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TOWARD A CONSTRUCTIONAL
EXPOSURE THERAPY
By T. V . Joe L ay n g and Aw a b Abde l- Ja l il
Exposure th erapy has beco me a CBT “gold standard” for
treating ma ny disorders, including anxi ety disorders, obsessive
compulsive disorder, and PTSD (Rauch et al., 2012). T hough the
delivery ve hicle may vary , and the theo retical underp innings
may be deba ted, there is general consen sus that many patients
find the pr ocedure uncomf ortable, chall enging, result ing in
troubling d rop-out rates (e.g., Eftekha ri et al, 2020 ; Steenkamp
et al., 202 0). The emphas is with these procedures is often the
elimination of the presen ting complaint . Those approa ches
seeking the elimination o f a problem ha ve been charac terized
by Goldiamo nd as patholog ical approache s. In contrast ,
approaches that instead “ establish beha vior the absen ce of
which is th e problem” (Go ldiamond, 1974 /2002) have be en
characteriz ed as construc tional. Goldia mond’s Constru ctional
Approach wa s developed in the 1970s, bu t its full imp lications
have not be en explored un til recently ( Layng, 2009; L ayng et
al., 2022).
(CONTINUED ON NEXT PAGE)
JT. V. Joe Layng i s a Fellow of the Association
for Behavio r Analysis: In ternational and h as
over 50 yea rs of experien ce in the experim ental
and applied analysis of b ehavior. He earne d a
Ph.D. in Be haviora l Sciences (bi opsychology) at
the Univers ity of Chicago . At Chicago, wor king
with pigeon s, he, along w ith Paul Andronis
and Israel Goldiam ond, investiga ted animal
models of p sychopathology , specifically th e
recurrence of pathologica l patterns (he ad-
banging) as a func tion of normal behavioral
processes, and the produc tion of untrai ned
recombinant , complex symb olic repertoires
from simple r behavioral c omponents, a proc ess
they descri bed as conting ency adduction . J oe
has extensi ve clinical be havior analysis
experience with a focus o n ambulatory
schizophren ia, especially the systemic as well
as topical treatment of d elusional speech and
hallucinato ry behavior. J oe has spent the last
several yea rs mentoring s tudents, and
interested investigators and practition ers in
nonlinear c ontingency ana lysis. He has
published a pproximately 6 0 articles or
chapters, a range of soft ware applicati ons ,
coauthored a self-instruc tion book Deci sio ns
and Judgeme nts in Ambiguo us Situations: A
Conceptual Introduction t o Signal Detec tio n
Theory for behavior analy sts and recently
coauthored the book Nonli near Contingency
Analysis: G oing Beyond Co gnition and
Behavior in Clinical Prac tice. Joe is a n a djunct
professor o f Behavior Ana lysis at Endicott
College and Partner, Gene rategy, LLC.
https://www .routledge.com /9780367689506
Advances in Cognitive Therapy
Fall 2022 Issue, Page 8
TOWARD A CONSTRUCTIONAL
EXPOSURE THERAPY
(CONTINUED)
By T. V . Joe L ay n g and Aw a b Abde l- Ja l il
One importa nt feature of the approach i s its reliance on a
“nonlinear contingency an alysis” (NCA). Layng et al.’ s (2022)
recent book , Nonlinear Co ntingency Anal ysis: Going Be yond
Cognition a nd Behavior in Clinical Prac tice, provides a modern
description of NCA and it s application to a range of clinical
phenomena, including thos e often found to be quite
challenging . NCA describe s how behavior that may appe ar to
be maladapt ive or dysfunc tional may ins tead be quite adaptive,
often in a sense heroic ( see for exampl e Layng & Andr onis,
1984). In N CA, the outcom es of a behavi or are analyze d in
terms of th eir costs and benefits, as w ell as those o f available
alternative behaviors. Wh en the costs a nd benefits of each
pattern are considered, t he behavior pa tterns compris ing the
presenting complaint are often found to be the most s ensible
patterns av ailable.
Often the g oal is to prov ide an alterna tive that resu lts in the
same or gre ater benefit, but at far les s cost. In oth er words,
patterns ne ed be establis hed, the absen ce of which is the
problem (af ter Goldiamond , 1974/2002; L ayng et al., 2 022).
