A Beginner’s Guide to Clinical Behavior Analysis
If you’re interested in studying how to treat ‘mental health’ issues, as a behavior analyst, Clinical Behavior Analysis (CBA) is the pathway you should be looking into.

Clinical Behavior Analysis (CBA) is not a new area for behavior analysis, in fact, behavior analysts treating “mental health” issues pre-dates the refocusing of the field to the treatment of Autism. Clinical Behavior Analysis involves using learning principles to help people who often identify as having “mental health” challenges change their behavior and improve their functioning. 

What is Clinical Behavior Analysis?
Clinical Behavior Analysis (CBA) is at the intersection of behavior analysis and psychology. It is the application of behavioral principles to changing behaviors previously considered to fit in within the are of ‘mental health’. Clinical Behavior Analysis focuses on changing behavior through functional analysis and reinforcement of more adaptive behaviors. CBA requires evaluating the impact of multiple levels of contingencies on the client and determining which level(s) of contingencies to intervene on to create the most impact in changing the client’s behavior. Changing the client’s behavior – also tends to change the client’s experience. Application of behavioral principles to ‘mental health’ has existed since Skinner’s time; however, much of CBA fell out of popularity during the Cognitive Revolution within psychology. Now, with ‘psychology’ in a replication crisis born of the constructs and methods that allowed for rapid growth and division from behavior analysis – CBA is rising again in popularity.

History of Clinical Behavior Analysis
Clinical behavior analysis was developed during a time of rapid growth and change in scientific psychology. With a strong interest in data-driven treatment, John B. Watson and other early behaviorists began researching methods that could be scientifically verified. They turned away from early clinical work with mental health issues—and techniques that couldn’t be measured or observed—and toward controlled experiments. They laid down a foundation for understanding how different operant and classical conditioning might be used to treat behaviors considered “mental illness.”

During the Cognitive Revolution, Clinical Behavior Analysis as a clear arm of behavior analysis fell out of focus; however, treatments based on behavior analytic principles grew within realms of “psychotherapy” traditions. These treatments are now often confused as themselves being CBA. Examples of these treatments that fall into this category include Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Functional Analytic Psychotherapy (FAP). To be clear – ACT, DBT, and Functional Analytic Psychotherapy may be performed in ways that are CBA – but they are not by default CBA. It is entirely possible to do ‘canned ACT’ or to otherwise do what people recognize as one of these treatments without using functional analysis to guide treatment. In those cases, these treatments are not CBA.

Acceptance and Commitment Therapy as Clinical Behavior Analysis
Acceptance and Commitment Therapy (ACT) has become very popular with behavior analysts, particularly as Relational Frame Theory (RFT) and as a clinical behavior analysis recently. There is much current debate over whether “ACT” is clinical behavior analysis. This debate is well warranted as ACT though grown out of Relational Frame Theory and explicitly behavior analytic principles diverged to compete with cognitive-behavioral treatment packages. This necessarily led to a language that would fit training a multitude of clinicians (mid-level terms) and result in higher inter-rater reliability in Randomized Controlled Trials (RCTs) against Cognitive Behavioral Therapy (CBT). Most would say “ACT” accomplished its goals here and now is recognized as a treatment efficacious for the treatment of a wide variety of “psychological” problems right alongside its former chief competitor, Beckian CBT. Now – the issue becomes that most of the existing training on ACT follows the patterns set during this period. These trainings are meant for psychotherapists, use imprecise mid-level terms that tend to confuse behavior analysts, and do not well prepare behavior analysts for utilizing ACT in ways consistent with behavior analytic scope and practice. 

Functional Analytic Psychotherapy as Clinical Behavior Analysis
Functional Analytic Psychotherapy has its foundation behavior analytic principles as a way of improving in-session behavioral repertoires. The clinician then seeks to generalize these in-session improvements to the client’s outside-of-session life. In recent years, this treatment has also begun to go the way that ACT did to become better recognized as an effective psychological treatment. This has included, again, developing standardized terminology and even beginning to focus on a more specific set of clinical problems. This again – is well suited for the treatment becoming a competitor in “psychotherapy” according to standards of Randomized Controlled Trials (RCTs) but does not bode well for the training of behavior analysts in this treatment according to their scope and capabilities.

