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Pearl, C., & Guarnaccia, V. (1976). Mu!timodal therapy and mental retardation. In A. A. Lazarus (Ed_), Mul/1modal bth1n•wr therapy. New York; Springer. Rachman, 5. )., & Wilson, G. T. (1980). Tlot tfftd• of p" and a case of post-traumatic stress. In A. A. Lazarus (Ed.), (asrl1ool ,if muilimodal !herapu New York: Guilford. . Steketee, G., Foa, E. B., & Grayson. J. B. (1982). Recent advances in the behaviorill treatment of obsessive-compulsives. AYCl1nv.< of Genrral P>ychi~ verbal stimuli and has been established and maintained because it does so. If this perspective is worthwhile, thert' should be a clear relationship between an ability to speak and an ability to respond to stimuli based on arbitrary relationships. There are data suggestive of this. It h;is recently been shown that children without productive speech or signing do not form equivalence classes (Devany, Hayes, s._ Nelson, 1986). If the present analysis h.1s validity, we should also bl' able to show that humlieve that certain things must change before others may change. That is, we must control A in order for B to happen. A person must get rid of depression in order to be happy. A person must get
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rid of anxiety in order to do frightening things. Thus, the presence of A must seemingly lead to efforts to get rid of A, gioen this con/ex/. Another type of behavior-behavior relationship is established. I believe that each of these contexts can produce pathological results at times. Since each is a set of contingencies established and maintained by the mainstream verbal community, the first goal of therapy must be to create a new verbal community, which operates within a different context-that is, within a different set of contingencies. This is very difflcult because the client brings a behavioral history in the door. Thus, when a therapist says something to a client, it is heard within the very contexts that need to be changed. For these reasons, my first goal in therapy is to challenge these contexts themselves. The only way I know to do this is to behave in ways that do not fit within these contexts. The contexts of literality, reason giving, and control are so fundamental that it is impossible to alter them by behaving "reasonably." Many of traditional "hard-nosed" behavioral interventions, for example, try to ignore these contexts without challenging them directly. In the long run, this strategy seems doomed to failure if the contexts themselves are part of the problem, because it !eaves those contexts ignored but intact. The only way to alter them is to do things that do not fit within them. The section that follows is a rough approximation of what might be said in the first therapy session after the initial assessment phase. Throughout much of the rest of the chapter, I will intersperse the session descriptions with textual asides to the reader. I shall assume the client has an "anxiety disorder" such as agoraphobia, since this disorder represents fairly well some of the major dynamics of the system in which clients function. Although most of the case descriptions will be hypothetical (in the interest of efficiency and clarity), virtually every sentence within these descriptions are sentences I have actually said, or a client has actually said. They are not just ''made up." THERAPIST: I want to begin to lay some groundwork today for us to work on your problems. You see, you've come in here wanting a solution to these problems, but I'm worried lest we first do things that will just dig you in deeper. It may be hard to see that part of the problem is what you have been calling "the solution." You have an idea of what you want and need in order to be able to handle these problems-but you had these ideas before you came in. You've tried this and you've tried that. Don't you sometimes wonder why none of these things have really worked? Sure, sometimes they have seemed to work, but ultimately they didn'totherwise you wouldn't be in here. Well, what if the problem is actually in part the very solutions you have been attempting? It is as if a person who came in to a doctor with a headache had been trying to cure the headache
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by hitting himself on the head. The first job the doctor would have would be to stop the hitting. Well. we are in a situation exactly like that. So I can't just run in and try to help. First I have to stop what has been getting things stuck. To do that you will have to allow me to take a fair amount of control over the next several sessions. J want you to know, however, that this is not the way therapy will be permanently. You may think at times over the next several sessions that I am just confusing you or maybe even not listening to you. That's part of what needs to happen to break down the system that has been keeping you stuck. My purpose in these opening remarks has been to do two things: to put on the table that I shall not dv what the client expects me to do and that I want the client's permission to take temporarily the control I need to get the job done. I want to have the client going into therapy with fair warning. THERAPIST: If we strip away all of the details, you are saying that what you need to be able to move ahead in your life is to rid yourself of an undesirable emotion: anxiety. If you could just