Behavioral Theories

4
BEHAVIORAL THEORIES
OF PSYCHOTHERAPY
DANIEL B. FISHMAN, SIMON A. REGO,
AND KATHERINE L. MULLER
All major systems of psychotherapy—behavior therapy, psychoanalysis,

family systems, humanistic therapy, and so forth—are embedded in a broad
paradigm that involves a number of dimensions. These dimensions include
(a) adherence to certain epistemological, philosophy-of-science assumptions;
(b) a particular set of theoretical positions; (c) a body of scientific and other
data; (d) particular collections of techniques and technologies; (e) specific val-
ues and ethical positions; and (f) a particular sociological, political, and histori-
cal context (Fishman, Rotgers, & Franks, 1988; Kuhn, 1962). In this chapter,
the focus is on the evolution of behavior therapy in terms of epistemology and
theory. However, because a full understanding of behavior therapy demands a
consideration of the interrelationships among the various components of the
entire paradigm, as just defined, we also devote some space to these relationships.
We view behavior therapy as closely linked to the patterns of thought
and values first developed during the Age of Enlightenment of the 17th and
18th centuries and later expanded in 20th-century terms. These include a
focus on rationally and scientifically derived, “value-neutral” technology used
in the service of promoting individual growth and freedom from irrational
authority and arbitrary privilege (see Fishman et al., 1988; Woolfolk &
Richardson, 1984).
101
In theoretical terms, we view behavior therapy as an approach to under-
standing behavior and behavior change that relies in large part on the tradi-
tional methodology of behavioral science, with significant links to learning
theory, cognitive psychology, and experimental psychology. Behavior is defined
broadly to include both overt actions and observable manifestations of covert
affective and cognitively mediated processes. These aspects of behavior may
occur at several levels and contexts: psychophysiological, individual, small
group, organizational, and community.
In practical terms, we regard behavior therapy as a data-based application
of theory to generate a technology, the primary goal of which is cost-effective,
constructive behavior change. By constructive, we mean behavior change
that is endorsed by all concerned and considered ethical. From the points of
view of theory and practice, we view behavior therapy as a major conceptual
advance rather than as simply another therapeutic innovation.
It is important to point out that in this book on the history of psychother-
apy, there is this chapter on behavior therapy and another chapter on cognitive
therapy. In practice, the procedures of these two systems are frequently merged
into cognitive behavior therapy (CBT). Their conceptual separation is based in
part on theoretical differences between these two. Behavior therapy began by
focusing on directly observable, overt behaviors and their interactions with the
directly observable, immediate physical and social environment. This focus
derived from the behavioral change principles of operant conditioning
(Thorndike and Skinner) and respondent conditioning (Pavlov) that came out
of learning experiments with animals, such as dogs, cats, pigeons, and rats, in
which cognition was generally not considered (Davison & Neale, 1990). In con-
trast, cognitive therapy in the work of theorists such as Beck (1963), Ellis (1962),
and Mahoney (1974) is based on the assumption that “the human organism
responds primarily to cognitive representations of its environments rather than
to these environments per se” (Kendall & Bemis, 1983). This way of thinking is
rooted in experiments in cognitive psychology with human beings who—unlike
experimental animals—have highly developed languages for capturing complex
and nuanced meanings and representations of the world. Thus, the focus in cog-
nitive therapy is on the personal meaning of the environment to an individual
rather than to the objective characteristics of those environments per se.
Hayes (e.g., Hayes, Masuda, Bissett, Luoma, & Guerrero, 2004) pro-
posed that the original focus on observable behavior and the objective envi-
ronment be considered a “first wave” in behavior therapy and that the
subsequent focus on cognitive representations of the environment be consid-
ered a “second wave.” Hayes has also been a leader in a new approach, which
he calls a “third wave” of behavior therapy, that focuses on internal cognitive
processes, like the second wave, but views the focus of understanding on how
these processes are functionally related to the objective environment, like the
102 FISHMAN, REGO, AND MULLER

first wave. In addition, third-wave behavior therapy emphasizes the distinctive
theme of a client learning to accept certain aspects of his or her behavior, cog-
nitions, feelings, or a combination of these. Adopting Hayes’s terminology,
this chapter primarily concentrates on first-wave and third-wave movements
in behavior therapy, whereas another chapter focuses on second-wave cogni-
tive therapy. Specifically, in the first part of the chapter, we focus mainly on
first-wave developments; in the second part, we address contemporary trends,
focusing primarily on third-wave developments together with a consideration
of the interrelationships among the three waves.
With regard to terminology, we use the term behavior therapy to refer to
all three waves of the field or just to first-wave behavior therapy, depending
on the context; the term cognitive therapy, or cognitive behavior therapy, to refer
to second-wave behavior therapy; and the term third-wave behavior therapy to
refer to that particular movement.
LEARNING THEORY BEGINNINGS
Behavior therapy as it is known today began to emerge in the 1950s. How-

ever, its origins can be traced to the Enlightenment, the period of European his-
tory emphasizing reason and scientific study of the natural world. For example,
the British empiricists, who spanned the period from 1600 to 1900, emphasized
four main principles: (a) that knowledge comes from experience with the world
rather than introspective rumination or divine inspiration; (b) that scientific
procedures have to be based on systematic observation rather than opinion,
intuition, or authority; (c) that the mind of the child is a blank slate (tabula
rasa) on which experience writes, so that adult mental life is primarily a record-
ing and unfolding of the previous environmental and experiential history of the
person; and (d) that consciousness is best viewed in terms of “mental chemistry”
in which thoughts can be broken down into basic elements connected through
various laws—such as continuity, similarity, and contrast—into more complex
ideas (Kimble, 1985).
These principles of the British empiricists were linked to the thinking
of the early psychologist J. B. Watson, who is frequently viewed as launch-
ing the system of behaviorism. The birth of this movement was marked by
Watson’s 1913 manifesto in the Psychological Review, titled “Psychology as
the Behaviorist Views It”:
Psychology as the behaviorist views it is a purely objective branch of nat-
ural science. Its theoretical goal is the prediction and control of behavior.
Introspection forms no essential part of its methods, nor is the scientific
value of its data dependent on the readiness with which they lend them-
selves to interpretation in terms of consciousness. The behaviorist, in his
BEHAVIORAL THEORIES OF PSYCHOTHERAPY 103

efforts to get a unitary scheme of animal response, recognizes no dividing
line between man and brute. The behavior of man, with all of its refine-
ment and complexity, forms only a part of the behaviorist’s total scheme
of investigation. (p. 158)
Thus, according to Watson, if psychology were to become a science, it
must become materialistic (as opposed to mentalistic), mechanistic (as opposed
to anthropomorphic), deterministic (as opposed to accepting of free will), and
objective (as opposed to subjective). For example, Watson viewed thinking as
“laryngeal habits,” that is, tiny movements of the vocal chords.
During this period Pavlov demonstrated that dogs could learn to sali-
vate at the ringing of a bell through a process of contiguous associations
between the bell and direct access to food. Thus, a previously neutral stimulus
(the bell) could become a conditioned stimulus because of its association with
an inherently positive, “unconditioned” stimulus (the meat powder). Likewise,
this process could include a previously neutral stimulus (e.g., the sight of a
stove) becoming a negative stimulus if associated with an inherently negative
stimulus (e.g., the burning of one’s finger on the stove).
Another closely related development was the establishment in 1913 of
Thorndike’s general principles of human and animal learning. Cats learned to
escape from a puzzle box to obtain release or bits of food as rewards. Studies
such as these led to the formulation of Thorndike’s (1911) law of effect:
Of several responses made to the same situation, those which are accom-
panied or closely followed by satisfaction of the animal will, other things
being equal, be more firmly connected with the situation, so that, when
it recurs, they will be more likely to recur; those which are accompanied
or closely followed by discomfort to the animal will, other things being
equal, have their connections with that situation weakened, so that,
when it recurs, they will be less likely to occur. . . . By a satisfying state of
affairs is meant one which the animal does nothing to avoid, often doing
such things as to attain and preserve it. (pp. 244–245)
Pavlovian classical conditioning and Thorndike’s (and, later, Skinner’s)
operant conditioning, in which the subject is rewarded for making the desired
response and punished whenever an undesired response is elicited, became
the foundation of behavioral learning theory for the next 50 years.
FORMATION OF BEHAVIOR THERAPY AS A DISTINCT MOVEMENT
In the first article devoted exclusively to behavior therapy in the Annual

Review of Psychology, Krasner (1971) suggested that 15 streams of develop-
ment came together during the 1950s and 1960s to form this new approach
to behavior change. These streams may be summarized as follows:

