principles and professional conduct were
chosen with regard to the likelihood that cognitive and behavioral spe-
cialists may be likely to encounter specific situations that require further
discussion.
Certain ethical standards, such as the prohibition against psychologists
engaging in a relationship involving “dual roles,” such as intimate or sexual
contact with current or former patients, are “no-brainers”; that is, it is clear
how such actions would be exploitive and potentially harmful, regard-
less of the therapist’s theoretical orientation. In other cases, the principles
and standards must be interpreted within the context of the psychologist’s
work, and they require more than an absolute “do not ever do this” rule.
For example, the ethics code does not address particular theoretical
orientations of therapy, assessment, or philosophies of science or teach-
ing. In reality, community standards in the practice of cognitive and
behavioral psychology practice may differ from other theoretical orienta-
tions in various ways. In other words, what may be considered ethically
questionable from a psychodynamic perspective may be considered both
ethical and desirable from a cognitive and behavioral perspective. As one
illustration, within specific psychoanalytic treatments in which a psychol-
ogist may consider the concept of therapeutic transference to be a major
part of the therapy encounter, psychotherapists may be expected to view
any self-disclosure as disruptive of the therapy process. According to this
theoretical model, the therapist’s self-disclosure may cross a boundary
that might be considered harmful to the patient. In contrast, while cog-
nitive and behavioral psychotherapists consider the therapeutic alliance
and the interpersonal relationship to be important aspects of treatment,
the theories upon which the treatment is based do not view the trans-
ference phenomenon to be a primary mechanism of action. Disciplined
self-disclosure that is based upon an individual case formulation of the
consequences of such a disclosure is the more predominant view among
cognitive and behavioral specialists. In some cases, self-disclosure that
has the goal of maintaining the therapeutic relationship or modeling
appropriate coping behaviors would not be considered a violation of
the professional boundaries between therapist and patient. Ethical prac-

tice requires, however, that the cognitive-behavioral therapist consider
whether self-disclosure is in the best interest of the patient, the function
that it will serve, and the wisdom of disclosing certain facts about oneself
or one’s history. It should be underscored, however, that cognitive and
behavioral approaches do not support therapists simply talking about
themselves or their feelings, largely due to the lack of scientific evidence
for such an approach and the potential to actually worsen the patient’s
symptoms through such disclosures.
While there is a great deal of empirical support for various techniques
in cognitive and behavioral psychology and the theory is strongly rooted
in learning research, ethical decision making specific to the specialty prac-
tice received little attention in the literature (Davis, 2009). We will first
turn our attention to some of the unique practices in cognitive-behavioral
interventions and will review the related ethical principles and standards.
We will then focus on a specific treatment strategy, exposure, since it is
frequently part of many treatment interventions in the specialty and rep-
resents some ethical challenges for practitioners. An exhaustive discussion
of all of the possible challenges and dilemmas that need to be addressed
through the ethics code and careful review of the empirical literature is
beyond the scope of this chapter.
Ethical Considerations in Cognitive-Behavioral Interventions

It should be stated very clearly at the outset that all of the ethical prin-
ciples and standards apply to all psychologists, regardless of their theo-
retical orientation or place of work. However, cognitive and behavioral
therapies differ from other therapeutic approaches, creating unique ethical
concerns. Considering the General Principles, Principle A initially states
that “psychologists strive to benefit those with whom they work and take
care to do no harm” (APA, 2002, p. 3). It can be argued that the empiri-
cal basis of cognitive and behavioral treatments offers a good example of
following this principle, as one hallmark of the specialty is to utilize treat-
ments that have demonstrated efficacy in randomized clinical trials that
have been conducted with great rigor. However, some of our very interven-
tions have, indeed, been reported to cause harm. A key example of this is
in behavioral treatments aimed at changing sexual orientation. In a study
of the experiences of individuals formerly treated with therapies aimed at
changing sexual orientation, Schroeder and Shidlo (2002) found that those
individuals who were treated with behavior therapy, particularly through
the use of aversive conditioning procedures, reported the greatest sense of

having been harmed rather than helped by the treatment than individu-
als treated with other questionable methods. Thus Principle A also says
that psychologists are “alert to and guard against personal, financial, social,
organizational, or political factors that might lead to misuse of their influ-
ence” (APA, 2002, p. 3). While the frightening portrayals of behavior mod-
ification in popular movies such as Stanley Kubrick’s A Clockwork Orange
have not been realized, having procedures that effectively change behav-
ior does not always lead to the use of such technology for the benefit of
individuals, and behavioral and cognitive-behavioral psychologists must
follow Principle E, which states that we “respect the dignity and worth
of all people, and the rights of individuals to privacy, confidentiality, and
self-determination” (p. 4).
In some ways, the collaborative nature of cognitive and behavioral inter-
ventions can be an excellent example of respecting the individual’s rights
to self-determination. This is the good news. It is standard practice in the
specialty for the therapist to work as a team member with the patient,
and the therapeutic process is transparent. In other words, cognitive and
behavioral therapists are explicit in providing psycho-education about the
cognitive and behavioral learning models to explain psychopathology, as
well as suggestions for treatment and working with patients to set mutually
agreed-upon goals. Respecting the individual’s right to self-determination
does not mean colluding with patients over maintaining unhealthy behav-
ioral patterns, and therapists would work to enhance motivation for change.
Interestingly, even the first five ethical principles demonstrate the need for
psychologists to think in an ethical manner, rather than assume that they
can simply apply a straightforward rule. Respecting the individual’s right
for self-determination is a prime example. We are required to do so, yet
we are also required to “do no harm.” How do we reconcile these prin-
ciples, for example, in the case of an extremely distressed individual who
expresses a strong desire to end a life of pain and misery through suicide?
It would seem that the patient has the right to be self-directed and make
such a decision. However, for the psychologist not to try to prevent such an
action would certainly do harm to the patient and potentially to others in
the patient’s life. In this situation, the community standard of care and the
principle to “do no harm” would trump the principle of self-determination,
and the ethical therapist would use whatever appropriate means necessary,
including consideration of involuntary hospitalization, in order to keep the
patient safe and help him to work on making his life one that is worth
living.
While the collaborative stance of the therapist in cognitive and behav-

ioral practice is conducive to promoting self-determination, the interven-
tions are often more a directive form of therapy than other approaches.
There is also extensive use of homework with expectations that patients will
carry on the work of therapy outside the therapy session. In some situations,
therapists may accompany patients outside the office to conduct behavioral
experiments, exposure exercises—which we will say more about later—or to
observe patient skills in vivo. Therapist self-disclosure has already been dis-
cussed, and cognitive-behavioral therapists may use themselves as a model
for certain behaviors, such as demonstrating how to approach a feared sit-
uation, or sharing how to cope with certain anxieties that are a common
experience among people. This active and directive nature of interventions
frequently used as part of cognitive and behavioral treatment necessitates the
consideration of several ethical standards. Such issues as informed consent,
avoiding multiple relationships, non-exploitative relationships, and main-
taining confidentiality all directly apply to circumstances in which a psy-
chotherapist may find him- or herself during the competent delivery of care.
Exposure Therapy
One of the most well-researched treatments for a variety of anxiety dis-
orders is exposure therapy. As discussed in Chapter 6, which focused on
interventions, exposure with response prevention is an efficacious treat-
ment for obsessive-compulsive disorder (OCD), and prolonged expo-
sure is efficacious in treating post-traumatic stress disorder (PTSD).
Additionally, imaginal and in vivo exposure components are used in
treatments for social phobia, panic disorder, specific phobias, and other
anxiety disorders. Yet, many therapists are reluctant to use exposure
because of concerns about the fact that patients will feel an increase in
distress during exposure exercises. As Martell, Safren, and Prince (2004)
have noted, “in general, anxiety disorder treatment involves the patient
doing the exact thing that has caused him or her most distress” (p. 98).
While it is true that the theory behind exposure requires that there is
initial distress experienced in order for habituation or new learning to
occur, it is important to consider that such treatments have some of the
strongest scientific support. In cases where patients are likely to expe-
rience increased distress as part of the treatment, the directive to “do
no harm” (American Psychological Association, 2002) must be consid-
ered and weighed against the benefits of the treatment. Additionally,
the ethical standard that psychologists do not work outside their area
of training (American Psychological Association, 2002) is relevant as

well. Specifically, psychologists who provide exposure-based treatments
should have the requisite training in both the learning theory and the
effective conduct of exposure therapy, under supervision with a variety
of patients. Indeed, there may be ethical concerns about not using expo-
sure when there is such a plethora of evidence that it is an efficacious
treatment. Not to use exposure because of fears that patients will tempo-
rarily be distressed might be analogous to a surgeon avoiding conducting
a needed operation out of fear that it will compromise the integrity of the
skin. Olatunji, Deacon, and Abramowitz (2009) address this issue and
cite a study by Norton, Allen, and Hilton (1983) showing that patients
themselves rated exposure therapy as acceptable in treatment of anxiety.
Therefore, while some therapists may believe that exposure is problem-
atic, patients who are suffering from disorders for which exposure is a
treatment do not seem to share the same concerns.
One fear that is frequently expressed about the use of exposure is that it
will exacerbate symptoms. This fear has particularly been expressed when
exposure is used to treat PTSD. While it could be expected that there would
be a temporary increase in symptoms, research has demonstrated that
this does not occur in a majority of cases (e.g., Foa, Zoellner, Hembree, &
Alvarez-Conrad, 2002). The Foa et al. (2002) study demonstrated that a
minority of individuals treated with exposure therapy for PTSD expe-
rienced an exacerbation of symptoms during treatment, but that they
remained in treatment and the temporary exacerbation did not predict a
negative outcome of the therapy. Moreover, Hembree, Foa, Dorfan, Street,
Kowalski, and Tu (2003) reviewed studies of exposure therapy in treat-
ing PTSD and concluded that patients did not drop out prematurely from
exposure therapy for PTSD at higher rates than for exposure therapy for
other anxiety disorders, despite the fact that exposure for PTSD requires
that patients relive their traumatic experience repeatedly. It is possible that
therapists themselves may find exposure aversive and therefore avoid it,
despite the fact that there is evidence that exposure is well-tolerated by
patients, and that it is efficacious in the treatment of anxiety. We propose
that not doing exposure despite the evidence for its use has ethical implica-
tions of withholding treatment that is known to be efficacious.
Despite the fact that exposure is efficacious, and that there is no evi-
dence to suggest that it will make patients worse in the long run, there
are several other ethical considerations that practitioners must take into
account. Olatunji, Deacon, and Abramowitz (2009) identify two particular
standards that must be considered: informed consent and confidentiality.
Given the directive nature of exposure, patients must be clear about the
rationale for exposure, expectations about a temporary increase of distress,
and discussion of some possible side effects, such as increased negative
arousal, that they may expect. The expectation is that fear will rise and as the
patient stays in the situation rather than escaping, the strength of the fear
will eventually decrease. Patients must be fully aware of this process prior
to beginning exposure. Exposure is used for a variety of patient problems,
and patients need to know what will be asked of them. For example, in the
case of PTSD, patients will be asked to describe in graphic detail their trau-
matic experience, and to either read the account, listen to it in a recording,
or share it with the therapist repeatedly. With regard to the treatment of
OCD, patients will need to face situations that they would either avoid or
only face if they were doing a ritualized compulsive behavior to neutralize
the fear. They are required to face increasingly fearful situations without
engaging in the compulsions. Socially anxious patients will work their way
up a hierarchy of frightening social situations and face them. The occur-
rence of anxiety and distress is part of the therapeutic process. Patients
need to know this in advance and to know of problems that can occur
before consenting to treatment. In cases of exposure-based treatments,
one problem that can worsen a learned fear may occur when habituation
does not occur because there was not enough time allotted and patients
leave the therapy session in a high state of arousal. This can be avoided
by anticipating when it is important to plan an increase in the length of
session time. In general planning, a 90-minute or longer session for expo-
sure allows time for habituation. As such, with regard to exposure-based
interventions, consideration of the time and schedule of exposure sessions
required is an important competency in specialty practice.
While patients may be less worried about exposure than some thera-
pists, it is still useful to frame treatment in such a way as to decease the like-
lihood of a fear of the treatment and to further reduce distress for patients.
In a recent study of exposure for contamination fears, Rachman, Shafran,
Rodomski, and Zysk (2011) found that exposure to a contaminant plus
the use of a sanitary wipe (a safety behavior) was as effective in reducing
contamination fears as was prolonged exposure without the use of safety
behaviors. This is an interesting study with implications for making treat-
ment more palatable, and it contradicts much of the concern that allow-
ing a patient to use any safety behavior will diminish the effectiveness of
exposure. However, whether or not this finding will be replicated and will
generalize to other disorders for which exposure is a treatment of choice
remains an empirical question.
Our discussion of the ethical issues to be considered in exposure ther-

apy is not meant to suggest that exposure is the only treatment for anxiety
disorders. However, it is a component of many treatments for anxiety, even
when conceptualized as a behavioral experiment to test a patient’s beliefs
and predictions, and facing fears may cause some level of distress in nearly
all treatments. For a more detailed history and examination of cognitive
and behavioral therapies for anxiety, including the development of expo-
sure techniques and other cognitive-behavioral treatments see Rachman
(2009).
The second ethical standard to which Olatunji and colleagues (2009)
refer is the requirement to maintain confidentiality when doing exposure.
Confidentiality is of a particular concern since exposure often occurs
outside the therapy office. For example, socially phobic patients are often
accompanied by the therapist in real-world situations, and working out of
the office may compromise confidentiality. Should the patient and ther-
apist run into an acquaintance of the patient, or an acquaintance of the
therapist for that matter, a brief conversation could ensue that could result
in an awkward need for some form of introduction. In the situation when
it is an acquaintance of the therapist who sees the dyad, not introducing
the patient may inevitably hint at the nature of the relationship. This is no
different, however, from the unfortunate and awkward situation that can
occur if a patient says hello to a therapist in a public situation and when
asked by a friend, “How do you know that person?” the therapist is either
silent or provides a vague answer. Most friends of therapists know not to
ask about such things, but there is an inherent suggestion that this could,
indeed, be a patient. Olatunji and colleagues suggest that the therapist and
patient may discuss a plan or even a “cover story” in the event that they are
approached by an acquaintance. They, and we, suggest that one must take
care in developing a cover story. Asking a patient to lie to a friend poses
clinical and ethical dilemmas. The therapist can be vigilant and plan that,
whenever possible, the two will discretely leave a situation if anyone is seen
that can be recognized before an encounter occurs. This does not neces-
sarily remove the possibility that someone knowing the patient may ask
him or her who the person (i.e., the psychologist) was who was with him
or her in that setting. Another way to reduce this problem is to conduct
exposures in a place where both parties are unlikely to run into people they
know. Other suggestions by Olatunji and colleagues are for the psycholo-
gist to remove any name badges, jackets, and so forth, that may identify
her as a professional. It might also be reasonable, given that exposures are
always planned in advance, for the psychologist to “dress down” on the
day so as not to bring attention to the difference in attire between doctor

and patient. In addition to real-world exposures, there are other situations
in which cognitive and behavioral assessment and/or interventions occur
outside the office.
Beyond the Office Walls

As we have discussed in the previous section, assessment and interven-
tion do not always occur just in the therapist’s office. Zur (2002) points
out that many have considered conducting therapy out of the traditional
office setting as a “slippery slope” to an ethical violation of a dual relation-
ship. However, it is important to consider the difference between a bound-
ary “crossing” and a boundary “violation.” The traditional boundaries of
conducting therapy in a professional office setting over a 50-minute hour
may require reconsideration in concert with an individual patient’s case
formulation and clinical treatment targets. For example, behavior analysts
working with populations such as intellectually and developmentally dis-
abled persons, children and families, and individuals in hospital, rehabili-
tation, or correctional facilities often conduct behavioral observations and
treatments in the patient’s residence. It would be ineffective, for example,
to bring a non-verbal patient who engages in self-injurious behaviors to
a therapy office to sit in a strange room and expect that any reasonable
assessment or intervention will occur or transfer to the patient’s real life!.
Boundary violations occur when a therapist steps out of his or her role
as therapist and becomes a friend, a financial backer, an employer, or a
sexual partner. Cognitive and behavioral interventions may take place in a
variety of settings, but the therapist is always to remain in the professional
role. The so-called “slippery slope” can be avoided by the therapist being
aware of not disclosing inappropriate personal information, maintaining
appropriate physical distance from the patient, and setting a very clear
agenda of what will be accomplished by the out-of-office experience that
is based upon their case formulation. All of these considerations should
have a clear documentation and purpose stated in the patient’s clinical file.
Consider an example of a therapist accompanying an anxious patient
out in the community to conduct a behavioral experiment testing the
patient’s belief that “if I am too direct with people they will become ver-
bally assaultive.” The therapist and patient have planned a script that
the patient will go to a variety of shops or cafes and make a very direct
request, for example, “I’d like a small coffee with just a little room for milk,
but please don’t fill the cup too full, thank you.” Knowing that the patient
has a tendency to misinterpret other peoples’ responses, the therapist

