UNIT - 5

BEHAVIOUR THERAPIES

Behaviour therapy - Origin

Behaviour therapy, initiated during the 1950s and 1960s, presented a

powerful challenge to the principles of psychoanalysis. Behaviour
therapy's focus on observable behaviours rather than the unconscious; on
the present rather than the past; and on short-temp treatment, clear goals,
and rapid change had considerable appeal
Historical Roots of BM
Ivan P. Pavlov (1849-1936) Classical Conditioning- He demonstrated that
a reflex action could be conditioned to a neutral stimulus. He called this a
CR.
Edward L. Thorndike (1874-1949) Law of Effect- behaviour that produces
a favorable effect on the environment is more likely to be repeated in
future.
John B. Watson (1878-1958) Stimulus-response psychology- In which
environmental events (stimuli) elicited responses. All behaviour was
controlled by it. Watson started behaviourism.

B.F. Skinner (1904-1990) Operant Conditioning- The consequence of

behaviour controls the future occurrence of the behaviour. His research
elaborated the basic principles of operant behaviour. Skinner’s work is the
foundation of BM.
Principles of Behavioural therapy
​ Behaviour is Learned: Behavioural therapy operates on the premise that
behaviour is learned through interactions with the environment. This
means that maladaptive behaviours, such as phobias or compulsions, are
not innate but rather acquired through experiences and reinforced over
time.
​ Focus on Observable Behaviour: Behavioural therapy focuses on
observable and measurable behaviours rather than on underlying thoughts
or emotions. This emphasis allows therapists to target specific behaviours
for change and to assess progress objectively.
​ Behaviour is Modifiable: Central to behavioural therapy is the belief that
behaviour can be modified or changed through systematic interventions.
By identifying the factors that maintain or reinforce maladaptive
behaviours, therapists can implement strategies to promote adaptive
behaviours.
​ The Role of Conditioning: Behavioural therapy draws heavily on the
principles of classical and operant conditioning. Classical conditioning
involves pairing a neutral stimulus with a naturally occurring stimulus to
elicit a conditioned response (e.g., associating a fear-provoking stimulus
with relaxation in systematic desensitisation). Operant conditioning
involves the use of reinforcement and punishment to increase or decrease
the likelihood of a behaviour occurring (e.g., providing rewards for
desired behaviours in token economies).
​ Emphasis on Empirical Validation: Behavioural therapy emphasises the
importance of empirically validating interventions through systematic
observation and measurement. Therapists use outcome measures to assess
the effectiveness of interventions and make data-driven decisions about
treatment.
 ​ Collaborative and Goal-Oriented Approach: Behavioural therapy is
typically collaborative, with the therapist and client working together to
set specific, achievable goals for treatment. These goals are often
behavioural in nature, focusing on changes in observable behaviours
rather than on abstract psychological constructs.
​ Focus on the Present and Future: While behavioural therapy may
explore past experiences to understand the development of maladaptive
behaviours, the primary focus is on the present and future. Therapists
help clients develop practical skills and strategies to manage current
difficulties and prevent relapse in the future.
​ Systematic and Structured Interventions: Behavioural therapy often
involves the use of structured and systematic interventions designed to
target specific behaviours. These interventions may include techniques
such as exposure therapy, behavioural activation, social skills training,
and contingency management.

Strengths and Limitation of Behavior therapy

Strength #1: Behaviour Therapy Characteristically Provides Us with a

Fine-Grained Analysis of How Individuals React to Specific Life Situations

➔ Behaviour therapy approached complex and debilitating human problems

by dimensionalizing them so that they could be thought of in terms of
variables, which may be defined in very specific ways. Bandura's (1986)
concept of "reciprocal determinism," for instance, has provided a
fine-grained analysis of how behavioural, cognitive, and environmental
variables are all mutually influential in understanding human functioning.
At a clinical level, the focus on specific determinants of human
behaviour, rather than on global characteristics of clients, has opened new
therapeutic avenues. Thus, instead of concluding that the fearful
 individual was "not ready to change," behaviour therapists created
hierarchies of increasingly more anxiety-producing situations that would
allow for an ongoing progressive reduction in anxiety

Limitation - one of the shortcomings of much of behaviour therapy has

been its failure to look at patterns of behaviour- patterns that may span
different times and settings in a client's life. This tradition of situational
specificity may be readily traced to the early writings of Mischel (1968),
who established the behavioural view of personality as one that
emphasised what people '"did" in various situations, rather than what they
"had" more globally. Mischel (1969) went on to suggest that "what people
do in any situation may be altered radically even by seemingly minor
variations in prior experiences or slight modifications in stimulus
attributes or in the specific characteristics of the evoking situation

Strength #2: Behaviour Therapy Has Typically Been Dedicated to

Development and Study of Specific Effective Techniques

➔ Behavioral methods of intervention have been subjected to extensive

research, and many have been demonstrated to be effective in treating
various clinical problems

Limitation A: Individual differences. :- Consistent with the group

comparison methodology that has characterised much of the outcome
research on behaviour therapy, individual differences have been viewed
as "error" or "noise." This tendency to neglect individual differences, as
most clinicians well know, can readily undermine the effectiveness of our
methods
Limitation B: Overlooking principle of change. To the extent that we as
behaviour therapists think in terms of techniques, we may also at times
lose sight of the underlying principle of change reflected in the technique.
The failure to look at the underlying principle can, in turn, prevent us
from considering and experimenting with techniques that might be even
more effective in implementing the change principle.

Strength #3: Behaviour Therapy Makes Use of a Skill Training

Orientation to Therapy
➔ In rejecting the disease model of psychological problems,
behaviour therapy has instead adopted an educational model,
whereby clients are taught skills for coping with realistic life
problems (Goldfried, 1980b). Thus, we serve not as healers, but
rather as teachers, trainers, and consultants.