1. the concept of behaviorism in experimental psychology;
2. the operant conditioning work of Thorndike and Skinner;
3. the development of Wolpe’s (1958) systematic desensitization;
4. the emergence of behavior therapy as an experimental science
at the University of London Institute of Psychiatry, Maudsley
Hospital, under the direction of Eysenck;
5. the application of conditioning and learning concepts to human
behavior problems in the United States from the 1920s to
the 1950s;
6. the interpretation of psychoanalysis in terms of learning theory
(e.g., Dollard & Miller, 1950);
7. the application of Pavlovian principles in explaining and chang-
ing both normal and deviant behavior;
8. theoretical concepts and research studies of social role learning
and interactionism in social psychology and sociology;
9. research in developmental and child psychology emphasizing
vicarious learning and modeling;
10. social influence studies of demand characteristics, experimenter
bias, hypnosis, and placebo;
11. an environmentally based, social-learning model as an alterna-
tive to the disease model of human behavior (Bandura, 1969;
Ullmann & Krasner, 1965);
12. dissatisfaction with the prevailing psychoanalytic model, par-
ticularly as articulated in Eysenck’s (1952) critical empirical
study of therapy outcome;
13. the development of the idea of the clinical psychologist as a
scientist–practitioner;
14. a movement within psychiatry away from the orthodox focus
on internal dynamics and pathology toward human interac-
tion and environmental influence; and
15. a Utopian emphasis on the planning of social environments to
elicit and maintain the best of human behavior (e.g., Skinner’s
[1948] Walden Two).
As Krasner (1982) pointed out, these streams of development were neither
independent nor static, and, as we shall show, new streams of influence are
continually emerging.
From an earlier perspective, in the United States the possibility of
explaining behavioral abnormalities in conditioning terms was first outlined
in the 1910s and 1920s (e.g., Dunlap, 1932/1972; Watson, 1924), with the
1930s through the 1950s exhibiting many attempts to explore the nature of
neurosis by inducing so-called neurotic behavior in various animals such as
the pig (Liddell, 1958) and the cat (Masserman, 1943; Wolpe, 1952). Of note

at this time from a practical point of view was the application of conditioning
concepts to the development of a method to prevent a child’s bed-wetting by
O. H. Mowrer and W. M. Mowrer (1938). In the procedure, a special pad with
an alarm bell was placed under the child during sleep. The moment any mois-
ture reached the pad, the alarm bell was triggered. The feeling of a full blad-
der (a conditioned stimulus) was then automatically paired with an alarm (an
unconditioned stimulus) that woke the child. Over time, the feeling of a full
bladder became associated with waking up.
Within universities, the integration of experimental research with clin-
ical procedures, coupled with a general dissatisfaction with prevailing psycho-
dynamic formulations, led to the development of behavior therapy as a viable
psychological intervention. As recounted from the personal experience of
Cyril Franks, a coauthor of the first edition of this chapter (Fishman & Franks,
1992), one notable origin of these developments was in the United Kingdom
at the Maudsley Hospital, the physical home of the University of London
Institute of Psychiatry, in the clinical psychology unit headed by Hans Eysenck.
At that time, the only available and generally acceptable form of psychotherapy
was based on psychoanalytic models carried out under the supervision of a
physician; the conceptual context of treatment was the medical model, which
views mental and emotional problems as diseases for which an “etiology” had
to be found, leading to some form of “treatment” and the possibility of a “cure.”
The clinical psychologist, as a nonmedical professional, was seen, at best, as
a useful ancillary worker.
In this context, clinical psychologists began to question the utility of
spending years studying a body of knowledge that stressed the methodology of
the behavioral scientist only to find that their professional work rested on the
goodwill and psychodynamic tutelage of physicians. Moreover, on the basis of
their rigorous training as behavioral scientists, the Maudsley psychologists
developed critiques of the reliability, validity, and general utility of traditional
psychiatric diagnoses; of the psychometric viability of the psychodynamically
based tests they were required to use in their assessment role; and of the effi-
cacy of psychodynamic therapy. These psychologists concluded that a prom-
ising alternative that avoided all these problems was stimulus–response (S-R)
learning theory—in particular, the work of Pavlov, which was rooted in sci-
entific experimentation and rigorous data collection and analysis. The goal
was learning theory–based assessment and intervention grounded in the idea
that psychopathological behavior was learned like any other behavior and
that it could be unlearned (i.e., changed or eliminated) by using the proper
learning principles. So it was that the concept of behavior therapy was born
(Franks, 1987).
Over the years, Eysenck’s many students established Maudsley enclaves
and offshoots throughout the world, with accomplishments such as publication

of the first behaviorally based textbook of abnormal psychology (Eysenck, 1960)
and one of the first collections of case studies in behavior therapy (Eysenck,
1964). This group was also responsible for the creation of the first journal
devoted exclusively to behavior therapy, Behaviour Research and Therapy, and
the invention of a name for this treatment, behavior therapy. (See Eysenck’s
1990 autobiography for a more detailed account of these events.)
During the late 1950s and early 1960s, a parallel development was
proceeding in South Africa led by a Johannesburg physician dissatisfied with
both the theory and clinical usefulness of psychodynamic concepts. First
in South Africa, and later in the United States, Joseph Wolpe (1958) used
Pavlovian principles to develop his widely disseminated psychotherapy by
reciprocal inhibition and the technique of systematic desensitization for the
treatment of fears. Wolpe’s ideas were pragmatically expanded by his South
African colleague Arnold Lazarus to new populations, such as school phobia
(Lazarus, 1959), and in new formats, such as group therapy (Lazarus, 1961).
In Wolpe’s systematic desensitization technique, the patient first learns
how to achieve a state of deep muscle relaxation (Jacobson, 1938). Then a
hierarchy of specific situations and scenes related to the patient’s fear is
created in terms of intensity of anxiety elicited by the situation. For example,
a patient with agoraphobia might assess being near the door of his or her house
as mildly anxiety arousing, walking in the neighborhood as moderately anxi-
ety arousing, and driving 10 miles from home as extremely anxiety arousing—
with a variety of associated situations filling in points along the hierarchy. The
therapist then begins the formal desensitization process. In it, the client first
engages in progressive muscle relaxation and then imagines the mildest scene
on the hierarchy that elicits anxiety. After 5 seconds or so, this experience is
followed by a period of terminating the scene image and returning to a state of
relaxation, such that the patient starts to learn to associate relaxation rather
than anxiety to the previously feared situation. Each scene in the hierarchy is
repeated until the patient reports experiencing virtually no anxiety while visu-
alizing it. In this way, the patient works his or her way stepwise through the
complete hierarchy.
Systematic desensitization was the first viable “talk therapy” alternative
to traditional psychodynamic forms of psychotherapy. Before the advent
of systematic desensitization, conditioning was applied exclusively to animals,
small children, seriously impaired individuals, or perhaps those suffering from
a highly focalized disorder. Now, an alternative to psychodynamic therapy
became available, an alternative that could be meaningfully and efficiently
applied to the sophisticated patients who came to a mental health profes-
sional’s private office for treatment of complex problems. In the years since,
Wolpe’s laborious procedures have been modified many times as a result of sub-
sequent study. However, their practical significance remains undiminished.

The 1950s and 1960s was a pioneering era characterized by ideology and
polemics in which behavior therapists strove to present a united front against
the common psychodynamic “foe.” As behavior therapy established itself in the
1970s as a respected treatment, behavior therapists gradually abandoned their
missionary zeal and searched for new frontiers within which to extend their
approach. These included outpatient psychotherapy practice, biofeedback,
health psychology, community psychology, and the worlds of business, admin-
istration, and government. For example, jobs were subjected to careful, system-
atic analysis, comparing those behaviors that were actually rewarded by salary
and promotions against those that were most desirable for achieving the goals
of the overall organization. By changing incentive systems, work behaviors
could then be brought into closer correspondence with organizational objec-
tives (Gilbert, 1978). It was an era of intellectual expansion into concepts,
methods, and ways of viewing data beyond those of traditional learning theory.
As mentioned earlier, it was also the era that ushered in the second wave of
behavior therapy—the rise of CBT—in part a reflection of the cognitive revo-
lution in psychology as a whole (Baars, 1986).
EMERGENCE OF SUBMOVEMENTS
In the 1970s, behavior therapy began to cohere into more or less dis-
tinct streams, all sharing a common methodological and learning theory core.
At least five were noteworthy (see Wilson & Franks, 1982). The first three
were applied behavioral analysis, a neobehavioristic S-R model, and psycho-
logical behaviorism. All three led to interventions that would fall into the
category of first-wave behavioral theories. The second two—social learning
theory and cognitive theory—fall into the more cognitively focused second
wave. All five continue to exist in some form today.
Applied behavior analysis (e.g., Austin & Carr, 2000) describes the
application of principles derived from Skinner’s operant conditioning to a
wide range of clinical and social problems, particularly mental retardation,
autistic spectrum disorders, and brain injury. For the most part, applied behav-
ior analysts are radical behaviorists, that is, their basic assumption is that behav-
ior is a function of its consequences and not of the individual’s particular
interpretation of the environment. There are few intervening variables, men-
talistic inferences are disavowed, and treatment methods are evaluated prima-
rily in terms of quantitative, single-case experimental designs in which the
participant serves as his or her own control. The emphasis is on the manipu-
lation of environmental variables to bring about behavioral change and on
the use of laboratory-based principles, such as reinforcement, punishment,
extinction, and stimulus control.

The neobehavioristic–mediational S-R model (Wilson & Franks,
1982) is particularly connected with the works of Pavlov, Mowrer, and
Wolpe. Intervening variables and hypothetical constructs are acceptable,
and publicly unobservable processes, such as the imaginal representation of
anxiety-eliciting stimuli in systematic desensitization, are accepted and
even encouraged.
Psychological behaviorism, which was originally called social behavior-
ism and then paradigmatic behaviorism by its developer Staats (1975, 1988),
emphasizes the integration of conditioning theory with traditional concepts
in personality, clinical, and social psychology (Staats, 2005). Staats viewed
the principles of reinforcement and contiguity as always present and inter-
acting in the development of personality, with operant conditioning
affecting overt behavior patterns and classical conditioning affecting emo-
tional and cognitive response patterns. Staats’s concept of cumulative–
hierarchical learning and development explains how complex combina-
tions of simple behaviors learned by basic conditioning can evolve, over
time, into three complex personality repertories of responses: sensory–
motor, emotional–motivational, and language–cognitive. Staats applied
the principles of conditioning to all areas of traditional psychology, including
such clinically relevant domains as personality assessment, psychopathology,
and psychotherapy.
Social learning theory, developed by Albert Bandura and his colleagues
(e.g., Bandura, 1969), constitutes, along with the cognitive theory (e.g.,
Beck, 1963), the mainstream of second-wave, contemporary, CBT. In its
more advanced form (e.g., Bandura, 1982), social learning theory is interac-
tional, interdisciplinary, and multimodal. Behavior is influenced by stimulus
events (primarily through classical conditioning), by external reinforce-
ment (through operant conditioning), and by cognitive mediational processes.
Behavior change is brought about largely through observational learning, a
process in which people are influenced by observing someone else’s behav-
ior. The term model is reserved for the exemplar, the person who demon-
strates the behavior that the observer views. Live modeling occurs when the
exemplar is directly seen, whereas symbolic modeling takes place when
the model is observed indirectly, as in movies, on television, by reading,
through an oral description of someone else’s behavior, or even by imagin-
ing a model’s behaviors. Social learning emphasizes reciprocal interactions
between the individual’s behavior and the environment. The individual is
considered capable of self-directed behavior change. Bandura’s theory of
perceived self-efficacy was one of the first major attempts to provide a uni-
fied theoretical explanation of how behavior therapy and other psychother-
apies work. Self-efficacy is the individual’s belief or expectation that he or
she can master a particular situation and bring about desired outcomes. It

