the behavior analyst today volume number 6, · pdf filebehavior to a third generation approach...

THE BEHAVIOR ANALYST TODAY VOLUME NUMBER 6, ISSUE NUMBER 2, 2005

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THE ROLE OF VERBAL CONDITIONING IN THIRD GENERATION BEHAVIORTHERAPY

JOSEPH CAUTILLIST. JOSEPH’S UNIVERSITY AND CHILDREN CRISIS TREATMENT CENTER

T. CHRIS RILEY-TILLMANEAST CAROLINA UNIVERSITY

SAUL AXELROD

PHILIP HINELINETEMPLE UNIVERSITY

Kohlenberg, Boiling, Kanter & Parker (2002) and Hayes (2004) have argued that a third generation has occurred inbehavior therapy. Hayes (2004) states the movement is characterized by several factors. These factors are, it: (a) isgrounded in empirical principles; (b) has a contextual and experiential focus giving priority to function of behaviorversus form; (c) emphasizes issues relevant to clinicians and clients; (d) synthesizes previous generations of behaviortherapy into the present form; and (e) deals with the questions raised from other traditions. To this end, this articlereviews the literature on the role of verbal conditioning in the counseling and consulting process. This literature holdsthe key to dealing with many challenges that currently face behavior therapists working from a constructional perspec-tive in their attempts to construct a helping process. In a particular, verbal conditioning could hold a central role inreducing unfavorable outcomes in psychotherapy and in answering questions of recovered memories.

Key words: third generation behavior therapy, conditioning, therapeutic relationships

Behavior therapy is witnessing a small revolution inthinking as the second generation of behavior therapyslowly gives way to the third generation (Kohlenberg,Boiling, Kanter & Parker, 2002; Hayes, 2004)1 . The thirdgeneration of behavior therapy is based more on contex-tual thinking and case conceptualizations. From the be-havior analytic tradition, several approaches are centralto the third generation of behavior therapy. These are (a)acceptance and commitment therapy (ACT) (Hayes,Strosahl, & Wilson, 1999) (b) behavioral activation (BA)(Martell, Addis, & Jacobson, 2001) (c) Functional Ana-lytic Psychotherapy (FAP)(Kohlenberg & Tsai, 1991) and(d) Integrative Behavioral Couples Therapy (IBCT)(Jacobson & Christensen, 1996). Most will acknowledgethat these new therapies have core differences; however,Hayes (2004) has presented five factors that criticallydefine the third generation of behavior therapy. These

1 The first generation of behavior therapy was interested in themoving of behavior therapy techniques based on principles ofclassical and operant conditioning from the lab into the clinic.The second generation of behavior therapy is characterized asa move toward more cognitive models of therapy and more ofa focus on rule governed behavior (Zettle, 2005).

are it is (a) grounded in empirical principles; (b) has acontextual and experiential focus, giving priority to func-tion of behavior versus form; (c) emphasizes issues rel-evant to clinicians and clients; (d) synthesizes previousgenerations of behavior therapy into the present form;and (5) deals with the questions raised from other tradi-tions. Many factors have given rise to the new wave inbehavior therapy2 .

The rise of these therapies may be in part due to theperceived equivalence in psychotherapies (see Gifford,2002); however, the meta-analysis that originally hintedat equivalence is seriously flawed both statistically andprocedurally (see Cautilli & Skinner 2001). Another rea-son for the third generation might be persistent failuresin outpatient cognitive therapies to produce more lastingor intensive clinical gains (Kanter, Cautilli, Busch, &Baruch, 2005). It is more likely that behavior and cogni-

2 Zettle (2005) describes these changes as they occurred in theevolution of Comprehensive Distancing -a second generationbehavior therapy based on Skinner’s account of rule governedbehavior to a third generation approach to behavior therapy -Acceptance and Commitment Therapy- based or relationalframe theory.

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tive therapies representing the two dominant empiricalapproaches to psychotherapy engage in a continuous dia-lectical dance, each solving problems, creating models,and in turn offering innovations. As time goes on, theyintegrate, depart, challenge each other’s models of phe-nomena, answer new questions, and reintegrate. Thirdgeneration behavior therapy is beginning to receive grow-ing empirical support for both its models of psychopa-thology and its technologies for treatment (see Hayes,Masuda, Bissett, Luoma, & Guerrero, 2004).

