Behaviour therapy

Behaviour therapy
Intervention
ICD-9-CM 94.33
MeSH D001521

Behaviour therapy, or behavior therapy (behaviour modification) is an approach to psychotherapy based on learning theory which aims to treat psychopathology through techniques designed to reinforce desired and eliminate undesired behaviours.[1]

Contents

History

Precursors of certain fundamental aspects of behaviour therapy have been identified in various ancient philosophical traditions, particularly Stoicism.[2] For example, Wolpe and Lazarus wrote,

While the modern behavior therapist deliberately applies principles of learning to this therapeutic operations, empirical behavior therapy is probably as old as civilization – if we consider civilization as having begun when man first did things to further the well-being of other men. From the time that this became a feature of human life there must have been occasions when a man complained of his ills to another who advised or persuaded him of a course of action. In a broad sense, this could be called behavior therapy whenever the behavior itself was conceived as the therapeutic agent. Ancient writings contain innumerable behavioral prescriptions that accord with this broad conception of behavior therapy.[3]

Possibly the first occurrence of the term "behaviour therapy" was in a 1953 research project by B.F. Skinner, Ogden Lindsley, Nathan H. Azrin and Harry C. Solomon.[4] Other early pioneers in behaviour therapy include Joseph Wolpe and Hans Eysenck.[5]

In general, behaviour therapy is seen as having three distinct points of origin: South Africa (Wolpe's group), The United States (Skinner), and the United Kingdom (Rachman and Eysenck). Each had its own distinct approach to viewing behaviour problems. Eysenck in particular viewed behaviour problems as an interplay between personality characteristics, environment, and behaviour.[6] Skinner's group in the United States took more of an operant conditioning focus. The operant focus created a functional approach to assessment and interventions focused on contingency management such as the token economy and behavioural activation. Skinner's student Ogden Lindsley is credited with forming a movement called precision teaching, which developed a particular type of graphing program called the standard celeration chart to monitor the progress of clients. Skinner became interested in the individualising of programs for improved learning in those with or without disabilities and worked with Fred S. Keller to develop programmed instruction. Programmed instruction had some clinical success in aphasia rehabilitation.[7] Gerald Patterson used programme instruction to develop his parenting text for children with conduct problems.[8] (see Parent Management Training). With age, respondent conditioning appears to slow but operant conditioning remains relatively stable.[9]

While many behaviour therapists remain staunchly committed to the basic operant and respondent paradigm, in the second half of the 20th century, many therapists coupled behaviour therapy with the cognitive therapy of Aaron Beck and Albert Ellis, to form cognitive behavioural therapy. In some areas the cognitive component had an additive effect (for example, evidence suggests that cognitive interventions improve the result of social phobia treatment.[10]) but in other areas it did not enhance the treatment, which led to the pursuit of Third Generation Behaviour Therapies. Third generation behaviour therapy uses basic principles of operant and respondent psychology but couples them with functional analysis and a clinical formulation/case conceptualisation of verbal behaviour more inline with view of the behaviour analysts. Some research supports these therapies as being more effective in some cases than cogntive therapy,[11] but overall the question is still in need of answers.[12]

Scientific basis

Behaviour therapy is based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. There has been a good deal of confusion on how these two conditionings differ and whether the various techniques of behaviour therapy have any common scientific base.

Contingency management programs are a direct product of research from operant conditioning. These programs have been highly successful with those suffering from panic disorders, anxiety disorders, and phobias.[13]

Systematic desensitisation and exposure and response prevention both evolved from respondent conditioning and have also received considerable research.