is viewed as a common cognitive mechanism that mediates the effects of all
psychological change procedures; that is, these procedures are postulated to
be effective because they create and strengthen a client’s expectations of
personal efficacy.
Cognitive theories, especially those developed by Beck (e.g., 1963),
Ellis (e.g., 1962), and Mahoney (e.g., 1974), emphasize the central role
of cognitive processes and private events as mediators of behavior change,
as nicely summarized into six basic assumptions (Kendall & Bemis, 1983,
pp. 565–566):
1. the human organism responds primarily to cognitive represen-
tations of its environments rather than to these environments
per se;
2. most human learning is cognitively mediated;
3. thoughts, feelings, and behaviors are causally interrelated;
4. attitudes, expectances, attributions, and other cognitive activ-
ities are central to producing, predicting, and understanding
psychopathological behavior and the effects of therapeutic
interventions;
5. cognitive processes can be cast into testable formulations that are
easily integrated with behavioral paradigms, and it is possible and
desirable to combine cognitive treatment strategies with enactive
techniques [such as behavioral rehearsal] and behavioral contin-
gency management; and
6. the task of the cognitive–behavioral therapist is to act as diag-
nostician, educator, and technical consultant, assessing mal-
adaptive cognitive processes and working with the client to
design learning experiences that may ameliorate these dysfunc-
tional cognitions and the behavioral and affective patterns with
which they correlate.
As we discuss subsequently, today these five submovements have coa-
lesced into two broader movements characterized by the different waves
in the field just discussed. Specifically, applied behavior analysis and the
neobehavioristic S-R model have coalesced into the first wave and psycho-
logical behaviorism, social learning theory, and cognitive theory into the
second wave. As mentioned earlier, a third wave has also emerged, led by
Marsha Linehan’s dialectical behavior therapy (DBT) and Steven Hayes’s
acceptance and commitment therapy (ACT). The third wave represents a
creative integration of Skinner’s radical behaviorism and other behavioral
principles with concepts from cognitive, experiential, and Eastern approaches,
emphasizing acceptance, mindfulness, cognitive defusion, dialectics, spir-
ituality, and relationship. In addition, their therapeutic methods often

use more experiential techniques and place a greater emphasis on contex-
tual factors.
WORLDWIDE ORGANIZATION OF BEHAVIOR

AND COGNITIVE THERAPY
Behavior therapy, together with cognitive therapy, CBT, and the more
recent third-wave therapies, has grown into a large, worldwide movement.
The largest behavior therapy association in the United States, the Associa-
tion for Behavioral and Cognitive Therapies (ABCT; http://www.abct.org)
is more than 40 years old, and in 2009 had more than 5,000 members (approx-
imately 60% professionals and 40% students). It embraces practitioners,
researchers, trainers, and students of both traditional behavior therapy and
CBT, as well as the newer third-wave approaches. The largest association of
applied behavior analysts in the United States is the Association for Behav-
ior Analysis International (ABAI; http://www.abainternational.org), which
has a membership of approximately 4,500 in the United States and 7,000 in
its 29 non-U.S. affiliated chapters.
The European Association for Behavioural and Cognitive Therapy
(EABCT; http://www.eabct.com) was formally established in 1976 and brings
together 41 individual associations from 29 countries. EACBT includes
25,000 individual clinician and researcher members.
There have been 12 World Congresses devoted to behavior therapy (the
first held in 1980), cognitive therapy (the first in 1983), or—since 1992—a
combination of cognitive and behavior therapies. Run by a World Congress
Committee (WCC; http://www.wcbct.org/index.htm), the last World Con-
gress of Behavioural and Cognitive Therapies as of this writing was held in
Barcelona in 2007, with an attendance of more than 1,000; the next is
planned for Boston in 2010. The WCC was established by mutual agreement
of seven organizations, each of which is represented on the WCC, including
ABCT, EABCT, the Australian Association for Cognitive and Behaviour
Therapy, La Asociación Latinoamericana de Análisis y Modificación del
Comportamiento, the International Association of Cognitive Psychotherapy,
the Japanese Association of Behavior Therapy, and the South African Behav-
iour Therapy Association.
Finally, a large number of journals, many in English, are devoted prima-
rily or exclusively to behavior therapy in all its various waves. For example,
in Thomson Reuters’s ISI Web of Knowledge (2009) listing of important,
English-language journals in clinical psychology, there are 14 such journals
(16%) among the 87 listed. Those among the 14 with the top three highest
5-year citation impact factors in English are Behaviour Research and Therapy,

Journal of Behavior Therapy and Experimental Psychiatry, and Cognitive Therapy
and Research.
DEFINITIONS OF BEHAVIOR THERAPY
Interestingly, the term behavior therapy was introduced more or less inde-
pendently by three widely separated groups of researchers: (a) by Skinner,
Solomon, and Lindsley in the United States in a 1953 status report to refer
to their application of operant conditioning to increase simple social behav-
iors in chronically hospitalized psychotic patients; (b) by Lazarus (1958) in
South Africa to refer to Wolpe’s application of his reciprocal inhibition tech-
nique to neurotic patients; and (c) by Eysenck’s (1959) Maudsley group in
the United Kingdom to describe their “new look at clinical intervention” in
which “behavior therapy” was defined as the application of modern learning
theory to the understanding and treatment of behavioral disorders.
Many authors (e.g., Erwin, 1978; Franks, 1990; O’Leary & Wilson,
1987; Spiegler & Guevremont, 2003) have pointed out that it is difficult to
articulate a succinct definition of contemporary behavior therapy that does
justice to the field. The definitional dilemma results from the fact that behav-
ior therapy, like many areas in the behavioral sciences, consists of a series of
overlapping domains, as represented in the five circles of Figure 4.1 (Fishman,
1988). The first four circles include the following:
1. therapeutic principles derived from operant and respondent
learning theory principles;
2. therapeutic principles derived from experimental psychology,
including cognitive psychology;
3. therapeutic techniques originated by behaviorally oriented
clinicians, such as contingency contracting and systematic
desensitization; and
4. ideas and strategies adapted from the general psychotherapy
literature, such as the relationship-enhancement methods of
Rogerian therapy that have been further developed by experi-
ential therapists (e.g., Elliott, Watson, Goldman, & Greenberg,
2003) and therapy process models taken from systems theory
(e.g., Kanfer & Schefft, 1988).
In Figure 4.1, the partial overlap among the circles is noteworthy. For
example, Circle 3 only partially overlaps Circles 1 and 2. This reflects the fact
that some of the techniques in Circle 3, such as contingency contracting, are
clearly deducible from the contemporary experimental principles associated
with Circles 1 and 2, whereas other accepted techniques in Circle 3, such as

Figure 4.1. The overlapping domains of the behavioral movement. From
Paradigms in Behavior Therapy: Present and Promise (p. 268), edited by
D. B. Fishman, F. Rotgers, and C. M. Franks, 1988, New York, NY: Springer.
Copyright 1988 by Springer Publishing Company. Reprinted with permission.
systematic desensitization, are not (Wilson & O’Leary, 1980). As another

example, Circle 4 overlaps only parts of Circles 1, 2, and 3. This reflects the
fact that, although some of the approaches from general psychotherapy, such
as goal setting, are clearly deducible from traditional behavioral techniques
and contemporary experimental principles, others, such as client-centered
relationship facilitation, are not.

Circle 5 embraces the other four and involves the methodological princi-
ples of behavioral science, such as empiricism, operational definition, quantifi-
cation, and experimental research design. As we describe in the next section,
these principles can be framed in epistemological terms either within the pos-
itivist paradigm (traditional experimental science) or within the alternative
epistemology of pragmatism and social constructionism (Fishman, 1988).
As an example of Circle 5, consider how behavior therapy experienced
the addition of cognitive approaches into its purview. Cognitive therapy deals
with internal experiences that are more inferential and can be only indirectly
observed, and thus requires a stretch of behavioral emphases on overtly observ-
able actions. However, cognitive behavioral therapists are more committed
than other therapists to linking these internal cognitive phenomena—even at
a deep, “underlying” level (Persons, 2008)—to overt behavioral and environ-
mental referents. Also, in concert with behavior therapy and unlike insight-
oriented therapies, cognitive therapy focuses primarily on present interactions
and relationships rather than developmentally historical ones, for the latter
are particularly difficult to link directly to observable behavioral and environ-
mental data. Finally, cognitive therapy is similar to behavior therapy in pre-
ferring relatively “value neutral” data and phenomena that involve less
emotionally and socially loaded concepts and that are “nearer” to the empiri-
cal data. Thus, cognitive therapy favors more observationally based and less
inferential data that is more likely to be agreed on by different observers.
Recognizing the difficulty of succinctly defining behavior therapy,
O’Leary and Wilson (1987) provided a useful list of nine common “core”
assumptions that behavior therapists hold. In our view, these beliefs are held
by the majority of contemporary behavior therapists:
1. Most abnormal behavior is acquired and maintained according
to the same principles as normal behavior.
2. Most abnormal behavior can be modified through the applica-
tion of social learning principles.
3. Assessment is continuous and focuses on the current determi-
nants of behavior.
4. People are best described by what they think, feel, and do in
specific life situations.
5. Treatment methods are precisely specified, replicable, and
objectively evaluated.
6. Treatment outcome is evaluated in terms of the initial induction
of behavior change, its generalization to the real life setting, and
its maintenance over time.
7. Treatment strategies are individually tailored to different prob-
lems in different individuals.

