Behavior therapy

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Behavior therapy is a form of psychotherapy used to treat depression, anxiety disorders, phobias, and other forms of psychopathology. Its philosophical roots can be found in the school of behaviorism, which states that psychological matters can be studied scientifically by observing overt behavior, without discussing internal mental states. In addition to the clinical application, parents, teachers, and coaches utilize behavior modification when attempting to guide children’s habits and self management skills. Discipline can take the form of behavior modification when methods such as reward, punishment, and reinforcement are used. A form of behavior therapy, Applied Behavioral Analysis, was a breakthrough therapy in the treatment of autistic children. The efficacy of these methodologies relies on appropriate and measured use, a skill that requires maturity and wisdom. When this is absent, behavior modification methods can take negative forms.

The history of behavior therapy progressed during the same time that the therapeutic methods of the Austrian psychoanalyst, Sigmund Freud, were greatly respected. In fact, all realms of psychology were strongly influenced by the work of this one man and his name became synonymous with the practice of therapy in common parlance. For half a century, his theories were relatively unchallenged. Behavior theorists in the 1950s and on began to combine other forms of psychological theory and practice to the work of making people well that is incorporated in behavior therapy models. It took courage for professionals in the field to challenge old, accepted ideas and many were harshly criticized. It has been to the betterment of the world that they endured the criticism so that greater understanding could prevail. As time unfolds more advanced forms of therapy emerge to address problems, including such a bold new understanding as the inclusion of cognitive psychology to behavior therapy. Further developments may include research from cultural, spiritual, neurological, and biological sciences.

Contents

Definition

Behavior therapy (also called behavior modification or behavioral therapy) may be defined as "the application of experimentally derived principles of learning to the treatment of psychological disorders."[1] In practice, it takes the form of “psychological counseling to change activity that is undesirable or potentially harmful. Treatment most often is directed toward changing harmful habits, such as discontinuing cigarette smoking, dieting to lose weight, controlling alcohol abuse, or managing stress more effectively."[2]

While founded in behaviorism, behavior modification has long been used by psychotherapists, parents, and caretakers of those with special needs who don't necessarily have a behaviorist "philosophy." It involves some of the most basic methods to alter human behavior, through operant reward and punishment. Classical conditioning, which aims to affect changes in behavior through associations between stimuli and responses, can also be a component of behavior modification, but it is generally less useful in applied settings because it focuses solely on basic involuntary reactions to stimuli and not on conscious learning associated with a behavior's function or context.

Overview

Behavior therapy is a form of psychotherapy used to treat depression, anxiety disorders, phobias, and other forms of psychopathology. It arose out of the German mechanist theory of psychology in the nineteenth century. Building upon the experimental work of Edward L. Thorndike and Ivan Pavlov, the behaviorists theorized that human activity was based on a learning model depending upon trial and error. Behavior that produced a pleasurable or useful result was retained and all other behavior was ignored and abandoned over time.

Pavlov’s Dog, Pavlov Museum, 2005

B. F. Skinner expanded the scope of behavior modification from Pavlov's work, which had found that dogs would salivate when the "conditioned stimulus" (a sound) that had previously been presented prior to the appearance of food was presented alone, with his concept of operant conditioning, which stated that learning may be shaped by the intentional rewarding of behaviors that approximate a desired behavior. For example, a chicken can learn to walk a tightrope with an umbrella in its beak when it is given food for learning to walk in a straight line, then for walking along a narrow board, then a thinner board, and so forth until it learns it will receive corn when it walks along a cord strung between two platforms. The combination of Pavlov’s and Skinner’s work led to the modern use of tools for shaping behavior in the educational and clinical arenas with such methods as token economies, aversive conditioning, and modeling.

Strictly following behavioral principles, there is no analysis of the individual's thoughts, but many argue that the therapy can be improved with cognitive components. The concept of punishment has had many critics, but it has legitimately effective uses in contexts such as behavioral "extinction," made especially popular in the childhood discipline technique of "time out." When misused, however, punishment can lead to affective (emotional) disorders, as well as to the target of the punishment eventually focusing only on avoiding punishment ("not getting caught") rather than improving behavior.