accompanies the patient so that they can compare notes about the various
responses. Thus, should the patient later say, “the barista got me the cup of
coffee, but she was quite abrupt with me” the therapist may counter, “what
I observed was that she said, ‘sure, I’d be happy to get that for you,’ smiled,
and gave you a cup of coffee with a little room, just as you’d asked.” They
then can have a productive discussion once they return to the therapist’s
office about the patient’s interpretations. Since the experiment is to see
how people, not just one person, react, the therapist and patient may walk
together to several places. It would be common to chit-chat along such a
walk. Should a patient ask questions such as “Do you get coffee here very
often?” or “Do you ever shop here?” the therapist may respond by saying
yes, or “I actually prefer a different coffee shop.” These could be innocu-
ous self-disclosures for most (although not all) patients. Getting into a
long discussion about types of coffee drinks the therapist prefers, or how
often he or she shops at a particular store, may take the emphasis off the
goal of the therapeutic intervention and stretch the limit of the boundary
crossing.
In another example, a psychologist conducting a behavioral analysis of
a child’s aggressive behavior at dinnertime, may make a visit to the family
home for the purpose of conducting a non-biased observation of family
interactions, triggers, or antecedent situations regarding the behavior, a
careful observation of the behavior itself, and the environmental conse-
quences for the behavior. In such a situation, the assessment can provide
very meaningful data for the behavior analysis, and remaining neutral and
objective are part of maintaining one’s professional role. Having dessert
with the family or participating in a family game or activity would repre-
sent a boundary violation.
Lastly, cognitive and behavioral psychologists, because of their spe-
cialized training, may bring an expertise to clinical situations that are
limited in certain geographic areas, or may be identified as someone who
is the local, trusted “expert.” When a cognitive and behavioral specialist
is approached by individuals seeking assessment and treatment whom
they know in a different context, this represents a “gray” area in which
careful consideration of pros and cons for the patient must be involved
in the decision as to whether or not to take on the case. For example, one
of the authors was a member of a large urban church that had significant
outreach and a commitment to support its members and surrounding
community. The therapist received a self-referral for “couples therapy”
for a member of the church and her fiancé. Although the therapist did
not directly participate in any groups, social events, or projects with this
individual, the specialist did occasionally see her and various members
of her family at church, and knew her well enough to extend a friendly
greeting.
The clinician’s first reaction was to refer the individual to someone else,
wondering if this might represent a possible compromise of objectivity.
The member attended church very infrequently, but her mother attended
with some regularity, and initial thoughts of how the therapist would have
to consider issues such as confidentiality and dual relationships were chief
considerations. The specialist provided some initial thoughts to the church
member regarding possible discomfort for her, her mother, and the con-
cern of a dual role. The potential patient explained that she and her fiancé
had waited a long time before making the step toward seeking help and
stated that their difficulties concerned a type of clinical problem for which
the therapist was known to be an expert. The couple also stated that this
therapist’s training and reputation were the reasons that they had trust in
working with this therapist. The therapist suggested an initial consulta-
tion in which their goals were heard and the therapist’s concerns for the
couple and their family were discussed. This resulted in a mutual deci-
sion to continue. Using a problem-solving framework, various alternatives
for counseling were considered, and the benefits and possible difficulties
inherent in each alternative were listed. Their ultimate decision was based
upon a joint consensus of far more positive consequences for them, which
significantly outweighed other considerations. These included a comfort
with and trust in the therapist, confidence that confidentiality could be
maintained, the therapist’s understanding of the cultural, spiritual, and
family factors involved, and agreement with the therapeutic approach that
would be used. Their strong preference was to engage in treatment with the
therapist, who ensured that they exhibited a clear understanding of mutual
roles and responsibilities. The therapist’s decision was based on the knowl-
edge that protection of their confidentiality would be maintained and the
assessment that objectivity would not be compromised, and was guided by
an aspiration of beneficence and non-maleficence. Specifically, this couple
had long held back painful experiences and the need for treatment. It was
possible that referral to someone else might have negative consequences
regarding their willingness to attend and ultimately on the therapeutic out-
come of their help-seeking. A final consideration was that the therapist
sought the consultation of a colleague who agreed with the decision and
assisted in treatment planning.
Summary
It can be argued that the practice of cognitive and behavioral treatment,
based on empirical evidence of the efficacy of treatments consisting of,
for the most part, carefully described therapeutic techniques, meets the
ethical principles of doing no harm, respecting patient’s autonomy, and
doing good. We know that the outcome literature suggests that we have
some of the most effective treatments. However, psychologists must abide
by the ethical standards set forth by the profession, and the practice of
cognitive-behavioral interventions may lead to inevitable “gray” areas in
which a careful case formulation and review of all relevant factors are
required as part of one’s ethical decision making. We have briefly discussed
and provided some examples of the particular challenges to cognitive and
behavioral practice and have offered suggestions for therapists to practice
according to the highest standards of the profession.
E LE VE N
Individual and Cultural Diversity
Consistent with the core foundational competencies in professional psy-

chology with regard to individual and cultural diversity, Fouad and col-
leagues (2009) outlined the following essential components of competency
as part of an ongoing initiative within professional psychology related to
defining and assessing competence. Intended as a resource for individual
and cultural diversity awareness, it provides an outline of areas in which
particular consideration of these competencies may be applied to cognitive
and behavioral psychology practice.
Area 1. Awareness of the self as shaped by individual and cultural

diversity
This competency requires cognitive and behavioral specialists to be

aware of how their own individual characteristic may impact assessment
and treatment. It includes being able to independently monitor and apply
knowledge of self as a cultural being in assessment, treatment, and consul-
tation. There is not one group of individuals who represent the “norm” for
human behavior. Examples of people not recognizing themselves as cul-
tural beings occur when people say “Why can’t [this newly immigrated
individual] learn to speak my language like everybody else?” or when
people from a dominant (e.g., in the US, straight, white male) group don’t
understand why it is important to talk about gender, sexual orientation, or
race/ethnicity. There can be an implicit notion that one from a dominant
culture does not have an ethnicity—or that sexual orientation or gender
issues only pertain to others. This misconception will inevitably render
Individual and Cultural Diversity 153
one blind to one’s own biases, culture-bound beliefs, and the need to
understand others from the diverse cultures and backgrounds from which
we all come. It also may result in professionals from a dominant culture
expecting that others from ethnic or cultural minority groups will take the
responsibility to deal with cultural concerns, to teach the dominant group
“what they need to know,” and in essence be “the face of diversity,” rather
than recognizing that culturally relative and diverse perspectives include
the dominant cultural perspective as just one form of diversity.
The recognition of how one’s cultural background influences vari-
ous aspects of practice, choice of specialty, and, as A. Nezu (2010) sug-
gests, how one’s cultural background may have shaped his or her “clinical
decision-making road map” (p. 172) is pertinent to all aspects of the work
of cognitive and behavioral specialists. For example, A. Nezu shares a per-
sonal reflection that his cultural background (being Japanese American)
may have influenced his choice of career as a cognitive-behavioral psychol-
ogist with an interest in empirically supported treatments. Additionally, he
describes the school environment that shaped his thinking about science,
where his career goals were initially developed. He also discusses contex-
tual aspects that shape one’s professional trajectory, and how his expe-
rience of being different from others (raised in a community where his
family was the only one of Asian descent) also informed his commitment
to applying empirically supported treatments in an idiographic fashion tai-
lored to individual clients who differ from the sample on which the studies
were based.
Recognition of how a psychologist brings his or her culture, back-
ground, and learning history to bear upon therapy can take many forms.
Psychologists from cultures that are collectivist—rather than individualist,
as are most Western cultures—bring a different awareness of how extended
families or religious and social groups may play an active role in the therapy
process (Mirsalimi, 2010), and that will inform the case conceptualization
and formulation. Lillian Comas-Díaz (2010) describes how her early expe-
riences of being a young Latina child in Chicago, then moving to Puerto
Rico at a young age, and also moving from the working class to the middle
class all affected how she views psychotherapy. Haldeman (2010) points
out how his own experience of being a member of an oppressed minority
(specifically, a gay man) influenced the way he formulates cases, but also
how his experience of cultural privilege (specifically, being a white man in
the US) impacts how he approaches cases.
Therapists must recognize that they themselves are stimulus objects
with all of their patients. Patients will react to therapists according to their
individual histories with similar people. All aspects of diversity come into
play here. A young, physically fit, attractive, female therapist working with
an older, obese, female patient may be experienced by that patient as inca-
pable of understanding her difficulties, or the patient may be reticent to
discuss her struggles out of fear of being judged. The patient may have had
negative experiences with attractive girls during her school years. Hamid
Mirsalimi (2010) reflected upon his experience of being a Iranian psy-
chologist in private practice in the United States following the attack on
the World Trade Center in 2001, when calls from white American patients
diminished. Even a therapist’s name may be a stimulus that triggers fears
and prejudice in patients or potential patients. On the other hand, some
patients may selectively seek treatment from a therapist who they believe
to be different from themselves. Haldeman (2010) noted that some of his
straight, female patients had actually sought out an openly gay male thera-
pist because, as in one case, “it makes a bridge to the world of men in
general” (p. 182).
Area 2. Awareness of others as shaped by individual and cultural

diversity requires cognitive and behavioral psychologists to
independently monitor and apply knowledge of others as cultural
beings in assessment, treatment, and consultation.
Cognitive and behavioral specialists must be aware of the extant

research on applying cognitive-behavioral therapy strategies with cul-
tural and ethnic minority populations. The available research on adapta-
tions and applications of such interventions with ethnically and culturally
diverse populations is sparse, and there are indications that low rates of
publication in the area have remained stable for the past ten years (Nezu
& Greenberg, 2012). In a review of research on cognitive and behavioral
therapies with ethnic minorities, Nezu and Greenberg found a limited
number of studies that had been conducted and reviewed selected exam-
ples of the studies, particularly randomized clinical trials (RCTs), which
represent the most highly regarded research to provide empirical support
for the use of a particular treatment with a particular population or for a
specific disorder.
Some examples of the studies reviewed by Nezu and Geenberg (2012)
that did conduct RCTs exclusively with ethnic minority populations are
Carter, Sbrocco, Gore, Marin, and Lewis (2003), who conducted a trial of
culturally adapted panic control treatment (PCT; Barlow & Cerny, 1988) in
a group format with African American participants. The results of the
study indicated that the participants in the culturally adapted PCT group
experienced a significant reduction in panic severity and number of panic
attacks. Kohn, Oden, Munoz, Robinson, and Leavitt (2002) examined the
efficacy of an intervention in which aspects of the African American culture
were deliberately integrated into a treatment for depressed, low-income
minority populations that had originally been developed by Muñoz and
Miranda (1986). The published results of this study showed a reduction in
depressive symptoms from pre-treatment to post-treatment, and the group
of participants who chose to be in the cognitive-behavioral therapy group
adapted for African American Women (AACBT) had reductions of symp-
toms at twice the rate of those who were in the non-adapted group.
Some studies examining the effectiveness of cognitive and behavioral
interventions with recent immigrants to the United States have been con-
ducted, shedding some light on the application of such approaches with
people from ethnic minority groups. Otto and Hinton (2006) studied an
adaptation of exposure-based cognitive-behavioral therapy for Cambodian
refugees experiencing post-traumatic stress disorder (PTSD). The authors
identified challenges and culturally appropriate adaptations that can be
made. The challenges included limited English, illiteracy, limited resources,
cultural barriers, somatic presentations of symptoms, and culture-specific
interpretations. Modifications to the treatment included providing the
intervention in a group format that did not mimic a classroom-like set-
ting (which might resemble experiences of living under a dictatorship),
slowing the pacing of the treatment, and allowing for open discussion.
Santiago-Rivera, Kanter, Benson, Derose, Illes, and Reyes (2008) con-
sidered similar challenges of language, education, and fewer financial
resources in a pilot adapting behavioral activation (BA) for depression in a
Latino/Latina health center with clients who were primarily recent immi-
grants from Mexico and Puerto Rico. Adaptations to BA included using
culturally sensitive activation targets in the context of Latino-specific val-
ues and beliefs, and focusing on stress and avoidance. The BA protocol
also was flexible enough to include addressing issues of unemployment,
helping the participants to use job searches, and addressing the under-
standable anxiety and avoidance that accompany the many tasks that can
be overwhelming for someone who is not fluent in English, or who may
be intimidated by bureaucratic institutions. Other adaptations included
using proverbs rather than acronyms to express concepts that are useful to
teach in a course of BA. The authors suggest that pasos de acción, or “action
steps,” minimize the stigma associated with depression and seeking mental
health treatment.
Practices and values that are important to patients because of their cul-
tural context may be beneficial to apply in the context of cognitive and
behavioral treatments. Cervantes (2010) and Comas Diaz (2010) both
describe the importance of understanding patients from a spiritual per-
spective, as this can be essential to the cultural beliefs and practices of
some patients. While this may seem at odds with an empirically driven
treatment like most cognitive and behavioral therapies, individual patient’s
beliefs can be very important to incorporate in treatment and should never
be discounted as irrational or foolish. Cervantes (2010) presents the role
of “La Virgen de Guadalupe” as an archetypal figure, representing a fusion
of indigenous beliefs with Catholicism in Mexican Catholicism. A patient
who prays for the intercession of “La Virgen” to help her face a feared
social situation may be using a helpful, curative strategy that should not be
regarded as safety behavior or superstitious thinking. Of course, one would
check to ensure that she was asking for strength or courage and not ask-
ing “La Virgen” to take her fear away or protect her from perceived social
disapproval. Still, one can practice competent cognitive-behavioral therapy
while remaining culturally sensitive and incorporating the patient’s cultural
wisdom and practices at the same time. With regard to spiritual-cultural
practices, Nezu and Nezu (2003) have provided suggestions regarding how
to integrate cognitive and behavioral practice with spiritual beliefs and tra-
ditions across various belief systems.
In their literature review of RCTs evaluating the efficacy of
cognitive-behavioral therapy with ethnic minority populations, Nezu and
Greenberg (2012) conclude that cognitive-behavioral researchers and cli-
nicians should take into account dimensions that may impact work with
ethnic minority populations. First, concerns about poverty and lower
socioeconomic status must be taken into account. The disenfranchise-
ment of ethnic minority and cultural minority groups from the dominant
culture can lead to serious economic disadvantage for many members of
these groups. Treatment providers must take into account the enormous
cost—financially but also in terms of getting child care, missing time at
work, and so forth—that is the real price ticket on cognitive-behavioral
therapy. Researchers need to strictly adhere to guidelines for the protection
of human subjects when it comes to providing financial incentives that
may be coercive to lower SES participants. Immigration status must also
be considered, as this is directly relevant to many aspects of clients seek-
ing therapy or participating in research. New immigrants may not be flu-
ent in English, and have not adapted culturally. For immigrants who have
not yet obtained legal status, participating in research or seeking treatment
from a behavioral health provider may be a threatening endeavor and may

trigger fears of having illegal immigration status discovered, resulting in
negative consequences. Seeking professional help for emotional problems
may be stigmatized in some cultures, and this stigma is another dimension
to consider. Cognitive and behavioral specialists must take into account
cultural values, the importance of family, and the importance of religion
and spirituality, and should use metaphors, analogies, and images that are
culturally relevant. Many participants from ethnic minority groups have
experienced discrimination in other settings and may expect the same
from research institutions or clinicians. These are some considerations that
can help cognitive-behavioral researchers and clinicians to be more cul-
turally sensitive and competent when working with participants or clients
from ethnic minority cultures. These considerations also apply to people
from sexual minorities, many of whom have multiple minority status (e.g.,
female, lesbian or bisexual, person of color, individual from a minority reli-
gious tradition, etc.).
Reviews of the literature concerning cognitive and behavioral therapies
with lesbian, gay, bisexual, or transgender studies yields an even smaller
sample of RCTs that have been conducted with this population exclusively.
In fact, the only studies that appear when one uses the descriptors of “ran-
domized” and “cognitive-behavior therapy” with any words depicting les-
bian, gay, bisexual, or transgender are most often studies on cognitive and
behavioral therapy trials with HIV-seropositive gay men. So, while these
data and studies are important for better treatment, the field continues to
lag far behind in culturally based cognitive-behavioral intervention tri-
als with LGBT participants. There are studies that have assessed unique
differences in LGBT populations, and some authors have combined the
cognitive and behavioral treatment literature with these other data to
propose an LGBT-affirmative cognitive-behavioral approach for these
populations (Martell, Safren, & Prince, 2004). It is also clear that there is
a great deal of ethnic and cultural diversity within LGBT communities.
This is not insignificant. Greene (1994) has pointed out, for example, that
lesbian women of color may face “triple jeopardy” regarding coping with
social stigma and oppression, being members of three groups that have
traditionally been marginalized by the larger culture (i.e., female, lesbian,
and a person of color). More recently, Greene (2007) has pointed out that
there may be quadruple jeopardy. Specifically, she describes the level of
social marginalization and disadvantage that makes life more difficult for
them. She illustrates how, from the moment they are aware of their sexual
minority status, they are equally aware of the challenges that their status
will bring to their lives. As Greene points out, lesbians must negotiate the
sexism that all women face. If they are members of ethnic minority groups,
they must negotiate racism. If they have a physical or perceptual disability,
they must additionally negotiate able-ism. Finally, when in advanced years
of life, they must negotiate ageism as well. Thus, all of the various loca-
tions of social disadvantage are intensified for lesbians. This underscores
the fact that lesbian women face the additional and ubiquitous challenges
that are a function of their sexual minority status. While much of this is
true for gay men of color as well, Greene (2007) underscores the point
that women in general were typically understudied in the mental health
literature and that now lesbians have become a “footnote” in the mental
health literature on women. Culturally sensitive cognitive and behavioral
specialists will be aware of these challenges for their LGBT clients, whether
those LGBT clients are younger, male, female, white, people of color, and
all other possible diversities that make the LGBT “community” in reality
LGBT “communities.”
There is often an assumption that any competent cognitive and behav-
ioral specialist who does not hold negative views of LGBT people can pro-
vide competent therapy. While this is true in part, there are still considerable
subcultural differences from majority culture that need to be considered.
As mentioned in the previous paragraph, there also are multiple identities,
other than simply being a member of the LGBT community, which provide
specific challenges. The number of “micro-aggressions”—“brief and com-
monplace daily verbal, behavioral and environmental indignities, whether
intentional or unintentional, that communicate hostile, derogatory, or
negative racial slights and insults to the target person or group” (Sue et al.,
2007, p. 273) also apply to slurs regarding sexual minority status and are
multiplied for LGBT people of color.
Consider a Christmas season afternoon for a gay, African American
male, stopping off at a store to purchase a bottle of wine to bring to a holi-
day party, who experiences the following. In the store, as he turns into the
wine aisle, he sees an older white male look at him briefly and then check
to make sure that his wallet is still in his back pocket. Once he is home, he
turns on his television for a little background noise while he’s fixing a des-
sert to bring to the party, and a commercial comes on wherein one male
character mistakes the statement of a second male character as a “come on”
and makes a subtle threat. When he then goes to the party, the hosts turn
on a classic old movie, Holiday Inn, and the young man is shocked to see a
blackface scene in this so-called “family classic.” While not directly hostile
toward this particular individual, each of these events can be experienced
as demeaning or, at the very least, may elicit emotional arousal for this
individual that others in his social group who are either not gay or not
black do not have to contend with.
Area 3. With regard to the interaction of self and others, it is

