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The Behavioral Paradigm

The self is... in continuous formation through choice of action.

-John Dewey

A range of intellectual traditions and philosophical perspectives have shaped the course of understanding and practice in the behavioral paradigm over the decades, and clinical scholars have come to encompass divergent ideas and methods in their conceptions of therapeutic action, change, and growth. The first generation of therapeutic approaches emerged in the 1950s, based on the experimental psychology of behaviorism. Practitioners focused on principles of learning and environmental conditions thought to influence overt behavior, drawing on conceptions of classical and operant conditioning.

Following the “Cognitive Revolution” of the 1960s, a second generation of thinkers increasingly centered on mental processes, attempting to bring mind into the behavioral paradigm. Practitioners developed new approaches, joining cognitive strategies and behavioral techniques in efforts to change patterns of thinking believed to perpetuate problems in living. Over the last quarter century clinicians have continued to expand the domains of theory' and practice in elaborating third-wave models of therapy, emphasizing the crucial role of emotion, meaning, validation, and acceptance, converging with concepts of therapeutic action set forth in the psychoanalytic, humanistic, existential, and Buddhist traditions. Behavioral approaches, rooted in positivism, shaped by the scientist-practitioner tradition, have been studied more frequently than any other form of therapy. Researchers have documented the efficacy and effectiveness of behavioral interventions for a wide range of problems in living over the years, and they are actively promoted as empirically supported forms of treatment, shaping models of evidence-based practice.

In this chapter I trace the emergence of the behavioral paradigm, outlining the orienting perspectives of classical approaches, representative versions of cognitive-behavioral therapy, and the third generation of functional and contextual models. I describe concepts of therapeutic action and illustrate the range of approaches encompassed in the paradigm in a review of pragmatic models that integrate ideas and methods across the three generations of practice. As in the other chapters in Part III, I consider the ways in which recent

The Behavioral Paradigm 117 developments in science of mind and the principles and values of clinical pragmatism enlarge our appreciation of essential concerns in behavioral conceptions of therapeutic action, change, and growth.

Origins

As we saw in the account of Freud’s research as a neuroanatomist, the Zeitgeist of late 19th century' Europe was shaped by the emergence of empiricism, an epistemological doctrine that emphasizes the fundamental role of observation, experimentation, and evidence in the development of knowledge. Historians trace the origins of the scientific discipline of psychology' to the work Wilhelm Wundt, a German researcher who established the first experimental psychology' laboratory' in 1879, carrying out studies of perception and psychophysics, and research on neurophysiology and behavior initiated by a series of Russian biologists, physiologists, and physicians, most notably Ivan Pavlov.

John B. Watson, a graduate of the University' of Chicago, drew on these converging lines of research at the turn of the 20th century, challenging the humanistic paradigm of William James that had shaped the development of American psychology. James had taken experience as the starting point of his person-centered psychology', while Wundt and Watson embraced the Germanic ideal of pure scientific research. In formulating his notion of behaviorism, Watson rejected the introspective method and the study of subjectivity', emotion, consciousness, and intentionality that had served as the foundation of mentalistic theories of psychology.

Watson embraced positivism in his effort to distinguish psychology' from philosophy and establish the discipline as an objective branch of natural science. In doing so he privileged materialism over mentalism, objectivity over subjectivity', and determinism over notions of free will, proposing that our behavior is governed by stimulus-response relationships. Watson’s behaviorism, expanding Pavlov’s research on conditioned reflexes and classical conditioning, emphasized linear models of causality, operational definition of concepts, specificity' in describing relationships between variables, and quantification (Watson, 1913; see Fishman & Franks, 1997, for expanded review of the history' of behavior therapy).

Subsequent thinkers, notably' C. L. Hull, E. L. Thorndike, and B.F. Skinner, elaborated theories of learning through the first half of the 20th century. Thorndike introduced principles of learning and reinforcement in formulating the “law of effect” that emphasized the role of positive and negative consequences of behavior, prefiguring conceptions of operant conditioning (Thorndike, 1905). Drawing on Thorndike’s contributions, Skinner elaborated basic principles of operant conditioning that informed methods of behavior modification in efforts to address problems in functioning associated with mental illness and developmental disabilities. He and his colleagues studied the use of operant conditioning strategies for treatment of behavioral problems perpetuated by psychosis at the Laboratory for Behavior Research at the

Metropolitan State Hospital in Waltham, Massachusetts, in the early 1950s. They would show how practitioners could apply the techniques of contingency management in the fields of mental health and education, introducing the term behavior therapy to describe the use of conditioning principles for a range of problems in living (Skinner, Solomon & Lindsley, 1953).

