Behaviour therapy

Behavior therapy
Intervention
ICD-9-CM 94.33
MeSH D001521

Behavior therapy is a broad term referring to psychotherapy, behavior analytical, or a combination of the two therapies. In its broadest sense, the methods focus on either just behaviors or in combination with thoughts and feelings that might be causing them. Those who practice behavior therapy tend to look more at specific, learned behaviors and how the environment has an impact on those behaviors. Those who practice behavior therapy are called behaviorists.[1] They tend to look for treatment outcomes that are objectively measurable.[2] Behavior therapy does not involve one specific method but it has a wide range of techniques that can be used to treat a person's psychological problems.[3] Behavior therapy breaks down into two disciplines: applied behavior analysis (ABA) and cognitive behavior therapy (CBT). ABA focuses on the application of learning theory to assess potential behavior-change procedures and CBT focuses on the thoughts and feelings behind mental health conditions with treatment plans in psychotherapy to lessen the issue.

History

Precursors of certain fundamental aspects of behavior therapy have been identified in various ancient philosophical traditions, particularly Stoicism.[4] 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 started 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.[5]

The first use of the term behavior modification appears to have been by Edward Thorndike in 1911. His article Provisional Laws of Acquired Behavior or Learning makes frequent use of the term "modifying behavior".[6] Through early research in the 1940s and the 1950s the term was used by Joseph Wolpe's research group.[7] The experimental tradition in clinical psychology[8] used it to refer to psycho-therapeutic techniques derived from empirical research. It has since come to refer mainly to techniques for increasing adaptive behavior through reinforcement and decreasing maladaptive behavior through extinction or punishment (with emphasis on the former). Two related terms are behavior therapy and applied behavior analysis. Emphasizing the empirical roots of behavior modification, some authors[9] consider it to be broader in scope and to subsume the other two categories of behavior change methods. Since techniques derived from behavioral psychology tend to be the most effective in altering behavior, most practitioners consider behavior modification along with behavior therapy and applied behavior analysis to be founded in behaviorism. While behavior modification and applied behavior analysis typically uses interventions based on the same behavioral principles, many behavior modifiers who are not applied behavior analysts tend to use packages of interventions and do not conduct functional assessments before intervening.

Possibly the first occurrence of the term "behavior therapy" was in a 1953 research project by B.F. Skinner, Ogden Lindsley, Nathan H. Azrin and Harry C. Solomon.[10] The paper talked about operant conditioning and how it could be used to help improve the functioning of people who were diagnosed with chronic schizophrenia. Early pioneers in behaviour therapy include Joseph Wolpe and Hans Eysenck.[11]

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.[12] 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.[13] Gerald Patterson used programme instruction to develop his parenting text for children with conduct problems.[14] (See Parent management training.) With age, respondent conditioning appears to slow but operant conditioning remains relatively stable.[15] While the concept had its share of advocates and critics in the west, its introduction in the Asian setting, particularly in India in the early 1970s[References 1] and its grand success were testament to the famous Indian psychologist H. Narayan Murthy's enduring commitment to the principles of behavioural therapy and biofeedback.

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.[16]) 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 cognitive therapy,[17] but overall the question is still in need of answers.[18]

Scientific basis

The behavioral approach to therapy assumes that behavior that is associated with psychological problems develops through the same processes of learning that affects the development of other behaviors. Therefore behaviorists see personality problems in the way that personality was developed. They do not look at behavior disorders as something a person has but that it reflects how learning has influenced certain people to behave in a certain way in certain situations.[1] Understanding how the process of learning takes place comes from research that has been done on operant and classical conditioning.

Behaviour therapy is based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. Classical conditioning happens when a neutral stimulus comes right before another stimulus that triggers a reflexive response. The idea is that if the neutral stimulus and whatever other stimulus that triggers a response is paired together often enough that the neutral stimulus will produce the reflexive response.[19] Operant conditioning has to do with rewards and punishments and how they can either strengthen or weaken certain behaviors.[20] 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.[21]

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.[22] 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).[23]

Assessment

Behavior therapists complete a functional analysis or a functional assessment that looks at four important areas: stimulus, organism, response and consequences.[24] The stimulus is the condition or environmental trigger that causes behavior.[25] An organism involves the internal responses of a person, like physiological responses, emotions and cognition.[24] A response is the behavior that a person exhibits and the consequences are the result of the behavior. These four things are incorporated into an assessment done by the behavior therapist.[25]