important for a cognitive and behavioral specialist to be aware
and sensitive to intersecting and complex dimensions of diversity,
for example, the relationship between one’s own dimensions
of diversity and one’s own attitudes toward diverse others to
professional work.
Another consideration that a culturally competent cognitive and behav-

ioral specialist will address is the diversity within ethnic minority groups.
Not only, as was stated earlier, can one not have any meaningfully complete
understanding of any one group of people from a particular cultural group,
but also, people may have multiple ethnic identities (e.g. Root, 1995) or
multiple identities in several areas (e.g. gender, ethnicity, sexual orienta-
tion; Greene, 1994).
Understanding the identification of multi-ethnic individuals with their
ethnic heritage or various ethnic heritages is necessary to ensure that one
not make an assumption that someone whose physical features suggest that
she is of a certain ethnicity identifies with that particular background when
in fact she does not identify as such. People also have multiple identities
that are not based on ethnicity, but also will identify with certain socioeco-
nomic class distinctions, or with a sexual minority, or identify as a different
gender from that suggested by their appearance. There is great complexity
involved in cultural, racial, ethnic, or sexual identity. Cognitive-behavioral
psychologists must never make assumptions based on physical characteris-
tics or behavioral presentations alone. As we stated earlier, simply believing
about oneself that one does not harbor negative attitudes toward anybody
is not sufficient qualification to work with diverse groups of people.
Anyone who has taken, either as a research participant or simply for
personal exploration, the Implicit Association Test (IAT; Greenwald,
McGhee, & Schwartz, 1998) has likely been surprised to find results stating
that they show a preference for people of their own race/ethnicity or sexual
orientation. While the reliability and validity of such a measure as the IAT
is beyond the scope of this chapter, the point remains that we all are subject
to our learning histories and conditioning. We each have classically condi-
tioned emotional responses toward other people, and we may be unaware
that we have been conditioned in these ways. We also are subject to making
explicit assumptions and having explicit biases. Culturally competent cog-

nitive and behavioral practitioners will not evade facing their own biases.
Multicultural competence is complex, but not necessarily onerous. The
requirements are for ongoing study, reviewing research data on cognitive
and behavioral intervention strategies conducted with relevant population
samples; ongoing training and supervision; and ongoing self-reflection
and, perhaps, self-directed change. These requirements hold true whether
one is from a dominant ethnic or social group, or from a numerical minor-
ity group. Nobody is exempt from seeing the world through his or her own
cultural lens, although some individuals may have learning histories that
make them more aware of the impact of the cultural lens on their interac-
tions with others, and particularly on their professional practices.
TWE LVE
Professional Identification
Cognitive and behavioral specialists have significantly evolved over the

past 75 years, since the nascent stages of their specialty, as described in the
Chapter 1. Rather than restate the evolution of the relatively new specialty,
it may be more useful to discuss how the current characteristics of the
professional identity of individuals who practice this specialty differ from
those of the past, as well as to consider the specialty’s future. As Dowd,
Clen, and Arnold (2010) stated in a recent article outlining the specialty
practice of cognitive and behavioral psychology, “Cognitive and behavioral
psychology is not a default description of what many clinicians do.” As
illustrated in previous chapters, the specialty is based upon the application
of learning principles and a wide scientific literature base to the develop-
ment of effective psychotherapeutic interventions.
The Journey from Mechanistic to Holistic

In Chapter 9, which focused on interpersonal considerations, we dis-
cussed how operant learning theory provides a theoretic base for under-
standing the dynamic functions involved in the complex interactions in
a relationship. Cognitive and behavioral interventions have evolved from
observations that were initially focused on the objective assessment of
overt environmental occurrences to the integration of vast amounts of sci-
entific literature to construct a comprehensive bio-psycho-social-neural
understanding of how these various components all result in our learned
patterns of emotional reactivity, thoughts, and behavior. Throughout the
development of the specialty, however, there has been a strong desire to
maintain the hallmark of empiricism that originally defined the specialty.

This preference for reliance on assessment and treatment interventions
with a strong evidence base characterizes the professional identity of the
cognitive and behavioral specialist. The commitment to evidence-based
treatment is often realized through the collection of baseline informa-
tion about a patient at the beginning of treatment and the use of ongo-
ing assessment to monitor the effectiveness of treatment using reliable and
valid measures. Despite different areas of specialty emphasis, cognitive and
behavioral psychologists generally agree that a shared goal is to help build
the patients’ resilience, or capacities to cope with life stress, without con-
tinuous and chronic dependency upon a psychotherapist.
Maintaining Professional Identification

Through Professional Organizations
One ongoing challenge for the specialty is that it has no specific psy-
chology division within the American Psychological Association (APA).
Although many cognitive and behavioral specialists are active mem-
bers of APA, their division membership is somewhat splintered across
several divisions. APA divisions with a strong cognitive and behavioral
presence include Division 12 (Society for Clinical Psychology), Division
12, Section 3 (Society for the Science of Clinical Psychology), Division
25 (Experimental Analysis of Behavior), and Division 33 (Intellectual
and Developmental Disabilities). This makes the specialty identifica-
tion in APA less clear than for other specialties. However, cognitive
and behavioral psychology has maintained specialty recognition by the
APA Committee for the Recognition of Specialties and Proficiencies in
Professional Psychology (CRSPPP) since 2000. Because of this recogni-
tion, the American Board of Behavioral Psychology, ABPP, actively par-
ticipates in the Council of Specialties, an organization consisting of all
specialties recognized by CRSPPP.
Board certification through the American Board of Cognitive and
Behavioral Psychology, under the umbrella of the overarching American
Board of Professional Psychology (ABPP), provides an assurance to both
the public and the profession that the specialist in cognitive and behavioral
psychology has met the education, training, and experience requirements,
as well as demonstrating the advanced competencies required by the spe-
cialty through an individualized, peer-reviewed examination. The ABPP
continues to remain a “gold standard” for peer assessment of competency
across its now 15 specialties.
Professional Identification 163
Meaningful involvement with the profession of psychology in general

and the specialty field of cognitive and behavioral psychology in particular
is an important part of the continued professional development of the cog-
nitive and behavioral specialist. Several organizations provide especially
meaningful opportunities for cognitive and behavioral specialists to learn
of advances in the field, to network with other professionals, and to engage
in continuing education opportunities. A few of these organizations are
mentioned below.
ASSOC I AT I O N F O R B EHAV IORA L

AND C O GN I T I V E T H E RA P IES (A B C T)
This multidisciplinary organization provides a major vehicle for collegial

interaction and professional development for cognitive and behavioral spe-
cialists. The stated mission of this organization is a commitment “to the
advancement of scientific approaches to the understanding and improve-
ment of human functioning through the investigation and application of
behavioral, cognitive, and other evidence-based principles to the assessment,
prevention, treatment of human problems, and the enhancement of health
and well-being” (ABCT webpage, retrieved September 2012). During ABCT
conventions, which are held every November, it is easy to find relevant pan-
els, symposia, and workshops that are recognized as formal, continuing edu-
cation activities for cognitive and behavioral specialists. Additionally, the
organization has a cooperative association with the American Academy of
Cognitive and Behavioral Psychology and the American Board of Cognitive
and Behavioral Psychology to provide convention spaces for board meet-
ings, ABPP board certification examinations, and preparatory workshops
for candidates who are interested in pursuing board certification.
T H E AM E R I C A N P S YC H OLOGIC A L S OC IETY
“APS was founded in 1988 to promote, protect and advance scientific psy-
chology at the national and international levels” (APS webpage, retrieved
November 2012). Many cognitive-behavioral specialists who are commit-
ted to promoting practice with a strong evidence base are members of APS,
which has shown strong growth since its inception.
Journals Relevant to the Specialty

There are many journals that are relevant to the specialty, as well as many
published therapy manuals. As is evident from Table 3.1 in Chapter 3, there
are many journals that are dedicated to the specialty. Additionally, many
clinical psychology journals will provide information concerning the latest
research with regard to cognitive and behavioral psychology. Finally, there
are many relevant journals from other fields or specialties, such as Science
or Neuropsychology, that may spotlight the importance of learning-based
theories and interventions to better understand psychological phenomena
associated with the journal.
There many texts that offer compendiums of assessment and interven-
tion across a wide range of disorders, life problems, and evidence-based
interventions. These include, but are not limited to, the Clinical Handbook
of Psychological Disorders: A Step-by-Step Treatment Manual (4th ed.;
Barlow, 2008), Cognitive Behavior Therapy (O’Donohue & Fisher, Eds.,
2012), Handbook of Cognitive-Behavioral Therapies (Dobson, 2010), and
the Encyclopedia of Behavior Modification and Cognitive Behavior Therapy
(Hersen & Rosqvist, 2005) These are just a few of the available handbooks
and compendiums available. Each year new handbooks and encyclopedias
are published, along with updated editions of previous volumes.
There are also many treatment manuals for the interventions described
in the previous chapters, as well as many other evidence-based interven-
tions that were not specifically highlighted in this book. These can often be
obtained through a search of the authors’ names who are associated with
a specific assessment technology or intervention. Additionally, several
publishers have developed series of manuals for the cognitive and behav-
ioral specialists. One such example is the Treatments That Work series,
published by Oxford University Press. Containing over 65 manuals and
workbooks for a wide range of interventions and treatments, this series
contains step-by-step detailed procedures for assessing and treating spe-
cific problems and diagnoses. The series also provides ancillary materials
that will approximate the supervisory process in assisting practitioners in
the implementation of these procedures in their practice. David Barlow
(2006) is the editor-in-chief of the series, which is devoted to communicat-
ing interventions with an evidence base to clinicians on the front line of
practice. With regard to the use of resources such as this for documenta-
tion of continuing professional development, some training manuals may
offer continuing education (CE) credit, often required of psychologists as
part of their licensure renewal. In the case of the Treatments That Work
series, Oxford University Press has partnered with PsychoEducational
Resources, Inc. (PER), so that CE credits are available for reading selected
volumes in the Treatments That Work Series. The website access for this
process is available in the list of websites below.
Professional Identification 165
Websites that have been mentioned throughout the book may also pro-
vide a wealth of information about specialty board certification though
ABPP, behavior analyst certification, specialty activities sponsored by the
AABT or the American Academy of Cognitive and Behavioral Psychology,
and upcoming conferences, continuing education opportunities, and pre-
sentations. These include:
http://www.aacbp.org/ (American Academy of Cognitive and Behavioral

Psychology).
http://www.abainternational.org/ (Association for Behavior Analysis).
http://www.abpp.org/i4a/pages/index.cfm?pageid=3315 (American Board
of Cognitive and Behavioral Psychology).
http://www.abpp.com/ (American Board of Professional Psychology).
http://www.abct.org (Association for Behavioral and Cognitive
Therapies).
http://www.apbahome.net/ (Association of Professional Behavior
Analysts).
http://www.bacb.com/ (Behavior Analyst Certification Board).
http://www.eabct.com/ (European Association for Behavioural and
Cognitive Therapies).
http://www.youtube.com/watch?v=g0KLDsjHH54 (Video overview of the
ABPP Specialty of Cognitive and Behavioral Psychology).
http://per-ce.net/ce/ttw.php (Website for continuing education credits for
the Treatments That Work series from Oxford University Press).
International Associations
There are cognitive and behavioral specialists practicing all over the
world. Organizations have been developed in North America (ABCT),
Latin America (Asociación Latinoamericana de Análisis, Modificación del
Comportamiento y terapia cognitivo conductual; ALAMOC), Asia (Asia
Cognitive Behavioral Therapy Association, ACBTA), the United Kingdom
(British Association for Behavioural and Cognitive Psychotherapies;
BABCP) and Europe (European Association of Cognitive and Behavioural
Therapies; EACBT). Additionally, there are global organizations that are
specifically focused on one of the areas of emphasis under the general
umbrella of cognitive and behavioral therapies, such as the International
Association for Cognitive Psychotherapy (IACBP). Every three years, six

organizations that promote education and dissemination of cognitive
and behavioral therapies around the world sponsor a World Congress for
Behavioral and Cognitive Therapies (WCBCT). The WCBCT provides an
opportunity for researchers and clinicians from all corners of the globe to
meet and discuss “state of the art” cognitive and behavioral psychothera-
pies across its many applications throughout the fields of psychology, psy-
chiatry, and related mental health service providers.
Applied Behavioral Analysis

Specific to the methods and technology of applied behavior analysts, there
are organizations, such as the Behavior Analyst Certification Board®, Inc.
(BACB®), that were developed to credential professionals and require
review and evaluation of their training and skills to protect the integrity
of such interventions. With regard to a worldwide focus, there is also the
Association for Behavior Analysis, International (ABAI), which is a non-
profit organization with a mission that supports the growth and vitality of
the science of behavior analysis through research, education, and practice.
Lifelong Learning and Continuing Professional Development

Cognitive and behavior specialists are committed to a lifelong learning
process. Although the theories upon which the specialty was originally
grounded have a long history, the paradigms of scientific study shift over
time, and communication innovations contribute to a continual surge of
new information. New technologies in brain imaging, virtual reality, and
other phenomena add to a deepening understanding of how people learn,
and cognitive behavioral specialists must remain current in their knowl-
edge of the science related to their professional work if they are to provide
the most competent patient care possible. Information from these new
frontiers are occurring as this book is written with regard to understanding
brain plasticity and the ways in which cognitive and behavioral interven-
tions can actually create new paths with regard to neuroprocessing, how
cognitive and emotional processes are related and often dependent upon
one another, and the efficacy of delivering interventions in non-traditional
ways, such as virtual reality or through the Internet. Cognitive behavioral
specialists are and will continue to be leaders in these emerging areas.
RE F E RE N C E S
AAPB. (2011). Retrieved June 23, 2012, from the Association for Applied Psychophysiology
and Biofeedback, Inc.: www.aapb.org/i4a/pages/index.cfm?pageid=1
ABCT (2012). Retrieved September 25, 2012, from the Association for Behavioral and
Cognitive Therapies: www.abct.org/Home/
Ader, R. (Ed.). (2007). Psychoneuroimmunology (4th ed., Vol. II). Burlington, MA: Elsevier
Academic Press.
Ader, R., & Cohen, N. (1975). Behaviorally conditioned immunosuppression. Psychosomatic
Medicine, 37, 333–340.
Ader, R., & Cohen, N. (1993). Psychoneuroimmunology: Conditioning and Stress. Annual
Review of Psychology, 44, 53–85.
Ader, R., Felton, D. L., & Cohen, N. (Eds.). (1981). Psychoneuroimmunology. Burlington,
MA: Elsevier Academic Press.
Alloy, L. B., Peterson, C., Abramson, L. Y., & Seligman, M. E. (1984). Attributional style and
the generality of learned helplessness. Journal of Personality and Social Psychology, 46,
681–687.
American Board of Cognitive and Behavioral Psychology. (2010). Cognitive and Behavioral
Psychology. Retrieved August 30, 2010, from American Board of Professional
Psychology: http://www.abpp.org/i4a/pages/index.cfm?pageid=3358
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., Text Revision). Washington, DC: Author.
American Psychological Association. (2002). Ethical principles of psychologists and code
of conduct. Washington, DC: Author.
American Psychological Association (2013, March). Definition of “psychology.” Retrieved
from http://www.apa.org/about/index.aspx.
Andrews, D. A., Zinger, I., Hoge, R. D., Bonta, J., Gendreau, P., & Cullen, F. T. (1990).
Does correctional treatment work? A clinically relevant and psychologically informed
meta-analysis. Criminology, 28(3), 369–404.
Antony, M. M., Orsillo, S. M., & Roemer, E. (Eds.). (2001). Practitioner’s guide to empirically
based measures of anxiety. New York: Kluwer Academic/Plenum Publishers.
Antony, M. M., & Roemer, L. (2011). Behavior therapy. Washington, DC: APA.
Astin, J. A., Beckner, W., Soeken, K., Hochberg, M. C., & Berman, B. (2002). Psychological
interventions for rheumatoid arthritis: A meta-analysis of randomized controlled trials.
Arthritis Care & Research, 47, 291–302.
168 References
Astin, J. A., Shapiro, S. L., Eisenberg, D. M., & Forys, K. L. (2003). Mind-body medicine: State
of the science: Implications for practice. Journal of the American Board of Family
Practice, 16, 131–147.
Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied
behavior analysis. Journal of Applied Behavioral Analysis, 1, 91–97.
Bandura, A. (1969). Principles of behavior modification. New York: Holt Rinehart &
Winston.
Bandura, A. (1976). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.
Bandura, A., & Walters, R. H. (1963). Social learning and personality development.
New York: Holt Rinehart and Winston.
Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., & Siqueland, L. (2009). Alliance
predicts patients’ outcome beyond in-treatment change in symptoms. Personality
Disorders: Theory, Research, and Treatment, 1, 80–89.
Barker, Lewis, M. (2000) Learning and behavior: Biological, psychological, and sociological
perspectives (3rd ed.). NJ: Prentice Hall.
Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and
panic. New York: Guilford.
Barlow, D. H. (Editor in Chief) (2006). Treatments That work. New York: Oxford
University Press.
Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment for emotional
disorders. Behavior Therapy, 205–230.
Barlow, D. H., & Cerny, J. A. (1988). Psychological treatment of panic. New York:
Guilford Press.
Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., &
Ehrenreich M. J. (2011). Unified protocol for transdiagnostic treatment of emotional
disorders: Therapist guide. New York: Oxford University Press.
Barlow, D. H., Nock, M. K., & Hersen, M. (2009). Single case experimental designs: Strategies
for studying behavior change (3rd ed.). Boston: Allyn and Bacon.
Baer, D. M., Wolf, M. M., & Risely, T. R. (1968). Some current dimensions of applied
behavior analysis. Journal of Applied Behavior Analysis, 1, 91–97.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: Penguin Books.
Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive
perspective. New York: Basic Books.
Beck, A. T., Freeman, A., & Davis, D. (2006). Cognitive therapy of personality disorders.
New York: Guilford Press.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.
Beck, R., & Fernandez, E. (1998). Cognitive-behavioral therapy in the treatment of
anger: A meta-analysis. Cognitive Therapy and Research, 22, 63–74.
Bell, A. C., & D’Zurilla, T. J. (2009). Problem-solving therapy for depression: A meta-analysis.
Clinical Psychology Review, 29, 348–353.
Bellack, A. S., Mueser, K. T., Gingerich, S., & Agresta, J. (2004). Social skills training for
schizophrenia: A step-by-step guide. New York: Guilford Press.
Beltman, M. W., Oude Voshaar, R. C., & Speckens, A. E. (2010). Cognitive-behavioural
therapy for depression in people with a somatic disease: Meta-analysis of randomised
controlled trials. The British Journal of Psychiatry, 197, 11–19.
References 169
Bennett, D. S., & Gibbons, T. A. (2000). Efficacy of child cognitive-behavioral

