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Verbal Change and Cognitive Change: Conceptual and Methodological Analysis for the Study of Cognitive Restructuring Using the Socratic Dialog

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In this paper, we will firstly delve in a behaviorally rooted theoretical analysis of the learning processes that could be involved in the employment of Socratic dialog as a means to achieve cognitive restructuring. Three observers analyzed the case of study attending to the client–therapist interaction during the cognitive restructuring using the Socratic method. Different types of Discriminative Stimulus–Response–Reinforcement interaction sequences were specified during the debate and after the client’s pro-therapeutic verbalizations. A progressive increase in the frequency of pro-therapeutic verbalizations was observed. Taking into account the limitations of a case study, our results seem to fit those obtained in previous studies and suggest a possible explanation of the therapeutic process in general and the Socratic method in particular (at least as it is employed here) in terms of verbal shaping and verbal chaining. These processes would lead to the learning of rational thoughts which, in turn, would guide the client’s overt behavior to make it more pro-therapeutic.
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Verbal change and cognitive change: Conceptual and methodological analysis for the
study of Socratic dialogue
María Xesús Froján Parga, Ana Calero Elvira, Rebeca Pardo Cebrián, and Miguel
Núñez de Prado Gordillo.
Universidad Autónoma de Madrid, Spain
Author Note
María Xesús Froján-Parga, Department of Biological and Health Psychology,
Universidad Autónoma de Madrid; Ana Calero-Elvira, Department of Biological and
Health Psychology, Universidad Autónoma de Madrid; Rebeca Pardo Cebrián,
Department of Biological and Health Psychology, Universidad Autónoma de Madrid;
Miguel Núñez de Prado Gordillo, Department of Biological and Health Psychology,
Universidad Autónoma de Madrid.
This research was funded by the Spanish Government (Ministerio de Ciencia e
Innovación, I + D + I Research Grants SEJ2007-66537-PSIC, PSI2010-15908). The
funding source had no involvement in design, collection, analysis and interpretation of
data, writing of the paper, or in the decision to submit the article for publication.
Correspondence concerning this article should be addressed to María Xesús
Froján-Parga, Universidad Autónoma de Madrid (Campus de Cantoblanco), Facultad de
Psicología, C/ Iván Pavlov nº 6, Madrid 28049 - ESPAÑA
E-mail: mxesus.frojan@uam.es; Phone: +0034-914973956; Fax: +0034-914975215
Abstract
In this paper we will firstly delve in a theoretical analysis of the learning processes that
could be involved in the Socratic dialogue from a behaviorist standpoint. This analysis
is supplemented with the case study of P., a woman requesting psychological help due
to difficulties in her relationship. Three observers analyzed this case attending to the
client-therapist interaction during the Socratic Method, and when a pro-therapeutic
verbalization occurred along the entire therapeutic process. Different types of Sd-R-R+
interaction sequences were specified during the debate and after the client’s utterance of
pro-therapeutic verbalizations. A progressive increase in the frequency of pro-
therapeutic verbalizations was observed. We conclude that the therapeutic process in
general and the Socratic debate in particular can be explained in terms of shaping and
verbal chaining. These processes would lead to the learning of rational thoughts which,
in turn, would guide the client’s overt behavior to make it more pro-therapeutic.
Keywords: Socratic dialogue, behaviorist standpoint, client-therapist interaction, verbal
shaping, verbal chaining.
INTRODUCTION
Cognitive behavior modification or cognitive therapy originated in the mid 70’s; its
theoretical basis, according to some authors, is to be found in methodological
behaviorism (Hayes, Follete & Follete, 1995; Pérez, 1996a; 1996b) or in some models
of cognitive behavior like the information processing model (Beck, 1995; Mahoney,
1974). It has in common with this last model the conceptualization of man as an active
processor of surrounding information: the information that reaches this processor is first
acquired, then transformed in complex codes and finally stored until it is recovered and
used in an activity. The inclusion of cognitive variables in behavior modification can be
explained by two main reasons: firstly, a certain dissatisfaction with some
methodological aspects of behaviorism, especially its search for general laws through
animal research (see Shimp, 1990); from the field of cognitive psychology, harsh
criticism of traditional behavior theories is manifested (Kazdin, 1978). Secondly, the
importance of cognitive factors in the explanation of phenomena related to perception,
language, memory and thought is acknowledged. Certain findings related to the role that
the knowledge of contingencies has on behavioral performance, or experiments on
semantic conditioning, that showed that this type of conditioning happened more in
accordance to the meaning of the words rather than their phonetic similarities, drove to
more research on the role of cognitive variables in the explanation of psychological
problems (see Kazdin, 1978). The cognitive leap (Mahoney, 1974) meant the
incorporation of cognitive techniques that already existed within other theoretical
frames, such as Ellis’ rational-emotive therapy and Beck’s cognitive therapy (Beck,
1995; Calero-Elvira, Froján-Parga, Ruiz-Sancho & Alpañés-Freitag, 2013; Caro, 2011;
Ellis, 1995; Kazdin, 1978; Meichenbaum, 1995; Robins & Hayes, 1995), as well as the
creation of some new ones from behavior modification itself (see Kazdin, 1978;
Meichenbaum, 1995).
The main characteristic of cognitive behavior modification is the importance it gives to
cognitive processes in the development, maintenance and modification of problem
behaviors (Caro, 2011; Kazdin, 1978; Mahoney, 1974; Robins & Hayes, 1995). Often,
the explanation of behavior lies more in the individuals’ perception of their surrounding
events than in those events themselves: the human being filters, transforms and “builds”
the experiences that constitute his or her “reality” (Beck, 1995; Caro, 2011; Ellis, 1995;
Kazdin, 1978; Pérez, 1984; Robins & Hayes, 1995). Cognitive behavior modification is
interested in changing problem behavior through the modification of thought processes.
In order for this change to be stable, that is, not situation-dependent, the cognitive
alteration must affect cognitive structures (schemata, beliefs) more than specific
thoughts (Caro, 2011; Kazdin, 1978; Robins & Hayes, 1995). To change these
structures, cognitive techniques are based in the use of linguistic tools that will allow for
the clients to reevaluate their irrational beliefs and maladaptive mental schemata, thus
changing their reactions to the world and themselves (Beck, 1995; Caro, 2011; Ellis,
1995; Kazdin, 1978). One of the most used tools in this regard is the so-called “Socratic
dialogue”, in which, through a concatenation of questions aimed at confronting the
client’s erroneous ideas with other possible interpretations of surrounding events,
cognitive change is effected (Calero-Elvira et al, 2013; Caro, 2011; Ellis & Grieger,
1977; Kazdin, 1978; Robins & Hayes, 1995).
However, assuming this standpoint entails a series of problems that put the fundaments
of cognitive techniques in question (though not their efficacy): do these linguistic
strategies really change these mental structures/schemata that supposedly underlie the
client’s problems? Or do they merely modify automatic thoughts (covert
verbalizations), that being enough to completely solve the client’s problems? It may
seem that this last option oversimplifies not only cognitive techniques, but also the
complexity of human thought; nonetheless, a detailed analysis of the implications of this
standpoint will allow us to see that it is not only not simplistic, but that it also allows for
a complete explanation of psychological change.
At its core, the standpoint we are going to present in this paper and which guides the
research we introduce in the next pages stems from the consideration of cognitive
factors as regular behaviors, subject to the same laws of learning than any other
behavior (Freixa, 2003; Holt, 1915; Marr, 1990; Ryle, 1949; Skinner, 1974), and thus
modifiable through behavioral procedures that can be experimentally studied in the
laboratory. Starting from this identification of cognitive factors with behavioral factors
we will firstly delve in a theoretical analysis of potential learning processes that could
be involved in the use of the Socratic dialogue, hypothesizing a combination of both
verbal shaping and chaining processes that would be at its (functional) core. These
processes would lead to the learning of rational thoughts (covert verbalizations) which,
in turn, would guide the client’ overt behavior to make it more pro-therapeutic (Calero-
Elvira et al., 2013; Calero-Elvira, Froján-Parga, Ruiz-Sancho & Vargas-de la Cruz,
2011; Froján-Parga & Calero-Elvira, 2011; Froján-Parga, Calero-Elvira & Montaño-
Fidalgo, 2006, 2009, 2010). This theoretical analysis will be supplemented with an
empirical study intended to endorse the proposed standpoint and whose results will be
discussed once the work is presented. To that end, we will start by analyzing the nature
of mind and mentalist concepts and their relation with language and its diverse
functions. In this regard, authors like Wittgenstein or Ryle must inevitably be
referenced (Arrington, 1990; Deitz, 1990; Primero, 2002; Tomasini, 2004, 2005;
Vargas-de la Cruz, 2011). On the other hand, regardless of our concluding that thoughts
are behavior too and, therefore, can be modified like any other behavior, we would still
have to explain the relation of the change in those thoughts with the “deeper” change in
the supposed cause of the problem: the mental schemata or mental structures.