Following the fundamental tenets of behaviorism, researchers assumed that basic learning mechanisms govern our most complex behaviors, disavowing the relevance of internal mental processes. Pavlov’s conceptions of classical conditioning, based on Aristotelian notions of association by contiguity, and Skinner’s formulations of operant conditioning, focused on the positive or negative consequences of behavior, served as the foundation for the earliest forms of behavioral intervention.

Evolution of Therapeutic Practice

Joseph Wolpe, trained as a psychiatrist in South Africa, built on Pavlovian formulations of classical conditioning, Hull’s conceptions of operant learning, and the neurology of Charles Sherrington in developing his therapeutic methods in the late 1950s, introducing counterconditioning techniques for the treatment of fear, anxiety, and avoidant behavior associated with a range of problems in living (Wolpe, 1958). Although scholars would challenge his theory of the fundamental mechanisms believed to govern change, based on neurological formulations of reciprocal inhibition, his experimental research shaped the development of exposure-based techniques in the wider domain of clinical practice. Methods of systematic desensitization, used in the treatment of fear and experiential avoidance associated with neurosis and anxiety disorders, combined methods of exposure and relaxation procedures through in-vivo engagement or visualization of anxiety-arousing situations. The repeated experience of exposure and relaxation was thought to break the associative links between stimuli and the experience of vulnerability, fear, and maladaptive behavior.

Hans Eysenck, working as a research psychologist in the Institute of Psychiatry' at the University of London, also drew on the work of Pavlov and Hull in his efforts to broaden the field of behavior therapy in the 1950s. His influential critiques of psychoanalytic psychotherapy and writings on emerging developments in behavioral intervention moved clinicians to experiment with a range of procedures at the Maudsley Hospital, using conditioning and reinforcement techniques, systematic desensitization, and behavioral rehearsal (Eysenck, 1952, 1959, 1972). In his efforts to advance the application of learning theory to clinical problems, Eysenck published the first behaviorally oriented textbook on abnormal psychology in 1960, followed by collections of case studies in behavior therapy (Eysenck, 1960, 1964). He founded the first major journal devoted to behavior therapy, Behavior research and therapy, in 1963. The Association for the Advancement of Behavior Therapy was established three years later.

The first generation of behavior therapists continued to apply basic principles of classical and operant conditioning in their efforts to treat a variety of problems in functioning, seeking to change maladaptive emotional reactions and patterns of behavior. As clinicians engaged a wider range of concerns in community settings, however, they increasingly realized the limits of therapeutic methods based on the reductive principles of behaviorism. Critiques of the first generation of behavioral approaches documented the limits of classical learning theory' and stimulus-response models of intervention that had failed to consider fundamental aspects of the mind and subjectivity, the complexities of problems in living, and the dynamics of change and growth.

Developments in the fields of cognitive science and artificial intelligence in the mid-1950s, prefiguring what we would come to know as the “Cognitive Revolution,” challenged scholars to take more account of the mental processes believed to mediate our experience of emotion and behavior. Using the metaphor of the mind as a computer, researchers introduced a serial processing model of cognition that would supersede behaviorism as the orienting paradigm in the discipline of psychology.

Scholars increasingly explored the dynamics of cognition, emphasizing the crucial role of motivation, appraisal, and meaning in our experience of vulnerability, problem-solving, and coping. Albert Bandura expanded cognitive models of personality and behavior, introducing concepts of observational learning, modeling, and self-efficacy (see Bandura, 1969, 1971, 1982). Walter Mischel challenged trait theories of personality, emphasizing the ways in which contexts and situations shape different patterns of behavior (see Mischel, 1971, 1973). The ways in which we make sense of experience, create meaning, negotiate problems in living, and cope emerged as fundamental concerns in the domain of psychotherapy.

Practitioners began to integrate behavioral methods and cognitive strategies in the 1970s, introducing the first versions of cognitive-behavior therapy, taking more account of thoughts and feelings in ways that classical behavioral practitioners had failed to consider in their formulations of dysfunction, intervention, and change. Clinicians drew on the cognitive approaches of Albert Ellis and Aaron Beck, originating in clinical practice rather than in the experimental psychology of behaviorism, shaped by philosophical traditions and psychodynamic thinkers (see Chapter 7).