interventions for antisocial behavior: A meta-analysis. Child & Family Behavior
Therapy, 22, 1–15.
Bernstein, D. A., Borkovec, T. D., & Hazlett-Stevens, H. (2000). New directions in progressive
relaxation training: A guidebook for helping professionals. Westport, CT: Praeger.
Bieschke, K. J., Fouad, N. A., Collins, F. L., & Halonen, J. S. (2004). The scientifically
minded psychologist: Science as a core competency. Journal of Clinical Psychology,
80, 713–724.
Bijou, S. W., Peterson, R. F., & Ault, M. H. (1968). A method to integrate descriptive
experimental field studies at the level of data and empirical concepts. Journal of Applied
Behavior Analysis, 1, 175–191.
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., &
Keane, T. M. (1995). The development of a clinician-administered PTSD scale. Journal
of Traumatic Stress, 8, 75–90.
Bouton, M. E. (2002). Context, ambiguity, and unlearning: Sources of relapse after
behavioral extinction. Biological psychiatry, 52, 976–986.
Bouton, M. E. (2007). Learning and behavior: A contemporary synthesis. Sunderland,
MA: Sinauer Associates.
Buck, M. (2010). Two-factor theory of learning: Application to maladaptive behavior.
School & Health, 21, 333–338.
Burns, D. D. (1980). Feeling good: The new mood therapy. New York: Avon Books.
Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (2001). Minnesota
Multiphasic Personality Inventory-2 Minneapolis: University of Minnesota Press.
Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of
cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review,
26, 17–31.
Cappas, N. M., Andres-Hyman, R., & & Davidson, L. (2005). What psychotherapists can
begin to learn from neuroscience: Seven principles of a brain-based psychotherapy.
Psychotherapy: Theory, Research, Practice & Training, 42, 374–383.
Carter, M. M., Sbrocco, T., Gore, K. L., Marin, N. W., & Lewis, E. L. (2003).
Cognitive-behavioral group therapy versus a wait-list control in the treatment of African
American women with panic disorder. Cognitive Therapy and Research, 27, 505–518.
Cervantes, J. M. (2010). Mestizo spirituality: Toward an integrated approach to psychotherapy
for Latina/os. Psychotherapy: Theory, Research, Practice, Training, 47, 527.
Choy, Y., Fyer, A. J., & Lipsitz. (2007). Treatment of specific phobia in adults. Clinical
Psychology Review, 27, 266–286.
Cohen, D. & Gunz, A. (2002). As seen by the other . . . : Perspectives on the self in the
memories and emotional perceptions of easterners and westerners. Psychological
Science, 13, 55–59.
Comas-Diaz, L. (2010). On being a Latina healer: Voice, consciousness, and identity.
Psychotherapy Theory, Research, Practice, Training, 47, 162–168.
Cook, T. D., & Campbell, D. T. (1979). Quasi-experimentation: Design and analysis issues
for field settings. Chicago: Rand McNally.
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analyses (2nd ed.).
Upper Saddle River, NJ: Prentiss Hall.
Craske, M. G., & Barlow, D. H. (2007). Mastery of your anxiety and panic: Therapist guide
(4th ed.). New York: Oxford University Press.
170 References
Cuijpers, P., van Straten, A., & Warmerdam, L. (2007). Behavioral activation treatments of
depression: A meta-analysis. Clinical Psychology Review, 27, 318–326.
Damasio, A. (1999). The feeling of what happens: Body and emotion in making
consciousness. New York: Harcourt.
Darwin, C. (1872). The expression of the emotions in man and animals. London: Murray.
Davidson, R. J. (2000). Affective style, psychopathology, and resilience: Brain mechanisms
and plasticity. American Psychologist, 55, 1196–1214.
Davidson, R. J., & Begley, S. (2012). The emotional life of your brain. New York: Hudson
Street Press.
Davidson, R. J., & Fox, N. A. (1982). Asymmetrical brain activity discriminates between
positive versus negative affective stimuli in human infants, Science, 218, 1235–1237.
Davis, D. D. (2009). Ethical challenges in cognitive behavioral research, training and
practice. Cognitive and Behavioral Practice, 16, 149–152.
Davis, M. (1974). Sensitization of the rat startle response by noise. Journal of Comparative
and Physiological Psychology, 8, 571–581.
Deffenbacher, J. L., Oetting, E. R., & DiGiuseppe, R. A. (2002). Principles of empirically
supported interventions applied to anger management. The Counseling Psychologist,
30, 262–280.
DeRubeis, R. J., Brotman, M. A., & Gibbons, C. J. (2005). A conceptual and methodological
analysis of the nonspecifics argument. Clinical Psychology: Science and Practice, 12,
174–183.
Dimeff, L. A. & Koerner, K. (Eds.), (2007). Dialectical behavior therapy in clinical
practice: Applications across disorders and settings. New York: Guilford Press.
Dimidjian, S., Barrera, Jr., M., Martell, C., Munoz, R. F., & Lewinsohn, P. M. (2011). The
origins and current status of behavioral activation treatments for depression. Annual
Review of Clinical Psychology, 7, 1–38.
Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., et al. (2006).
Randomized trial of behavioral activation, cognitive therapy, and antidepressant
medication in the acute treatment of adults with major depression. Journal of Consulting
and Clinical Psychology, 74, 658–670.
Ditto, B., Eclache, M., & Goldman, N. (2006.) Short-term autonomic and cardiovascular
effects of mindfulness body scan meditation. Annals of Behavioral Medicine, 32,
227–234.
Dobson, K. S. (Ed.). (2010). Handbook of cognitive-behavioral therapies. New York:
Guilford Press.
Dobson, K. S., & Khatri, N. (2000). Cognitive therapy: Looking backward, looking forward.
Journal of Clinical Psychology, 56, 907–923.
Doss, B. D., Thum, Y. M., Sevier, M., Atkins, D. C., & Christensen, A. (2005). Improving
relationships: Mechanisms of change in couple therapy. Journal of Consulting and
Clinical Psychology, 73, 624–633.
Dowd, E. T. (2000). Cognitive hypnotherapy. New York: Jason Aronson.
Dowd, E. T. Chen, S. L., & Arnold, K. D. (2010). The specialty practice of cognitive and
behavioral psychology. Professional Psychology: Research and Practice, 41, 89–95.
Dymond, S., & Roche, B. (2009). A contemporary behavior analysis of anxiety and
avoidance. Behavior Analyst, 32, 7–27.
D’Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification.
Journal of Abnormal Psychology, 78, 106–126.
References 171
D’Zurilla, T. J., & Nezu, A. M. (2007). Problem solving therapy: A positive approach to
clinical intervention (3rd ed.). New York: Springer.
D’Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (2004). Social problem solving: Theory
and assessment. In E. C. Chang, T. J. D’Zurilla, & L. J. Sanna (Eds.), Social problem
solving: Theory, research, and training (pp. 11–27). Washington, DC: American
Psychological Association.
Edinger, J. D., & Carney, C. E. (2008). Overcoming insomnia: A cognitive-behavioral
approach. New York: Oxford University Press.
Eells, T. D. (Ed.). (2007). Handbook of psychotherapy case formulation. New York:
Guilford Press.
Eells, T.. D., Lombart, K. M., Kendjelic, E. M., Turner, L. C., & Lucas, C. P. (2005). The
quality of case formulations: A comparison of expert, experienced, and novice
cognitive behavioral and psychodynamic therapists. Journal of Consulting and Clinical
Psychology, 4, 579–589.
Ekers, D., Richards, D., & Gilbody, S. (2008). A meta-analysis of randomized trials of
behavioural treatment of depression. Psychological Medicine, 38, 611–623.
Ekman, P., & Rosenberg, E. L. (Eds.). (1998). What the face reveals: Basic and applied
studies of spontaneous expression using the Facial Action Coding System (FACS).
New York: Oxford University Press.
Ellis, A. (1962). Reason and emotion in psychotherapy. Oxford, England: Lyle Stuart.
Ellis, A. (1977). The basic clinical theory of rational-emotive therapy. Handbook of
rational-emotive therapy. New York: Springer.
Ellis, A. (2003). Cognitive restructuring of the disputing of irrational beliefs. In W.
O’Donohue, J. E. Fisher, and S. C, Hayes Eds., Cognitive behavior therapy: Applying
empirically supported techniques to your practice (pp. 79–83). Hoboken, NJ: Wiley
& Sons.
Ellis, A., & Bernard, M. E. (Eds.). (1985). Clinical applications of rational emotive therapy.
New York: Plenum.
Ellis, A., & Harper, R. A. (1975). A guide to rational living (3rd ed.). North Hollywood,
CA: Melvin Powers.
Ellsworth, P. C. (1994). William James and emotion: Is a century of fame worth a century of
misunderstanding? Psychological Review, 101, 222–229.
Epp, A. M., & Dobson, K. S. (2010). The evidence base for cognitive-behavioral therapy.
In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (pp. 39–73).
New York: Guilford Publications.
Eysenck, H. J. (1962). Conditioning and personality. British Journal of Psychology, 53,
299–305.
Fabiano, G. A., Pelham, W. E., Coles, E. K., Gnagy, E. M., Chronis-Tuscano, A., & O’Connor,
B. C. (2009). A meta-analysis of behavioral treatments for attention-deficit/hyperactivity
disorder. Clinical Psychology Review, 29, 129–140.
Falender, C. A., Erickson Cornish, J. A., Goodyear, R., Hatcher, R., Kaslow, N. J.,
Leventhal, G., Shafranske, E., Sigmon, S. T., Stoltenberg, C., & Grus, C. (2004). Defining
competencies in psychology supervision: A consensus statement. Journal of Clinical
Psychology, 60, 771–785
Ferguson, C. J. (2009). An effect size primer: A guide for clinicians and researchers.
Professional Psychology: Research and Practice, 40, 532–538.
172 References
Ferster, C. B. (1973). A functional analysis of depression. American Psychologist, 28,

