Behavioral Interventions
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Chapter 10 Behavioral Interventions
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Purpose of This Chapter Most of our behavior is not new behavior. In fact, most of our behavior patterns, whether they are how we put on our shoes, eat our meals, walk the dog, or pay our bills, have such a history that we probably can’t remember why we started doing them the way we do. These behavior patterns have power in our lives—power to make our lives less complicated, and a competing power to make us more resistant to change. In this chapter, we examine how persons change patterns of behavior that have become dysfunctional, less effective, or even unnecessary. Some patterns relate to behaviors that interfere with a client’s goals, hopes, or needs; others are behaviors that might be missing from a client’s patterns of interaction, leading to a failure to achieve desired goals, hopes, or needs. Perhaps the most important aspect of this chapter is the emphasis on a client’s responsibility in this process of change, and how the client and counselor work together to accomplish the client’s objectives. A variety of symptoms can be treated using the behavioral interventions described in this chapter, including affective symptoms such as phobic responses, cognitive symptoms such as compulsive thought patterns, and behavioral/systemic patterns.
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Considerations as You Read This Chapter
Behavior is the part of human existence that communicates to others how a person feels, what a person thinks, and who a person is. Because it is available to others through their observations, behavior becomes the communication channel that connects an individual to other people. Behavior is the tool or means by which people accomplish, perform, or in other ways achieve the goals that they set. Behavior can be the cause of a person’s failures, mistakes, or disappointments. Because behavior is the outward manifestation of a person’s inner self, it may sometimes seem to be unconnected to him or her. Many client problems involve some manifestation of behavior; often, the best approach to working with client problems is by addressing behavioral changes.
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Thus far, we have examined how feelings and thinking are implicated in human problems, and how affective and cognitive interventions can alleviate problems. In this chapter, we address problems that are established in behavior patterns—the things people do, or fail to do. Behavioral interventions are intended to help clients change their habits when they interfere with achievement of their goals, ambitions, or values, or when they contribute to negative outcomes. Behavioral interventions are based on learning theory. Because of this, behavioral interventions are often thought of as skill development and to draw upon the teaching aspect of counseling.
Clients present with a vast range of skill deficits, from some that are mild and not terribly debilitating to those that are serious and far-reaching. One example of such a contrast is the middle-age man who wishes he could stand up to his father. He does not “suffer” from their relationship except when he is with his father, which only occurs when he travels to his parents’ home for holidays. He is quite satisfied, by contrast, with his relationship to his wife and children. On the other end of the spectrum, Pinto, Rahman, and Williams (2014) describe a program to teach recently incarcerated women advocacy skills, such as learning new interpersonal behaviors as well as some fundamental skills of leadership, as an important means by which they can be empowered to succeed after incarceration. Based on the life situations clients present and the counselor’s willingness to engage in behavioral interventions, the life skills to be mastered may be life- enhancing or life-changing.
Although a large number of interventions can be classified as behavioral in nature and focus, perhaps the most common ones include imitation learning (social modeling), skills training (including behavioral rehearsal or
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role-playing), relaxation training, systematic desensitization, and self- management exercises.
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Behaviorial Interventions and Theory Most behavioral interventions can be traced back to three originating schools of behavioral thought: Pavlov’s original conceptualizations, called classical conditioning; B. F. Skinner’s later modifications of Pavlov’s work, known as operant conditioning; and Albert Bandura’s additions to these approaches, referred to as social modeling.
The classical conditioning model was based on Pavlov’s animal experiments in which he sought to understand how learning occurs. It assumed that behavior changes when new conditions in the environment emerge. When his dogs learned to associate the ringing of the bell at the gate to their kennels with feeding, they began to anticipate the feeding time whenever the bell rang. In human terms, the theory holds that when the smell of pie in the oven typically means the arrival of favorite relatives (and enjoying a delicious pie), just the aroma can change one’s mood. This model for learning tended to address very basic human physiological responses.
B. F. Skinner used the research laboratory to explain more-complicated learning patterns typical of human behavior. Again, by using animals to study patterns of learning, he looked at how a behavior or skill is acquired. He found that newly acquired skills could be refined, enhanced, and shaped
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by the manner in which rewards were given. This approach, called shaping, is based on the following axiom:
The likelihood of occurrence of any future event is directly related to the consequences of past similar events.
Most parents have learned that a bedtime story when a child is agreeable about bedtime is an incentive for the child to be agreeable the next evening. The child has learned that agreeable behavior is followed by something pleasant—that is, a reward. Skinner called this operant conditioning. As the child grows, and especially when parenting challenges occur, it is important to reward behavior that leans toward the desired goal, whether that is cleaning one’s room or doing one’s homework. In other words, rewards are not only paired with a completed task, but with positive steps toward the completed task as well. Because many behaviors are unlikely to be changed all at once, this aspect of operant conditioning is an important one.
Bandura (1969) viewed both Skinner’s and Pavlov’s models as basic but not complete explanations for how most human learning occurs. He reasoned that most people learn in a “safe” way—by observing other people learning and then imitating their behavior. Most children have learned that this really works—that is, copying the behavior of others who seem to gain the approval of adults. Bandura called this approach social learning. It has also been referred to as observational learning, vicarious learning, and imitation learning. It is based on the use of a model—someone or something—to observe carefully and then imitate. The more influential the model, the more quickly learning occurs. Therefore, children tend to follow other children they deem as attractive models; adults are influenced by advertisements that include favorite athletes or popular entertainment personalities.
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All three of these approaches are based on experimental study of human learning. People use all three of these patterns when they learn something new; therefore, it makes some sense that these learning approaches might also be viable when behavior change is called for. This is the rationale for introducing behavioral interventions into the counseling process.
Behavioral interventions share certain common assumptions and elements:
Maladaptive behavior (behavior that produces undesirable personal or social consequences) is often the result of learning. Maladaptive behavior can be weakened or eliminated, and adaptive behavior can be strengthened or increased through the use of learning principles. Behavior (adaptive or maladaptive) occurs in specific situations and is functionally related to specific events that both precede and follow these situations. For example, a client may be aggressive in some situations without being aggressive in most situations. Thus, behavioral practitioners attempt to avoid labeling clients using such arbitrary descriptors as aggressive. Instead, emphasis is placed on what a client does or does not do that is aggressive, and what situational events cue or precipitate the aggressive response, as well as events that strengthen or weaken the aggressive response. Clearly defined outline or treatment goals are important for the overall efficiency of these interventions and are defined individually for each client. Behavioral interventions focus on the present rather than the past or future and are selected and tailored to each client’s set of problems and concerns.
Characteristics of clients who seem to have the most success with behavioral interventions include
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A strong goal orientation—people who are motivated by achieving goals or getting results An action orientation—people who have a need to be active, goal- focused, and participating in the helping process An interest in changing a discrete and limited (two to three) number of behaviors
Behavioral interventions have also been used extensively and found to be very suitable in schools, mental health agencies, or situations with time- limited counseling.
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Goals of Behavioral Interventions Although the definition of the term behavior has expanded in recent years to include covert or private events such as thoughts, beliefs, and feelings (when they can be specified clearly), as well as overt events or behaviors that are observable by others, this chapter is focused primarily on overt behaviors. The goal of behavioral interventions is to increase what could be called adaptive behavior—that is, those behaviors that assist the client in meeting stated goals. In addition to developing new behaviors, a goal of behavioral interventions may also involve weakening or eliminating behaviors that work against the desired outcome (e.g., eating unhealthy snacks when you wish to lose weight).
Behavioral interventions have been used in many different settings (such as schools, agencies, business and industry, and correctional institutions), with a great variety of human problems (including learning and academic problems, motivational and performance problems, marital and sexual dysfunction, skills deficits, and anxiety), and with maladaptive habits (such as overeating, smoking, substance abuse, and procrastination). In this chapter, we focus primarily on the behavioral interventions that seem to be most useful for working with people in the general population (as opposed to those in institutional settings). These include social modeling, behavioral rehearsal and skills-training approaches, relaxation training, systematic desensitization, and self-management interventions.