Wittgenstein (1953) charges against the representationist conceptualization of language,
which proposes the idea that the meanings of words are learnt through acts of ostensive
teaching (see also Arrington, 1990; Deitz, 1990; Primero, 2002; Tomasini, 2004, 2005).
Ostensive teaching consists of learning situations in which a language expert (an adult)
points at an object and names it in front of someone who is learning (a child). By means
of that act of ostensive definition, as the representationists see it, the child would
acquire the meaning, the concept that is represented by the word the adult used to design
the object. Wittgenstein, however, points at the fact that this act of ostensive definition
can only happen within the boundaries of language; the child needs to know the rules of
this “language-game” beforehand in order for him to be able to establish the link
between the word-sign, the gesture-sign and the referent object. Otherwise, it would be
impossible for the novel speaker to apprehend the association between the word and the
referent that was pointed at by the expert, and not any other possible association
(Arrington, 1990; Tomasini, 2004, 2005). Wittgenstein thus equates the meaning of a
term with its usage in concrete contexts, so that the child would not learn the names of
things, but verbal behaviors that include those names and allow him to contact the
objects designated by those names (Primero, 2002). Given that all human beings learn
language in the same way (by “playing” the same “language-games”), there can be no
‘personal’ or, in Wittgenstein’s terms, ‘private’ language. Therefore, it is impossible for
a person to express, for example, a sensation (pain) through a word (the word “pain”) in
such a way that the referent of the word was different from the referent that another
person names with the word “pain”. Consequently, Wittgenstein’s argument (1953)
supports the notion of a functional equivalence between the covert event that constitutes
the referent (namely, feeling pain) and its public denomination (the word “pain”). This
standpoint allows for the interpretation of the supposed cognitive causes of behavior
(mental schemata) in terms of covert or overt behavior (both linguistic and non-
linguistic): we could explain a person’s behavior by exclusively referring to what they
do or say (verbalized thought).
As we have seen, the inference proposed from a cognitivist standpoint is that thoughts
are a manifestation of a supposedly underlying, internal, mental scheme; in fact, not
only cognitive behavior modification but also methodological behaviorism considers
behavior as a mere means to getting to know the true object of psychology: the mind
and cognitive processes (for a review on the different kinds of behaviorism, see
Bélanger, 1999). The problem is that this standpoint leads us to an essentially
tautological theoretical model: using again the word “pain” as an example, when we use
it we are referring to sensations that exist regardless of them being named; that is to say
there is, in fact, a sensation that we learn to designate as pain. On the contrary, a client
that observes him or herself, following the therapist’s instruction to do so, doesn’t
observe the mental schemata that supposedly cause the automatic thoughts, but those
thoughts themselves. It would seem, then, that the term mental schema” only designs
the thoughts that are verbalized by the clients. A cognitive therapist could be observing
the client’s behavior while assuming that he/she is only seeing the manifestation of an
inferred inner mental scheme, of which we cannot have further evidence than the very
behavior the therapist aims to explain by resorting to the mental schema. In Ryle’s
words (1949), it is an error of the kind that a visitor would commit if, after being shown
a campus with its faculties, its sports center, its library, etc., he asked “but where is the
University?”
Opposite to the standpoint of cognitive behavior modification or methodological
behaviorism, the proposals made by radical behaviorism constitute a meaningful
theoretical advancement. It’s not about denying the existence of covert cognitive
processes, nor about providing the sort of tautological argument aforementioned, but
about going to the root (hence the name “radical”) of the psychological phenomenon:
behavior as the object of study of psychology (Skinner, 1974). From this perspective,
the term “behavior” does not allude to the responses of an organism, but to the
interaction between an organism and its environment; that is, the functional relation
established between these responses and the stimuli that evoke or elicit them (Santacreu,
Hernández, Adarraga y Márquez, 2002). In this regard, covert phenomena, as any other
psychological phenomenon, could function either as responses or as stimuli1. That is
what Skinner (1974) means when he asserts that the only difference between the “world
outide the skin” and the world “under the skin” is a difference in the number of potential
observers of behavior. When behavior is overt, manifest, it is public. However, when
behavior is covert, it is private, which means it’s only accessible to a single observer.
But this single observer can refer to us these covert phenomena, by means of his/her
linguistic and non-linguistic behavior. Thus, these covert phenomena are, in every other
respect, exactly as behavioral as manifest behavior. And since Wittgenstein (1953), as
we exposed earlier, had completely ruled out the possibility of the existence of a private
language, it doesn’t seem problematic at all to assert that the psychologist can in fact
access his client’s covert behavior through what the client says or does. This argument
has an implicit assumption: that thought, or at least the kind of thought that could be
conceived as “inner dialogue” or “self-verbalization”, is nothing but an “internalization
or automatization of audible speech, which is socially learnt (see Alcaraz, 1990; Holt,
1915; Mowrer, 1954; Primero, 2002; Skinner, 1957; Varela, 2008). Thus, in a socio-
linguistic environment that gradually shapes the “social speech” of a child, teaching him
to verbalize “to himself”, inner speech would be a natural consequence of the normal
learning process and would constitute a perfect example of what we could call
“behavioral thrift” (Alcaraz, 1990; Mowrer, 1954; Skinner, 1957; Varela, 2008). But the
most interesting thing about this argument is that, if covert phenomena are as behavioral
as manifest behavior, why posit that the former causes the latter? (Freixa, 2003; Ryle,
1949; Skinner, 1974; Varela, 2008). There is, of course, one sense in which covert
behavior ‘causes’ manifest behavior. This is what happens, for example, when the kind
of thoughts we could call “inner speech” are the ones that elicit or evoke observable
responses. But those same thoughts can be considered to be responses, elicited or
evoked by environmental stimuli (both from the public environment which we can all
access and the private environment that constitutes covert behavior). Consequently,
stimuli that are generated by the action of an organism in its environment can also
1 The allocation of the stimulus function or response function concerns only the researcher that is
analyzing a specific behavioral segment, and does not depend on the supposed nature of the behavioral
events.
constitute the cause of the kind of thought we call self-verbalizations (Marr, 1990;
Skinner, 1953).
We are not in any case concluding that cognitive techniques in general and the Socratic
dialogue in particular are useless; rather, their efficacy is beyond any doubt (Brestan &
Eyberg, 1998; Calero-Elvira, Froján-Parga & Montaño-Fidalgo, 2011; Caro, 2011;
Chambless et al, 1996, 1998; Nathan & Gorman, 2007). The biggest contribution of the
cognitive techniques has been the systematization of verbal procedures for the
modification of behavior in clinical settings, in a moment in which behavioral
psychology, for reasons that go beyond the scope of this paper, had abandoned the study
of language as a possible motor of clinical change. The problem with these techniques
lies in the theoretical assumptions that accompany them and that are used to explain
their functioning (Calero-Elvira et al., 2013).
The study of language from a behavioral standpoint has been undertaken from the
paradigms of classical and operant conditioning. Regarding classical conditioning, it
was Pavlov himself who alluded to language as a second signaling system that allowed
for the occurrence of conditioning processes: the human being could acquire new
responses without having a direct contact with the unconditioned stimulus (Alcaraz,
1990; Kazdin, 1978; Skinner, 1957). Within this same paradigm, Mowrer (1954)
developed an explanatory theory of the possible relation between events, both linguistic
and physical: such relations, which he called “sentences”, work as conditioned devices
whose main effect is to produce new associations (new learning), setting transition or
meaning transference processes in motion. There are four kinds of sentences: thing-
thing, thing-sign, sign-thing and sign-sign. The meaning of a word, according to
Mowrer, is a set of responses (sensory, autonomous and/or motor) which are elicited
when the word is presented; meanings are transferred from event to event -whether
these events are words (linguistic events) or things (physical events)- through classical
conditioning processes. This does not mean that in every sentence in which two words
appear together one of them becomes a mere synonym for the other because the
meaning of one is transferred to the other. The new words associated were previously
conditioned stimuli that had acquired their eliciting abilities by means of previous thing-
sign classical conditioning processes; what Mowrer asserts is that, due to a new
conditioning process, the meaning of a word is associated with the meaning of another.
