How does behavior therapy actually work?

A chapter from one of my self-help books gives an insight. At the end of the page you will also find information on practices in Hamburg and other national professional associations.

Psychotherapy based on behavioral therapy

By Carsten Hobbje & amp; F.-Michael Stark

Updated excerpt from the book.
Stark, F.-M., Esterer, I. & amp; Bremer, F. (Ed.) (2002) Ways out of madness. Therapies for psychotic illnesses. (Updated and expanded new edition) Bonn, Psychiatrie Verlag

1. Where does it come from

Behavioral therapy was developed on the basis of findings from scientific psychology. The exploration of the conditions that are responsible for the acquisition and change of behavior was groundbreaking. There are several roots of today’s so-called cognitive behavioral therapy, which are associated with different names.
At the beginning of this century, the Russian neurologist PAWLOW observed that innate behaviors can be triggered not only by the situations originally intended for them, but also by previously neutral stimuli. The classic example was the dog that drooled not only when he saw his food, but later also when he heard the bell that he always heard at the same time as he was eating. This process of learning, linking the original stimulus with an actually neutral stimulus, is called “classic conditioning”. Today, this process explains, among other things, how fear – an innate emotional reaction – can occur in actually completely harmless circumstances such as tight spaces or elevators.
The theories for learning from success, also known as “operant conditioning”, were developed by SKINNER in the fifties in order to be able to explain the acquisition of non-innate behavior even more comprehensively. In short, this means: An individual learns through the experience of success and failure. Positive consequences or reinforcements increase the frequency of certain activities, negative consequences such as punishment reduce a certain behavior or make it disappear completely.
In the last few decades the laws according to which humans develop within their lifespan have been further researched. The acquisition of knowledge, the connections between feelings, physical processes, the subjective evaluations of the environment and the corresponding behavior are the basis for understanding most mental disorders. This is associated with the names of well-known behavioral theorists and therapists such as Mahoney, Meichenbaum and Ellis.
New findings are constantly being incorporated into the corresponding models or new methods are being developed. Behavioral therapy sees itself as the concrete application of the possibilities derived from it in order to change conditions that contribute to the development or maintenance of mental and physical illnesses. These can be possibilities of influence that are available to the person, or conditions that can be found in his environment and are related to the disturbance of well-being.
The effectiveness of behavior therapy is constantly checked in numerous studies. Compared to other treatment methods, it has proven to be consistently just as effective, and even demonstrably more successful in certain areas.

2. What is the idea behind it

Behavioral therapy assumes that every behavior can be learned, maintained and unlearned again according to the same principles. Behavior is not only understood to be the externally visible activity of the person, but also the internal processes such as feelings, thinking and physical processes. Dealing with the environment requires numerous learning and adaptation efforts. We feel comfortable when we are able to react flexibly to these psychological and physical demands, taking appropriate account of our needs.
If one’s own abilities are insufficient to meet key needs such as social security, satisfying relationships or a self-determined way of life, or if external circumstances prevent this, well-being is impaired. The consequences can be mental and physical illnesses.
The effect of behavior therapy is to set learning processes in motion both inside and outside the treatment. The person should be put in a position to change his own – often habitually occurring – behavioral patterns that have hitherto stood in the way of his well-being.
In this way, a person suffering from depression can learn during therapy to behave more confidently and thus to have more satisfying experiences in meeting other people. Often enough, early acquired thought patterns such as “I can only be satisfied with myself if I am at least as good as everyone else in my environment” contribute to disturbances. Such a distorted standard can often not be maintained in the long term. Rather, it leads to deep-seated dissatisfaction, fear of failure, as well as other negative assessments and can contribute to a mental disorder or physical complaints in the long term or in particularly stressful situations. Here it is important to set other more appropriate and achievable goals

  • learning skills to cope with fearful situations,

  • influencing thought processes that are repeatedly experienced as stressful in dealing with oneself or the environment and which prevent important goals from being achieved – e.g. exams, calm mastering of difficult situations,

  • learning skills to make life a little more positive and satisfying, e.g. “enjoyment training” or ways to make everyday life better.