Historical development

Behaviorism as a psychological approach

Main article: Behaviorism

Methods of modifying behavior for the benefit of society or that of the individual date to the earliest recorded history. The military, religious orders, schools, families, and penal codes contain elements found in modern behavior modification techniques such as modeling, positive and negative reinforcement, token economies, and systematic desensitization. Behavior therapy grew out of the academic theory of behaviorism, which began to flourish in the latter part of the nineteenth century and reached its zenith in the mid twentieth century.

Burrhus Frederic Skinner

Burrhus F. Skinner, popularly known as B. F. Skinner, is perhaps the best known of the behaviorists. He introduced the term, behavior therapy, into psychological texts and to the general public though he did not treat human patients himself. He subscribed to William James’ statement that behavior precedes feelings and that “people are sorry because they cry,” rather than the more traditional belief that people cry because they are sorry. Skinner is best known for his theory of “operant conditioning.” Operant conditioning is based upon the intentional shaping of behavior by exposing a subject to a situation in which it is rewarded for minute movements toward the desired behavior.

Token economies are a variation of operant conditioning and are used in parenting training, teaching and penology, to name some typical applications. Parents have learned to use stars on refrigerator charts to reward desired behavior. Extinction of undesired behavior has been attempted with aversive techniques such as mild electric shocks, unpleasant tastes and other methods which have been applied to addictions and aberrant behavior. In parenting, some aversive techniques are “time outs” and “grounding.” The movie A Clockwork Orange popularized an extreme version of aversive conditioning using conditioned stimuli to eliminate antisocial behavior.

By the late 1950s, this strict approach had run its course as it became clear that mind could not be excluded from theories of human behavior and is not merely a consequence, but a motivator of behavior. Human beings were observed to continue to react to conditioned stimuli long after reinforcement had ceased. Some theorists concluded the reinforcement schedule had been internalized and maintained by humans’ ability to imagine and create situations internally and autonomously. Because of this ability, humans had the possibility of altering responses to stimuli by using the power of imagery and cognition to alter the same behavior they had previously maintained and strengthened. These realizations led to the pairing of behavioral theory with cognitive and emotional approaches. Thoughts and feelings were defined as a type of behavior and incorporated into behavior theory, producing the modern practice of cognitive behavioral therapy, as behaviorism moved into the clinical realm in the 1960s.

Search for appropriate therapies to treat psychological disorders

The early pioneers of behavioral therapy were primarily disaffected psychoanalysts, disappointed in the results of traditional Freudian therapy. The Freudian model had been unchallenged through the first half of the twentieth century and efforts to move psychology in a different direction took time and courage. Change is usually opposed by the dominant mental model in all walks of life. Psychology was not different in this regard. The pioneering psychologists that broke from the old paradigm met opposition and criticism from many of their peers, although they were applying some of the experimental data from behaviorism to new clinical work. Two of the early practitioners were Joseph Wolpe and Albert Ellis.

Aaron Beck (1921) has been called the father of cognitive therapy. He created several therapeutic tools that are in current use. These include the Beck Scales, Beck Depression Inventory (BDI), Beck Hopelessness Inventory, and Beck Anxiety Inventory. David Burns expanded upon Beck’s approach and has developed a model for treating depression, anxiety, and obsessive compulsive disorders utilizing cognitive, behavioral, and emotional interventions. Marsha Linnehan developed Dialectical Behavioral Therapy as an effective treatment for severe character disorders. Her approach is based upon intervening at the point of emotional disregulation and teaching alternative responses and ways to substitute other more functional behaviors.

Behavior therapy for Autism

A form of behavior therapy called Applied Behavior Analysis (ABA) has found successful application in the treatment and education of children with autism. The name of O. Ivar Lovaas is widely associated with ABA-based treatment, as he was one of the first psychologists to demonstrate that children with autism could learn language, play, social, self-help, and academic skills.