Dialectical Behavior Therapy as Clinical Behavior Analysis
Dialectical behavior therapy (DBT) is a form of therapy developed by Marsha Linehan, Ph.D., that emphasizes chain analysis, fading, and reinforcement of less dangerous behaviors in its population of interest. This approach has been shown effective in treating people who suffer from intense suicidal urges or self-harming behaviors like cutting or drug addiction. Despite how DBT has held to its roots somewhat more effectively than it would seem ACT and Functional Analytic Psychotherapy have – it is also in this writer’s opinion likely the most out-of-scope for behavior analysts simply due to the typical target applications of the overall treatment package. There are many places where topography can be picked up under supervision for behavior analysts and treatment methods may be taught consistent with behavioral principles and behavior analysts’ scope of practice. DBT applied to “borderline personality disorder” is well appreciated for its difficulty and danger in application. True “DBT” is performed with a team of clinicians, with a great deal of support, and is not for behavior analysts beginning to develop skills in Clinical Behavior Analysis. 

Clinical Behavior Analysis as Clinical Behavior Analysis
It’s because of the incompatibilities in how some of these treatments are now taught that I prefer to refer to Clinical Behavior Analysis as “Clinical Behavior Analysis.” If we are clear in labeling it differently, it will be easier for behavior analysts wanting training in ACT or other treatment techniques to find clinicians able to train them in ways consistent with their scope and behavioral principles. This does not again mean that one cannot learn the techniques used in “ACT” but that one will likely be learning them without the use of mid-level terms and with more precise and clear linking to behavior principles. 

by Angela Coreil, PhD

In my recent invited talk at CalABA on Clinical Behavior Analysis as a way of unifying the behavioral sciences, I alluded to a series of painful learning experiences that brought me to Clinical Behavior Analysis.

My training path has been long and winding – all with the intention of finding ways to improve clinical treatment. You see, I grew up with a close family member experiencing a great deal of impairment, emotional pain, and later addiction. I was present for years of this family member seeking treatment and even as a child seeing failures in the systems meant to help her. I watched her go through the revolving door of inpatient units, which became like brief vacations to her. I watched as therapists seemed helpless to soothe her pain. And, I watched as she was prescribed pill after pill to ease her pain. I was at an early age effectively an involuntary ‘mental health’ crisis worker.

This led to a passion for understanding human behavior and a desire to find better ways to address human suffering. I believed that I could best influence treatment by becoming a process and outcomes researcher and set upon a long path to become this. I spent a number of years gaining experience on process and outcomes studies at a number of major research institutions in Houston, Texas where I lived. Then I happened upon on a job as a Research Coordinator for a project called “Opportunity Houston.” This was a large grant focused on treating dual diagnosis (mental health + addiction) homeless individuals. The study focused in some respects on enriching the environments of those experiencing addiction by providing housing and work, contingent on improving maintenance of sobriety. I later learned this was a study in part of Kelly Wilson’s design, an ACT founder. At the time, I would not have known who he was but the William “Dub” Norwood was my advisor there and he was an early ACT devotee.  

It was through him that I began to be exposed to ACT and then entered the University of Houston – Clear Lake for my master’s in Clinical Psychology. Following this, I started my doctorate in Clinical Psychology under Rob Zettle, Steve Hayes’ first student who played a strong role in developing ACT back when it was called “Comprehensive Distancing.” Throughout my master’s I found myself drawn to ACT, in its stance that human suffering was a natural part of the human experience and often an extension of otherwise adaptive behavior. In my early exposures to Beckian Cognitive Behavior Therapy, I was often presented with a list of ‘cognitive distortions’ and told that treatment would in part be helping clients recognize their ‘cognitive distortions.’ At the time, I found this conceptualization offensive and insensitive. I could not imagine myself telling other humans experiencing pain that their painful thoughts were ‘distortions’ of reality.

I would say that the way that clinical psychology training is currently structured – learning deeply the key elements of treatment is not an easy experience. We are typically taught behavioral principles but soon after we begin to divide off into camps to learn the particular language ways of our chosen orientations. I broke from this tradition repeatedly because beyond my allegiance to “ACT” was the guiding rule that my mission was to find ways to understand and improve treatment as a process researcher. I became more fluid in ACT treatment and began to depart from “canned ACT” in the early years of my doctorate. I had early experiences of clients with Obsessive-Compulsive Disorder” finding ways to “compulse” (momentarily avoid or reduce their anxiety) with the very ACT exercises I provided them. One client taught mindfulness, returned the next week to tell me how effective mindfulness had been in reducing their anxiety. I asked what had occurred and the client recounted engaging in mindfulness ‘instead of’ compulsions each time they became anxious. 