Limitation. Although this skill training emphasis has served us well

in dealing with a number of clinical problems (e.g.,
unassertiveness), it may be limiting at times by fostering a
tendency to lapse into a didactic and overly directive approach to
intervention. In this regard, research findings by Patterson and
Forgatch (1985) showed that therapeutic efforts at "teaching"
parents to work more effectively with their children resulted in
more noncompliance than did attempts at "support" and
"facilitation."

Strength #4: Behaviour Therapy Primarily Focuses on the Client's

Current Life Situation In behavioural interventions, the emphasis is
on the "here and now" in the client's life, rather than the "there and
then."
➔ In our attempt to avoid focusing on early childhood
experiences-with the notable exception of dealing with
 issues of early abuse- we as behaviour therapists have dealt
primarily with what is going on between sessions in the
person's current life. The objective is to provide homework
assignments, so that clients can take behavioural risks and
have success experiences. As a result of this focus on
between-session experiences, behaviour therapy has been
successful in shortening the course of interventions
Limitation A: In-session issues. Because of our focus on between-session
problems or successes in the client's life, we may at times overlook
in-session issues, sometimes to the detriment of therapeutic progress. Take
the example of a 53-year-old depressed accountant who had a long history
of previous psychodynamic therapy. He came to us because he wanted a
more directive approach and something that would focus more on his
current life situation. When assertiveness training was presented as a
relevant approach in helping him to get better control over his current life
and thereby alleviate his depression, the client responded with
ambivalence. Although he wanted something that was different from what
he had been doing in his past therapy, he continued to emphasise the need
to get further insight into the developmental origins of his problem. We
explained, however, that the primary focus would be on encouraging more
structured types of success experiences. Although the client agreed to the
intervention procedures, he resisted following through on homework
assignments. The client became increasingly more depressed, and
indicated that he was not getting what he wanted from therapy. Precisely
because he was so unassertive, he had difficulty in showing his
disappointment and anger directly. It was only after the focus was shifted
to this insession issue, and he was encouraged to express his anger toward
the therapist more directly, that he finally acknowledged that he could
benefit from assertiveness training.
Limitation B: Our reactions to the client. With our relative inattention to
the therapeutic interaction, we as behaviour therapists have also often
failed to recognize the importance of our own reactions to the client.
Henry, Schacht, and Strupp (1990) have shown that clients can evoke
therapist hostility (i.e., blaming, ignoring, separating), especially in
therapists who are critical toward themselves. Not surprisingly, such
reactions were associated with either no change or with actual
deterioration.

Strength #5: Behaviour Therapy Has Been Influential in Encouraging

Psychotherapy Outcome Research
➔ Perhaps the most significant characteristic of behaviour therapy, is a
commitment to bridge the gap between scientific training and
clinical practice (O'Leary & Wilson, 1987). By advocating an
objective and controlled evaluation of treatment methods, we not
only have provided the field with effective and replicable
techniques, but also have forced clinicians of other persuasions to
demonstrate empirically their therapeutic effectiveness (c~f.
Eysenck, 1952)
Limitation- Although behaviour therapy has made significant strides
in determining whether or not various behavioural procedures work,
we have yet to acquire a clear understanding of how they work.
Strength #6: Behaviour Therapy Has Provided Various Forms of
Intervention to Reduce Specific Symptomatology Rather than providing
the same general approach to every type of psychosocial problem,
 ➔ behaviour therapy has developed a variety of interventions
directly targeting the client's problem. Guided by the
theoretical assumption that the "symptom is the neurosis,"
behavioural interventions have traditionally focused on the
manifest problem (vs. hidden or latent cause) as felt by the
client and/or as observed by others. Behavioural methods are
aimed at (1) emotions experienced as debilitating and
uncontrollable (e.g., panic), (2) overt behaviours that the client
wants to get rid of (e.g., compulsive rituals) or acquire (e.g.,
social skills), and (3) predominant and often explicit modes of
thinking that interfere with functioning (e.g., catastrophic
thinking)
Limitation. Because of the emphasis on treating problems that
may best be characterised by Axis I disorders, behaviour
therapy has attended less to the complexity of interpersonal
problems (e.g., personality disorders), instead dealing with
explicit and isolated components of client functioning.

In noting the strengths and then highlighting the associated potential

shortcomings of behaviour therapy, it would be misleading to conclude
that we are worse off than are adherents to other orientations. Indeed, over
the years, we have developed a number of innovative, systematic
procedures for dealings with a wide variety of clinical problems.
Behavioural interventions have provided important breakthroughs in the
treatment of anxiety disorders, have given impetus to the development of
the field of behavioural medicine, and have made inroads in the treatment
of a variety of problems in children. In addition, our advocacy of
methodological behaviourism has underscored the need to specify one's
clinical methods, and to subject them to empirical tests of accountability.

Empirical status of Behavioural therapy

Behavioural therapy has a strong empirical basis, supported by decades of

research demonstrating its effectiveness across a wide range of psychological

disorders and problems. Here are some key points regarding the empirical status

of behavioural therapy:

​ Efficacy in Treating Various Disorders: Behavioural therapy has been

found to be effective in treating numerous psychological disorders,
including anxiety disorders (such as phobias, panic disorder, and
generalised anxiety disorder), mood disorders (such as depression),
obsessive-compulsive disorder (OCD), post-traumatic stress disorder
(PTSD), substance use disorders, eating disorders, and many others.
​ Well-Established Techniques: Many specific techniques used within
behavioural therapy, such as exposure therapy for anxiety disorders,
behavioural activation for depression, and contingency management for
substance use disorders, have been extensively researched and shown to
be highly effective.
​ Evidence-Based Practice: Behavioural therapy is considered an
evidence-based practice, meaning that its techniques and interventions are
supported by rigorous scientific research demonstrating their efficacy and
effectiveness. This evidence comes from randomised controlled trials,
meta-analyses, and systematic reviews conducted by researchers and
clinicians worldwide.
 ​ Comparative Effectiveness: Behavioural therapy has been compared to
other forms of therapy, such as cognitive therapy, psychodynamic
therapy, and pharmacotherapy, in numerous studies. While different
approaches may have their unique strengths, behavioural therapy
consistently demonstrates comparable or superior effectiveness in treating
certain conditions, particularly anxiety disorders and behavioural
problems.
​ Integration with Other Approaches: Behavioural therapy is often
integrated with other therapeutic approaches, such as cognitive therapy
(forming cognitive-behavioural therapy or CBT), acceptance and
commitment therapy (ACT), dialectical behaviour therapy (DBT), and
mindfulness-based interventions. These integrative approaches have also
been extensively researched and shown to be effective for various
psychological difficulties.
​ Continued Research and Development: Behavioural therapy continues
to evolve through ongoing research and development. New techniques
and adaptations of existing interventions are continually being explored
to enhance treatment outcomes and address the needs of diverse
populations.