8. Behavior therapy is broadly applicable to a full range of clinical
disorders and educational problems.
9. Behavior therapy is a humanistic approach in which treatment
goals and methods are mutually contracted [between client and
therapist]. (O’Leary and Wilson, 1987, p. 12)
Another way of broadly summarizing the distinctive themes of behav-
ior therapy is represented by Kanfer and Schefft’s (1988) six “think rules” that
help to capture important attitudes and skills that behavior therapists model
and teach their clients. These include the following:
䡲 Think Behavior—Assist the client to redefine problems [and
goals] in terms of [concrete] behaviors [rather than in abstract
concepts like traits, e.g., “My goal is to overcome my social anx-
iety by meeting with non-family members at least once a week
in nonwork situations” rather than “My goal is to overcome my
social anxiety by trying to understand why I’ve always been
such a shy, withdrawn person.”].
䡲 Think Solution—Get the client to ask continuously, “What is
the least I can do to improve the situation?”
䡲 Think Positive—Have the client identify personal strengths and
the positive aspects of any event or change effort.
䡲 Think Small Steps—Set limited goals to enhance the probability
of success and permit continuing reappraisal.
䡲 Think Flexible—Help the client to develop alternatives and
back-up plans and to be prepared for the unexpected.
䡲 Think Future—Focus on the future and encourage rehearsal and
planning. (Kanfer & Schefft, 1988, p. 122)
A METATHEORY OF CONTEMPORARY BEHAVIOR THERAPY
A theory in psychology is a conceptual framework that identifies impor-

tant dimensions of human experience and behavior and that describes rela-
tionships among these dimensions. A metatheory is a fundamental viewpoint
that stands “behind,” or logically prior to, the theory. Thus, a metatheory
consists of those assumptions that are made before the creation, validation,
and refinement of a specific theory.
Table 4.1 presents an overview of the metatheoretical location of earlier
and later versions of behavior therapy, relative to other systems of psycho-
therapy and applied psychology theory. The table thus highlights the different
underlying assumptions among therapy systems. It is organized as a grid formed
by two cross-cutting typologies of metatheoretical assumptions: epistemological

TABLE 4.1
Metatheoretical Location of Behavior Therapy Within Applied Psychologya
Epistemological paradigm
Logical positivism Social constructionism
Dominant
theoretical Positivist Pragmatic Hermeneutic
worldview paradigm paradigm paradigm
Trait McCrae & Costa’s Psychometric Freud’s theory of

(2003) five- polling models oral, anal, and
factor theory of for predicting phallic character
personality voter preferences types (e.g., Freud,
in presidential 1924)
elections (e.g.,
Zogby Inter-
national, 2008).
Interactional Earlier and later Later behavior ther-
behavior therapy apy theory only
theory
Organismic General systems Program evaluation Structural family
theory as applied theory (e.g., therapy theory
to living systems Patton, 2008) (e.g., Minuchin,
(e.g., Miller, 1978) 1974)
Transactional Qualitative research Constructivist
(Patton, 2002) psychotherapy
theory (Neimeyer
& Mahoney, 1995)
a
Empty cells involve logically incompatible perspectives and thus cannot support viable theories.
paradigms (divided into the positivist, pragmatic, and hermeneutic; Fishman,

1999) and worldviews (divided into trait, interactional, organismic, and
transactional; Altman & Rogoff 1987). (Note that the discussion that fol-
lows focuses on the position of behavior therapy in Table 4.1. For more
details about how the nonbehavioral examples of applied psychology fit into
Table 4.1 and for more details about the table generally, see Fishman &
Franks, 1992.)
Epistemological Paradigms
Epistemology is the branch of philosophy that investigates the origins,

nature, methods, and limits of human knowledge. An epistemological para-
digm sets forth the criteria according to which the relevance and validity of
a particular body of knowledge are judged. In other words, philosophically
speaking, no knowledge is given in any absolute sense. Rather, a variety of
possible, coherent epistemological systems are set forth, and the evaluation
of a statement’s truth or falsity will depend, in part, on the epistemological

criteria chosen for the evaluation and not just on the content of the state-
ment per se (Fishman, 1999; Gergen, 1985).
Until recently, American psychology was dominated by the epistemol-
ogy of conventional natural science, that of logical positivism. In broad terms,
logical positivism contends that there is an external world independent of
human experience and that objective, “scientific” knowledge about this world
can be obtained through direct sense experience, as interpreted within the
framework of theory-embedded, hypothesis-testing laboratory experiments.
The data on which this knowledge is founded consist of discrete, molecular,
sensorily based “facts,” all of which can eventually be quantified. Knowledge
is in the form of a cumulative body of context-free, universal laws about the
phenomenon studied. Psychologists who have adopted a positivist perspec-
tive generally assume that the universal laws that emerge from scientific study
will have a form such that they can eventually be applied to help solve signif-
icant psychological and social problems in a unique, rationally based manner.
In contrast to logical positivism, social constructionism posits that the real-
ity of an individual or group experience is, to a substantial degree, conceptually
constructed rather than sensorily discovered by that group. Objective knowledge
about the world is significantly limited because “facts” and “raw data” can be
known only within a particular, pre-empirically established cultural, social, and
linguistic context. As reflected in Table 4.1, social constructionism has encour-
aged the growth of two types of nonpositivist epistemological paradigms. The
more radical is a hermeneutic paradigm that emphasizes qualitative interpre-
tation, experiential and symbolic meaning, a place for subjectivity and intu-
ition, and a historically situated psychology. This model views the goals and
proper methods of psychology as similar to those of history, literary criticism,
and investigative reporting (Messer, Sass, & Woolfolk, 1988).
The alternative approach spawned by social constructionism is that of
the pragmatic paradigm (Fishman, 1999, 2005; Polkinghorne, 1992), a hybrid
between the experimental and hermeneutic approaches. Like the hermeneu-
tic paradigm, the pragmatic paradigm is based on social constructionism and
rejects the theory-based laboratory experiment and the search for general psy-
chological laws, advocating instead for contextually embedded, case-based
knowledge. However, like the experimental paradigm, the pragmatic paradigm
values a quantitative, atomistic, observational approach and adapts some of the
research methods of the laboratory into quasi-experimental and single-subject
research designs.
The origins of the behavior therapy movement are clearly embedded in
logical positivism. Watson’s original model for behavioristic theory was that
of experimental animal psychology, and this model was continued by Hull,
Skinner, Tolman, Guthrie, and other learning theory researchers in the
so-called Age of Grand Theory (Kimble, 1985). Applying the model of physics

and chemistry, these researchers assumed that there are a few basic, universal
laws of learning that apply to both animals and humans. In line with this view,
these researchers pursued scientific psychology by focusing on publicly observ-
able, circumscribed behaviors such as the food-seeking activities of white mice
or pigeons under controlled laboratory conditions. As also shown in Table 4.1,
whereas some groups in later behavior therapy theory have remained within the
experimental paradigm (Baars, 1986; Wilson & Franks, 1982), others have
moved away from the experimental epistemological paradigm into the pragmatic
paradigm (Fishman, Rotgers, & Franks, 1988).
There are at least three reasons that many behavior theorists have moved
from the experimental to the pragmatic paradigm. First, as behavior therapy
began in the 1960s, the experimental paradigm was coming to an unsuccess-
ful end. Its demise was derived in large part from the failure of animal-based
learning theorists to agree on a single theory and the failure to apply and val-
idate models of learning theory to complex human behavior in rigorous ways
(Baars, 1986; Erwin, 1978; Kimble, 1985). A second reason came from the
experiences of most behavior therapy practitioners. They discovered that they
could practice effectively without having to show a tight link between their
practices and the experimental literature (e.g., Hayes, Barlow, & Nelson-Gray,
1999). A third reason for behavior therapy’s movement away from the exper-
imental paradigm, beginning in the 1960s, was the loss of support for logical
positivism in the philosophical community (Erwin, 1978; Fishman, 1999).
One of the clearest and most explicit, early statements of the move
by behavior therapists toward the pragmatic paradigm was made by Azrin
(1977). This applied researcher began his career solidly aligned with the
positivist paradigm but was led to an identification with the pragmatic par-
adigm after focusing on the development of effective change programs for
significant human problems in areas such as controlling aggression, toilet
training, marital adjustment, alcoholism, tics, and job finding. In line with
the pragmatic paradigm, Azrin took his measurement methods from the
experimental tradition, but the substance of what he did was pragmatically
focused, with an emphasis on emergent clinical techniques and practical
success with specific problems in specific situations, not on the derivation
of theory-based, general laws.
In a similar vein, an early, important textbook on behavior therapy by
Spiegler (1983) also reflects pragmatic thinking. He described his approach
as “operational,” viewing behavior therapy “in terms of how it functions and
what it accomplishes (rather than in terms of theoretical explanations of why
it works)” (Spiegler, 1983, p. xvii).
Also around this time, Edwin Erwin (1978), a philosopher of behavior
therapy, argued on epistemological grounds against the positivist view of
behaviorism, which asserts that in principle, only publicly observable behav-

