35 Behavior Therapy

G. Padma Priya

1. Introduction

Behavior therapy can help people learn to manage and reduce aggressive impulses, compulsive behaviors, and anger outbursts. It can help them improve their current coping skills or learn new ones so that they’re more equipped to handle challenging or unfamiliar situations. The techniques and strategies used in behavior therapy are also fairly straightforward and easy for most clients to understand and learn. Behavioral therapies have contributed to greater understanding of the learning processes and have also significantly influenced measurement strategies for identifying psychological problems such as anxiety disorders. Overall, behavioural therapies are not generally used on their own in treating psychological disorders however the techniques used in behavioural therapies are applicable to treatment in a wide variety of settings. This module discusses principles and strategies of behaviour therapy, strategies of learning theory, and the application of these principles and strategies in assisting clients to replace maladaptive behaviours with adaptive behaviour.

2. Genesis of Behaviour therapy:

Behavioural therapy was developed first in the 1950s, initially by the application of learning theory to the treatment of a variety of neurotic symptoms. Studies of learning in animal had indicated that behaviours could be conditioned and maintained by particular patterns of stimulus and reward. For example, in Pavolov’s early experiments, dogs had been conditioned to salivate in response to a bell which originally had been sounded at the same moment as the appearance of food (classical conditioning’). B.F. Skinner showed that animals repeated behaviours which were rewarded in some way, as by the presentation of food (‘operatant conditioning’). Behaviour therapists regarded neurotic symptoms as learned maladaptive behaviours, and drew on theories of classical and operant learning to devise strategies for modifying and eradicating these behaviours. For example, Wolpe (1973) treated phobic patients by exposing them progressively to the feared situation after inducing a state of relaxation, his rationale being that their fearful response would be inhibited if the formerly feared situation were associated with pleasurable feelings (‘reciprocal inhibition’). Operant methods found application in the modification of undesirable behaviors and in the reversal of behavioural deficits in institutionalized chronic schizophrenic patients (‘token economy programmes’).

3. Objectives:

The objectives formulated are to

• Define terms specific to behaviour therapy.
• Learn and apply principles, strategies of behaviour therapy.
• Discuss the goals of behavioural therapeutic approaches.
• Differentiate between classical and operant conditioning and other forms of behaviour modifications.

4.  Definition

Wolpe (1973) defined behavior therapy as a conditioning therapy involving ‘the use of experimentally established principles of learning for the purpose of changing maladaptive behavior’.

5. Essential features of behavioural therapy

Behavioural treatments incorporate a number of diverse techniques, but have several essential features in common.

1. Behavioural treatments are aimed primarily at the modification of current, observable behaviours.

2. Behavioural treatments begin with a detailed behavioural analysis, in which the therapist identifies the antecedents of a symptom (that is, the factors which provoke it), the problem behavior itself (the behavioural manifestations of the symptom), and its consequences for the patient and those around him. This analysis, the ABC of behavioural therapy, permits the therapist to decide on the most appropriate technical intervention to apply.

3.Treatment programmes are designed cooperatively by therapist and patient in order to recognize and tackle the idiosyncrasies of each individual’s symptoms.

4.The patient is recruited actively into the treatment process by being encouraged to participate in the identification of appropriate goals for treatment.

5.The patient monitors the frequency and severity of the target symptom as therapy progresses, often by keeping a diary of its occurrence.

6.The therapist measures the target behaviour before, during and after treatment in order to ensure selection of the most effective therapeutic techniques and to evaluate the progress and outcome of treatment.

7.The patient carries out homework tasks between treatment sessions.

8.The patient relatives or friends are recruited as co-therapists in the treatment, accompanying and encouraging the patient in the agreed homework assignments.

6.  Therapeutic goals

Following are the list of behavior therapy in individual goals.