A concrete example: in the sentenceThomas is a thief, the set of sensory,
autonomous, motor, etc. responses (that is, the meaning) that are elicited by the word
“thief” is associated with the set of sensory, autonomous, motor, etc. responses that
were already elicited by the word “Thomas”.
Mowrer’s approach is a very correct conceptualization of intervening processes in
which is considered to be one of the key functions of language: the referential function.
This function is conceived as the ability of linguistic signs to refer to objects, events and
other phenomena that are not physically present. We are able to react to verbal
descriptions in a similar way to how we react to the described events (Arrington, 1990;
Kazdin, 1978; Ribes, 1990; Vargas-de la Cruz, 2011). The meaning transference
processes proposed by Mowrer could explain why, through language, we can modify a
person’s behavior regarding certain environmental events, without the need for those
events to be physically present. The verification of this fact has given rise, within the
paradigm of operant behavior, to the study of “rule-governed behavior”, so called in
order to differentiate it from the kind of behavior that is directly shaped by
environmental contingencies (Baron & Galizio, 1990; Malott, Malott & Trojan, 1999;
Miltenberger & Ortega, 2012; Vargas-de la Cruz, 2011). Risking excessive synthesis,
when words acquire an apetitive or aversive meaning through conditioning, the stimuli
complex word-meaning can itself acquire an operant function, discriminative of an
approach or avoidance behavior, respectively (Baron & Galizio, 1990; Malott, Malott &
Trojan, 1999; Miltenberger & Ortega, 2012; Vargas-de la Cruz, 2011). Following
Mowrer (1954), if I associate the word “Thomas” with the word thief”, the generated
suspicion responses will easily discriminate a series of watchfulness or avoidance
operant behaviors, even if Thomas has never stolen anything from me (environmental
contingency).
As it can be easily concluded, whether it is through classical or operant conditioning,
what we are alluding to here is verbal control of behavior. And if we can verify that
verbal control in natural, non-programmed contexts, it is easy to conclude that the
therapist can achieve it in a controlled (but nonetheless natural) setting, such as the
clinical setting, in order to induce the desired therapeutical changes in the client’s
behavior. In this way, linguistic techniques can be used by the therapist to modify
inadequate verbal control (dysfunctional, irrational thoughts with which Socratic debate
deals) that might be the root of the problem. This approach will be specified in the
explanation of the Socratic dialogue.
In previous research, we have advocated for a reconceptualization of verbal tools for
behavior modification and, specifically, Socratic dialogue itself, as a process of change
in the client’s verbalizations due to a systematic combination of both verbal shaping and
chaining processes (Calero-Elvira et al., 2013; Calero-Elvira, Froján-Parga, Ruiz-
Sancho et al, 2011; Froján-Parga & Calero-Elvira, 2011; Froján-Parga et al, 2006, 2009,
2010). We will illustrate the point using an extremely simple instance of Socratic
dialogue: the therapist identifies (or helps the client identify) an irrational thought
(verbalization) (R1). Next, the therapist makes a question to begin the questioning of R1
(a re-evaluation question) which discriminates a new response from the client (R2).
Should R2 approach the kind of verbalization that the therapist deems appropriate to
achieve the objectives of the session, he will emit a new re-evaluation question (a new
discriminative stimulus), which will be followed by R
3 from the client. This would
continue until RN appears, the final answer that will consist of a pro-therapeutic
verbalization uttered by the client and which was the aim of the Socratic debate. Each
and every one of the questions emitted by the therapist functions as a discriminative for
the following answer and as a reinforcer for the previous answer, although we have
verified in previous research that many of the R uttered by the client and that approach
the aim of the debate are followed by an explicit verbal reinforcer emitted by the
therapist. In this way, the client’s verbalizations, which were originally referring his/her
dysfunctional behavior when faced with problematic situations, gradually approach
more pro-therapeutic forms, in which the content of the verbalizations refers to
“healthier” behaviors that the client says he/she has done or will do (Calero-Elvira et al.,
2013).
This conceptualization of the Socratic dialogue as a combination of verbal shaping and
chaining processes could generate some criticism, focused on us only dealing with the
“tip of the iceberg” of the problem and not dealing with the real change, the cognitive
change. However, and returning to Wittgenstein (1953) and Ryle (1949), the client’s
thoughts (their covert behavior) can only be inferred through their overt behavior
(motor, verbal, physiological), which would be the only evidence we have. As we have
previously said, there is no reason to consider covert behavior to be qualitatively
different from overt behavior, and therefore we can assert that the modification of
audible verbalizations emitted by the clients can in turn modify their inaudible
verbalizations: their thoughts (those that occur in a linguistic form, which are the ones
with which we deal here). There is, of course, the possibility that the clients were not
verbalizing the truth about what they think, and therefore they would be thinking and
doing something different to what they say they are doing and thinking. However, this
is not a theoretical or conceptual problem, but one related to the therapist’s efficacy in
using the relevant motivational operations in the relation with his/her client, and to the
latter letting himself/herself be counseled and guided by the former. A problem, on the
other hand, that would just as well affect the Socratic debate if it was to be explained
from a non-behavioral explanation since, regardless of the explanation, the verbal
strategy remains the same.
Another expectable criticism would point out that a change in the client’s verbalizations
(covert and overt) inside the clinic would not necessarily imply a change of behavior
outside the clinic. In general, the stance of a behavior therapist regarding the saying-
doing correspondence can be expressed in the following manner: “if the frequency with
which a person says they are going to do X when facing Y situation rises, so does the
probability that the person, in fact, does X when facing Y”. That is, indeed, a regularity
verified in very different settings (Catania, Shimoff & Matthews, 1989; Hayes, Bissett,
Korn, et al., 1999) which in turn provides evidence that supports the existence of a kind
of behavior control that is different from the control of behavior by direct environmental
contingencies: verbal control of behavior (or rule-governed behavior, as we earlier
called it) (Hayes, Brownstein, Zettle, Rosenfarb & Korn, 1986; Skinner, 1969; Zettle &
Hayes, 1982). Mowrer’s approach to the transference of meaning, along with verbal
control of behavior, allow us to explain how the therapist can change the client’s
behavior in problem situations that occur outside the clinical setting through the use of
this combination of verbal shaping and chaining procedures that modify the client’s
overt and covert verbalizations inside the clinical setting.
In order to empirically support this approach, our research team has carried out several
studies on the Socratic debate (Calero-Elvira et al., 2013; Calero-Elvira, Froján-Parga,
Ruiz-Sancho & Vargas-de la Cruz, 2011; Froján-Parga & Calero-Elvira, 2011; Froján-
Parga, Calero-Elvira & Montaño-Fidalgo, 2006, 2009, 2010), whose results allow us to
propose the hypotheses that guide the study we present here:
Hypothesis 1: the dialogue established between client and therapist during the
Socratic debate can be specified in a series of Sd-R-R+ sequences.
Hypothesis 2: new pro-therapeutic verbalizations emitted by the client after the
Socratic debate will increase in frequency in the following treatment sessions and will
be reinforced by the therapist.
Hypothesis 3: the increase in the pro-therapeutic verbalizations emitted by the
client due to the debate will be related to an increase in the verbalizations that describe
pro-therapeutic behaviors that were performed in extra-clinical contexts.
METHOD
Sample
In this study, a clinical case is presented. P. was a 32-year-old woman that requested
individual psychological help due to the difficulties she was experiencing in her
relationship. he intervention was carried out by a female therapist with more than 15
years of experience in a private clinic, the Therapeutic Institute of Madrid (Spain). All
clinical sessions were recorded with the client’s consent, using a CCTV system.
The treatment, which followed cognitive-behavioral guidelines, was carried out through
ten sessions. Each one of them lasted for one hour approximately. The first three were
assessment sessions; the therapist used the fourth one to explain the client her functional
analysis and the proposed treatment. Between sessions five and 10 the intervention
program was implemented. It mainly consisted in the application of cognitive
restructuring as a means to modify the client’s maladaptive verbalizations. These were
related to various aspects of her relationship (jealousy and control behaviors, arguments
with her partner and negotiation of certain aspects of their coexistence) and to her
partner’s family. Once the changes in her verbalizations were achieved, the therapist
proposed instructions to P. so that she engaged in behavioral tasks that would imply her
practicing the achieved changes in her daily life. The sessions were weekly until session
six, when the schedule changed to one session every two weeks. Between sessions nine
and 10, the inter-session period was extended to one month. The process of intervention
ended with the client discharge when the clinical objectives were achieved. These
objectives are presented on table 1.