857–870.
Ferster, C. B. (1981). A functional analysis of behavior therapy. In L. P. Rehm (Ed.),
Behavior therapy for depression: Present status and future directions (pp. 181–196).
New York: Academic Press.
Flitcroft, A., James, I. A., Freeston, M., & Wood-Mitchell, A. (2007). Determining what
is important in a good formulation. Behavioural and Cognitive Psychotherapy, 35, 325.
Foa, E. B., Hembree, E. A., & Rothbaum, B. 0. (2007). Prolonged exposure therapy
for PTSD: Emotional processing of traumatic experiences. Therapist guide.
Foa, E. B., & Jaycox, L. H. (1999). Cognitive-behavioral theory and treatment of posttraumatic
stress disorder. In D. Spiegle (Ed.), Efficacy and cost-effectiveness of psychotherapy (pp.
23–61). Washington, DC: American Psychiatric Press.
Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S., Campeas, R., Franklin, M. E., . . . Tu,
X. (2005). Randomized, placebo-controlled trial of exposure and ritual prevention,
clomipramine, and their combination in the treatment of obsessive-compulsive disorder.
The American Journal of Psychiatry, 162, 151–161.
Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic
stress disorder in rape victims: A comparison between cognitive-behavioral procedures
and counseling. Journal of Consulting and Clinical Psychology, 59, 715–723.
Foa, E. B., Zoellner, L. A., Feeney, N. C., Hembree, E. A., & Alvarez-Conrad, J. (2002).
Is imaginal exposure related to exacerbation of symptoms? Journal of Consulting and
Follette, W. C. (1996). Introduction to the special section on the development of theoretically
coherent alternatives to the DSM system. Journal of Consulting and Clinical Psychology,
64, 1117–1119.
Follette, W. C., & Hayes, S. (1992). Behavioral assessment in the DSM era. Behavioral
Assessment, 14, 293–295.
Follette, W. C., & Houts, A. C. (1996). Models of scientific progress and the role of theory
in taxonomy development: A case study of the DSM. Journal of Consulting and Clinical
Psychology, 64, 1120–1132.
Fouad, N. A., Grus, C. L., Hatcher, R. L., Kaslow, N. J., Hutchings, P. 5., Madson, M.
B., . . . Crossman, R. E. (2009). Competency benchmarks: A model for understanding
and measuring competence in professional psychology across training levels. Training
and Education in Professional Psychology, 3, 5–26
Foxx, R. M. (1996). Twenty years of applied behavior analysis in treating the most severe
problem behavior: Lessons learned. The Behavior Analyst, 19, 225.
Franklin, M. E., & Foa, E. B. (1998). Cognitive-behavioral treatments for obsessive-compulsive
disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work
(pp. 339–357). Oxford, England: Oxford University Press.
Freud, S. (1915/1957). J. Strachey (Ed. and Trans.). The standard edition of the complete
psychological works of Sigmund Freud. London: Hogarth Press.
Frijda, N. H. (1988). The laws of emotion. American Psychologist, 43, 349–358.
Garber, J., & Seligman, M. E. (Eds.). (1980). Human helplessness: Theory and applications.
New York: Academic Press.
Garcia, J., & Koelling, R. A. (1966). Relation of cue to consequence in avoidance learning.
Psychonomic Science, 123–124.
References 173
Gilbert, P., and Leahy, R. L., (2007). The therapeutic relationship in the cognitive behavioral
psychotherapies. New York: Routledge/Taylor & Francis Group.
Gillespie, C. F., & Nemeroff, C. B. (2005). Early life stress and depression. Current Psychiatry,
4, 15–30.
Gilson, M., Freeman, A., Yates, M. J., & Freeman, S. M. (2009). Overcoming
depression: A cognitive therapy approach (2nd ed.). New York: Oxford University Press.
Gloaquen, V., Cottraux, J., Cucherat, M., & Blackburn, I. (1997). A meta-analysis of the
effects of cognitive therapy in depressed patients. Journal of Affective Disorders,
49, 59–62.
Goldapple, G., Segal, Z., Garson, C., Lau, M., Bieling, P., Kennedy, S., & Mayberg, H. (2004).
Modulation of cortical-limbic pathways in major depression: Treatment-specific effects
of cognitive behavior therapy. Archives of General Psychiatry, 61, 34–41.
Goldfried, M. R. (2003). Cognitive-behavior therapy: Reflections on the evolution of a
therapeutic orientation. Cognitive Therapy and Research, 27, 53–69.
Goldfried, M. R., & Davidson, G. C. (1976). Clinical behavior therapy. New York: John
Wiley & Sons.
Goldfried, M. R., & Davidson, G. C. (1996). Clinical behavior therapy (2nd ed.).
New York: Holt, Rinehart, & Winston.
Goldfried, M. R., & D’Zurilla, T. J. (1971) Problem solving and behavior modification.
Goldfried, M. R., & Kent, R. N. (1972). Traditional versus behavioral personality
assessment: A comparison of methodological and theoretical assumptions. Psychological
Bulletin, 77, 409–420.
Goldin, P. R., Ziv, M., Jazaieri, H., Kraemer, H., Heimberg, R. G., & Gross, J. J. (2012).
Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-behavioral
therapy for social anxiety disorder. Journal of Consulting and Clinical Psychology, 80,
1034–1040.
Gorn, G. J. (1982). The effects of music in advertising on choice behavior: A classical
conditioning approach. Journal of Marketing, 46, 94–101.
Gottman, J. M., & Notarius, C. I. (2000). Decade review: Observing marital interaction.
Journal of Marriage and Family, 62, 927–947.
Greenberg, Leslie S. (2002). Integrating an emotion-focused approach to treatment into
psychotherapy integration. Journal of Psychotherapy Integration, 12, 154–189.
Greene, B. (1994). Lesbian women of color. In L. Comas-Diaz & B. Greene (Eds.), Women
of color: Integrating ethnic and gender identities in psychotherapy (pp. 389–427).
New York: Guilford.
Greene, B. (2007). Delivering ethical psychological services to lesbian, gay, and bisexual
clients. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.). (2nd ed.). Handbook
of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients
(pp. 181–199). Washington, DC: American Psychological Association.
Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. (1998). Measuring individual differences
in implicit cognition: The Implicit Association Test. Journal of Personality and Social
Psychology, 74, 1464–1480.
Groopman, J. (2007). How doctors think. New York: Mariner Books.
Gross, J. J., & Thompson, R. A. (2007). Emotional regulation: Conceptual
foundations. In J. J. Gross (Ed.), Handbook of emotional regulation (pp. 3–26).
174 References
Grossman, P., Nieman, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress
reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research,
57, 35–43.
Guidano, V. F., & Liotti, G. (1983). Cognitive processes and emotional disorders: A structural
approach to psychotherapy. New York: Guilford Press.
Gur, R. C., Gur, R. E., Resnick, S. M., Skolnick, B. E., Alavi, A., & Reivich, M. (1987). The
effect of anxiety on cortical cerebral blood flow and metabolism. Journal of Cerebral
Blood Flow Metabolism, 7, 173–177.
Haldeman, D. C. (2010). Reflections of a gay male psychotherapist. Psychotherapy Theory,
Research, Practice, Training, 47, 177–185.
Hanrahan, F., Field, A. P., Jones, F. W., & Davey, G. C. L. (2013). A meta-analysis of cognitive
therapy for worry in generalized anxiety disorder. Clinical Psychology Review, 33,
120–132.
Harris, R. (2009). ACT made simple: An easy-to-read primer on acceptance and
commitment therapy. Oakland, CA: New Harbinger.
Haukebo, K., Skaret, E., Ost, L. G., Raadal, M., Berg, E., Sunberg, H., & Kvale, G. (2008).
One- vs. five-session treatment of dental phobia: A randomized controlled study.
Journal of Behavior Therapy and Experimental Psychiatry, 39, 381–390.
Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational frame theory. A post
Skinnerian account of human language and cognition. New York: Kluwer Academic/
Plenum Publishers.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2005). Acceptance and
commitment therapy: Model, processes, and outcomes. Behaviour Research and
Therapy, 44, 1–25.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment
therapy: An experiential approach to behavior change. New York: Guilford.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Folette, V. M., & Strosahl, K. (1996). Experiential
avoidance and behavioral disorders: A functional dimensional approach to diagnosis
and treatment. Journal of Consulting & Clinical Psychology, 64, 1152–1168.
Haynes, S. N., & O’Brien (Eds.) (2000). Principles and practice of behavioral assessment.
New York: Kluwer Academic/Plenum Publishers.
Haynes, S. N., & Williams, A. E. (2003). Case formulation and design of behavioral
treatment programs: Matching treatment mechanisms to causal variables for behavior
problems. European Journal of Psychological Assessment, 19, 164.
Hays, P. (2009). Integrating evidence-based practice, cognitive-behavior therapy, and
multicultural therapy: Ten steps for culturally competent practice. Professional
Psychology: Research and Practice, 40, 354–360.
Hays, P. A. (2001). Addressing cultural complexities in practice: A framework for clinicians
and counselors. Washington, DC: American Psychological Association.
Hembree, E. A., Foa, E. B., Dorfan, N. M., Street, G. P., Kowalski, J., & Tu, X. (2003). Do
patients dropout prematurely from exposure therapy for PTSD? Journal of Traumatic
Stress, 16, 552–562.
Hendriks, G. J., Oude Voshaar, V. R. C., Keijsers, G. P. J., Hoogduin, C. A. L., & van
Balkom, A. J. L. M. (2008). Cognitive-behavioural therapy for late-life anxiety
disorders: A systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 117,
403–411.
References 175
Hersen, M., & Rosqvist, J. (2005). Encyclopedia of behavior modification and cognitive
behavior therapy: Adult clinical applications (Vol. 1). Thousand Oaks, CA: Sage
Publications.
Hofmann, S. G., Heering, S., Sawyer, A. T., & Asnaani, A. (2009). How to handle
anxiety: The effects of reappraisal, acceptance, and suppression strategies on anxious
arousal. Behaviour Research and Therapy, 47, 389–394.
Hofmann, S. G., & Smits, J. A. J. (2008). Cognitive-behavioral therapy for adult anxiety
disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical
Psychiatry, 69, 621–632.
Hope, D. A., Heimberg, R. G., & Turk, C. L. (2006). Managing social
anxiety: A cognitive-behavioral therapy approach: Therapist guide. New York: Oxford
University Press.
Hopko, D. R., Lejuez, C. W., LePage, J. P., Hopko, S. D., & McNeil, D. W. (2003). A brief
behavioral activation treatment for depression: A randomized trial within an inpatient
psychiatric hospital. Behavior Modification, 27, 458–469.
Hopko, D. R., Lejuez, C. W., Ruggiero, K. J., & Eifert, G. H. (2003). Contemporary behavioral
activation treatments for depression: Procedures, principles, and progress. Clinical
Hull, C. L. (1943). Principles of behavior. New York: Appleton-Century-Crofts.
Jacobsen, E. (1928). Progressive relaxation. Chicago, IL: University of Chicago Press.
Jacobsen, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral activation treatment for
depression: Returning to contextual roots. Clinical Psychology: Science and Practice, 8,
256–270.
James, W. (1884). What is emotion? Mind, 9, 188–220.
Jayasinghe, S. R. (2004). Yoga in cardiac health (a review). European Journal of Preventative
Cardiology, 11, 359–365.
Jones, M. C. (1924). The elimination of children’s fears. Journal of Experimental Psychology,
7, 382–390.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain
patients based on the practice of mindfulness meditation: Theoretical considerations
and preliminary results. General Hospital Psychiatry, 4, 33–47.
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to
face stress, pain, and illness. New York: Delta.
Kahneman, D., Slovic, P., & Tversky, A. (1982). Judgment under uncertainty: Heuristics and
biases. New York: Cambridge University Press.
Kanfer, F. H., & Grimm, L. G. (1977). Behavioral analysis: Selecting target behaviors in the
interview. Behavior Modification, 1, 7–28.
Kanter, J. W., Callaghan, G. M., Landes, S. J., Busch, A. M., & Brown, K. R. (2004). Behavior
analytic conceptualization and treatment of depression: Traditional models and recent
advances. The Behavior Analyst Today, 5, 255–274
Kanter, J. W., Tsai, M., & Kohlenberg R. J. (Eds.) (2012). The practice of functional analytic
psychotherapy. New York: Springer.
Kaslow, N. J., Borden, K. A., Collins, F. L., Forrest, L., Illfelder-Kaye, J., Nelson, P.
D., . . . Willmuth, M. E. (2004). Competencies Conference: Future directions in
education and credentialing in professional psychology. Journal of Clinical Psychology,
80, 699–712.
176 References
Kaslow, N. J., Rubin, N. J., Forrest, L., Elman, N. S., Van Horne, B. A., Jacobs, S. C., . . . &
Thorn, B. E. (2007). Recognizing, assessing, and intervening with problems of
professional competence. Professional Psychology: Research and Practice, 38, 479.
Kassinove, H., & Tafrate, R. C. (2002). Anger management: The complete treatment
guidebook for practitioners. New York: Impact.
Kazdin, A. E. (2000). Behavior modification in applied settings (6th ed.). Belmont,
CA: Wadsworth Publishing.
Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimmering, R. T. (1989). Implosive (flooding)
therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20,
245–260.
Kelly, G. A. (1955). The psychology of personal constructs (Vol. I and II). London,
England: Routledge.
Kendjelic, E., & Eels, T. D. (2007). Generic psychotherapy case formulation training
improves formulation quality. Psychotherapy Theory, Research, Practice, Training,
44, 66–77.
Klein, J. B., Jacobs, R. H., & Reinecke, M. A. (2007). Cognitive-behavioral therapy
for adolescent depression: A meta-analytic investigation of changes in effect-size
estimates. Journal of the American Academy of Child and Adolescent Psychiatry, 46,
1403–1413.
Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense
and curative therapeutic relationships. New York: Plenum.
Kleim, S., Kröger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline
personality disorder: A meta-analysis using mixed-effects modeling. Journal of
Consulting and Clinical Psychology, 78, 936–951.
Kohn, L. P., Oden, T., Muñoz, R. F., Robinson, A., & Leavitt, D. (2002). Brief report: Adapted
cognitive behavioral group therapy for depressed low-income African American
women. Community Mental Health Journal, 38, 497–504.
Koerner, K. (2007). Case formulation in dialectical behavior therapy. In T. D. Eells,
(Ed.), Handbook of psychotherapy case formulation (2nd ed., pp. 317–348).
Kvale, G., Berggren, U., & Milgrom, P. (2004). Dental fear in adults: A meta-analysis of
behavioral interventions. Community Dentistry and Oral Epidemiology, 32, 250–264.
Kohlenberg, R. J., Kanter, J. W., Bolling, M. Y., Parker, C. R., & Tsai, M. (2002). Enhancing
cognitive therapy for depression with functional analytic psychotherapy: Treatment
guidelines and empirical findings. Cognitive and Behavioral Practice, 9, 213–229.
Kohlenberg, R. J., & Tsai, M. (1993). Functional analytic psychotherapy: Creating intense
and curative therapeutic relationships. New York: Plenum.
Kuyken, W., Padesky, C., & Dudley, R. (2009). Collaborative case conceptualization: Working
effectively with clients in cognitive-behavioral therapy. New York: Guilford Press.
Larsen, R. J., & Buss, D. M. (2009). Personality psychology: Domains of knowledge about
human nature (4th ed.). New York: McGraw-Hill.
Lazarus, A. (1973). Multimodal behavior therapy: Treating the “basic id.” Journal of Nervous
and Mental Disease, 156, 373–450.
Lazarus, A. A. (1989). The practice of multimodal therapy: Systematic, comprehensive, and
effective psychotherapy. Baltimore, MD: Johns Hopkins University Press.
Lazarus, A. A. (1996). Behavior therapy & beyond. Northvale, NJ: J. Aronson.
References 177
Lazarus, A. A. (1997). Through a different lens: Commentary on “behavior therapy: Distinct

but acculturated”. Behavior Therapy, 28, 573–575.
Lazarus, A. A. (2001). A brief personal account of CT (conditioning therapy), BT (behavior
therapy), and CBT (cognitive behavior therapy): Spanning three continents. In W. T.
O’Donohue, D. A. Henderson, S. C. Hayes, J. E. Fisher, & L. J. Hayes (Eds.), A history of
behavioral therapies: Founders personal histories (pp. 155–162). Reno, NV: Context Press.
LeDoux, J. E. (1996). The emotional brain. New York: Simon & Shuster.
LeDoux, J. E. (2000). Emotion circuits in the brain. Annual Review of Neuroscience, 23,
155–184.
LeDoux, J. E. (2003). Synaptic self: How our brains become who we are. New York: Penguin.
Lejuez, C. W., Hopko, D. R., LePage, J., Hopko, S. D., & McNeil, D. W. (2001). A brief
behavioral activation treatment for depression. Cognitive and Behavioral Practice, 8,
164–175.
Levenson, R. W. (1999). The intrapersonal functions of emotion. Cognition and Emotion,
13, 481–504.
Lewinsohn, P. M., Biglan, A., & Zeiss, A. S. (1976). Behavioral treatment of depression.
In P. O. Davidson (Ed.), The behavioral management of anxiety, depression, and pain
(pp. 91–146). New York: Brunner/Mazel.
Lewinsohn, P. M., & Graf, M. (1973). Pleasant activities and depression. Journal of
Lewinsohn, P. M., & Libet, J. (1972). Pleasant events, activity schedules and depression.
Lewinsohn, P. M., Youngren, M. A., & Grosscup, S. J. (1979). Reinforcement and depression.
In R. A. Depue (Ed.), The psychobiology of depressive disorders: Implications for the
effects of stress (pp. 291–316). New York: Academic Press.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder.
Magill, M., & Ray, L. A. (2009). Cognitive-behavioral treatment with adult alcohol and
illicit drug users: A meta-analysis of randomized controlled trials. Journal of the Study
of Alcohol and Drugs, 70, 516–527.
Malouff, J., M., Thorsteinsson, E. B., Rooke, S. E., Bhullar, N., & Schutte, N. S. (2008).
Efficacy of cognitive behavior therapy for chronic fatigue syndrome: A meta-analysis.
Clinical Psychology Review, 28, 736–745.
Malouff, J. M., Thorsteinsson, E. B., Schutte, N. S. (2007). The efficacy of problem solving
therapy in reducing mental and physical health problems: A meta-analysis. Clinical
Mahoney, M. J. (1974). Cognition and behavior modification. Oxford, England: Ballinger.
Mahoney, M. J. (1977). Reflections on the cognitive-learning trend in psychotherapy.
American Psychologist, 32, 5–13.
Mahoney, M. J., & Lyddon, W. J. (1988). Recent developments in cognitive approaches to
counseling and psychotherapy. The Counseling Psychologist, 16, 190–234.
Marlatt, G. A., & Marques, J. K. (1977). Meditation, self-control, and alcohol use. In
R. B. Stuart (Ed.), Behavioral self-management: Strategies, techniques, and outcomes
(pp. 117–153). New York: Brunner-Mazel.
Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for
guided action. New York: Norton.
178 References
Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for
depression: A clinician’s guide. New York: Guilford Press.
Martell, C. R., Safren, S. A., & Prince, S. E. (2004). Cognitive and behavioral therapies with
lesbian, gay and bisexual clients. New York: Guilford.
Maslow, A. H. (1968). Toward a psychology of being (2nd ed.) New York: Harper and Row
(original work published in 1954).
Meichenbaum, D. (1977). Cognitive-behavior modification: An integrative approach.
New York: Plenum Press.
Millon, T., & Bloom, C. (Eds.). (2008). The Millon Inventories: A practitioner’s guide to
personalized clinical assessment (2nd ed.). New York: Guilford Press.
Miltenberger, R. G. (2012). Behavior modification: Principles and procedures (5th ed.).
Belmont, CA: Wadsworth.
Mineka, S., & Zinbarg, R. (2006). A contemporary learning theory perspective on the
etiology of anxiety disorders: It’s not what you thought it was. American Psychologist,
61, 10–26.
Mirsalimi, H. (2010). Perspectives of an Iranian psychologist practicing in America.
Psychotherapy Theory, Research, Practice, Training, 47, 151–161.
Moher, D. (1998). CONSORT: An evolving tool to help improve the quality of reports
of randomized controlled trials. Journal of the American Medical Association, 279,
1489–1491.
Moses, E. B., & Barlow, D. H. (2006). A new unified treatment approach for emotional
disorders based on emotion science. Current Directions in Psychological Science, 15,
146–150.
Mowrer, O. H. (1948). Learning theory and the neurotic paradox. American Journal of
Orthopsychiatry, 18, 571–610.
Mowrer, O. H. (1951). Two-factor learning theory: Summary and comment. Psychological
Review, 58, 350–354.
Mowrer, O. H. (1960). Learning theory and Behavior. Hoboken, NJ: Wiley & Sons.
Mumma, G. H., & Mooney, S. R. (2007). Incremental validity of cognitions in a clinical case
formulation: An intra-individual test in a case example. Journal of Psychopathology and
Behavioral Assessment, 29, 17–28.
Muñoz, R.F., & Miranda, J. (1986). Group therapy for cognitive-behavioral treatment of
depression. Unpublished treatment manual. San Francisco, CA: San Francisco General
Hospital Depression Clinic.
Murphy, S., & Zajonc, R. (1993). Affect, cognition, and awareness: Affective priming with
suboptimal and optimal stimuli. Journal of Social and Personality and Social Psychology,
64, 723–739.
Nader, K., Schafe, G., & LeDoux, J. E. (2000). Fear memories require protein synthesis in
the amygdala for reconsolidation after retrieval. Nature, 406, 722–726.
National Center for Posttraumatic Stress Disorder (2007). Overview of PTSD. Retrieved
August 2, 2012, from: http://www.ptsd.va.gov/professional/pages/ptsd-overview.
Newman, C. F. (2010). Competency in conducting cognitive-behavioral therapy: Foun-
dational, functional, and supervisory aspects. Professional Psychology: Research and
Practice, 47, 12–19.
Nezu, A. M. (1986). Efficacy of a social problem-solving therapy approach for unipolar
depression. Journal of Consulting and Clinical Psychology, 54, 196–202.
References 179
Nezu, A. M. (2010). Cultural influences on the process of conducting psychotherapy: Personal