Behavior therapy is a dynamic and creative process.Each client presents a new challenge because clients dif-fer in genetics, behavioral histories, current life situa-tions, desires, goals, values, and needs. Each relation-ship between therapist and client calls for the use of flex-ible skills to create the helping relationship (Williams,2002). Creation of or the building of skills and not sim-ply the elimination of behavior problems is the centralcore value of behavior therapy (Goldiamond, 1974).

Hayes (2004) points out that the synthesizing of pre-vious generations of behavior therapy into the presentform is one of the primary goals of the third generationof behavior therapy. Interestingly, as second generationbehavior therapies became increasingly cognitive, a vastbody of research on verbal conditioning drifted from ac-tive use by behavior therapists. This paper attempts toreview that literature and integrate it into third genera-tion behavioral therapies.

THE GROUNDING IN EMPIRICAL PRINCIPLESAt the core of each of the behavioral models such as

FAP, IBCT, and Behavioral Activation is the assumptionthat the consequences of a person’s verbal behavior in-fluence what the person says. As we will argue, this modelhas substantial representation in the literature; however,as many behavior therapists began to seek cognitive ex-planations of behavior, this literature became less popu-lar. This empirical base places the focus of therapysquarely on the therapeutic relationship— between thetherapist and the client in therapy and the consultant andconsultee in consultation.

Several early laboratory experiments suggested thatconditioning could indeed control verbal behavior(Greenspoon, 1955; Verplank 1955). These studies foundthat various environmental stimuli could reinforce classesof verbal responses. The types of relational stimuli usedvaried from simple “encouragers” (Verplank, 1955) tonodding the head and saying “mmm” or “huh-uh”(Greenspoon, 1955; Haildum & Brown, 1956). Manyresearchers have replicated this effect (Cohen, Kalish,Thurston, & Cohen, 1954; Hildum & Brown, 1956;

Rogers, 1960; Sapolsky, 1960; Salzinger & Pisioni, 1958,1960; Wilson & Verplank, 1956). Verbal statements ofmemories also proved susceptible to conditioning (Quay,1959). In addition, the more subtle influences in the re-lationship tempered the effect (Sapolsky, 1960), as didglobal experimenter characteristics (Binder, McConnell,& Sjoholm, 1957). Conditioning can control verbal be-havior in the experimental laboratory. The next questionto answer was “Can conditioning control verbal behav-ior in the therapeutic setting?”

In studies of therapeutic verbal behavior, Williams(1964) provided a bridging review of basic research onverbal conditioning and suggested at the end of his re-view that verbal conditioning had much to offer thoseinterested in studying the counseling process. Murray(1956) analyzed a verbatim, “nondirective” case of CarlR. Rogers, and found that the categories of verbal behav-ior that were followed by brief statements ofacknowledgement or approval by the therapist increasedin frequency. Those categories in which Carl Rogersshowed disapproval decreased in frequency. In a similarstudy, Truax (1966) analyzed audio recordings of psy-chotherapy sessions conducted by Rogers. He coded therelation between the category areas that Rogers showedapproval to disapproval. Traux (1966) found that the re-lationship between approval and disapproval was con-tingent.3 He also found that Rogers reinforced certainclasses of verbal responses, but did not reinforce otherclasses of verbal responses. In particular when the clientengaged in problem solving and decision making state-ments, he was more likely to receive an “uhm” and wasrelatively likely to ignore when he would engage in com-plaining. Analysis of subsequent sessions revealed thatthe client made a significantly greater number of state-ments in the reinforced classes and a significantly fewernumber in those classes that received no counselor-thera-pist reinforcement.

In another study, Truax (1968) studied group coun-seling with patients primarily diagnosed with schizophre-nia. Patients increased their amount of self-explorationif they received reinforcement in the form of accurateempathy for doing so. This created some interest for hu-manistic therapists who at the time were conducting psy-chotherapy research. Rogers (1960) found that he couldincrease negative self-reference statements by saying“mmm-hmmm” and nodding. In addition, Rogers (1960)

3 A contingency can be calculated by the probability that abehavior will result in consequence X compared to the prob-ability that X will occur without the occurrence of the behav-ior.

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showed the opposite (positive self-reference statements)could lead to client improvements. Studies like those justmentioned, led Wilson, Hannon, and Evans (1968) tocaution therapists that their lack of awareness of the typesof behavior that the therapist in session was reinforcingcould lead to deterioration of the client’s condition. In anow well-recognized and common axiom in training coun-selors, Hildum and Brown (1956) cautioned, “the thera-pist who believes in the importance of the Oedipus com-plex could elicit Oedipal content by means of selectivereinforcement” (p. 110).

