Chapter#03

Clinical Interventions
Behavior Therapy
Content:
 Introduction to Behavior Therapy
 Functional Analysis/ ABC Model
 Reinforcement and its types, Relaxation Exercise, Thought Stopping, Systematic
Desensitization, Assertiveness Training, Exposure Technique
 Contingency Management (Shaping, Time out, Contingency Contracting, Response Cost,
Token Economies)
Introduction to Behavior Therapy
Behavior therapy refers to the range of treatments and techniques which are used to
change an individual’s maladaptive responses to specific situations. Altering the maladaptive
responses can often alleviate psychological distress and psychiatric problems.
Behavior therapy is a term that describes a broad range of techniques used to maladaptive
behaviors. The goal is to reinforce desirable behavior and eliminate unwanted ones. Rooted
in the principles of behaviorism, a school of thought focused on the idea that we learn from our
environment, this approach emerged during the early part of 20th century and became the
dominant force in the field for many years. Edward Thorndike was one of the first to refer to
the idea of modifying behavior. Unlike the types of therapy that are rooted in insight (such as
psychoanalytic therapy and humanistic therapies), behavioral therapy is action-based. Because
of this, behavioral therapy tends to be highly focused. The behavior itself is the problem and the
goal is to teach people new behaviors to minimize or eliminate the issue. Behavioral therapy
suggests that since old learning led to the development of a problem, then new learning can
fix it. Behavioral therapy is problem-focused and action-oriented. For this reason, it can
also be useful for addressing specific psychological concerns such as anger management
and stress management.
The first early examination of behavior therapy examined how fears and phobias are
learned and demonstrated the role of classical conditioning in their genesis. The early treatments
of phobic disorder and systematic desensitization. This technique requires deep muscular
relaxation before the patient is asked to imagine increasingly anxiety-provoking situations.
Exposure does not use relaxation but involves the patient in gradually facing up to the feared
situation. It is the treatment of choice for phobic and obsessive-compulsive disorders.
Modern behavior therapy can be divided into three main types of techniques. First,
there are the exposure treatments used in a range of anxiety disorders. Second, there are methods
aimed at teaching new skills such as in social skill deficits, marital disharmony, and sexual
dysfunction. Third, there are reinforcement or reward programs. These are based on rewarding
desired behaviors and ignoring or suppressing undesirable ones. They are most commonly used
in the chronic institutionalized patient. Behavior therapy is commonly used in conjunction
with cognitive therapy when the patient’s thinking patterns are also examined and
therapist together. Behavior therapy is also often combined with drug treatment.
Behavior therapy is focused on helping an individual understand how changing
their behavior can lead to changes in how they are feeling. The goal of behavior therapy is
usually focused on increasing the person’s engagement in positive or socially reinforcing
activities.
Functional Analysis/ ABC Model
Functional analysis examines the causes and consequences of behavior. It is
underpinned by the principles of behaviorism and behavioral analysis. It seeks to understand a
specific target behavior (or problem behavior) and identify the triggers and reinforcers
that cause and maintain the behavior. Functional analysis can be applied across a wide range
of settings and conditions, since it focuses on the individual and the immediate context of their
behavior, rather than their diagnosis. Within cognitive behavioral therapy, functional analysis
can be used to help clients understand their own behavior, and it can be applied more directly as
method of assessment, formulation and treatment.
What is Functional Analysis?
Functional analysis takes its name from the goal of understanding the function that a
particular behavior performs. The function of the behavior is defined as a response to
particular contingencies in the environment or in the person. Contingencies are the casual
relations between the behavior (the response) and things that happen before it (antecedents) or
after it (the consequence).
Haynes & O’Brien (1990) define functional analysis as “The identification of
important, controllable, causal functional relationships applicable to a specified set of
target behaviors for an individual client”. It is a method of behavior analysis which is an
intervention designed to modify behavior according to certain principles. Assessments and
treatments for the problem behaviors are designed using the principles of behaviorism, applied
behavioral analysis (ABA), and functional analysis. Functional analysis has its origin in work
with children and young adults and the treatment of problem behavior by people with
developmental disabilities. Carr proposed that self-injury in his client group may be a
learned behavior that is maintained through reinforcement- For example, receiving attention
from other people following the behavior, or a means to escape an activity or stimulus that they
found aversive. Lwata and colleagues used single-subject experiments to test whether self-injury
could be modified by changing these hypothesized reinforcers. Thus, the function of self-injury
behavior was analyzed and from this, the causes of behavior were identified.
