kohlenberg bolling, kanter & parker. clinical behavior analysis

8/3/2019 Kohlenberg Bolling, Kanter & Parker. Clinical Behavior Analysis

1/6

KOHLENBERT, BOLLING, KANTER & PARKERCLINICAL BEHAVIOR ANALYSIS: WHERE IT WENT WRONG. HOW ITWAS MADE GOOD AGAIN. AND WHY ITS FUTURE IS SO BRIGHT.Robert J. Kohlenberg, Madelon Y. Bolling, Jonathan W. Kanter & Chauncey R. ParkerUniversity of Washington

This paper traces the birth, quiescence and renaissance of clinical behavior analysis (CBA). CBAis the application of radical behaviorism to outpatient adult behavior therapy. Itaddresses thequestion of how talking in the consult ing room helps the client outside of the office, in his or herdaily life. The answer as formulated by CBA has led to exciting and significant developments withconsiderable promise for improving therapeutic interventions. A brief historical account ofCBA isdescribed that involves the interplay of three strands involving clinical applications of behaviorism:behavior therapy, applied behavior analysis, and the development of the Association for theAdvancement of Behavior Therapy (AABT). These strands are traced through publications inBehavior Therapy from its inception to the present. We contend that there is a need in AABT andin behavior therapy in general for what CBA has to offer. As we see it, the major problems facingthe AABT membership with its current emphasis on cognitive therapy and empirically validatedtreatments include the lack ofa coherent theoretical base that can embrace all of the techniquesused by behavior therapists. Now with all the behavioral procedures that have been developed, ahorrendous question arises, "When do you use which procedure for what kind of person? " Weconclude that far from being a thing of the past, CBA has a bright future in answering this question.Behavior analysis of the therapeutic situation offers a unique, coherent theoretical base that canembrace all techniques used by behavior therapists, including cognitive therapy strategies.Clinical behavior analysis (CBA) isdefined as the application of radical behaviorism(Skinner 1953, 1974) to answer the most basicquestion about outpatient adult behavior therapy(or any other type of psychotherapy)(Kohlenberg, Tsai & Dougher, 1993). Sinceoutpatient treatment consists of verbalinterchanges' between client and therapist, thequestion is this: what is the mechanism thatexplains how this talking helps the client outsideof the office in his or her daily life? In this

paper, we contend that CBA is an exciting, new,and significant development that holdsconsiderable promise for improving therapeuticinterventions. We also recognize that mostbehavior therapists are only superficiallyfamiliar, if at all, with CBA and are not aware ofits considerable potential as a highly effectivetreatment. There are several factors that accountfor the relative invisibility of CBA, not least ofwhich is its mercurial appearance over the last46 years.T HE B IR TH OF CBA

In Science and Human Behavior (1953),Skinner gave an analysis of psychotherapy,

1 As we define it , verbal interchanges include makingcontracts , emotional expression, delivering rewards, etc . Formore on this broad conception of what is verbal, see Skinner(1957).

including behavioral interpretations of termssuch as resistance, repression, and freeassociation. Following this work, very little waspublished on CBA other than the insightful, butlargely ignored papers by Charles Ferster (1967,1972a, 1972b, 1972c, 1979). Neither Ferster norSkinner intended to devise new approaches totreatment in these writings. Instead they wrotein behavioral language, demonstrating a moreuseful way of describing, understanding, and inFerster's case, teaching the change process. So,CBA got its start quite early in 1953 and then allbut disappeared until its reemergence in 1987with the publication of an edited book(Jacobson, 1987). The Jacobson book containedchapters by Hayes (1987) and Kohlenberg &Tsai (1987) that described in detail theirapproaches to using Skinnerian principles totreat outpatient adults. We will refer to thishiatus as the quiescent period ofCBA. Thereasons that behavior analysts did not pursueCBA playa role in understanding the nature ofits renaissance.

eBA's Quiescent PeriodOur historical account of CBA involvesthe interplay of three strands involving clinicalapplications of behaviorism. These are behaviortherapy, applied behavior analysis, and thedevelopment of the Association for theAdvancement of Behavior Therapy (AABT).