Early attempts to capitalize on the use of reinforce-ment in the counseling session proved very successful.For example, Ryan and Krumboltz (1964) attempted todetermine whether counselors could use verbal approval(expressions such as “fine” or “yep” or “good”) to in-crease clients’ statements of deliberations and decisions.They defined the deliberation response class of statementsas those involving a tentatively weighing of possible al-ternatives. Next, they defined decision response class ofstatements as those that pertained to conclusions that werereached in the past, alternatives that were rejected, ordecisions that were reached during the counseling inter-view. They assigned 60 male students to one of two coun-selors and one of three treatment intervention conditions:(a) decision responses reinforced, (b) deliberation re-sponses reinforced, and (c) decision-deliberation re-sponses not reinforced. The procedure called for eachstudent to attend 20 minute individual counseling ses-sions. Finally, they divided the sessions into operant treat-ment and extinction periods.

The authors found that both response classes -delib-eration and decision statements increased during the re-inforcement period (acquisition stage). In addition, de-

liberation and decision making statements declined whenreinforcement was withdrawn (extinction phase). Thus afunctional relationship was established between the pres-ence of verbal approval and the occurrence of delibera-tion and/or decision making statements. Moreover, thecounselors were differentially effective; that is, one ofthe counselors was clearly superior in terms of produc-ing the desired changes with the study participants.

With respect to generalization, the study observed stu-dent performance on a projective measure. Using the pro-jective measures, those clients whose decision making-responses were reinforced by verbal approval continuedto do so at a higher rate than did those clients exposed tothe other treatment protocols. The result was statisticallysignificant (p.> .05). Finally, none of the clients indicatedan awareness of the response-reinforcement relationshipduring their interviews.

In a separate study, which attempted to follow up onsome of the questions from Ryan and Krumboltz (1964),Samaan and Parker (1973) 4 compared the effects of ver-bal reinforcement counseling to advice-giving. They stud-ied the effects of verbal reinforcement versus advice-giv-

4 Samaan and Parker (1973) had one basic response class –information seeking behavior. They defined the information-seeking responses class within the interview included expres-sions of past, present, active or intent for future seeking ofrelevant information. For the study, they defined information- seeking behaviors outside of the interview as consisting ofwriting, reading, talking, self-information, visiting, listening,and job exploration. In this study, Samaan and Parker (1973)assessed the latter through interview questionnaires. Interviewquestionnaire represents a limitation of the study since no di-rect measures were employed to determine if what was saidoccurred.

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ing counseling on the frequency of information-seekingresponses within the interview. In addition, they attemptedto measure generalization by the frequency and varietyof information-seeking behavior engaged in by the clientoutside of the counseling interview. Four counselors ad-ministered the two treatments (and a no-treatment con-trol) to 50 clients in two individual counseling sessionsone week apart.

Verbal reinforcement counseling resulted in signifi-cantly more information seeking responses within theinterview (p. < .05). While not reaching statistical sig-nificance, the verbal reinforcement intervention resultedin marginally (p < .10) greater information-seeking be-havior outside the interview. In addition, the study con-tained some evidence of generalization under verbal- re-inforcement counseling by what the study referred to asa “marginally significant correlation” (p < .10) betweeninformation seeking within and outside of the interview.Moreover, the study found that verbal reinforcement wassubstantially superior to advice giving with respect toinformation seeking and the generalization of informa-tion seeking responses. The authors did not mention evi-dence of client awareness in the study. The generaliza-tion of the information seeking behavior outside the ses-sion might be accounted for by a history of correspon-dence for linking what one says to what one does (seeOsnes & Adelinis, 2005). The basic effect of condition-ing of verbal decision making responses was replicatedmany times (see Table 1).