There are three stages of functional analysis. First, a process of assessment records and
monitors the target behavior and its antecedents and consequences in order to generate
hypotheses about the contingencies that shape it. Contingencies are the things on which the
behavior depends. For example, a behavior’s antecedents are the contexts, stimuli and events
that are present before the behavior occurs and can be considered triggers. A behavior’s
consequences are the things that occur as a result of the behavior and can be considered to be the
reinforcers that maintain it and make it more likely to be happened in future. Once hypotheses
about the contingencies have been generated, the second stage of functional analysis is
preparatory work for the final, third stage in which experiments are conducted to directly test
those hypotheses with an individual client. When working within a cognitive-behavioral
framework, you can consider the three stages of functional analysis as parallel to assessment,
formulation and intervention with evaluation.
For many, the third stage of experimental work forms the core of functional analysis
since it is at this stage that hypothesized reinforcers of the behavior are modified, allowing
identification of the things that cause and maintain the behavior. For example, following
functional analysis, self-injurious behavior in individuals with developmental difficulties is
decreased when rest periods or rewarding activities were introduced during academic sessions
(i.e., the hypothesis was that self-injury was a way to interrupt the academic sessions) or
was extinguished by removing the sensory stimulation that self-injury behavior provides.
Distinctive Features of Functional Analysis:
Functional analysis is distinguished from other types of assessment and intervention by these
features:
 Functional behavior analysis concerns itself with the behavior of individuals.
 Functional analysis concerns itself with the function of problem behavior.
 Functional analysis assumes that behavior cannot be understood in isolation.
 Functional analysis leads directly to the treatment interventions. The hypotheses
formulated during the first stages of functional analysis are tested by experimental
interventions. The interventions change or modify the contingencies in order to treat the
problem behavior. Antecedents are removed or replaced and consequences are changed,
where possible. The behavior itself can also be replaced by introducing a different, more
adaptive behavior.
Behaviors Treated using Functional Analysis:
Some practitioners assume that functional analysis is best applied with clients who
have developmental or cognitive difficulties or that it can only be applied to a voluntary
motor behavior (hitting, self-injury and so on). However, the principles of functional analysis
can be very successfully applied as a tool for assessment, formulation, and intervention within
cognitive-behavioral framework with high functioning clients. Some example categories of
behaviors that can be fruitfully approached using functional analysis include:
 Observable behaviors: For example, eating, hitting, seeking reassurances, using
substances, self-harm
 Inhibiting or suppressing an urge, feeling or thought: For example, distracting oneself
so as to avoid an urge to self-harm, suppressing an intrusive thought.
  Thoughts or cognitions that the client is able to report or record: For example, worry,
rumination, self-criticism, self-distraction, compulsive counting, or post morteming-
reviewing memories in an attempt to be certain.
 Feeling that can be reported and rated: For example, anxiety, sadness, anger.
 Physiological responses that can be reported and rated: For example, heart racing,
nausea, temperature change, dry mouth.
 Communication behaviors within a relationship: For example, overly critical
responses, not validating what the other person is saying, or responding negatively
whenever certain topics are introduced.
Choosing Target Behavior for Functional Analysis:
For functional analysis to be helpful, a single target behavior should be identified. This is not
always straightforward, and it is common for there to be multiple related problem behaviors. It is
important that the targeted behaviors are a high priority for the individuals and not just
symptoms defined by their diagnosis. An effective way to choose the behavior is to work through
the process of prioritization that focuses on “Ultimate Outcome”.
Example of using Functional Analysis to address problem behavior:
Functional analysis examines the causes and consequences of behavior- it is a “Powerful
method of empirically identifying the variables that maintain a problem behavior”. The three
stages of functional analysis can provide a systematic means to identify a problem behavior,
understand the triggers (antecedents) and consequences that maintain it, and then to introduce
interventions.
For example, a female client might present with problematic eating behaviors, and in
particular describe raiding the fridge in middle of night and binge eating. The clinician and the
client could carefully explore what happened during the day before a night-time binge. The
antecedents could be that client would deliberately restrict their eating during the day and find
the feeling of huger rewarding because it was consistent with her goal of losing weight.