Most behavior therapists use objective assessment methods like structured interviews, objective psychological tests or different behavioral rating forms. These types of assessments are used so that the behavior therapist can determine exactly what a client's problem may be and establish a baseline for any maladaptive responses that the client may have. By having this baseline, as therapy continues this same measure can be used to check a client's progress, which can help determine if the therapy is working. Behavior therapists do not typically ask the why questions but tend to be more focused on the how, when, where and what questions. Traditional tests like the Rorschach inkblot test or personality tests like the MMPI (Minnesota Multiphasic Personality Inventory) are traditionally used for behavioral assessment because they are based on the personality trait theory where it assumes that a person's answer to these methods can predict behavior. Behavior assessment is more focused on the observations of a persons behavior in their natural environment.[26]

Behavioral assessment specifically attempts to find out what the environmental and self-imposed variables are. These variables are the things that are allowing a person to maintain their maladaptive feelings, thoughts and behaviors. In a behavioral assessment "person variables" are also considered. These "person variables" come from a person's social learning history and they effect the way in which the environment affects that person's behavior. An example of a person variable would be behavioral competence. Behavioral competence looks at whether a person has the appropriate skills and behaviors that are necessary when performing a specific response to a certain situation or stimuli.[26]

When making a behavioral assessment the behavior therapist wants to answer two questions: (1) what are the different factors (environmental or psychological) that are maintaining the maladaptive behavior and (2) what type of behavior therapy or technique that can help the individual improve most effectively. The first question involves looking at all aspects of a person, which can be summed up by the acronym BASIC ID. This acronym stands for behavior, affective responses, sensory reactions, imagery, cognitive processes, interpersonal relationships and drug use.[27]

Clinical applications

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,[28][29][30] forgiveness in couples,[31] chronic pain,[32] stress-related behaviour problems of being an adult child of an alcoholic,[33] anorexia,[34] chronic distress,[35] substance abuse,[36] depression,[37] anxiety,[38] insomnia[39] and obesity.[40]

Functional analysis has even been applied to problems that therapists commonly encounter like client resistance, partially engaged clients and involuntary clients.[41][42] Applications to these problems have left clinicians with considerable tools for enhancing therapeutic effectiveness. One way to enhance therapeutic effectiveness is to use positive reinforcement or operant conditioning. Although behavior therapy is based on the general learning model, it can be applied in a lot of different treatment packages that can be specifically developed to deal with problematic behaviors. Some of the more well known types of treatments are: Relaxation training, systematic desensitization, virtual reality exposure, exposure and response prevention techniques, social skills training, modeling, behavioral rehearsal and homework, and aversion therapy and punishment.[3]

Relaxation training involves clients learning to lower arousal to reduce their stress by tensing and releasing certain muscle groups throughout their body.[43] Systematic desensitization is a treatment in which the client slowly substitutes a new learned response for a maladaptive response by moving up a hierarchy of situations involving fear.[44] Systematic desensitization is based in part on counter conditioning. Counter conditioning is learning new ways to change one response for another and in the case of desensitization it is substituting that maladaptive behavior for a more relaxing behavior.[45] Exposure and response prevention techniques is also known as flooding and response prevention.[46] Flooding and response prevention is the general technique in which you expose an individual to anxiety-provoking stimuli while keeping them from having any avoidance responses or keeping them from freaking out.[46]

Virtual reality therapy provides realistic, computer-based simulations of troublesome situations. The modeling process involves a person being subjected to watching other individuals who demonstrate behavior that is considered adaptive and that should be adopted by the client. This exposure involves not only the cues of the "model person" as well as the situations of a certain behavior that way the relationship can be seen between the appropriateness of a certain behavior and situation in which that behavior occurs is demonstrated.[47] With the behavioral rehearsal and homework treatment a client gets a desired behavior during a therapy session and then they practice and record that behavior between their sessions. Aversion therapy and punishment is a technique in which an aversive (painful or unpleasant) stimulus is used to decrease unwanted behaviors from occurring. It is concerned with two procedures: 1) the procedures are used to decrease the likelihood of the frequency of a certain behavior and 2) procedures that will reduce the attractiveness of certain behaviors and the stimuli that elicit them.[48] The punishment side of aversion therapy is when an aversive stimulus is presented at the same time that a negative stimulus and then they are stopped at the same time when a positive stimulus or response is presented.[49] Examples of the type of negative stimulus or punishment that can be used is shock therapy treatments,[50] aversive drug treatments [51] as well as response cost contingent punishment which involves taking away a reward.

