Chapter 5: Growth Resources in Behavior-Action Therapies
The behavior-action therapies are a diverse cluster of therapeutic approaches that share the
conviction that all the problems which people bring to therapy are essentially unconstructive behavior resulting from faulty learning. Using many different techniques, these therapies apply the basic principles of learning theory to enable people to unlearn ineffective behavior and learn more constructive behavior in its place. The behavior therapies are also called "action therapies"
because of their emphasis on using direct, action-oriented methods to enable clients to learn new behavior. These therapies contrast with all the "insight therapies" derived from Freud, which regard dynamic inner changes in attitudes, feelings, and self-perception as the primary means of therapeutic change including changes in behavior.
The foundations of behavior therapies were constructed by the Russian physiologist Pavlov's experiments in conditioning animals early in this century.(1) Around 1920 behaviorist psychologist John B, Watson and his students discovered that they could produce phobias in children by simple conditioning procedures and cure those who were already phobic by
counter-conditioning. In the 1930s, psychologist O. Hobart Mowrer developed a classical conditioning method for treating enuresis that proved effective. He used a pad and a bell that rings when the child wets the bed. Around 1950, Joseph Wolpe (then a South African psychiatrist) developed a counter-conditioning method called "systematic desensitivation," which he found eliminated neurotic anxieties in many of his patients in a relatively brief time. He obtained dramatic results in treating phobias and sexual impotence, both of which were considered relatively intractable in psychoanalytic therapies.(2) Around the middle 1950s some of
behavioral psychologist B. F. Skinner's students at Harvard began to apply to human beings his methods of instrumental or operant conditioning,(3) developed during a quarter century of laboratory research mainly with animals. Whereas Wolpe has concentrated on extinguishing old unadaptive behavior, these therapies emphasized shaping new constructive behavior through positive reinforcement. By simply rewarding behavior that was constructive and reality-oriented, in mental hospital wards (using a so-called "token economy") they found that they could
increase drastically such "uncrazy" behavior on the part of psychotic patients, many of whom had not responded to traditional therapies.
Since 1960, the floodgates of behavior therapies have opened wide. Learning theory principles
have been applied to many types of problems in living. "Some of the most important applications have been to the training of retarded children, to the elimination of sexual disorders, to the large-scale amelioration of adult psychotic behavior, to the training of autistic children, to the re-education of delinquent adolescents . . . to marriage counseling, to weight control and to
The behavior therapies derived from the research of Skinner focus exclusively on changing overt, measurable behavior. In contrast, the cognitive-behavior approaches broaden the focus to also include changing "covert behavior" such as beliefs, expectations, concepts, and feelings. Aaron Beck's
"cognitive therapy"(5) and Albert Ellis' "rational emotive therapy"(6) emphasize the crucial role of thoughts and beliefs in maintaining and changing unadaptive behavior. Albert Bandura's approach employs classical and operant conditioning methods to change behavior but he uses these in a social learning framework that highlights the importance of cognitive processes in facilitating and maintaining desired changes.(7) Unlike Skinner, who sees behavior as entirely the product of conditioning by the external social environment, the cognitive behavior therapists
emphasize the human capacity for self-directed behavior change. They focus on helping people increase self-control and mastery over their own lives. The cognitive behavior therapies provide the most useful growth resources currently available among the behavior therapies.
Learning theory principles probably will be applied to an increasing variety of personal, family, and community problems in the years ahead. Behaviorism is the dominant orientation in most academic departments of psychology. There is therefore an enormous pool of knowledge and
expertise available there for enriching the therapeutic disciplines. It is salutary, indeed, that the findings of the mainstream of empirical research in psychology are now being applied to resolving a host of severe human problems. The application of the general principles of learning to the growth work of functional people is a natural and potentially productive extension of these
In my experience, many of the working concepts and techniques of behavior-action therapies are effective in helping people change and grow. From a growth perspective, these therapies do not constitute a totally adequate therapeutic approach for everyone. However, they do provide a variety of conceptual and practical tools that can be integrated with resources from other therapies for use in enabling growth. In this chapter, I will highlight some growth resources from the behavior-action therapies which I have found useful. I also will describe some resources from several approaches that, though not usually labeled behavior therapies, all focus primarily on changing overt and/or covert behavior.