A CONTEXTUAL AND EXPERIENTIAL FOCUSGIVING PRIORITY TO THE FUNCTION OF BE-

HAVIOR VERSUS THE FORMMany applications of verbal conditioning exist in the

counseling literature. These applications provide the ba-sis for a functional interpretation of verbal responseclasses that occur in session and indicated how the rein-forcement of such classes can affect behavior outside thesession. The goal of many of these studies was to targetbehaviors seen as critical to various populations. For ex-ample, with an extremely difficult clinical population suchas “sociopaths” verbal conditioning was shown to be ef-fective (Bryan & Kapsche, 1967). They worked with male“sociopaths” to condition first-person pronoun responsesin an effort to increase personal accountability. This canbe seen as an important outcome for sociopaths, who tendto blame others for their behavior rather than themselves.With a less severe population, Williams and Blanton(1968) studied the role of conditioning in male,nonpsychotic psychotherapy in-patients. In this study, theywere able to increase “feeling response,” which was seen

by the authors as a positive outcome.Verbal conditioning has been shown to increase func-

tional classes with relatively high functioning populationsin the counseling relationship. For example, Dicken andFordham (1967) conditioned positive self-reference andpositive affective responses in female college students.This demonstration of a functional relationship can sug-gest that therapists attending to self-reference and affectcan differentially increase or decrease such responses.This was replicated by Ince (1968), who also conditionedpositive self-reference responses in female college stu-dents. Also with female college populations, Lanyon(1967) conditioned response relevant common to parent’sconcerns in female college students. Kramer (1968) usedconditioning to increase the questioning of appropriate-ness of past and present behaviors, responsibility, andpositive responses in male and female college students.

With younger populations the results seem similar.Hansen, Niland, and Zani (1969) conditioned social ac-ceptance responses in elementary school children. WhileMyrick (1969) looked at male junior high school studentsand reinforced increasing self-reference responses.

Working out the best guidelines to suggest for condi-tioning became a central issue of parametric studies inthe counseling literature during that time. To this end,Denner (1970) found that “crafty” therapists, those whocould condition their clients without the client’s aware-ness, were more effective at conditioning verbal behav-ior. In addition, clients rated their verbal style as “lessclear” and “less certain.” However, Denner (1970) alsofound that if the client was informed about the condi-tioning procedure, those clients learned more rapidly. Theprocess of verbal conditioning proved powerful, evengetting an individual with schizophrenia, who had notspoken in years, to speak (Issacs, Thomas, andGoldiamond, 1960). Parametric studies showed that allof these results could occur either with or without theawareness of the subject (Patterson, 1963). Ince (1968)stated:

“By using behavioral principles, such as those employed inthis study, the counselor or psychotherapist will be able toquantifiably measure the behavior of the client or patient whenthe client first comes for assistance, measure his own responsesto this, and finally to note the effects of his behavior upon theclient. By refusing reinforcement, in specified amounts and atspecified times, the counselor will be able to precisely deter-mine which of his behaviors produced the desired effect uponthe client’s behavior. And, by measuring the behavior of theclient prior to, during, and following the reinforcement proce-dure, the counselor will be able to state the degree and direc-tion of change in the client’s behavior.” (p. 144)

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Hosford (1969) followed with a comprehensive re-view in the behavioral counseling research with a strongemphasis on verbal conditioning. He concluded that ver-bal conditioning was a significant factor in the counsel-ing process whether counselors were aware of its use ornot. Erthal (1980) investigated the similarities and dif-ferences between verbal conditioning and psychotherapy.She found many therapies, who purportedly rejected ver-bal conditioning, actually employed verbal conditioningwith clients.

The above factors can tell us much about the possiblefunctions of verbal behavior within the counseling andtherapy session. They suggest that a major function ofverbal statements within the therapy setting might be toget the counselor or therapist’s attention. In addition, thesestatements could generalize as either contingency-shapedbehavior or rule-governed codes of conduct from the ses-sion. Thus social reinforcement may hold more powerthan previously thought and could create problems forthe client.

DEALING WITH THE QUESTIONS RAISED FROMOTHER TRADITIONS

Verbal Conditioning and False Memory

One current controversy in the psychotherapy litera-ture is the concept of false memory. Rosenwasser, Cautilli,& Reynolds, (1997) demonstrated that verbal condition-ing combined with instructions could produce distortionsin memory leading clients to judge pictures of bruises asmore severe than the participants initially perceived themto be. However, they failed to find durability in the phe-nomena. Loftus (1993) successfully implanted memoriesfalse memories in various subjects most notably a 14-year old, who she encouraged to falsely believe that hewas lost in a mall at five years old. The initial reactionfrom the therapeutic community was that false memoryrepresented a form of societal backlash and social denialof male violence (Zerbe-Enns, 1996).