reflections of an ethnic minority psychologist. Psychotherapy Theory, Research,
Practice, Training, 47, 169–176.
Nezu, A., & D’Zurilla, T. J. (1979). An experimental evaluation of the decision-making
process in social problem solving. Cognitive Therapy and Research, 3, 269–277.
Nezu, A., & D’Zurilla, T. J. (1981). Effects of problem definition and formulation on decision
making in the social problem-solving process. Behavior Therapy, 12, 100–106.
Nezu, A. M., D’Zurilla, T. J., Zwick, M. L., & Nezu, C. M. (2004). Problem-solving therapy
with adults. In E. C. Chang & T. J. D’Zurilla (Eds.), Social problem solving: Theory,
research, and training (pp. 171–191).
Nezu, A. M., & Greenberg, L. M. (2012). Cognitive and behavioral therapies for diverse
populations: A “report card” regarding research activities. The Clinical Psychologist,
65, 7–8.
Nezu, A. M., & Nezu, C. M. (Eds.). (2008). Evidenced-based outcome research: A practical
guide to conducting randomized controlled trials for psychosocial interventions.
New York: Oxford University Press. (a)
Nezu, A. M., & Nezu, C. M. (Eds.). (2008). The “devil is in the details”: Recognizing
and dealing with threats to validity in randomized controlled trials. In A. M. Nezu &
C. M. Nezu (Eds.), Evidenced-based outcome research: A practical guide to
conducting randomized controlled trials for psychosocial interventions (pp. 3–24).
New York: Oxford University Press. (b)
Nezu, A. M. & Nezu, C. M. (Eds.) (in press). Handbook of cognitive and behavioral
therapies. Oxford Library of Psychology Series. New York: Oxford University Press.
Nezu, A. M., Nezu, C. M., & Cos, T. A. (2007). Case formulation for the behavioral and
cognitive therapies: A problem-solving perspective. In T. D. Eells (Ed.), Handbook of
psychotherapy case formulation (2nd ed.; pp. 349–378). New York: Guilford Press.
Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2007). Solving life’s problems: A 5-step guide to
enhanced well-being. New York: Springer Publishing.
Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment
manual. New York: Springer Publishing.
Nezu, A. M., Nezu, C. M., Felgoise, S. H., McClure, K. S., & Houts, P. S. (2003). Project
Genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer
patients. Journal of Consulting and Clinical Psychology, 71, 1036–1048.
Nezu, A. M., Nezu, C. M., Friedman, S. H., Faddis, S., & Houts, P. S. (1998). Helping cancer
patients cope: A problem-solving approach. Washington, DC: American Psychological
Association.
Nezu, A. M., Nezu, C. M., & Jain, D. (2005). The emotional wellness way to cardiac
health: How letting go of depression, anger, and anxiety can heal your heart. Oakland,
CA: New Harbinger.
Nezu, A. M., Nezu, C. M., & Lombardo, E. R. (2001). Cognitive-behavior therapy for
medically unexplained symptoms: A critical review of the treatment literature. Behavior
Therapy, 32, 537–583.
Nezu, A. M., Nezu, C. M., & Lombardo, E. R. (2004). Cognitive-behavioral case formulation
and treatment design: A problem-solving approach. New York: Springer Publishing.
Nezu, A. M., Nezu, C. M., & Lombardo, E. (2006). Behavioral and cognitive influences. In
F. Andrasik (Ed.), Adult psychopathology: Comprehensive handbook of personality and
psychopathology (Vol. 2, pp. 35–51). New York: Wiley.
180 References
Nezu, A. M., Nezu, C. M., & Perri, M. G. (1989). Problem-solving therapy for
depression: Theory, research, and clinical guidelines. New York: Wiley.
Nezu, A. M., & Perri, M. G. (1989). Problem-solving therapy for unipolar depression: An
initial dismantling investigation. Journal of Consulting and Clinical Psychology, 57,
408–413.
Nezu, A. M., & Ronan, G. F. (1985). Life stress, current problems, problem solving, and
depressive symptomatology: An integrative model. Journal of Consulting and Clinical
Nezu, A. M., & Ronan, G. F. (1988). Stressful life events, problem solving, and depressive
symptoms among university students: A prospective analysis. Journal of Counseling
Nezu, A. M., Ronan, G. R., Meadows, E., & McClure, K. (Eds.). (2000). Practitioner’s
guide to empirically based measures of depression (ABCT Clinical Assessment Series).
New York: Kluwer Academic/Plenum Publishers.
Nezu, A. M., Saad, R., and Nezu, C. M. (2000). Clinical decision making in
supervision: “. . . And how does that make you feel?” Cognitive and Behavioral Practice,
7, 338–342.
Nezu, C. M., Finch, Jr., A. J., & Simon, N. P. (2009). Becoming board certified by the
American Board of Professional Psychology. New York: Oxford University Press.
Nezu, C. M., & Nezu, A. M. (2003). Awakening self-esteem: Spiritual and psychological
techniques to improve your well-being. Oakland, CA: New Harbinger.
Nezu, C. M., Nezu, A. M., & Gill-Weiss, M. J. (1992). Psychopathology in persons with
mental retardation: Clinical guidelines for assessment and treatment. Champaign,
IL: Research Press.
Nock, M. K., Janis, I. B., & Wedig, M. M. (2008). Research designs. In A. M. Nezu &
C. M. Nezu (Eds.), Evidenced-based outcome research: A practical guide to
Nock, M. K., & Kazdin, A. E. (2005). Randomized controlled trial of a brief intervention
for increasing participation in parent management training. Journal of Consulting and
Norberg, M. M., Krystal, J. H., & Tolin, D. F. (2008). A meta-analysis of d-cycloserine
and the facilitation of fear extinction and exposure therapy. Biological Psychiatry, 63,
1118–1126.
Norcross, J. C., & Karpiak, C. P. (2012). Clinical psychologists in the 2010s: 50 years of
the APA Division of Clinical Psychology. Clinical Psychology: Research and Practice,
19, 1–12.
Norton, G. R., Allen, G. E., & Hilton, J. (1983). The social validity of treatments for
agoraphobia. Behavior Research and Therapy, 21, 393–399.
Novaco, R. W. (1977). A stress inoculation approach to anger management in the training
of law enforcement officers. American Journal of Community Psychology, 5, 327–346.
O’Donohue, W. T., & Fisher, J. E. (Eds.). (2012). Cognitive behavior therapy: Core principles
for practice. New York: Wiley.
O’Donohue, W. T., & Fisher, J. E. (Eds.). (2009) General principles and empirically
supported techniques of cognitive therapy. Hoboken, NJ: Wiley.
O’Donohue, W. T., Fisher, J. E., & Hayes, S. C. (2003). Cognitive behavior therapy: Applying
empirically supported techniques in your practice. New York: Wiley.
References 181
Okazaki, S., & Tanaka-Matsumi, J. (2006). Cultural considerations in cognitive-behavioral

assessment. In P. A. Hayes & G. Y. Iwamasa (Ed.), Culturally responsive
cognitive-behavioral therapy (pp. 257–266). Washington, DC: American Psychological
Association.
Olatunji, B. O., Deacon, B. J., & Abramowitz, J. (2009). The cruelest cure? Ethical issues in
the implementation of exposure-based treatments. Cognitive and Behavioral Practice,
16, 172–180.
Olson, M. A., & Fazio, R. H. (2002). Implicit acquisition and manifestation of classically
conditioned attitudes. Social Cognition, 2, 89–103.
Orsillo, S. M., & Roemer, L. (2011). The mindful way through anxiety: Break free from
chronic worry and reclaim your life. New York: Guilford Press.
Öst, L. G. (1989). 1-session treatment for specific phobias. Behaviour Research and Therapy,
27, 1–7.
Öst, L. G., Brandberg, M., & Aim, T. (1997). One versus five sessions of exposure in the
treatment of flying phobia. Behavior Research and Therapy, 35, 987–996.
Otto, M. W., & Hinton, D. E. (2006). Modifying exposure-based CBT for Cambodian refugees
with posttraumatic stress disorder. Cognitive and Behavioral Practice, 13, 261–270.
Overmeier, S. F. & Seligman, M. E. (1967). Failure to escape traumatic shock. Journal of
Experimental Psychology, 74, 1–9.
Padesky, C. A. (1996). Developing cognitive therapist competency: Teaching and
supervision models. In P. M. Salkovskis (Ed.), Frontiers of cognitive therapy (pp. 266–
292). London: Guilford Press.
Padesky, C. A., & Greenberger, D. (1995). Clinician guide to mind over mood.
Panskepp, J. (1998). Affective neuroscience: The foundations of human and animal
emotions. New York: Oxford University Press.
Pavlov, I. P. (1927). Conditioned reflexes: An investigation of the physiological activities of
the cerebral cortex.
Pavlov, I. V. (1941). Conditioned reflexes and psychiatry. New York: International.
Perri, M. G., Nezu, A. M., Patti, E. T., & McCann, K. L. (1989). Effect of length of treatment
on weight loss. Journal of Consulting and Clinical Psychology, 57, 450–452.
Petti, P. V. (2008). The use of a structured case presentation examination to evaluate clinical
competencies of psychology doctoral students. Training and Education in Professional
Persons, J. B. (1989). Cognitive therapy in practice: A case formulation approach.
New York: W. W. Norton.
Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy.
Persons, J. B., & Tomkins, M. A. (2006) Cognitive-behavioral case formulation. In
T. D. Eells (Ed.), Handbook of psychotherapy case formulation (pp. 290–316).
Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihand, S. J., & Foa, E. B. (2010). A
meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical
Powers, M. B., Zum, M. B., Vörding, V. S., & Emmelkamp, P. M. G. (2009). Acceptance
and commitment therapy: A meta-analytic review. Psychotherapy and Psychosomatics,
78, 73–80.
182 References
Psychotherapy Networker. (2007, March/April). The most influential therapists of the past
quarter-century. Washington, DC: Author.
Rachman, S. (2009). Psychological treatment of anxiety: The evolution of behavior therapy
and cognitive-behavior therapy. Annual Review of Clinical Psychology, 5, 97–119.
Rachman, S., Shafran, R., Radomsky, A. S., & Zysk, E. (2011). Reducing contamination
by exposure plus safety behaviour. Journal of behavior therapy and experimental
psychiatry, 42, 397–404.
Ramnerö, J., & Törneke, N. (2008). The ABCs of Human Behavior. Oakland, CA: New
Harbinger.
Reger, M. A., & Gahm, G. A. (2009). A meta-analysis of the effects of internet- and
computer-based cognitive-behavioral treatments for anxiety. Journal of Clinical
Reiser, R. P., & Milne, D. (2012). Supervising cognitive-behavioral psychotherapy: Pressing
needs, impressing possibilities. Journal of Contemporary Psychotherapy, 42, 161–171.
Rescorla, R. A., & Heth, C. D. (1975). Reinstatement of fear to an extinguished conditioned
stimulus. Journal of Experimental Psychology: Animal Behavior Processes, 1, 88–96.
Rescorla, R. A., & Solomon, R. L. (1967). Two-process learning theory: Relationships between
Pavlovian conditioning and instrumental learning. Psychological Review, 74, 51–182.
Rescorla, R. A., & Wagner, A. R. (1972). A theory of Pavlovian conditioning: Variations
in the effectiveness of reinforcement and non-reinforcement. In A. H. Black & W. F.
Prokasy (Eds.). Classical conditioning II: Current theory and research (pp. 64–99).
New York: Appleton-Century.
Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault
victims. Journal of Consulting and Clinical Psychology, 60, 748–756.
Resick, P. A., Monson, C. M., & Chard, K. M. (2007). Cognitive processing therapy: Veteran/
military version. Washington, DC: Department of Veterans Affairs.
Robinson, E. A., & Eyberg, S. M. (1981). The dyadic parent–child interaction coding
system: Standardization and validation. Journal of Consulting and Clinical Psychology,
49, 245–250.
Robinson, T. R., Smith, S. W., Miller, M. D., & Brownell, M. T. (1999). Cognitive behavior
modification of hyperactivity-impulsivity and aggression: A meta-analysis of
school-based studies. Journal of Educational Psychology, 91, 195–203.
Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment for
generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches
with existing cognitive-behavioral models. Clinical Psychology: Science and Practice,
9, 54–68.
Roemer, L., & Orsillo, S. M. (2006). An open trial of an acceptance-based behavior therapy
for generalized anxiety disorder. Behavior Therapy, 38, 72–85.
Rosen, A., & Proctor, E. K. (1981). Distinctions between treatment outcomes and their
implications for treatment evaluation. Journal of Consulting and Clinical Psychology,
49, 418–425.
Root, M. P. (Ed.). (1995). The multiracial experience: Racial borders as the new frontier.
New York: Sage Publications.
Rosnow, R. L., & Rosenthal, R. (2008). Assessing the effect size of outcome research. In
A. M. Nezu & C. M. Nezu (Eds.), Evidence-based outcome research: A practical guide to
References 183
Rothbaum, B. O., Hodges, L. F., Kooper, R., Opdyke, D., Williford, J., & North, M. (1995,
Summer). Virtual reality graded exposure in the treatment of acrophobia: A case report.
Behavior Therapy, 26, 547–554.
Rotter, J. B. (1982). The development and application of social learning theory.
New York: Praeger.
Rouf, K., Fennell, M., Westbrook, D., Cooper, M., & Bennett-Levy, J. (2004). Devising effective
behavioural experiments. In J. Bennett-Levy, G. Butler, M. Fennel, A. Hackmann, M.
Mueller, & D. Westbrook (Eds.), Oxford guide to behavioural experiments in cognitive
therapy (pp. 21–58). Oxford: Oxford University Press.
Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult
ADHD: A cognitive-behavioral treatment program therapist guide. Oxford: Oxford
University Press.
Santiago-Rivera, A., Kanter, J., Benson, G., Derose, T., Illes, R., & Reyes, W. (2008).
Behavioral activation as an alternative treatment approach for Latinos with depression.
Psychotherapy: Theory, Research, Practice, Training, 45, 173–185.
Santini, E., Muller, R. U., & Quirk, G. J. (2001). Consolidation of extinction learning
involves transfer from NMDA-independent to NMDA-dependent memory. Journal of
Neuroscience, 21, 9009–9017.
Schmaling, K., Fiedelak, J. I., Katon, W. J., Bader, J. O., & Buchwald, D. S. (2003). Prospective
study of the prognosis of unexplained chronic fatigue in a clinic-based cohort.
Psychosomatic Medicine, 65, 1047–1054.
Schroeder, M., & Shidlo, A. (2002). Ethical issues in sexual orientation conversion therapies: An
empirical study of consumers. Journal of Gay & Lesbian Psychotherapy, 5, 131–166.
Schulte, D., & Eifert, G. H. (2002). What to do when manuals fail? The dual model of
psychotherapy. Clinical Psychology: Science and Practice, 9, 312–328.
Segal, Z. V., Teasdale, J. M., & Williams, J. M. (2002). Mindfulness-based cognitive therapy
for depression: A new approach to preventing relapse. New York: Guilford Press.
Seligman, M. E. (1975). Helplessness: On depression, development, and death. San
Francisco: W. H. Freeman.
Seligman, M. E. (2011). Flourish: A visionary new understanding of happiness and
well-being. New York: Free Press.
Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction.
American Psychologist, 55, 5–14.
Seligman, M. E., Kaslow, N. J., Alloy, L. B., Peterson, C., Tanenbaum, R. L., & Abramson,
L. Y. (1984). Attributional style and depressive symptoms among children. Journal of
Abnormal Psychology, 93, 235.
Seligman, M. E. P., Rashid, T., & Parks, A. C. (2006). Positive psychotherapy. American
Psychologist, 61, 774–788.
Serketich, W. J., & Duman, J. E. (1996). The effectiveness of behavioral parent training to
modify antisocial behavioral in children: A meta-analysis. Behavior Therapy, 27, 171–186.
Shadish, W. R., Cook, T. D., & Campbell, D. T. (2002). Experimental and quasi-experimental
designs for generalized causal inference. Boston: Houghton Mifflin.
Skinner, B. F. (1938). The behavior of organisms: an experimental analysis. Oxford,
England: Appleton-Century.
Skinner, B. F. (1953). The science of human behavior. Toronto, Ontario: The Macmillan
Company.
184 References
Skinner, B. F. (1966). An operant analysis of problem solving. In B. Kleinmuntz (Ed.),