TABLE 1 APPROXIMATELY HERE.
Variables and instruments
The variables that were analyzed in the clinical case were:
- Therapist’s verbal behavior: The codification of the therapist’s verbal behavior
followed the therapist system of categories, SISC-CVT, developed in our previous
works (Calero-Elvira, 2009; Calero-Elvira et al., 2011; Calero-Elvira et al., 2013;
Froján et al., 2008; Virués-Ortega, Montaño-Fidalgo, Froján-Parga, &Calero-Elvira,
2011). It has shown adequate inter-rater agreement levels (percentage of agreement
among observers from 71% to 82%, Cohen’s kappa from .65 to .76, p< .01; Calero-
Elvira et al., 2013). The therapist’s verbal behavior was codified on a moment-to-
moment basis throughout all sessions pertaining to the case.
- Client’s verbal behavior: in this regard, two different category systems were
used.
o The codification of the client’s verbal behavior followed the client system of
categories, SISC-CVC, developed in our previous works with an adequate level of
agreement (percentage of inter-rater agreement ranged from 72% to 91%, Cohen’s
kappa from .60 to .80, p< .05; Calero-Elvira et al., 2013; Ruiz, 2011). Regarding the
client’s verbal behavior, the codification was also carried out on a moment-to-moment
basis throughout all the sessions. Despite the employed system is very complex and
includes numerous categories, only those pro-therapeutic verbalizations uttered by the
client throughout the treatment were coded for this study.
o Additionally, the SISC-COT system Calero-Elvira, 2009; Calero-Elvira et al.,
2011; Calero-Elvira et al., 2013) was used during the Socratic debates to classify each
one of the client’s utterances according to their degree of approximation to the
objectives of the debate. This system has already shown an adequate reliability
(percentage of inter-rater agreement ranges from 60% to 86%; Cohen’s kappa values
range from .48 to .71, p<.01; Calero-Elvira et al., 2013). Again, the client’s verbal
behavior was coded on a moment-to-moment basis throughout all the Socratic debates.
The relevant fragments of the Socratic debates were identified through previously
developed guidelines (Calero-Elvira, 2009). According to these guidelines, a Socratic
disputation is defined as a dialogue between therapist and client in which the former
makes the latter reflect on the appropriateness of his/her cognitions in an attempt to
modify the client’s dysfunctional thoughts, mainly through questioning and
disputational strategies.
The categories used to code the therapist’s and client’s verbal behavior are presented in
Table 2. The software The Observer XT (Noldus Information Technology, version 11.0)
was used for the observation and coding of the therapist’s and client’s verbal behavior.
TABLE 2 APPROXIMATELY HERE
Procedure
This study was based on a clinical case that had been observed and coded in previous
studies. The procedure of observation and moment-to-moment coding was described
elsewhere (Calero-Elvira et al., 2013; Ruiz, 2011). Therefore, in the following lines we
only describe the procedure used to perform the analyses of the case here presented.
Three observers participated in this study, all of them experts in the coding of verbal
behavior. The main observer is a clinician with a master degree in Clinic Psychology.
The other two have a Ph.D in Clinical Psychology and an ample experience in therapy.
They oversaw all the observation and analysis procedure. This procedure can be divided
in the following stages:
1. Case observation and analysis of the therapeutic objectives: In the first place, the
main observer watched all the recordings of the case, pointing out the clinical objectives
that were proposed by the therapist.
2. Classification of pro-therapeutic verbalizations: compliance and well-being. The
observers agreed upon which criteria were to be used in the classification.
Verbalizations could be classified as compliance verbalizations (compliance with
therapeutic tasks, i.e., P. said she had followed an instruction emitted by the therapist)
or as well-being verbalizations (i.e., P. indicated her well-being or her positive
emotional reactions regarding the therapeutic objectives).
3. Identification of pro-therapeutic verbalizations: based upon these criteria, the
main observer identified and transcribed each of the moments in which compliance and
well-being verbalizations were uttered by P.
4. Data analysis. Once the coding procedure was complete, data analyses were
performed. Firstly, all three-term sequences (stimulus-response-stimulus) that occurred
both in moments of debate and in any other moment were identified and manually
counted every time a pro-therapeutic verbalization uttered by P. happened throughout
the therapeutic process. These three-term sequences were defined as starting with a
verbalization emitted by the therapist that was followed by a verbalization emitted by
the client, which was in turn followed by another verbalization emitted by the therapist.
This way, all the hypothetical functions of the clinician’s verbalizations could be
analyzed later. Finally, all pro-therapeutic verbalizations (compliance and well-being)
that were uttered in each session were identified and manually counted, and both were
related to the therapeutic objectives and the maladaptive verbalizations from which the
debates had started.
RESULTS
1. Functional sequences in the therapist-client interaction during the Socratic
debate.
Throughout the therapeutic process, different Socratic debates related to the therapeutic
objectives occurred. In session six, there was a debate regarding jealousy and control
(objective 1). In sessions six and seven the debate alluded to the client’s relation with
her partner’s family (objective 3). Finally, in sessions nine and 10 the debate was about
the negotiation of different issues on the couple’s coexistence (objective 5).
After analyzing the dialogue of the debates, different types of interaction sequences
could be specified. Six types of behavioral chains, which amounted to 40% of all
interactions during the debate, were found. There were three different types of
sequences in which the client showed an approximation to the therapeutic objective
(VAT): sequences in which the therapist emitted discriminative verbalizations before
and after the client’s emission of VAT; sequences in which the therapist discriminated
and reinforced; and sequences in which the therapist discriminated and informed. The
most common sequences that were related to verbalizations opposed to the therapeutic
objective (VOT) were: discriminating before and after the client’s response,
discriminating and punishing and discriminating and informing. The other 60% of
interaction sequences was very heterogeneous, and corresponded to activities such as
informing, giving instructions regarding tasks to be completed, or motivating the client
to change. Examples of the most common interactions can be found in figures 1 and 2.
The data seem to support hypothesis 1, in which we proposed that the dialogue that is
established between the client and the therapist during the Socratic debate can be
specified in a series of Sd-R-R+ sequences.
FIGURE 1 APPROXIMATELY HERE
FIGURE 2 APPROXIMATELY HERE
2. Evolution of the client’s pro-therapeutic verbalizations after the Socratic debate
and analysis of the therapist-client functional sequences.
Regarding the therapist’s behavior before and after the client’s utterance of pro-
therapeutic verbalizations, it was found that the most common sequences in the sessions
that followed a Socratic debate are: sequences in which the therapist reinforces before
and after the client’s pro-therapeutic verbalization (32%); sequences in which the
therapist discriminates a verbal response by the client and, when the latter emits a pro-
therapeutic verbalization, the former reinforces it (27%); and those sequences in which
the therapist discriminates verbal responses by the client before and after the latter’s
pro-therapeutic verbalizations (14.4%). Frequencies and percentages of all interaction
sequences related to pro-therapeutic verbalizations can be found in Table 3; Table 4
shows examples of the most frequent interactions.
TABLE 3 APPROXIMATELY HERE
TABLE 4 APPROXIMATELY HERE
A progressive increase in the frequency of pro-therapeutic verbalizations is observed in
the analysis. Their total frequency was 141 verbalizations throughout the therapy; 27
(19.15%) of them were emitted prior to the treatment (sessions one to four) and 114
(80.85%) during the treatment (sessions five to 10).
These data, along with data shown in Table 3, show evidence supporting the second
hypothesis of this study: the new pro-therapeutic verbalizations that are emitted by the
client after the Socratic debate will increase in frequency in the treatment sessions that
come after it, and will be reinforced by the therapist.
Next, pro-therapeutic verbalizations emitted by the client were separated in two groups
in order to analyze them more thoroughly: on the one hand, verbalizations related to
compliance with instructions emitted by the therapist; on the other, verbalizations that
expressed well-being. This was done in order to investigate the third hypothesis of this
study: the increase in the pro-therapeutic verbalizations emitted by the client due to the
debate will be related to an increase in the verbalizations that describe those pro-
therapeutic behaviors performed outside clinical settings. These verbalizations will be
verbally reinforced by the therapist.