Principles and Methods of Behavior Therapies
There are several working assumptions that the diverse behavior therapies hold in common.(8)
In the parentheses following each of these assumptions, I will contrast them with the assumptions of traditional, psychoanalytically oriented therapies:
(1) Behavior therapies regard the painful "symptoms" that bring people for help as the real problem to be treated. (Traditional therapies see symptoms as surface manifestations of deeper, usually hidden causes.) (2) Behavior therapies consider and treat life-and-growth disrupting problems as faulty, maladaptive learning. (Most traditional therapies accept the medical model, which understands mental, emotional, and relational problems as "illnesses" that must be healed.) (3) The primary therapeutic focus of behavior therapies is on changing behavior, overt and/or
covert. The overall aim is to help people unlearn life-destructive behavior and learn life-enhancing skills. Improved behavior generally produces improved feeling. (The focus of traditional therapies is on changing destructive feelings, attitudes, and self-perceptions through insight, which is assumed to produce behavioral changes.) (4) The behavior therapies see the therapist primarily as a teacher of effective behavior. (The traditional therapies view the therapist as a healer or enabler of inner growth.) (5) Behavior therapies are present-oriented. They see the origins of behavior as largely irrelevant to therapeutic change and growth. (Traditional therapies focus on helping people
relive the origins of problems in the past and thereby finishing incomplete growth.) (6) Behavior therapies seek to identify and change the stimuli that trigger problematic behavior and the rewards (positive reinforcements) that cause it to be repeated and earned. (Traditional therapies seek to identify and change hidden "causes" from the past that continue to influence the present from
the unconscious mind.) (7) Most behavior therapies emphasize the importance of having limited, specific, and measurable behavioral change goals so that the effectiveness of therapy can be empirically validated. (Traditional therapies tend to define their goals more globally and subjectively so that empirical measurement of their effectiveness is very difficult if not impossible.) (8) Most behavior therapists regard a therapeutic relationship of warmth and trust as important because it facilitates more rapid learning. Skinnerian-based therapists generally view the therapist-client relationship as of little importance to change in therapy. (Traditional therapies understand the establishment of a therapeutic relationship as essential since the relationship is the primary arena of therapeutic change.) (9) Because the goals are limited and concrete in behavior therapies, and their methods designed to facilitate specific learnings, they tend to be shorter in
duration. (Traditional therapies tend to be longer-term.) (10) Behavior therapies have an aura of hope based on the conviction that what has been learned can be unlearned and the belief that everyone has some capacity to learn new, more constructive behavior. (There is a feeling associated with some traditional therapies that deeply diminished growth can be unblocked only
partially and via a long, expensive process.)
An Illustration of the Behavior Therapy Process
To illuminate the process and some of the methods of cognitive-behavior therapy, here is how Mrs. S., a twenty- nine-year-old, part-time librarian was helped:(9)
When she came for therapy, she described strong feelings of worthlessness, anxiety, and depression accompanied by tension, headaches, and insomnia. Tranquilizers from her physician had not helped. She sought therapy when her husband accused her of being "mentally disturbed" and threatened to divorce her. The therapist spent the first session listening to her pain and thus establishing a trustful, cooperative relationship. Then he began a behavioral assessment of Mrs. S.'s situation, seeking to identify the particular behavioral excesses (e.g., frequent rages) and behavioral deficits (e.g., underassertiveness) that were producing her distress. The therapist asked
her to keep a diary in which she recorded daily events and her reactions to them. This self-monitoring helped both Mrs. S. and the therapist discover the timing and frequency of her distress-causing behavior. After a half-dozen sessions, the assessment pinpointed these behavior difficulties which became the goals of therapy -- her unassertiveness; her inability to express her feelings, which the therapist saw as leading to a build-up of anger, resentment, and guilt (about her anger); the fact that she had never experienced orgasm; and her low opinion of
herself, which was reinforced by the covert behavior of self-deprecating thoughts.
During the process of making the behavioral assessment, the therapist decided tentatively on several therapeutic tools that he could use in helping her change her painful behavior and feelings. Since most of her problems focused on her marriage relationship, Mrs. S. agreed to include her husband in the therapy. The therapist began a program of relaxation training to help her learn
to relax at will whenever she became aware of rising tensions. This gave her a means of reducing her insomnia, headaches, and anxiety. The therapist simultaneously started assertiveness training, coaching her as she rehearsed more assertive ways of responding in situations in which she had been hyper-submissive. The third facet of therapy was a Masters and Johnson type approach to helping the couple deal with her lack of orgasms. With the support and collaboration of her husband, she began to have orgasms after a few weeks. The quality of their relationship was enhanced by this success and by Mrs. S.'s more outgoing behavior. To help her extinguish her self- deprecating thoughts, the therapist encouraged her to list and repeat to herself several true and constructive statements about herself that were incompatible with her unrealistic feelings of worthlessness. After about four months of therapy, Mrs. S. had achieved a dramatic lessening of her depression, self-rejection, and anxiety. Using her new emotional freedom and self-confidence, she decided to return to school to pursue an advanced degree. This account shows how cognitive-
behavioral methods can be used to help persons claim and develop their strengths, enrich their relationships, and expand their vocational horizons.
Behavioral Methods in Marital Counseling
Behavior-action therapies provide a variety of resources for marriage counseling as well as for other relational counseling and therapy. Marital happiness is seen by behavior therapists as
produced by particular need-satisfying behavior. All married couples are both students and teachers of each other. They constantly increase or decrease the probability that need-satisfying behavior will occur in the other. David Knox, a behavior marital therapist, states: "Marital behaviors, like all behaviors, are learned, or rather taught -- according to their consequences. A
reinforcer is a consequence that increases the probability that a specific behavior will recur."(10) Counseling consists of identifying the particular behaviors that are satisfying and those frustrating for a given couple, and then, using learning theory, teaching them to increase the valued behaviors
while decreasing need-depriving behaviors.
I find it useful in marriage counseling and therapy to encourage couples to describe their problems in terms of the specific behaviors that each would like decreased, terminated, modified, increased, or developed. This emphasis establishes concrete goals toward which they need to work to make their marriage more satisfying and pleasurable. Since the goals they set involve specific behaviors, both the couple and the counselor can know when they are making progress in moving toward these goals.
Three behavioral methods are particularly useful in marriage and family counseling. Selective reinforcement consists of helping couples or family members identify the specific responses that reward desired and undesired behaviors and then teaching them to increase the reinforcement of desired behavior and to terminate reinforcement of undesired behavior. It is often very enlightening for couples to discover the ways they are "sinking their own canoe" by unwittingly rewarding the very behavior they find annoying in each other. Nagging, for example, tends
to reinforce negative behavior by rewarding it with attention.