• Overcoming deficits in behavioural repertoires
• Strengthening adaptive behaviours
• Weakening or eliminating maladaptive behaviours
• The capacity to relax
• The ability to assert oneself
• Effective social skills
• Adequacy at sexual functioning
• Capacity for self-control

7.  Behaviour therapy has to be subjected to:

Behavioural methods are applied in the treatment of some neuroses, particularly phobic-anxiety states and obsessive-compulsive disorders; habit disorders, including tics, smoking and eating disorders; conduct disorders in children, the mentally handicapped, and chronic schizophrenic patients; and in some marital and family disorders. Treatments are designed to reduce symptoms and behaviours which are distressing and disruptive, or to promote desirable and adaptive behaviours. In many psychiatric disorders, symptomatic behaviours trouble both the patient and those around him. Many of these behaviours are amenable to modification or eradication by behavioural therapy.

8. Process of therapy

In behaviour therapy, therapists need to conduct and formulate a behavioural assessment so that treatment goals can be selected and specified. Such an assessment entails descriptions of what the problems are, how they appear to have arisen, and what maintains them. Frequently, the main goal or goals of treatment are called target behaviours. Clearly defined goals assist therapists to select appropriate interventions to attain them. In most instances, client and therapist will agree on goals and treatment interventions. Where disagreement exists, further discussion may be all that is necessary to resolve the issue. Referral to another therapist may be indicated if disagreement persists. Adequate behavioural assessments allow therapists to identify the context, antecedents and consequences of the responses they wish to treat, while inadequate behavioural assessments may lead to the wrong methods being applied to the wrong problems. Behavioural assessment and monitoring take place throughout a course of behaviour therapy and not just at the beginning. One function of such monitoring is to see whether treatment goals are being achieved. Another function is to see whether therapists or clients think it advisable to alter or revise their goals.

Often behaviour therapy treatment is short term. For instance, a therapist might contract with a client to pursue a treatment plan for two to three months and re-evaluate progress at the end of this period. Therapy lasting from 25 to 50 sessions is also fairly common, though any contact over 100 sessions is rare. Behaviour therapy session vary in length, from the traditional therapeutic hour to 30 minutes when specific interventions are in use. The various assessments are,

• Behavioural observation: Behavioural observation during role play situations and observing from real-life settings.
• Self-monitoring: Clients are asked to collect baseline data by monitoring their current behaviour.
• Questionnaire: Therapists ask the clients to complete self-report questionnaires which includes medical information.

9.  Therapeutic interventions

Behaviour therapists have a collection of interventions which they tailor to assist clients to attain their goals. The various therapeutic techniques are

• Systematic Desensitization
• Assertive Training
• Modeling
• Token economy
• Aversion therapy
• Imagery
• Progressive muscle relaxation

9.1 System desensitization:

This is the best known and most widely used application of Wolpe’s reciprocal inhibition principle for the treatment of phobic reactions. It is based on the simple principle that one cannot be both relaxed and anxious at the same time. Consequently, if increasingly more anxiety- provoking stimuli are experienced while the patient is in a deeply relaxed state, the relaxation response will be substituted for the anxiety–inducing stimuli.

Therapy starts with one or a few interviews and the administration of some personality questionnaires, mainly intended to discover the patent’s major sources of anxiety. Before desensitization process begins, the patient is first trained in relaxation and an anxiety hierarchy is created. Other techniques involve hypnosis, the imagining of very relaxed situations and attending to breathing patterns. Although some are simply unable to master the technique, most patients can, after training, relax their whole body in a few minutes.

An example of an appropriate use of systematic desensitization is the treatment of a client who has an irrational fear of elevators. The therapy would incorporate three basic steps:

1.Muscle relaxation and relaxation therapy, 2. Construction of a hierarchy representing the anxiety-producing situations the client typically faces and needs to overcome, and 3. Graduated and progressive pairing through emotive imagery of the anxiety- producing situations with the relaxed state of the client (Wolpe, 1982). The desensitization sessions would be continued until the client could “stand,” without debilitating anxiety, to be presented with elevator scenes and finally could go alone to an elevator and ride it without discomfort.