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Behavioral Intervention Skills
Behavioral Skills
Describing Behaviors Helping the client understand the complexity of behavioral tasks; breaking tasks down into sequential behaviors
Modifying Behaviors Helping the client change behavior patterns when it is deemed appropriate
Contracting Helping the client establish commitments, timelines, and recordkeeping for change
Supporting and Reinforcing Helping the client assess and recognize levels of progress toward goals
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Behavioral Interventions
Social Modeling Using examples from other sources to teach the client how and what to change; included in this cluster of interventions are overt modeling, symbolic modeling, and covert modeling
Role-Play and Rehearsal Using simulations to examine and rehearse new behaviors, verbal interactions, and so on; relies on practice and feedback
Anxiety Reduction Methods Helping client assume control over muscular or kinesthetic processes as a method to counter learned anxiety responses to certain stimuli
Symptom Prescription Helping clients regain control over their behavior by instructing them to engage the symptom rather than attempt to avoid it
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Self-Management Helping the client learn how to observe and manage behavior patterns over time; includes self-monitoring (observing and recording one’s behavior), self-contracting (making a commitment to oneself to work on changing behaviors outside of counseling), and self-reward (learning ways to reward oneself when behavioral goals are achieved)
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Basic Behavioral Skills Counselors working on behavioral change use a number of basic skills in their work that involve ways of conceptualizing behavior and behavior change. The starting point is the task of describing behavior.
Describing Behaviors
Describing or deconstructing one’s behavior is not as easy as it might appear. Athletes and their coaches have become adept at behavior description because they must break behavioral processes down (e.g., a successful free throw in basketball) into the many sub-behaviors that are part of the behavior. Thus, their description for a free throw includes how the athlete’s feet are positioned, the rhythm of the throw, the arc that is created as the ball approaches the net, and so on.
However, if you are on a basketball team and not successfully converting many free throws, one of the first things a coach may do is analyze your present actions and then reconstruct them toward the “model” free throw. Counselors helping clients make behavioral changes do much the same thing. Consequently, counselors must understand how to do behavioral analysis and how to restructure behavior patterns so they can coach their clients in this change process.
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Modifying Behaviors
As already noted, many people simply do not think behaviorally. Before the counselor can gain a commitment from clients to enter into behavioral change processes, the client must recognize the relationship between certain target behaviors and their consequences. Thus, you might find yourself saying, “It seems like every time you do this, then that happens. Do you agree? Because you don’t like it when that happens, perhaps we could start thinking about ways of breaking the pattern.” Saying this does not resolve the issue, however. The point is that you will find it necessary to help clients understand the process of behavior change as well as giving them strategies to implement change.
Contracting
Several times we have mentioned the importance of gaining client commitment with counseling goals. One demonstrated way to do this is the counseling contract. It seems to be a human quality to feel more committed to a task if a contract is involved. The contract is developed between the counselor and client. The interesting part about contracting is that a contract tends to be more effective when the client actually signs his or her name to it (e.g., Smith, 1994). There is nothing legal about this act, but psychologically it does seem to make a difference for clients. Regardless of whether the client signs the contract, writing down the conditions of the contract together is quite important.
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Supporting and Reinforcing
As clients begin the challenging process of changing behaviors that have long been part of their repertoire, and thus are familiar, they often need support and reinforcement. This can be as simple as telling the client, “You can do it,” or “That was a good effort.” Not to give the client this kind of feedback may be interpreted by some that they are not doing it right or that they are failing. It is also possible to overdo these supporting words. If that happens, the comments begin to lose their effect, or you may be viewed as having lower standards than the client has.
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Using Behavioral Interventions
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Social Modeling
Much of the work associated with social modeling has been initiated or stimulated by Bandura (1977). Three approaches, or models, have emerged: the overt model, the symbolic model, and the covert model. Each of these approaches can be used in working with clients.
The overt social modeling approach uses one or more persons as a model to illustrate the behavior to be learned or refined. The overt model may be live (also called in vivo) or recorded for viewing at a later time. It is overt because it is apparent that this model is someone to be observed and imitated.
The symbolic social modeling approach might include animated cartoon or fantasy characters, schematics, narratives, or slides. A good example is the training videos produced to help a person learn how to use new computer software. The process takes the learner through a step-by-step process, with the ultimate goal that the learner can repeat the process later without the help of the training video.
The covert modeling approach uses imagination in the learning process. We noted earlier that this mental process makes covert interventions cognitive rather than behavioral. However, because so many behavioral counselors refer to this process, we break our own rule to include it here as well. The covert model—whether a person, cartoon character, or schematic diagram— is imagined rather than shown. Covert models may be the client (called self-modeling) or someone else enacting the behavior with increasing deftness. Various cues (e.g., specifying sensory images or inner reactions) can be supplied to support the imagined scenario.
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Live (Overt) Modeling With live modeling, the desired behavioral response is performed in the presence of the client. Live models can include the counselor, a teacher in a developmental guidance class, or a client’s peers in a counseling group. Usually, the counselor provides a modeled demonstration via a role-play activity in which he or she takes the part of the client and demonstrates a different way that the client might respond or behave.
Live modeling can be a most versatile tool for the school counselor, the rehabilitation counselor, or the family counselor, to name only a few. Scenarios can vary from helping youth understand how to manage conflict (by observing a videotape of other youth doing so after an altercation), to helping long-term unemployed adults whose lives are complicated by a mental disability learn stronger self-presentation skills (by having successful persons from the same program agree to present to these clients), to helping family members see a new way to communicate. The counselor’s role can vary from being an actor in the modeling exercise to being the choreographer or being the narrator. What follows is a modeling session in which the counselor served as narrator. The scene is a group guidance session involving 12 seventh-graders. The counselor has been working with 6 of the students on a project, “Using the Library to Learn about Careers.” The second 6 students are new to the group and are just beginning the project.
Live modeling is particularly useful in instances in which the client is assessed as truly lacking a skill set. The modeled demonstration provides cues that the client can use to acquire
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Using Live Modeling with Middle-School
Students
C��������: Today, we have some new faces in our group. I think all of you ‐ already know each other. For convenience, I’m going to call you the “Old-Timers” and you the “New Bunch.” The Old-Timers have been working on a project to learn about jobs. I’m going to ask them to demonstrate some of the things they have been doing. We’ll use something called a fishbowl. What that means is that the Old-Timers sit in a small circle. The rest of us sit outside the circle and observe the Old-Timers as they talk about their project. We do this for about 15 minutes and then we trade places. The New Bunch will come into the inner circle and the Old-Timers will sit around the outside. Any questions? [Nervous noises, chairs moving, people getting settled. The Old-Timers are familiar with this exercise. They were introduced to it when they were in the role of the New Bunch a few weeks earlier.] Now, if everyone is ready, Old-Timers, I would like for you to talk to each other about the topic: “Fifty ways to choose a career—all in the library.”
O��-T�����: [A discussion begins, slowly at first, about how to use the library to find out about careers. Diff erent members of the group talk about how they got started, who in the library helped them find the right books, which books were most helpful, how they preferred the computer career software for some of the research, funny things they discovered about some careers, and so on. There is a lot of joking. It doesn’t look like a great learning experience, but the point
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is made that learning about jobs can be fun and that the library is a neat place to get career information. They also learned the process of approaching the right librarian and knowing what to ask for. After about 15 minutes, the counselor interrupts, summarizes what was said, and asks the two groups to trade places. Some groans, teasing, playful putdowns follow as students change seats.]
C��������: Now, New Bunch, it’s your turn. I’d like you to show the Old-Timers what you can do. This time, the topic will be, “Things I am going to do in the library to learn about jobs.”
N�� B����: [More groans, jokes, moving of chairs. Talk begins slowly. Someone makes a joke. All laugh. Finally, someone gets into the spirit and says she would like to find out about becoming an astronaut. Everyone laughs. Counselor intervenes, commends student for her question, challenges group to come up with a plan for using the library to help her find out about becoming an astronaut. The group begins, more or less in earnest, and the information that characterized the first group’s discussion comes out again, this time focusing on the topic of finding out about becoming an astronaut.]
those new responses to replace those that blocked learning the desired skill. For example, a client who wishes to be more assertive may benefit from seeing the counselor or a peer demonstrate such behaviors in role- played situations. The following exchange between the counselor (model) and the client (wishing to be more assertive) illustrates how such a session might go.
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Modeling Assertive Responses
C��������: Today, Nancy, I thought we might do a role-play—that’s where you and I enact someone other than ourselves, and our “play” is a scenario in which you are returning some unusable merchandise to a local store.
N����: That sounds awful. I don’t like to have to return things to the store.
C��������: I know. But you said you wished you could do that sort of thing without getting turned inside out. Don’t worry. I’m going to play you and you are going to play the part of the store employee. Okay?
N����: [smiling] Well, that’s a little better. Okay.
C��������: You begin first, by asking me if I need some help.
N����: Hello, can I help you? [as employee]
[as N����] C��������: Yes. I purchased this baptismal gown for my daughter’s baby, but after the baby was born, my daughter realized it was too small. I’d like to exchange it if I may.