2 4 8


2/6

THE BEHAVIOR ANALYST TODAYBehavior therapy is the application oflaboratory-based principles oflearning (in theearly years) to human problems and acommitment to empiricism in evaluating theeffects of the treatment. Applied behavioranalysis is more narrowly defined as theapplication of operant conditioning laboratoryprinciples to treating and solving humanproblems - in other words, the Skinnerian basedtreatment approach. Although both areapplications of Skinnerian operant principles toreal human problems, CBA is distinct fromapplied behavior analysis in that it focuses onoutpatient "talk" therapy, whereas appliedbehavior analysts pay very little attention to suchtherapy. AABT is the dominantprofessional/scientific organization to whichbehavior therapists belong and, with itsjournal,Behavior Therapy, is the primary voice ofbehavior therapy.

In 1966, during CBA's quiescent period,AABT was established, and its journal, BehaviorTherapy, came into existence in 1969. AlthoughCBA was quiescent, applied behavior analysiswas not. In fact, applied behavior analysisplayed a very significant role in the developmentof behavior therapy during these early years.Applied behavior analysis was considered one ofthe two pillars of behavior therapy, the otherbeing desensitization and classical conditioningbased treatments.

During this period, behavior analysiswas in the mainstream of behavior therapy.There was a virtual explosion of research onbehavior change techniques based upon operantprinciples (e.g., Ayllon &Azrin, 1965; O'Leary&Becker, 1967; Wolf, Risley, &Mees, 1964).In the years 1970 to 1978, a casual tabulation ofthe papers published in Behavior Therapyshowed that about 40% of the empirical andtreatment papers referred to the operant termscontingency, reinforcement, extinction, ordiscriminative stimulus. Many of the publishedgraphs were cumulative records (a favorite ofbehavior analysts) that showed a baselinecondition, a reinforcement condition, and anextinction condition. These graphs showed howthe therapist's within-session actions (e.g.,applications of reinforcement and punishment,shaping, exposure to feared stimuli) produced

VOLUME 3, ISSUE 3, 2002behavior change. It is important to point out thatin these papers, the behavior changes that werethe goal of treatment were also observed duringthe session; we will elaborate on the significanceof this later. There were, of course, equivalentnumbers of papers on desensitization andclassical conditioning applications and it was notunusual for individual papers to have referencesto both.

Given that applied behavior analysiswas a foundation of behavior therapy and had astrong presence both in AABT and in itsjournal,it might well have continued playing asubstantial role. However in the 1980s and1990s, through an unexpected, curious turn ofevents, applied behavior analysis became aminor presence in the pages of BehaviorTherapy (with the notable exception discussedlater in this paper) though AABT, with over4000 members, had grown and prospered. Mostbehavior analysts now belong to the Associationfor Behavior Analysis and publish their work inanother journal, the Journal of Applied BehaviorAnalysis. Our explanation for this turn of eventsis closely related to the quiescence and eventualrenaissance of CBA.

First, behavior therapists becameincreasingly interested in working with adults inthe outpatient psychotherapy environment.Applied behavior analysts, on the other hand,mainly worked in settings that differed from thetypical psychotherapy office. Further, the kindsof problems that applied behavior analysts dealtwith were not typical problems of the adultoutpatient such as depression, problems of theself, difficulties in intimate relationships, andexistential anxiety. Instead the behavior analystwas extremely effective in treating problemssuch as head banging, poor math performance,hyperactive school children, tics, mutism, towelhoarding, and lack of rudimentary self care skillsin hospitalized patients with schizophrenia. So,given the growing interest in adult outpatientproblems and the seeming inappropriateness ofapplied behavior analysis, behavior therapistsbecame less interested in applied behavioranalysis. Even more telling, many appliedbehavior analysts left the fold and turned tocognitive therapy for guidance in doing office-

24 9


3/6

KOHLENBERT, BOLLING, KANTER & PARKERbased treatment (Hawkins, Kashden, Hansen &Sadd, 1992).