Exchange contracting is another valuable tool in all relationship counseling. After both persons identify the specific behaviors they would like changed, the counselor helps them negotiate a mutually acceptable contract specifying what behaviors each will terminate or increase in exchange for changes in the other. A related behavioral technique called shaping is useful in this do-it-yourselves change process. Shaping consists of breaking down a complex interacting cluster of behaviors (such as a marriage relationship) into small components. By focusing on and reinforcing one or two components at a time, persons in marriage counseling gradually reshape their own relationship. Behavioral methods, like any marriage-counseling tools, can be effective only if both parties value the relationship enough to have some commitment to reconstructing it.
To illustrate how behavioral approaches can be integrated with traditional role-relationship counseling methods, here are the steps that often occur in the process of couple marriage counseling:(11)
Step 1 -- The counselor establishes rapport with both persons by listening with warmth and empathy as they take turns describing the painful problems that brought them for help. The
pattern of their self-other defeating behavior gradually becomes clearer as the counselor listens and asks gently probing questions to clarify how each responds in their negative cycles of interaction.
Step 2 -- The counselor describes briefly how behavioral change methods and exchange contracting may help them decrease their pain and increase their satisfactions. After the anger and hurt have been expressed and thus reduced (which frees the couple to hear and think more
clearly), the counselor may say:
From what you've shared with me, it's clear that each of you is experiencing tremendous pain and not much satisfaction in your relationship. You're caught in a mutual hurting cycle. Each of you, out of your pain, is responding in ways that bring more hurt. An example of how this vicious cycle operates in your relationship is ---. I'd like to encourage you to learn how to interrupt this self-sabotaging cycle and get more satisfactions for both of you back into the way you relate. This would involve working out at each session an agreement about what each of you is willing to do, during the coming week, to make things better for your spouse in exchange for changes on the
other's part to make things better for you.
Step 3 -- If both agree, they are asked to prepare (perhaps as "homework") a list of the specific undesirable behaviors that each would like the other to change, ranking these from the least to the most undesirable.
Step 4 -- Both are also asked to make a list of how they respond to behaviors they find undesirable in each other, to discover how they unwittingly have rewarded such behavior.
Step 5 -- Each then prepares a list of satisfying behaviors he or she would like to have increased or added by the other, rank ordering this list also.
Step 6 -- In light of these lists, the spouses are then coached as they negotiate a simple, workable "exchange contract" in which each agrees to reduce or eliminate some undesirable behavior and replace it with behavior the other desires. To encourage implementation, positive and negative consequences should be specified for each person, in addition to the positive satisfaction of what the other agrees to do -- e.g., a back rub or no back rub; golf or no golf. The counselor serves as communications facilitator and arbitrator, giving them affirmation (positive reinforcement) as they gradually learn the essential skill of negotiating a more fair and workable mutual change contract. The probability of successful implementation of the early change plans is increased if the couple is encouraged to begin with relatively low-priority, low-threat items on both their desired and undesired lists.
Step 7 -- The couple is encouraged to implement their change contract between sessions, expressing approval (positive reinforcement) whenever a desired behavior replaces an undesirable one in the mate's behavior. They are asked to avoid reinforcing undesirable behavior by ignoring it when it occurs. Whatever increase they achieve in reciprocal, satisfying behavior tends to be self-reinforcing. In subsequent weeks, the couple is helped to move to higher (and more difficult)
priority wants and needs in their exchange re-contracting.
Step 8 -- During the process of self-change, the couple is asked to each keep careful records of
their own and the other's success in implementing the agreement. These records are brought to counseling sessions, making it possible for clients and therapist to monitor concrete changes in the behavioral aspect of their relationship.
Couples should be encouraged to "shape" new desired behavior patterns in each other by affirming even very small steps toward those goals -- e.g., "I really appreciate your hanging up your clothes, dear" (ignoring other messy behavior that hasn't changed). Both individuals are encouraged to use "contingency contracts" with themselves and to reward themselves when they
do something that both persons desire -- e.g., I agree with myself to watch my favorite television program only if I have spent -- (amount of time) with the children during the preceding week."
Throughout the change process, the counselor tries to model positive reinforcement by expressing affirmation of each of their small successes in learning new, desired behaviors. The counselor may coach the couple by behavioral rehearsal during the sessions to help them practice the new mutual-fulfilling behaviors (including more effective communication skills) which they will need to implement their exchange contracts and learn better ways of coping with marital conflict and
crises. For example, the counselor may ask: "Will you show me how you plan to communicate so as to prevent the buildup of resentment between you?"
This behavioral exchange process is more complicated in actual practice than it sounds when the steps are summarized. The effectiveness of the techniques can be increased markedly if they are integrated with insights and methods from other therapies. For example, structural analysis from TA can be used to help couples learn to "keep their Adult in the driver's seat" so that they can negotiate and implement a more mutually satisfying marriage contract. (See chap. 6.) Behavior
therapy methods should be used flexibly and in conjunction with methods from traditional therapies that deal directly with change-blocking feelings and attitudes.