ior is worthy of scientific study. Rather, Erwin introduced the concept of
“pragmatic behaviorism,” which he defined as
the philosophical assumption that clinical problems should generally be
analyzed in behavioral terms. . . . In treating a client, behavioral counter-
parts should generally be sought that correlate with (but are not equiva-
lent to) any relevant problematic mental state. Treatment should focus
primarily on behavior, not because the mind is behavior, but for practi-
cal reasons. . . . It may be of some use to learn, for example, that an obese
patient has a craving for food, but it is even more useful to learn how
many eating responses are engaged in each day and under exactly what
conditions. (1978, p. 80)
Building on this view and that of Mahoney (1974), Fishman (1988)
defined pragmatic behaviorism in terms of a commitment to a variety of
methodological principles for the conduct of behavior therapy, as embodied
in Circle 5 in Figure 4.1. These principles include an emphasis on (a) empiri-
cism; (b) variables that are objective, specific, and concrete; (c) the analysis
of problems into smaller parts to be dealt with one at a time; (d) quantifica-
tion; (e) a view of behavior as a sample (rather than a sign) of personality;
(f ) functional analysis of the relationship between behavior and the environ-
ment; and (g) linkage of all cognitive and affective variables used to behav-
ioral and environmental referents.
Worldviews
On the basis of the work of philosophers John Dewey and Steven Pepper,
Altman and Rogoff (1987) posited four distinct worldviews for categorizing the
core content of various types of psychological theories, as shown in Table 4.1.
The trait view—for example, as associated with the well-known five-
factor theory of personality—sees behavior as emerging from the individual.
In other words, individuals act as they do primarily because of their inherent
natures, without much attention to the temporal aspects of behavior or to the
contexts within which the behaviors are embedded.
The interactional view—associated particularly with behavior therapy—
treats the person and the environment as separate underlying entities that
interact in a linear, causal, predictable manner, like the parts of a watch or
dynamo. Psychological phenomena are analyzed in terms of the antecedent
conditions that lead to certain behaviors, which in turn lead to various con-
sequences, which in turn become antecedents for certain subsequent events.
The organismic view—associated particularly with systems theory—
conceives of both the person and the social environment as a system with
complex, reciprocal, and dynamic relationships and influences among its var-
ious parts and subsystems. Change usually occurs in accord with underlying

regulatory mechanisms such as homeostasis and long-range directional
teleological mechanisms (e.g., psychological development from birth to
adulthood).
Finally, the transactional view emphasizes the role of varying perspec-
tives on a particular purposive action or pattern of such actions in a person’s
life, such as deciding to apply to graduate school or to go out on a date. The
act is viewed as intrinsically embedded in the individual’s surrounding life
context and unfolding in time. Thus, the event is viewed as a complex and
holistic phenomenon.
Although behavior therapy began as narrowly focused within a posi-
tivist interactional worldview, over time the field has branched out to add
interactional view components from the other worldviews to its root. Brief
illustrations of the root and its branches follow.
Interactional Theories
Perhaps the clearest examples of pure, interactional theory are Watson’s
behaviorism and the animal-based conditioning research in the Age of Grand
Theory. The metatheory behind both of these projects involves a mechanistic,
billiard-ball, linear causal model that focuses on functional links between pres-
ent environmental stimuli and an organism’s responses. This view was carried
over into the early development of behavior therapy procedures by Skinner,
Solomon, and Lindsley (1953), who applied animal-based operant learning the-
ory to the alleviation of socially unresponsive schizophrenic behavior.
Although cognitive components were present early in behavior ther-
apy’s development in the form of covert conditioning (e.g., Cautela, 1970),
Mahoney (1974) described how this model conformed to the interactional
worldview:
Thoughts, images, memories, and sensations are described as covert stim-
uli, covert responses, or covert consequences. The skull becomes a rather
crowded Skinner box in which such conventional principles as reinforce-
ment, punishment, and extinction are said to describe the function and
patterning of [these covert events]. (p. 61)
Interactional Theories With Trait Components

Persons (1989, 2008) developed a highly recognized theory that empha-
sizes underlying, traitlike mechanisms—such as core beliefs and basic skill
deficits—behind overt dysfunction and distress. Young has developed a typology
of these underlying beliefs and created schema-focused therapy. He posited
five major themes or domains in dysfunctional schemas: Disconnection and
Rejection; Impaired Autonomy and Performance; Impaired Limits; Other-
Directedness; and Overvigilance and Inhibition. More about schema therapy

can be found in the chapter on cognitive therapy and also on the schema
therapy website, http://www.schematherapy.com/id73.htm.
Another example of behavior therapy’s incorporation of trait-based
approaches is its general acceptance of the psychopathology categories embod-
ied in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published
by the American Psychiatric Association.
Interactional Theories With Organismic Components

Because of the importance of the environment in the interactional
approach, and because of the social context of much behavior, behavior ther-
apists became interested early on in social interaction, social relationships, and
the social environment generally. In his 1968 book, Peterson demonstrated
how functional analysis could be applied using a similar perspective for solving
dysfunction in an individual, a family, and a social system (such as a state psy-
chiatric hospital). To show the link between individual and group behavior,
Peterson (1968) pointed out that social interaction (as distinct from the “inter-
actional” worldview)
refers to a class of social phenomena involving mutuality of stimulation and
effect. . . . Explicit behavior by person 1 serves as a stimulus for person 2,
who reacts in some way. This either terminates the interchange or leads to
a further reaction on the part of person 1, perhaps to an action-reaction
chain of indefinite length. . . . [Thus] in his motives and cognitive beliefs,
each person takes the other, who has his own motives and beliefs, into
account. When relatively stable patterns of [social] interaction develop
between two individuals, a relationship has been formed. . . . Groups of
people [socially] interacting can be studied as emergent units. A different
class of phenomena can be examined, and with this a new order of com-
prehension may result. (pp. 82–84)
Many later behavior theorists built on this type of reasoning to integrate
concepts from family systems therapy into cognitive behavior therapy with cou-
ples (e.g., Baucom, Epstein, LaTaillade, & Kirby, 2008) and families. An excel-
lent example of the latter is behavioral-family systems therapy for negotiating
parent-adult conflict (Robin & Foster, 2002). In this therapy, a detailed analy-
sis of contingency arrangements from the interactional, behavioral tradition
provided an excellent starting point for a functional analysis of family mem-
bers’ behavior with each other. This then is combined with organismic ele-
ments to address “the circular nature of [social] interaction patterns and the
hierarchical structure of families, which overlay contingency arrangements”
(Robin & Foster, 2002, p. 7).
In addition, behavior therapists have embedded their principles within
the concepts of community psychology, designing interventions to have an

impact on communities as systems. For example, Henggeler, Schoenwald,
Borduin, Rowland, and Cunningham’s (1998) multisystemic therapy with
antisocial children and adolescents involves managing and reengineering
the antecedent stimuli and consequences of a youth’s total environment
that are associated with acting-out behavior by coordinating with all rele-
vant caregivers (e.g., parents and guardians, school personnel, child welfare
workers, police officers, recreational workers, probation officers, and psy-
chotherapists). In the process, new and more positive social support systems
are created for the youth.
Interactional Themes With Transactional Elements

As mentioned earlier, many behavior therapists have conceptualized
behavior therapy within a social constructionist, pragmatic metatheory (e.g.,
Azrin, 1977; Fishman, 1999; Kanfer & Schefft, 1988; Nelson, 1983; Persons,
2008). A major aspect of this perspective is the emphasis on the contextual
specificity of behavior. The focus is on solving particular problems in particu-
lar situations, not on the derivation of empirically confirmed general laws. This
perspective leads to a focus on the individual case study (Fishman, 1999), which
in turn highlights the fact that each treatment program with a client—be it an
individual, group, or organization—consists of a social interactional process
over time between a particular client and a particular behavior change agent.
This process involves a series of sequential, interdependent steps or
phases. How such phases link with transactional thinking is outlined in Kanfer
and Schefft’s (1988) process model of therapeutic change. It consists of seven
phases: (1) role structuring and creating a therapeutic alliance; (2) developing
a commitment for change; (3) behavioral analysis; (4) negotiating treatment
objectives and methods; (5) implementing treatment and maintaining motiva-
tion; (6) monitoring and evaluating progress; and (7) maintenance, generaliza-
tion, and termination of treatment.
These phases generally take place in an interdependent, sequential
manner, although progress through the phases is not consistently linear. The
evolution of these phases reflects a transactional worldview because, given
the great variety of patterns created by different choice point decisions, each
case brings its own idiosyncratic particularities.
BEHAVIOR THERAPY TODAY
As mentioned in the introductory portion of this chapter, we have organ-

ized the history of behavior therapy into three distinct waves: a first wave that
focuses on functional relationships between observable behavior and the objec-
tive environment; a second wave that focuses on cognitive representations of

the environment rather than on characteristics of the objective environment
per se; and a third wave that encompasses the cognitive processes and inner
experience of the second wave, while focusing on how these internal processes
are functionally related to the objective environment (sometimes called func-
tional contextualism), like the first wave.
Given the separate chapter in this book on second-wave cognitive
therapy, we consider four main topics in the remainder of this chapter: the
status of first-wave behavior therapy, the status of third-wave behavior ther-
apy, contrasts and complementarities between second-wave and third-wave
therapies, and the rediscovery by behavior therapy of the research poten-
tial of the case study.
Today’s First-Wave Behavior Therapy
Today’s first-wave behavior therapy can be organized around individu-

alized assessment and treatment planning for particular, contextualized
behavior problems. The focus (Spiegler & Guevremont, 2003) is on (a) oper-
ationalizing problems and goals in behavioral terms, (b) assessing the main-
taining conditions of the problem behaviors through direct observation and
the functional analysis of their relevant environmental antecedents and con-
sequences, (c) using the assessment to develop a treatment plan, and then
(d) conducting and monitoring the results of implementing the treatment
plan, with revisions of earlier steps made if necessary on the basis of monitor-
ing data. First-wave behavior therapy entails a large menu of techniques and
strategies from which to choose for treatment planning, all directly traceable
to aspects of operant and respondent conditioning principles. These include
procedures such as (a) stimulus control (reducing the antecedent cues that
trigger problematic behavior); (b) differentially reinforcing behaviors for
which increase is desirable through the use of strategies such as contin-
gency contracting and token economies; (c) reducing undesirable behaviors
through aversive punishment and/or nonaversive techniques such as response
cost, overcorrection, and time out; (d) decreasing anxiety through in vivo and
imaginal desensitization; and (e) teaching social and problem-solving skills
through modeling.
A noteworthy example of first-wave behavior therapy is the work
of Gordon Paul and associates (e.g., Paul & Lenz, 1977; Rhoades, 1981).
Although the work was completed between 35 and 40 years ago, it represents
a gold standard for what can be accomplished with a particularly difficult pop-
ulation such as the severely and chronically mentally ill—namely, increasing
patient functioning along with impressive cost savings. That it has rarely been
replicated is, unfortunately, a testament to the power of politics over rational
program design (Rhoades, 1981; for one of the replications, see Silverstein