The emergence of the third wave of behavior therapies at the end of the 20th century’ reflected a radical shift in the philosophical perspectives that had shaped mechanistic conceptions of behavioral learning and serial models of cognition, moving from simplistic stimulus-response models of cause-effect relationships to non-linear, multi-causal perspectives. Scholar-practitioners increasingly' acknowledged the failings of logical positivism and reductive stimulus-response models in efforts to address the complexities of problems in living, embracing a pragmatic paradigm that challenged clinicians to broaden conceptions of behavior and to explore the contexts, functions, and consequences of sensations, feelings, thoughts, and actions.

Drawing on Buddhist traditions, relational psychoanalysis, existential thought, and experiential approaches in the humanistic paradigm, practitioners introduced conceptions of acceptance, validation, and mindfulness that would help patients engage and observe—rather than attempt to control, challenge, or change— their experience of sensation, feeling, thought, imagery', and other forms of behavior that perpetuate suffering and problems in living.

From this perspective the intent is not to change the experience itself but to transform the way in which we relate to subjective states and circumstances through shifts in perspective, observing, accepting, and exploring challenging conditions without becoming overwhelmed by them. The dialectical behavior therapy' of Marsha Linehan, the functional analytic psychotherapy of Robert Kohlenberg and Mavis Tsai, and the acceptance and commitment therapy of Stephen Hayes and colleagues exemplify' the orienting perspectives and pragmatic concerns of the third generation, though practitioners continue to integrate concepts and strategies introduced in earlier formulations of behavior therapy. Recent developments in therapeutic practice focus on methods believed to facilitate growth across a range of diagnostic categories, moving clinical scholars to introduce “process-based” therapeutic approaches (see, for example, Barlow & Farchione, 2017; Hayes & Hoffman, 2018).

Models of Therapy

I outline three models in greater detail that illustrate the diverse forms of therapeutic action we encompass in the behavioral paradigm, exemplifying the principles and values of clinical pragmatism.

Cyclical Psychodynamics: Wachtel

Paul Wachtel has developed an integrative model of psychotherapy that bridges basic concepts and methods across the behavioral paradigm with the orienting perspectives of relational psychoanalysis, cognitive therapy, the experiential approaches of the humanistic tradition, and systemic points of view. Following his training in psychoanalysis in the 1970s, he came to appreciate the depth and complexity' of understanding that had shaped psychodynamic conceptions of personality and relational life, recognizing the crucial role of unconscious processes, defenses, and conflict in our experience of vulnerability and problems in living.

In his critiques of the classical psychoanalytic paradigm, however, he argued that thinkers had overvalued early developmental experience in their formulations of vulnerability, failing to appreciate the ways in which current patterns of behavior, capacities and skills, relational life, and social surrounds perpetuate problems in living. Classical psychoanalytic thinkers had privileged “inside-out” notions of causality, focusing on concepts of developmental arrest and the dynamics of inner life, but failed to consider the influence of “outside-in” conditions that behavioral thinkers had emphasized in their formulations of problems in living, therapeutic action, learning, and change.

Drawing on the work of Walter Mischel, Wachtel increasingly realized the ways in which subjective experience and patterns of behavior vary considerably from context to context, coining to emphasize the importance of attending to the concrete particularities of what we feel, think, say and do in different situations and the variety of contingencies that shape ways of living in the present.

The person in context is his focal concern, and his conceptions of personality development and problems in living are based on a circular model of causality. He centers on the dynamics of “cycles of reciprocal causation between intrapsychic processes and the events of daily living,” emphasizing “repetitive cycles of interactions between people” in his relational approach (Wachtel, 2011, p. 68). Inner experience and outer realities create and evoke the other through perceptual inclinations to see the old in the new and behavioral inclinations to evoke the old in the new (Wachtel, 2008, p. 104). The recursive dynamics of inner life and outer experience recreate the other. In his schema, childhood experiences are formative not because they “arrest” the development of the self but because they initiate developmental trajectories that predispose us to feel, think, and act in ways that continue to perpetuate a particular direction. In this sense the precipitants of problems in functioning lie in the interactive present, not in the distant past.