Sex Therapy and Enhancement Using Cognitive Behavioral Methods
The newer therapies for sexual dysfunctions and diminution provide a clear illustration of the therapeutic value of learning theory principles. Traditional psychoanalytic therapists view persistent problems of sexual dysfunction as surface symptoms of underlying conflicts and anxieties related to deeply fixated psychosexual development. Understood in this way, the only hope for recovery is long-term analytic therapy. Unfortunately, the general effectiveness of such
therapy in treating sexual problems has not been impressive.(12) In sharp contrast to this approach, the short-term sex therapies pioneered by William H. Masters and Virginia E. Johnson, using cognitive-behavioral approaches, often produce impressive therapeutic results. In these therapies, many problems of sexual dysfunction are understood as being rooted not in deep psychosexual pathology but in faulty learning in two areas -- learning sex-negative rather than sex-affirmative feelings and attitudes, and failing to learn the behavioral skills that enable two people to pleasure each other effectively and thus enjoy sex more fully.
Much of the treatment in these approaches is not "therapy" in the traditional sense but simply
attitudinal and behavioral reeducation. In these therapies sex-affirmative attitudes and feelings are gradually developed by a couple as they identify with positive understandings and attitudes of the therapist and as they learn, through coaching and practice, new, non-demand pleasuring skills. Performance and fear-of-failure anxieties, which cause much sexual dysfunction and diminution, are gradually extinguished. This is done by focusing on practicing sensate arousal exercises for their own inherent pleasure, with no intention or need to "succeed" by reaching any goal such as orgasm. Non-demand pleasuring exercises also have proved to be useful for couples who do not suffer major sexual problems but simply wish to develop more of their pleasure potentials.
The effectiveness of behavioral sex therapy techniques is increased when they are integrated with psychodynamic insights and therapeutic methods and with resources from marriage therapy. Helen Singer Kaplan's approach utilizes resources for all three of these therapies.(13) Traditional psychotherapy is used when needed to resolve anxieties and inner conflicts that block change-producing use of the behavioral techniques. Marital therapy is used to resolve interpersonal anger and conflicts that diminish full sexual responsiveness and feed a couple's resistance to doing behavior-changing exercises. It should be noted that often there is positive or negative reciprocity between sex and the other forms of communication in a marriage. As the marriage relationship grows stronger, sex tends to improve, and vice versa. Guided imagery techniques can also be a valuable part of sex therapy with persons who fail to respond to
initial behavior intervention (due to pleasure or failure anxieties) or who fail to reach the level of sexual arousal that they desire.(14) Behavioral sex therapies, supplemented by psychodynamic therapy and marital therapy when needed, have had a dramatically higher rate of effectiveness in
treating sexual dysfunctions than have the traditional therapies.
Growth Resources in Reality Therapy
Reality therapy, developed by psychiatrist William Glasser, is an action-oriented therapy that aims at enabling people to change their behavior so that it will fulfill their basic needs (to give and receive love and to feel worthwhile to themselves and others) in the real world of relationships in ways that do not deprive others of the possibility of fulfilling their needs.(15) (This is what Glasser means by "responsibility.") Although Glasser does not identify his approach with the cognitive behavior therapies, its effectiveness can best be understood in learning theory and
Glasser rejects the pathology model of traditional psycho- therapy, believing that labeling people with psychological and relational problems "sick" robs them of responsibility for changing their behavior and gives them an excuse for continuing as they are. He faults traditional therapies
for concentrating on exploring the past and the unconscious, and on attempting to help people change attitudes or achieve insight before they change their destructive behavior. He assumes that people have the ability to change their behavior if they choose. Glasser declares, "Waiting for attitudes to change stalls therapy whereas changing behavior leads quickly to change in attitudes,
which in turn can lead to fulfilling needs and further better behavior."
In reality therapy, the therapist is essentially a teacher of more need-satisfying living who uses a three-step process of growth:
First, there is involvement: the therapist must become so involved with the patient that the patient can begin to face reality and see how his behavior is unrealistic. Second, the therapist must reject the behavior that is unrealistic [irresponsible] but still accept the patient and maintain his involvement with him. Last, . . .the therapist must teach the patient better ways to fulfill his needs within the confines of reality.(16)
The heart of the second step is continuing confrontation with the destructive consequences of behavior. No "reasons" for the client's irresponsible, need-depriving behavior are sought or accepted by the therapist. The therapist actively works to get clients to face the reality they are
avoiding including the self-defeating consequences of their behavior. Questions such as these are asked, "Does what you are doing get you what you really want?" "If not, what will you do differently in order to obtain the consequences you want?" When clients are confronted persistently by a therapist with whom they are involved, they are forced repeatedly to decide whether they will take the responsible path. When they decide that they do not like the negative
consequences of their irresponsible behavior, they become more open to learning responsible behavior, which produces more satisfying consequences.
Reality therapists painstakingly help persons to examine their daily activities and relationships to learn more effective ways of behaving and relating which will satisfy their basic needs. The therapist must be a firm reality-respecting guide and model: "The therapist must be a very responsible person -- tough, interested, human and sensitive. He must be able to fulfill his own needs and must be willing to discuss some of his own struggles, so that the patient can see that
acting responsibly is possible though sometimes difficult."(17) By his attitudes and responses to the client's behavior, the therapist seeks to reinforce reality-based, responsible behavior.
One of the values in Glasser's approach from a holistic growth perspective is his commitment to applying reality therapy's philosophy and principles to institutional-societal systems. His
Schools Without Failure, for example, applies his approach to increasing the capacity of schools to help develop more effective and responsible children and youth.