et al., 2006). Using social learning principles, Paul and colleagues redesigned
and restructured a traditional state hospital ward that housed patients with
chronic schizophrenia who had been hospitalized for an average of 17 years
and who were functioning at such a low level of self-care or who had mani-
fested such excesses in bizarre behavior that they had been rejected for
extended-care community placement. Paul et al. randomly assigned patients
to their social learning program and to a treatment-as-usual (TAU) condi-
tion. After 2 years, 25% of the social-learning patients were indistinguishable
from the normal population on reliable, observation-based measures of self-
care and social functioning (Rhoades, 1981, p. 15). At the end of the pro-
gram, of the 40 social-learning patients who were treated, 36 (90%) were
released to board-and-room homes, and three others (7.5%) achieved self-
supporting, independent living. In contrast, of the 29 patients receiving the
TAU, only 13 (45%) were released to board-and-room homes and none (0%)
to independent living (Rhoades, 1981, p. 3). Because of the lower cost of non-
hospital alternatives, the social-learning program was found to be 4 times as
cost-effective as TAU (Rhoades, 1981).
Paul’s success was based on extending operant principles in an explicit,
systematic, sophisticated manner. For example:
䡲 Paul correctly hypothesized that the residents’ dysfunctional
behavior was maintained by the interactions with high-school-
equivalent, aide-level staff (whom he called “change agents” to
properly highlight their role), who before Paul’s intervention
responded with negative attention to residents’ disturbing
behaviors and by ignoring residents’ less frequent incidents of
nondisturbing behavior. Thus, Paul’s main intervention was to
train the staff in responding to specific resident behaviors in
the opposite way—by reinforcing residents’ approximations
of functional behaviors and by either ignoring dysfunctional
behaviors or using time-out when residents’ engaged in aggres-
sive, harming behaviors.
䡲 The program was designed to maximize ongoing contact between
staff and residents, including meals and morning and evening
routines, which provided a time for explicit training in self-care
skills and structured skill-training groups during the day in areas
such as prosocial behavior and communication, functional arith-
metic, reading, writing, speaking, homemaking, and grooming.
This resulted in 85% of each resident’s waking hours devoted to
structured time with staff in acquiring skills to overcome spe-
cific deficits in behavior, compared with only 36.2% of such
structured time in the TAU.

䡲 Staff fidelity to the treatment was assessed by the detailed, struc-
tured observation of representative samples of staff–resident
interaction. The direct observation of client behaviors is a pre-
ferred mode of measurement in first-wave behavior therapy,
because self-report instruments—typical of second-wave and
third-wave approaches—are mediated by complex cognitive
and linguistic processes of memory and generalization that are
required of the client. These processes are viewed by advocates
of first-wave approaches as typically distorting and simplifying
the gold standard results achieved by direct, third-party obser-
vation of behavior.
Another distinctive and successful first-wave behavior therapy is parent–
child interaction therapy (PCIT; Brinkmeyer & Eyberg, 2003). PCIT is a
parenting skills training program for young children with disruptive behavior
disorders that targets change in parent–child interaction patterns. In a first,
child-directed interaction phase of treatment—that integrates elements from
play therapy and attachment theory—parents learn positive attention skills in
a play situation with their child. These skills include (a) describing rather than
criticizing the child’s behavior, (b) praising the child’s behavior when war-
ranted, and (c) ignoring when possible the child’s negative behavior. The
emphasis is on increasing positive parenting and warmth in the parent–child
interaction as the foundation for discipline skills that are introduced in the
second, parent-directed phase of treatment. In this second phase, and within
the child-directed context, parents learn and practice giving clear instructions
to their child when needed and following through with praise or time-out dur-
ing in vivo discipline situations. Parents are taught to apply the skills calmly
and consistently in the clinic until they achieve competency and are ready to
generalize the skills to their home environment. Parent-directed homework
assignments proceed gradually from brief practice sessions during play to appli-
cation at just those times when it is necessary for the child to obey.
Today’s Third-Wave Behavior Therapy
Steven Hayes (2004) has been a leading advocate of third-wave thera-

pies, which focus on internal cognitive processes, like the second wave, but
view the focus of understanding on how these processes are functionally
related to the objective environment, like the first wave.
The following are generally considered third-wave therapies: accept-
ance and commitment therapy (ACT; Hayes, 2004); dialectical behavior
therapy (DBT; Linehan, 1993); behavioral activation (BA; Martell, Addis, &
Jacobson, 2001); functional analytic psychotherapy (Kohlenberg & Tsai, 1991);

cognitive behavioral analysis system of psychotherapy (McCullough, 2000);
and mindfulness-based cognitive therapy (Segal, Williams, & Teasdale, 2002).
As examples, we briefly consider the first three of these.
Acceptance and Commitment Therapy

The difference between second-wave and third-wave therapies can be
illustrated by a client, Ms. X, who has the thought, “People in my team’s
group meeting at work will look down on me when they see that I am blush-
ing because of my social anxiety.” Second-wave cognitive therapy contends
that such thoughts contain thinking errors that should be challenged and
eventually replaced by alternative, more functional thoughts, such as, “My
team members might notice that I am blushing but will also pay attention to
the substance of what I have to say as it relates to why our team is meeting.”
Third-wave therapies, such as ACT, take a different approach and contend
that the problem is not in the content of Ms. X’s thought but rather in the
context of the thought—that is, how Ms. X views the thought. Specifically,
if Ms. X. can distance herself from the thought—realizing that the thought is
just a thought and does not necessarily correspond to objective reality—then
the power of the thought to amplify Ms. X’s anxiety and thus perhaps to pre-
vent her from attending the meeting will be importantly lowered. In Hayes’s
(2005) terms, the original upsetting thought will be defused from reality and
thus defanged of some of its potency:
When you learn to view your thoughts as thoughts, occurring in the here
and now, you still “know what they mean” (the verbal relations are still
there; that is, you still know to what you thoughts refer). But the illusion
dissolves that the thing being thought about is present merely when you
think about it. This greatly reduces the impact of the symbols . . . [Thus,]
the thought, “I am having the feeling that I am anxious,” is quite differ-
ent from the thought, “God, I am so anxious!” The first statement is more
defused than the second. For that reason, it is less anxiety-provoking.
When you learn to defuse language, it becomes easier to be willing to be
present, to be conscious, and to live the life you value, even with the nor-
mal [cognitive] chatter going on in your head. (p. 70)
ACT offers a variety of techniques through which a client such as Ms. X
can distance herself from her negative thoughts, for example, by looking at
her thoughts as though they were floating leaves on a moving stream or by
“watching the mind-train”—that is, looking down from a bridge at a slow
freight train with each car labeled on top with a negative thought (Hayes,
2005, pp. 66–67). This defusion process, along with acceptance (nonjudg-
mental awareness), being in contact with the present moment (“showing
up”), and viewing one’s self as context (“contacting the transcendental sense

of self in which all experience is safe”) constitute crucial acceptance and
mindfulness processes in ACT therapy.
The commitment and behavior change dimensions of ACT for a client
like Ms. X would include her selecting and engaging in behaviors that are
consistent with her personal values—that is, doing what she wants to do.
Thus, if Ms. X. wants to do well at work and to advance, she will be encour-
aged to pursue these activities behaviorally while also accepting and being
mindful (through distancing and defusing) of such anxious thoughts as, “I am
anxious” and “I am blushing, and this makes me even more anxious.” As can
be seen by the demands of ACT on the individual client, at the core of the
various ACT processes is the need for psychological flexibility.
Dialectical Behavior Therapy

In working with parasuicidal borderline clients in the late 1970s,
Marsha Linehan found that these clients experienced the first-wave and
second-wave therapy emphasis on change as invalidating. In studying session
tapes of such therapy with borderline clients, Linehan’s team noticed that
therapists would abandon change-oriented interventions when a patient
demonstrated a negative response (e.g., anger, withdrawal, shame, threatened
self-harm) and that clients would “reward” a therapist with social connection
or warmth when they were allowed to move to another subject the clients
preferred.
Linehan responded to these observations by making modifications to
second-wave CBT and creating DBT. On the basis of dialectical philosophy,
in which polar opposites are considered an intrinsic part of reality, Linehan
added acceptance-oriented validation strategies to balance dialectically the
change-oriented strategies that were already part of the therapy. To help bor-
derline patients, who have particular problems with emotional regulation,
DBT teaches patients to recognize and accept the existence of simultaneous,
opposing forces, such as the experience of not wanting to engage in a certain
behavior and yet knowing that one has to engage in it to reach a certain
desired goal. To help patients on the acceptance side of the equation, DBT—
like ACT—uses mindfulness procedures. Another distinctive third-wave
theme in Linehan’s multifaceted, DBT approach includes seeing therapy as a
multistage process that links directly to a patient’s environment, includ-
ing systematic, behavior-based efforts to (a) enhance and maintain a client’s
motivation to change, (b) enhance a client’s capabilities, (c) augment
individual therapy with behavioral skills groups and phone coaching, and
(d) structure the environment so that treatment can effectively take place—
for example, by working with local hospital emergency rooms so that patients
are not highly reinforced for making parasuicidal gestures (Linehan, 1993).