ABA, also referred to asDiscrete Trial Training, uses a one-to-one therapist-child ratio and the "antecedent-behavior-consequence" (ABC) method; interventions based on this work involve trials or tasks. Each consists of (a) an antecedent, which is a directive or request for the child to perform an action; (b) a behavior, or response from the child, which may be categorized as successful performance, noncompliance, or no response; and (c) a consequence, defined as the reaction from the therapist, which ranges from strong positive reinforcement to a strong negative response, "No!" ABA techniques based on B. F. Skinner's Verbal Behavior claim to have succeeded in helping nonverbal children start to talk, typically going from zero words to several dozen. By allowing children to express their needs, even rudimentary speech can alleviate frustration and tantrums.

Lovaas' ABA methods are widely regarded as the first scientifically validated therapy for autism. Early intensive intervention, consisting of 35-40 hours per week of therapy, generally before school-age, seems to be critical to achieving optimal outcomes.

Tools

Modification

Behavior modification is a technique of altering an individual's reactions to stimuli through positive reinforcement and the extinction of maladaptive behavior.

While founded in behaviorism, behavior modification has long been used by psychotherapists, parents, and caretakers of the disabled, generally without any underlying behaviorist philosophy. It involves the most basic of methods to alter human behavior, such as reward and punishment, aversion therapy, reinforcement, and even biofeedback. The cultivation of life skills are often a central focus.

Analysis of the patients’ thoughts is not required, but many non-behaviorists feel the therapy can be powerfully improved with such cognitive analysis. Punishment is also frowned upon in many contexts, with extinction of conditioned reflexes often in its place.

A major focus of behavior modification is giving compliments, approval, encouragement, and affirmation; a ratio of five compliments for every one complaint is found to be most effectual in altering another's behavior in a desired manner.[3]

Behavior-based approaches to improving occupational safety and performance focus on the study of safety behaviors before and after various interventions to the safety behavior of the individuals involved. The three items for introduction of a behavior-based system are: Antecedent, behavior, and consequence (ABC). According to behavior modification theory, worker behavior may be influenced by systematically reinforcing the right behavior until a new habit if formed.

From a sociological point-of-view, if punishment is too harsh or the withholding of rewards is too harsh, the subject may seem to be corrected of the maladaptive behavior by scientific measurements, but if a bad example is set, this bad example and the bad feelings that result, as in causing an affective disorder (such as an emotional disorder), the subject could cause the re-infliction of punishment as a chain reaction in society. The punishment and the bad feelings that result may spread through society and be the cause of a contagious reaction referred to as social illness.

Systematic desensitization (SD) is a type of behavioral therapy, developed by South African psychiatrist Joseph Wolpe based on Pavlovian conditioning, used to help overcome phobias and other anxiety disorders. To begin the process of systematic desensitization, one must first be taught relaxation skills in order to control fear and anxiety responses to specific phobias. Once the individual has been taught these skills, he or she must use them to react towards and overcome situations in an established hierarchy of fears. The goal of this process is that an individual will learn to cope and overcome the fear in each step of the hierarchy, which will lead to overcoming the last step of the fear in the hierarchy. Systematic desensitization is sometimes called "graduated exposure therapy."

Clinical procedures

Specific phobias are one class of mental illness often treated through the cognitive therapy process of systematic desensitization. When individuals possess irrational fears of an object, they tend to avoid it. Since escaping from the phobic object reduces their anxiety, patients’ behavior to reduce fear is reinforced through negative reinforcement, a concept defined in operant conditioning. The goal of SD is to overcome this avoidance pattern by gradually exposing patients to the phobic object until it can be tolerated. In classical conditioning terms the elicitation of the fear response is extinguished to the stimulus (or class of stimuli).

Coping Strategies

Half-lotus position.

Prior to exposure, the therapist teaches the patient cognitive strategies to cope with anxiety. This is necessary because it provides the patient with a means of controlling their fear, rather than letting it build until it becomes unbearable. Relaxation training, such as meditation, is one type of coping strategy.