Drawing on the later work of Freud and the interpersonal perspectives of Harty' Stack Sullivan and Karen Horney (see Chapters 4 and 5), he emphasizes the fundamental role of fear and anxiety in his conceptions of dysfunction, linking problems in living to “vicious circles” of feeling, thought, and behavior. Fear and anxiety' create states of distress, compromising the course of development, constricting ways of being, relating, and living as one attempts to manage the continued experience of suffering. His formulations of neurosis are based on the assumption that we avoid crucial feelings, thoughts, behaviors, and situations in efforts to regulate anxiety', compromising the development of basic capacities and skills in living that require practice and shaping over the course of development.

While the function of defensive behavior is to limit the experience of vulnerability and anxiety', such protective strategies potentially generate the very psychological and interpersonal outcomes one fears, perpetuating problems in functioning. However much insight and understanding one develops about the origins of problems in living, he explains, the pattern perpetuates itself so long as one “keeps living the way he does. And he keeps living that way because he is afraid not to” (Wachtel, 2011, p. 74). Fear and anxiety override insight and understanding.

We carry out our life across different contexts and situations, he observes, “and our behavior, both adaptive and maladaptive, is always in relation to someone or something” (2011, p.77). It is crucial, accordingly, to focus on the concrete particulars of daily living, exploring the dynamics of inner life and outer realities.

In his formulations of change, shaped by Jean Piaget’s conceptions of assimilation and accommodation, new behaviors produce new consequences and different feedback, which foster the development of insight, shaping subsequent patterns of feeling, thought, and action. As he emphasizes, “internal change and change in overt patterns are not really alternatives, they are two aspects of one process, and neither alone will yield reliable and satisfying results” (2011, p. 323). Change in one domain facilitates change in the other through complex feedback processes.

Over the course of psychotherapy the patient and practitioner explore the dynamics of intrapsychic life, interpersonal functioning, and contextual factors that perpetuate problems in living, clarifying maladaptive patterns of feeling, thinking, and acting that emerge in the give and take of everyday life, often recreated in the interactive experience of the therapeutic process through enactments and transference-countertransference reactions.

Drawing on concepts of classical conditioning, Wachtel assumes that one of the most powerful sources of change is direct exposure to feared aspects of inner experience (sensations, feelings, thoughts, images, memories) or actual conditions in the outer world. Methods of exposure activate, challenge, and disrupt vicious circles of feeling, thought, and action, strengthening the development of capacities and skills to deal with feared conditions. Activation of problems in functioning may occur through guided exploration of focal concerns or through enactments in patient-therapist interaction. Transference and countertransference reactions provide in-vivo opportunities for experiential learning (Wachtel, 2008, 2011).

Like third-wave behavioral practitioners, Wachtel recognizes the crucial role of acceptance and challenge in his understanding of therapeutic action, change, and growth. He outlines principles and techniques of therapeutic communication that foster the development of capacities and skills through experiential learning in the clinical situation. He makes pragmatic use of a range of behavioral concepts and procedures over the course of treatment, including in-vivo exposure and systematic desensitization, relaxation techniques, modeling, role-playing, skills training, and planned activities in the surrounds of everyday life.

Deepened understanding and insight are crucial in helping patients strengthen their sense of personal agency and the “experience of oneself as the vital center giving direction to daily actions and choices” (2011, p. 102). In accordance with behavioral conceptions of change, however, Wachtel emphasizes the crucial functions of action and experiential learning in the outer world. Over the course of the therapeutic process patients strengthen capacities and skills that have been compromised by fear, avoidance, and restrictions of opportunity, and engage the experience of living more fully and deeply in the present (for expanded accounts see Wachtel, 2014).

Dialectical Behavior Therapy: Linehan

Marsha Linehan introduced the first version of dialectical behavior therapy in 1993 as an integrative approach for the treatment of problems in functioning

The Behavioral Paradigm 123 associated with borderline personality disorder. Drawing on relational concepts from the humanistic paradigm, she emphasized the crucial role of the therapeutic alliance and the clinician’s validation of the patient’s experience in change and growth. She integrated core concepts and methods of behavioral intervention based on the principles of classical conditioning and operant learning, including exposure, contingency management, and skills training, and fundamental elements of Zen Buddhism and the practice of mindfulness, which emphasizes the radical acceptance and validation of experience without attempting to change it. Linehan came to think of the approach as a behavioral treatment program, encompassing individual psychotherapy, skills training, telephone coaching, and peer consultation.