Figure 3 shows a notable increase in both types of pro-therapeutic verbalizations
starting from session five and reaching a peak in the last session of the treatment
(session 10). Both types of verbalizations are shown to be evolving in a similar way,
with those that express compliance being the ones that change most notably once the
treatment begins. This provides more evidence regarding the third hypothesis, as does
the analysis shown in Table 3 in which the therapist’s reinforcing of pro-therapeutic
verbalizations emitted by the client is evident.
FIGURE 3 APPROXIMATELY HERE
Regarding the evolution of pro-therapeutic verbalizations throughout the therapy, a
certain correspondence between both the content and therapeutic objective of the debate
and the increase in pro-therapeutic verbalizations that refer to those concrete objectives
is found. Most of the pro-therapeutic verbalizations are found in two specific objectives:
objective 1 (jealousy and control) and objective 3 (relationship with her partner’s
family), and also with the general objective (well-being). Among these three, they
amount to 58.8% of all pro-therapeutic verbalizations. The objective in which the fewest
number of pro-therapeutic verbalizations is found is objective 5 (unification and
negotiation of certain coexistence issues). These represent a 2.8% of the total. In
sessions seven, eight and 10 is when the greatest number of pro-therapeutic
verbalizations is found (56.7% of the total frequency throughout the therapy). The
evolution of these verbalizations in relation with the general therapeutic objectives and
throughout the process of intervention can be seen in Figure 4.
FIGURE 4 APPROXIMATELY HERE
For a detailed analysis of the evolution of pro-therapeutic verbalizations emitted by the
client throughout all session in each of the therapeutic objectives, as well as those anti-
therapeutic verbalizations that serve as starting points for the Socratic debate, please
refer to Figure 5.
FIGURE 5 APPROXIMATELY HERE
DISCUSSION
The results obtained in this study support our research group’s conceptualization of the
Socratic debate as a procedure combining shaping and verbal chaining. The results of
earlier studies pointed towards the plausibility of this standpoint (Calero-Elvira et al.,
2013; Calero-Elvira, Froján-Parga, Ruiz-Sancho & Vargas-de la Cruz, 2011; Froján-
Parga & Calero-Elvira, 2011; Froján-Parga, Calero-Elvira & Montaño-Fidalgo, 2006,
2009, 2010), which has become even more solid after this study. Even acknowledging
the limited generalizability of the results in a single-case study with descriptive
methodology, they have been clear enough for us to be able to propose some interesting
conclusions.
In the first place, the fact that all three hypotheses were confirmed must be highlighted:
the Socratic dialogue can be described in terms of S-R-R+ sequences; those pro-
therapeutic verbalizations that are a product of the Socratic debate increase in frequency
throughout the treatment; lastly, those verbalizations that refer to the performance of
pro-therapeutic behaviors outside clinical settings also increase their frequency.
Regarding the results that confirm the first hypothesis, Figure 1 showed that the
therapist, when dialoging with the client, reinforces those verbalizations that approach
the final objective (VAT); that is, a new verbalization that will be the starting point for
the establishment of pro-therapeutic behaviors outside the sessions. These results show
the dialogue as a combined process of shaping and chaining: if a verbalization uttered
by the client approaches the therapeutic objective, it is reinforced by the therapist; if it
doesn’t, the therapist emits a new discriminative stimulus (a question) or an informative
verbalization that will give rise to a new question (which is to say that through the
dialogue, the client’s response is shaped). In a dialogue between the therapist and the
client (or any other dialogue), the questions asked by the therapist discriminate the
client’s verbalization that they precede and reinforce the one they follow, thus following
the typical scheme of verbal shaping. That is why we can find Sd-R-R+ sequences,
when the client answers in the desired manner; or Sd-R-Sd sequences, when the client’s
response can be further elaborated to increase its pro-therapeutic character, and thus the
therapist emits another question. But there is yet a third type of sequences we wish to
discuss, because they are of great interest to us: those in which the client’s verbalization
is followed by an explanatory (informative) verbalization emitted by the therapist (see
Figure 1). When the client does not easily verbalize the idea that would approach to the
therapeutic objective, the psychologist may make it easier for the client by putting him
or her in a favorable motivational state. This motivational state can be achieved by
explicitly anticipating the consequences of a given behavior; describing a situation in an
objective, non-emotional way; reminding the client of other situations in which he/she
or people with similar problems have successfully faced; or providing technical or
clinical knowledge that will contribute to the clarification of the situation that is being
dealt with. The research on motivation from the field of behavior analysis has focused
on the so-called “establishing operations” (Michael, 1982; 1993; 2000). During the
Socratic dialogue, a discriminative stimulus can be made to be more salient, a response
more adjusted to the objective and a reinforcer more potent when the therapist emits a
particular kind of verbalizations (which we called informative function in our
category system) that act as establishing operations. In other studies by this research
group (Calero-Elvira et al., 2013; Calero-Elvira, Froján-Parga, Ruiz-Sancho & Vargas-
de la Cruz, 2011; Froján-Parga & Calero-Elvira, 2011) we have found the presence of
these verbalizations accompanying the Sd-R-R+ (or P+) to be fundamental in order for
the client’s response to follow the line the therapist intended it to follow. If cognitive
restructuring is to be understood as a combination of shaping and chaining processes,
these establishing operations must be taken into account.
An identical scheme is followed in those dialogues in which the client’s response strays
from the objective of the debate (VOT), the difference being that, in this case, the
verbalization is followed by punishment (see Figure 2). And, just like it happened when
the consequence was a reinforcement, the therapist may discriminate another response
in an attempt to further approach the objective of the debate or to offer more
information that will make it easier for the client to reevaluate his/her VOT.
Regarding our second hypothesis, we have noted an increase in pro-therapeutic
verbalizations that the client starts to emit after the Socratic debates are ended and
throughout the therapeutic process that continues from that moment on. The importance
of the Socratic debate as a procedure for psychological change does not end when the
client has more rational thoughts (i.e. emits more rational verbalizations), but when
these are generalized to different areas of his/her life and give rise to more pro-
therapeutic behaviors outside the clinical context. The second of our hypotheses deals
with this first objective: an increase in pro-therapeutic verbalizations and their
generalization to different areas of the client’s life. In this sense, we observe how in the
studied case, in pre-treatment sessions only 27 pro-therapeutic verbalizations appeared,
as opposed to the 114 that appeared in the treatment sessions. However, what’s more
interesting from our perspective is the relation between this increase and what the
therapist is doing: he/she is systematically reinforcing these verbalizations, which can
explain their increase. We could ask whether the same effect would occur even if the
therapist didn’t reinforce those verbalizations; the answer could be “yes”, if non-
programmed reinforcing processes were occurring in the client’s environment (their
daily life) that would have the same effect. However, a good therapist cannot risk things
happening by chance: reinforcement in the client’s daily life must happen (it is a
requisite for the maintenance of the clinical success once the therapy is concluded), but
in order for it to happen, first the client has to behave (do, say, think) in accordance with
the new ways to look at the world that he/she has developed through the debate. For that
to happen, it is essential that the therapist supports those verbalizations that describe
those new perspectives (by reinforcing them). In this regard, we find the very same
sequences we found during the debate: the client’s responses are followed either by a
reinforcement emitted by the therapist, by a new discriminative (thus making it obvious
that the shaping process does not end when the debate “officially ends) or by
informative verbalizations intended to, once more, generate a motivational climate
that’s favorable for the consolidation of the verbalizations. In the introduction to this
paper we provided an explanation as to why the therapist’s reinforcement of what the
client says inside the clinical setting could give rise to changes in what the client
says/does outside the clinical setting. This explanation was provided in terms of the
referential function of language. We’ve seen that Mowrer’s (1954) works provide a
solid foundation for the conceptualization of the clinical setting as a natural setting in
which, in fact, the client’s problem behaviors occur “live”, and therefore there are ways
to modify those behaviors inside the clinic itself. This idea has been central to the so-
called contextual therapies, whose bases can be found in the applied analysis of
behavior and Skinnerian radical behaviorism: Acceptance and Commitment Therapy
(ACT, Hayes, Strosahl, & Wilson, 1999) and Functional-Analytic Psychotherapy (FAP,
Kohlenberg y Tsai, 1991). According to Mowrer’s explanation, we could say that the
client’s narration of his/her daily situations (whether problematic or not) has a
functional value (in terms of the responses it evokes) that’s very similar to that of the
daily situations themselves. Therefore, the mechanisms for the meaning transference
proposed by Mowrer could explain why, through language, we can modify a person’s
behavior when faced with certain environmental events, with no ostensible need to
modify the behavior directly in those situations or when facing exactly those evets. The
explanation for the mechanism of meaning transference that was proposed in the
introduction goes beyond its specific application to the Socratic debate. Actually, it
would encompass all the therapeutic process, since regardless of the technique that is
being used, most of the therapy occurs through a dialogue between the therapist and the
client in which there are countless occasions for the learning of behaviors (that will
happen in the extra-clinical environment) through linguistic exchanges in session.
