Behaviour therapy

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J.Middleton Copyleft 1996 October

An explanation and evaluation the Behaviorist approach to Psychotherapy.

In this essay I shall explain what the behaviorist approach is. In order to do this I shall be examining the historical perspective of behaviourism.

I shall need to evaluate the behaviourist approach and it's effectiveness in the treatment of the whole person and shall briefly compare it to some of the other approaches to treatment.

The fundamental approach of behaviourism and psychoanalytical therapy seems diametrically opposed and it will be interesting to see how some therapists are able to incorporate both of these approaches into their treatment techniques.

Behaviourism is defined in the Collin's Dictionary as" the guiding principle of certain psychologists who hold that the proper basis of psychological science is the objective study of behaviour under stimuli".

What does this mean? We shall come back to this statement.

Psychotherapy is defined in the Collin's Dictionary as "The treatment of disease by psychological means". The definition of psychotherapeautic is even more interesting " The treatment of disease by psychological means. The treatment of disease by psychological or hypnotic means".

It is interesting that here we come to a definition of treatment using hypnosis. This essay is being written with hypnosis and hypnotherapy in mind as the main tool to use treatment approaches in therapy.

In fact modern psychotherapy often doesn't use hypnosis at all.

I feel a more rational definition to behaviourism to be " Techniques to change behaviour; without evaluating/using any analysis of how the problem arrived, why it might be there - and what might be behind it; without any need to understand or delve at the source of the difficulty."

It might be fairer to describe behaviourism as "1.The evaluation of the individual in his environment in order to determine what factors around him are responsible for his problem, and 2. manipulation of the environment or the individual in order to ameliorate the difficulty."

Pavlov was the first person who is noted as examining behaviour. He was a Russian physiologist who is noted as the father of 'Classical conditioning'. Outlining the Stimulus and response connection, teaching us about an unconditioned stimulus, paired with a conditioned stimulus resulting in a conditioned response. He initially worked with dogs as his subjects. He also taught us about 'extinction , when the conditioned response decreases, and 'spontaneous recovery' when it returns later.

Classical conditioning can also be generalised, similar stimuli, creating similar responses. The ability to distinguish the two he called 'discrimination'.

Pavlov was also able to create a neurotic dog. This illustrates discrimination. When the two stimuli he wanted the dogs to respond to were too similar the dog became neurotic as it couldn't distinguish between the two. It tried desperately to free itself from it's harness, it whined, growled, barked frantically and lost control of it's bowels. It had become emotionally unstable.

J.B.Watson was the first theorist in the 1900's to advance the behaviourist approach and said "give me a dozen healthy infants - well formed - and my own specific world to bring them up in and I'll guarantee to take any one at random and train him to become any specialist he might select." Watson showed the strength of classical conditioning, by conditioning Little Albert to be afraid of a white rat. He did this by making loud noises every time the child saw the rat, In fact the conditioning was so strong that he then generalised his fear to all furry, white objects.

Skinner took conditioning many steps further by outlining the process he called operant conditioning. B.F. Skinner demonstrated how learning takes place and once proposed that all learning (i.e. all psychology) could be explained by the acquisition of learning by operant conditioning. More recently it is considered as being one of the many ways in which behaviour may be altered.

Operant conditioning is concerned with the reinforcement of behaviours that are already occurring spontaneously. These behaviours are referred by Skinner as Operants. Many operants may be involved in a piece of complex behaviour, and they may be selectively reinforced towards that behaviour in a process called Shaping.

To demonstrate operant conditioning in the laboratory, a rat is placed in a box, called a 'Skinner box'. Because the rat has been previously deprived of food, it is assumed that the rat will be ' motivated' to look for food.

So operant conditioning refers to increasing the probability of a response in a particular stimulus environment by following the response with reinforcement.

Behaviour therapy and modification have taught us that the principles from learning theory can be introduced to modify undesirable behaviour. Using first rats and then pigeons, Skinner did the groundwork for behaviour therapists to begin applying these ideas to humans.

Learning theory, unlike Piagetian or Freudian theory, concentrates on overt behaviour ( that which is easily seen) rather than what goes on within the mind.

In this theory the power of the environment and experiences are stressed and the role of biological maturation is minimised. It views the child as a malleable creature who wants more pleasure than pain and will do things that will gain rewards and steer away from actions which are punished. Learning looked at in this way is simply "the process by which behaviour is modified as a result of experience".

Theorists propose two fundamental mechanisms for behaviour change. 1. forming associations through conditioning. 2. by the observations of models ,i.e. parents, friends, authority figures etc.

Behaviour therapy is, therefore, an attempt to ensure that the desired behaviour is immediately and appropriately rewarded, (Contiguous), and that undesired behaviour is not rewarded. For example if a child throws things around in the room and screams and shouts, he is rewarded during periods when he is sitting quietly and not rewarded/punished when he is being destructive.