When that o ccurs, the dis turbing behavi or is no longe r the
pattern of choice and dec reases in freq uency without being
targeted fo r elimination. The emphasis is on establis hing
alternative s, not elimina ting the distu rbing pattern. The
consequence s that were ma intaining the disturbing beh avior
are still a vailable.
There are t wo nonlinear i nterventions: topical and sy stemic.
Both can pl ay a role in s uccessful inte rvention. In n onlinear
topical int ervention, bui lding alternat ives to the di sturbing
behavior th at provide the same or bette r benefits, bu t at less
cost, is th e target of in tervention. In systemic inte rvention,
establishin g repertoires other than tho se that are a direct
alternative to the distur bing pattern i s the goal. Th at is, the
problem pre sented may not , in fact, be the problem to be
solved. A d etailed discus sion of both c an be found in Layng et
al. (2022). Here, we will briefly descr ibe a nonlinea r topical
NCA procedu re that is sho wing great pro mise as a new form of
exposure th erapy: Constru ctional Exposu re Therapy (CE T).
The primary consideration when choosing
repertoires to establish is: Will the n ew
alternative pattern provi de the same or more
benefits th an the disturb ing pattern or other
available a lternatives? N ext, what prec isely is
the behavio r to be establ ished that wil l achieve
that outcom e? We then nee d to determine
where the p atient is now, and what stre ngths
they may ha ve upon which to build. What
change proc edures will be used to get f rom
where the p atient is to w here they want to be,
is the next step. Finally , determine th e
consequence s that will ma intain the pat ient’s
behavior th rough the chan ge procedures, and
how will pr ogress be meas ured. Where po ssible,
the same co nsequences mai ntaining the
presenting complaint can be harnessed a nd
used to mai ntain behavior through the c hange
procedures (Goldiamond, 1 974/2002; 2022 ).
(CONTINUED ON NEXT PAGE)
Awab Abdel- Jalil e arned his MS i n Behavior
Analysis at the Universit y of North Texas and is
currently a doctoral stud ent at the Ins tit ute for
Applied Beh avior Science of Endicott Co lle ge. At
UNT, with J esús Rosales-R uiz, he participa ted in
streamlinin g and carrying out construct ion al
programs fo r first-genera tion college s tud ents an d
students fr om low- income familie s. He is the
Constructio nal Coach at E astern Florida Au tism
Center and Great Leaps Ac ademy where he tr ains
staff, and works w ith parents on programs based
on the cons tructional app roach and nonline ar
contingency analysis. Awa b coauthored t he book
Nonlinear C ontingency Ana lysis: Going Beyo nd
Cogntion an d Behavior in Clinical Pract ice .
https://www .routledge.com /9780367689506
Advances in Cognitive Therapy
Fall 2022 Issue, Page 9
TOWARD A CONSTRUCTIONAL
EXPOSURE THERAPY
(CONTINUED)
By T. V . Joe L ay n g and Aw a b Abde l- Ja l il
In the case of patterns a ssociated with anxiety disor ders,
typical exp osure therapy attempts to el iminate the de bilitating
effects of targeted S —> R or S — (medi ating cognitiv e events) —>
R relations that are thou ght to be resp onsible for, o r a product
of the ofte n quite severe anxiety repor ted by the pat ient.
Exposure br ings the patie nt into progre ssively greate r contact
with the ev ent as they ov ercome their f ear or anxiety , and
perhaps cha nge their thin king, at each step in the pr ogram.
Each closer approximation leads to an e ven closer
approximati on eventually removing the t riggering S —> R
relation. S ome patients m ay find this d istressful and abandon
therapy as a result.
What separa tes CET from t ypical exposur e therapies is th at it is
an operant or consequenti al approach, r ather than one based
upon a more reactive S —> R approach wh ere the stimul us is
considered to elicit or t rigger certain emotions, tho ughts, and
escape beha viors. “This a pproach reform ulates the tem por ally
based S the n R relation t o include the consequences o f
behavior. U nder this appr oach the initi al S assumes a function
differing f rom the elicit ing one noted for the S —> R relation.