Overall, the empirical status of behavioural therapy is robust, with a substantial

body of evidence supporting its effectiveness in treating a wide range of

psychological disorders and problems. It remains a cornerstone of contemporary

psychotherapy practice and continues to be refined and expanded through

ongoing research and clinical innovation.

Behavioural Assessments
The behavioural assessment examines and measures numerous components of
behaviour to determine why a given behaviour happens and what causes that
behaviour. These would comprise overt behaviours, feelings, cognitions, and the
variables that govern them, which might come from within or outside the
individual
Types of Behavioural assessment

​ Direct Assessment − The behaviour recording is done in this case as

it occurs in the scenario.
​ Analogue Assessment − This entails monitoring behaviour under
simulated settings because the behaviour may sometimes not occur in
a natural scenario.
​ Indirect Assessment − The behaviour is not witnessed in this case
but is inferred through retrospective analysis.
​ Idiographic Assessment − This explains the individual in question's
behavioural qualities. For example, consider a youngster with Attention
Deficit Hyperactivity Disorder, and the assessment, in this case, is
disorder-focused.
​ Contextual Assessment − This evaluation technique focuses on the
environmental cues that produce the behaviour.

Functional Behaviour Analysis

FBA are integral tools in behavioural analysis, widely used to address and
manage behaviours of concern in the home, at school or in care.

FBA is a step by step process which typically starts with the identification of the
behaviour of concern and concludes with an evaluation to see if the
interventions designed as a result of the behaviour assessment have worked.

The seven steps from FBA are:

1. Identify the behaviour of concern

2. Gather Information
 3. Analyse the Information
4. Formulate a Hypothesis
5. Develop a Intervention Plan
6. Implement the Plan / Intervention
7. Monitor and Evaluate

GOAL SETTING IN BEHAVIOR THERAPY

Developing a Plan to Change Behavior Once behaviour therapists believe they
have obtained enough information to have at least a basic understanding of their
clients and to put their concerns in context, clinicians and clients collaborate to
develop a plan, generally characterised by the following eight steps:
1. Describe the problem behaviour. . Review the nature of the problem and its
history. Explore the context of the target (unwanted) behaviours.
2. Establish a baseline, reflecting the current frequency, duration, and severity of
the target behaviours
3.Determine goals.
-Make sure that goals are realistic, clear, specific, and measurable.
- Make sure that goals are meaningful to the client.
-State goals positively. "Alive at work on time at least twice this week" is a
more appealing goal than "Avoid being late to work at least twice this week.:
4.Develop strategies to facilitate change.
- Change precipitating conditions that trigger undesirable behaviours.
- Teach skills and provide information that contribute to the desired change.
-Review and enhance impulse-control strategies.
- Use additional strategies such as modelling, rehearsal, and systematic
desensitisation to facilitate positive change.
-Formulate appropriate reinforcement contingencies and, if indicated,
meaningful consequences.
- Carefully plan implementation of the change process as well as ways to
monitor and record the outcomes of that process.
- Client and clinician make a written contract; clinician encourages the client to
share the commitment to change with others.
5. Implement the plan.
6. Assess progress and evaluate the success of the plan.
-Monitor and review the results of the implementation.
-Emphasize successes.
- Identify and address any obstacles to change.
- If necessary, revise the plan.
7.Reinforce successes to promote empowerment and continue progressing and
making positive changes.
8 Continue the process by making plans to promote maintenance of gains and
prevent relapse

SYSTEMATIC DESENSITIZATION

Developed in 1958 by Joseph Wolpe

● Desensitization is a behavioural therapy technique used to reduce or

eliminate fear, anxiety, or phobias by gradually exposing an individual to
the feared stimulus or situation in a controlled and systematic manner.
● It is a form of exposure therapy
● Techniques organised around classical conditioning
○ As described by Wolpe, systematic desensitization is a three-step
process. During the first phase of treatment, clients work
collaboratively with a clinician to generate a hierarchy of fears or a
list of anxiety-evoking stimuli that are arranged from least to most
anxiety provoking.
 ○ Next, clients are taught progressive muscle relaxation (PMR) or
other exercises that generate a calm physiological state (i.e., an
incompatible response to anxiety).
○ After a client is reliably able to achieve a relaxed state using PMR,
the client is directed through a series of exposure sessions in which
hierarchy items are confronted in a graded manner, starting with
the least anxiety-provoking item on their list while simultaneously
engaging in PMR.
○ Clients are progressed to the next item on their hierarchy when the
initial stimulus generates little or no anxiety. If progression from
one stage to the next leads to an exacerbation of anxious
responding, the client may return to the previous stage for
additional exposure.
○ When the client has progressed through the hierarchy, and items
rated as most anxiety-provoking no longer evoke an anxious
response, the treatment is deemed to have been successful

Why does systematic desensitisation work ?

- Emotion processing
- Habituation
- Extinction
- Self efficacy

Foa and Kozak

(1986) proposed the emotional processing theory, which suggests that

anxiety-evoking stimuli activate fear structures, or networks of associations
between anxiety-related cognitions, emotions, and behaviors, such as escape or
avoidance. Repeated exposure to fear-evoking stimuli in the absence of
predicted negative consequences leads to the acquisition of new information
that is incompatible with the original fear associations, which, when integrated
into the existing fear structures, weakens and replaces maladaptive fear
associations. In contrast, Craske et al. (2008) proposed an inhibitory learning
model of exposure, suggesting that exposure to anxiety-evoking stimuli
generates new learning that actively competes with and inhibits, rather than
replaces, the original stimulus-danger associations

Techniques of Systematic desensitisation

During exposure sessions, anxiety-evoking stimuli are generally presented in

one of two ways: imaginal or in vivo.