The abandonment of the Skinnerianapproach in mainstream behavior therapy wasbased on an unfortunate and misguidedassumption. The process was as follows: First itwas correctly concluded that applied behavioranalysis was effective for a wide variety ofproblems ranging from self destructivebehaviors in severely disturbed children toproblematic learning difficulties of children inclassrooms. Second it was clear that the kindsof problems that applied behavior analysis wasused for all had one thing in common, namelythe focus on actual within-session occurrencesof the client's problematic behavior andimprovement. That is, in order to use operanttechniques, the therapist had to observe theproblematic behavior directly, deliver therewards and punishments, and actually see thebehavior change. Third, it was assumed thatmost of the problems presented by outpatientadults, such as "difficulties in intimaterelationships" or "depression," or "anger"occurred only outside the therapy session in theirdaily life and could not be observed andreinforced directly by the therapist duringtypical office treatment. This last assumption,we believe, was erroneous.

In addition to this erroneous conclusion,there were other barriers that deterred behaviortherapists from using Skinnerian based methodsfor outpatient adults. Some applied behavioranalysts themselves uncritically accepted theerroneous conclusion and, as discussed byHawkins et al. (1992), became cognitivetherapists. Others inappropriately used operanttechniques with adults that further added to theprevailing misconception that behavior analysishad little to offer in the adult treatment arena.For example there were procedures such ascontracting, e.g., "I'll fine you a nickel if youdon't do this and that kind of behavior or if youweren't nice to your wife", or only payingattention to a client with depression if they weresmiling, or asking a husband to earn points fortaking out the garbage that could be redeemablefor sex with his wife. So, during the early yearsof behavior therapy and continuing till justrecently, applied behavior analysts were not very

effective in devising treatments that addressedthe daily life problems of adult outpatients.Thus we agree with Wulfert, in thisseries, that that particular form of the Skinnerianapproach failed to meet an important need for

expanding the scope of behavior therapy. Wealso agree that this failure set the stage for theso-called "cognitive revolution," becausecognitive therapy easily lent itself to officetreatment.The Renaissance

Unfortunately, the fact that problematicclient behavior actually occurs in the office wasoverlooked by most behavior analysts. Onereason for this oversight was that behavioranalysts were focusing their efforts in othersettings. They were doing very well with thepopulations in institutions such as schoolclassrooms, mental hospitals and even wholecommunities. But Behavior Therapy stoppedpublishing this kind of work because thereadership had more interest in office treatment,so cognitive therapy papers appeared withincreasing frequency. We suspect that thoseapplied behavior analysts who didn't embracethe cognitive perspective, left AABT and joinedthe Association for Behavior Analysis,published in their own journal (The Journal ofApplied Behavior Analysis) and more or lessabdicated their role in outpatient treatment tocognitive therapists.

This situation set the stage for arenaissance of clinical behavior analysis. Howdid we get back on track? From our perspective,the watershed event in this whole clinicalbehavior analysis area was Steve Hayes' work(Hayes, 1987;Zettle & Hayes, 1982;). He tookSkinner's Verbal Behavior (1957) and applied itto outpatient individuals while investigating theunderlying principles with correspondinglaboratory work. For the first author,Kohlenberg, Hayes' work was an eye opener,because early in his own career during the1970s, he was a radical behaviorist at heart, butwasunable to use Skinnerian principles whendoing outpatient treatment. At that time, it wasdifficult to conceptualize outpatient treatment inSkinnerian terms because the framework wasn't

250


4/6

T H EB E H A V lOR A N A L Y S T TOO A Y

there. Then SteveHayes' work changed that.There were many other contributors who addedto this, but it was a concentrated effort on hispart that made the critical difference. Thissymposium that is gathered here today is a directresult of Hayes' application of radical behavioralprinciples to outpatient treatment. Now there isa way for behavior analysts to start talking aboutwhat goes on in a talk therapy situation.

Behavior therapists abandoned appliedbehavior analysis and the idea of using theSkinnerian approach, as we said, due to anerroneous conclusion that problems presented byoutpatient adults do not occur in the therapysession. We do not think that the therapyenvironment actually differs significantly fromthe client's daily life environment. On thecontrary, we contend that most people's dailylife problems are the same kinds of problemsthat occur in-vivo, during office treatment. Indaily life, our problems have to do with relatingto other people, and therapy requires the clientand therapist to relate to one another.Functionally speaking, the way you knowwhether a client-therapist environment is thesame or different from the environment on theoutside is whether or not it evokes the samekinds of problems the client reports havingoutside of therapy. And in fact, if therapists takea functional view of client behavior, they seethat the same kinds of client problems actuallydo happen in the office as in daily life. That'sbecause the therapy situation is part of daily life:it's not separate from the natural world. Thatbeing the case, the behavior analyst who's usedto working with behavior as it occurs in aclassroom or Skinner box, actually has the sameopportunity to do something with on-goingclient behavior in the outpatient therapy office.