And that is directly linked to our third hypothesis. For this hypothesis supportive
evidence has also been provided: the increase in the client’s descriptions of his/her own
pro-therapeutic behaviors performed outside the clinic occurs simultaneously with the
increase in the client’s pro-therapeutic verbalizations. In order to test this hypothesis, we
had to sort the verbalizations that described the client’s well-being apart from those that
described compliance with the tasks that the client was instructed to do by the therapist.
In Figure 3 the parallel evolution of both kinds of positive verbalizations throughout
therapy can be seen. It can also be seen that, from session five on (which was the first
treatment session), the verbalizations of compliance outnumber those of well-being in
practically all sessions. In short, it’s not enough for the client to verbalize how well they
feel, but they must, in their daily life (when the therapist is not there to reinforce or
elicit that kind of verbalizations), behave in a non-problematic way. However, since the
therapist cannot be present at that moment to directly reinforce that behavior, he/she
must evoke during the clinical session the description of the out-of-session behavior so
as to reinforce that description. There is a noteworthy result in session nine (Figure 3),
where there is a pronounced decrease of both verbalizations of well-being and
compliance. In this session, the therapist tackles some aspects of objective 5
(negotiation and unification of certain coexistence issues) which, since they implied
changes in her partner’s behavior, had not yet been fully achieved. Pro-therapeutic
verbalizations decrease in order to bring up those conflictive topics in the clinical
context so that the therapist can shape new verbalizations that will allow for the
resolution of the existing problems. One month later, in session 10, verbalizations of
well-being and compliance not only reach but they surpass in some cases their previous
levels. Figure 4 shows the evolution of pro-therapeutic verbalizations sorted by the
clinical objective to which they refer.
Lastly, figure 5 allows us to study in a very visual way how the client’s verbalizations
throughout the therapeutic process change. Obviously, not all verbalizations emitted by
the client have been transcribed; only those that were representative of the client’s
improvement. We’ve sorted the verbalizations by session and by objective (a general
objective and five specific objectives that were related to so many problematic areas).
Besides, we thought it could be interesting to highlight those verbalizations that alluded
to the client’s general well-being, whose increase is a ubiquitous, even if not necessarily
explicit, objective of any clinical intervention. In figure 5, the evolution of pro-
therapeutic verbalizations of both kinds can be clearly seen, as well as how they
multiply as the therapeutic process progresses, describing not only moods but also new
behaviors in which the client is starting to engage in her daily life.
The results of our work, with the aforementioned limitations, are further evidence that
the therapeutic process in general and the Socratic debate in particular can be explained
in terms of shaping and verbal chaining. The operant processes of reinforcement and
punishment together with the pavlovian processes that allow for the modification of the
client’s emotional response through the use of language offer a solid foundation for the
Socratic debate.
Some authors might consider that “reducing” the Socratic debate to a process of verbal
conditioning amounts to eliminating this strategy’s “depth” and lowering it to its most
epidermal aspects. We think this couldn’t be farther from the truth; in the introduction
to this paper we also alluded to Wittgenstein’s philosophical theory (1953) and his
defense of the socially learnt character of meanings, as well as the functional
equivalence between a private phenomenon (namely a thought) and its public
denomination. On one hand, Mowrer’s work (1954), independent of Wittgenstein’s
though coherent with it, shows how acts and the words that describe them are related
without the need for a physical contact, so that we can react to the description of an
event just as we would if we were faced with the events themselves. This was already
said by cognitive therapists, but Mowrer provides the key to the explanation of this
phenomenon: classical (or pavlovian) conditioning. Thus, what had been kept in a mere
descriptive level until now (thoughts are related to feelings, people act guided more by
the thoughts they have than by the external event) can from this moment on reach an
explanatory level through the processes of classical and operant conditioning. We must
not forget that the reinforcing power of a stimulus is determined, in many cases, by
processes of classical conditioning. Besides, this approach allows for the equating of
thought and behavior (thought as just one more type of behavior, as we proposed in the
introduction) and the study of cognitive change as a behavioral change, ruled by the
same processes that govern any other kind of behavior. This means overcoming the
Cartesian dualism to which Beck’s (Beck, 1967; Beck, Rush, Shaw, & Emery, 1979)
and Ellis’ (1962) original approaches inevitably drove us with their sort-of bio-medical
model of psychological problems. Their version of the bio-medical model was even
more problematic (if that is possible at all) than the original, since the internal
phenomena that those authors proposed as causes of the behavior are not organic, but
mental or intrapsychical (mental schemata). This, far from being a solution to the
problem, makes it even more problematic because of the philosophical implications it
entails. If the etiology is neither environmental nor inner structural/ organic, we would
be proposing the existence of a second substance that could alter behavior: some sort of
non-materialistic “mind”, completely separated from the body and its physical relation
with the environment.
A single-case study like the one we present here can only hope to be a starting point for
new research on the study of language in clinical settings from a radical behaviorist
standpoint. Both its philosophical and experimental foundations are sufficiently potent
to serve as an alternative to the traditional cognitive conceptualization. The overcoming
of Cartesian dualism and tautological explanations, along with the possibility of an
experimental analysis of the therapeutic procedures, can be a desirable target for the
development of a scientific psychology.
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Table 1. Therapeutic objectives
General
objectives
Increasing her well-being
Improving her relationship
Specific
objectives
1. Eliminating jealousy and control behaviors: eliminating thoughts
and emotions of insecurity and mistrust regarding her relationship,
modifying irrational thoughts regarding romantic relationships and
eliminating checking behaviors with her partner.
2. Sharing more enjoyable activities as a couple: P. must share activities
that her partner enjoys and both must share more time together engaging
in activities that both find enjoyable.
3. Improving her relation with her partner’s family: increasing
interaction and making it more amiable.
4. Reducing arguments and improving how P. expresses her annoyance
or anger to her partner (reproaches, etc.).
5. Negotiating certain aspects of P.’s coexistence with her partner
(economic issues, etc.).
Table 2. Therapist and client verbal behavior category systems.
Observed subject
(moment)
Codes Definition
Therapist (all
along the
therapy)
Discriminative Verbalization by the therapist, typically a question, that
evokes a patient’s response (verbal or otherwise).
Explicit instructions, prompting, and motivational
operations are excluded.
Reinforcement Verbalization by the therapist showing approval,
agreement, and/or acceptance of patient’s behavior.
Punishment Verbalization by the therapist showing disapproval,
rejection, and/or non-acceptance of patient’s behavior.
Informative Verbalization by the therapist conveying technical or
clinical knowledge to a non-expert person.
Motivational Verbalization by the therapist that explicitly expresses
the consequences that the client’s behavior will have,
is having, has had or could have on clinical change.
Instructional Verbalization by the therapist intended to increase the
odds of a given behavior by the client happening in or
out of the clinical context.
Client (all along
the therapy)
Pro-therapeutic
verbalizations
Compliance: the client describes she has complied with
a guideline proposed by the therapist.
Well-being: the client expresses her well-being or
positive emotional reactions in relation to the
therapeutic objectives.
Client (Socratic
method)
VAT Any verbalization that approaches the therapeutic
objective of the Socratic debate.
VIT Any verbalization intermediate with respect to the
therapeutic objective of the Socratic debate.
VOT Any verbalization that opposes the therapeutic
objective of the Socratic debate.
Table 3. S-R-S interaction sequences in relation to the pro-therapeutic verbalizations
emitted by the client throughout the therapeutic process, expressed in percentages and
frequencies.
S-R-S interaction sequences Absolut
frequency %
Reinforcement- Pro-therapeutic V.1- Reinforcement 31 32%
Discriminative- Pro-therapeutic V. -Reinforcement 26 27%
Discriminative- Pro-therapeutic V.-Discriminative 15 15.4%
Reinforcement- Pro-therapeutic V.-Discriminative 6 6.2%
Other- Pro-therapeutic V.- Reinforcement 3 3.1%
Reinforcement- Pro-therapeutic V.-Informative 3 3.1%
Informative- Pro-therapeutic V.-Reinforcement 3 3.1%
Other sequences2 10 10.3%
1 Pro-therapeutic V.: Pro-therapeutic verbalization.
2Other sequences: Interaction sequences that occurred in two or less occasions each.