When using imaginary exposure, the therapist vividly describes a scene

depicting the lowest item on a client’s hierarchy, while the client is seated in a
comfortable chair and in a relaxed state.

In contrast, in vivo exposure involves clients directly confronting feared

real-world stimuli while engaging in a relaxation exercise. Although research
suggests that in vivo exposure tends to be more effective than imaginal exposure
in reducing anxious responding and avoidance behaviour

Interoceptive exposure is a technique used in the treatment of panic disorder .

It refers to carrying out exercises that bring about the physical sensations of a
panic attack, such as hyperventilation and high muscle tension, and in the
process removing the patient's conditioned response that the physical sensations
will cause an attack to happen.

Virtual reality desensitisation Virtual reality exposure therapy (VRET) is a

form of exposure therapy that uses technology. Exposure therapy seeks to help
decrease the intensity of the stress responses you might have to situations,
thoughts, or memories which provoke anxiety or fear. Mostly used in PTSD.

EXTINCTION
Extinction is the process of no longer presenting a reinforcer. Examples of
extinction include ignoring a crying child, working without being paid, or not
responding to someone who is talking to you. Parents may use the basic
principle of extinction when dealing with a child. On the one hand, for example,
if a child grabs her mother’s pants and pulls, the mother may choose to ignore
the behavior and let it extinguish. If she responds to the child warmly, she runs
the risk of positively reinforcing the pants-grabbing behavior.

1.Flooding - Flooding is a behavioral approach used in elimination of

unwanted fears or phobias. In flooding, the client is either directly
exposed to or imagines highly frightening events in a protected setting.
Presumably, the fear-inducting stimuli will lose their influence once the
individual is fully exposed to them and discovers that no harm occurs.
Following a discussion of the person’s fears, in a typical flooding
procedure the person is then asked to imagine the most feared situation.
The therapist describes the salient fearful elements to enhance
visualization. Thus an individual who is fearful of elevators is asked to
imagine boarding a glass-enclosed high-speed elevator, then watching
through the glass as the elevator rapidly rises from the ground level to the
20th floor
Implosive therapy
Implosive therapy (or implosion therapy) is a form of exposure therapy similar
to the imaginal form of flooding, with which it can be confused. Although there
are similarities, the terms implosive therapy and flooding cannot be used
interchangeably. Both implosive therapy and flooding expose the client to
anxiety arousing stimuli for prolonged durations. Flooding deals with the actual
Stimulus or its image, while in implosion therapy anxiety is aroused by only
imagining the simuli (without direct contact). Further, implosive therapy
involves imagined scenes that are often exaggerated by a therapist and often
relate to the client's most feared fantasy. Finally, the anxiety that is provoked
during implosive therapy is often addressed using psychodynamic approaches
(e.g., addressing an oral fixation).
Implosive therapy is flooding with these characteristics:
(a) All presentations of anxiety situations are done by having the client imagine
scenes.
(b) The imagined scenes are often ones of exaggerated or impossible situations
designed to elicit as much anxiety as possible.
(c) The scenes are often based on hypothesized sources of anxiety, some of
which are psychodynamic in nature.
These hypothesized sources of anxiety center around such things as hostility
towards parental figures, rejection, sex, and dynamic concepts like Oedipus
complex and death wish.
It can be used in
- Panic disorder
- Specific phobia
- PTSD
- OCD
Exposure and response prevention
The Exposure in ERP refers to exposing yourself to the thoughts, images,
objects and situations that make you anxious and/or start your obsessions. While
the Response Prevention part of ERP, refers to making a choice not to do a
compulsive behavior once the anxiety or obsessions have been “triggered.” All
of this is done under the guidance of a therapist at the beginning though you will
eventually learn to do your own ERP exercises to help manage your symptom
It is the most effective therapy in the treatment of OCD.
Elements of ERP
- Fear avoidance model
- Performing compulsive rituals
 ERP aims to break the cycle of eliminating rituals and avoidance thus
- Providing to tolerate distress without engaging in
counterproductive behaviours
- Providing “Corrective information”
Detailed Investigation of OCD Symptoms
▪ “Functional (behavioral) analysis”
▪Guided by the conceptual framework
▪Gather specific information about the antecedents, behaviors, and
consequences
▪ External fear cues
▪ Intrusive obsessional thoughts and beliefs
▪ Feared consequences associated with cues and obsessions
▪ Avoidance and rituals
▪ Consequences of avoidance and rituals
▪ Leads directly to the treatment plan
Setting Up the Treatment Plan
▪Generate list of situations and thoughts for exposure
▪Realistically safe
▪Evoke obsessional distress and urges to ritualize
▪Patient rates subjective units of discomfort (SUDS) for each situation or
thought
▪Collaborative effort in generating exposure list
▪Generate a list of rituals to target

COVERT EXTINCTION

Covert extinction requires the client to imagine themself performing a problem

behaviour and then to imagine that a common reinforcing stimulus does not
occur. Thus, covertly, the client performs behaviours in the absence of
contingent reinforcement, conditions that have been shown to be effective in
promoting the extinction of overt behaviours.

Negative practice

Negative practice is a technique in which a problem behavior is deliberately

repeated, or practiced, by a patient to decrease the response in the long term.
Negative practice has been used as a response reduction procedure primarily
for habits, such as tics or nail biting, stuttering; or in the treatment of specific
types of anxiety. It was developed by Dunlap in 1932.