Comprehensive and well-tested therapy programs are not only available for coping with stress and self-confidence, but also for dealing more successfully with physical illnesses, for changing eating habits, for coping with grief and traumatic experiences, for treating sexual disorders, for health-promoting lifestyle habits and for certain disorders such as depression and psychotic illness.
Often, in the course of behavioral therapy, you will learn a relaxation method such as autogenic training or the Jacobsen method for muscle relaxation. This is often a first step in avoiding or reducing tension and stress. In role-playing games you will practice how to behave more confidently in social situations, e.g. how to convey to your partner that he should refrain from caresses when he is drunk or how you can calmly and clearly enforce the higher grouping that has long been due with your superior. If it is a matter of anxiety preventing you from moving freely and carefree in your environment, you will be prepared – specifically and according to your possibilities – to visit the relevant places and situations directly in the company of the therapist.
Gradually, you will try out the coping options you have newly acquired in therapy and develop the ability to cope better and with fewer impairments in everyday life. If self-deprecating thoughts or excessive self-claims prevent you from being satisfied with yourself, you will learn to question the meaning of these thoughts. According to the motto “It is not things that make you unhappy, but how we look at them”, attempts are made to correct unrealistic self-assessments or distorted perceptions of the world.
The therapy can be carried out in the form of one-on-one sessions, in groups or with the involvement of family members. Sometimes it will be necessary to seek inpatient treatment, but in most cases outpatient therapy is sufficient. The duration and intensity of the therapy depends on the severity of the complaints, their variety and susceptibility. The motto “less is more” applies, i.e. only as much therapy as necessary in order to independently achieve the goals and needs that are most important for well-being. A therapy period – in the case of outpatient therapy – of more than a year and more than 25 sessions is rather the rarity.
All in all, the aim of all efforts is directed towards concrete difficulties in life. At the end of the therapy you should be able to react more appropriately, more competently and more flexibly to future demands or to change unhappy circumstances.
Behavioral therapy groups, so-called social competence, self-confidence or problem-solving groups, can be a good opportunity to learn and practice new behaviors or lost security in a playful way. In individual cases, this can lead to a considerable reduction in burdens such as social isolation or persistent sterile arguments with the family or at work and thus represent protection against renewed overload, which in the worst case can lead to a relapse.
In individual behavior therapy, too, those individual conditions are worked out that repeatedly lead to overload and blockages. In role-playing games, through homework, and through active restructuring of familiar thought patterns, attempts are made to set positive changes in motion.

5. What are the risks

As with any therapy, the key to success lies in proper implementation. Responsible and well-trained therapists are the most important prerequisites for a treatment that is supposed to do more than harm.
The second important condition is that the person affected – as far as he is able to do so – becomes a critical partner of the therapist with a willing to change.
Third, the earlier a patient decides on therapy, the better the prospects.
The intensification of symptoms or crises during the therapeutic process, the appearance of new, different complaints are not uncommon side effects of psychotherapy. A mutually trusting relationship, a self-critical, carefully working therapist and the willingness of the patient to gradually develop personal responsibility for his own condition are decisive for achieving the desired, realistic therapy goals. This also means accepting difficult phases during therapy, addressing them and actively participating in overcoming them.
When this is the case, the risks of behavior therapy tend to be small compared to the likely benefits. Constant review of the methods used on the one hand and the therapist’s obligation to repeat s wiederholt seine Annahmen und die Entwicklungen während der Behandlung systematisch und möglichst genau zu überprüfen, helfen, unerwünschte Wirkungen zu mindern und Fehlschlägen vorzubeugen.
Allerdings: Wird die Therapie nicht fachgerecht durchführt, kommt ein Arbeitsbündnis nicht zustande oder treten nicht absehbare kritische Lebenssituationen wie z.B. Scheidung auf, sind ernste Komplikationen wie bei jeder anderen Therapieform nicht auszuschließen. Und: Niemand sollte von einer Verhaltenstherapie ein problemloses, glückliches Leben, die tiefe Erkenntnis über den Sinn des Lebens und die Beantwortung aller Fragen erwarten.

