Please see attached.
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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.
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Applying Interventions to
Dialectical Behavior Therapy
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Behavioral Interventions Used in
Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) uses affective and cognitive
interventions, but not because emotional catharsis or insight is the goal;
rather, DBT is founded on the premise that once the client trusts the
therapist adequately and feels validated and understood by the therapist,
the real goal of developing life skills that will offer new and healthier
options for the client becomes evident. Thus, behavioral change is the crux
of DBT, and the word skills is used throughout the DBT literature to describe
the desired outcome of the therapy (Dimeff & Koerner, 2007; Miller,
Rathus, & Linehan, 2007).
For programs that have invested in DBT as their primary delivery method,
group work is often the context for skill development. Therefore, the
portions of this chapter that discuss role-play, behavioral rehearsal, and the
receiving of feedback are descriptive of the interventions used by DBT
therapists in their work. Of course, counselors who align themselves with
DBT tenets can use these same behavioral interventions within individual
counseling. In group work or individual counseling, once the stage of skill
development has been reached in DBT, all of the interventions described in
this chapter could conceivably be used. Each DBT therapist develops his or
her preferred interventions for behavioral change, and the DBT literature
describes the use of a host of such interventions across different clinical
populations. The content of this chapter can serve as a primer for
developing one’s own repertoire.
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Intervention Strategies
Complete the table below.
Create a 50- to 75-word scenario for a client who is displaying the highlighted behavior intervention. Brainstorm topics or factors that may affect the client when dealing with this situation. What interventions and strategies would you use with this client? Please use peer reviewed sources only
Interventions
Goals
Client Scenario/Factors
Intervention/Strategies
Affective
Cognitive
Behavioral
Systemic
Copyright 2020 by University of Phoenix. All rights reserved.
Copyright 2019 by University of Phoenix. All rights reserved.
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