eliminate, reduce, manage, or otherwise control your anxiety, !hen you could move ahead. In other words, it is the anxiety that is the problem: As long as it is here, at least as long as it is so intense, your life will never work. CLIENT: That's right. No one could live with the anxiety I have. THERAPIST: Okay. And what I want you Ill notice is that a great deal of behavior has emerged from this perspective. You've really tried hard to accomplish this goal. You've done everything you know how to do. CLIENT: Yes, but nothing has really worked. Some things work a little-I don't know what I'd do without tranquilizers, for example. Still, I haven't really licked it yet. THERAPIST: And you're here for me to help do that, but what I want you to know right from the beginning is that I can't and I won't. You think that there is a way out; that you just don't have the right technique. So I'm supposed to give you the right one. I don'/ have ii lo give. It doesn't exist. There is no way out. Within the system in which you're functioning you are trapped. Look, don't you deep down have the feeling that you're hopeless? Haven't you thought that? And that's scared you, hasn't it? Well, I'm sorry to have to be the one to tell you, but your fears are correct. Held in the way you are holding it, the situation is hopeless. No joke. No fooling. I mean it. There is no way 1)ut. CLIENT: Well, then why am I coming to see you? Why am I paying you money to help me? What can you do for me? Tf-IERAPIST: I don't know. I'm certainly not going to help you get rid of your anxiety, to get rid of your worries, to get al! your thoughts lined up
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in a row. You've played that game for years and ii hasn't u•orkrd. You know that. Well, I'm here to say that it never will CLIENT: You mean I'm just hopeless. I should give up. THERAPIST: In a sense, yes. Actually, you are not hopeless. But the system within which you are functioning has no hope of working. It will never make your life work. CLIENT: So what is the other system? You seem to be implying that there is another way. THERAPIST: Well, first, there is no/ another way to get accomplished what you want accomplished. There is a way to have your life get unstuck, but right now I can't tell you what that is because you wouldn't hear me. You'd hear the words, and then promptly put them back into the same old system that is the real problem in the first place. That system is everywhere. It's in the room right now. If fact, I can say with complete confidence that what you think I'm trying to say is not what I'm saying at all. If you think you understand me right not I want you to know that what you think I'm saying is not what J'n1 saying. The use of paradox in this way, if done in moderation, is one of the fastest ways to loosen up the verbal system with which the client comes into therapy. It puts clients in an untenable situation-if they understand it, they don't. This is a direct attack on the context of literality. As clients notice their opinions about what the therapist is saying, they also cannot take them literally because whatever they think is being said isn't. This allows the therapist to say things to clients that wouldn't have an impact if the sentence first had to be understood to be useful. THERAPIST: Let me give you a metaphor that might help you see what I'm saying. The situation you are in is something like this. Imagine a large field. You are blindfolded, given some tools, and told to run through the field. Unknown to you, though, there are holes in this field. They are widely spaced in most places but sooner or later you accidentally fall into one. Now, when you fall into the hole, you start trying to get out. You don't know exactly what Ill do, so you take the tool that seems most useful, and you try to get out. Unfortunately, the too! you were given is a shovel. So you dig. And you dig. But digging is an action th,1t makes holes, not a way to get out of them. You might make the hole deeper, or larger, or there might be all kinds of passageways you can build, but you'll probably still be stuck in this hole. So you try other things. You might try to figure out exactly how you fell in the hole. You might think, "If I just hadn't turned left at the rise, I wouldn't be in here." And of course that is literally true, but it doesn't make any difference. Even if you kne\v every step you took, it wouldn't get you out of the hole. So we're not going to spend a lot of time trying to figure out the details of your past-m client's motivation to lhange. In th~ language of rule-governed behavior, it serves as an au;.;1ncnl11/-that is, as a rule that works in part by changing the reinforcing effectiveness of certain consequences (Zettle & Hayes, 1982). In this case, finding a n('w way to approach the situation becomes of paramount importance. It is then that clients will really begin to search their assumptions in a way they haven't before. Undoubtedly sorne readers see this approach as harsh or even dangerous. It could be if clients had the sense thCh to
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approach. I'm not attacking them-I'm attacking the system. A slight twinkle in the eye helps make that clear. The way it actually works in therapy can be seen from the following interchange from .i transcript of a workshop I gave for clinicians, which was also attended by one of my agoraphobic clients:
,.'