Applied behavior analysis is using behavioral methods to modify certain behaviors that are seen as being important socially or personally. There are four main characteristics of applied behavior analysis. First behavior analysis is focused mainly on overt behaviors in an applied setting. Treatments are developed as a way to alter the relationship between those overt behaviors and their consequences.[52]

Another characteristic of applied behavior analysis is how it(behavior analysis) goes about evaluating treatment effects. The individual subject is where the focus of study is on, the investigation is centered on the one individual being treated. A third characteristic is that it focuses on what the environment does to cause significant behavior changes. Finally the last characteristic of applied behavior analysis is the use of those techniques that stem from operant and classical conditioning such as providing reinforcement, punishment, stimulus control and any other learning principles that may apply.[52]

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.[53] Social skills training has some empirical support particularly for schizophrenia.[54][55] However, with schizophrenia, behavioral programs have generally lost favor.[56]

Some other techniques that have been used in behavior therapy are contingency contracting, response costs, token economies, biofeedback, and using shaping and grading task assignments.[57]

Shaping and graded task assignments are used when behavior that needs to be learned is complex. The complex behaviors that need to be learned are broken down into simpler steps where the person can achieve small things gradually building up to the more complex behavior. Each step approximates the eventual goal and helps the person to expand their activities in a gradual way. This behavior is used when a person feels that something in their lives can not be changed and life's tasks appear to be overwhelming.[58]

Another technique of behavior therapy involves holding a client or patient accountable of their behaviors in an effort to change them. This is called a contingency contract, which is a formal written contract between two or more people that defines the specific expected behaviors that you wish to change and the rewards and punishments that go along with that behavior.[57] In order for a contingency contract to be official it needs to have five elements. First it must state what each person will get if they successfully complete the desired behavior. Secondly those people involved have to monitor the behaviors. Third, if the desired behavior is not being performed in the way that was agreed upon in the contract the punishments that were defined in the contract must be done. Fourth if the persons involved are complying with the contract they must receive bonuses. The last element involves documenting the compliance and noncompliance while using this treatment in order to give the persons involved consistent feedback about the target behavior and the provision of reinforcers.[59]

Token economies is a behavior therapy technique where clients are reinforced with tokens that are considered a type of currency that can be used to purchase desired rewards, like being able to watch television or getting a snack that they want when they perform designated behaviors.[57] Token economies are mainly used in institutional and therapeutic settings. In order for a token economy to be effective their must be consistency in administering the program by the entire staff. Procedures must be clearly defined so that there is no confusion among the clients. Instead of looking for ways to punish the patients or to deny them of rewards, the staff has to reinforce the positive behaviors so that the clients will increase the occurrence of the desired behavior. Over time the tokens need to be replaced with less tangible rewards such as compliments so that the client will be prepared when they leave the institution and won't expect to get something every time they perform a desired behavior.[60]

Closely related to token economies is a technique called response costs. This technique can either be used with or without token economies. Response costs is the punishment side of token economies where there is a loss of a reward or privilege after someone performs an undesirable behavior.[60] Like token economies this technique is used mainly in institutional and therapeutic settings.[57]

Considerable policy implications have been inspired by behavioral views of various forms of psychopathology. One form of behavior therapy, habit reversal training, has been found to be highly effective for treating tics.

Third generation

The third-generation behaviour therapy 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.[61] This area includes acceptance and commitment therapy (ACT), cognitive behavioral analysis system of psychotherapy (CBASP) (McCullough, 2000), behavioural activation (BA), functional analytic psychotherapy (FAP), integrative behavioural couples therapy and dialectical behavioural therapy. These approaches are squarely within the applied behaviour analysis tradition of behaviour therapy.

ACT may be the most well-researched of all the third-generation behaviour therapy models. It is based on relational frame theory.[62] Other authors object to the term "third generation" or "third wave" and incorporate many of the "third wave" therapeutic techniques under the general umbrella term of modern cognitive behavioral therapies.[63]

Functional analytic psychotherapy is based on a functional analysis of the therapeutic relationship.[64] It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement.[65] In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.[66]

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component.[67] Behavioural activation is based on a matching model of reinforcement.[68] A recent review of the research, supports the notion that the use of behavioural activation is clinically important for the treatment of depression.[69]

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.[70] 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.[71]

Organizations

Many organisations exist for behaviour therapists around the world. The World Association for Behavior Analysis offers a certification in behaviour therapy . 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) .

Treatment of mental disorders

Many have argued that behaviour therapy is at least as effective as drug treatment for depression, ADHD, and OCD.[72] Although, two large studies done by the Faculty of Health Sciences at Simon Fraser University indicates that both behaviour therapy and cognitive-behavioural therapy(CBT) are equally effective for OCD. CBT has been proven to perform slightly better at treating co-occurring depression.[73]

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.