Successful treatment requires, of course, that patients should be free of fears in real as well as imagined situation. Scientist claimed that as many as 91 percent of phobic patients treated by his technique were cured or markedly improved. Others have made more modest claims. Some have argued that desensitization to be truly effective must involve concurrent and systematic exposure to real-life as well as imagined threats.

9.2 Assertive training:

Teaching assertive responses is conceptualized by Wolpe (1973) as another illustration of the reciprocal inhibition principle, for one cannot be assertive and timorous at the same time. Thus, practicing more assertive behaviours in a situation which formerly aroused anxiety and inhibition reduces the strength of the anxiety-related response.

Treatment starts with discussion of threatening interpersonal situations and the patient is aided in identifying the appropriate expressive responses. First in more mild, later in more intense situations the patient is encouraged to try out new behaviours. He is asked to keep notes of the significant interplays with others, what happened, how he acted, what consequences it had, and the like. This both makes the patient more attentive to his own behavior and gives the therapist information about specific problems needing attention. In time the patient should develop an increased sense of control and adequacy.

To assist in the development of the necessary skills, considerable use of behavior rehearsal is made. Behaviour rehearsal is a technique similar to psychodrama, role-playing or social modeling. The patient has to reenact past experience or anticipated difficulties of the future, with the therapist playing a complementary role. Roles may then be reversed, with the therapist acting the patent’s part and the patient now the antagonist. This procedure gives the patient the opportunity to understand social interactions better, discover the skill needed, practice them in the presence of a nonthreatening therapist, rehearse them in role-playing, get feedback on their effectiveness and guidance on their use in real life.

9.3 Modelling:

Modelling particularly for children, an important part of learning is based on watching and imitating others. Bandura developed a form of behavior modification based on social modelling. In earlier work, he had found that a child observing an adult acting aggressive is more likely to be aggressive himself than a child not exposed to such a model.

As a therapeutic measure, Bandura points to three ways in which modeling can influence behaviour:

1. It can serve as a basis for learning new skills and behavior. Eg: The apprentice watching the master learns in this fashion. So too, withdrawn children shown a film of children interacting harmoniously subsequently showed more mature social behaviours;

2. It can serve to eliminate fears and inhibitions. Eg: observing another child playing happily with a dog can reduce the subject’s fear of the animal; and

3. Finally it can facilitate preexisting behavior patterns. Eg: seeing others remove their hats as they enter building encourages us to do the same.

In clinical practice, modeling has been found useful for the reduction of unrealistic fears ie, in treating phobias. The efficacy of such an approach was demonstrated by Bandura, Blanchard, and Ritter in the treatment of snake phobias.

 1. Live modeling with participation.

2.   Symbolic modeling, in which subjects watched a film rather than a live model interplay with a snake; 3. Systematic desensitization, in the manner of Wolpe, involving imagined contact with snakes coupled with deep relaxation; and 4. No treatment. While all three treatment groups showed marked reductions of fear compared to the untreated group who did not change, the method of live participant modeling was clearly superior to the others.

9.4 The token economy:

One of the more recent and promising applications of the operant conditionsing approach is the token-economy programs used to modify the behavior of institutionalized psychotic patients. As in other Skinnerian methods, emphasis is on the therapist’s control of the environmental reinforcement contingencies to the patient’s behaviours, toward the end of reducing the probability of disturbed behaviours and increasing the frequency of desired ones.

There are three issues to consider in developing a contingent reinforcement program in a token-economy study. 1. The staff of the institution should designate the patient behaviours felt to be desirable, and hence to be reinforced; 2. A medium of exchange is established, a token that stands for something else (the back-up reinforcers). These are often poker chips, small cards, imitation coins, or even trading stamps; and hence to be reinforced; 3. The back-up reinforces themselves are decided. These are the special privileges and pleasure for which the tokens can be traded and might include weekend passes, movie shows, TV time, special foods, or a private room. Each of these is given a price, so that more tokens are required for the more desirable and fewer for the less wanted items. Similarly, “wages” are set so that more reinforcement is given for greater accomplishments. When the patient acts in desired ways, he receives the proper number of tokens which he can save or spend as he wishes on a greater or lesser reward.