Evidence continued to mount and one famous case offalse accusations of preschool personnel known as theMcMartin preschool case brought the issue to nationalattention. Garven, Wood, Malpass, and Shaw (1998)5

found that the interviewing techniques in the McMartinpreschool case induced children to make false allegationsagainst a classroom visitor. When reviewing the videosof the interviews, they found that the interviewers exten-sively used verbal reinforcement along with “co-wit-nessed”5 information in the process. Garven, Wood, andMalpass (2000) more closely examined the informationin the interviewing process. Children who received the

verbal reinforcement process made 35% of the allega-tions against the visitor, while only 12% of the controlchildren did. For events that the authors defined as “fan-tastic,” the differences were even more striking: 52% ofthe group receiving reinforcement for allegations madethe claim, while only 5% of the control children did. Thesechildren repeated the allegations even after reinforcementwas discontinued in the second interview. These allega-tions later were proven false. The authors concluded thatchildren can “swiftly be induced to make persistent falseallegations of wrong doings”

SYNTHESIZING OF PREVIOUS GENERATIONSOF BEHAVIOR THERAPY INTO THE PRESENT

FORM: VERBAL BEHAVIOR ANDCONDITIONING

Integration into Therapies

Kohelnberg and Tsai’s (1991) functional analysis ofthe therapeutic relationship is an example of a third gen-eration behavioral therapy that uses verbal conditioning.It attempts to capitalize on the use of verbal conditioningin therapy but enhances the process by two factors. Thefirst is that it uses Skinner’s (1957) concept of supple-mentation. This is a process by which critical elementsare identified as clinically relevant and targeted for inter-vention. The second is that it uses a behavior develop-ment model of “self” based on Skinner’s (1957) analysisof verbal behavior.

Supplementation is a process used to enhance thera-pist awareness of clinically relevant behavior. The pro-cess makes therapists more aware of multiply controlledspeech statements of the client, by identifying relevanthistorical variables in the client’s life that may establishconditioning histories. Through this awareness, therapistscan recognize “clinically relevant behavior” as it arisesin the therapeutic session and condition improvement orredirect continued problematic behavior.

In addition, Skinner’s (1957) functional analysis ofverbal behavior is used to build a developmental modelof self. This model is then used to identify and treat vari-ous problems of self through verbal conditioning such asdissimilative identity disorder. (See Kohlenberg & Tsai,1991, as well as Phelps, 2001 for a relatedconceptualization.) FAP has a number of case reports of

5 An example of co-witnessed information would be to say toa child who said that he did not see something happened astatement like “That’s funny, [insert child name] said that hesaw it.”

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success even with severely impaired populations (e.g.,Holmes, Dykstra, Williamns, Diwan, & River, 2003).

Behavioral activation attempts to provide idiographicfunctional assessment of clients’ problem behavior(Kanter, Callaghan, Landes, Busch, and Brown, 2004;Martell, Addis, & Jacobson, 2001). Conditioning of ver-bal behavior in the therapeutic session represents anotherway for therapists to help increase environmental rein-forcement for clients. If problem-solving behavior, canbe shaped in session as Krumbolz and Ryan (1964) sug-gest, and will generalize outside of session, then this canhave a powerful impact on a client’s ability to lessen pun-ishment and increase reinforcement outside of session.

Integrative behavioral couple’s therapy attempts tobuild acceptance between partners (Cordova, 2003;Chapman & Compton, 2003). Studies of verbal condi-tioning in both the individual setting and the group set-ting show conditioning are effective in increasing thenumber of self-acceptance statements (Hansen, Niland,& Zani, 1969). Therapist use of verbal conditioning couldenhance the acceptance of couples of one another’s dif-ferences, while the misuse of conditioning could lead toa decline in the couple’s acceptance of themselves andtheir partners.

Integration into Consultation

Third generation behavioral technologies have hadlittle impact on the consultation process to date. Condi-tioning of verbal behavior can be a good starting pointfor this technology to affect consultation. Behavioral con-sultation is defined as a problem solving process (Bergan& Kratchowill, 1990). If consultants can strategically useverbal conditioning to help consultees to increase deci-sion making, develop plan strategies and tactics and im-prove problem solving, this can result in improved be-havior in students.