Reality therapy, as a therapeutic tool, is uncomplicated in its working concepts and effective in
much short-term counseling. It is particularly effective with troubled adolescents and with adults who are acting out their problems in ways destructive to themselves and others; with adults who have a pattern of self-sabotaging, impulsive behavior; with alcoholics; and with persons having
underdeveloped or distorted consciences who need firmer and more constructive inner controls to guide their behavior. Reality therapy provides a simple and useful approach for helping almost anyone who is coping ineffectively with crises. Unless it is supplemented by other therapies, it is not adequate with persons who are suffering from distorted or punitive consciences, from severe
inner conflicts, or meaning- of-life issues that block constructive behavior changes. But in our society, where so many people act out their hunger for love, esteem, and meaning in destructive, irresponsible ways, Glasser's therapy is a valuable growth resource.
Growth Resources from Crisis Counseling
Crisis intervention methods, as these have developed over the last four decades, offer resources to help oneself and others cope with both developmental and accidental crises growthfully. Research pioneered by Erich Lindemann and Gerald Caplan at Harvard increased the understanding of how people cope with a wide variety of losses and crises. These research findings have provided a solid conceptual foundation for the development of crisis intervention techniques (which have many affinities with reality therapy and the approach of the ego analysts). Let me summarize the working principles of crisis intervention theory.(18) To "get inside" these principles experientially, I recommend that you apply them to a current or recent crisis in your own life:
(1) Crises happen in rather than to us. The heart of a crisis is our response to a situation that we experience as stressful or emotionally hazardous. Since a crisis is essentially an inner experience, we have the potential of choosing to respond in ways that mobilize our coping resources. (2) The life situations in which we are vulnerable to inner crises are those in which we experience a loss or the threat of a loss of something important in our lives. A cluster of painful feelings -- e.g., grief,
anxiety, confusion, powerlessness, depression, anger, disorientation, inner paralysis -- constitute the essence of the crisis experience. These feelings result from the ineffectiveness of our old coping skills to meet the psychological needs that are present after the loss. (3) Stresses, changes, losses, and crises occurring in a short time span are cumulative. As Thomas Holmes's research
demonstrates, experiencing a series of major changes in a short period of time makes people vulnerable to developing psychological, psychosomatic, or relationship problems.(19) This fact underlines the crucial importance of providing support and caring to persons going through multiple changes and losses. (4) Crises are forks in our growth road. If we learn to cope constructively with a heavy crisis or series of crises, we will develop new personality skills for
handling future crises. The human personality is like a muscle. If we use it to cope with difficulties, it grows stronger. If we avoid using it, by various escape mechanisms, it grows weaker. (5) Most of us have a variety of hidden resources that we can mobilize for handling crises. We usually don't discover these inner strengths until stressful circumstances force us to do so. This is why crises are potential growth opportunities, (6) The goals of crisis counseling are to help people do their "grief work" (expressing, working through, and resolving the painful feelings), mobilize their coping potentialities, including learning new coping skills, and thus to grow stronger. (7) Discovering the origins of inadequate responses to crises is usually
unnecessary to improve coping. As William Menninger put it, "You don't need to know how a fire started to put it out." The focus of crisis counseling, as of behavioral therapies generally, is learning to act more effectively in the present. (8) Experiencing the energy of hope for change when we are traumatized by crises, provides the power that is essential for mobilizing our inner
resources. Hope often is the important variable in determining how we cope in difficult life situations. The counselor's function as hope-awakener is therefore crucial in crisis intervention work.(20) Realistic hope is awakened by a variety of means. It is "caught" from the counselor's
warm support and affirmation of the person's potential capacities for coping. It grows stronger as the person gradually learns to take constructive action. (9) A key resource for coping with our
crises is the strength and quality of our interpersonal support system. Crisis counseling seeks to help people turn to others who care about them, believe in them, and are honest with them. (10) Handling heavy stresses, losses, and handicaps constructively tends to give one instant rapport with other people confronting similar crises. In crisis work it is important to encourage people
to reach out with an "insider's" understanding and caring to others in similar deep water. The experience of mutual growthing, which is part of the power of self-help groups like AA, illustrates a dynamic that can be used productively in much crisis counseling.
It is possible for us human beings to transform many of the minuses in our lives into at least partial pluses! It is an expression of the wonder of being human when people take miserable circumstances and discover unexpected possibilities for some good, even some growth in them! Asking people, after they have coped with a heavy crisis, questions like these -- "What have you learned from this painful situation?" or "Has anything positive come out of this miserable situation you've been in?" -- helps awaken awareness of ways they have grown, as a result of struggling to handle the crisis.
Growth Resources in Rational-Emotive Therapy
Rational-Emotive Therapy (RET) is a cognitive therapy (rather than a behavior therapy) created by psychologist Albert Ellis. It complements behavior therapies by focusing on the cognitive
determinants of ineffective behavior. According to Ellis, the well-being and growth of persons are determined by how they use four essential and interdependent human processes -- perceiving, feeling, acting, and thinking. Disturbances in our feelings, perceptions, and action arise, to a considerable degree, from irrational and invalid thoughts and beliefs such as these:(21)
--I must be perfectly adequate, competent, and achieving before I can think of myself as being worthwhile.
--I must be approved or loved by almost everyone I know for virtually everything I do.