A Grand Theory for Behavior TherapyWe contend that there is a need in

AABT and in behavior therapy in general forwhat CBA has to offer. As we see it, the majorproblems facing the AABT membership with itscurrent emphasis on cognitive therapy andempirically validated treatments include the lackof a coherent theoretical base that can embraceall of the techniques used by behavior therapists(Branch, 1987). During the rapid growth period

VOLUME 3, ISSUE 3, 2002

of behavior therapy there was almost no interestin theory. Now with all the behavioralprocedures that were developed, a horrendousquestion arose, "When do you use whichprocedure for what kind of person?"In fact, this is a big question for alltherapies, and we behavior analysts are actuallyin a good position to answer it. There is nothing

in a behavior analytic approach that rules outany procedure. We can do anything. We mightconceptualize it in different terms than acognitive therapist might, but basically we canembrace every treatment procedure that AABThas ever had presented at conventions orpublished in their journal. We can fit it into atheoretical structure and solve the problem ofdeciding which procedure to use. The idea thatbehavior analysis offers an integrative treatmentapproach is very compelling. There really isn'tany other theory or theoretical approach that canembrace every procedure, from cognitiveinterventions to free association. Kohlenberg &Tsai (1994), who used CBA to embracepsychoanalytic and cognitive therapyprocedures, demonstrated the integrativepossibilities of this approach.

The Bright Future for eBAThere has been a recent spate of reportsshowing that medication is better than

psychosocial treatment for a variety of disorderssuch as depression. If medication is in factbetter, then it's not a problem. But many of usthink that psychosocial treatments could bebetter and are preferable in the long run. Nowwhat's the solution to the problem? We mustdevelop more powerful treatments. Again,looking at the last two 1997 issues of BehaviorTherapy, the innovative treatments withpromising futures that were mentioned the mostcame from the behavior analytic tradition.

We're in a position to offer somethingnew to the field. One strategy for doing that is tobuild upon something that's already there. Thisis fairly easy to do if you look at the integrativepower of behavioral analysis referred to above.As a case example, we have done a behavioralanalysis of cognitive behavior therapy fordepression and have come up with some very

251


5/6

K 0 H LEN BERT. BOLL I N G. K AN T E R & PAR K E Rpromising improvements that should enhanceefficacy. One such improvement is based on thenotion that maximum change occurs whenimprovements in the client's behavior arereinforced as they occur, within the therapist-client relationship. For example, a client whofeels isolated because slbe always needs toappear strong, competent and in control,happens to admit a fear or a weakness to thetherapist. If the therapist responds honestly thats/he feels closer to the client as a result of thisdisclosure, that this may help the client to riskmaking such a disclosure with selected othersoutside of therapy, consequently feeling lessisolated. In other words, an in-session, directlyobservable client behavior (admitting aweakness to the therapist) occurred and wasimmediately reinforced', We have beenconducting anNIMH treatment developmentstudy to find out if these in-vivo enhancementscould be implemented. Although the study isnot yet completed, preliminary results indicatethat experienced cognitive therapists can learnhow to do the enhanced treatment. As shown inFigure 1,therapists doing the enhancedtreatment with clients with depression makemuch more use of the therapist-clientrelationship as an in-vivo example of their dailylife problems.

2 Technically , the event is not known to be reinforcing untilwe can observe future occurrences of the client behavior inquestion.

1.8,...--- --------~..,

1.7

1.6l'2 1.5~ 1.4.~Q 1.31~ 1 .2

~ 1.1'S~ I.0lo--- _._--...,.-__,_------I.

".

'. .. . . - .. - _ .. - - . . . . . . . . . . . . . _ . . . . . .'.. . . . -~ .. " CTFECT

12 16

SessionFigure 1. Use of the therapist client relationship in sessions 4, 8,12, and 16 fur clients receiving either Cognitive Therapy (CT,n=15) or the functionally-enhanced Cognitive Therapy (FEeT,n=23). The use of the therapist client relationship was measuredby trained raters using the Therapist In-vivo Strategies Scale(parker, Bolling, &Kohlenberg, 1996) on videotapes of therapysess ions from the NIMH treatment development s tudy. Highscores indicate more use of the client-therapist relationship.