Rather than a relationshi p between S an d R such that S elicits a
subsequent R, the relatio nship between the two is def ined by
the consequ ences that fol low. …Such a c onsequential a nalysis
does not ig nore stimuli o r responses [o r the emotions and
thoughts], but attempts t o evaluate the m in the conte xt of their
consequence s. When conseq uences can be related to beh avior
such that t heir occurrenc e is predicate d on the occur rence of
both the st imulus (or occ asion) and the response (or behavior), a
contingency is defined. W hen occasions and behaviors, both
psychologic al and physiol ogical, are in vestigated in such a
contingent relation, diff erent outcomes may be observ ed than
if the occa sions and beha viors are inve stigated alone ” (Layng et
al., 1999, p. 46, bracket s added; also see Layng et a l. 2022).
In the labo ratory, the re moval of, or e scape from an aversive
event has b een shown to b e a powerful r einforcer for the
behaviors t hat produce su ch removal or escape (see
Goldiamond, 1975a; Layng et al., 2022). Thus, one con sequence
that may ma intain avoidan ce behavior of clinical inte rest is the
distance cr eated from the aversive even t (Katz & Rosa les-Ruiz,
2022).
CET harness es this conseq uence and make s it
contingent on other behav iors that occu r when the
participant is calm. Stat ed otherwise, the same
consequence , distancing, is used as a ( negative)
reinforcer for behaviors other than tho se
indicating fear or avoida nce. In recent years, this
NCA approac h to exposure has resulted i n
replacing t he fearful or aggressive res ponses of
animals oft en considered untreatable wi th other
behaviors t hat improve th e animal’s wel lbeing and
quality of life (Fernande z, 2020; Heide nreich, 2022;
Katz & Rosa les-Ruiz, 2022 ; Snider, 2018 ). Further,
the procedu res have been extended to hu mans
who exhibit phobias and o ther strong fe ar
responses, such as the fe arful refusing of food and
water. Usin g CET, Miller (2022) was abl e to re-
establish e ating in about one hour with an 11-year-
old boy who se fear of foo d and water ha d led to his
hospitaliza tion. Some cas es have also r equired a
systemic in tervention, wh ere other cons equential
relations r esponsible for the pattern n eeded to be
addressed ( see Goldiamond , 1975b; Layng et al.,
2022).
The procedu res comprising CET were pion eered by
Jesús Rosal es-Ruiz and hi s students at the
University of North Texas (see for exam ple Snider,
2007; Rentf ro, 2012). Bri efly stated— a nd not
intended as a guide— the stimulus is pr esented at a
distance wh ere the indivi dual first sim ply “alerts”
to it. If f ive seconds el apses without an attempt to
escape or e motional respo nse, the stimu lus is
removed, th us reinforcing the calmer be havior
with that d istancing. Sub sequently, the aversive
event is br ought closer a nd removed, ag ain, after 5
seconds. If there is an e scape response , the
stimulus is removed, and the program is reset to its
last succes sful stimulus presentation. At no time is
the consequ ence, distanci ng, withheld. In essence
the partici pant has two w ays of achievi ng the
distance: 1 ) being calm o r doing other things, or 2)
indicating distress. This provides the participant
with one de gree of freedo m (number of
alternative s minus one, n -1; Goldiamond , 1976) at
all times. In this way, t he patient is never asked to
give up a c onsequence imp ortant to them ,
providing g enuine choice and some contr ol over
the situati on (see de Fer nandes & Dittr ich, 2018;
Goldiamond, 1974). Once c lose, and the
constructio nally defined behaviors are occurring,
the time of presentation is extended. T he targeted
behaviors t hat occur in c lose proximity to the once
aversive st imulus can be reinforced wit h a variety
of positive reinforcers, both tangible and social.
These behav iors are the o utcomes that a re
constructio nally targeted for establish ment. Little
distress is experienced.
(CONTINUED ON NEXT PAGE)
Advances in Cognitive Therapy
Fall 2022 Issue, Page 10
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TOWARD A CONSTRUCTIONAL
EXPOSURE THERAPY
(CONTINUED)
By T. V . Joe L ay n g and Aw a b Abde l- Ja l il
https://ww w.routledge.co m/978036768950 6
Advances in Cognitive Therapy
Fall 2022 Issue, Page 11