Problem solving: Research, methods, and theory (pp. 133–171). New York: Wiley.
Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., & Buysse,
D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for
persistent insomnia. American Journal of Psychiatry, 159, 5–11.
Solomon, R. L. (1980). The opponent-process theory of acquired motivation: The costs of
pleasure and the benefits of pain. American Psychologist, 35, 691–712.
Solomon, R. L., & Corbit, J. D. (1974). An opponent-process theory of motivation: Temporal
dynamics of affect. Psychological Review, 81, 119–145.
Spek, V., Cuijpers, P., Nyklíček, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based
cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis.
Psychological Medicine, 37, 319–328.
Staats, A. W., Staats, C. K., & Heard, W. G. (1959). Language conditioning of meaning using
a semantic generalization paradigm. Journal of Experimental Psychology, 57, 187–192.
Stampfl, T. G. (1987). Theoretical implications of the neurotic paradox as a problem in
behavior theory: An experimental resolution. The Behavior Analyst, 10, 161–173.
Stegge, H., & Terwogt, M. M. (2007). Awareness and regulation of emotion in typical and
atypical development. In J. J. Gross (Ed.), Handbook of emotional regulation (pp. 269–286).
Stice, E., Rohde, P., Shaw, H., & Marti, C. Nathan (2012). Efficacy trial of a selective
prevention program targeting both eating disorder symptoms and unhealthy weight
gain among female college students. Journal of Consulting and Clinical Psychology, 80,
164–170.
Stockhorst, U., de Friesa, D., Steingruebera, H. J., & Scherbaumb, W. A. (2004). Insulin and
the CNS: Effects on food intake, memory, and endocrine parameters and the role of
intranasal insulin administration in humans. Physiology and Behavior, 83, 47–54.
Stowell, J. R. K. (2003). Psychoneuroimmunology. In A. M. Nezu, C. M. Nezu, & P. A. Geller
(Eds.). Health psychology (pp. 75–98) New York: Wiley.
Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Barber, J. P., Brown, G. K., & Beck,
A. T. (2006). Early alliance, alliance ruptures, and symptom change in cognitive therapy
for avoidant and obsessive-compulsive personality disorders. Journal of Consulting and
Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L.,
& Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical
practice. American Psychologist, 62, 271–286.
Sukhodolsky, D. G., Kassinove, H., & Gorman, B. S. (2004). Cognitive-behavioral therapy
for anger in children and adolescents: a meta-analysis. Aggression and Violent Behavior,
9, 247–269.
Tarrier, N. (Ed.). (2006). Case formulation in cognitive behaviour therapy: The treatment
of challenging and complex cases. New York: Routledge.
Tarrier, N., & Calam, R. (2002). New developments in cognitive-behavioural case
formulation. Epidemiological, systemic, and social context: An integrative approach.
Behavioural and Cognitive Psychotherapy, 30, 311–328.
Tarrier, N., Taylor, K., & Gooding, P. (2008). Cognitive-behavioral interventions to reduce
suicide behavior: A systematic review and meta-analysis. Behavior Modification, 32,
77–108.
References 185
Task Force for Common Language in Psychotherapy Procedures (I. Marks, Coordinating
Ed.). (2010). Common language in psychotherapy procedures (CLP). Retrieved October
26, 2010, from http://www.commonlanguagepsychotherapy.org/index.php?id=6.
Tatrow, K., & Montgomery, G. H. (2006). Cognitive behavioral therapy techniques for
distress and pain in breast cancer patients: A meta-analysis. Journal of Behavioral
Medicine, 29, 17–27.
Taylor, D. J., & Roane, B. M. (2010). Treatment of insomnia in adults and children: A practice
friendly review of research. Journal of Clinical Psychology: In Session, 66, 1137–1147.
Thompson, R. F., & Spencer, W. A. (1966). Habituation: A model phenomenon for the study
of neuronal substrates of behavior. Psychological Review 73, 16–43.
Torneke, N., Luciano, C., & Salas, S. V. (2008). Rule-governed behavior and psychological
problems. International Journal of Psychology and Psychological Therapy, 8, 141–156.
Trudeau, K. J., Mostofsky, E., Stuhr, J. K., & Davidson, K. W. (2008). Explanation of
the CONSORT statement with application to psychosocial interventions. In A. M.
Nezu & C. M. Nezu (Eds.), Evidence-based outcome research: A practical guide to
Turk, D. C., & Wilson, H. D. (2013). Chronic pain. In A. M. Nezu, C. M. Nezu, & P. A. Geller
(Eds.) Health Psychology (pp. 292–318). New York: Wiley.
Ullmann, L. P., & Krasner, L. (1969). A psychological approach to abnormal behavior.
Englewood Cliffs, NJ: Prentice Hall.
Umbreit, J., Ferro, J. B., Liaupsin, C. J., & Lane, K. L. (2007). Functional behavioral
assessment and function-based intervention: An effective, practical approach. Upper
Saddle River, NJ: Pearson.
Vurbic, D., Gold, B., & Bouton, M. E. (2011). Effects of D-cycloserine on the extinction of
appetitive operant learning. Behavioral Neuroscience, 125, 551–559.
Walker, C. E., Hedberg, A. G., Clement, P. W., & Wright, L. (1981). Clinical procedures for
behavior therapy. Englewood Cliffs, NJ: Prentice-Hall.
Walters, G. D. (2000). Behavioral self-control training for problem drinkers: A meta-analysis
of randomized control studies. Behavior Therapy, 31, 135–149.
Watson, J. B. & Raynor, R. (1920). Conditioned emotional reactions. Journal of Experimental
Wells, A. (2005). Detached mindfulness in cognitive therapy: A metacognitive analysis
and ten techniques. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 23,
337–355.
Wells, A. (2009). Metacognitive therapy for anxiety and depression. London: Guilford Press.
Wilhelm, S., & Steketee, G. S. (2006). Cognitive therapy for obsessive compulsive
disorder: A guide for professionals. Oakland, CA: New Harbinger Publications.
Wilson, K. G., Hayes, S. C., Gregg, J., & Zettle, R. D. (2001). Psychopathology and
psychotherapy. In S. C. Hayes, D. Barnes-Holmes, & B. Roche (Eds). Relational frame
theory: A post Skinnerian account of human language and cognition (pp. 211–238).
New York: Kluwer Academic/Plenum.
Witkin, H. A. (1977). Field dependence and interpersonal behavior. Psychological Bulletin,
84, 661–689.
Witkin, H. A., Lewis, H. B., Hertzman, M., Machover, K., Meissner, P.B., & Wapner, S. (1954).
Personality through perception: An experimental and clinical study. New York: Harper.
186 References
Wolitzky-Taylor, K. B., Arch, J. J., Rosenfield, D., & Craske, M. G. (2012). Moderators and
non-specific predictors of treatment outcome for anxiety disorders: A comparison
of cognitive behavioral therapy to acceptance and commitment therapy. Journal of
Wolpe, J. (1952). Experimental neurosis as learned behavior. British Journal of Psychiatry,
43, 242–268.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford
University Press.
Wolpe, J. (1969). The practice of behavior therapy. New York: Pergamon.
Wolpe, J. (1990). The practice of behavior therapy (4th ed.). New York: Pergamon Press.
Yardakul, L., Holttum, S., & Bowden, A. (2009). Perceived changes associated with autogenic
training for anxiety: A grounded theory study. Psychology and Psychotherapy: Theory,
Research and Practice, 82, 403–419.
Young, J. E. (1990). Cognitive therapy for personality disorders: A schema-focused
approach. Sarasota, FL: Professional Research Exchange.
Young, J. E. (1994). Cognitive therapy for personality disorders: A schema-focused approach
(revised ed.). Sarasota, FL: Professional Resource Press/Professional Resource Exchange.
Young, J. E., & Klosko, J. S. (1993). Reinventing your life: How to break free from negative
life patterns. New York: Plume.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide.
New York: Guilford Press
Zajonc, R. (1984). On the primacy of affect. American Psychologist, 39, 117–123.
Zimmerman, G., Favrod, J., Trieu, V. H., & Pomini, V. (2005). The effect of cognitive
behavioral treatment on the positive symptoms of schizophrenia spectrum
disorders: A meta-analysis. Schizophrenia Research, 77, 1–9.
Zur, O. (2002). Out-of-office experience: When crossing office boundaries and engaging
in dual relationships are clinically beneficial and ethically sound. In A. A. Lazarus, &
O. Zur (Eds.), Dual relationships and psychotherapy (pp. 88–97). New York: Springer.
K E Y T E RM S
American Board of Cognitive and Behavioral Psychology: The national board that
credentials doctoral level psychologists in cognitive and behavioral practice through
review of one’s educational and experiential background, as well as via an examination.
It is one of several boards of the American Association of Professional Psychology.
Applied behavioral analysis: A set of treatment approaches that are based on operant
conditioning paradigms that focus on manipulation of environmental variables in order
to change behavior.
Behavior analysis: An approach to assessment that provides a learning-based explanation
for the etiology, selectivity (hypotheses concerning how this person developed the
target problem), and maintenance (regardless of original etiological function, why the
problem continues to occur) of the target behavior. After observing the target behavior
of interest, a functional analysis is employed to help to identify the current conditions
that are maintaining the behavior.
Case formulation: A set of hypotheses about the causes, precipitants, and maintaining
influences of a person’s psychological problems (cognition and emotion), interpersonal
problems, and behavioral problems.
Classical conditioning (also known as associative learning): Learning that occurs through
repeated pairings of two stimuli; through repeated pairings of two stimuli, a conditioned
stimulus will come to elicit a response that is similar to the response originally elicited
by the first stimulus.
Cognitive therapy: Usually refers to the therapeutic approach originated by Aaron
Beck, which helps individuals to overcome negative thinking patterns and schemas
that are believed to lead to depressive and/or anxious emotional reactions to stressful
circumstances.
Exposure-based therapy: A treatment approach that has the patient willingly experience
the anxiety and fear associated with a given set of stimuli, whether real or imagined. It is
often paired with a procedure termed response prevention that limits a person’s ability to
engage in behaviors that could help him or her avoid experiencing the fear.
Instrumental learning (also referred to as operant conditioning): Occurs through various
types of reinforcement and punishment events that follow behavioral responses,
within specific situational contexts. Through operant conditioning, under various
discriminating learning contexts, an association is made between a behavior and a
consequence for that behavior.
188 Key Terms
Modeling: A form of learning by which individuals learn from observing others engaging
in behavior that is reinforced.
Positive reinforcers: Favorable events or outcomes that are presented following a behavior.
In situations that reflect positive reinforcement, a response or behavior is strengthened
by the individual’s experience of something pleasant, such as praise or a direct reward.
Punishment: The presentation of an adverse event or outcome that causes a decrease in the
behavior it follows.
Randomized controlled trials: A between-subjects research strategy that evaluates the
efficacy of a particular psychotherapy intervention by randomly allocating individuals
to the experimental (treatment) group and one or two more comparison conditions.
Single case experimental design: A within-subjects research strategy that evaluates the
impact of treatment on a given individual (or set of individuals in the case of multiple
baseline designs) whereby he or she serves as one’s own control comparison.
Systematic desensitization: A treatment to reduce fear and anxiety based on the notion
that such anxiety can be decreased by having a patient learn to replace the anxious
response to a feared stimulus with one that is more relaxing.
INDEX
A-B-A-B design, 58, 59f anxiety, 73, 126

A-B-A design, 58 anxiety disorders, 139
A-B-C formulation, 100 classical conditioning and, 15–16
ABC observation, behavior, 71 exposure therapy, 144–148
A-B design, 57 applied behavioral analysis, 166
Academy of Cognitive Therapy, 6 applied behavior analysis, 66, 69
acceptance and commitment therapy Asia Cognitive Behavioral Therapy
(ACT), 44t, 54, 95, 109–110 Association (ACBTA), 165
adaptive behavior, strategies Asian Canadians, 78
increasing, 117–118 Assessment of Competencies
addictive design, 53 Benchmarks Workgroup, 39
ADDRESSING, assessment association, learning by, 14
framework, 78 Association for Advancement of
Ader, Robert, 16–17 Behavior Therapy, 5
adult anxiety disorders, 42 Association for Behavioral and Cognitive
affective neuroscience, 21 Therapies (ABCT), 6, 74, 163
African American women, cognitive- Association for Behavior Analysis, 6
behavioral therapy (AACBT), 155 Association of Behavior and
aggression, 42, 121 Cognitive Therapies, 5
agoraphobia, 15 associative learning, 9, 10t, 11–14
alcohol and drug abuse, 42 attention-deficit/hyperactivity
American Academy of Cognitive and disorder, 42, 115
Behavioral Psychology, 163, 165 attention placebo, 51
American Board of Behavioral attributional theory, 10t
Psychology, 5 autogenic training, intervention, 94–95
American Board of Cognitive autonomic arousal, measures of, 76
and Behavioral Psychology autonomic nervous system, 16
(ABCBP), 5, 6, 163 avoidance
American Board of Professional behavior, 97
Psychology (ABPP), 5, 39, 125, 162 self-reinforcing nature of, 92–93
American Psychological Association avoidance learning, 10t, 26–27
(APA), 39, 55, 140, 162 AWARE (accepting the anxiety,
American Psychologist, 30 watching emotions and
anger, 15, 42, 45t, 70, 115 rating the intensity), 109
anger management, 96, 126, 128 Axis I, 74
anti-social behavior of children, 42 Axis II, 74
190 Index
Bandura, Albert, 108 brain imaging, 76

social learning theory, 4, 28–29 breathing retraining, 94
Barlow, David, 164 British Association for Behavioral
Beck, Aaron T., 4, 31, 31–33, 100 and Cognitive Psychotherapies
Beck, Judy S., 101, 103 (BABCP), 165
behavior brooding, 104
construct of, 8
measures of overt, 72–73 Cambodian refugees, PTSD, 155
specifics of behavior analysis, 69–72 case formulation
strategies decreasing challenging, 119 common ground of models, 83–84
behavioral activation (BA), 7, 25 dynamic paradigm, 80–81
culturally sensitive, 155 hypothesis, 81
depression, 43t Nezu model of, 82
behavioral assessment overview of cognitive-
autonomic arousal, 76 behavioral models, 82–83
brain imaging, 76 Person’s model, 82–83
characteristics, 66–68 research, 81–82
culturally relevant, 78–79 Case Illustration, 90
current status, 66 Catholicism, 156
evolution of, 68–69 chronic fatigue syndrome, 42, 44t
extending, to covert processes, classical, 9
73–74 classical conditioning, 12, 14
physiologic assessment, 75–76 and anxiety disorders, 15–16
physiologic assessment of contemporary models, 16–17
sexual functioning, 77 emotional theories, 20–22
sleep studies, 77 claustrophobia, 92
standardized tests, 77 clinical decision-making road
structured and semi-structured map, 153
interviews, 74–75 clinically relevant behaviors (CRBs), 112
behavioral interventions, 88–89 Clinician-Administered Post Traumatic
behavioral parent training (BPT), 44t Stress Disorder (CAPS), 75
behavioral retaliation, 24 A Clockwork Orange, Kubrick, 143
behavioral self-control training (BSCT), 45t cognition, 28
Behavior Analyst Certification cognitive and behavioral interventions,
Board, 6, 166 87–91. See also interventions
behaviorism, 3 ethical considerations, 142–144
behavior therapy, assessment cognitive and behavioral
approaches, 65 psychology, 3, 89–90
Behavioural Research and Therapy, 40 characteristics, 6–8
belly breathing, 94 journals, 41t
biofeedback, 77, 95, 126 major theories, 10t
blood pressure (BP), 76 meta-analyses of, interventions,
borderline personality disorder, 41–42, 43–45t
42, 44t, 75, 83 operant conditioning, 22–26
Boulder Conference on Graduate path to formal recognition, 5–6
Education in Clinical Psychology, 3 scientific basis of, 40–42
Index 191
cognitive attentional syndrome Comas–Díaz, Lillian, 153

(CAS), 113–114 Commission for the Recognition of
cognitive-behavioral case Specialties and Proficiencies in
formulation, 80–81 Professional Psychology (CRSPPP), 6
common ground of models, 83–84 Committee for the Recognition of
overview of models, 82–83 Specialties and Proficiencies
research, 81–82 in Professional Psychology
cognitive-behavioral psychologists (CRSPPP), 162
beyond the office walls, 148–150 Common Language in Psychotherapy,
confidentiality, 147–148 web-based project, 90
consultation, 125–130 Competencies Conference: Future
ethical considerations, 142–144 Directions in Education
interpersonal interactions, 137–139 and Credentialing, 39
supervision and teaching, 130–133 Competencies Conference Scientific
teaching competency, 133–134 Foundations and Research
cognitive behavioral theories, 10t Competencies Workgroup, 39
cognitive-behavioral therapy (CBT), 4, 54 competency
acceptance and commitment supervision, 131–133
therapy (ACT), 109–110 teaching, 133–134
behavioral activation (BA), 110 component analysis, 52
dialectical behavior therapy conditioned response (CR), 11
(DBT), 111–112 conditioned stimulus (CS), 11, 12
functional analytic confidentiality, therapy, 147–148
psychotherapy (FAP), 112 CONSORT (Consolidated Standards of
megacognitive therapy, 113–114 Reporting Trials) Statement, 55, 56f
mindfulness–based cognitive constructive design, randomized
therapy, 112–113 controlled trial (RCT), 53
problem–solving therapy (PST), 110–111 construct validity, 46, 48t
third wave, 108–109 consultation
treatment manuals, 114–116 advice, feedback and
cognitive construct theory, Kelly, 28 recommendations, 129
cognitive hypnotherapy, 7 cognitive-behavioral
cognitive interventions, 88 psychologists, 125–130
cognitive-processing therapy implementing interventions,
(CPT), 7, 106–107, 128 129–130
cognitive reappraisal, 103, 104 recognizing situations, 128–129
cognitive therapy contingency management, 118–119
assessing thoughts, 104 continuing education, training
Beck, 32–33 manuals, 164
behavioral experiments for coping strategies, 104–105
hypothesis testing, 105–106 core beliefs, 101
coping strategies, 104–105 correctional facilities, behavioral
guided discovery, 103 interventions, 127
looking for evidence, 104 cortisol, 76
Socratic dialogue, 104 Council of Specialties (CoS), 6
cognitive therapy (CT), 100 couples therapy, ethics, 149–150
192 Index
culture efficacy, cognitive and behavioral

behavioral assessment, 78–79 treatments, 42
beliefs and practices, 156 Ekman, Paul, 21
of psychologists, 153–153 Ellis, Albert, 4, 31, 100
cyclophosphamide, saccharine and, 16–17 Ellsworth, emotional theories, 20–21
emotion
Damasio, Antonio, 21 classical conditioning and
Darwin, 20 contemporary, theories, 20–22
D-cycloserine (DCS), 19–20 theories of, 8, 9, 10t, 36–37
dental anxiety, 42 emotional reactivity, 13
dentist’s drill, 11, 12 ethical challenges, 140–142, 151
depression, 15, 42, 43t, 115, 126 beyond the office walls, 148–150
Beck, 31–33, 106 cognitive-behavioral
cognitive distortions, 33t interventions, 142–144
Diagnostic and Statistical Manual of confidentiality, 147–148
Mental Disorders (DSM-IV), 66 do no harm, 143, 144
dialectical behavior therapy gray area, 140–141
(DBT), 7, 83, 109 self-disclosure of therapists, 141–142
borderline personality disorder, 44t standards, 140
development, 111–112 Ethical Principles of Psychologists
diathesis-stress model, depression, 32 and Code of Conduct, 140
differential reinforcement of alternative ethnic minority populations, cognitive
behavior (DRA), 121 and behavioral therapies, 156–157
differential reinforcement of European Association of Cognitive and
incompatible behavior (DRI), 121 Behavioral Therapies (EACBT), 165
dismantling studies, randomized European Canadians, 78
controlled trial, 52–53 evidence-based interventions, 87–88
diversity evolution, behavioral assessment, 68–69
awareness of self, 152–154 exposure and response
behavioral activation (BA), 155 prevention (ERP), 7, 97
cultural, 153, 154–159 exposure therapy, 92
ethnic minority populations, 156–157 anxiety disorders, 144–148
interaction of self with others, 159–160 intervention, 96–97
multi-ethnic individuals, 159 exposure with response prevention
sexual orientation, 157–159 (ERP), intervention, 98–99
documentation, supervision external validity, 46, 47t, 48t
competencies, 132–133 extinction learning, 12, 13
domains, 34 psychopharmacologic
do no harm, 143, 144 enhancement of, 19–20
drive reduction theory, 4
drug placebo, 51 fear conditioning, 13
dual roles, 141 feared stimuli with relaxation response, 4
D’Zurilla, Thomas J., 4, 61, 107 fear learning, 13
fear of flying, 92
Eells, Tracy, 83 feedback, 95, 129, 138
effect size, 42 Felten, David, 17
Index 193
Ferster, C. B., 25 interpersonal interactions, 137–139

field dependence theory, Witkin’s, 28 inter-related reliability, 81
Foa, Edna, 27, 94, 98, 145 interventions
forgetting, 13 autogenic training, 94–95
Franks, Cyril, 4 biofeedback, 95
Freud, 20 cognitive and behavioral, 87–91
functional analysis of behavior, 66 cognitive therapy techniques, 101–106
functional analytic psychotherapy evidence-based, 87–88
(FAP), 112 exposure treatment, 96–97
exposure with response
galvanic skin response (GSR), 76 prevention (ERP), 98–99
gender, self awareness, 152–153 information-processing theory, 99–106
general orientation, 62 integrated treatments with
Goldfried, Marvin, 4 behavioral, emotional and
grounded in science, 39 cognitive components, 106–108
guided imagery, 126 learning and conditioning
theories, 91–99
habituation, 18–19 manuals and texts, 165
Haynes, Steven, 66, 67, 82, 83 progressive relaxation
Hays, Pamela, 78 training (PRT), 93–94
heart rate (HR), 76 prolonged exposure (PE), 97–98
higher order conditioning, 14 rational emotive behavior
Hull, Clark Leonard, 3, 26 therapy (REBT), 100–101
hypothesis systematic desensitization, 92–93
behavioral experiments for visualization, 95–96
testing, 105–106 interviews, structured and semi-
case formulation, 81 structured, 74–75
in vivo exposure, 19
idiographic approach, 80
imitative learning, 9 James, William, 5
immigration status, cognitive- Jones, M. C., 68
behavioral therapy, 156–157 Journal Article Reporting
Implicit Association Test (IAT), 159 Standards (JARS), 55, 56t
information-processing theories, 9 Journal of Abnormal Psychology, 40
cognitive therapy techniques, 101–106 Journal of Consulting and Clinical
interventions from, 99–106 Psychology, 40, 55, 66
rational emotive behavior journals
therapy (REBT), 100–101 cognitive and behavioral, 41t
insomnia, 42, 115 relevant to specialty, 163–165
instrumental conditioning, 36–37
instrumental learning, 10t, 22 Kelly, George, 4, 28, 29
internal validity, 46, 47t knowledge, competency areas of, 131
International Association for Cognitive Kubrick, Stanley, 143
Psychotherapy (IACBP), 165–166
international associations, 165–166 lack of psychopathology, 61
interoceptive exposure, 99 La Virgen de Guadalupe, 156
194 Index
law enforcement officers, 128 mindfulness meditation, 126