N����:
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How long ago did you purchase it? [as employee]
[as Nancy] C��������: Two months ago, I’m afraid. I know your return policy is 30 days, but I hope you will accept it in exchange.
[as employee] N����: Well, since you only want to exchange it, I think we can do that.
Following the role-play, the counselor and Nancy discussed the interaction, and then they conducted a second role-play, this time with Nancy as herself and the counselor as the store employee. Then they evaluated Nancy’s performance and identified some ways she could improve. This was followed by a third role-play in which Nancy again was herself. Her performance in the third role-play was much improved and she felt successful. Live modeling in which the client is a participant is limited by the client’s willingness to participate in an imagined situation as an actor, unless you and the client can take an impending real situation that both of you can rehearse. If your client is particularly withdrawn, you may wish to use other persons as the modeling participants.
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Symbolic Modeling Although live models have much impact on the client, they are sometimes difficult to use because the counselor cannot control the accuracy of the demonstration of the behavior being modeled. To correct for this, many counselors use symbolic models through video recordings, audio recordings, or films in which a desired behavior is introduced and ‐ presented. For example, symbolic models could be used with clients who want to improve their study habits. Reading about effective study habits of successful people and their scholastic efforts is a first step to help clients identify desired behaviors. Next, clients can listen to a recording or watch a video illustrating persons who are studying appropriately. Once effective symbolic models are developed, they can be stored easily and retrieved for future use by the same or different clients.
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Covert Modeling Covert modeling, also called imaging, is a process in which the client ‐ imagines a scene in which the desired behavior is displayed. The imagined model can be either the client or someone else. The first step is to work out a script that depicts the situation(s) and desired responses. For example, if an avoidant client desires to learn to communicate more successfully with a partner, scenes could be developed in which the client is having a successful discussion. One scene might be as follows:
It’s Friday night. You would like to go to a movie, but your partner is very tired. You acknowledge your partner’s tiredness, but suggest that a movie might prove relaxing as well as entertaining. Your partner thinks about it for a moment, and then agrees.
Imaging serves two purposes: It brings the appropriate behaviors into focus, and it serves to construct a success image into the person’s mind. Both are desired outcomes. This is often used in coaching athletes. However, the same intervention can be used to coach persons who must learn to be calmer under stress, to avoid taking that first drink, to bypass a sarcastic comment to one’s partner, and so forth.
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Characteristics of the Modeled Presentation The way in which a presentation is modeled can affect the client’s ability to pay attention to and remember the demonstration. It is important that the model be presented in a way that engages the client. The first part of the modeled presentation should include instructions and cues about the features of the modeled behavior or activity. A rationale for the use of modeling should also be given to the client prior to the demonstration.
Behaviors to be modeled should minimize the amount of stress that the client might experience in the presentation. Distressing and anxiety- provoking stimuli may interfere with the client’s observation powers, processing, or remembering. For this reason, the counselor should be checking in with the client frequently regarding the client’s reaction to the model.
Complex patterns of behavior should be broken down and presented in smaller and more easily understood sequences. If too many behaviors or an overly complex model is presented to the client at one time, the likelihood of learning is greatly diminished. You can seek the client’s input about the presentation of modeled behaviors to ensure that the ingredients and pace of the modeled demonstration are presented in a facilitative manner and to be sure that the client noticed the key ingredients of the modeled behavior(s).
It is advisable to process the modeled behavior after it has been completed, or even during the demonstration. If the counselor models taking initiative, for example, he or she could stop the demonstration and make a point about what he or she did that is different from being passive in a situation.
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Practicing the goal behavior or activity also increases the effectiveness of the modeling procedure. In addition to practice in the counseling session, the counselor might assign homework to the client for practice outside the session. Self-directed practice can enhance the generalization of the target behavior from within the session to real-life situations. If a client experiences difficulty in performing a particular activity or behavior, instructional aids, props, or counselor coaching can facilitate successful performance.
Modeling and Self-Efficacy Self-efficacy refers to the perception a client has about his or her ability and confidence to handle a situation or to engage in a task successfully. It has been found to be a major variable that affects the usefulness of modeling interventions (Bandura, 1988). It is not sufficient to assume that clients will simply observe a model—live, symbolic, or covert—and acquire the skills to achieve desirable results. Clients “must also gain enough self-efficacy [confidence] that they can perform the needed acts despite stress, changes, moments of doubt, and can persevere in the face of setbacks” (Rosenthal & Steffek, 1991, p. 75). Thus, modeling interventions must be designed that emphasize not only outcomes but also attitudes and beliefs about oneself. Self-efficacy is not a global concept—that is, it does not reflect self-confidence in general—but rather it refers to the confidence in oneself to achieve a particular goal. For example, Ozer and Bandura (1990) developed a modeling program to teach women self-defense skills. The program not only included modeling various self-defense skills, but also modeled ways in which the women could acquire trust in their self-defense skills, particularly in the face of adverse situations.
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Desirable Characteristics of Models Clients are more likely to learn from someone whom they perceive as similar to themselves. Cultural characteristics such as cohort, gender, social class, ethnic background, and attitudes should be considered when selecting potential models. When a “match” is not possible, we have some evidence (e.g., Atkinson, Casas, & Abreu, 1992) that a sensitivity and respect for the client’s culture can bridge the dissimilarity divide. In other words, the feminist male counselor can successfully counsel the feminist female client; the middle-class African American counselor who is sensitive to her privilege can counsel the economically disadvantaged African American client, and so forth. This being said, achieving a connection across major cultural identities is a multistep process. Therefore, counselors must be vigilant in determining if they continue to be credible models for their clients.
In an early contribution to the literature on modeling, Meichenbaum (1971) suggests that a coping model might be more helpful to clients than a mastery model—that is, a client may be able to identify more strongly with a model who shows some fear or some struggle in performing than the model who comes across perfectly. Clients can also learn more from modeling when exposed to more than one model. Warmth and nurturance by the model also facilitates modeling effects.
When modeling fails to contribute to desired client changes, the counselor should reassess the characteristics of the selected model(s) and the format of the modeled presentation. In many cases, modeling can provide sufficient cues for the client to learn new responses or to extinguish fears. In other instances, modeling may have more impact when accompanied by practice of the target behavior. This practice can occur through role-play and rehearsal in the counseling session or as assigned homework.
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Role-Play and Behavior Rehearsal
Role-play and behavior rehearsal interventions promote behavior change through simulated or in vivo enactment of desired responses. Common elements in the application of role-play and rehearsal interventions include the following:
1. A reenactment of oneself, another person, an event, or a set of responses by the client
2. The use of the present, or the here and now, to carry out the reenactment
3. A gradual shaping process in which less difficult scenes are enacted first and more difficult scenes are reserved for later
4. Feedback to the client by the counselor and/or other persons
Depending on the therapeutic goal, role-playing procedures can be used to uncover affect or to achieve catharsis. It can also be a stimulus for the client to increase awareness. We next discuss role-play as a way to facilitate behavior changes.
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Role-Play as a Method of Behavior Change Behavior rehearsal uses role-play and practice attempts to help people acquire new skills and to help them perform more effectively under threatening or anxiety-producing circumstances. Behavior rehearsal is used primarily in three situations:
1. The client does not have but must learn the necessary skills to handle a situation (skill acquisition).
2. The client must learn to discriminate between inappropriate and appropriate times and places to use the skills (skill facilitation).
3. The client’s anxiety about the situation must be reduced sufficiently to allow the client to use skills already learned, even though the skills are currently inhibited by anxiety (skill disinhibition).
Suppose you have a client who wants to be more self-disclosing with others but doesn’t know where to start learning how. In this case, the client might have a deficit repertoire (lack of skills and knowledge) in self- disclosure and must learn some new communication skills. Or the client may have the necessary communication skills but needs clarification or discrimination training to learn when and how to use those skills to self- disclose. Many clients have the skills but use them inappropriately. A person may self-disclose too much to disinterested persons and then withhold from persons who are interested in them. In another case, the client’s anxiety can inhibit the use of these skills. Behavior rehearsal can then be used to help the client gain control over the anxiety reaction.
In addition to the practice effects gained from behavior rehearsal, the intervention can often provide important demonstrations about how the client actually behaves in real-life situations. For example, it isn’t unusual for clients to describe a behavior or interaction one way, and then portray the interaction in a different way. Such contradictions can then be resolved
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in the session. Experts believe that the role-played behavior is far more likely to be accurate than the interaction as described by the client. This makes role-playing an important part of the assessment process, too.