Behavior avoidance test (BAT) is a behavioral procedure in which the therapist measures how long the client can tolerate an anxiety-inducing stimulus[14]. The BAT falls under the exposure-based methods of Behavior Therapy. Exposure-based methods of behavioral therapy are well suited to the treatment of phobias, which include intense and unreasonable fears (e.g., of spiders, blood, public speaking). The therapist needs some type of behavioral assessment to record the continuing progress of a client undergoing an exposure-based treatment for phobia. The simplest possible assessment approach for this is the BAT. The BAT approach is predicted on the reasonable assumption that the client’s fear is the main determinant of behavior in the testing situation. BAT can be conducted visual, virtually, or physically, depending on the clients’ maladaptive behavior. Its application is not limited to phobias, it is applied to various disorders such as Post-Traumatic Stress Disorder (PTSD) and Obsessive-Compulsive Disorder (OCD).[15]

Social skills training teaches clients skills to access reinforcers and lessen life punishment. Operant conditioning procedures in meta-analysis had the largest effect size for training social skills, followed by modelling, coaching, and social cognitive techniques in that order.[16] Social skills training has some empirical support particularly for schizophrenia.[17][18] However, with schizophrenia, behavioural programs have generally lost favour.[19]

Applied to problem behaviour

Behaviour therapy based its core interventions on functional analysis. Just a few of the many problems that behaviour therapy have functionally analysed include intimacy in couples relationships,[20][21][22] forgiveness in couples,[23] chronic pain,[24] stress-related behaviour problems of being an adult child of an alcoholic,[25] anorexia,[26] chronic distress,[27] substance abuse,[28] depression,[29] anxiety,[30] and obesity.[31]

Functional analysis has even been applied to problems that therapists commonly encounter like client resistance, particially engaged clients and involuntary clients.[32][33] Applications to these problems have left clinicans with considerable tools for enhancing therapeutic effectiveness. One way to enhance therapeutic effectiveness is to use positive reinforcement or operant conditioning.

Many have argued that behaviour therapy is at least as effective as drug treatment for depression, ADHD, and OCD.[34] Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy (habit reversal training) has been found to be highly effective for treating tics.

Third generation

Of particular interest, in behaviour therapy today are the areas often referred to as Third Generation Behaviour Therapy.[35] This movement has been called clinical behavior analysis because it represents a movement away from cognitivism and back toward radical behaviourism and other forms of behaviourism, in particular functional analysis and behavioural models of verbal behaviour. This area includes Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Analysis System of Psychotherapy (CBASP) (McCullough, 2000), behavioural activation (BA), Kohlenberg & Tsai's Functional Analytic Psychotherapy, integrative behavioural couples therapy and dialectical behavioural therapy. These approaches are squarely within the applied behaviour analysis tradition of behaviour therapy.

Acceptance and Commitment Therapy is probably the most well-researched of all the third generation behaviour therapy models. It is based on Relational Frame Theory.[36]

Functional Analytic Psychotherapy is based on a functional analysis of the therapeutic relationship.[37] It places a greater emphasis on the therapeutic context and returns to the use of in session reinforcement.[38] In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.[39]

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component.[40] Behavioural activation is based on a matching model of reinforcement.[41] A recent review of the research, supports the notion that the use of behavioural activation is clinically important for the treatment of depression.[42]

Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1966) for the difference between contingency-shaped and rule-governed behaviour.[43] It couples this analysis with a thorough functional assessment of the couple's relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness.[44]

Organisations

Many organisations exist for behaviour therapists around the world. The World Association for Behavior Analysis offers a certification in behaviour therapy [8]. In the United States, the American Psychological Association's Division 25 is the division for behaviour analysis. The Association for Contextual Behavior Therapy is another professional organisation. ACBS is home to many clinicians with specific interest in third generation behaviour therapy. The Association for Behavioral and Cognitive Therapies (formerly the Association for the Advancement of Behavior Therapy) is for those with a more cognitive orientation. Internationally, most behaviour therapists find a core intellectual home in the International Association for Behavior Analysis (ABAI) [9].

Characteristics

By nature, behavioural therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behaviour ultimately has), probabilistic (viewing behaviour as statistically predictable), monistic (rejecting mind–body dualism and treating the person as a unit), and relational (analysing bidirectional interactions).[45]

Behavioural therapy develops,adds and provides behavioural intervention strategies and the programs for clients and adds training to people that care for the facilitate successful lives in the communities.

Methods

See also

References

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Behaviour therapy. (2003). Retrieved from http://www.1936.cupe.ca/Benchmarks/BT.pdf