Cost-Benefit Analysis in CBT: An Exercise in Behavioral Economics

It is seldom easy to change entrenched behavior patterns, especially when fears are involved. It helps to be able to think and act ‘outside the box’.

One of the prime axioms of Behavior Theory is that we are creatures of economy. That is, when it comes to our behavior, we tend to do what will most efficiently yield reinforcement, and avoid adverse consequence. Therapists working within the Cognitive-Behavioral Therapy (CBT) paradigm always have to keep this in mind when trying to assist others in the process of change. Change, as we all know too well, is always difficult and sometimes particularly painful. So, the more we can do to reduce the ‘cost’ of change and/or increase the perceived ‘benefits’ of doing things differently, the more likely we are to replace our old, dysfunctional but ingrained habits with new, healthier ones. And many therapists find it helpful to collaborate with their clients early on in the assessment process to compile a ‘cost-benefit analysis’ of their presenting problems. A thorough and accurate analysis will usually reveal how the benefits of a behavior — even the benefits of a problem behavior — have been outweighing the cost of changing that behavior, thus keeping us ‘stuck’ in our behavioral ruts. A prime therapeutic challenge then becomes finding innovative ways to lessen the cost of change.

I once counselled a young man (whom I’ll call ‘David’) who suffered from panic and ‘agoraphobia’ (i.e. fear of open or public places). Now, everyone who’s ever suffered through the kind of intense anxiety associated with Panic Disorder will tell you their symptoms were “the worst ever.” But David’s level of distress was among the most severe I’d witnessed and as a result, he was pretty much incapacitated when it came to executing the daily activities most of us would consider common and routine. He rarely went out of his house and when he did, his thoughts were constantly focused on returning as quickly as possible to the perceived safety and security of ‘home base.’ During the years I knew David, there were no such things as cellular phones, and when he ventured to drive he would only take a route in which he knew there to be several operational phone booths, just in case he felt the need to phone a hospital emergency room. David’s panic symptoms were literally holding him prisoner.

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Like most panic sufferers, what David feared most was not so much the activities he avoided, but rather the distressing symptoms he experienced during a panic episode. That’s why he so easily let himself slip into a pattern of avoiding situations he anticipated might bring on the symptoms he deeply dreaded. And because his symptoms were so unusually intense, it’s fair to say that they had virtually taken control of David’s life. He had attempted at times to push himself to overcome his symptoms, but they always got the better of him. He was firmly stuck in the classic vicious cycle of panic.

Now, when it comes to fears or phobias, the solution to ridding oneself of them is really quite simple: face them head-on. You need to do the very things you fear to do. Of course, we all know this is much easier to say than do. And within a CBT framework, there are several techniques you can use to change the kinds of thoughts and attitudes that predispose avoidance behaviors, all of which are helpful in eventually overcoming the fears. Still, the most powerful antidote is engaging in the activities you fear, which always comes with a cost. And devising an innovative strategy to lessen the cost of change in David’s case was a real challenge indeed. I really had to think ‘outside the box.’ In the process, some unusual strategic interventions came to mind, which fortunately proved to be just the ticket for helping David reclaim his life.

David had a passion for food, and had always dreamed of managing his own restaurant one day. And he loved getting ideas for new culinary creations, but was hesitant to try out various eating establishments because of his dread to go out in public. He’d therefore resigned himself to only reading magazines and watching an occasional program on television for his ideas. But he felt ‘safe’ whenever we met, so it was instantly appealing to him when I came up with the notion that we should meet and work on his strategy for overcoming his panic at an eatery close to his home. And he barely noticed it when, after a couple of visits, I changed the meeting location to a trendy new place a greater distance away — one that, interestingly, didn’t have any easily accessible public phones along the route. And he noticed it even less when we gradually stepped up to more crowded places. David’s love for the unique fare we sampled at each location and the ideas he got from atmospheres promoted at each place were powerful motivators. And before he knew it, David was doing the very thing he feared to do most: going out in crowded public places. Sometimes I’d ‘excuse’ myself from the table for a calculated period of time, and on one occasion I not so accidentally came uncharacteristically late, leaving him to fend for himself in a new location. Slowly, and systematically, David’s symptoms weakened and he overcame his fears. It’s all in a day’s work for a strategically-minded cognitive-behavioral therapist.

As any reader of my books In Sheep’s Clothing and Character Disturbance and online posts knows, I also like working within the cognitive component of CBT. Helping folks challenge and change the thinking patterns and attitudes that predispose their behaviors is rewarding work in itself, and I’ve dedicated much of my professional life to that enterprise. But focusing on behavior itself is important, too, especially when you remember how much more likely it is that a person will replace one behavior for another when the perceived pluses of doing so outweigh the minuses. David’s successful treatment really helped bring that important message home for me. And it motivated me in all my collaborations with clients to be ever on the lookout for crafty ways to lower the costs they face when making crucial changes in their lives.

• anxiety and stress
• CBT
• in practice
• phobia
• therapy