I went back to Rob and told him what had occurred and in his monotone way of beating a dead horse for my benefit he said ‘Yes, of course.’ And, then followed it with the ‘Hole in the Field’ metaphor to illustrate how I’d simply given the client a new shovel. Now, I would need to again – get them to drop their new improved ‘shovel.’ This was all in the context of learning Exposure and Response Prevention (ERP) also known within the behavior analytic community still as desensitization.

It was working in OCD and specializing in a particular technique that was widely endorsed across theoretical orientations as the ‘gold standard’ (i.e., ERP) for treating anxiety and related disorders that allowed me, I believe, to be able to track more about the differences in models as a I learned. After learning this technique well embedded in ACT, I sought out an Advanced Assistantship with the closest highly regarded research and treatment specialty center in Kansas. My clinical supervisor was widely regarded as a highly-skilled Beckian Cognitive Behavioral Therapy clinician and researcher. My initial learning experiences here were somewhat disorienting; however, as I went in with experience and skill validated by ACT experts. Fairly quickly into my training at this center, it became clear that ACT was not particularly favored by my supervisor and to treat clients under her supervision using similar language was quick to elicit punishment.

I remember writing back to my lab at that time and questioning whether I was actually proficient in ERP and ACT. The response I received was telling – but for years I did not fully understand the impact of what I was told in the full context of my academic experience. Rob told me that my ACT and ERP was fine and that I would simply have to ‘learn their language.’ He mentioned that as Steve Hayes’ first student he was also sent to work under the competing theoretical model for his internship year – under Aaron Beck. Though he never disclosed much about this experience directly it often seemed apparent that his internship year had probably not been easy on him.

I’d like to say that I won this particular CBT expert over; in fact, I learned the language and got out as soon as possible. I seemed to be fighting a battle far bigger than myself with zero footing as a new mother of a 4-month old just pre-internship. From here, I moved onto working at Rogers Memorial Hospital under Brad Reimann and running the day-to-day clinical management of an adult Intensive Outpatient Program for OCD in Oconomowoc, Wisconsin. By that time, I had mastered the CBT language and found myself commended and promoted for my treatment skill.

by Angela Coreil, PhD

Fields Ready for Change: Notes from CalABA 2022

As I sit here today, recalling my experience of CalABA and the responses to talks, including but not limited to my own talk on unifying the sciences, it is clear that change is both needed and wanted. We find ourselves in a world where COVID has altered how we operate in our lives and in our world. We have found ourselves in the ‘Great Resignation’ of people leaving their positions and rethinking their priorities out of necessity.

I too have been on this journey. Long before 2020, I found myself embedded in a system of seemingly unworkable contingencies. This led to several years of inventing and reinventing myself and my career – and finally to freedom from the system that had held me down for a decade. It is from this perspective and with this experience that I find myself advocating for the field to be better, not because I am the right person to do so, but because I built myself a system that allows me to speak up more freely than most.

At CalABA 2022, I was able to speak at my first in-person conference since freeing myself from academia. I found myself re-invigorated by the presence, energy, and curiosity of those who attended my talk: Clinical Behavior Analysis: Unifying the Behavioral Sciences. It was inspiring to see how many people were already thinking about how to find a common language between behavior analysis and psychology and how many people were working in positions where they both needed and wanted more guidance on how to navigate the intersection between our fields.

There were a number of patterns that were evident in the responses of attendees. First, many were unaware that Clinical Behavior Analysis has existed since the 1950s. Second, the pervading thought was that additional degrees would help broach this gap – yet, those with multiple degrees broaching both fields still had the same questions. “Which hat am I operating under?”, “How do I know if I am still in scope?”, “Where does ‘ACT’ begin and end in relation to RFT and to the clinical situation I find myself in on a daily basis?” Many were struggling with how to speak to colleagues and stakeholders about the areas where our fields meet and divide. And, as I presented regarding the bubble forming as more behavior analysts enter the field and nearly all enter the Autism treatment area – there was recognition of how this affects the perception of behavior analysis, drives the narrowing of treatment programs, and ultimately will leave behavior analysts vulnerable to changes that are not under their control (e.g., changes in the DSM, etc).