Linehan centers on the paradoxical dynamics of acceptance and change in her dialectical conceptions of therapeutic action. In the course of her practice she came to believe that traditional cognitive behavioral models of intervention, emphasizing the process of change, potentially invalidate the patient’s subjective experience and sense of reality, intensifying arousal, compromising cognitive function and coping capacities.

Drawing on the principles of Buddhist thought, she introduced perspectives and practices that would help patients strengthen their capacities to accept, tolerate, and validate inner experience and outer realities rather than attempt to avoid, challenge, or change them. She integrated mindfulness meditation in efforts to help patients engage the experience of the present, accepting the flow of sensations, feelings, thoughts, and images without judgement or attempting to change inner states. The clinician reaffirms the ways in which the patient’s feelings, thoughts, and actions make sense in light of earlier experience and current circumstances.

While methods of validation foster the experience of acceptance, problemsolving strategies focus on change. In this sense the approach seeks to foster a synthesis between alternative positions in light of changing needs, capacities, and circumstances. The therapist carries out a functional analysis of behavior, exploring the antecedents and consequences of feelings, thoughts, and actions, considering a variety of approaches in light of changing needs, capacities, and circumstances, encompassing methods of exposure, contingency management, skills training, behavioral rehearsal, and cognitive restructuring. The model includes educational strategies that help patients strengthen skills in emotional regulation, distress tolerance, mindfulness meditation, and interpersonal effectiveness.

Linehan describes four stages of therapy in her efforts to address the range of problems in functioning associated with borderline personality disorder. In broad outline, the first stage focuses on patterns of behavior that potentially threaten life, compromise quality of life, or limit capacities to make use of help and care in the clinical situation. The second stage strengthens capacities to experience and process the dynamics of emotion through methods of exposure and acceptance. The third stage centers on the development of capacities and skills that facilitate efforts to pursue life goals in light of essential concerns, values, and purposes. The fourth stage, emphasizing the practice of mindfulness, seeks to deepen capacities for meaning and fulfillment.

Although the model is carefully structured, the approach is idiographic, focused on the particular circumstances of the clinical situation. If the patient has not developed the skills needed to negotiate current challenges and problems in living, for example, the therapist assumes an educational role, creating opportunities for instruction and practice. If the patient is unable to make use of capacities because of emotional dysregulation, the therapist attempts to help the patient restore stability through methods of exposure and mindfulness practice that strengthen tolerance of distress (Linehan, 1993; Linehan & Dexter-Mazza, 2008).

In a recent account of her work, Linehan describes the approach as “pragmatic, down-to-earth therapy... a program of self-improvement” (2020, p. 172). In accord with the values of clinical pragmatism, she emphasizes the “egalitarian relationship” between the therapist and the patient (2020, p. 168).

Acceptance and Commitment Therapy: Hayes and Colleagues

The acceptance and commitment therapy of Stephen Hayes and colleagues, developed over the last quarter century, provides a radical alternative to traditional behavioral approaches centered on the treatment of symptoms associated with specific disorders, challenging patients to develop capacities and skills instrumental in their efforts to pursue goals in accord with fundamental values, concerns, and purposes.

Working as a scientist-practitioner in the behavioral tradition, Hayes created the approach for patients who find themselves unable to change the content of feelings, thoughts, and actions that perpetuate problems in living. The therapeutic process seeks to help patients reinterpret the meaning of their subjective experience by creating new contexts of understanding, shifting the ways in which they relate to sensations, feelings, thoughts, and images, moving toward valued behavior and outcomes. In this sense the approach converges with existential concerns in the psychoanalytic and humanistic paradigms of psychotherapy.

He assumes that a range of problems in functioning originate in experiential avoidance, vicious circles of cognition, and patterns of rigidity that limit capacities to act in accordance with essential concerns, values, and goals. Problems in functioning that appear uncontrollable or distressing in one context become different phenomena in another context, Hayes proposes, explaining: “By establishing a posture of psychological acceptance, events that formerly were taken to be inherently problematic become instead opportunities for growth, interest, or understanding” (Hayes, 1994, p. 13). The goal is to help patients strengthen capacities to engage, experience, and observe the dynamics of inner life, working to strengthen agency and pursue goals in the sendee of growth and individuation.