The procedure for behavior rehearsal using role-play consist of a series of graduated practice attempts in which the client rehearses the desired behaviors, starting with a situation that is manageable and is not likely to backfire. Behaviorists call this process successive approximation—that is, learning easier parts of a complex skill, then moving to the next more difficult part, and so on. The rehearsal attempts may be arranged in a hierarchy according to level of difficulty or gradations of stress. Adequate practice of one situation is required before moving on to a scene that requires more advanced skills. The practice of each scene should be very similar to the situations that occur in the client’s environment. To simulate these situations realistically, you may wish to use props and portray the other person involved with the client as accurately as possible. This portrayal should include acting out the probable response of this person to the client’s new or different behavior.
Behavior rehearsal can be either overt or covert (imagined). Both seem to be quite effective. It’s probable that a client could benefit from engaging in both of these approaches. Initially, the client might practice by imagining and then move on to acting out the scenario with the counselor. Covert rehearsal can also be assigned as a homework intervention. The client is asked to rehearse more challenging situations once he or she reports some command over those skills, building up to a more challenging situation, and the counselor’s in-session observations are in line with the client’s report.
Feedback is an important part of role-play and behavioral rehearsal interventions and is a way for the client to recognize both the problems and successes encountered in the practice attempts. Feedback also should be
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constructive, specific, and directed toward behaviors the client can potentially change; it should also include positive comments about skills that are adequately demonstrated. Feedback may be supplied by video- and audio-recorded playback of the client’s practices. These recorded playbacks are often more useful objective assessments of the client’s behavior than verbal descriptions alone. You may find that your assessment of the client is more important early in the feedback process, but eventually, it is desirable for the client to begin using accurate self- assessments in the feedback process.
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Skill Training
Skill training is an intervention composed of several other interventions that we have already discussed: modeling, behavioral rehearsal, successive approximation, and feedback. It may target a variety of issues, including problem-solving skills, decision-making skills, communication skills, social skills, assertion skills, and various coping skills. To develop a skill- training program, you must first identify the components of the skill to be learned; then you arrange components in a learning sequence that reflects a continuum from less difficult to more difficult or less stressful to more stressful. Training then proceeds by modeling each skill component, having the client imitate the modeled behaviors, providing feedback, and repeating the sequence, if appropriate. Skill-training protocols exist for most skills that might be taught in the counseling setting and may be found in the professional counseling literature or online. To illustrate how a training protocol might be developed, let’s examine an assertion-training protocol.
Assertion training is a tool for overcoming social anxiety that inhibits a person’s interactions with others. Many persons who need assertiveness training describe an early history in which they have been taught that the rights of others supersede their own rights. Typical assertion skills involve the ability to make requests; to refuse requests; to express opinions; to express positive and negative feelings; and to initiate, continue, and terminate social interactions. In assertion training, you begin by having the client identify one situation in which he or she wants to be more assertive, and then identify what assertive behaviors are involved and what the client would like to say or to do. The situation is modeled and role-played consistently in the session until the client can be assertive without experiencing any anxiety. Then the learned skill is transferred to situations outside the counseling setting through homework assignments. Once the client is able to exhibit the desired skills independent of counseling, the
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process is deemed successful. Success at assertiveness will generalize to other situations, as well—that is, it becomes easier for clients to be assertive on their own without assistance and feedback.
As an illustration, suppose you are working with a young woman who expresses unease about her relationship with the young man she is dating. She reports that he physically “comes on too strong” for her on occasion, but she doesn’t want to offend him because she really likes him. In light of the epidemic of date rape in our society, this is an opportunity for this young woman to learn some protective skills that will reduce the likelihood that she will be a victim of sexual assault, either with this present boyfriend or in her future. In such an instance, you must first help your client identify the very first cues that her consciousness gives her that she is uncomfortable, probably using some visualization work with this client. Some cognitive work may also be necessary to address some irrational beliefs that interfere with the behavior she would like to execute. For example, she may be reluctant to make her boyfriend angry because he may break up with her, and this is perceived by her as a loss. Only after these issues have been addressed are you ready to move to skill development. This is an important point: Often clients have fears and thoughts that undercut their ability to act. Counselors must address these first, or behavioral interventions will fail because they are premature. Once it is appropriate to proceed, you work with your client to imagine the kind of situation where she has difficulty being assertive, model more assertive responses, have your client practice new behaviors, offer feedback, and so on. Finally, with this and many other behaviors, it is desirable for the client to practice her new skills in less personally vulnerable situations than those posed by her boyfriend. For example, she may say no to a friend who wants her to see a movie that she has already seen and didn’t particularly like, something she wouldn’t do in the past. Practice in the real world, noting reactions (and perhaps recording them in a journal), and discussing
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progress with you as her counselor are important steps that assist her in reaching her ultimate goal.
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Case Illustration of Skill Training
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The Case of Andrew
Andrew is a 27-year-old Caucasian male who lives in a group home for persons with intellectual challenges. The home supervisor, Phil, has suggested to Andrew that he might want to talk to the counselor about improving some social skills. Phil reports that Andrew is very timid in the home, and this leads others to take advantage of him. When Andrew lived at home, his parents were overly protective of him, made all decisions for him, and took care of all interactions with the outside world. After Andrew’s father had a heart attack, his parents decided that Andrew needed to be prepared to live separately from them, and applied for him to enter this residence. Andrew has been here for four months. He says that he’s happy enough, likes the other residents, and doesn’t mind that they tease him. Phil, however, suggests that he might not always like his apartment mates in the future and that he might want to learn additional ways of interacting. Andrew agrees that this would be okay with him.
Fred, the counselor who is assigned to the residence, first explained the process of skill training, noting that it involves a good bit of role-playing. Andrew thought that sounded like fun. Fred also asked if he could involve Phil in a session or two, and Andrew liked that idea a lot. With Phil’s help, Fred and Andrew came up with a list of incidences in the residence where Andrew might have been at a disadvantage because of a lack of skills. Some of these involved assertiveness; others were more about Andrew’s inexperience in social situations that added to his reputation as an outsider.
Eventually, Andrew and Fred identified several “moments” (again, with some help from Phil) that had occurred in the past few weeks where social skills were lacking. Once they had their list, Fred worked with Andrew to put them in order from easier to most difficult. At this point, Andrew was ready to start working with the first situation on the list. Fred proceeded to do role-plays with Andrew for the easiest situation. Fred played Andrew in
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these role-plays to model new skills. Andrew then practiced the skill, and reported that this was more fun than he expected. Fred followed each practice session with pointers. They then identified a situation that was likely to occur within the next day where Andrew could practice his new skill. With Andrew’s permission, Phil was recruited to monitor Andrew’s progress and would spend a few minutes in each subsequent counseling session to inform Fred how Andrew was doing. According to Phil at the third such briefing, Andrew had made a new friend in the residence and things were going quite well. Andrew’s smile indicated that he agreed.
There is a tendency during skill training for counselors to terminate role- playing with too few trials, possibly because the counselor assumes clients are more comfortable with the new skills than they really are. The counselor may also want to discuss how the client can handle unexpected or varied responses from the other party who is involved in the scenario. For example, in Andrew’s situation, Andrew had little experience to draw on to predict others’ responses. Therefore, Fred had to role-play multiple responses to each of Andrew’s emerging skills in order to enhance the likelihood that things would go well when Andrew tried them out with other residents.
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Anxiety Reduction Methods
Many clients who seek help do so because of strong negative emotions labeled as fear or anxiety. Researchers have identified several types of anxiety, including somatic anxiety, which may manifest itself in body sensations such as stomach butterflies, sweaty palms, and rapid pulse rate; cognitive anxiety, which may be apparent in an inability to concentrate or in intrusive, repetitive, panicky, or catastrophic thoughts; and performance or behavioral anxiety, typically manifested by avoidance of the anxiety-arousing situation.
Some anxiety is believed to be helpful and can actually lead to successful performance; however, when it reaches an intolerable or uncomfortable level, a person should seek help for it. Various strategies are used for anxiety reduction. In this chapter, we describe two of the more common behavioral interventions: relaxation training and systematic desensitization.
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Relaxation Training The most common form of relaxation training used by behavioral counselors is called progressive relaxation or muscle relaxation (Jacobson, 1939). Muscle relaxation has long been used to treat, or complement other treatments for, a wide variety of problems, including generalized anxiety and stress, headaches and psychosomatic pain, insomnia, and chronic illnesses such as hypertension and diabetes. Relaxation training is often used as an adjunct to short-term counseling. Relaxation can be an effective way of establishing rapport and a sense of trust in the counselor’s competence. Muscle relaxation is also a major component of systematic desensitization, which we discuss in the next section.