However, this would cause her to wake in the night feeling extremely hungry, and binge on food
(the problem behavior). In this case, the short-term consequence of binge eating was a feeling of
pleasure that came with relieving her physiological state of starvation. A subsequent
consequence of binge eating was feeling disgusted with herself. Following use of Antecedent
Behavior Consequence (ABC) model, the therapist could suggest that managing food
intake during the day in a healthier manner might lead to reduction in night-time binge
eating. This more positive behavior (of calorific intake) would also align with the client’s desires
and values to be healthy. The client and the therapist would therefore be able to develop a
treatment plan based around this.
Applying Functional Analysis to Therapist-Client Relationship:
Functional analysis can also be used to manage and improve the therapist-client
relationship. Persons (2008) describes several examples where elements of functional analysis
were applied in this way. For example, a client contacted the therapist regularly and at various
hours of the night, and during those contacts, threatened to commit suicide. Initially, the therapist
attended to these contacts by providing support over the phone, entering into long conversations,
and trying to “Talk down” the client. The behavior developed into a problem, becoming
unmanageable for the therapist. Applying some principles of functional analysis, it was
hypothesized that the therapist’s initial response to the behavior acted as a social reward
(i.e., attention) and a reinforcing consequence that increased the frequency of the behavior.
To address the behavior, the therapist altered the contingencies. Instead of entering into
prolonged discussions, the therapist provided the client with suicide helpline number and stated
that they would call the emergency services. Within a few weeks, the behavior had reduced in
frequency and the therapist had a means to deal quickly with any future instances.
More subtle example includes applying functional analysis to therapist-client interaction.
Persons consider how therapist responses moment to moment work to change the client’s
disclosures during therapy. For example, a client may avoid discussing difficult topics in
each session, preventing the therapist from making progress. On reflection and considering
the client’s behavior of avoidance, the therapist observes that they unintentionally reward the
avoidance behavior by changing their question or changing the subject when they notice that the
client is becoming distressed. This would encourage the therapist to try a different approach;
encourage the client to consciously and deliberately approach difficult topics and “Sit with” the
feelings of distress.
Reinforcement
The term “Reinforcement” means to strengthen and used in psychology to refer to
anything stimulus which strengthens, and encourages the designated behavior, or increases the
probability of specific responses. For example, if you want your dog to sit on command, you
may give him a treat every time when he sits for you. The dog will eventually come to
understand that sitting when told to will result in a treat. This treat is reinforcing because he likes
it and will result in him sitting when instructed to do so.
Types of Reinforcement:
There are two different types of reinforcement:
1. Positive Reinforcement
2. Negative Reinforcement
These types are discussed in detail below:
1. Positive Reinforcement: Positive reinforcement involves adding something to increase
response, such as giving a piece of candy to a child after they clean their room.
Positive is the equivalent of a plus sign, meaning something is added to or applied to the
situation.
Real-world examples of Positive Reinforcement: During practice for your office softball
team, the coach yells, “Great Job”, after you throw a pitch. Because of this, you are more
likely to pitch the ball the same way again. This is an example of positive reinforcement.
 Another example is while at work, you exceed your manager’s sales quota for the
month, so you receive a bonus as a part of your paycheck. Money is a conditioned
reinforcer, making it more likely that you will try to exceed the minimum sales quota again
next month.
2. Negative Reinforcement: Negative Reinforcement involves removing something to
increase response, such as canceling a quiz if students turn in all of their homework for
the week. By removing the aversive stimulus (the quiz), the teacher hopes to increased
the desired behavior (completing all homework). Negative is the equivalent of minus
sign, meaning something is removed or subtracted from the situation.
Real-world examples of Negative Reinforcement: You go to your doctor and get yearly
flu shot to avoid coming down with the flu. In this case, you are engaging in a behavior
(getting a shot) to avoid an aversive stimulus (getting sick). This is an example of negative
reinforcement.
Another example is if you slather aloe vera gel on a sunburn to prevent the burn from
hurting, applying the gel prevents an aversive outcome (pain), so this is an example of
negative reinforcement. Because engaging in the behavior minimizes an aversive outcome,
you will also be more likely to use aloe vera gel again in the future.