Goal 2: The Problem is Control The next issue that is typically covered is the nature of the system that has (T('ated the trap. As is apparent from the section above, I believe the nature of this is thl' inapprupriatl' attempt to (ontrol private behaviors. This effort is based on the view that these behaviors are themselves causes of major life difficulties. Rather than expand on my theoretical rationale for this at this point, I shall go directly to a description of the approach taken with clients. THERAPIST: The situation you are in is something like a person trying to deal with an inappropriately p!aced public address system. Have you ever been at a speech and hents in the first place. I know of no behavioral technique that cannot be rationalized within a contextual approach, except for some forms of cognitive therapy. For example, when [ am working with agoraphobics, we generally start to do deliberate approach exercises at about this point (about six sessions into therapy). The exposure work, however, is not designed to reduce anxiety. Instead, exposure gives people an opportunity to practice experiencing anxiety without also struggling with anxiety. It is as well an opportunity to make and keep commitments. The qL1estion I always ask clients before they try exposure is, "Out of the place in which there is a distinction between you and the things you experience, are you willing to experience your thoughts and feelings without defense, denial, covering up, avoiding, trying: to chang:e, or any othf'r kind of struggle-arid do what really works for you in this situation by keeping your commitment?" If the answer is "no," we go back to the earlier part of therapy and find out what the hang~up is. If the answer is "ye~." it is time to g:o to exposure. During exposure, I continually work with the client to recognize the distinction between them as a person and the private behaviors they are experiencing. I encourage the client tn feel whatever is there to feel, including anxiety, and not to struggle with it. The commitment to expe-
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riencing one's own feelings must be fairly strong. I use the example of a child throwing a tantrum to get candy. If the child knows that the parent has a limit and will give in if it is reached-perhaps 5 minutes-guess how long the tantrum will last? In the same way, if a client is willing to be anxious, it is important not to let it be a half~measure. Like the child, a client's emotions will know the limits and likely exceed them. There is no bluffing oneself. Imaginal exposure such as desensitization is now an opportunity to both feel anxiety and let go of the struggle with it. As I say to my clients, "Just keep your eyes open, your feet on the floor, and your hands off." By this I mean that the client should see the emotion or thought, but neither run from it nor stru~gle with it. A metaphor suggested originally by a client that I sometimes use is this: "Imagine you are in a tug-of-war with an enormous monster, who seems intent on pulling you into a pit. You struggle more and more, but the harder you struggle the stronger he becomes. Instead of struggling, you can do something even more effective: drop the rope. Unless you join the battle, the monster (e.g., anxiety) can have no control." I sometimes use deliberate "willingness exercises" to practice "dropping the rope." For example, I sometimes have the client sit about a foot from me and look me in the eyes for two minutes without talking or laughing. As I do this, I encourage the client to experience but not buy into any feelings, thoughts, and so on th,1t, if taken literallly, would interfere with the exercise (including such "helpful" thoughts as "I'm going to do this right"). Some forms of cognitive therapy as it is usually taught can also be used to some degree. Rational-emotive therapy is very difficult to integrate within this perspective because it comes so close to saying that you shouldn't think cert.1in thoughts. This sri