Behavior analysis can even help withproblems that are perplexing to cognitivetherapists regarding such issues as cognitivestructures, cognitive products, and automaticthoughts, specifying exactly how they differ andhow to change them (Kohlenberg &Tsai, 1991).We have some very good solutions to thesequestions that are based on distinctions betweenrule-governed and contingency-shaped behavior.So, not only can we improve treatment but wecan also help cognitive therapy and make somefriends. We agree with Wulfert that we need toreach out, offer something, and learn something,rather than just being critical of our AABTbrothers and sisters. Our study on enhancingcognitive behavior therapy has shown what agood treatment cognitive therapy is and howdifficult it is to do properly. We employedexperienced cognitive behavior therapists andhave learned to appreciate what they do. It isactually a very good treatment: it's easy toundersell cognitive therapy if you don't see it inaction and appreciate how difficult it is to doproperly.

Although behavior analysis was out ofthe picture till very recently we think the currentstatus is good, based on certain bits of evidence.First of all, Steve Hayes is the president ofAABT and a behavior analyst. Not only that,

25 2


6/6

THE BEHAVIOR ANALYST TODAYbut Neil Jacobson, a recent radical behavioralconvert, chided the audience in his 1991AABTpresidential address that AABT wasn'tbehavioral anymore and had ignored functionalanalysis. Secondly, if you look at AABTprograms, you'll find there are more and morebehavior analysts actually presenting at AABT.Third, more evidence can be found in the lasttwo issues of the 1997Behavior Therapy. Theseissues were devoted to an assessment of the last30 years and the future of AABT and behaviortherapy. Interestingly enough, they were editedby two behavioral analysts, Rob Hawkins andJohn Forsyth, good evidence that clinicalbehavior analysis once again has a strongpresence in AABT. Some may not like the ideathat we are using "influencing AABT or being inAABT" as a measure of the health ofCBA. Butgiven the size and influence of AABT, it's ameaningful measure. Fourth, if you lookthrough those last two 1997 issues of BehaviorTherapy, it's remarkable how much attention isbeing given to behavior analysis by mainstreambehavior therapists. References to Kohlenberg& Tsai and Hayes are frequent. That's evidencethat clinical behavior analysis is more presentthan it has been since the very early years. Soour assessment is that the current status of CBAis good and our future is bright.REFERENCES

AyI loo, T.& Azr in , NJI (1965). Th e mealllrel1X:llt m dr e i n i O O m I e n t o fbe l :J av i a' o fp s ydodes Journa l qfthe&per imenta lAmlys is of Behav ior , 8, 53-62.

B r a n d J , MN. (1987) BdIav iocana lysis: A caxx:ptual an dempirical r o s e fo r behav ior~y. Behavior T h e r a p i s t , 4 ,79-84

Fe rs te r, C .B . ( 1961) . A rb it ra ry a nd n a I u r a l re inf i rcenxnt . T h ePs;dv log icaJRemrd , 22,1-16.

F e r! ie r, C .B . ( 1972 a ~ O i n ic al re inf t ro:m:nt . &m~ inP s y c h i a u y ; 4 ( 2 ), 10 l- 111 .

Fe rs te r, C .B . ( 1972b ~ A n experimental a na ly s is o f c l in i c al~ 7heP s;dv log ica l Reard 2 2 , 1 -1 6.

F e rs te r, C .B . ( 1fJTk).~fiom the sta ldpo into fab e h a v i O O s t . ln 1.D. Kee lm (Ed) , PIofXl/h:J low ina n i m a l s : R e s e a r d z a n i d in ia J l i m p I i c n t i o o s . N ew Y ak :A c al em i c P re s.

VOLUME 3, ISSUE 3, 2002Fe rs te r, C .B . ( 1979 ). A llb:r.iay mxIeI ofp;ycho1hernpy. ln P.

Sjoden (Ed) , T ends in beIuvior t h ! r r J p y . N ew Y ak :A ca le m ic P re s.