Hayes thinks of behaviors as acts in context, evaluated by their effectiveness in bringing about outcomes that foster flexibility, change, and growth. He enlarges conceptions of behavior to encompass the dynamics of cognition and the symbolic meaning of language, drawing on Skinner’s philosophy of radical behaviorism, focusing on the functions of verbal behavior.

The functional analysis of behavior clarifies the antecedents (discriminative stimuli), focal behaviors (response repertoire), and consequences (contingencies of reinforcement). The expanded conceptions of behavior allow practitioners to move beyond the realm of observable, overt events and explore the functional relationships among the meanings of behavioral antecedents and their consequences.

Formulations of therapeutic action, based on the principles of classical and operant conditioning, encompass a range of approaches and methods in efforts to alter the variables that precipitate problems in living and shape the contingencies of reinforcement in accord with the patient’s values and commitments. Practitioners seek to strengthen the development of capacities for presence, acceptance, clarification of values, and commitment to action in light of fundamental concerns and goals. The core principles of change and growth emphasize engagement of the present moment (awareness of here and now experience approached with openness, interest, and curiosity); the attitude of acceptance (embracing the flow of sensations, feelings, thoughts, images and memories without judgment or challenge); cognitive defusion (challenging tendencies to reify thoughts, feelings, images, and memories); clarification of values and purposes; and commitments to action in constructive efforts to develop capacities and achieve goals.

Therapeutic Action

As we have seen, the behavioral paradigm challenges us to focus on the concrete particularities of the clinical situation, centering on immediate concerns, exploring what our patients feel, think, do, and want, and clarifying the dynamics of specific processes and the nature of concrete conditions thought to perpetuate problems in functioning. From the behavioral point of view, as we have seen, the self is “in continuous formation through choice of action," as Dewey proposed (1916, p. 408).

Clinical scholars continue to emphasize notions of learning in their formulations of what is the matter and what carries the potential to help, drawing on concepts of capability, mastery', and growth. We have learned ways of dealing with particular situations that now limit us, presumably, and the fundamental aim of intervention is to help us learn more functional ways of negotiating concerns, coping with problems in living, and strengthening capacities and skills.

We consider the role of context, language, meaning, values, action, experiential learning, and the development of skills in our formulations of therapeutic action, change, and growth. Wachtel documents the growing emphasis on emotion, acceptance, and validation in his accounts of the behavioral paradigm, emphasizing the experiential character of therapeutic methods that foster efforts to learn by doing, strengthening capacities and skills (Wachtel, 1997, 2011).

In contrast to classical models of behavioral treatment that had focused largely on technical procedures, contemporary practitioners increasingly recognize the crucial role of the therapeutic alliance and the collaborative nature of intervention in accord with the principles and values of clinical pragmatism. Therapists and patients explore the concrete particulars of current concerns, working to clarify the contexts, antecedents, dynamics, and consequences of feelings, thoughts, and actions that perpetuate problems in living.

From the perspective of the behavioral paradigm, what we feel, think, say, and do varies from situation to situation, shaped by changing contexts and circumstances, and practitioners focus on specific patterns of stimulus and response across the relationships, activities, and surrounds of everyday life.

Following the fundamental principles of operant conditioning, clinicians assume that the consequences of behaviors increase or decrease the likelihood that particular patterns of feeling, thinking, and acting will recur. In carrying out the functional analysis of behavior, accordingly, practitioners and patients careftilly explore the outcomes of feelings, thoughts, and actions associated with problems in living, taking account of the contexts of focal concerns and the contingencies thought to reinforce maladaptive patterns of functioning. The goal of the analysis is to identify specific stimuli that activate problematic forms of behavior, factors that reinforce dysfunctional patterns, and conditions that strengthen the development of capacities, skills, and adaptive outcomes. Clinicians draw on conceptions of reinforcement, extinction, shaping, and practice in structuring the course and activities of intervention (Antony, Roemer & Lenton-Brym, 2020).

Psychotherapists across the foundational schools of thought continue to recognize the role of operant conditioning in change and growth, broadening concepts of therapeutic action to take account of crucial sources of reinforcement operating in the core conditions of the relationship and the dynamics of interactive experience as well as contingencies that shape behavior in the ongoing relationships, activities, and surrounds of everyday life, often neglected in case formulations (see Wachtel, 1997, for discussion of contingencies that reinforce behavior in the clinical situation and everyday life).