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dealt with in the same way, generalization becomes more likely. In a sense, they learn the strategy, not just the specific instance. Finally, I have many of my clients participate in a group toward the end of individual therapy. The group consists of former clients, and current clients late in therapy. It meets once each month, and tends to focus on ways to expand the progress they have made into other areas. Due to a move, I just recently had to terminate a group of this sort after 2Y2 years. The last year was not even spent directly on anxiety but on issues chosen by the group, such as friends, money, sex, jobs, intimate relationships, and so on. By seeing the relev.1nce of this approach to general life issues, clients seem to become better able to generalize what they are learning in therapy to new topics. Given the support from the mainstream culture for reasons and emotional struggle, one would think that maintenance would be very difficult in this approach. The reinforcement for normal rule following continues. In this approach the therapist can't just cover the major issues once. They have to be covered again and again. When clients finally break through, however, the issue seems to change. Maintenance continues to be an issue, but a surprisingly moderate one. Once the system is seen clearly, it is difficult to go back to it fully. It is hard to believe one's beliefs 100°10 after it is clear that beliefs are just more behavior. The two mechanisms I use for maintenance are the group I just mentioned and booster sessions as needed. About half of my clients will see me once or twice in the year following termination, just to clear up a sticking point. Usually this can be done quite rapidly, because they simply have to make contact with the repertoire established e. New York: Viking. Azrin, R. D., & Hayes, S. C. (1984). The discrimination of interst within a heterosexual interaction: Tra1n1ng. genralization, and effect; on social skills. Behavior Thrmpy. 15, 173-184. Baron, A., & Galizio, M. (1983). /nstrudwnal rnPllrol of !rurnan operanl bfhamor. Th, Poy,i.o/og1
/ J1m1 New York Guilford. Devany, /. M., Hayes, S. C., & Nel5n, R. 0. (19tlo). Equivalence class formation in language-able and language-disabled children. /ounrn/ o/ //,e £,-prnmo1Ja/ A11uiy.>I! 4 Beluwior, 46, 243-257. Ga!izio, M. (1979). Contingency-shaped and rule-governed behavir: Instructional control of human loss avoidance. /ounrnl o/ ll1t l:J:i•rnmootal A1w/~,,, v/ Brh1wwr. J 1, 53-70. _ Harzem. P., Lowe, C., & Bagshaw, M. (1'17111. Verbal conlrol 1n human operant behavic>r. l I" Psyrlwfogirnl Record. 28, 405-423. Hayes, S. C. (1984). Making sense of spirituality. 8..lral'1g-VJd rule>: Ntu' definili''"'- data. anJ dirert10'1.rn, Z., Zettle. R. D, Rosenfarb. I., & Cuupl'T, L. (1982, December). Rufrgovtrnr•I br/1aoc'1al st,1ndarJ s .. tt1ng1 /ounwl of Applird Behavoor Analy>r.r. 39, 157-104 Lowe. C F.. Har7em, P_, & Bagshaw, M. (1978). Species differences in temp-oral control of behavi"r IL Human perforn,~nce. Journal of lho• [t/'"""'""'' Ana/.v of Behavwr, 29, 351301 Lowe, C. F., Harzem, P., & Hughes. S. (\978). Determinants of operant behavior in humans; Somt> diliPrt>nces from anim,1ls. Q11arfrrlv /011r11ol of Exprrimoolu! Psychology. JO, 373-386. Mahoney, M. /- ( 1974 )_ (ogno!rmr ,,,.,/ brlravwr m0Jr{.,a!10P1. Cambridge, MA: Ballinger. Matthews, B. A. ShimoH, E .. Catania, A. C., & Sagvolden, T. (1977). Uninstructed human rl"sponding: Sensitivity to ratio and intPrval contingf'ndes. Journal of the Elperimrn/a/ Analy!!• of Brha1s of Behavior, 37, 5-22. Sidman, M., & Tailby, W. (1983). Conditional d1s.:-rimination vs. matching to sample: An exp;insiun oft hrch and lhrra/ly (VoL J )_ Nt>w York: Academic l'res>Zett!e, R [)_, & J·byPs, S. C. ( JQ8.~). ThP (•ffr