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by John Wesenberg, M.S., BCBA, LBA

                                                                                         Defusion, ACT and RFT

A core process of Acceptance and Commit Therapy (ACT) is defusion. ACT processes by nature are often confusing for behavior analysts as they are not described precisely, and often cannot be. Defusion is often described assisting client in “creating some distance”, though momentary, from their thoughts and feelings that function as ‘rules.’ Defusion is meant to help the client contact direct contingencies when relating to verbal symbolic stimuli has become more dominant. In terms of Relational Frame Theory – defusion occurs when we alter the form, function, or frequency of a stimuli such that histories of verbal relating fall away and direct contingencies are briefly contacted.

For example, a popular exercise demonstrating defusion is the ‘milk, milk, milk” exercise. In this exercise, the clinician brings up “milk” and asks participants to think about milk. The clinician may then ask if in the process of thinking about “milk” whether the client is able to in some sense contact the taste, texture, or experience of their previous history with milk. Most individuals will report that they can contact “milk” though not present in the room with them now. The clinician may then engage the client in an exercise where the word “milk” is repeated in rapid succession, out loud, for a minute. Following this exercise – the clinician may ask what the client may have noticed about their experience of “milk” during and directly after the exercise. When the exercise has functioned as intended, the client will often report that they noticed things they had not before – for example that “milk, milk, milk” said repeatedly and rapidly sounds like “quacking” or that during the exercise they briefly ‘lost’ connection with their previous ‘experience’ of the taste, feel, etc of “milk.” Thus – defusion is meant to use the properties of verbal symbolic behavior to alter briefly which contingencies the client can track.     

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Reference

Barnes-Holmes, Y., Barnes-Holmes, D., McHugh, L., & Hayes, S. C. (2004). Relational frame theory: some implications for understanding and treating human psychopathology. International Journal of Psychology and Psychological Therapy, 4, (2), 355-375).

by John Wesenberg, M.S., BCBA, LBA

Rule Governance and use of Values to Facilitate Exposure for OCD

Behavior is dynamic and influenced by many contingencies simultaneously. Relational Frame Theory (Hayes et al., 2001) is an extension of behavior analytic principles to the human ability to learn language/symbols and the affects of these over-riding behavioral repertoires on our behavior. This extension accounts for much of human psychopathology that had defied previous parsimonious behavior analytic explanations.

“Values” are verbal constructions of meaningful directions for our lives. For example, a person may value “being a warm father.” This is by nature something that can never be “completed” but we can also always act in accordance with this statement. Orienting to values can serve as a motivating augmental. That is, the stimulus functions of a particular stimulus may be augmented to make them more or less salient.  For example, changing a diaper may for most be a rather aversive experience but for the father who holds the value of “being a warm father” and brings this to the experience of changing diapers – diaper changing may be transformed to almost an enjoyable task!

Within the clinical context, treatment of Obsessive Compulsive Disorder may be facilitated through presenting stimuli that remind the individual of their values at key points during exposures. For example, an individual who engages in excessive washing/ cleaning compulsions due to contamination concerns may be ‘stuck’ in a loop of avoiding an aversive experience in the short term through compulsions (e.g., excessive bathing and grooming). If this individual values “being a warm father” as described above – this may be used to help facilitate new flexibility in his behavioral repertoire in the presence of normally aversive and avoided “contamination.” For example, in treatment the father may be asked to engage in exposures that involve changing mock or real diapers. The client may normally rate this as a “7” on a scale from “[not anxiety provoking at all] 0 to 10 [extremely anxiety provoking]” normally. The clinician can present the task in the context of conversation that prompts the client to attend to their values, for example “John, I know that you value being a warm father. Does loving your child and caring for them warmly mean that you will care for their basic needs?” “Can you bring your love for your child into this moment to help you move towards what matters most?” [Note: All examples are by nature topographical and function of these statements must be assessed and applied ideographically, rather than topographically.] If these statements function as a motivative augmental for the client – the client may report that their starting anxiety rating lowered, “I know that I said this was a ‘7’, but now it feels like a ‘5’ when I think of my son.” Additionally, you may see that the client is more willing to approach, maintain contact, or resist compulsions – as the aversive functions of ‘contamination’ are augmented to a more workable range for the client.

Sign up for our mailing list or check out our continuing education if you’d like to learn more about clinical behavior analysis or rule-governed behavior!