The basic premise of using muscle relaxation to treat anxiety is that muscle tension exacerbates or adds to anxiety and stress; in addition, relaxation and anxiety are not compatible states. Consequently, an individual can experience a reduction in felt anxiety by causing relaxation to occur in muscle groups on cue or by using self-instructions. The procedure involves training clients to contract and then relax various muscle groups, to recognize differences between sensations of muscle contraction and relaxation, and to induce greater relaxation through the release of muscle tension and suggestion. Suggestion is enhanced by counselor comments throughout the procedure, directing the client’s attention to pleasant (relaxed) sensations, heavy or warm sensations, and so on. After going through the procedure several times with the counselor’s assistance, clients are encouraged to practice it on their own, daily if possible, and often with the use of recorded instructions as a guide. (Commercially prepared relaxation CDs and DVDs are available, as are models on the Web, or you can suggest that the client record the session in which you are teaching the client how to relax muscle groups on their smart phone or another device so they have it at home to use for practice.)
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Relaxation training should occur in a quiet environment free of distracting light, noise, and interruptions. If possible, the client should lie on a couch, a reclining chair, or a pad on the floor. (This latter option is most practical when working with a relaxation training group.) The counselor uses a quiet, modulated tone of voice when delivering the relaxation instructions. Each step in the process (tensing and relaxing a specific muscle) takes about 10 seconds, with a 10-second pause between each step. The entire procedure takes 20 to 30 minutes, and it is important not to rush. The process is illustrated next.
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Tension Release through Muscle
Relaxation
First, let your body relax. Close your eyes and visualize your body letting go. [Pause] Now we are going to the muscles of your face. First, smile as broadly as you can. Tighter. Relax. [Pause] Good. Now again, smile. Smile. [Pause] Relax. Now your eyes and forehead. Scrunch them as tightly as you can. Like a prune. Tighter. [Pause] Relax. Good. Note the difference between the tension and relaxation. Feel the warmth flow into the muscles as you relax. Now, again, make a prune face. Tighter. [Pause] Relax. Relax.
Let all of the muscles in your face relax. Around your eyes, your brow, around your mouth. Feel your face becoming smoother as you let go. [Pause] Feel your face become more and more relaxed.
Now, focus on your hands. Clench them into fists and make the fists tight . . . tighter. Study the tension in your hands as you tighten them. [Pause] Now release them. Relax your hands and let them rest. [Pause] Note the difference between the tension and the relaxation. [Pause] Now, tighten your hands into fists again. Tighter . . . tighter. Relax. Let them go. Feel the tension drain out of your hands as they release. [Pause]
Now bend both hands back at the wrists so the muscles in your lower arms tighten. Tighter . . . Relax. Again, feel the tension flow out of your arms and hands. As the tension releases, a warmth enters your muscles to replace the tension. Try to recognize the warmth flowing in. [Pause] Bend both hands back and tense your lower arms
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again. Tighter. Relax. Feel the warmth replacing the tension. Relax further. Deeper. Good.
Now we will move to your upper arms. Tighten your biceps by pulling your bended arms to your chest. Tighter. Tighter. [Pause] Relax. Let your arms drop. Let the tension flow out. Let the warmth flow in. Relax. Deeper. Try to reach an even deeper level of relaxation of your arms.
And now your shoulders. Shrug your shoulders and try to touch them to your ears. Feel and hold the tension. Tighter. [Pause] Now relax. Relax. Let go. Feel the tension leave. Deeper. Good. Tighten your shoulders again. [Pause] Relax. [Pause] Relax. Feel all of the muscles in your hands, arms, shoulders, face. Feel them letting go. Deeper into relaxation. Deeper.
As these muscles relax, direct your attention to your chest muscles. Tense them. Tighter. [Pause] Relax. Again. Pull your chest muscles tighter and tighter. Tighter. [Pause] Relax, relax. [Pause] Now your stomach muscles. Tighten your stomach. Harder. Tighter. [Pause] Relax. Feel the tension flow out of those muscles. Feel them grow softer. Relax. Feel the warmth. Relax. [Pause] Now tense the stomach muscles again. Good. Tighter. Relax, relax. Feel the difference. Good.
Focus now on your buttocks. Tense your buttocks by holding them in or contracting them. Feel the tension. Tighter. Relax. [Pause] Now tighten them again. Tighter. [Pause] Relax. Let your whole body go. Feel the tension flow out of your body. Feel the warmth flow into your body. Feel the warmth pushing the tension out. Let go. Relax. [Pause]
Now locate your legs. Tighten your calf muscles now by pointing your toes toward your head. Tighten them. Relax. Let your feet drop.
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Feel the muscles letting go. Again now. Tighten your calf muscles. Point your toes toward your head. Tighter. [Pause] Relax. Good. Feel the muscles go soft, smooth, warm.
Stretch both legs out from you. Reach as far as you can with your legs. Extend them. Extend them. [Pause] Relax. Let them drop. Feel the difference in your muscles. Feel the leg muscles relax. Concentrate on the feeling. Now stretch your legs again. Point your toes. Extend, extend. [Pause] Relax. Drop your feet. Relax. Deeper. Feel the warmth rush in. Let the tension go. Let your legs relax even deeper. Let them relax deeper still. Feel your whole body letting go. Feel it. Remember the feeling. Relax.
Now I am going to go over all of the muscle groups again. As I name each group, try to notice whether there is any tension left in the muscle. If there is, let it go. Let the muscle go completely soft. Think of draining all of the tension out. Focus on your face. Explore your face for tension. If you feel any, drain it out. Let the face soften, become smooth. Your hands. Let the tension drip from your fingertips. Visualize it dripping out, draining from your hands, your arms. [Pause] Your shoulders. Is there any tightness, tension there? If so, let it loose. Open the gates and let it flow outward, filling the space with warmth. Now your chest. Let your mind explore for any tension. Your stomach. Let the tightness go. Softer. Your buttocks. [Pause] If you find any tension in your buttocks, let it flow out. Down through your legs, your calves, your feet to your toes. Let all of the tension go. Sit quietly for a moment. Experience the relaxation, the tension is gone. Your body feels heavy, soft, relaxed. [Pause] With your eyes still closed, record this memory in your mind. What it feels like to be so relaxed. [Pause]
Now, before you open your eyes, think about how relaxed you are. Think of a scale from 0 to 5, where 0 is complete relaxation, no
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tension. A 5 is extreme tension, no relaxation. Tell me where you place yourself on that scale right now.
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Systematic Desensitization Systematic desensitization is an anxiety-reduction intervention developed by Wolpe (1958, 1990) and based on the learning principles of classical conditioning. This type of learning involves the pairing (occurring close together) of a neutral event or stimulus with a stimulus that already elicits or causes a reflexive response, such as fear. Desensitization uses counterconditioning—the use of learning to substitute one type of response for another—to desensitize clients to higher levels of fear or anxiety. In desensitization, a counteracting stimulus such as relaxation is used to replace anxiety on a step-by-step basis. Wolpe (1982) explains this process:
After a physiological state inhibiting anxiety has been induced in the [client] by means of muscle relaxation, [the client] is exposed to a weak anxiety-arousing stimulus for a few seconds. If the exposure is repeated, the stimulus progressively loses its ability to evoke anxiety. Successively stronger stimuli are then similarly treated. (p. 150)
Desensitization is often the treatment of choice for phobias (experienced fear in a situation in which there is no obvious external danger) or any other disorders arising from specific external events. It is particularly useful in instances in which the client has sufficient skills to cope with the situation or perform a desired response, but avoids doing so or performs below par because of interfering anxiety and accompanying arousal.
However, desensitization is inappropriate when the target situation is inherently dangerous (such as mountain climbing) or when the person lacks appropriate skills to handle the target situation. In the latter case, modeling, rehearsal, and skill-training approaches are more desirable. Counselors can determine whether a particular client’s anxiety is irrational or is the result of a truly dangerous situation or a skills deficit by engaging
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in a careful assessment of the presenting problem. Effective desensitization usually also requires that a client be able to relax and to engage in imagery, although occasionally responses other than relaxation or imagery are used in the intervention.