Table 4. Examples of the most frequent S-R-S interactions between the therapist and the
client related to the pro-therapeutic verbalizations emitted by the client throughout the
therapeutic process.
S-R-S type of sequence Examples
Reinforcement –Pro-therapeutic V.-
Reinforcement
Session 7 example.
Therapeutic objective: 4. Arguments with
her partner.
T: Good (responding to the client’s
description of how the argument with her
partner would have been in other moment).
C: Despite I felt like telling him, I didn’t
say anything.
T: Very good.
Discriminative-Pro-therapeutic V.-
Reinforcement
Session 7 example.
Therapeutic objective: 1. Jealousy and
control.
T: And if he had done it, what would have
happened? (if her partner had gone out)
C: Well, nothing, I’d have had to accept it.
T: Perfect.
Discriminative-Pro-therapeutic V.-
Discriminative
Session 10 example.
Therapeutic objective: 3. Relation with her
partner’s family.
T: Did you say hello to her? (to one of her
partner’s family members with whom she
has a strained relationship).
C: Yes, I said hello, but we didn’t have any
contact beyond that.
T: And have you kept on having contact
with his family?
Reinforcement – Pro-therapeutic V.-
Discriminative
Session 6 example:
Therapeutic objective: Couple general.
T: So both of you are calm, satisfied, good.
C: Yes, things are calm now, at least on my
side, and on his side too, I feel good.
T: And what about his family?
Figure 1. Most frequent interaction sequences in the Socratic debates when the client
emits verbalizations that approach the objective of the debate (VAT).
Objective of the debate: the client must verbalize that saying hello to her sister-in-law is
not hypocritical.
(Previously the client had been instructed to say hello to her sister-in-law and call her by
her name. The client verbalizes that doing so might seem hypocritical).
T: What do you want to achieve by doing it?
C: I don’t have the objective of sounding like a hypocrite.
T: But what do you want to achieve? Is being her friend your objective? Is it telling her
“you’re an idiot”?
T: But what do you want to achieve? Is being her friend your objective? Is it telling her
“you’re an idiot”?
C: It’s being kind.
T: That’s right! Being kind.
T: (The therapist uses an example of a very friendly greeting she could use with her
sister-in-law)
C: That’s fake.
T: Totally. But using a polite expression such as “Hi, H., how are you?” with that
objective (trying to improve your relationship) is not hypocritical.
DIS. VAT DIS.
DIS. VAT REF.
DIS. VAT INF.
Figure 2. Most frequent interaction sequences in the Socratic debates when the client
emits verbalizations that are opposite to the therapeutic objective of the Socratic debate
(VOT).
Objective of the debate: the client must verbalize that her partner doesn’t always get
home very late, and that it isn’t a big deal.
(The client had previously verbalized this about her partner’s behavior when he goes
out with friends: “it’s always the same, he gets home in the small hours”).
T: Is it always the same? How often does he do it?
C: Getting home at seven in the morning, he does that very often.
T: But how often does he do it?
T: But how often does he go out?
C: When he goes out.
T: Really! (in an ironic tone). Of course, “when he goes out”. Imagine this: “I only go
out in New Year’s Eve and come home at 7 in the morning”, that means 100% of the
times I go out I get home at 7 in the morning.
T: What about you?
C: I’m incapable of doing that and it seems very strange to me, and I don’t understand
how he can be out until seven in the morning.
T: Most parents don’t understand how they children can go out beyond 22.30, I mean,
there are people who have fun and some can be out until 7, 10 or until 17.00 the next
day, I mean, to each their own. So forget about you not being able to do it, because
that’s not the measure of something being feasible or not.
DIS. VOT CAS.
DIS. VOT DIS.
DIS. VOT INF.
Figure 3. Frequency of compliance and well-being verbalizations emitted by the
client throughout the intervention.
0
2
4
6
8
10
12
14
16
18
S. 1S. 2S. 3S. 4S. 5S. 6S. 7S. 8S. 9S. 10
Compliance
Well-being
Frequency
Assessment and
explaining
Treatment
Figure 4. Frequency of pro-therapeutic verbalizations emitted by the client throughout
the intervention in relation with the therapeutic objectives.
NOTE:
The sessions in which there were cognitive restructuring debates have been circled.
0
1
2
3
4
5
6
7
8
9
10
S. 1S. 2S. 3S. 4S. 5S. 6S. 7S. 8S. 9S. 10
GENERAL
RELATIONSHIP
GENERAL
1. Jealousy and
control
2.Couple activities
3. Partner's family
4. Arguments
5. Coexistence
Evaluation and assessment Treatment
Frequency
Figure 5. Anti-therapeutic verbalizations emitted by the client prior to the debate and
evolution of pro-therapeutic verbalizations throughout the treatment in relation to
therapeutic objectives.
MACRO OBJECTIVE
General well-being
Objective 1
Jealousy and control
GENERAL OBJECTIVE
Improving her
relationship
678 910
On the phone I was very
normal .
When he told me he was
going out I found something
to do.
I didn’t think it was the
right time for that and I
didn’t want to do that
(checking),I told myself
“it’s ok, nothin
g
’s wron
g
”.
I told him: “hey, maybe you
feel like going with him”.
If you want to go out it’s
fine by me, really”.
Nothing. I’d have had to
accept it.
I didn’t sa
y
an
y
thin
g
at all.
I didn’t say anything else to
him although I was dying to.
No (she didn’t have a hard
time when L. went out
)
.
Truth is I didn’t feel bad, I
was busy.
Yes, I am more relaxed,
it’s not like it was
before.
Fine in that regard
I’m ok with him going
out.
Fine, it’s under control.
Truth is I’m quite fine.
Yes (they are satisfied), the
truth is now things (her
relationship) are laid back
now and I feel good.
From a general standpoint,
it’s been good.
Fine, I’m ha
ppy
.
But I did and I feel really
good about mysel
f
.
As of now, my
relationship is going very
well.
OBJECTIVES ANTI-THERAPEUTIC VERBALIZATON (prior to the debate) PRO-THERAPEUTIC VERBALIZATIONS EMITTED BY THE THERAPIST THROUGHOUT THE TREATMENT
Look at how many things I’m
doing, I can’t even recognize
myself.
Not only good, but
outstandingly so. With L.
In general, fine.
Fine (when asked
how she was).
But it’s all right, there have
been small quarrels, but
things are different now.
The general impression
is ver
y
g
ood.
There are small
changes in me that
are obviously noticed.
Yes, I’m very happy
(relationship)
I feel
g
ood.
I’m actually very good.
Yes (her sister thinks
she’s more calm now
)
.
With good results
(guidelines ).
My state is one of total
relaxation.
My daily life is
normal… I’m satisfied.
We’ve made a big
progress.
That feeling of being
calm, of happiness.
She notices I’m fine
now (her mother).
- “Always the same, these hours. I can’t
understand how he can be out until 7 in
the morning”.
-“I started having doubts about with
whom has he been”.
-“It’s more likely for him to cheat on me if
he goes out at night”.
My friend noticed I’m
different now.
The general impression is
very good.
My friends noticed.
She said: “ok, fine”
(without getting angry,
despite he was going to
be late for dinner).
I think it will be fine, I
don’t have bad
expectations.
I thought about doing…
(while he’s away).
Objetive 3
Partner’s family
Objetive 5
Negotiation in
coexistence
Objetive 2
Couple activities
Objetive 4
Arguments
“If you want we can go to
your mother’s when we’re
done” and we went there.
I proposed for us to go to
her home, and we did.
I did it, despite it was hard
for me.
Later in her home I was
fine, I wasn’t awkward, I
was fine.
We went to have lunch
with his famil
y
.
I asked him whether we
were going to go to his
mother’s.
I wouldn’t mind going to
our town
.
The family thing has
sta
y
ed the same.
Before I practically
didn’t go to her home,
now I go at least once a
week, which is
something, I believe.
Fine (in their town,
with L.’s family).
Yes (she was fine with
L.’s
p
arents
)
.
It wasn’t that bad, I
was fine, I felt good.
This Saturday we’re
going to have lunch at
her sister’s.
(She greeted her): Hello.
Yes (she’s kept in
touch).