Reference

Barnes-Holmes, Y., Barnes-Holmes, D., McHugh, L., & Hayes, S. C. (2004). Relational frame theory: some implications for understanding and treating human psychopathology. International Journal of Psychology and Psychological Therapy, 4, (2), 355-375).

Hayes, C. S., Barnes-Holmes, D., & Roche, B. (2001). Relational Frame Theory: A Post- Skinnerian Account of Human Language and Cognition. New York, NY: Kluwer Academic/ Plenum Publishers

by John Wesenberg, M.S, BCBA, LBA.

The Function of Instructions in the Therapeutic Context

Instructions, both explicit and implicit, are important to providing the best care to an individual in the therapeutic context. The difficulty is determining the interlocking contingencies needing to be shaped and strengthened in a package treatment. For this analysis, exposure and response prevention (ERP) for individual’s diagnosed with obsessive-compulsive disorder (OCD) will be the exemplar of how and when to use instructions in clinical care. Detailed, explicit instructions and feedback are important to a client in clinical care for the following reasons:

1. Therapeutic stimuli such as exposure assignments, practice and interoceptive forms, help with fluency and maintenance of expectations for a longer, and more consistent performance. These stimuli, when arranged and taught correctly, are easily accessible, readable, understandable, and sustained in the individual’s life in and out of treatment.
2. Instructions and feedback can be communicated in clear contingencies of reinforcement to promote behavior momentum and consistency in responding. If… then… or first… then… statements indicate when to engage in activities that maintain responding. These contingencies are strengthened by incorporating values and personal preferences. Establishing operations (abolishing and motivating effects of stimuli) are accounted for and manipulated by communicating in clear and specific rules.
3. Direct rules will create long-lasting maintenance of buy-in and momentum for responding correctly to stimuli that evoke fears. When the patient understands the contingencies that create the tools that allow them to respond differently to fear-evoking stimuli, there is a higher probability of effective maintenance and generalization.
4. Rules can be used as augmentals, in that rules may serve to alter the reinforcing value or punishing value of consequences. Augmentals act as an establishing operation for increases in intensity or magnitude of an exposure or new stimulus class. For example, a therapist may say to a client, “If you are able to look at another person and respond with a one word answer when that person initiates a question 80% of opportunities for a week, you are able to play the Nintendo Switch at the end of the week,” will probably result in the client seeking feedback on their responses to others, which was previously a neutral stimulus, and attempting to meet the criterion.

Now, let’s specifically look at how indirect, implicit instructions and metaphorical feedback are important to effective clinical care.

1. Metaphors and indirect instructions allow an individual to derive flexible instructions from mapping of contingencies onto previous experiences. This prevents client’s from over-following non-functional rules rather than responding appropriately to their context and contingencies as they occur. Therapists must always be aware that they are typically perceiving a client partially through their own verbal report and possibly biased rule-governed perceptions of themselves, others, and the world. Providing direct rules can dysfunction when therapists provide instruction based on how they believe behavior functions in contexts that they cannot directly observe and manipulate. Therapists must be mindful that providing metaphorical rules can assist a client in responding and learning effectively from contingencies as they occur; rather than responding by following what the therapist ‘says’ the client learns to track their environment better.
2. Metaphors increase the variability of how an individual responds to stimuli. Variability in responding increases the possibility for accessing new contingencies of reinforcement when responding to stimuli in the natural environment.
3. Metaphors are also most effective in reflecting complex instructions that require that the client begin to track the functions of their own behavior in context. For example, in explaining how exposures work to provide opportunities for learning, a therapist may let the client know that exposure therapy is ‘more like learning to ride a bike’ than attending ‘talk therapy’ – that the therapist’s role is much like ‘getting the client on the bike repeatedly and instructing on how best to improve performance.’ Further, the therapist may state that much like learning a bike – verbal instructions alone will not effectively produce the complex behavioral repertoire of sensing one’s weight shifting in motion and continuously correcting one’s behavior in reaction to felt positive and negative consequences.
4. Metaphorical feedback evoke a context for an endless opportunity of possibilities. This is exciting to an individual because of the behavioral cusps they are currently contacting and could be contacting in the future.

Reference

Houmanfar, R., Rodrigues, J., & Smith, G., S. (2009). Role of communication networks in behavioral

systems analysis. Journal of organizational behavior management, 29, 257-275, DOI:                          10.1080/016086093092102