The intervention involves three basic steps and takes about 10 to 30 sessions, on average, to complete, depending on the client, the problem, and the intensity of the anxiety:
1. Training in deep muscle relaxation 2. Construction of a hierarchy representing emotion-provoking
situations 3. Graduated pairing through imagery of the items on the hierarchy with
the relaxed state of the client
In addition to these three, a fourth step is often added, which is to test out one’s progress in vivo—that is, with the actual feared circumstance. For example, a client who has developed a fear of driving after an accident may begin by turning on her car and backing up to the end of her driveway as a first step. If this is too stressful, she may begin with her husband in the car with her at first. Each successive step is discussed with the counselor to review any level of anxiety that occurs. If necessary, imagery work is repeated until such time that the client reports virtually no anxiety.
Training in deep muscle relaxation follows the procedure discussed earlier. If the client is unable to engage in muscle relaxation, some other form of relaxation training, such as that associated with yoga or meditation, may be used.
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Hierarchy Construction Hierarchy construction involves identification of various situations that evoke the conditioned emotion to be desensitized, such as anxiety or fear. It may also involve something extrinsic to the client, such as snakes or airplanes, as well as something intrinsic, such as feelings of losing control. The counselor and client can discuss these situations in the counseling sessions, and the client can also keep track of them as they occur in vivo by using notes. As each situation is identified, it is listed separately on a small index card.
Three possible types of hierarchies can be used in desensitization, depending on the parameters and nature of the client’s problem: spatio- temporal, thematic, or personal. The spatio-temporal hierarchy consists of items that relate to physical or spatial dimensions, such as distance from a feared object, or time dimensions, such as time remaining before a feared or avoided situation (e.g., taking a test). Spatio-temporal hierarchies are particularly useful in reducing client anxiety about a particular stimulus object, event, or person.
Thematic hierarchies consist of items representing different parameters surrounding the emotion-provoking situation. For example, a client’s fear of heights may be greater or less depending on the contextual cues surrounding the height situation (e.g., a cliff with no guardrail) and not just one’s distance from the ground; or a client’s social anxiety may vary with the type and nature of various interpersonal situations.
Personal hierarchies consist of items representing memories or uncomfortable ruminations about a specific person or situation with which the client has some personal history. Personal hierarchies can be quite useful in desensitizing a client to conditioned emotions produced either by a loss-related situation (e.g., loss of one’s job) or dissolution of a
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relationship (e.g., by death, divorce, separation). Personal hierarchies can also be used to countercondition a client’s avoidance behavior to, for example, a particular person who has become aversive to the client. A typical personal hierarchy might begin with an item that has almost no effect on the client’s anxiety, and then move up a scale of anxiety stimuli to the point where the client typically reacts with high anxiety. Possible sources of client anxiety include sensitivity to criticism, fear of losing a personal relationship, and fear of looking stupid.
Regardless of which type of hierarchy is used, each usually consists of 10 to 20 different items. After each item is listed on a separate index card, the index cards are arranged by the client in order from the lowest or least anxiety-provoking to the highest or most anxiety-provoking. The ordering process is also facilitated by a particular scaling and spacing method. Although there are several possible scaling methods, the most commonly used is the Subjective Units of Disturbance Scale (SUDS; Wolpe & Lazarus, 1966). The scale ranges from 0 to 100: 0 represents absolute calm or no emotion; 100 represents panic or extreme emotion. The client is asked to specify a number between 0 and 100 that best represents the intensity of his or her reaction for each item. Effective hierarchies usually consist of items at all levels of the SUDS. If there are more than 10 points between any two items, probably another item should be inserted.
After the hierarchy has been constructed and you have trained the client in muscle relaxation or some variation thereof, you are ready to begin the pairing process. This aspect of systematic desensitization can be summarized in the following steps adapted from Wolpe (1990):
1. You and your client discuss and agree on a signaling process that the client can use to let you know if and when anxiety begins to be felt. A common signaling system is to have the client raise an index finger if any anxiety (or other conditioned emotion) is experienced.
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2. You then use the exercise to induce a state of relaxation for the client.
3. When your client is deeply relaxed, you describe the first (least emotion-provoking) item on the hierarchy to the client and ask him or her to imagine that item. The first time, you present the item only briefly, for about 10 seconds, provided the client does not signal anxiety first. If the client remains relaxed, you instruct him or her to stop visualizing the scene and either to relax or to imagine a pleasant (or comforting) scene (e.g., a sandy beach in summer). Stay with this scene for about 30 seconds.
4. Return to the first anxiety hierarchy item, describe it again, and remain with it for about 30 seconds. This second presentation should include as much detailed description as you gave the first time.
5. If the client again indicates no anxiety, you have the option of repeating steps 3 and 4, or moving to the second item in the hierarchy. Typically, an item may require from 3 to 10 repetitions before achieving a SUDS of 0. Scenes that have been desensitized in a prior session may need to be presented again in a subsequent session.
�. When your client signals anxiety present (by lifting an index finger), you immediately return to the relaxation process (step 2) until the client is fully relaxed again. Then you return to the anxiety hierarchy at a lower level (one where the client experienced no anxiety) and begin the process again. Gradually, you work back to the hierarchy level where anxiety was experienced. If anxiety is experienced again, repeat this process. Usually within two to three repetitions, the client is able to move through this level of the hierarchy without experiencing anxiety. If a client continues to experience anxiety in a given item, Cormier and Nurius (2003, p. 561) note there are at least three things a counselor can do to eliminate continued anxiety resulting from presentation of the same item: add a new, less
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anxiety-provoking item to the hierarchy; present the same or the previous item to the client again for a shorter time period; or assess if the client is revising or drifting from the scene during the imagery process.
There is one note of caution regarding the manner in which the counselor responds to a client who is indicating no anxiety. The tendency is to respond to the client’s relaxed state by saying “Good,” or some similar remark. The counselor’s intent is to communicate to the client, “You are doing just what you should be doing.” However, early on, Rimm and Masters (1979) note that this could have just the opposite effect, reinforcing the client’s not signaling anxiety, and thus disrupting the process. For this reason, it is better if the counselor gives no response as long as the client is not indicating the presence of anxiety.
Each new desensitization session begins with the last item successfully completed during the previous session and ends with a no-anxiety item. The pairing process is usually terminated in each session after successful completion of three to five hierarchy items, or after a duration of 20 to 30 minutes (10 to 15 minutes for children). Occasionally, however, a client may be able to concentrate for a longer period and complete more than five items successfully.
Because systematic desensitization may continue over several weeks, it is important that you keep accurate written notations about what you did and your client’s success each session. Notes should include what item on the hierarchy has been achieved, how many times the item was presented, the length of time in seconds for the presentation of the last two items, and the SUDS scores for each presentation. As items are successfully completed without anxiety within the counseling session, you may assume that your client will be able to confront them in real-life settings also without experiencing undue anxiety or discomfort. However, you should caution
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your client not to attempt to encounter the hierarchy situations in vivo until 75 to 80 percent of the hierarchy desensitization process has been completed successfully.
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Case Illustration of Anxiety Reduction
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The Case of Carole
Carole was mugged on her way home from a neighborhood bar and restaurant two months ago. After trying to put it behind her, she has sought counseling because her fears have interfered with her way of life. Carole is a healthy woman in her mid-thirties. She enjoys walking and running and reports that she lives in a “relatively safe” neighborhood. The person who mugged her had mugged another person the same night and was apprehended. Carole has never been afraid before, but now reports looking over her shoulder whenever she goes for a run or a walk, even during daylight, but especially after dark. Carole has a small dog and wants to be able to walk her dog in the evenings without concern. She understands that the mugging has affected her more deeply than she thought, has tried to rationalize her way out of it, but has not been successful. She is open to any other method the counselor can suggest.
Carole’s counselor suggested systematic desensitization and explained the process. They began by creating a hierarchy of stimuli that appear to make Carole apprehensive. Once completed, the counselor used the relaxation method and subsequently began to introduce items at the bottom of Carole’s hierarchy. Carole had a difficult time maintaining a relaxed state even at the bottom of her hierarchy. Upon further discussion with the counselor, it became evident that Carole had not really started at the beginning—that is, Carole started her hierarchy when she approached the door to leave her apartment. The fact was that Carole’s anxiety would actually begin at least 30 minutes prior to this, when she realized that the evening news was beginning and once it was over, it would be time to walk her dog.
Over several sessions, Carole worked hard to tackle her fears. She began visualizing daytime walks or runs outside and eventually moved to evening walks. When asked about an image that would help her return to a relaxed
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state when she felt anxious, she chose interacting with her dog, who always makes her smile. Therefore, when Carole would reach a new step on her hierarchy, felt some anxiety, and raised her index finger to cue her counselor, the counselor would direct her to think of Violet, her dog.