There has been a development towards combining techniques to treat psychiatric disorders. Cognitive interventions are used to enhance the effects of more established behavioral interventions based on operant and classical conditioning. An increased effort has also been placed to address the interpersonal context of behavior.[74]

Behavior therapy can be applied to a number of mental disorders and in many cases is more effective for specific disorders as compared to others. Behavior therapy techniques can be used to deal with any phobias that a person may have. Desensitization has also been applied to other issues such as dealing with anger, if a person has trouble sleeping and certain speech disorders. Desensitization does not occur over night, there is a process of treatment. Desensitization is done on a hierarchy and happens over a number of sessions. The hierarchy goes from situations that make a person less anxious or nervous up to things that are considered to be extreme for the patient.[75]

Modeling has been used in dealing with fears and phobias. Modeling has been used in the treatment of fear of snakes as well as a fear of water.[76]

Aversive therapy techniques have been used to treat sexual deviations [77] as well as alcoholism.[78]

Exposure and prevention procedure techniques can be used to treat people who have anxiety problems as well as any fears or phobias.[79] These procedures have also been used to help people dealing with any anger issues as well as pathological grievers (people who have distressing thoughts about a deceased person).[80]

Virtual reality therapy deals with fear of heights,[81] fear of flying,[82] and a variety of other anxiety disorders.[83] VRT has also been applied to help people with substance abuse problems reduce their responsiveness to certain cues that trigger their need to use drugs.[84]

Shaping and graded task assignments has been used in dealing with suicide and depressed or inhibited individuals. This is used when a patient feel hopeless and they have no way of changing their lives. This hopelessness involves how the person reacts and responds to someone else and certain situations and their perceived powerlessness to change that situation that adds to the hopelessness. For a person with suicidal ideation, it is important to start with small steps. Because that person may perceive everything as being a big step, the smaller you start the easier it will be for the person to master each step.[58] This technique has also been applied to people dealing with agoraphobia, or fear of being in public places or doing something embarrassing.[85]

Contingency contracting is used to treat any behavioral problems that an individual may have. It has been used to deal with behavior problems in delinquents and when dealing with on task behaviors in students.[59]

Token economies are used in controlled environments and are found mostly in psychiatric hospitals. They can be used to help patients with different mental illnesses but it doesn't focus on the treatment of the mental illness but instead on the behavioral aspects of a patient.[86] The response cost technique has been used to address a variety of behaviors such as smoking, overeating,stuttering, and psychotic talk.[87]

Treatment outcomes

Systematic desensitization has been shown to successfully treat phobias about heights, driving, insects as well as any anxiety that a person may have. Anxiety can include social anxiety, anxiety about public speaking as well as test anxiety. It has been shown that the use of systematic desensitization is an effective technique that can be applied to a number of problems that a person may have.[88]

When using modeling procedures this technique is often compared to another behavioral therapy technique. When compared to desensitization, the modeling technique does appear to be less effective.[89] However it is clear that the greater the interaction between the patient and the subject he is modeling the greater the effectiveness of the treatment.[89]

Aversive treatment of sexual deviations according to the empirical literature has generally seen a reasonable degree of success and this includes follow up periods.[77]

While undergoing exposure therapy a person usually needs five sessions to see if the treatment is working. After five sessions exposure treatment is seen to benefit the patient and help with their problems. However even after five sessions it is recommended that the patient or client should still continue treatment.[80]

Virtual Reality treatment has shown to be effective for a fear of heights.[81] It has also been shown to help with the treatment of a variety of anxiety disorders.[83] Virtual reality therapy can be very costly so therapists are still awaiting results of controlled trials for VR treatment to see which applications show the best results.[90]

For those with suicidal ideation treatment depends on how severe the person's depression and feeling of hopelessness is. If these things are severe the person's response to completing small steps will not be of importance to them because they don't consider it to be a big deal.[58] Generally those who aren't severely depressed or fearful, this technique has been successful because the completion of simpler activities build up their confidences and allows them to continue on to more complex situations.[91]

Contingency contracts have been seen to be effective in changing any undesired behaviors of individuals. It has been seen to be effective in treating behavior problems in delinquents regardless of the specific characteristics of the contract.[59]

Token economies have been shown to be effective when treating patients in psychiatric wards who had chronic schizophrenia. The results showed that the contingent tokens were controlling the behavior of the patients.[86]

Response costs has been shown to work in suppressing a variety of behaviors such as smoking, overeating or stuttering with a diverse group of clinical populations ranging from sociopaths to school children. These behaviors that have been suppressed using this technique often do not recover when the punishment contingency is withdrawn. Also undesirable side effects that are usually seen with punishment are not typically found when using the response cost technique.[87]

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).[92]

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

Methods

See also

References

  1. 1 2 O'Leary, K. Daniel, and G. Terence Wilson. Behavior Therapy: Application and Outcome, 7-12. Englewood Cliffs, NJ: Prentice-Hall, 1975. Print.
  2. ↑ O'Leary, K. Daniel, and G. Terence Wilson. Behavior Therapy: Application and Outcome, 12-14. Englewood Cliffs, NJ: Prentice-Hall, 1975. Print.
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