A good relationship,
and I feel more and
more relaxed.
We see each other
more often (L.’s
family).
My homework, that
conversation I had to
have, I did it and it
went well
.
So yes, we have
reached an
agreement and it’s
all good, quite good.
On Sunday we watched
a movie at home.
I told him in a good
manner (what’s bothering
her).
I went to the football match.
Yesterday we were there,
we went shopping
together, we went to…
On Sunday afternoon we
w
e
n
t
to
In the afternoon we
went to IKEA.
And I
f
elt liberated (when
she told L. what was
bothering her).
We do argue, but very
differently.
In other times I’d have said
to him… and that would
have started an argument,
but i didn’t say anything.
Despite I felt like telling
him, I didn’t say anything.
There are arguments, but
we have a different way of
saying and accepting
things, both he and I.
I tell him in another way, I
control that now.
Its on the same level, I
go to see some matches.
Most days we go
out together.
I yielded. Those small
things would have made
me angry before, I’m
sure.
After that we went to
drink something and we
were with friends of ours.
I went to the football
match.
Last Friday we went for
a walk here, in Madrid…
we had dinner and we
went home. We went out to have
something to drink.
Before I probably told
him things in an
unpleasant way and
with a bad tone, now I
use a more amiable
tone.
We went out to have
something to eat.
I watch it for a while
(match) then we go to
the movies…
I told L. I’m sorry, I
shouldn’t have
answered like
that…
I tried to practice
cutting our
argument.
- “Many times I think that since I’m at
home and I make less than him, I have to
do it”.
- “I feel guilty” (for telling him to do
things).
- “I was very disappointed” (that he had
doubts about marrying her).
- “I’m under the impression that she wants
to be seen as better than me” (sister-in-
law).
- “It was a slight that I didn’t like at
all“(when her sister-in-law didn’t say hello
to her).
- (Saying hello to her sister-in-law calling
her by her name) “That’s going to sound
hypocritical”. We later went to his
mother’s. We went to her
NOTES: The therapeutic objectives that have not been subjected to a Socratic debate are shown in gray.
Pro-therapeutic verbalizations in grey boxes are those that express positive emotions and well-being.
Pro-therapeutic verbalizations without grey boxes express compliance with the guidelines emitted by the therapist.
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Thesis
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Psychological interventions are effective in the treatment of people diagnosed with severe mental disorder (SMI). The empirical evidence to determine the efficacy of treatments has been generated in the evidence-based practice in psychology movement. Thanks to this movement, several treatments have been shown to be effective in solving the psychological problems related to SMI diagnoses (schizophrenia, bipolar disorder, major depression, and borderline personality disorder). While there is agreement on the efficacy of various treatments for these problems, no consensus has been reached on the basic psychological principles and processes that explain the efficacy of the treatments. Knowing that something works does not imply knowing why it works. In this context, this work endorses the usefulness of a process research with a functional-analytical perspective of human behavior. Specifically, as in Clinical Behavior Analysis, this work shares the interest in the study of the processes involved in the verbal control of behavior. The purpose of this work is to analyze the verbal interaction between therapists and clients diagnosed with severe mental disorder. For this, an observational system for analyzing the verbal interaction between the therapist and the client has been designed, refined, and validated. This system is based on a functional analytical perspective of verbal behavior, so all its categories are based on a functional description. This system facilitates the analysis of the learning processes that are set in motion in the verbal interaction during clinical session. In fact, this work analyzes the allocation of the different functions of verbal behavior of various therapists throughout different cases (6 therapists in 12 different cases with 76 sessions in total). Specifically, the performance of the therapists of two groups (cases with SMI and without SMI) at different times (36 evaluation sessions and 40 treatment sessions) is described. Also, a sequential analysis of the verbal interaction was carried out and the therapist’s performance patterns that are related to a greater size of the effect of the psychological intervention on the client's behavior were analyzed. To conclude, we analyze the performance of a therapist with training in behavior analysis in the psychological treatment of a person diagnosed with SMI (16 sessions in total). In this case, a descriptive and sequential analysis of the therapist’s performance is also carried out and her performance is related to the change in the client's behavior. In general, these studies have allowed us to study the processes of verbal control of behavior that operate during psychological treatments. Also, the role of the therapist's verbal behavior in the efficacy of psychological treatments is discussed.
Article
Background Cognitive restructuring is one of the most complex application procedures in psychotherapy. It is widely used by psychologists from different orientations. However, the guidelines on how to apply it do not usually have empirical evidence and there is a lack of knowledge about the mechanisms of change that explain it. Aims The analysis of verbalizations that therapists emit during the Socratic method could help to better understand the functioning and strategies of effective debates. Method In this study, specific verbal interaction sequences were analysed using observational methodology. The sample consisted of 113 Socratic questioning fragments belonging to 18 clinical cases, treated by behavioural therapists. Results Among other findings, it was found that using questioning together with certain previous verbalizations directed the client’s response more effectively and those successful debates were characterized by using the aversive component in a frequent and contingent way. Conclusion This study shows the most effective way to establish such an interaction in the Socratic method (following a style closer to Ellis’s argumentative debate), which entails relevant practical applications in therapy.
Article
Full-text available
This review summarizes the current meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders. A search of the literature resulted in a total of 16 methodologically rigorous meta-analyses. Our review focuses on effect sizes that contrast outcomes for CBT with outcomes for various control groups for each disorder, which provides an overview of the effectiveness of cognitive therapy as quantified by meta-analysis. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger, childhood somatic disorders, and chronic pain were in the moderate range. CBT was somewhat superior to antidepressants in the treatment of adult depression. CBT was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. Large uncontrolled effect sizes were found for bulimia nervosa and schizophrenia. The 16 meta-analyses we reviewed support the efficacy of CBT for many disorders. While limitations of the meta-analytic approach need to be considered in interpreting the results of this review, our findings are consistent with other review methodologies that also provide support for the efficacy CBT.
Book
The initial conceptualization of this book was much more narrow than the final product that has emerged. I started out believing that it would be enlightening to have a group of acknowledged rational-emotive therapy (RET) expert practitioners with well-established literary credentials write about how they approach the problem of modifying dient irrationality. Many RET practitioners of all levels of experience are, on the one hand, enamored of the economy, the precision, and the accuracy of psychological insight that RET theory offers, but they are, on the other hand, equally frustrated by their own inability to "persuade" or otherwise change some of the dients they work with more quickly or even at all. Indeed, dients themselves frequently express the view that RET is illuminating, yet they find themselves at the same time puzzled and perplexed by their inability to make the substantial changes that RET invites. It became dearer as I discussed the project with many of the contrib­ utors that to practice RET effectively requires more than just innovative and persistent assessment and intervention techniques. For example, Rus­ sell Grieger expressed the view that more prerequisite work needs to be done on the value and philosophical systems of dients-induding person­ al responsibility and the philosophy of happiness-before many dients can show significant shifts in their thinking. Susan Walen raised the gener­ al issues of how effective RET can be in the treatment of biologically driven affective disorders.
Chapter
Behavior modification encompasses a variety of conceptual and theoretical positions, methodological approaches, treatment techniques, and historical developments. Because behavior modification is not a monolithic approach, it is important to convey the range of developments that converged over the course of the history of the field. This chapter traces the history of behavior modification as a general movement. Individual conceptual approaches and techniques that comprise behavior modification are obviously important in tracing the history, but they are examined as part of the larger development rather than as ends in their own right. This chapter examines major influences that finally led to the formal development of behavior modification and behavior therapy.1
Chapter
The cognitive model of depression originated in a series of studies of clinical depression conducted by Beck in the late 1950s. Although these studies arose from the desire to secure empirical evidence in support of psychoanalytic theories of depression, the psychoanalytic model proved difficult to confirm empirically. Rather, the data suggested an alternate formulation, namely, that the depressed patient was characterized by a particular kind of thinking: he tended to regard himself as a “loser.” The dreams he reported, his early memories, his responses to projective tests, and the material he generated in a clinical setting all tended to reflect certain stereotyped themes: he saw himself as a person who was continually deprived, frustrated, and thwarted, whose prospects were dim, and who had little chance of improving them. Beck also observed that depressed patients made certain logical errors—among them overgeneralization, arbitrary inference, and selective abstraction. Beck concluded that the negative thinking typical of the depressed patient—his negative bias in interpreting events—might underlie his depressed moods. It followed that correcting this thinking might then improve the mood and other symptoms of depression (Beck, 1967/1972).