Conclusive Remarks of monograph Habits, Their Making and Unmaking:-

ü Voluntarily negative practice under the conditions of wanting to
eliminate the habit, then the habit could be modified. Voluntarily negative
practices are the initial part of the process of eliminating the habit.
ü Desire to eliminate the habit is the foundation of the curative process.
ü Negative practice is not to yield to the impulse but to initiate the
practice voluntarily in the absence of the impulse.
ü Negative practice was the beginning of the learning process of not
performing the habit.
ü Negative practice was intended to bring an involuntary behavior under
voluntary control.

Negative practice and paradoxical Intention:

Negative practice has been compared to other techniques such as paradoxical
intention and therapeutic paradox, both of which have their origins in analytic
psychotherapy. Although the techniques vary by theoretical orientation, in each
case patients are encouraged to continue their problematic behavior on a
schedule established by the clinician. A major distinction between negative
practice and these methods involves the role of the clinician: for paradoxical
 intention and therapeutic paradox, the patient–clinician relationship is seen as
paramount; in negative practice, patient variables are considered essential to
therapeutic success.

Stimulus satiation

Stimulus satiation in which the client is flooded with the reinforcer repeatedly
until it loses much or all of its reinforcing effect. A child who keeps playing
with matches might be sat down with a large number of matches to strike and
light. This would be continued until lighting matches lost their reinforcing
effect. It is not known how or why stimulus satiation works, but it seems to
contain components of aversive counterconditioning and respondent extinction
of reinforcing effects. Stimulus satiation has been used in the treatment of
smoking by dramatically increasing the number of cigarettes smoked and/or the
rate of smoking the cigarettes. This stimulus satiation produced a significant
reduction in smoking with 60 percent of the subjects abstinent at six months.

Skill training

Behavior Skills Training (BST) is a four-step procedure for teaching new skills,
involving the following: Instruction, Modeling, Rehearsal, and Feedback
(Miltenberger, 2004). It is a comprehensive approach that can be used to teach a
wide range of skills or behaviors to a variety of people (Ward-Horner &
Sturmey, 2012). BST has been shown to be effective in training students,
teachers, paraprofessionals, etc. quickly when these instructional procedures are
used (Gianoumis, Seiverling, & Sturmey, 2012). The efficacy of BST is often
measured by criterion of skill acquisition rather than a set amount of time.

Steps for Implementation

Step 1: Instruction – Describe the target skill verbally or in writing (this
may include a task analysis). Sometimes, professionals start and end here.
As in, "Well I told her what to do like 8 times, but she still isn't doing it!".
Effective teaching includes more than just commands.
Step 2: Modelling – This step SHOWS the person what to do. It is
important to model the skill with the actual student in the actual
environment (or the closest approximation possible). Be sure to practise to
fluency before modelling the skill. Visual supports and video modeling can
support this step further.
Step 3: Rehearsal – Beyond modelling, skill acquisition requires that
instruction provides the learner to practice with supervision. It is vital to
practice new behaviors in role-play, then the actual situation to ensure not
only mastery, but also fluency.
Step 4: Feedback – Feedback can sometimes be skipped due to time
constraints. However, this step is critical in improving skill sets. If
possible, immediately correct mistakes while the person can still change it.
Positive praise statements are used before corrective feedback. Supportive
feedback is used to tell the person what they performed correctly.
Corrective feedback is used to tell the person what they need to do to
perform the skill or behaviour correctly. Don’t wait until the entire
procedure is completed to correct a mistake in the first step or the person
may learn the wrong skill by practising it wrong
Importance of skills training -
● Behavioural change
● Functional improvement
● Addressing deficits
● Empowerment and self efficacy
● Coping with challenges
● Bulking social competence
Assertiveness training
Assertiveness Training is a form of Behaviour Therapy designed to help people
stand up for themselves -to empower themselves in more contemporary terms .
●Assertion Training (AT) has a long history. As early as 1949, Andrew Salter in
Conditioned Reflex Therapy described an early form of assertion training
(Lange & Jacubowski, 1976). Wolpe (1958) and Lazarus (1971) were the other
behaviour therapists who more clearly differentiated assertion from aggression
and used various role play procedures as part of their assertion training.
●Assertion training programmes became popular mainly after 1970s as a means
of increasing personal effectiveness and improving interpersonal relationships
(Nadim, 1995).
Two major goals are :

1.One goal of Assertion TRaining is to increase peoples behavioural repertoire

so that they can make the choice of whether to behave assertively in certain
situations .
2.Another goal is to teaching people to express themselves in ways that reflect
sensitivity to the feelings and rights of others .

Assertiveness training promotes the use of I statements as a way to help

individuals express their feelings and reactions to others.

Types of assertive behaviours

1)ASKING FOR WHAT YOU ARE ENTITLED TO

Eg: Correcting the mistake when you receive incorrect change

2) STANDING UP FOR YOUR RIGHTS

Eg: Objecting when a person steps ahead of you in line

3) REFUSING UNREASONABLE OR INAPPROPRIATE REQUESTS

Eg: Saying no when a friend asks to borrow money you can’t spare

4) EXPRESSING OPINIONS AND FEELINGS (EVEN WHEN THEY

ARE UNPOPULAR OR NEGATIVE)

Eg: Voicing your conservative views in a group of liberals

5) EXPRESSING DESIRES AND REQUESTS

Eg: Telling your partner what you want

Steps involved in assertiveness training

1. Information gathering- Participants are asked to think about the list of
areas in their life in which they have difficulty asserting themselves.
2. Test out new behaviour - The next stage in assertive training is usually
role-plays designed to help participants practice clearer and more direct
forms of communicating with others. The role-plays allow for practice
and repetition of the new techniques, helping each person learn assertive
responses by acting on them.
3. Feedback looping - Feedback is provided to improve the response, and
the role-play is repeated.
4. Generalising and application - Client is asked to practice assertive
techniques in everyday life, outside the training setting.

Techniques

1.Broken Record : The "broken record" technique consists of simply repeating

your requests or your refusals every time you are met with resistance. A
disadvantage with this technique is that when resistance continues, your
requests may lose power every time you have to repeat them. If the requests are
repeated too often, it can backfire on the authority of your words. In these cases,
it is necessary to have some sanctions on hand.
2.Fogging: Fogging consists of finding some limited truth to agree with in what
an antagonist is saying. More specifically, one can agree in part or agree in
principle.
3. Negative Inquiry: Negative inquiry consists of requesting further, more
specific criticism.
4. Positive Inquiry: It is a technique to handle positive compliments.