6. Was ist besonders wichtig

Generell gilt: Wie bei allen Therapieformen sollten Sie auch bei der Wahl eines Verhaltenstherapeuten oder einer -therapeutin darauf achten, daß Sie das Gefühl haben, zu diesem Menschen einen vertrauensvollen Kontakt aufnehmen zu können. Sie haben in der Regel zwei bis drei Therapiestunden Zeit, sich zu entscheiden. Leider wird diese Entscheidungsfreiheit oft dadurch eingeschränkt, dass viel zu wenig freie Therapieplätze vorhanden sind. Trotzdem lohnt es sich manchmal zu warten. Sie sollten aber dabei beachten, dass Entscheidungsschwierigkeiten für einen Therapeuten oft von einem generellen Widerstand gegenüber der Therapie überlagert sind. Die wichtigste inhaltliche Frage an Ihren Therapeuten ist, inwieweit dieser Erfahrung in der Behandlung mit Ihren Problemen bzw. Ihrer Erkrankung hat und wie er sich den Behandlungsablauf vorstellt. Auch sollten Sie über Ihre Zielvorstellungen klar und deutlich sprechen.
Menschen mit einer psychotischen Erkrankung sollten bei der Wahl des Therapeuten zusätzlich darauf achten, das ihr Therapeut auch Erfahrung mit akut psychotisch erkrankten Patienten gesammelt hat, um eine mögliche Rückfallgefährdung während der Therapie kompetenter beurteilen zu können. Diese Erfahrung kann man eigentlich nur während einer längeren Tätigkeit in einer psychiatrischen Klinik der Regelversorgung erlangen. Dies wären also entweder Ärzte für Psychiatrie oder Diplom-Psychologen, die dort gearbeitet haben. Diplom-Psychologen müssen nach den neuen Ausbildungsrichtlinien für Verhaltenstherapie ein Jahr Tätigkeit in einer psychiatrischen Klinik nachweisen.
Eine Verhaltenstherapie kann kurz nach der Entlassung aus der Klinik beginnen, sollte sich aber am Anfang eher nur auf die weitere Stabilisierung als Therapieziel konzentrieren z.B. über das Erlernen der persönlichen Frühwarnzeichen für Belastungen Stressfaktoren erkennen und vermeiden helfen. Komplexere Probleme sollten erst dann angegangen werden. Medikamente müssen während einer Verhaltenstherapie nicht abgesetzt werden, sind sogar sinnvoll, da sie einen gewissen Schutz vor Überlastung darstellen. Eine Reduktion während der Therapie sollte nur in Absprache mit Ihrem Therapeuten erfolgen. Ist dies vom Grundberuf her ein Diplom-Psychologe, sollte dieser sich darüber mit Ihrem behandelnden Psychiater in Verbindung setzen und auch im Kontakt bleiben.

7. Was kostet es

Die Kosten für eine Einzeltherapiestunde betragen zwischen 80 und 100 Euro, die in der Regel auf Antrag des Therapeuten von den Krankenkassen übernommen werden. Die Krankenkassen fordern von Ihrem Therapeuten ein Gutachten, in dem er Ihren Fall und seine Therapiestrategie darstellen muss. Ein psychologischer Therapeut muss Sie noch zusätzlich zu einem Arzt schicken, um körperliche Erkrankungen auszuschließen.

8. Wie finde ich einen qualifizierten Therapeuten?

Diplom-Psychologen, die eine Psychotherapieausbildung mit der staatlichen Prüfung der Approbation abgeschlossen haben, können sich in einer Praxis niederlassen und ambulante Psychotherapie anbieten. Allerdings gibt nur eine geringe Anzahl von sogenannten Kassensitzen, die direkt mit den Krankenkassen abrechnen können. Leider zeigt es sich, dass die niedergelassenen psychologischen Psychotherapeuten mit Kassensitz überlange Wartezeiten haben. Deshalb haben manche Krankenkassen sich zusätzlich zu dem offiziellen Weg bereit erklärt im sogenannten Erstattungsverfahren direkt mit einem approbierten Psychologischen Psychotherapeuten auch ohne Kassensitz über die Bezahlung der Therapie zu verhandeln. Sprechen Sie mit Ihrer Kasse, dazu müssen Sie nachweisen, dass sie vergeblich bei Therapeuten mit Kassenzulassung sich um einen Therapieplatz bemüht haben und dass Sie einen approbierten Therapeuten gefunden haben, der Ihnen einen Platz anbieten kann.
Eine Liste der an Ihrem Ort praktizierenden Verhaltenstherapeuten erhalten Sie von Ihren Krankenkassen auf Anfrage. Auch die Landesärztekammern haben Listen. Dort sind aber nicht die Spezialisierungen bzgl. bestimmter Problembereiche verzeichnet. Sie müssen dann notfalls mehrere anrufen, um die notwendigen Informationen einzuholen.
German adresses:, or,
Here you find therapists who I know personally Liste von Therapeuten in Hamburg, .

Selection of addresses from professional associations:

Deutsche Gesellschaft für Verhaltenstherapie e. V.
Neckarhalde 55
72070 Tübingen
Telefon: 07071 / 9434 0
Telefax: 07071 / 9434 35

Deutscher Fachverband Verhaltenstherapie (DVT),
Geschäftsstelle DVT,
Georgskommende 7,
48143 Münster
Telefon: 0251-44075,
FAX: 0251 / 44074

Deutsche Ärztliche Gesellschaft für Verhaltenstherapie e.V (DÄVT)
c/o Präsident:
Prof. Dr. phil. Dr. med. Serge K. D. Sulz, Dipl.-Psych.,
Nymphenburger Straße 185
80634 München
Fax 089-130793-17
Tel. 089-130793-19

Arbeitsgemeinschaft für Verhaltensmodifikation Deutschland (AVM-D),
Dr.-Haas-Straße 4
96047 Bamberg
Telefon: (0951) 208 52 11

Arbeitsgemeinschaft für Verhaltensmodifikation Österreich (AVM-Österreich)
Vierthalerstraße 8/2/8
AT-5020 Salzburg