Clinicians have come to appreciate the powerful influence of exposure in efforts to address a range of problems in functioning, introducing a variety of methods that help patients negotiate the experience of fear and avoidance. Patients engage anxiety-arousing situations in real life through in-vivo forms of exposure. Focused exploration of the dynamics of inner life and imaginal approaches in the therapeutic process help patients generate the experience of feelings, thoughts, and memories that they perceive as threatening. Interoceptive modes of exposure allow patients to recreate the visceral experience of feared sensations through different forms of activity that engage physiological

The Behavioral Paradigm 127 processes instrumental in the distressing reactions (for reviews of exposure methods see Anthony, Roemer & Lenton-Brym, 2020; Barlow, 2004; and Wachtel, 1997, 2011).

Eye movement desensitization and reprocessing (EMDR), developed by Francine Shapiro, is a version of exposure therapy that employs imaginal flooding and cognitive restructuring in efforts to help patients process and integrate traumatic experience (Shapiro, 2017). The approach, using rapid, rhythmic eye movements and other forms of bilateral stimulation, encompasses a range of behavioral procedures.

In contrast to traditional concepts of therapeutic action set forth in the psychodynamic and humanistic paradigms, behaviorally oriented practitioners often use structured activities and tasks in efforts to help patients develop capacities and skills through experiential learning.

Over the course of the therapeutic process the clinician may model effective ways of dealing with particular situations, engage the patient in role-play of anticipated circumstances, or provide structured opportunities for the development and practice of behaviors within the sessions. Skills training approaches focused on communication, social interaction, assertive behavior, and problemsolving have been developed for the treatment of problems in living associated with a range of conditions, including schizophrenia, depression, anxiety disorders, and stress-related disorders. The clinician functions as an educator, consultant, or role model, providing information, instruction, and feedback.

Methods of behavioral activation, originally developed for the treatment of depression, challenge extended periods of inactivity, withdrawal, and avoidance associated with a range of conditions that limit opportunities to generate enriching experience and engage positive sources of reinforcement. The therapist and patient carry' out a functional analysis of behavior and collaborate in efforts to plan tasks and re-regulate patterns of activity in the routine of everyday' life.

Practitioners have expanded concepts of therapeutic action in third-wave models of therapy, as noted earlier, increasingly emphasizing the attitude of acceptance, validation, meaning, values, and mindfulness practices. The goal is to help patients engage rather than avoid, challenge, or judge the dynamics of inner life that perpetuate problems in functioning. Patients focus on sensation, emotion, thought, imagery, or memory' in an active experience of observation, exploration, and acceptance.

Over the decades researchers have demonstrated the efficacy and effectiveness of behavioral interventions for a wide range of disorders and problems in living. Although a review of the empirical literature is beyond the scope of this chapter, researchers have provided carefully focused accounts of studies and meta-analyses (see Antony, Roemer & Lenton-Brym, 2020; Hoffman, Asnaani, Vonk, Sawyer & Fang, 2012; Nathan & Gorman, 2014).

Although clinicians in the evidence-based practice movement continue to embrace nomothetic models of therapy, using standardized protocols for the treatment of specific symptoms associated with particular diagnostic categories, surveys show that most behaviorally oriented practitioners take an idiographic approach to intervention, making flexible use of a range of ideas and methods in light of the particular circumstances of the clinical situation (Antony, Roemer & Lenton-Brym, 2020). David Barlow distinguishes “psychological treatments,” or subgroups of technical procedures focused on treatment of specific symptoms associated with particular mental disorders, from broader conceptions of psychotherapy intended to address a wider range of concerns and problems in living (Barlow, 2004).

From the perspective of clinical pragmatism, as noted earlier, practitioners may combine technical procedures developed in standardized treatment protocols with ideas and methods from other schools of thought over the course of psychotherapy. As we will see in the case reports presented in Chapter 9, behavioral concepts and methods lend themselves to applications in integrative approaches across the foundational schools of thought (for further reviews of assessment procedures and methods of intervention see Anthony, Roemer & Lenton-Brym, 2020; Wachtel, 1997).