Reinforcement and Response Strength:
How and when the reinforcement is delivered can affect the overall strength of a
response, the following qualities can measure and describe response strength:
 Accuracy: Did the reinforcement deliver the desired response?
 Duration: How long did the response continue?
 Frequency: How often did the response occur?
 Persistence: Did the response each and every time?
Reinforcement Schedule:
The timing of when a reinforcer is presented can be manipulated. During the early
stages of learning, continuous reinforcement is often used. This involves reinforcing a response
each and every time it occurs, such as giving a puppy a treat every time it pees outside. Once a
behavior has been acquired, a partial reinforcement schedule can be used.
Relaxation Exercise
Relaxation exercise a method used to help reduce muscle tension and stress, lower blood
pressure and control pain. Example of relaxation techniques include tensing and relaxing
muscles throughout the body, guided imagery (Focusing the mind on positive images),
meditation (Focusing on thoughts), and deep breathing exercises.
Techniques of relaxation are discussed below:
1. Progressive Muscle Relaxation: In progressive muscle relaxation, you focus on slowly
tensing and then relaxing each muscle group. You start to tense and relax the muscles
 in your toes. You gradually work your way up to your neck and head. You can also start
with your head and neck and work down to your toes. Tense your muscles for about
five seconds and then relax for 30 seconds, and repeat.
2. Visualization: In visualization, also called guided imagery, you may form mental
picture to take a visual journey to a peaceful, calming place or situation. To relax using
guided imagery or visualization, try to use as many senses as you can, such as smell,
sight, touch, and sound. If you imagine relaxing at the ocean, think about the smell of
salt’s water, the sound of crashing waves, and the feel of the warm of sun on your body.
You may want to close your eyes and sit in a quiet spot. Loosen any tight clothing and
focus on your breathing. Aim to focus on the present and think positive thoughts.
3. Deep Breathing: Deep breathing is very effective relaxation exercise. You can practice
deep breathing by following a series of steps which are enlisted below:
 Sit comfortably with your back straight. Put one hand on your chest and other on
your stomach.
 Breathe in through your nose. The hand on your stomach should rise. The hand on
your chest should move little.
 Exhale through your mouth, pushing out as much air as you can while contracting
your abdominal muscles. The hand on your stomach should move in as you
exhale, but your other hand should move very little.
 Continue to breathe in through your nose and out through your mouth. Try to
inhale enough so that your lower abdomen rises and falls. Count slowly as you
exhale.
If you find it difficult breathing from your abdomen while sitting up, try lying
down. Put a small book on your stomach, and breathe so that the book rises as you inhale
and falls as you exhale.
4. Meditation: Meditation is a mental exercise that trains attention and awareness. Its
purpose is often to curb reactivity to one’s negative thoughts and feeling, which
though they may be disturbing and upsetting and hijack attention from moment to
moment, are invariably fleeting. The 3R’s of meditation is Recognize, Release and
Return. There are generally seven steps of meditation:
 Sit upright comfortably
 Gently close your eyes
 Breathe deeply
 Slowly scan your body, and notice any sensations
 Be aware of any thoughts you are having.
 When your mind wanders, focus on your breathe
 Gently open your eyes when you are ready.
Thought Stopping
Thought stopping, also known as thought suppression, is a behavioral modification
technique involving intentionally preventing thoughts you would rather not entertain. Cognitive
behavioral therapies may integrate thought stopping, proposing that repeated prevention
fades negative thoughts from awareness. Thought stopping encourages individuals to abruptly
and firmly order a thought by doing something irritating. For example, individuals may snap a
rubber band on their wrists to disrupt an unpleasant.
While our ability to think, problem-solve, pay attention, remember, cherish, and create is
a tremendous asset that allows us to survive and thrive, such skills can also work against us.
Overthinking can exacerbate stress, contribute to metal health disorders, and prevent us
from enjoying inner peace and satisfaction. So, wanting to stop specific thoughts or
overthinking is natural. So, thought stopping is not an ideal method of overcoming such
problems.
There are seven ways of thought stopping:
1. Scattered Counting: Start counting with any number and then jump around 14, 89, 30,
57 etc. it takes more concentration to come up with the next number when you have to
think about what it will be and this helps take your mind off the thoughts that are
troubling you.