Indirect evidence suggests that conditioning can af-fect consultee’s “perception” (or seeing behavior to theradical behaviorist) in the consulting relationship. Forexample, Wickstrom (1991) found that consultant sup-portive statements, following emissions of difficulties theclient was having, had a positive correlation on the over-all rating of teacher satisfaction. Researchers should becautious with the findings from this study becauseWickstrom’s study (1991) was hampered by a small prob-lem improvement and sample size of only 9 participants.

In addition to the above, Huges and DeForest (1993)found a significant positive correlation (r= .46, p< .05)between the consultant’s use of positive validation state-ments to the teachers and the overall rating by the teach-ers as to the consultant’s overall effectiveness. Interest-

ingly, Huges and DeForest (1993) found no correlationbetween problem improvement and this category. Finally,Marten, Lewandowski, and Houk (1987) found a corre-lation of .54 between the teachers’ perception of satis-faction and consultant’s validation statements (no p val-ues given). Using sequential analysis, Martens and col-leagues (1987) found that the sequence where the teachergradually specifies the child’s behavior and the consult-ant makes a statement validating the teacher’s statementaccounted for 42% of the variance in teacher satisfac-tion. They found no effect on child improvement for thissequence. The question of course is open as to whetherthe consultee’s behavior can effect the perception thatthe consultant has of the consultee.

EMPHASIS ON ISSUES RELEVANT TO CLINI-CIANS AND CLIENTS

Another issue of particular interest to third genera-tion behavior therapies is focusing on issues that affectclinicians. Two areas that verbal conditioning might bewell suited to clinician interest are (a) the effects of suchprocesses on the behavior of the therapist and (b) a moreproductive dialogue on the old debate of the negative ef-fects of psychotherapy.

The Effects of Such Processes on the Behavior of theTherapist

Reinforcement of verbal behavior and its opposite,the punishment of verbal behavior, can have profoundeffects of the therapeutic relationship. Cautilli andSantilli-Connor (2000) argued that many functional fac-tors within the therapeutic relationship can create resis-tance from clients in therapy and consultees in consulta-tion. Clients’ failures to do what they are supposed to do,can create frustration for the therapist. Recent researchhas found that consultee’s resistance can punish consult-ant therapeutic behavior and that this can decrease con-sultant therapeutic statements and consultants’ percep-tion of their own effectiveness (Cautilli, 2005). More re-search needs to be done in this area, but it may be thatthis problem could lead consultant burnout.

A More Productive Dialogue on the Old Debate of theNegative Effects of Psychotherapy

In the late 1970’s and through the mid 1980’s, psy-chology was riveted on the discussion of negative out-comes in psychotherapy. The discussion seemed to dis-appear from the journals without adequate follow up. Onepossible reason was that many authors were convincedthat research designs needed to be improved to distin-guish casualties from “spontaneous deterioration” in

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which the client’s condition declined as a result of lifeevents or their own biological factors (Mays & Franks,1980; Rachman & Wilson, 1980). Rachman and Wilson(1980) offered a logical argument for spontaneous dete-rioration “If spontaneous deterioration did not take place,mental health workers would join the ranks of theunemployed.”(p. 99).

Another possible reason was that the process had justbegun at the time for psychotherapy to be accepted asmore than just support but as a viable clinical treatment.During this time, a national debate was occurring overwhether psychotherapy should be paid for under insur-ance plans. Many in the field were concerned that dete-rioration effects attributable to psychotherapy would leadto rejection of psychotherapy being an intervention paidfor by insurance carriers. Mays and Franks (1980)claimed:

“The negative effects in psychotherapy is raised at acritical juncture in the history of mental health profes-sionals. The increase in third party payments for psycho-therapy services has resulted in greater concern for evi-dence that psychotherapy is safe and effective….” (p. 78)

From a historical perspective, it seems apparent thatthe aforementioned condition combined with the poormethodological vigor of the day, led many to conclude asdid Strupp, Hadley & Gomez-Schwartz (1971) “Aftercritically reviewing psychotherapy outcome…. nearly allof the studies are marred with multiple flaws.” (p.28).While others more open to the possibility of deteriora-tion, but not wanting to attribute it to therapy, such asMays and Franks (1980) stated “our estimate of deterio-ration rates, ….are 1% for behavior therapy, 3% for in-sight therapy, and 7% for controls.”(p. 88)