The purpose of using token rather than primary reinforcers is that they bridge the delay between the occurrence of the desired behaviour and the ultimate reinforcement. Thus, as the patient make his bed, sweeps the floor, or takes on a job responsibility, he immediately receives the requisite tokens.

9.5 Aversion therapy:

Aversion therapy is a controversial technique that is infrequently used by counselors and is not recommended for most school situation with children. It is sometimes used in clinics by highly skilled therapist to help clients who want to be helped and whose maladaptive behavior are not amenable to intervention through other strategies. Aversion therapy employs procedures such as electric shock, emetics, stimulus satiation, unpleasant mental or visual imagery, or unpleasant sounds or verbal descriptions to inhibit unwanted behaviours. Competent behavior therapists have treated difficult problems such as drug and alcohol addiction, sexual deviation, and smoking by combining aversive techniques with other behavioural procedures. The goal of this therapy is to get the client to “associate an undesirable behaviour pattern with unpleasant stimulation or to make the unpleasant stimulation a consequence of the undesirable behaviour”.

In clinical practice aversion techniques have been applied mainly in the effort to eliminate addictions and destructive or deviant behaviours. A best know example is the management of chronic alcoholism. An emetic (a nauseating drug) is mixed into an alcoholic drink, so that drinking lead to sickness and vomiting. After a number of such occasions the sight of the drink alone may lead to nausea. Similar procedures have been used, to better advantage, with more motivate patients suffering from heavy smoking, obesity, or sexual problems.

9.6 Imagery

Imagery is an adaptable therapeutic approach used to facilitate positive self-talk. Mental pictures under the control of, and initiated by, the client may correct faulty cognitions. The client pictures past significant memories and present events that, combines with relaxation therapy and role playing, increase his awareness of situational events and other variables resulting in maladaptive behaviour.

Imagery technique have been used with a couple with severe marital problems. The marital partner complained of being depressed, anxious, unable to sleep, and sexually dysfunctional. Both were unable to express anger. The partners were asked to picture the parent of the opposite sex, imagine their spouse standing next to the parent, and note characteristic similarities. They therefore identified characteristics in each other they remembered in their parents with whom they had poor interpersonal relationships. When their perceptions of each other were changed, their relationship improved. Imagery is also an important aspect of systematic desensitization and has been successfully used with clients experiencing phobias.

9.7 Progressive muscle relaxation

Muscle relaxation is a potent treatment strategy for dealing with a variety of client problems such as psychological distress, chronic sleeplessness, and so forth. Anxiety lessens when muscles relax. More than 40 years ago, Edmund Jacobson recognized that muscle relaxation was a therapeutic tool for stress-related problems. After studying the physiological and psychological effects of muscle relaxation, he comfortably positioned clients and taught them to tense and relax the main muscle groups of their bodies. He then shared the monitoring information with the clients who were eventually able to use only passive activity to relax.

Wolpe (1973) demonstrated that progressive muscle relaxation, combined with mental pictures of a feared situation or increased association with the feared object in graduated increments, could desensitize phobic clients. Muscle relaxation is physiologically incompatible with the anxiety, evoking response.

10. Conclusion:

    Hope this module gave an insight into the principles of behaviour therapy, strategies of learning theory, and the application of these principles and strategies in assisting clients to replace maladaptive behaviours with adaptive behaviour. Learning refers to that process that brings about a change in behaviour. Behaviour therapy has proven to be a practical, efficient, parsimonious way of assisting clients and families to change their behaviour by the application of learning theories. Behaviour therapy is the essence of behaviourism. Behaviourism is a philosophical approach to life, as well as a psychological discipline built on a precise scientific orients to the problems of man and to her living organism. Behaviourism represents reality and therefore views behaviour that is outside of the expected social norms as maladaptive, not as a symptom of disease, a form of deviance or deficit.

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