H lMk im , RP, Ka>hdfn, J,Hensen, DJ, &S O O d , DL (1992).The i n c r e a l i n g reIirence to "oognitive" v a r i a b l e s inbehaviorthe r apy: A 2O -ye a - emp ir i ca l a na ly s is . T h e BehaviorT h e r a p i s t , 15, 115-ll8 .

Haye i , S.c . (1987). A c r n t e x t u a J appuach to 1 h cr ap e ut i c ~fu N . S . J O O Jb m . (Ed) , Psyr:hotherapist in diniaJl pvctice:Cognitiwanibehavinralperspedives(pp.327-387).NewY a k: G .r ll ix tl P re s.

JIUlbm, N . S . (Ed) . (1987). Psyr:hotherapist in clinical pvctice:C ogn i t iw an i b e ha v in r a l p er sp ed iv e s. N ew Y ak : CbiIi :nlPres.

Kob leobeg Rl, &T sa i, M ( 19 87 ). F u n di on a J analytic~. fuN . S. Jaxhm ( E d ) , P s ; d 1 o t h e r a p i s J s indiniaJl 'poaice: C ogn i t iw a n i b eh a vi nr a l ' p e r s p e a i v e s (pp.388443). New Ya k : G .r ll ix t lP re s .

Koh lenbc rg , RJ, & T sa i, M ( I C fJl ) .Fu rd iona l amlytic~: A guidefo r creating intense ani C U 1 ' I J t i wt h e r u p e u t i c r e l a ti o n s h i p s . N ew Y ak : P le nu m

Koh len lx : r g , RJ, & T sa i, M (1994 ~ F un dio na J analytic~y : A b e h a v i o r a l w o a c h to1reltmentandi n t e g r a i o n . Journa l o fPs;d1othe rapy In teg ra t ion , 4 , 1 75 -201.

Koh len lx : r g , RJ., Tsa i ,M. ,&Dougbe r , MJ. (1m). 'Ibedimens ioos o f c li n i ca l b ehav io r a n a 1 y s i s . the BefwkJrA n a l y s t , 16,271-282.

O 'L e ar y,K D .,& J 3e O O ;r , W . C.(I 96 ~ B eh av io rr md if ia ti rn o fIIIal jus I :nm d IN> : A td:n r e i n f ! r c e m e n t p r og r nmExceona l C h i l d r e n , 3 3 , 6 3 7 -6 4 2 .

I ' l Ikfr , CR. , Bo l l i ng , M Y , &Koh len lx : r g , RJ. (1996). Therapistin-viw strategy s c a l e . Unpublishtrl ma n ll .'D i p. S ea tt le :U n i v e r s i t y ofWll' lhingtoo.

Skinner,B.F.(l953~ Scimceanihumanbeluvior. N ew Y akMacmil lm.Sk inne r , B .F . (1951) . Verfu l beIuvior. New Yak : A p p l e t o n . -

Century-Qu1is.Ski n n er , B .F . ( lCJ74~Alxmtbeh:wiorism. New Yak Knop fWolf ; MM., Risley, T, &Mees, HI.(1964) . A wlica tir n o f

qJeI1IIlt andi t i r n i ng r r o c a J u r e ; to 1 h e b eh av io rp ro bl em s o f1Ila u t i s t i c dilld. Behaviour R e s e a r d z ani1herapy, 1,305-312

Z e t t l e , RD , &Hayes, S . c. ( 1 982 ) .Rule goverred b e h a v i o r : Ap o t e n t i a l t h oo ret ic a l ~ i O C o o g n i t i v e - b e h a v i o o d1 h e r n p y . ln P . C . Kenda l l (Ed) ,AdIuna?s in cognitiwb e h a v i o r o l r es ea r ch an i t h !r rJ py (VoL 1~New Yak :A c al em i c P re s.

A u th o r N o te : Addre ssedi100a l ro lTe .~ J () Jldenc e to : Rober t J.Kohlenberg, D i r e c t o r o fO i n ic al T ra in i n g, D e p a r t m e n t ofPsydlology 351635, Univ t ' lSi tyofW!flh ingtrn, S e a t t l e ,WA 98195 -16 35. Emai l: i l ! p ( q uw .m i ng lmedu

2 5 3

kohlenberg bolling, kanter & parker. clinical behavior analysis

Documents