Patients might be taught to focus on their breathing or to think about happy situations. Another means of relaxation is cognitive reappraisal of imagined outcomes. The therapist might encourage subjects to examine what they imagine happening when exposed to the phobic object, allowing them to recognize their catastrophic visions and contrast them with the actual outcome. For example, a patient with a snake phobia might realize that they imagine any snake they encounter would coil itself around their neck and strangling them, when this would not actually occur. Research at the University of Pennsylvania has demonstrated the effectiveness of this technique in helping subjects reduce similar animal phobias.

Progressive Exposure

The second component of systematic desensitization is gradual exposure to the feared object. Continuing with the snake example, the therapist would begin by asking their patient to develop a fear hierarchy, listing the relative unpleasantness of various types of exposure. For example, seeing a picture of a snake in a newspaper might be rated 5 of 100, while having several live snakes crawling on one’s neck would be the most fearful experience possible. Once the patient had practiced their relaxation technique, the therapist would then present them with the photograph, and help them calm down. They would then present increasingly unpleasant situations: A poster of a snake, a small snake in a box in the other room, a snake in a clear box in view, touching the snake, and so on. At each step in the progression, the patient is desensitized to the phobia through the use of the coping technique. They realize that nothing bad happens to them, and the fear is gradually extinguished.

Current trends

Studies have shown cognitive behavior therapy to have equal effectiveness with medication in treating most situational depression and the combination of the two is rated the most effective approach available. This approach has become an accepted treatment of depression, anxiety, and obsessive-compulsive disorders.

In the medical field, Carl Simonton has used behavioral tools in conjunction with conventional cancer treatment.[4] In controlled trials at UCLA Medical Center, patients who received this combination of treatments lived twice as long as patients receiving only conventional cancer treatment. Behavioral concepts are also used in weight loss programs, smoking cessation, and eating disorders where they are usually combined with other approaches with significant success.

Since behaviorism was first formulated, the range of observable behavior has dramatically increased. Earlier tools such as blood pressure cuffs, x-rays, and EKG machines have been succeeded by a flood of technology such as PET and CAT scans that make it possible to actually observe changes in brain activity in response to carefully presented stimuli, bringing the brain and its activity directly into the realm of observable behavior. Similar advances have occurred in general knowledge of synapses, serotonin, and other messenger compounds in the nervous system, making the realm of the observable immeasurably more complex and vast than in nineteenth century Germany.

The realms of behavioral science have permeated modern society. The realm of advertisement has grown increasingly sophisticated, and behavioral theory permeates the workplace with implemented theories of variable reinforcement, token reinforcement, and benefits.

In the first decade of the twenty-first century, behavioral therapy and its philosophical parent, behaviorism, have not become the definitive and final answer to the questions of human motivations, nor the only approach to alleviating problems and suffering, but they are a vital and effective part of the search for meaning and understanding of human behavior that constitutes the core of psychology.

Endnotes

  1. Encyclopedia Brittanica, Behavior therapy. Retrieved March 7, 2007.
  2. Encyclopedia Brittanica, Psychotherapy behavioral therapy. Retrieved March 7, 2007.
  3. Robert and Evelyn Kirkhart, "The Bruised Self: Mending in the Early Years," The Child and His Image: Self Concept in the Early Years. (New York: Houghton Mifflin Company, 1972).
  4. Simonton Center, About Dr. O. Carl Simonton and Simonton Cancer Center. Retrieved August 8, 2007.

References

  • Clark, David M. and Christopher G. Fairburn. 1997. Science and Practice of Cognitive Behaviour Therapy. Oxford University Press. ISBN 0192627260
  • Hunt, Morton. 1993. The Story of Psychology. New York: Doubleday Publishing. ISBN 0385471491
  • Lindsley, O., B.F. Skinner, and H.C. Solomon. 1953. Studies in Behavior Therapy. Walthama, MA: Metropolitan State Hospital.
  • Seligman, Martin E.P. 1993. What You Can Change and What You Can't: The Complete Guide to Self Improvement. Knopf. ISBN 0679410244

External links

All links retrieved January 15, 2013.

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