350 Clinical Psychology
with a nonpoisonous snake and encouraged to go as close as
they could to it and, if they were willing, to pick it up. Each
student completed a Fear Thermometer, a rating of how much
fear was experienced. The therapy consisted of devising a
hierarchy of imagined scenes involving snakes, with scenes
arranged from neutral to the most fear arousing. Then the stu-
dent was taught to relax, asked to imagine the least fear-
arousing scene, asked to relax, and so on until the student
became able to imagine scenes higher and higher in the
hierarchy without feeling anxious, a procedure known as
“systematic desensitization.” Finally the BAT and Fear Ther-
mometer were readministered, and it was found that these
students had become significantly less afraid of snakes than
randomly assigned students in a control group. Critics of
such analogue studies noted that the results might have been
less impressive had neurotic patients and their fears been
tested.
Nevertheless, later research supported the effectiveness of
desensitization procedures of various kinds in dealing with a
variety of symptoms. For example, exposure with response
prevention (allowing a patient to experience what happens
when a compulsion is not permitted) is a kind of in vivo de-
sensitization that has come to be regarded as appropriate
in the treatment of obsessive-compulsive disorders (Foa &
Goldstein, 1978).
Another major behavioral approach to treatment is behav-
ior modification, or applied behavior analysis, which comes
from the experimental work and writing of B. F. Skinner
(1938). Although Skinner’s experimental work was almost ex-
clusively with animals, neither he nor his followers have been
reluctant to apply his principles to humans, including clinical
populations (Skinner, 1971). Sidney Bijou, who served as di-
rector of clinical training when Skinner chaired the psychol-
ogy department at Indiana University, pioneered in the use of
operant conditioning with persons with mental retardation
(Bijou, 1996). Applied behavior analysis has become a main-
stay of psychological treatment of persons with mental retar-
dation and pervasive developmental disorders such as autism.
It has been used to teach social and self-help skills like dress-
ing, toileting, and proper table manners, as well as dealing
with defiant, aggressive, and self-injurious behaviors.
Nathan Azrin at Anna State Hospital in Illinois demon-
strated the utility of behavior modification with adult mental
patients (Ayllon & Azrin, 1968) and the usefulness of token
economies, in which the performance of desired behaviors
earns tokens that can be exchanged for rewards (much as oc-
curs in our society where money is given for work). Exten-
sive research on token economies in mental hospitals was
done by Gordon Paul and his colleagues (e.g., Paul & Lentz,
1977). Their research with long-term, regressed, and chronic
schizophrenics focused on developing such practical behav-
iors as making their beds, behaving well at mealtime, partic-
ipating in the classroom, and socializing with others during
free time. Paul’s research showed that his program of behav-
ior therapy and milieu therapy (moral treatment) improved
symptoms when compared with the results of routine hospi-
tal management, and that behavior therapy was more effec-
tive than milieu therapy alone in bringing about the desired
changes.
The principal assessment procedure advocated by Skin-
nerians is the functional analysis of behavior: a determination
of what may be rewarding or maintaining undesirable behav-
iors and what may serve to reward or establish the perfor-
mance of behaviors that are desired. A functional analysis
requires observation, preferably in the setting where the
behaviors are to be modified, in order to assess the frequency
of their occurrence and their consequences. Gerald Patterson
(1974) pioneered in the use of direct behavioral observations
in natural settings to record the behavior of aggressive chil-
dren and their families in their homes. His research led to a
theory of coercion in which the child is seen as both the de-
terminer and victim of episodes of escalating violence in the
family and to controlled research on the behavioral treatment
of child aggression.
Another major category of behavior therapy is cognitive
therapy or cognitive behavior therapy. Two pioneers in this
area were George A. Kelly and Albert Ellis. Kelly (1955)
viewed his clients as resembling scientists in their attempts to
make sense of the world around them. He used a diagnostic
procedure called the Role Construct Repertory Test to ascer-
tain their beliefs about themselves and others. The therapist
then negotiated with the client about what changes might be
desired and how these could be accomplished. Using fixed
role therapy, the client was encouraged to rehearse or play-
act the new role, first with the therapist, then with others.
Albert Ellis (1958) developed rational emotive therapy; here
the patient’s opinions and attitudes are explored for irrational
beliefs (“I can’t make a mistake and must be perfect. My feel-
ings are out of my control”), which the therapist then at-
tempts to make more reasonable and rational.
Martin Seligman (1975) stimulated much research on the
treatment of depression. Based upon previous research with
dogs that were prevented from avoiding or escaping an elec-
tric shock, he noted that when they were in a situation where
the shock could not be avoided, such animals simply gave up
and endured the pain. They had learned to be helpless, and
perhaps, he reasoned, the same process of ineffectiveness and
feeling unable to cope occurred among humans who were
depressed. This had obvious treatment implications, but fur-
ther study indicated the need for the concept of attribution