2. Verbal Interruption: The traditional way to stop thoughts in their track is with a verbal
interruption. This could be literally spoken out loud, if you comfortable doing so, or
spoken to yourself in your head, shouting “Stop” or “Enough” or “Not Now”. This can
be done as many times as you need to calm your mind.
3. Positive Self-Talk: If your thoughts are particularly negative or scary, try restructuring
them into ones that empower you. Instead of thinking “I am so nervous about bombing
this presentation at work” try thinking “It is OK to be nervous ad I can deal with
this”.
4. What is the Worse that could Happen: If You are able, imagine going to the worst
scenario. What would happen if you did lose your job? How would you handle it? What
kind of plan would you make to revamp your resume? Picturing yourself tackling the
worst possibility often gives us confidence that even if the worst were to happen, we
would still be able to handle it.
5. Auditory Distraction: Our obsessive thoughts ca be so loud in our head, and one great
way to drown them out is by listening to something else. Put on your favorite music, your
favorite podcast, or an audio book you find interesting.
6. Muscle Isolation: Unwanted thoughts and obsessions keeps us stuck in our mind. By
feeling our body intentionally through muscle isolation, we can draw the attention away
from our brain and into different parts of our body.
7. Meditation: Regular meditation changes the structure of brain and strengthen your
ability to combat negative thoughts. Start by practicing mindfulness breathing for five
minutes a day. You can picture your distressing thoughts like clouds, drifting by you, or
like cars passing on the road. Overtime, you can work up to 10 minutes, 20, or even an
hour of meditation.
 Systematic Desensitization
Systematic desensitization is a behavioral therapy technique used to treat anxiety,
phobias, OCD and PTSD. It is based on the idea that client has learned a conditioned aversive
response (usually fear or disgust) to a specific stimulus and that this association can be
broken by counter-conditioning. The stimulus may be a specific situation, such as meeting new
people, in the case of social anxiety, or a specific thing like spiders, in the case of arachnophobia.
It could also be places, sounds, sights, and events associated with a traumatic experience with
PTSD.
Systematic desensitization uses counter conditioning to teach a client a new response to
the stimulus using relaxation techniques during graded exposure to the stimulus. In this way,
the original fight-or-flight response of the sympathetic nervous system is replaced by the
relaxation response of the parasympathetic nervous system.
The technique is called systematic desensitization, as the counter conditioning graded
exposure proceeds systematically through three phases:
1. The client learns relaxation techniques that will counter condition their response to the
aversive stimulus.
2. The therapist and client collaborate to produce hierarchy of the client’s intensity of
response to the stimulus at different levels of exposure to the stimulus.
3. The client is desensitized to the stimulus through systematically graded exposure to the
stimulus and practices relaxation techniques to counter their aversive fight-flight response
during the exposure.
These three phases are practiced over several sessions and homework may also be given to
maintain the counter conditioning between sessions.
Real Life Example of Systematic Desensitization & Phobia Treatment:
Arachnophobia is a relatively common phobia of spiders. When treating this, or any other
phobia, the therapist and client would produce a list of scenarios about the feared object or
situation and the client would then rate their anxiety levels in each situation on a scale of 1 to
10.
These stimulus-response scenarios are ordered from the least intense at the lowest level
(1) up to the most intense (10) at the top.
At the start, the therapist might simply discuss spiders and then lead the client through a
relaxation practice. Next, the therapist introduces pictures of spiders, and again leads the
client through a relaxation practice.
The next step would be watching spiders on video, plus practicing relaxation. With each
greater exposure, the therapist is careful not to overwhelm the client. The client’s usual fear
response is gradually replaced by an increasing sense of relaxation, from in-vitro (controlled
condition) to in-vivo (real-life) exposures.
 Graded exposure is always accompanied by relaxation. Steps could include exposure
to a realistic plastic spider in the room, then in their hand. Next, a dead spider and asking the
client to touch it with a stick, then with their hand. After that, the client could be exposed to a
spider in a transparent container, then asked again to approach the container and touch the
spider with a stick.
Finally, at the highest grade of exposure, they could be in a room alone with a dead
spider, then with a spider in a container for a short period, and even a live spider they can
learn to trap and remove. This will equip the client with the skills necessary to deal with
spiders in real life rather than feeling disabled by their phobia.