Carole’s situation was complicated by the fact that she couldn’t totally avoid walking outside during the initial stages of desensitization because of her dog. Therefore, at the counselor’s suggestion, she asked a neighbor who also owned a dog if they could walk together, telling the neighbor about her situation and that she was in counseling to become more comfortable. This request was received well, and only when Carole felt ready for in vivo work did she start to take walks alone, first in daytime only, and eventually at twilight. She also talked about the mugging event with her neighbor, and they had good conversations about what is safe and what is not. Carole decided that she had been a bit foolhardy walking home alone later in the evening the night she was mugged. Therefore, while engaged in systematic desensitization, Carole was also letting in other opinions about her behaviors and altering them somewhat. For example, she decided that if she had to walk her dog after twilight, she would only walk up and down her street. Counseling ended when Carole reported that she felt reasonably improved in terms of anxiety. She was pleased to report that she had encountered a man walking toward her recently as she was walking her dog and, although she was aware of him, her anxiety was relatively low. She felt especially pleased that she did not feel any need to look behind her after he passed.
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Symptom Prescription: A Second-Order Behavioral Intervention
Symptom prescription is an intervention under the general category of paradoxical interventions that are used by some therapists. Worden (1994) notes that within the context of family therapy, removing a client’s symptom may threaten the family’s homeostasis—that is, the patterns and relationships that have become familiar to family members. We posit that this can also be true for individuals—that is, changing one behavior may throw clients off their game, so to speak. Therefore, as hard as they try to change that behavior, something appears to sabotage their efforts. Introducing a paradoxical intervention may be of help in this case, even if it seems illogical at first (as most second-order interventions do).
Telling a person to “be spontaneous” is a good example of a paradox. By definition, you can’t make yourself be spontaneous. Sometimes, one way to assist a client is to “assign” the problem that, paradoxically, helps the client break through whatever is interfering with their ability to do so on their own efforts. For example, if an anxious client follows an instruction to deliberately become more anxious at a time that is convenient to the client (i.e., a time when it won’t interfere with daily activity), the client’s compliance with the instruction actually brings the anxiety under the control of the client, something that has eluded the client until that point. Discovering that the anxiety is controllable in this manner is a first and necessary step toward symptom control.
Types of problems that lend themselves to symptom prescription are those in which the client feels no sense of control, such as compulsive worrying. For example, let’s say you have a client who suffers from insomnia and reports a long list of solutions that have been tried but found lacking.
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Insomnia tends to be accompanied by excessive or even compulsive rumination. The typical complaint is, “I just can’t seem to turn my mind off when I go to bed.”
Given this complaint, you might wish to prescribe the symptom, which would be for the client not to try to go to sleep even if it requires doing some other task. The point of this intervention is that one can be trapped into fighting oneself when trying to control a spontaneous process (falling asleep). Trying to control its opposite (staying awake) somehow manipulates the person’s internal processes such that he or she can then let go. Yet another example, one that is used frequently and with considerable success, is to warn the client not to expect to get over a crisis too quickly. By prescribing the symptom—in this case, the client’s fear that the crisis will not recede—the counselor may actually help the client recover more quickly. Such is the paradoxical nature of the psyche.
Symptom prescription is potentially a fruitful intervention. We hope it goes without saying, however, that any symptom that is overtly harmful to the client should never be prescribed. One would never prescribe that a parent shame a child or drink alcohol if one is addicted or any other such dangerous activity.
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Self-Management
Self-management interventions are based on a participant model of counseling that emphasizes client responsibility and are specifically designed to strengthen client investment in the helping process. Self- management may eventually eliminate the counselor as a middle person and ensure greater chances of success because the client invests so directly in the change process.
Self-management interventions are among the easiest and most effective tools to use with clients. However, it is the counselor’s responsibility to introduce and structure the interventions so that the client fully understands the assignment and the payoff. Self-monitoring, self-reward, and self- contracting are among the more frequently used interventions.
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Self-Monitoring Self-monitoring involves two processes: self-observation and self- recording. In self-observation, the client notices or discriminates aspects of his or her behavior. Self-recording involves using very specific procedures to keep a record of what the client is doing. Taken together, self-monitoring involves having your client count and/or regulate a target behavior—for example, an undesirable habit or a self-defeating thought or feeling. The process of self-monitoring seems to interfere with the target by breaking the stimulus–response association and drawing the behavior into consciousness or awareness, where a choice or decision to enact the behavior can occur. Most weight-reduction systems use self-monitoring as part of their weight-reduction plan.
The initial step in setting up a self-monitoring intervention with a client is selection of the behavior to be monitored or changed. Usually, clients achieve better results if they start by counting only one behavior. Self- monitoring seems to increase the frequency of positive or desirable behaviors and to decrease the frequency of negative or undesirable behaviors, an effect called reactivity. Self-monitoring of neutral (neither positive nor negative) behaviors results in inconsistent behavior change. For this reason, it is important to have clients monitor behaviors they value or care most about changing.
Deciding how to monitor the behavior depends on the circumstances of the client’s environmental context and the nature of the behavior to be monitored. Generally, clients are asked to count either how often a behavior occurs or how long a particular condition lasts. If the counselor is interested in focusing on how often a behavior occurs, frequency counts are obviously appropriate. However, if the counselor simply wants to reduce the amount of time dedicated to a particular behavior pattern, then recording the length of time spent talking on the telephone, studying,
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playing a computer game, or participating in any other activity is appropriate. Occasionally, clients may wish to record both the time and frequency of a behavior.
Where the observed behavior is qualitative (e.g., better or worse, warmer or colder, happier or sadder), a response scale may be used in which 0 and 7 represent the extremes. The client is asked to rate the quality of his or her behavior somewhere between 0 and 7 at each interval. For example, the therapist might say to the client, “On a scale of 0 to 7, rate how confident you are feeling right now?”
The timing of self-monitoring can influence any change that is produced by this intervention. If the client wishes to decrease the frequency or duration of a monitored behavior (e.g., reduce the number of cigarettes smoked), it is more effective to record the event prior to lighting the cigarette. If the objective is to increase the frequency or duration of a monitored behavior (e.g., a positive self-statement), then the intervention is more effective if the client records the event after its occurrence.
Counting behaviors is the initial step in self-monitoring. The second and equally important step is charting or plotting the behavior counts over a period of time. This permits your client to see progress that might not otherwise be apparent. It also permits your client to set daily goals that are more attainable than the overall goal (successive approximation). Clients can take weekly cumulative counts of self-monitored behaviors and chart them on a simple line graph. After initial recording efforts are successful in initiating change, it is useful for clients to continue recording in order to maintain change. Often, clients’ motivation to continue self-monitoring is enhanced if they reward their efforts for self-monitoring.
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Self-Reward Self-reward involves intentionally giving oneself a reward following the occurrence of a desired response or behavior. Self-rewards seem to function in the same way as rewards that are external reinforcements.
There are three major factors to consider when teaching clients how to use the self-reward intervention: (a) choosing the right reward, (b) knowing how to give the reward, and (c) knowing when to give the reward. Rewards can be objects; contact with other persons, activities, images, and ideas; and positive self-talk.
Self-reward is a normal human behavior. You go shopping and see a new pair of exercise shoes and say to yourself, “I’m going to buy those and start exercising.” The only problem is that the self-reward was not predetermined, and it was given before the desired behavior. We have already noted that if you wish to increase a particular behavior, you should reward yourself after the behavior occurs. Thus, the better approach is, “I’m going to start exercising four times a week. If I complete the first two weeks, I’ll buy myself a new pair of shoes.”
Self-rewards do not have to be objects—rather, they can be a favorite walk with the purpose of thinking about one’s success. It can be watching a movie or TV show recorded on DVR. In short, whatever the client views as pleasant can be used as a reinforcement, as long as it doesn’t undercut the desired change (e.g., it’s not a good idea to smoke a cigarette as a reward for not smoking for two weeks!).
Clients can be asked to create a so-called reward menu that varies from small to quite large rewards that they value and would like to receive. These rewards can be further defined as current reinforcers (something enjoyable that occurs on a daily basis, such as eating or reading) and potential
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reinforcers (something that could occur in the future and would be satisfying and enjoyable, such as going out to dinner with friends or taking a trip).
The rewards clients select should be potent, but not so valuable that the clients would not give them up in the event that the target behavior was not achieved—in other words, the reinforcer should be strong enough to make working for it worthwhile and, at the same time, not so indispensable that the client refuses to make it something that must be earned.