--When I am very frustrated, treated unfairly, or rejected, I must view myself and things in
general as awful and catastrophic.
--My emotional misery is derived from external pressures, and I therefore have little ability to control or change my feelings.
--I must preoccupy myself and keep myself anxious about things that seem dangerous or fearsome.
--I must blame myself (and others) severely when I (or they) make serious mistakes or do something wrong.
--It is catastrophic if I cannot find perfect solutions to the grim realities in my life.
--It is easier to avoid facing difficulties than to take self-responsibility and develop more rewarding self-discipline.
--All the beliefs held by respected persons or by our society are accurate and should not be questioned.
The process by which we disturb ourselves has three stages according to RET: A. Activating event -- Someone criticizes us harshly and unfairly. B. Belief system -- Our perception of this
event is colored by the irrational belief that one's worth is dependent on others' approval. C. Consequent emotion -- As a result, we feel depressed, worthless, and as though a major catastrophe has occurred.
The process of correcting these feelings has two steps: D. Disputing the irrational belief -- This
involves learning to identify the irrational thoughts or beliefs that we are saying to ourselves and then correcting these self-damaging inner statements. E. Event is transformed -- The activating event is reevaluated in light of a rational and valid idea -- "I don't have to be approved by everyone in order to have a sense of my basic worth." Constructive feelings and behavior flow from the rational belief.
RET therapists actively challenge their clients' irrational ideas, expectations, and beliefs. They teach their clients to do the same and then to substitute rational, self-accepting ideas for dealing with the inevitable frustrations, which occur in everyone's life in this very imperfect world. Ellis describes how he works with a client: "I try many maneuvers to try to achieve a consistent goal:
to see how quickly I can get him to . . . understand exactly what he is doing to make this thing bothersome, and to discover what he can do to stop bothering himself."(22)
The basic theory of RET is useful in helping people identify and interrupt the disruptive belief-feeling-behavior cycles in which they are caught. Most psychotherapies deemphasize the role of concepts and beliefs in producing emotional distress and distorted behavior. In contrast, this therapy (and others like it) recognizes the critical influence of the cognitive dimension in both our problems and our growth.
The cognitive therapies provide valuable resources for those of us who are concerned with correcting growth-diminishing religious beliefs. The rigid theology of many individuals and
families both reflects and reinforces the rigid values and life-style by which they constrict their growth and freedom. Head-on attacks on their defensive, security-giving belief systems (as in the RET's approach) often are ineffective in helping them change to more growthful beliefs. But it is important for pastoral counselors and other therapists to be aware of the ways in which their
beliefs feed and exacerbate their negative feelings and behavior. The therapist's gentle but direct efforts to enable them to reevaluate and revise their pathogenic beliefs may help them gradually relax their defensive hold on growth-constricting beliefs. Such "theotherapy" usually takes considerable time, but it can be crucial in liberating the potentials of individuals and family
systems to grow spiritually and otherwise.(23)
Some Limitations of Behavior Therapies
The behavior therapies have both strengths and weaknesses when viewed from a whole-person, growth perspective. There is validity in their view that all persons function (to at least some degree) like computers programmed by past experience. (In persons whose growth is severely
blocked, e.g., psychotics, the automaton-like aspects of their personalities dominate much of their behavior.) As behavior therapists claim, the principles of learning on which their therapies are explicitly based also describe the ways in which the change produced by other therapies takes place. Certainly the techniques for self-reprogramming of faulty learning -- e.g., those developed by the sex therapies -- can be valuable to persons all along the mental health continuum.
But the underlying philosophy of personality in classical behaviorism is partial and therefore, by itself, an incomplete understanding of human beings. Radical behaviorists like B. F. Skinner understand all human behavior reductionistically, as controlled entirely by the external environment. Skinner declares: "As we learn more about the effects of the environment we have less reason to attribute any part of human behavior to an autonomous controlling agent."(24) Such a view ignores the fact that there is a self-determining, inner dimension to persons, a dimension that is most evident in relatively whole or "healthy" persons. This view eliminates human freedom, choice, and intentionality. By attending only to external, observable behavior, the radical behaviorists make therapeutic change measurable, but they achieve this by ignoring all the rich, inner choiceful dimensions, all the complexity and mystery of human beings. Such a view also ignores the dimension of Spirit, the transcendent Self.
Fortunately, most behavior therapists do not operate out of a rigid S-R (stimulus-response) Skinnerian model of personality. Rather they work from an S-O-R (stimulus-organism-response) model, which recognizes that most people have some ability to choose among their options. The cognitive-behavior therapists have corrected the Skinnerian view of persons to a considerable
degree by focusing on changing inner, covert behavior such as beliefs and feelings as well as overt behavior.