With today’s technology, it is possible to use what is called VRET, which stands for
Virtual Reality Exposure Therapy. This is an in-vivo form of systematic desensitization.
VRET permits clients to work through each level of their anxiety hierarchy with the added
safety and control of virtual reality. VRET can also be conducted remotely or as homework
between sessions.
Assertiveness Training
Assertive definition is simply having confidence and communicating in a confident way.
Assertive training teaching confidence, not aggression. Assertiveness training is a form of
therapy that has been used since the 1970’s to help people learn how to better communicate their
needs and wants so that they don’t feel taken advantage of or used. Assertiveness training can be
very helpful to people who learned to be passive or passive aggressive due to the circumstances
that they grew up in.
Assertiveness training is a form of behavior therapy designed to help people stand up
for themselves, in more contemporary terms. Assertiveness is a response that seeks to maintain
an appropriate balance between passivity and aggression. Assertive responses promote fairness
and equality in human interactions, based on a positive sense of respect for self and others. The
purpose of assertiveness training is to teach persons appropriate strategies for identifying
and acting on their desires, needs, and opinions while remaining respectful of others.
How is the Assertiveness Training Done?
Therapists help the clients which interpersonal situations are problems for them and
which behaviors needs the most attention. In addition, therapist needs to identify beliefs and
attitudes the clients may have developed that lead them to become too passive. Therapists take
into account the client’s particular cultural context in this process. Therapists may use a
combination of interviews, tests, or role-playing exercises as part of this assessment. Therapists
help clients understand what assertiveness is and how behaving assertively may be helpful.
Inaccurate or unproductive attitudes and beliefs about assertiveness are discussed. Once clients
understand the importance of assertive behavior for their situation, therapist help them develop
more assertive behavior. For example, using a technique called behavioral rehearsal, a situation
is described and then role played by the client and the therapist. Initially, the therapist may play
the role of the client and model assertive behavior. The client and the therapist then switch the
roles and the client practices the new behavior. The therapist gives supportive, honest feedback
after each role-play exercise in order to help the client improve his or her skills.
Assertiveness training is based on the idea that assertiveness is not in-born, but is a
learned behavior. Although some people may seem to be more naturally assertive than
others, anyone can learn to be more assertive.
Exposure Technique
Exposure therapy is a behavior therapy used in CBT that involves exposing yourself to
something that causes anxiety, distress or another negative response. For example, if you are
afraid of heights, exposure therapy could involve you putting yourself in safe controlled
situations that involve being off the ground- such as taking an elevator to a roof top. Although
doing so may initially spike your anxiety or stress, the idea is that you eventually get comfortable
with the discomfort and free yourself of the fear. Fear is often maintained by avoidance
behavior and the goal of exposure therapy is to overcome avoidance behavior by exposing
you to your fears, usually one step at a time, and encourages you to sit with the discomfort
until it becomes manageable. Overtime, you can learn that the thing you fear isn’t actually
harmful and create more realistic expectations and associations. For example, you may discover
that being high off the ground doesn’t always result in injury.
Exposure therapy is a popular treatment for many anxiety-related issues, including
phobias, social anxiety disorder, obsessive compulsive disorder (OCD), and Post Traumatic
Stress Disorder (PTSD). It can also be used to treat eating disorders and chronic pain.
Exposure therapy can come in many forms, but all of them require you to confront your
fears, either in-person or in simulated circumstances. Although you can try many of these
approaches on your own, exposure therapy is likely to be more effective when performed under
the guidance of a therapist. Following are some important types of exposure therapy:
1. In-Vivo Exposure: This involves direct exposure with your source of fear. For
example, if you have a fear of flying, you might get a plane. If you have a fear of heights,
you might take an elevator to the top floor of building.
2. Imaginal Exposure: As the name implies, this approach involves using your
imaginations to simulate or recall a frightening experience. An approach known as
written exposure therapy takes this a step further. You repeatedly imagine a distressing
situation, such as past trauma, and write it down.
3. Virtual Reality Exposure: This approach requires the use of VR technology but allows
you to safely confront your fears. This might be used when in-vivo exposure is not an
option. For example, you might want to expose yourself to the experience of a plane
without actually buying a ticket.