Behavioral Activation for Depression
BA in the third wave (Martell, Addis, & Jacobson, 2001) expands on
earlier behavioral interventions recommended in both the first and second
waves of behavior therapy. BA emphasizes the relationship between activity
and mood and the role of contextual changes associated with decreased access
to reinforcers, which are hypothesized to be a major cause of depression. BA
highlights the centrality of behavioral patterns of avoidance and withdrawal
by patients with depression from situations such as interpersonal relation-
ships, occupational and other daily-life demands, or distressing thoughts and
feelings. Because approaching potential antidepressant reinforcers—such as
seeking out new and unfamiliar social contacts—is often initially punishing,
avoidance of contact minimizes distress in the short term but is associated
with increasing long-term difficulty (e.g., isolation from others). Thus,
increased activation is a tactic used to break this cycle.
Like ACT, BA seeks to identify and promote engagement with activi-
ties and contexts that are reinforcing and consistent with an individual’s
long-term goals. Activation strategies include self-monitoring, structuring
and scheduling daily activities, rating the degree of pleasure and accomplish-
ment experienced during engagement in specific daily activities, assessing
the function of avoidance behaviors, exploring alternative behaviors related
to achieving participant goals, and using role-playing to address specific
behavioral deficits. In addition, BA can include behavioral strategies for tar-
geting rumination, including an emphasis on the function of ruminative
thinking and on moving attention away from the content of ruminative
thoughts toward direct, immediate experience.
Contrasts and Complementarities Between Second-Wave

and Third-Wave Therapies
The differences between adherents of the two waves have at times

become politicized, with a battle for dominance in the field (Cloud, 2006;
Hayes, 2008; Hoffman, 2008). Here we attempt to offer balanced arguments
documenting contrasts and complementarities between second-wave therapy
(hereafter “CBT”) and third wave therapy (hereafter “ACT,” a leading rep-
resentative; for more details on the arguments, see Arch & Craske, 2008;
Heimberg & Ritter, 2008).
From the perspective of ACT, CBT’s cognitive restructuring excessively
focuses on the content per se of cognition, further embedding clients into
anxiety-arousing thoughts and pushing clients toward trying to avoid and
suppress their upsetting thoughts—a process Hayes (2005) called experien-
tial avoidance. In contrast, from the perspective of CBT, “the acceptance
of thoughts in ACT, which includes ‘letting go’ of thoughts as they arise . . .

could be misunderstood and misused as encouragement of thought suppression”
(Arch & Craske, 2008, p. 267). Each side cites studies to support its position. In
fact, both ACT and CBT use methods of coping with anxious cognition that
require additional thinking not to get too tied up in the anxious cognition.
The additional thinking takes the form of self-talk or coaching at a bare
minimum. Even on a silent meditation, self-talk in the form of verbal coaching
is readily present.
Both ACT and CBT use procedures for encouraging patients to stay in
contact with their upsetting thoughts: in ACT, the goal is to immerse one-
self in such thoughts using a distancing perspective, and in CBT, it is first to
focus on and articulate them (e.g., by monitoring automatic thoughts) and
then challenge and change them. A possible common pathway here is that
both ACT and CBT involve the exposure of patients to previously avoided
negative thoughts, which blocks experiential avoidance. Thus, a common
mechanism of change could be through the behavioral principle of extinc-
tion, such that exposure to upsetting thoughts without the occurrence of a
negative outcome will lead to the extinction of those thoughts.
The debate between ACT and CBT adherents sometimes includes the
contrasting goals of valued living versus symptom reduction, respectively, as
the desired outcomes of therapy. ACT’s stated goal is to have the patient
accept anxious and other emotionally disturbing thoughts by distancing and
defusing from them, freeing the patient to then concentrate on pursuing his or
her behavioral goals. CBT’s stated goal is to identify dysfunctional thoughts
and then to challenge and change their content so that the content no longer
generates upset. However, it seems unlikely that CBT therapists aim to reduce
anxiety so that their clients can do nothing all day. Nor is there any hard evi-
dence that promoting anxiety symptom reduction in CBT versus valued liv-
ing in ACT results in different therapy outcomes (Arch & Craske, 2008).
Moreover, it would seem that successfully reducing symptoms through CBT
would free clients to pursue their goals successfully and, in a parallel way, that
successfully pursuing goals via ACT would help clients to think differently
about themselves and the world and thus to reduce their symptoms.
Back to Metatheory
The battles between third-wave adherents (e.g., Hayes, 2008) and second-
wave adherents (e.g., Hoffman, 2008) are occasionally framed as a debate
about the nature of the laws that govern objective reality. In this context,
each side claims that scientific data show that their movement corresponds
more closely to this objective reality. For example, Hayes (2005) claimed that
ACT is logically derived from a distinctive epistemology (functional contex-
tualism) and a distinctive theory of language (relational frame theory, or
RFT) and that based on conducting experiments empirically testing aspects

of this theory, “we think we’ve found what is at the core of the human mind
itself” (p. 17). In addition, Hayes (2008) argued that because CBT goes
against the laws of RFT, CBT is just wrong. In fact, he claimed that CBT is
not based on scientific theory but on “tribal tradition” (p. 286). On the other
side, the CBT adherent Hoffman (2008) argued not only that CBT is based
on a coherent scientific theory but that there is clear empirical evidence sup-
porting the efficacy of cognitive restructuring and the fundamental notion
that change in cognitions mediates (i.e., causes) changes in emotions and
overt behaviors. Moreover, Hoffman argued, “although . . . acceptance strate-
gies are not routinely used in CBT, they are certainly compatible with the
CBT model” (p. 283). In fact, Hoffman claimed, third-wave therapies are not
really new, and we should therefore “abandon the terms ‘new wave’ and ‘third
wave’” (p. 284).
In terms of the earlier discussion about metatheory, as summarized in
Table 4.1, the Hayes–Hoffman dialogue is located in the positivist-paradigm
column, which is quite different from the social constructionist, pragmatic-
paradigm column. (Note that at some points Hayes [e.g., 2008] has stated that
ACT is based on a constructionistic and pragmatic epistemology, but for the
present discussion, we are focusing on the positivist aspects of his statements
about ACT.) Epistemological pragmatists view theories as conceptual tools,
whose value and validity are based not on their correspondence to objective
reality but on their capacity to solve real-world problems (Fishman, 1999,
2005). In line with this perspective, for many years within CBT, clinicians
have combined strategies associated with first- and second-wave practice—
for example, cognitive restructuring and behavioral activation approaches in
working with depressed and anxious clients—and the practical effectiveness
of this combination has led to its rapid acceptance and proliferation. Also in
line with this perspective, more recently, behavioral clinicians have begun to
integrate second- and third-wave treatments in their case conceptualizations
and practice. (For a thorough example of such integration, see Persons, 2008.)
It should also be noted that the main claims for the efficacy and effec-
tiveness of all three waves of behavior therapy are based on their pragmatic
capacity to result in better outcomes in randomized clinical trials compared
with control treatments—not on their theoretical validity or persuasiveness
per se. Lists of therapies determined to be empirically supported treatments
(Society of Clinical Psychology, 2009; http://www.div12.org) on the basis of
their successful performance in randomized clinical trials reveal that not only
are all of the first-wave and third-wave approaches described in this chapter
on the lists, but many second-wave approaches are as well (see the chapter on
cognitive therapy in this volume for a discussion of these). In fact, for the
some disorders—such as depression, borderline personality, and bulimia—not
only behavior and cognitive therapies but also psychodynamic therapies are

on the lists. From the pragmatist’s point of view, this simply means that dif-
ferent conceptual tools can lead to similar results, just as different carpenter
tools can get similar jobs done.
Back to Definition
In reviewing the differences and similarities between second-wave and
third-wave therapies, we have seen clear theoretical and political differences
between them, for example, in some of the contrasts between their positions
on cognitive restructuring versus cognitive defusion. This is reflected in sep-
arate professional and scientific associations of CBT, such as the International
Association of Cognitive Psychotherapy (http://www.the-iacp.com), and
of third-wave therapy, such as the Association for Contextual Behavioral
Science (http://www.contextualpsychology.org). However, both waves have
a commitment to the methods of psychological science, for example, using con-
cepts that can be operationally defined in the descriptions of their therapy,
including the creation of therapy manuals; quantitatively measuring relevant
variables to monitor the therapy process and to assess its outcome; and conduct-
ing randomized clinical trials to assess the efficacy of the treatment. Thus, it is
particularly within pragmatic behaviorism—that is, Circle 5 of Figure 4.1—that
the continuity among the various waves of behavior therapy can be found.
REDISCOVERING THE CASE STUDY
The origins of behavior therapy are replete with the importance of case
studies. For example, in the 1920s, J. B. Watson and Rayner (1920) demon-
strated the principle of learned fear by showing how the nine-month-old
Little Albert became afraid of white rats when their presence was associated
with loud noises and how this fear generalized to the sight of other animals,
such as rabbits and dogs. A few years later, Mary Cover Jones (1924) clini-
cally demonstrated counterconditioning by helping young Peter, who began
with a fear of rabbits, to lose this fear through the experience of being fed in
the presence of a rabbit—first placed a few feet away from Peter, then gradu-
ally moved closer on subsequent occasions.
From the 1930s to the 1960s, behavior therapy continued to focus on the
individual case. Examples are Skinner’s (1938) research on the functional
analysis of the individual organism in context as the basic unit of research, the
case study approach to behavior therapy at the Maudsley Hospital in London
(Jones, 1956), and Ullmann and Krasner’s (1965) Case Studies in Behavior
Modification, which persuasively demonstrated the effectiveness of behavior
change through particular cases.

