Commonalities in Approach to Cognition

  Although there is a great deal of debate in the field regarding the most precise and effective way to conceptualize and address cognitions in therapy, important commonalities in the approach to cognitions, even across disparate perspectives within behavior therapies, have also emerged (e.g., Arch & Craske, 2008). Teasdale et al. (2002) found that both traditional cognitive therapy and mindfulness-based cognitive therapy were associated with increases in meta-cognitive awareness, or decentering (recognizing thoughts as mental events rather than as indicators of truth or the nature of the self), which accounted for reductions in risk of depressive relapse. It may be, then, that both the process of identifying and challenging thoughts and the process of enhancing awareness and acceptance of thoughts are effective through the mechanism of altering the antecedent function of thoughts (in other words, changing the responses individuals have to these thoughts and the behaviors they engage in after the thoughts). For example, Sumi came to therapy because she felt socially isolated and lonely. Through monitoring, she discovered that when opportunities to socialize emerged, she immediately had the thought that she would not be able to easily relate to people and as a result they would not like her. After these thoughts, she typically chose to turn down the opportunity to socialize. Over time, she became able to notice these thoughts, as well as her impulse to decline social invitations that often occurred in association with these thoughts. She began to choose instead to engage socially, despite her discomfort and fear. She was able to make this change by cultivating acceptance of her internal experience rather than trying to change these thoughts. However, the same outcome might have occurred if therapy had involved challenging this cognition and generating alternative cognitions that were equally or more likely, which could similarly have led her to be more decentered from the thought and able to engage in actions that were important to her regardless of her thoughts.

Another commonality in the approach to cognition across behavior therapies is an emphasis on the importance of experiential learning. In traditional cognitive therapy, behavioral experiments play an important role in the process of challenging cognitions and developing new, alternative cognitions. In behavioral approaches, although verbal instruction may be used, direct experience is seen as the most powerful and flexible form of learning because it puts individuals in touch with natural contingencies that will maintain behavior change and allow for flexible responding to changing contexts. Experience is also emphasized in cognitive therapy in its emphasis on hot cognition, or cognitions that are closely tied to emotional reactions, as opposed to cold cognitions, or a more detached mode of thinking. This emphasis on thoughts that are associated with emotional responses makes emotional exposure a significant aspect of even strictly cognitive therapies (Arch & Craske, 2008). As such, all of these approaches likely include a component of learning to tolerate emotional responding or learning new, nonthreatening associations to internal responses that have been associated with threat.

CONCLUSION

  This overview of behavior theories was intended to provide a framework for clinical decision making based in empirically supported principles of learning. We have also provided a brief discussion of the varying views of the role of cognition in behavior therapies while identifying some potentially common mechanisms of change among these disparate approaches. In the next chapter, we provide an overview of the strategies that commonly stem from these theories. As described earlier, these strategies should be implemented in accordance with the individualized, culturally sensitive case conceptualization that is derived from a careful functional analysis (as described in the beginning of the next chapter).

¹ Initially, this learning process was thought to involve learning a response to a stimulus because that stimulus had been associated with another stimulus that automatically elicited that response. However, an extensive body of research has demonstrated that an association is learned between the previously neutral stimulus and the US and that associations are also learned regarding the context in which these pairings take place (Rescorla, 1988). In addition, conditioning can result in a different response to the CS than the response to the US, one that is preparatory for the potential occurrence of the US and matched to the properties of the CS (Rescorla, 1988). Although classical conditioning continues to often be described in terms of learning responses, the term learned associations is a technically more accurate description of this type of learning.

  The Therapy Process

  We begin this chapter with a detailed discussion of behavioral assessment and how behavior therapists view the relationship between assessment and treatment. Next, we review specific techniques and strategies that are frequently used by behavior therapists. We also discuss the role of the therapist–client relationship in behavior therapy, along with obstacles and challenges in the use of behavior therapy. Finally, we offer three case examples to illustrate how behavioral techniques are used in practice.

BEHAVIORAL ASSESSMENT

  Behavior therapy depends on thorough assessment, typically based on the same behavioral principles that underlie treatment. This section includes a description of the process of behavioral assessment, a discussion of functional assessment (an important aspect of behavioral assessment), and information on some of the most commonly used behavioral assessment techniques.