4. Interoceptive Exposure: Interoceptive exposure requires you to induce physical
sensations that you are afraid of. This can be useful for panic disorder, in which bodily
sensations like increased heart rate, trigger panic.
5. Prolonged Exposure Therapy: This approach combines imaginal and in-vivo
exposure therapy and might be used to treat PTSD. You repeatedly recall the
 traumatic events to a therapist while using your imagination to visualize what happened.
The aim is to process the event and reassess your perception, moving from negative to
neutral or positive.
6. Exposure and Response Prevention (ERP): OCD can be treated with a type of therapy
called exposure and response prevention (ERP). If you have OCD, you may use ritualized
behavior to manage anxious thoughts, such as repeatedly washing your hands to manage
your anxiety of germs. However, in ERP, you practice tolerating the discomfort of
anxiety without using your rituals.
Not all types of exposure are equally effective for every condition. Some research shows
that in-vivo exposure, for instance, may have longer-lasting benefits on social anxiety
than virtual reality exposure.
Contingency Management
Contingency management refers to a type of behavioral therapy in which
individuals are reinforced or rewarded for evidence of positive behavioral change. In
contingency management, a contingency is a contingent event or condition: something that
is liable to happen as an adjunct to or result of something else. An example might be having
an agreement with one’s teenager such that she must be home by 11;00p.m. each school
night in order to be able to go to a weekend concert. In other words, attending the concert is
contingent on getting home on time. Management refers to supervising or overseeing
something: in the case of contingency management, this would mean overseeing the agreed
upon behaviors and contingencies. Using the earlier example, Dad might monitor the teen’s
arrival time each school night to assure the requirements for the contingency (home on
time= concert tickets) were met.
Contingency management is also called the carrot-and-stick method. This behavioral
approach encourages the people to change their behavior to receive a reward (the carrot)
and avoid punishment or negative consequences (the stick).
A key term in the contingency management is reinforcement. The purpose of using
contingency management as a part of drug and alcohol treatment is to encourage pro-
recovery behavior (e.g., abstinence, session attendance, work toward vocational, social, or
educational goals) by giving reinforcements when such behaviors are performed or by
withholding reinforcement when such behaviors are abandoned (e.g., drinking/ using drugs,
not keeping appointments). This idea of using reinforcement and consequences to shape
behavior is known as operant conditioning.
Following are some important techniques of contingency management to modify
behavior:
1. Time out: A time out is a form of behavioral modification that involves temporarily
separating a person from an environment where an unacceptable behavior has occurred.
The goal is to remove that person from an enriched, enjoyable environment, and
therefore, lead to the extinction of the offending behavior. For example, when a child
displays the inappropriate target behavior, he or she is immediately removed from the
activity for a period of time. Example of this type of time-out is to send a child to the
corner of the room or a chair positioned away from the ongoing activity. There are two
types of time out:
Exclusionary Time Out: Exclusionary time out is in place when a person is removed
from a reinforcing environment for a pre-specified period of time. Cooper et al. list the
three different methods of exclusionary time out and these are:
 Time Out Room: time out within a room created specifically for a time out
 Partition Time Out: Time out behind a partition.
 Hallway Time Out: Student stands outside the classroom.
Non-Exclusionary Time Out: A non-exclusionary time out is in place when the person
is allowed to remain within the reinforcing environment but is not permitted to engage in
any reinforcing activities for a pre-specified period of time; this form of time out removes
reinforcers from the individual. Cooper et al. list four different methods for
implementing a non-exclusionary time out and these are:
 Time Out Ribbon: Each children wear a ribbon that can be taken off them to
implement a time out.
 Planned Ignoring: A time out where social attention is removed.
 Contingent Observation: The child has to sit and watch others engage in
reinforcing activities.
 Withdrawing a Specific Reinforcer: Removing a positive reinforcer (e.g., a toy)
from a child for engaging in a target behavior.
Examples of Exclusionary and Non-Exclusionary Time Out:
Example One: Everyone in Tom’s class has free time and they are playing with toys
of their choices. During this free time, Tom punches one of his classmates.
Exclusionary Time Out: The teacher guides Tom to a separate partitioned room in the
corner of the main classroom where he cannot see or engage with the rest of the class. He
has to remain behind the partition for 2 minutes.