If clients select material rewards that aren’t portable enough to be carried around for immediate reinforcement, they might consider the following intermediate options as immediate rewards:
1. Tell a significant other about their behavior to elicit their encouragement. Social reinforcement can be very powerful in helping clients to find extra opportunities to be reinforced, and also to ward off urges and temptations.
2. Assign points to each occurrence of the desired behavior; after accumulating a specified number of points, trade it in for a larger reinforcer. Points (sometimes called tokens) are useful because they make it possible to use a variety of reinforcers and also make it easy to increase a behavior gradually.
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Self-Contracting Clients who are able to identify and be responsible for their behaviors often acknowledge that their current actions are resulting in some undesirable consequences. They can see how they would like the consequences to be different. They may or may not realize that in order to change those consequences, they must first modify the behaviors producing them. Behavior change of any kind can be slow. Therefore, getting clients to make behavior changes is not easy. You must first obtain the client’s commitment to change.
The behavioral contract is a useful intervention for gaining a client’s cooperation and commitment. Behavioral contracting is used by a growing number of theoretical approaches but has been popularized by behavioral and reality therapists. The contract specifies what actions the client agrees to take in order to reach the desired goal. Contracts provide important structure for clients. In addition to giving the client a “map” to follow and steps that are within the client’s ability, contracts also extract a level of commitment from the client. The contract contains a description of the conditions surrounding the action steps: where the client will undertake such actions, how (in what manner) the client will carry out the actions, and when (by what time) the tasks will be completed. Because these contract terms are specified in writing and signed by the client, we refer to this intervention as self-contracting. The most effective contracts have terms that are completely acceptable to the client, are very specific, and reflect short-range goals that are feasible. Self-contracts often are more successful when they are paired with self-reward.
In some cases, a self-contract may also include sanctions that the client administers for failure to meet the contract terms. However, the rewards and sanctions should be balanced, and a self-contract that emphasizes positive terms is probably more effective.
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Self-contracts are very useful in working with children and adolescents because the conditions are so concrete. When contracts are used with children, several additional guidelines are applicable, including the following:
1. The required behavior should be easy for the child to identify. 2. The total task should be divided into subtasks, and initial contracts
should reward completion of each component or subtask. Other steps can be added later, after each successive target behavior is well established.
3. Smaller, more frequent rewards are more effective in maintaining the child’s or adolescent’s interest in working for change than larger, less frequently administered rewards.
4. In the case of a self-contract, rewards controlled by the child or teenager are generally more effective than those dispensed by adults. For example, a child who completes his workbook pages at school by lunchtime may dispense a variety of accessible rewards to and for himself, such as free time, visiting the library, and drawing. This helps the child feel in control of his or her work.
5. Rewards follow rather than precede performance of the target behavior to be increased. The client must agree to complete the specified activity first before engaging in any part of the reward.
�. The client must view the contract as a fair one that, in an equitable way, balances the degree of work and energy expended and the resulting payoffs or consequences.
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Client Commitment to Self-Management A critical problem in the effective use of any self-management intervention is having the client use the intervention regularly and consistently. Clients are more likely to carry out self-management programs if certain conditions exist, including the following:
1. The use of the self-management program provides enough advantages or positive consequences to be worth the cost to the client in terms of time and effort.
2. Clients believe in their capacity to change. Because beliefs create one’s reality, the belief that change is possible helps clients try harder when they get stuck or are faced with an unforeseen difficulty in their change plans.
3. Clients’ use of self-management processes reflects their own standards of performance, not the standards of the counselor or of significant others. (One note of caution: Counselors sometimes suggest a goal, or society often seems to suggest a goal. Such borrowed goals work against self-management efforts if clients are merely learning how to behave in accordance with standards that are foreign to them.)
4. Clients use personal reminders about their goals when tempted to stray from the intervention plan. A written list of self-reminders that clients can carry at all times may prove helpful in this respect.
5. If the client secretly harbors an escape plan (e.g., “I’ll study every day except when my friend drops over” or “I’ll diet except on Sundays”), this should be made explicit. Concealed escape plans are likely to wreak havoc on the best-conceived self-management programs.
�. The self-management program is directed toward maintenance as well as initial acquisition of target behaviors. For this to occur, you must take into account the client’s lifestyle.
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7. The client’s use of the program may be strengthened by enlisting the support and assistance of other persons—so long as their roles are positive, not punishing. Peers or friends can aid the client in achieving goals through reinforcement of the client’s regular use of the self-management strategies and reminders to resist temptations.
�. The counselor maintains some minimal contact with the client during the time the self-management program is being implemented. Counselor reinforcement is quite important in ‐ successful implementation of self-management efforts.
You can provide reinforcement easily through verbal approval or by acknowledging progress. Have the client contact you regularly during the course of the self-management program. This enables you to provide immediate encouragement and, if necessary, to modify the program if it is flawed.
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Case Illustration of Self- Management
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The Case of Kareem
Kareem is a 14-year-old boy who has scored very high on ability tests but has performed consistently below his ability level in school. He admits that his poor grades are the result, for the most part, of what he describes as “not really trying.” When asked by the counselor to define and give examples of this, Kareem notes that he rarely takes homework home, or if he does, he doesn’t complete it. He also says that he rarely opens a book, and often had not studied for tests. As a direct result of a series of events that occurred in his neighborhood, Kareem sought out the counselor for help in changing his behavior. He has decided that he wants to go to college and was starting to realize that his bad grades would adversely affect this possibility unless he pulled them up. He is concerned because he doesn’t know how to change what he refers to as “bad study habits.”
The counselor supports Kareem’s newly found goals and explains some of the rationale and process of a strategy called self-management. She points out that Kareem, rather than she, would be in charge of setting specific goals for his performance and monitoring his progress. She assures him that she will be there to help him start the process and to assist whenever he needs help. This appeals to Kareem, who states that he is tired of having so many other people on his back about doing better in school.
Because Kareem’s present base rate for studying is almost zero, the counselor initially discusses some realistic goals that he might want to set for himself as part of a self-contract. She helps him build in a self- monitoring system and a self-reward process. Kareem decides to set the following goals and action steps for his contract:
Goal: To improve my rate of homework assignment completion during the next nine-week grading period from 20 to 85 percent.
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Action Steps: To keep a daily record of assigned homework and to establish a time and place at home where I will work on homework every day. On Fridays, I will do Monday’s homework. On Saturdays, I will be free from schoolwork, but on Sundays, I will review my assignments and organize my books for the next school day.
In addition, he completes a reinforcement survey and selects eight potential rewards that he could use to reinforce his action steps. Kareem includes a bonus clause in his self-contract, which specifies an additional reward any week he exceeded the 85-percent level of homework completion. His self-contract is illustrated in Figure 10.1 .
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Figure 10.1 Behavioral Self-Contract
The counselor explains a self-monitoring system that Kareem could use to track his progress. She suggests that he use a daily log to record completion of each homework assignment (a large poster board with each school day of the month and a thermometer-like graph to show the percentage of his homework that he completes). She also asks Kareem if he wants to use any outside source to verify completion of assignments,
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but he indicates that he doesn’t need that. Finally, she and Kareem agree to meet each Monday morning, and he is to show her his monitoring chart (which he could roll up and store in his locker easily). Kareem’s log for the first week is shown in Figure 10.2 .
Figure 10.2 Assignment Record
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Kareem found the self-management strategy to work. Several conditions contributed to this outcome: He was highly motivated; he did not want others to be monitoring him; he chose a reasonable goal and action steps; he liked the counselor; the counselor liked him and was clearly supportive of his goal, his motivation, and his plan; and the counselor followed up religiously on the Monday morning commitments.
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Client Reactions to Behavioral Interventions Behavioral interventions are often very appealing to clients, particularly in the initial stages of counseling, when clients are highly motivated and want something to be done about their situations. The specificity, concreteness, and emphasis on action that these interventions offer help clients feel as if something important is being done on their behalf.
As the helping process continues, some of the clients’ initial enchantment with the procedures may wear thin as they discover the difficult and sometimes painful work of changing fixed and established behavior patterns. Successful use of behavioral interventions requires a significant investment of time, energy, and persistence from clients—daily practice, homework assignments, accurate record keeping, and so on.
To counteract any potential pitfalls or letdowns, counselors who rely heavily on behavioral interventions during the helping process must also generate involvement with the client through a positive relationship and commitment to action. When counselors use behavioral approaches, they must find ways to strengthen the client’s compliance with the demands of the intervention. Compliance can be enhanced in a number of ways, including creating positive expectations, providing detailed instructions about the use and benefits of an intervention, having the client rehearse the
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intervention, and having the client visualize and explore beneficial aspects of change.