The analytic emphasis on the deeper dynamics of human behavior and the behaviorist emphasis on regarding behavioral "symptoms" as real problems both have therapeutic validity. As the behavioral therapies hold, many maladaptive learned behaviors do require therapeutic attention. Alcoholism is a vivid example of a "runaway symptom." The excessive drinking, which leads eventually to alcoholism, initially may have been motivated by anxiety and conflicts from
deeper levels of the personality. But the use of alcohol as a self-prescribed pain-deadener creates a runaway symptom of increasing drinking in a vain attempt to overcome the psychological and physiological pain resulting from previous excessive drinking. What began as a surface symptom becomes a problem demanding treatment in itself. As AA has shown, unless the vicious cycle of this addictive process can be interrupted (by avoiding the first drink), sobriety will not be
achieved and any underlying psychological problems will remain inaccessible to therapy. But some alcoholics feel worse, not better, when they stop drinking. Their intrapsychic sources of conflict, guilt, and anxiety must be treated by psychotherapy if their sobriety is to be permanent. This same principle applies to many non-alcoholics. It is possible to change some destructive feelings by
learning to behave more constructively. But some hidden, conflictual feelings must be resolved therapeutically if behavioral changes are to be permanent. A whole-person approach focuses simultaneously in therapy on changing both overt behavior and underlying feelings, values, attitudes, concepts, and beliefs (covert behavior). This often involves the use of behavioral methods in conjunction with complementary methods from depth therapists.
Psychologist Perry London, who has contributed to the development of the behavior-action therapies, observes:
Not all the problems that people bring to psychotherapy can be, with equal ease, identified as limited problems of function, and even when they can, it is not always possible to restore functioning without radical changes in the patient's system of meaning. Phobias are good examples of clear-cut symptoms where function is lost and may be directly restored, and we may likewise grant that many other psychic problems rest in learned anxieties. . . . But one cannot
speak so glibly of dysfunction of husbands who are unhappy with their wives and seek counsel, or of young people who, fearing an insecure and shadowed future, fear to cast themselves into it in love and work , . . , or the aging whose fear of what is ahead co-mingles with regret at what is left behind, and seek both solace and repair.(25)
In the contemporary world it is impossible to ignore the epidemic of meaninglessness, which produces many of the psychological, psychosomatic, behavioral, and relational problems of those who come seeking help. Behavioral methods are most effective with clear behavioral dysfunction. They become progressively less helpful for problems in which meaning-emptiness plays a larger and larger role.
Behavior therapies have been labeled by some of their critics in the humanist tradition as forms of "mind manipulation" and even "therapeutic brainwashing." There is evidence that learning theory techniques have been misused in manipulative ways in some institutional settings without
the informed consent of those being changed. It is probably true that behavioral approaches lend themselves to this type of manipulative, covert misuse. But it is invalid to dismiss all the helpful behavioral approaches because they are vulnerable to misuse. As in all sound therapy, persons who come for help should be free to choose the goals of change. The choice ordinarily is made in
collaboration with the therapist, but the directions of change desired by the persons receiving therapy usually should be ultimately respected. Behavioral methods should be used openly and their probable effects explained to the clients. With persons not able to make the decision for themselves -- e.g., very small children and mentally ill persons who are out of touch with reality -- it may be necessary for others to choose the directions of change without their consent. But such exceptions to the basic principle of self-determination should be made with great caution, using built-in safeguards, and only with persons who are really incapable of choosing. The ultimate goal of the behavioral methods, when they are used growthfully, is to teach troubled persons self-help tools for enabling them to increase their own self-determination and effectiveness in living. This is the way in which many of the cognitive behavior therapies are now being used.
It is important to use behavior therapies in the context of systems-oriented approaches (described in chapters 9 and 10). Otherwise behavior therapies, like any individualistic approaches, can be misused to adjust people to pathogenic relationships, institutions, or cultures. To do this is to inhibit, in the long run, full human growth.
Finally, it is important to use behavioral methods with a light touch and a nonmechanistic style. This anecdote illustrates the importance of this approach:
A famous rat psychologist has been trying for years to conduct experiments which would show him how to raise the 1. Q. of rats. . . . [He] persevered and set up laboratory situation after laboratory situation and educational environment after educational environment and the rats never
seemed to get any smarter. Finally, quite recently, he issued a statement that the only thing he could discover in ten years which made rats any smarter was to allow them to roam at random in a spacious and variegated environment.(26)
What is true of rats seems to be even more true of human beings!
For Further Exploration of Growth Resources in Behavior-Action Therapies
Beck, Aaron T. Cognitive Therapy and Emotional Disorders. New York: International Universities Press, 1976. Integrates cognitive and behavior approaches.
Clinebell, Howard. Growth Counseling: Coping Constructively with Crises. Nashville: Abingdon Press, 1974. A series of eight crisis-counseling training courses on cassettes with a users' guide.
Dustin, Richard, and George, Rickey. Action Counseling for Behavior Change. Cranston, R.I.: Carroll Press, 1977, Discusses learning theory, action counseling techniques with individuals and groups.
Ellis. Albert, and Harper, Robert A. A Guide to Rational Living. Englewood Cliffs, N.J.: Prentice Hall, 1961. Applies the rational-emotive therapy approach to problems in living.
Foreyt, John P., and Rathjen, Dianna P., eds. Cognitive Behavior Therapy, Research and
Application. New York: Plenum Press, 1978. A collection of papers on the use of cognitive behavior methods with a variety of types of problems.
Glasser, William. Reality Therapy: A New Approach to Psychiatry. New York: Harper, 1965.
An introduction to the theory and practice of reality therapy.
--Schools Without Failure. New York: Harper, 1969. Applies reality therapy principles to
Kaplan, Helen Singer. The Illustrated Manual of Sex Therapy. New York: The New York Times Book Co., 1975. A manual on sex therapy illustrated with drawings of couples.
--The New Sex Therapy: Active Treatment of Sexual Dysfunction. New York: Brunner/Mazel, 1974. A book on the theory and practice of Kaplan's sex therapy, integrating methods from learning theory, dynamic psychotherapy, and marital therapy.