Non-Exclusionary Time Out: The teacher guides Tom to the time out chair within the
classroom where he has to sit in and watch as his classmates enjoy free-time. He must sit
there for 2 minutes.
Example Two: Brain was enjoying playing with a soccer ball in the playground but
then kicks it at another student to hurt them
Exclusionary Time Out: If the teacher told brain that he had to go into the library
detention room for 10 minutes, this would be an exclusionary time out as he had lost
access to the reinforcing environment (playground).
 Non-Exclusionary Time Out: If the teacher took the ball off the Brain for 10 minutes
but let him remain in the playground, this would be a non-exclusionary time out as he has
lost access to the soccer ball (reinforcer) but remains within the environment
(playground).
2. Contingency Contracting: Contingency contracting, a specialized form of operant
conditioning, is a behavioral contract between individuals (often parents or teachers)
who wish to see changes in behavior and those (children or students) whose behavior is
to be changed. The contracts, usually written out and signed by those involved, allow
the rewards and punishments of various behaviors to be negotiated by both parties. For
example, a parent and child enter into a contingency contract to get the child to
finish his homework before dinner time, after which, he earns some TV time. Every
time, he satisfactorily finishes his homework before dinner time, he gets to watch TV for
an hour after dinner. If he fails to finish his homework satisfactorily, then instead of
enjoying some TV time, he has to use that time to finish his homework.
3. Response Cost: Response cost, also called conditioned aversive stimulus, is a special
case of a punishment procedure that involves taking away desirable possessions,
points, tokens or privileges in planned, incremental steps following the occurrence
of undesirable behavior or failure to meet a specific goal. If the positive reinforcement
strengthens a response by adding a positive stimulus, then response cost has to weaken a
behavior by subtracting a positive stimulus. In response cost, after the response, the
positive reinforcer is removed which weakens the frequency of response. It is often used
as a behavior therapy on its own and in conjunction with reinforcement in token
economies. A common example of a response cost is a ticket issued by a police officer
for offenses such as speeding while driving. The removal of money (a positive reinforcer)
contingent on the occurrence of the undesired behavior may decrease the future
likelihood of the behavior (i.e., speeding).
Difference Between Response Cost and Time Out: With time out, the person is
removed from access to all sources of reinforcement contingent on problem behavior.
With response cost, a specific amount of a reinforcer the person already possesses is
removed after the problem behavior.
4. Token Economy: Token economy is based on operant learning theory which states
that rewards and punishments shape behaviors. Token economy is a behavioral
management practice that focuses on rewarding an individual for displaying the desired
behavior. A token economy is the practice of physically rewarding an individual for their
demonstrations of specific behaviors that are established as an expectation. Tokens
present the number of times the individual demonstrated and successfully
completed the desired behavior. Token economy as a behavioral strategy were first
used in mental institutions to reward patients for their completion of tasks and
compliance of rules. By rewarding patients with tokens, they were able to earn the
desired reward and this promoted compliance with rules and policies. Example of
school-based token economy include that student earn tokens or points for demonstrating
positive behaviors, such as being respectful, completing homework or helping their peers.
 These tokens can be exchanged for rewards, such as stickers, small toys, or privileges
like extra free time.
5. Shaping: Behavior shaping, or shaping is a systematic approach of teaching new skills or
modifying the existing behaviors. It involves breaking down a desired behavior into
smaller, manageable steps, allowing individuals to gradually progress towards the
desired outcome. It is most of the time used to establish a behavior that is not generally
performed by an individual. In order for shaping to be successful, it is important to
clearly define the behavioral objective and the target behavior. Example of shaping
include teaching child positive habits. We use shaping when we teach a children habits
like washing their hands or putting away toys. Generally, a parent will reward them with
stickers by completing small tasks. Overtime, they will learn instinctively to do the task
without receiving the reward. Another example of shaping in the classroom is
teaching students to sit quietly until all of the students in the class have completed
their work. An example of shaping is when a baby or toddler learns to walk.
There are seven steps to shape the new behavior:
Step 1: Define the desired behavior
Step 2; Break down the desired behavior into small steps
Step 3: Identify the starting point
Step 4: Reinforce each small step
Step 5: Gradual adjustments
Step 6: Be patient and flexible
Step 7: Reinforce the final behavior