5. Negative Assertion: Negative assertion is agreement with criticism received

but the style of communicating is such that it is made clear that one accepts their
self in spite of the negative trait or behaviour.

6. I-Statements: I-statements can be used to voice one's feelings and wishes

from a personal position without expressing a judgment about the other person
or blaming

Differently abled population

●Has proven useful in increasing perceived social efficacy and interpersonal

skill of differently abled individuals (Glueckauf & Quittner, 1992)

Helping occupations

●Increased assertiveness and self esteem and decreased levels of stress in

nursing and medical students (Lin et al, 2004)

Schools

●Linked with decreased anxiety, stress and depression, and increased self
esteem in high school students (Eslami et al, 2016)
●Effective in preventing peer pressure or bullying (Avsar, 2017)
Strengths
Assertiveness training can help in the following ways:

●Helps one to become self confident

●Increases self esteem
●Improves communication skills
●Facilitates honesty in relationships.
●Understand and recognise feelings
Limitations
●Individuals from collectivist cultures may find it difficult to be assertive.
●Confusion can arise if one does not fully understand the difference between
assertion and aggression.
●Individuals can face difficulty in generalising the learning made in sessions to
real life situations.
●Inaccurate appraisals of situations may cause an individual to set unrealistic
goals for self and/or get assertive in extreme situations.
Modelling
Modeling is the technique of behaviour modification proposed by Albert
Bandura. It is relatively simple and is designed to assist clients in learning new
behavior patterns. It is based on the principle of observational learning. Two
things that are needed in modeling are: Ideal Model and Modeled behaviour or
Desired Behaviour by the model (to be learned by the client)
Types of Modelling
Symbolic modeling : Different modelling formats, such as use of video, film,
slide presentation, and so on are used. With symbolic modeling, the model is
somehow recorded while demonstrating the desired/modeled
responses/behaviour. Then, the client is exposed to the recorded version of the
modeling demonstration.
• Covert modeling: In this, behaviour modifications are done through use of
imagery. The client is instructed to imagine the model demonstrating the desired
response, rather than actually witnessing the situation. For covert modeling, it is
needed that the observer must be able to create detailed cognitive/ mental
images.
• Live, or in vivo, modeling: In this, the live models are presented and they
perform that behaviour which we want the client to learn.

Steps of modelling
● Attention: Paying attention on desired/modeled behaviour.
● Retention: Keeping the desired/modeled behaviour in memory.
● Motivation: Intrinsic motivation to copy the behaviour.
● Motoric reproduction : Acting out the desired/modeled behaviour in real
life.

According to Albert Bandura, the effectiveness of modelling gets affected by

following factors:
• The success of copied behaviour is dependent upon the way desired behaviour
is exhibited. If the desired behaviour is not exhibited properly the desired result
will never be achieved.
• Further, age, gender, culture, race, SES of model also affects modelling. It is
believed that modelling is more likely to produce the desired impact if the
model is similar to the observer(s), or has a high status. More precisely,
modelling is effective when an adult client is working with an adult model.
• Modelled behaviour should be based on client’s abilities and developmental
level.
• The observer has to observe the model for the exposure to have an effect
Applications
Modeling has also been used effectively in anger management and in abuse
cases who frequently lack important behavioural skills.
• It is helpful in treating individuals with anxiety disorders, post-traumatic
stress disorder, specific phobias, obsessive-compulsive disorder, eating
disorders, attention-deficit/hyperactivity disorder, and conduct disorder .
• It is also widely used in helping individuals acquire such social skills as
public speaking or assertiveness. People who lack assertiveness, including the
ability to say "no“ are being treated through modeling.
Advantages
It is cost effective because demonstration of a skill requires minimal cost of
resources.
• This is an interactive approach where the trainer direct and learner witnesses a
demonstration. Further, the trainer can visit with each participant to evaluate
their attempts at the skill and correct.
• Learning in this technique focuses largely on learner attempting the skill. The
learner gets the opportunity to interact with their peers, collaborate and discuss
their learning with the instructor in real life situations. This allows for the
learner to determine the course of the session as it leaves a great deal of space
for participation and questions.
Disadvantages
In this method, there lacks a scope for creativity as the training provides the
learner with one model for which to perform a skill. Rather than allowing the
learner to complete a task using their own creativity you limit the learner by
allowing completion by following one set of prescribed tasks.
• In order to get the positive results, the trainer should be expert in using
techniques for behaviour modification. The trainer has the opportunity to
teach the learner a skill by demonstrating it themselves so must be competent in
the skill they are attempting to train to avoid teaching it incorrectly. If the
training is for a very specific skill the trainer may need to be outsourced to find
an expert and this becomes expensive.
• Modelling utilizes a simplistic behaviour models. As training sessions are
limited and resources and therefore, behaviour are performed in its simplest
form.
• In this technique, the theory is skipped over as the primary purpose of the
learning theory is to display a skill that encourage trainees to replicate it.
Trainees do not see underlying theories and concepts as their focus is on the
action itself.
• Since, this technique involves repetitive learning as it encourages trainees to
practice. In addition to this, it appeals only to those learners who get benefit
from physically doing what they have just seen as a method for learning
(Ormrod, & Davis, 2004).

Behavioural rehearsal
a technique used in behavior therapy or cognitive behavior therapy for
modifying or enhancing social or interpersonal skills. The therapist introduces
effective interpersonal strategies or behavior patterns to be practiced and
rehearsed by the client until these are ready to be used in a real-life situation.
The technique is also commonly used in assertiveness training. Also called
behavioral rehearsal.