In the 1970s, Goldfried and Davison’s (1976) groundbreaking book Clin-
ical Behavior Therapy connected behavior therapy to the whole psychotherapy
tradition. The authors did so by providing detailed case examples throughout
and by presenting the extended case illustration of “Ann,” a 35-year-old woman
with multiple diagnoses.
In the 1980s, we find this illustrative statement by the editor (Nelson,
1983) of the journal, Behavioral Assessment, who reminded us of the case-based,
idiographic tradition in the behavioral movement:
[Nomothetic] psychometric criteria . . . are antithetical to behavior
theory. . . . Given the assumption that behavior is situation-specific,
concurrent validity across different assessment situations should not be
predicted. Given the assumption that behavior frequently varies across
response systems, concurrent validity across different assessment meth-
ods should be not expected. . . . For each client, an assessment process
must be delineated that takes into account his or her unique problematic
situations and response systems. (pp. 199, 201)
However, in the 1990s, behavior therapy moved away from individual
case study toward the group-based, nomothetic direction. Although the
applied behavior analysis branch of behavior therapy—following from Skinner’s
work—continued to have a commitment to experimental work at the indi-
vidual case level through single-subject research designs (Hayes, Barlow, &
Nelson-Gray, 1999), this era saw the rest of behavior therapy move strongly
toward large group designs. Federal grants were plentiful for conducting ran-
domized clinical trials of manualized treatment procedures designed to address
patients whose problems ideally were delimited to a particular psychopatholog-
ical category of the DSM. In 1995, the Society of Clinical Psychology (Divi-
sion 12 of the American Psychological Association) used the results of these
randomized clinical trials to create its first public list of empirically supported
treatments, and in 1998, the theoretical and empirical background of this list
was described and discussed in detail in Nathan and Gorman’s (2007) book, A
Guide to Treatments That Work. The Division 12 list thrives today on its web-
site (Society for Clinical Psychology, 2009; http://www.div12.org), and the
third edition of the Nathan and Gorman book was published in 2007.
Nevertheless, as clinical experience with manualized therapy has accu-
mulated, in recent years the superiority of exclusively following the nomo-
thetic model has been increasingly questioned, and alternatives have been
developed. Consider the following examples.
䡲 Experts have learned in using treatment manuals that they must
augment and revise the manuals on the basis of individual patient
needs, values, and preferences and that they must address obsta-
cles, such as patients who will not do the homework (Huppert &

Abramowitz, 2003; Rego et al., 2009). For example, the use of
metaphors and the nuances of language are reviewed as arenas
that go beyond manuals but are crucial in engaging and commu-
nicating with patients.
䡲 Some researchers have developed “manualized principles”
(Rego et al., 2009) that provide a conceptual guide to therapy
but do not dictate a linear sequence of specific “manualized
protocols” to be followed, as in earlier work. Two examples are
Henggeler et al.’s (1998) manual for working with oppositional
youth and Linehan’s manual (1993) for working with patients
with borderline disorder.
䡲 Seasoned clinicians have discovered the inherent set of trade-
offs between highly prescriptive manuals and clinician flexibil-
ity in adapting therapy to the individual case. Five examples of
these trade-offs (Addis et al., 1999), respectively, include (a) a
focus on a general diagnostic category versus on the individual
client, (b) a focus on therapeutic techniques versus on the ther-
apeutic relationship, (c) a focus on adherence to a manual ver-
sus on integration of the manual with the client’s individual
situation, (d) a focus on adherence to the manual versus being
genuine with the client, and (e) a focus on the therapist believ-
ing in what the manual says about positive outcome versus on
recognizing that an individual client may not improve as much
as the manual says.
䡲 A recent movement toward unified, transdiagnostic treatment
manuals—for example, for emotional disorders (Barlow, Allen,
& Choate, 2004) and eating disorders (Fairburn, Cooper, &
Shafran, 2003). Barlow and colleagues (2004) explained that
they developed their unified manual that cuts across emotional
disorders in part because of the reality that diagnostically spe-
cific, manualized protocols have become overly numerous and
complex, logistically restricting effective training and dissemi-
nation. They also pointed out that a deepening understanding
of the nature of emotional disorders reveals commonalities in
etiology and latent structure among them that supersedes their
differences. The transdiagnostic treatments are designed to
be adaptable to the idiographic complexities of each individual
case and thus fall into the category of manualized principles
rather than manualized protocols.
A final example of the trend away from a primary focus on manualized
treatments for specific diagnoses has been the growing interest in the field in

individualized case formulation and treatment planning. In 1989, Jacqueline
Persons published a book laying out a case formulation approach in CBT,
drawing on both first- and second-wave theory. For the next 19 years, this
book was a highly popular seller and was recently published in a new, revised
version (2008), integrating third-wave therapies. Moreover, Persons is now
the editor of a book series on individualized evidence-based treatments, with
eight titles as of November 2008, including first-, second-, and third-wave
therapies.
In Person’s (1989) book, she discusses the dialectic of nomothetic, man-
ualized treatment versus idiographic, individualized formulation and treat-
ment planning as follows:
I struggle in this book to rely on the empirically supported therapies
(ESTs). . . . The EST protocol assumes that the mechanisms causing and
maintaining the symptoms of the patient who is being treated at that
moment match the mechanisms that underpin the design of protocol.
The protocol also assumes that the patient’s goal is to treat the DSM dis-
order targeted by the protocol. These assumptions often appear to be
incorrect.
My solution to these problems, described in detail in this book, is to
recommend that clinicians examine the EST protocols to understand the
formulations that underpin them and how the interventions in the pro-
tocol flow out of the formulations. Then they can use that information
(not the step-by-step procedures of the protocol itself) to guide their
work. To facilitate those tasks, this book includes three chapters that lay
out in detail the principles of the three major groups of models that
underpin most ESTs: [second-wave] cognitive models (especially Beck’s
theory), [first wave] learning theories, and [third wave] basic models of
emotion. The approach to cognitive-behavior therapy described here is
[designed to be] . . . responsive to the situation at hand, guided by clear
thinking, and evidence based. (p. vii)
As behavior therapists refocus on the importance of integrating
nomothetic treatment manuals with individualized treatments, the field
has rediscovered its earlier interest in nonexperimental case studies. This is
reflected in the recent establishment of two peer-reviewed journals publish-
ing cases studies of this type, the print journal Clinical Case Studies (CSS;
Hersen, 2002) and the online, open-access journal Pragmatic Case Studies
in Psychotherapy (PCSP; Fishman, 2005; http://pcsp.libraries.rutgers.edu).
Although both journals are multitheoretical, it is important to note that both
were started by editors associated with behavior therapy, both have promi-
nent behavior therapy researchers and practitioners on their editorial boards,
and both have published a substantial number of behavior therapy case stud-
ies from all three waves.

CONCLUSION
Behavior therapy started in the dog laboratory of Pavlov, the cat labora-
tory of Thorndike, and later the pigeon laboratory of Skinner. The discipline
then developed by applying the respondent and operant learning principles that
emerged from these laboratories to complex human behaviors. During this
application process, researchers and practitioners retained from the experience
of the animal laboratory a commitment to the experimental method, including
the operational definition of key variables, quantification, and reliable observa-
tion of animal and then human behavior. These aspects of what we have called
pragmatic behaviorism have continued.
At the same time, behavior therapy has incorporated into its first wave
of learning theory the cognitive theory that emerged from the cognitive rev-
olution, forming the field’s second wave. In addition, a third wave has recently
developed, focusing on accepting emotional experience through mindfulness,
which emerged by linking cognition and emotional processes back to a first-
wave concern with how internal experience functionally relates to the objec-
tive environment. Along the way, behavior therapy has extended itself from
individual, to group, to community, to business settings; it has diversified its
epistemology from a positivist base to include a pragmatic perspective; and it
has developed both nomothetic, manualized and idiographic, case-based inter-
vention models.
We will not be surprised to see additional theoretical waves and new
methodological developments in the future. However, we believe the core
of behavior therapy will endure in a commitment to theory that is schol-
arly, logically clear, directly linked to data, and primarily rooted in the
interactional worldview (see Figure 4.1); to therapy principles and proce-
dures that are evidence-based; to measurement methods designed to ensure
accountability; and to a focus on outcomes that result in concrete improve-
ment in patients’ lives.
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4

All major systems of psychotherapy—behavior therapy, psychoanalysis,

102 FISHMAN, REGO, AND MULLER

LEARNING THEORY BEGINNINGS

Behavior therapy as it is known today began to emerge in the 1950s. How-

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 103

FORMATION OF BEHAVIOR THERAPY AS A DISTINCT MOVEMENT

In the first article devoted exclusively to behavior therapy in the Annual

104 FISHMAN, REGO, AND MULLER

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 105

106 FISHMAN, REGO, AND MULLER

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 107

108 FISHMAN, REGO, AND MULLER

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 109

110 FISHMAN, REGO, AND MULLER

WORLDWIDE ORGANIZATION OF BEHAVIOR

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 111

DEFINITIONS OF BEHAVIOR THERAPY

112 FISHMAN, REGO, AND MULLER

systematic desensitization, are not (Wilson & O’Leary, 1980). As another

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 113

114 FISHMAN, REGO, AND MULLER

A METATHEORY OF CONTEMPORARY BEHAVIOR THERAPY

A theory in psychology is a conceptual framework that identifies impor-

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 115

Trait McCrae & Costa’s Psychometric Freud’s theory of

paradigms (divided into the positivist, pragmatic, and hermeneutic; Fishman,

Epistemology is the branch of philosophy that investigates the origins,

116 FISHMAN, REGO, AND MULLER

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 117

118 FISHMAN, REGO, AND MULLER

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 119

Interactional Theories With Trait Components

120 FISHMAN, REGO, AND MULLER

Interactional Theories With Organismic Components

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 121

Interactional Themes With Transactional Elements

BEHAVIOR THERAPY TODAY

As mentioned in the introductory portion of this chapter, we have organ-

122 FISHMAN, REGO, AND MULLER

Today’s First-Wave Behavior Therapy

Today’s first-wave behavior therapy can be organized around individu-

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 123

124 FISHMAN, REGO, AND MULLER

Today’s Third-Wave Behavior Therapy

Steven Hayes (2004) has been a leading advocate of third-wave thera-

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 125

Acceptance and Commitment Therapy

126 FISHMAN, REGO, AND MULLER

Dialectical Behavior Therapy

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 127

Contrasts and Complementarities Between Second-Wave

The differences between adherents of the two waves have at times

128 FISHMAN, REGO, AND MULLER

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 129

130 FISHMAN, REGO, AND MULLER

REDISCOVERING THE CASE STUDY

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 131

132 FISHMAN, REGO, AND MULLER

BEHAVIORAL THEORIES OF PSYCHOTHERAPY 133