Lazarus’ multimodal therapy, 4 Minnesota Multiphasic Personality
Lazarus, Arnold, 31 Inventory (MMPI–II), 74, 77
learned association, 11 Mirsalimi, Hamid, 154
learned helplessness, 10t, 28, 30 modeling, 9
learning modeling effect, 28
associative, 9, 11–14 Mowrer, two-factor theory, 26–27
continuing professional Multimodal, psychotherapy, 31
development, 166 multiple baseline designs,
evolutionary receptivity of, 11 research, 58–59, 60f
neurosubstrates of, 19
new skills, 107–108 negative punishment, 24
reciprocal inhibition, 92 Neuropsychology (journal), 164
school settings, 127 Newman, Cory, 130, 137
theories, 26–27 Nezu, Arthur, xi, 90, 190
learning by association, 14 Nezu, Christine Maguth, xi, 90, 189
learning theory, panic disorder, 99 N-methyl-D-aspartate (NMDA), 19–20
lesbian, gay, bisexual or transgender non-associative learning, 10t, 18–19
(LGBT), cognitive and no-treatment control, randomized
behavioral therapies, 157–159 controlled trial (RCT), 50
Lewinsohn, Peter, 25
Life Events Checklist (LEC), 75 obsessive-compulsive disorder
lifestyle modification, 126 (OCD), 15, 97, 98, 144, 146
life traps, 102 operant, 22
Linehan, Marsha, 7, 82, 111, 113 operant conditioning, 9, 22–26
locus of control, Rotter, 28 opponent process theory, 37–38
overgeneralization, 32
Mahoney, Michael, 4, 30–31 Overmeier, J. B., 30
maladaptive schemas, 34, 35t overt behavior, measures of, 72–73
management, contingency, 118–119 Oxford Library of Psychology, 90
Martell, Christopher, xi, 189
Mastery of Your Anxiety and Panic pain, 42
(MAPS) program, 115 panic, 73
megacognitive therapy, 113–114 panic control treatment (PCT),
Meichenbaum, Donald, 31 culturally adapted, 154–155
meta-analyses, cognitive and behavioral panic disorder, learning theory, 99
interventions, 41–42, 43–45t parametric design, randomized
Metacognitive Therapy, 95 controlled trial (RCT), 53–54
Mexican Catholicism, 156 Pavlov, Ivan, 3, 11, 68
Millon Clinical Multiaxial Pavlovian conditioning, 9
Inventory (MCMI), 77 penile plethysmography, 77
Millon Multiaxial Inventory III, 74 personal construct theory, 10t
mind/body approaches, personal information processing, 31
interventions, 126–127 phallometric assessment, 77
mindfulness-based cognitive phobias, systematic desensitization, 92
therapy, 112–113 physical health problems, 42
Index 195
physiologic assessment, 75–76 prolonged exposure (PE)

physiologic measures, intervention, 97–98, 128, 144
autonomic arousal, 76 post-traumatic stress disorder
placebo, attention, 51 (PTSD), 128, 144, 145–146
polysomnography, 77 prompting, 118
positive mental health, 61 psychoneuroimmunology, 16, 17
positive reinforcers, 24 psychosomatic medicine, classical
post-traumatic stress disorder conditioning models, 16–17
(PTSD), 15, 75, 97, 98, 115 psychotherapy, functional analytic, 138
Cambodian refugees, 155 punishment, 23, 24, 119–121
cognitive-processing therapy
(CPT), 106–107, 128 radical acceptance, 112
interventions, 127–128 randomized controlled trial (RCT)
prolonged exposure (PE), attention placebo, 51
128, 144, 145–146 comparable treatment, 52
potentiation, 18 constructive design, 53
predictive validity, 81 construct validity, 46, 48t
preparedness, 11 control conditions, 50–52
pre-post design, 50 ethnic minority populations, 156–157
problem orientation, 61 external validity, 46, 47t, 48t
problem-solving skills, 62 internal validity, 46, 47t
problem-solving therapy (PST), 7, 109, 126 lesbian, gay, bisexual or
bridge between theory and transgender (LGBT), 157–159
practice, 61–62 no-treatment control, 50
contemporary, 110–111 parametric design, 53–54
depression, 43t research method, 45–60
learning new skills, 107–108 standardized guidelines, 54–55
mental and physical health problems, 44t statistical conclusion validity, 46, 49t
randomized controlled threats to validity, 46, 49
trial (RCT), 52–53 treatment as usual (TAU), 51
professional boundaries, therapist, 141–142 treatment mediators, 54
professional identification treatment moderator, 54
American Psychological treatment outcome designs, 52–54
Society (APS), 163 waiting-list control (WLC), 50–51, 52
applied behavioral analysis, 166 rational emotive behavior therapy
Association for Behavioral and (REBT), 31, 32t, 100–101
Cognitive Therapies (ABCT), 163 rational emotive psychotherapy, 4
international associations, 165–166 reciprocal inhibition, 4, 92
journals, 163–165 recognition of social context,
lifelong learning and continuing, 166 competency areas of, 132
maintaining, 162–163 reinforcement, 23
from mechanistic to holistic, 161–162 relational frame theory (RFT),
professional values, competency 10t, 34, 36, 110
areas of, 132 relaxation training, 94, 96, 126
progressive relaxation training research, bridge between theory
(PRT), 7, 93–94 and practice, 61–62
196 Index
research designs slippery slope, 148

A-B-A-B designs, 58, 59f social anxiety, 115
A-B-A designs, 58 social learning theory, 9, 10t
A-B designs, 57 Bandura, 28–29, 108
multiple baseline designs, 58–59, 60f Rotter, 28, 29–30
single case designs, 55, 57–59 social phobia, 15
research methods, randomized social problem solving (SPS), 110–111
controlled trial, 45–60 Socratic dialogue, cognitive reappraisal, 104
respondent, 9 Solomon, Richard, 37–38
Rotter, locus of control, 28, 29–30 standardized guidelines, randomized
Royal London Homeopathic Hospital, 94 controlled trial, 54–55
rule-governed behavior (RGB), 34, 36 statistical conclusion validity, 46, 49t
ruminating, thoughts, 104 stimulus-stimulus learning, 11
stress hormone levels, 76
saccharin, cyclophosphamide with, 16–17 stress management, 126
schemas, 102 stress response, 93
schema theory, 33–34 structured and semi-structured
schizophrenia disorders, 45t interviews, 74–75
schizophrenia symptoms, 42 sugar pill, placebo, 51
school settings, learning environments, 127 suicidal behavior, 42, 45t
Science (journal), 164 supervision
scientifically minded, 39 competency areas of, 132
self-awareness documentation, 132–133
cultural diversity, 152–154 teaching and, 130–133
interaction with others, 159–160 systematic desensitization, 4, 92–93
self-blaming thoughts, 24–25
self-determination, individual’s teaching
rights, 143–144 competency, 133–134
self-disclosure, therapist, 141–142 supervision and, 130–133
self-injury, 121 temperamental vulnerability, 16
Seligman, Martin, 28, 30, 37 therapy-interfering, 112
sensitization, 18–19 third wave, cognitive and behavioral
sexual disorder, 15 therapy, 108–109
sexual functioning, physiologic Thorndike, Edward L., 3, 26, 68
assessment of, 77 time-out, punishment, 119, 120–121
sexual orientation tirade, 72
cognitive and behavioral training, competency areas of, 132
therapies, 157–159 treatment as usual (TAU), 51
self awareness, 152 treatment efficacy, 52
shaping, 118 treatment manuals, 114–116
single case designs, research, 55, 57–59 treatment mediators, 54
single stimulus learning, 10t, 18–19 treatment moderator, 54
skills, competency areas of, 131–132 treatment outcome designs, 52–54
Skinner, B. F., 3, 22, 26, 34, 68, 138 Treatments That Work, Oxford
Skinnerian conditioning, 9 University Press, 164
sleep medicine, 77 triple jealousy, LGBT community, 157–158
Index 197
two-factor theory, 9, 10t, 26–27 waiting-list control (WLC), 50–51, 52

Type II error, case formulation, 82 Western medicine, 127
Witkin, field dependence theory, 28
unconditioned response (UR), 11 Wolpe, Joseph, 4, 68
unconditioned stimulus (US), 11, 12 World Congress of Behavioral and
underlying assumptions, 102 Cognitive Therapies (WCBCT),
unified approach, 109 6, 166
unified treatment approach, 80 World Trade Center, 154
worry/generalized anxiety disorder, 42
virtual systematic desensitization, 7
visualization, intervention, 95–96 Young, Jeffrey, 33–34, 35t, 102
AB OUT T H E A U T H O RS
Dr. Christine Maguth Nezu is a licensed and board-certified psycholo-

gist who has been in private practice for 25 years. A tenured Professor
of Psychology and Medicine at Drexel University, she conducts clinical
research regarding the effectiveness of cognitive and behavioral interven-
tions across many types of problems and patient populations. Additionally,
she serves as a clinical consultant to the US Department of Veterans Affairs
and Department of Defense, and she has adapted Problem Solving Therapy
(PST), the cognitive and behavioral treatment that she co-developed, to
programs to help individuals who have returned from military service face
the challenges of civilian life. As a past President of the American Board
of Professional Psychology (ABPP), she is well-known in the profession
for her clinical expertise, research accomplishments, and leadership in
professional psychology and specialty board certification. She was are-
cently a featured therapist on the website of the Association for Behavioral
and Cognitive Therapies, and serves as an examiner for ABPP Board
Certification for the specialty of Cognitive and Behavioral Psychology.
Christopher R. Martell, Ph.D., ABPP, a licensed and board-certified

psychologist in clinical and cognitive and behavioral psychology special-
ties, and has published widely on the topics of applying cognitive and
behavioral therapies with sexual minority clients and on the practice of
behavioral activation in the treatment of depression. He is an internation-
ally recognized workshop leader, and has trained and supervised CBT
therapists from all mental health specialties. Dr. Martell is a past President
of the Washington State Psychological Association (WSPA), the Society
for the Psychological Study of Lesbian, Gay, Bisexual and Transgender
Issues (APA Division 44), and of the American Board of Cognitive and
Behavioral Psychology (ABCBP). He has served on the Board of Directors
of the ABCBP since 2003.
200 About the Authors
Dr. Arthur M. Nezu, a Distinguished University Professor at Drexel

University in Philadelphia, is also a licensed and board-certified psycholo-
gist in the specialties of clinical psychology, cognitive and behavioral psy-
chology, and clinical health psychology. At Drexel, Dr. Nezu holds joint
appointments in psychology, medicine, and public health. He is the current
Editor of the Journal of Consulting and Clinical Psychology and an Associate
Editor of Archives of Scientific Psychology. He is the co-developer of
ProblemSolving Therapy (PST), an evidence-based, cognitive-behavioral
intervention that has been adapted for many clinical populations across the
age span, both here and abroad. He is a past President of the Association of
Behavioral and Cognitive Therapies and the American Board of Cognitive
and Behavioral Psychology, and has served as Chair for the World Congress
of Behavioral and Cognitive Therapies.
AB OUT T HE SE RI E S E D I T O RS
Arthur M. Nezu, Ph.D., ABPP, is a Distinguished Professor of Psychology,

as well as a Professor of Medicine, and Public Health at Drexel University.
He is also currently a clinical consultant to the US Department of Veterans
Affairs and Department of Defense.. He is a fellow of multiple profes-
sional associations including the American Psychological Association,
and board-certified by the American Board of Professional Psychology in
Cognitive and Behavioral Psychology, Clinical Psychology, and Clinical
Health Psychology. Dr. Nezu is widely published, serves as the current is
incoming Editor of the Journal of Consulting and Clinical Psychology, and
has maintained a practice for three decades.
Christine Maguth Nezu, Ph.D., ABPP, is Professor of Psychology and

Medicine at Drexel University, and clinical consultant to the US Department
of Veterans Affairs and Department of Defense. With over 25 years expe-
rience in clinical private practice, consultation/liaison, research, and
teaching, Dr. Maguth Nezu is board-certified by the American Board of
Professional Psychology (ABPP) in Cognitive and Behavioral Psychology
and Clinical Psychology and is a fellow of the American Psychological
Association.. She is also a past President of ABPP. Her research has been
supported by federal, private, and state-funded agencies and she has served
as a grant reviewer for the National Institutes of Health.

(Specialty Competencies in Professional Psychology) Christine Maguth Nezu, Christopher R. Martell, Arthur M. Nezu - Specialty Competencies in Cognitive and Behavioral Psychology-Oxford University Pres

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

(Specialty Competencies in Professional Psychology) Christine Maguth Nezu, Christopher R. Martell, Arthur M. Nezu - Specialty Competencies in Cognitive and Behavioral Psychology-Oxford University Pres

Uploaded by

Copyright:

Available Formats

Specialty Competencies in Cognitive

and Behavioral Psychology

Arthur M. Nezu, PhD, ABPP, and Christine Maguth Nezu, PhD, ABPP

Oxford is a registered trademark of Oxford University Press in

Published in the United States of America by

© Oxford University Press 2014

Library of Congress Cataloging-in-Publication Data

To my life partner Mark Edward Williams, M.Div., MSW, Ph.D.,

To the patients who have trusted in our competence

1904 Pavlov wins Nobel Prize for Physiology.

1913 Radical behaviorism is launched by Watson.

1927 Backward conditioning developed by Mary Cover Jones.

1938 Joseph Wolpe develops systematic desensitization treatment based

1950–1960 Behavioral psychologists explore the clinical relevance of learning

1960–1970 Clinical behavior therapy is established.

1962 Albert Ellis develops rational emotive psychotherapy (RET).

1969 George Kelly develops cognitive construct theory.

1970–1980 Expansion and inclusion of cognitive theories and positive psychology

1980–1990 Construct of learning expanded to include schemas and implicit

1980–1990 Adaptation of Eastern influences of mindful meditation and awareness.

1987 American Board of Behavioral Psychology established.

1992 American Board of Behavioral Psychology recognized by the American

1990–2000 Advances in neuroscience reveal emotional learning pathways

2000 Behavioral psychology recognized by Commission for the Recognition

2000 American Board of Behavioral Psychology adopted its current name,

2000–present Increasing recognition of the common elements among cognitive

About the Series in Specialty Competencies in

PA R T I History and Background 1

PA R T I I Functional Competencies in Assessment 63

PA R T I I I Functional Competencies in Intervention 85

PA R T I V Other Functional Competencies 123

PA R T V Foundational Competencies 135

t welve Professional Identification 161

This series is intended to describe state-of-the-art functional and founda-

in Professional Psychology put forth a series of guiding principles for the

In writing this volume, we, in collaboration with our co-author

History and Background

The converging paths of the applied specialty of cognitive and behav-

drive reduction theory (1943), whereas the influence of respondent condi-

Orsillo, 2002) as critical components of the cognitive-behavioral thera-

The Path to Formal Recognition

changes by organizations that promoted cognitive and behavioral thera-

Deﬁnition and Unique Characteristics of the Specialty

practice regarding a wide range of problems and populations. The spe-

conscious and non-conscious level of awareness. Applied behavioral analy-

Conceptual Foundations and Theories

THEO RY B R IEF DESC R IPT IO N NOT E D T H E ORI S T S F URT H E R R E A D I N G

known as Pavlovian or respondent conditioning, was initially based upon

many factors that influence the strength of a learned association, an indi-

“forgetting” of a conditioned response. Because extinction is a principle

The Ubiquity of Learning by Association in Everyday Life

Classical Conditioning and Anxiety Disorders

describe a hypothetical case in which two individuals are both exposed to

Contemporary Classical Conditioning Models

was classically paired with saccharine. When the cyclophosphamide was

Single Stimulus (Non-Associative) Learning

The learning principles of sensitization and habituation can be par-

Psychopharmacologic Enhancement of Extinction Learning

and exposure therapy by either enhancing NMDA receptor function dur-

The Evolutionary Context of Classical Conditioning and Contemporary

(1994) review of the emotional theories, and Levenson’s (1999) theory of

or controlled, conscious or non-conscious; however, such regulation is a

Examples of Operant Conditioning

in a ritual of hand-washing to decrease anxiety, or an academic working