OPERANT PROCEDURES

TOKEN ECONOMY
A system of behavior modification based on operant conditioning that utilizes
systematic reinforcement of a target behavior. “Tokens”are given contingent on
performance of the desired behavior, which then can be exchanged for
reinforcers within a predetermined economy system.
The use of the token economy as a clinical intervention began in the 1950s and
1960

Procedure
Designing a token economy involves the following suggested steps (Cooper et
al. 2007; Kazdin 1977):
1. Identify target behavior(s) and rules. Target behavior(s) should be observable
and measurable, and the criteria for successful task completion (i.e., how many
tokens must be earned in order to receive the reinforcer) should be specified for
the individual.

2. Select tokens. Tokens should be tangible symbols that are given immediately
to the individual as a consequence of exhibiting the target behavior(s).
Frequently used tokens include checkers and tally marks.

3. Select a variety of reinforcers. The individual should be provided with several

possible reinforcers to work toward earning. Reinforcers are typically preferred
activities, items, and events.

4. Create procedures for earning tokens and exchanging for reinforcers. The
contingency for earning tokens and when they may be exchanged for the
reinforcer should be explicitly stated to the individual. If response cost is
incorporated into the token system, then the loss contingencies should also be
defined.

5. Establish a ratio of exchange. It is suggested that the initial ratio of exchange

be small in order to provide the individual with more

CONTINGENCY MANAGEMENT

Contingency management can be defined as a process through which the

reinforcement and punishment of child behavior are assessed and the
environment's responses to the child's behavior (i.e., the contingency structure)
are altered to effect behavior change.
The dual purpose of contingency management is to decrease maladaptive
behavior and increase adaptive behavior.

Behaviorists suggest that a breakdown in the environmental contingency

structure underlies a child's maladaptive behavior or absence of appropriate
behavior.

The goal, then, of contingency management is to restructure the child's

environment to include consistent consequences so that the child can learn how
to behave appropriately as a result of the new environmental structure

The design and implementation components most common to contingency

management plans include (a) reinforcement assessment, (b) measurement of
the target behavior, (c) contingency contracting, and (d) implementation of the
contingency management plan.

Reinforcer assessment
Positive reinforcer and negative reinforcer
There are several selection issues that need to be taken into account when
introducing a reinforcer into the environment.
● First, it is important to select consequences that are of value to the child,
because not all stimuli and events are reinforcing to every child.
● Gender and developmental level should be considered, as well as the
child's individual preferences

Baseline Measurement

Assessment should be an ongoing process in the development and

implementation of a contingency management plan.
The first step in developing any contingency management program is to
establish clearly which of the child's behaviors are targeted to increase or
decrease. Clear behavioral goals help the therapist and contingency manager
determine whether the child is on track and behaving appropriately. These goals
can include the addition of new behaviors to the child's repertoire, the increased
frequency of already present positive behavior, or the decreased frequency of
already present negative behavior. A contingency management plan also can
target the reduction of negative parent or teacher behavior (e.g., criticism,
authoritarian commands, attention to maladaptive child behavior). However, the
focus of this entry is on child behavior.

Accurate assessment of the baseline rate for maladaptive behavior, the

intensity of the behavior, and the naturally occurring environmental stimuli
and reinforcers that serve to maintain the maladaptive behavior is
important for the design of the contingency management plan. This assessment
should be conducted at the beginning of therapy and should include a thorough
evaluation of the antecedents to the behavioral event, the nature of the behavior,
and the consequences of the child's behavior.
Assessment methods can include parent report, child self-report, child
self-monitoring, and direct observation. A parent, teacher, trained observer, or
therapist can conduct direct observations of child behavior, and the resultant
data should be plotted on a behavior chart.

Contingency Contracting

Contingency contracts can include behavioral contracts, daily report cards, and
group contingencies. Behavioral contracts are the most frequently used form of
contingency contracting. When designing a behavioral contract, the child and
contingency manager agree upon one or more specific behaviors to target. It is
important for the child and manager to set realistic goals and specific
consequences, because if the goal is too large, the child will become less
motivated to work on the target behavior and the contract will fail. In addition to
agreeing upon the target behaviors, the dyad decides when the contract has been
fulfilled and what to do should the contract fail. Renegotiation may be needed if
the terms of the contract are met too easily or if the contract proves too difficult
for the child.

Daily report cards can be used with children who have disruptive classroom
behavior and typically involve a child, parent, and teacher working together.
Several target behaviors are selected, phrased in positive terms (i.e., letting the
child know what behaviors are expected), and rated on their presence or absence
during the school day by the teacher. If the child performs the behavior during a
specific time period, he or she receives positive feedback on the daily report
card. This report is sent home to the child's parent, who reads it, signs it, and
provides at-home rewards contingent upon demonstrated performance of the
adaptive classroom behavior. In addition to motivating a child to perform
adaptive classroom behavior, daily report cards can be a valuable
communication tool between parents and teachers.

Group contingencies are especially useful in settings including more than one
child (classroom, sibling group, day care, extracurricular group). When using
group contingencies, the consequences (reinforcing or punishing) for group
members depend on the behavior of other members. For example, in
consequence sharing, an entire group of children receives a reward contingent
on the good behavior of one child. Alternatively, interdependent group
contingency involves a group of children receiving a reward contingent on the
good behavior of the entire group.

Implementing the Contingency Management Plan

The therapist monitors the execution of the program and provides frequent
feedback about the execution of the contingency management plan to the parent.

Contingency management can include a number of specific techniques (e.g.,

successive approximations, selective attention, discrimination training, and
extinction), but the most frequently used techniques are contingent punishment,
time-out, response cost, and differential reinforcement of other behavior (DRO).

APPLICATION

Contingency management is a hallmark of empirically based treatments for

childhood disorders. Specifically, research supports the use of contingency
management for attention-deficit/hyperactivity disorder, anxiety disorders,
chronic pain, conduct disorder, depression, distress due to medical procedures,
encopresis, enuresis, obesity, oppositional defiant disorder, phobias, and
pervasive developmental disorders. Taken together, there is more research
evidence to support the efficacy of behavioral treatments of childhood disorders
than any other treatment modality.