Neuroscience and Therapeutic Action

As emphasized in earlier accounts of neuroscience and attachment, clinical scholars propose that the interactive experience of the therapeutic process carries the potential to activate bonding processes associated with neuroplasticity, strengthening capacities to process subjective experience, regulate sensation and emotion, engage relational life, and initiate activities that sponsor change and growth. Although conceptions of therapeutic action in traditional models of behavioral and cognitive-behavioral intervention have emphasized technical procedures rather than the core conditions and functions of the therapeutic relationship, as discussed earlier, the second and third generations of practitioners have increasingly recognized the crucial role of the therapeutic alliance, collaboration, and the dynamics of interactive experience. Clinicians have reformulated psychodynamic and humanistic accounts of relational experience from a behavioral perspective, emphasizing concepts of acceptance, validation, and reinforcement.

Researchers assume that moderate arousal or “optimal stress” fosters neuroplasticity, learning, change, and growth, as outlined in Chapter 2. A variety of methods and activities encompassed in the behavioral paradigm carry the potential to intensify the experience of emotion, challenging patients to engage, embody, tolerate, and accept sensations, feelings, thoughts, images, and memories associated with fear, avoidance, and problems in living, creating conditions thought to activate the production of neurotransmitters and hormones instrumental in long-term potentiation, neural integration, and cortical reorganization.

As we have seen, behavioral thinkers continue to focus on the dynamics of association in formulations of learning, change, and growth, centering on the relationships between stimuli, responses, and reinforcing conditions. Associative connections are strengthened by their repeated conjunction, in reality or in imagination.

Over the years, practitioners have elaborated different methods of exposure and desensitization believed to challenge and weaken the associative links between stimuli and responses, fostering the reorganization of neural networks, strengthening capacities to regulate emotion. Methods of behavioral activation and skills training help patients challenge the inertia and avoidance associated with a range of problems in functioning, likely to generate moderate levels of stress associated with neuroplasticity.

Beyond the experiential opportunities of the therapeutic process itself, clinicians have encompassed a wide range of methods and activities in their efforts to help patients act in the course of everyday life, initiating new patterns of behavior in the outer world, including skills training, structured tasks, and planned activities. Some clinicians combine traditional behavioral methods of intervention with “bottom-up” practices believed to engage subcortical regions of the brain, including relaxation techniques, mindfulness meditation, music, dance, tai chi, and other forms of activity that use physical movement and breath, reregulating physiological states and emotion. Drawing on converging lines of study in the fields of neuroscience and trauma, researchers urge clinicians to expand the range of therapeutic approaches that engage the domains of sensation, emotion, action, and movement, hopeful that more bodily oriented forms of intervention will offer the possibility of “reprogramming” automatic physical reactions that perpetuate problems in functioning (see Van der Kolk, 2014, p. 168).

Concluding Comments

As we have seen, the earliest versions of behavioral treatment emerged from the epistemological doctrine of empiricism, based on concepts of classical and operant conditioning, disavowing the relevance of mental constructs and subjective experience, treating thoughts and feelings as epiphenomena. Over time, researchers and practitioners engaged a wider range of ideas, expanding the scope of theory and practice in more complex versions of cognitive-behavior therapy and third-wave models of treatment.

Contemporary' thinkers have come to embrace pragmatic philosophy as an alternative to the mechanistic worldview that had shaped earlier approaches, viewing behavior as “acts in context,” focusing on the functional relations and consequences of sensations, feelings, thoughts and actions, judging ideas and methods by their outcomes—what practical difference they' make in the concrete particularities of everyday' life (see Follette & Callaghan, 2011; Hayes & Hoffman, 2018; and Masuda & Rizvi, 2020, for discussion of pragmatic philosophy and the orienting perspectives of third-wave behavioral therapy). The pragmatic paradigm rejects the search for general laws that had shaped the experimental psychology' of behaviorism, focusing on the particular experience of the whole person in context (see Masuda & Rizvi, 2020, for an expanded discussion of “elemental realism” and “functional contextualisin’’ in the behavioral paradigm).

Emerging models of therapeutic action, emphasizing flexible use of ideas and methods in idiographic, “process-based” approaches to help and care, engage essential concerns in the formulations of clinical pragmatism outlined here. Clinicians center on the subjectivity of the individual, taking account of values, meaning, commitments, and goals; the crucial role of the therapeutic relationship, collaboration, use of interactive experience, and methods of communication; and the fundamental importance of action and experiential learning in understanding, change, and growth—learning by doing, as Dewey emphasizes in his pragmatic philosophy.

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