Knox, David. Dr. Knox's Marital Exercise Book. New York: David McKay, 1975. A do-it-yourself guide for couples using behavior methods to resolve problems in such areas as communication, sex, alcohol, friends, parents, children, and money.
--Marriage Happiness, A Behavioral Approach to Counseling. Champaign, III.: Research Press, 1971. A valuable application of behavioral techniques to marriage counseling and therapy.
Levis, Donald J., ed. Learning Approaches to Therapeutic Behavior Change. Chicago: Aldine, 1970. A series of papers exploring the history, principles, and theory of behavioral therapy.
London, Perry. The Modes and Morals of Psychotherapy. New York: Holt, Rinehart and Winston, 1964. Contrasts insight and action types of therapy, and describes the approaches of some of the major behavioral therapies.
Mash, Eric J.; Handy, Lee C.; and Hamerlynck, Leo A. Behavior Modification Approaches to Parenting. New York: Brunner/ Mazel, 1976. The uses of behavioral methods in training parents.
Stone, Howard. Crisis Counseling. Philadelphia: Fortress Press, 1976. A succinct introduction to
crisis intervention methods.
--Using Behavioral Methods in Pastoral Counseling. Philadelphia: Fortress Press, 1979. A practical guide to the use of behavioral approaches.
Stuart, Richard B., and Davis, Barbara. Slim Chance in a Fat World Champaign, III.: Research Press, 1972. A behavioral approach to overcoming obesity.
Switzer, David K. The Minister as Crisis Counselor. Nashville Abingdon Press, 1974. Describes crisis intervention theory and it use by pastoral counselors, with chapters on grief, family crises, and divorce.
Wolpe, Joseph; Salter, Andrew; and Reyna, L. J. The Conditioning Therapies. New York: Holt, Rinehart and Winston, 1964. Describe the challenge of various conditioning therapies to psychoanalysis.
Yates, Aubrey J. Behavior Therapy. New York: Wiley, 1970 Describes the application of behavioral methods to a wide variety o human problems.
1. The main points of this historical sketch are paraphrased from a brochure announcing the First Annual Southern California Conference on Behavior Modification, October, 1969.
2. See Joseph Wolpe, Psychotherapy by Reciprocal Inhibition (Stanford: Stanford University Press, 1958).
3. Operant conditioning uses rewards to reinforce the learning of desired behavior and withholding of rewards or punishment to eliminate destructive behavior. Operant conditioning is
the type used in most behavior therapies.
4. From the brochure described in note 1.
5. See Beck's Cognitive Therapy and Emotional Disorders (New York:
International Universities Press, 1976).
6. See Albert Ellis and Robert A. Harper. A Guide lo Rational Living (Englewood Cliffs, N.J.: Prentice-Hall, 1961), and Ellis, et al.. Growth Through Reason (Palo Alto, Calif.: Science and
Behavior Books, 1971).
7. See Bandura, Principles of Behavior Modification (New York: Holt, Rinehart & Winston, 1969).
8. These principles are paraphrased from a list of principles developed by H. J. Ehsemch in 1958. See Donald J. Levis, ed.. Learning Approaches to Therapeutic Behavior Change (Chicago: Aldine, 1970), pp. 12-13.
9. This case was described by G. Terence Wilson and Gerald C. Davison in "Behavior Therapy, A Road to Self-Control," Psychology Today, October, 1975, pp. 54-60.
10. Dr. Knox's Marital Exercise Book (New York: David McKay, 1975), p. 28.
11. These steps are adapted from "Behavioral Approaches to Marital Therapy," by Robert Liberman in Couples in Conflict, eds. Alan S. Gurman and David G. Rice (New York: Jason Aronson, 1975), pp. 207-78.
12. See Jeffrey C. Steger, "Cognitive Behavioral Strategies in the Treatment of Sexual Problems,"
in John P. Foreyt and Dianna P. Rahtjen, eds., Cognitive Behavior Therapy, Research and Application (New York: Plenum Press, 1978), pp. 83-84.
Kaplan, The New Sex Therapy (New York: Brunner/Mazel, 1974), and The Illustrated
Manual of Sex Therapy (New York: The New York Times Book Co., 1975).
14. See Steger, "Cognitive Behavioral Strategies," pp. 91-92.
15. Reality Therapy (New York: Harper, 1965), p. 15.
16. Ibid., p. 25.
17. Ibid., pp. 26-27.
18. Crisis theory and methods are discussed in more detail in my book Basic Types of Pastoral Counseling, chaps. 8 and 9.
19. For a description of Holmes's stress score, see my book Growth Counseling for Marriage Enrichment (Philadelphia: Fortress Press, 1975), pp. 64-65.
20. For a discussion of the power of hope in therapy, see Growth Counseling, pp. 48-49.
21. These irrational ideas are paraphrased from Ellis and Harper, A Guide to Rational Living, pp. 185-87.
22. Growth Through Reason, p. 3.
23. For methods of facilitating spiritual growth, see Growth Counseling, chap. 4.
24. Beyond Freedom and Dignity (New York: Alfred A. Knopf, 1971), p. 96 and 102,
25. The Modes and Morals of Psychotherapy (New York: Holt, Rinehart and Winston, 1964), pp. 121-22.
26. J. Hearndon, How to Survive in Your Native Land (New York: Simon & Schuster, 1971), p. 116.