It is always difficult to have a productive discussionover matters that might increase professional liability;however, since the publication of American Psychologi-cal Association establishing efficacious practices in psy-chotherapy (American Psychological Association (APA),Division 12, 1995), now is probably the time to have amore productive discussion over the factors linked totherapists that might cause client deterioration in therapy.Since the phenomena did not appear to be limited to anyone particular form of therapy, a process that is subtleenough to occur in all psychotherapy relationships couldbe at the base. This common factor suggests a possiblerole for verbal conditioning within the therapeutic rela-tionship. Kaul and Bednar (1986) reviewed extensivelythe literature on group casualties and discovered a casu-alty rate of approximately three percent. In his review ofthe literature, Bergin (1981) suggested that calculationof global rates for individual therapy would be impos-

sible, given the large variations in studies. Some studieshave linked therapist behavior to such client deteriora-tion (sometimes referred in the literature to as therapycasualties) in group therapy (Liberman, Yalom, & Miles,1973) and in individual therapy (Lambert, et. al. 1986;Ricks, 1974; Sachs, 1983; Truax & Mitchell, 1971). Therole of verbal conditioning in casualty outcomes need tobe assessed.

While it is easy to see that an overly punishing orcold therapist could produce unfavorable outcomes (Lam-bert, Bergin, & Collins, 1977), a verbal conditioning ap-proach would suggest the opposite behaviors to thosereviewed in the section on verbal conditioning could alsobe reinforced by well intentioned therapists. Such fac-tors may lower a sense of self worth and/or build depen-dency on the therapist. For example, as previously stated,Ince (1968) conditioned positive self-reference responsesin female college students. A less than skilled therapistcould accidentally reinforce negative self-reference re-sponses. In another example, a therapist quick to “help”and give clients answers when they try to develop them,may inadvertently reinforce client indecisiveness and re-inforce client dependency. A third generation behaviortherapy like FAP would suggest that reinforcing clini-cally relevant problem behaviors in a session would in-crease those behaviors. Thus, clients who continually goto therapy and talk about how poorly they see themselves,after many sessions might increasingly see themselvesas less and less competent.

Some therapists, because of lack of knowledge of con-ditioning and various prompting strategies, engage in in-competent or well-meaning but misguided behaviors,sometimes with disastrous consequences for patients(Loftus, 1993; Pope, Simpson, & Weiner, 1978). In addi-tion, specific therapist behaviors, such as instructions onthe therapist’s part encouraging clients to speculate(Loftus, 1993; Schreiber, Wentura, and Bilsky, 2001) andreinforcement for engaging in accusatory behavior(Garven, Wood, & Malpass, 2000) at least in children,can create false memories and accusations. These factscreate a much more complex view of the therapy pro-cess. In this view an empathetic, caring, and warm thera-pist, who contingently reinforces the wrong behaviorscould have negative effects on clients. This process isdoubly problematic given that therapist may have littletraining on verbal conditioning and shaping of responses.To the last, we believe that third generation behavior thera-pist have much to add to the debate.

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Author Contact InformationJoseph Cautilli, Ph.D., Children’s Crisis Treatment Center, 1823Callowhill St., Phila., PA Tel.: 215-496-0707 ext. 1166, email:[email protected]

T. Chris Riley-Tillman, Ph.D., East Carolina University, Departmentof Psychology, Rawl Building, Greenville, North Carolina 27858-4353,Tel.: 252-328-6800. Email: [email protected]

Saul Axelrod, Ph.D., Department of Curriculum, Instruction, and Tech-nology in Education, Temple University, 441 Ritter Hall, Broad andMontgomery, Philadelphia, PA 19122, Tel.: 215 - 204 – 6060. Email:

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[email protected].

Philip Hineline, Ph.D., Department of Psychology, Temple Univer-sity, Weiss Hall, Cecil B. Moore Ave., Philadelphia, PA 19122. Tel.:215-204-1573, email: [email protected].

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Erratum:

Ommission from Cautilli et al. BAT 6.2 (2005) on Verbal conditioning - The following reference wasmissing:Ryan, T.A & Krumboltz, J.D.(1964). Effects of planned reinforcement counseling on client decision-making behavior. Journal of Counseling Psychology, 11, 315-323.

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ERRATA

In the article Cautilli, J.D., Riley-Tillman, T.C., Axelrod S. and Hineline, P. (2005): “The Role of Verbal Conditioning in Third Generation Behavior Therapy” - The Behavior Analyst Today, 6.(2), Page 138-145, all references to Boiling should be Bolling. _____________________________________________________________________________

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