AVERSION
Faradic aversion
•FA refers to a specific technique used in aversion therapy that involves the
application of faradic current, a type of electrical stimulation, as an aversive
stimulus
Covert sensitization
•Covert sensitization to demonstrate that conditioned nausea responses can be
trained in alcoholic patients through the use of imagination & verbal suggestion
without the use of an emetic drug
Aversion relief procedures
•In aversion relief the subject is enabled to stop the aversive stimulus by
performing more appropriate behavior, which will lead to feelings of relief.
Avoidance conditioning
•Avoidance conditioning, as part of classical conditioning, refers to a process in
which a subject is taught to avoid "punishment" as part of a two-part process; a
neutral stimulus (such as a bell or a light) that precedes the unpleasant
"punishment" (such as an electric shock). The subject quickly learns to avoid
the punishment by responding to the neutral stimulus

SELF CONTROL PROCEDURE

Self-control strategies help individuals to become aware of their own patterns of
behavior and to alter those patterns (usually by creating artificial rewards or
punishments) so that the behavior will be more or less likely to occur.

THOUGHT STOPPING
Thought stopping is a strategy that involves blocking and replacing unwanted,
distressing thoughts. The technique is sometimes used in cognitive-behavioral
therapy (CBT) as a way to halt or disrupt negative thoughts.Then, a more
adaptive or helpful thought can then be substituted for the unhelpful one.

The focus on thought stopping is to disrupt, dismiss, and replace the unwanted
thought. Some of the different strategies that you might use to do this include:

● Saying "Stop!" inside your mind

● Holding a visualization in your mind whenever you have the thought
● Clapping your hands or snapping your finger whenever the thought enters
your mind
● Making a checkmark on a piece of paper every time you have the thought

Thought stopping has often utilized as a way to treat many different problems,
including:
 ​ Agoraphobia
​ Anxiety
​ Catastrophic thinking
​ Intrusive thoughts
​ Obsessive-compulsive behavior
​ Rumination disorder
​ Social anxiety

Paradoxical Intention

Paradoxical intention is a technique that was developed by Victor

Frankl and is used as a cognitive technique that consists of
persuading a patient to engage in his or her most feared behavior.
In the context of insomnia, this type of therapy is premised on the
idea that performance anxiety inhibits sleep onset. Paradoxically, if
a patient stops trying to fall asleep and instead stays awake for as
long as possible, the performance anxiety is expected to diminish;
thus, sleep may occur more easily. In clinical practice, some
patients are fairly reluctant to use this procedure, and compliance is
often problematic. Sleep restriction therapy, a similar technique with
a different rationale, may be more readily accepted by patients.

Procedure

● Evaluation of the problem.

● Redefinition of the symptoms according to the data of the

evaluation. In this step, the psychologist aims to give new

meanings to the symptoms.

 ● Indication of the paradoxical changes depending on the issue.

● Conceptualization of the changes according to the paradox.

● Prevention of relapses.

● Follow-ups.

Advantages

•Encourage to indulge in an exaggerated behaviour

•Shift the attitude towards symptoms
•Disrupt the anxiety provoking cycle
•Incorporates humour and playfulness
•Promotes a sense of personal autonomy
•Problems associated with activity of the sympathetic nervous system

BIOFEEDBACK

Biofeedback is a mind–body technique in which individuals learn how to

modify their physiology for the purpose of improving physical, mental,
emotional and spiritual health. Much like physical therapy, biofeedback
training requires active participation on the part of patients and often
regular practice between training sessions. Clinical biofeedback may be
used to manage disease symptoms as well as to improve overall health and
wellness through stress management training.
Biofeedback is a self‐regulation technique through which patients learn to
voluntarily control what were once thought to be involuntary body
processes. This intervention requires specialised equipment to convert
physiological signals into meaningful visual and auditory cues, as well as a
trained biofeedback practitioner to guide the therapy. Using a screen such
as a computer monitor, patients get feedback that helps them develop
control over their physiology
Surface electromyography (sEMG) is perhaps the most common
physiological variable monitored using biofeedback. sEMG feedback is
used in a variety of disorders such as tension headache, chronic pain,
spasmodic torticollis and temporomandibular joint dysfunction.
Electroencephalography (EEG) feedback, also called neurofeedback, is
used in ADHD and epilepsy and is increasingly the focus of research and
other applications.

•Thermal Biofeedback: Thermal biofeedback involves the use of sensors to

measure and provide feedback on skin temperature. It helps individuals learn to
regulate peripheral blood flow and skin temperature, which can be useful for
conditions such as migraines or Raynaud's disease.
Heart Rate Variability (HRV) Biofeedback: HRV biofeedback focuses on
measuring and providing feedback on heart rate patterns and variability.
Electroencephalography (EEG) Biofeedback or Neurofeedback: EEG
biofeedback, also known as neurofeedback, utilizes sensors placed on the scalp
to measure and provide feedback on brainwave activity. Neurofeedback is
commonly used in the treatment of conditions like ADHD, anxiety disorders,
and certain sleep disorders.
Galvanic Skin Response (GSR) Biofeedback: GSR biofeedback measures
changes in skin conductance, which can reflect emotional arousal and stress
levels

•Respiratory Biofeedback: This technique involves measuring and providing

feedback on breathing patterns, respiratory rate, and depth of respiration. It
helps individuals learn diaphragmatic breathing and other breathing techniques
to promote relaxation and stress reduction.

•Blood Pressure Biofeedback: This technique involves the measurement and

feedback of blood pressure levels. It can be useful for individuals with
hypertension or other blood pressure-related conditions, helping them learn
techniques to regulate blood pressure through relaxation and stress reduction.

F•FA refers to a specific technique used in aversion therapy

that involves the application of
faradic current, a type of
electrical stimulation, as an
aversive stimulus
aradic aversion:
senes Training
is a form of
Behaviour
Therapy
designed to
help people
stand up for
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themselves in
more
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terms
Assertiveness
Training is a
form of
Behaviour
Therapy
designed to
help people
stand up for
themselves -to
empower
themselves in
more
contemporary
terms