For people, rewards can be many things. They be material rewards such as food, sweets, cigarettes, money or toys, or ; they may be social, for example praise or attention. Anything which is rewarding can be used as long as it is used immediately following the desired behaviour. In some cases as in hospitals for the mentally handicapped or psychiatrically ill, tokens are used which are easier to handle than material rewards. This is called a token economy system. These avoid the problems of satiation (eating too much and thus not wanting any more). These tokens can then be exchanged at the end of the day or week for a variety of rewards, such as money, privileges like visits out of the hospital, clothes ,outings etc.

Such a scheme was used in an experimental study by Burchard and Barrera (1972). Their experiment was carried out using a token economy system designed for the rehabilitation of mildly mentally handicapped adolescent boys who displayed a high frequency of anti-social behaviour. Tokens were mostly earned through achievement in the workshop and were exchanged for a variety of rewards, such as meals, recreational trips, clothes or purchases. A time-out procedure was also adopted where boys had to sit on a bench behind a partition, hence having time out from being able to receive reinforcers; also a response cost procedure was employed during which reinforcers were removed, thus tokens were removed. Time out and deprivation of tokens occurred following swearing, personal assault, property damage or other undesirable behaviour. They found that these things repressed the boy's bad behaviour, but in some boys one technique might be more effective than another.

Behaviour modification is being applied to a whole variety of what are traditionally considered disturbed behaviours with good results. The main practical difficulties are being able to find suitable reinforcers and to apply the techniques constantly. Some critics have suggested that behaviour modification may succeed in changing behaviours but not the processes that underlie them, and also that it could be used to teach that behaviour which best fits the demands of the institution rather than that which is in the individual's best interest.

Using such a Token economy system within an institution presents many difficulties. For example the Staff have to ensure that reinforcement and removal of tokens must occur constantly. In other words all staff, day and night staff have to be a part of such a scheme. They also have to carry out their involvement fully for such a system to work. It only requires one staff member to fail at their task for the effectiveness to lessen. Organising and carrying out such a scheme requires much time and cost. It is an expensive and time consuming way to change behaviour, and if some of the staff are not committed to the scheme it could likely fail. There is also no attempt to address the cause behind why the children are trouble makers, and what might be a more humane way of helping them. Who decides what is or is not acceptable behaviour. The members of staff within the institution not the individual children themselves. Such a scheme could be open to unlimited abuse. It is no accident that in closed environments of hospitals and homes, that regularly staff members are caught physically and mentally abusing defenseless people.

Social learning theory accounts for some of the techniques used for behaviorist approaches in psychotherapy.

It is based on Skinner's ideas of learning, however to account for complex situations and was modified in two main ways,. 1. The limitation of reinforcement to account for complex attitudes has been recognised 2. The concept of observational learning has been introduced. Much of the work was carried out by Bandura 1973 in experimentation with children. He proposed through his work on aggression in children that to acquire behaviour, you need only to be exposed to it and the use of that behaviour is only produced if production has been rewarded. This has impact on the use of therapy and even on the perceived personality of the therapist himself. Modelling can be used as a therapy with the therapist carrying out the desired activity in an exemplary fashion. Role play could also be used as a method of behaviour rehearsal. Role play is when the patient is asked to take on and act out a part which illustrates another point of view than his own. This can help the personality to take on the role of the other.

Modelling and role play have their problems. The therapist decides what is appropriate behaviour to model or role play. No therapist no matter how unbiased he or she feels they are cannot be wholly impartial. Their own opinions and feelings can influence what they personally feel is appropriate behaviour. This might not be in the patients best interests for his particular circumstance.

Counter conditioning or systematic desensitization has been described and conducted by Wolpe (1958-76). It is most often used with phobias and fears such as spiders. The therapist teaches the patient to relax, until the person is able to imagine the spider, and through relaxation, tolerate the thought. Research has indicated that being able to cope with anxiety provoking situations in the imagination is related to a reduction in anxiety when these situations are encountered in real life. Following this phase of treatment, the patient is then encouraged to confront spiders and related objects in real life.

The desensitization procedure may be carried out in the absence of the real feared object by imagining the objects or it can be carried out by direct exposure (on a generalisation gradient) to real objects. Wolpe (1961) has argued that the reduction in anxiety generated by imaginal or covert desensitisation will generalise to real situations almost completely.

Systematic desensitisation would seem to be one of the most commonly used techniques employed by therapists from a range of orientations. This might be because it is one of the most straightforward of approaches and is also very effective. The difficulties here, involve ensuring the hierarchy of fear/anxiety is appropriate and accurate. It is very easy to miscalculate and create a worse problem than before treatment. The other assumption behaviourists often make is that relaxation is the only resource to use with desensitisation. It might be more effective in some cases, such as working with a fear of public speaking to create some other more effective resource. Excitement or feelings of confidence could be more appropriate. Bandler and Grinder (1979) in their work 'Frogs into Princes' cite many such other 'feeling state' resources which might be more useful than relaxation.

Flooding is another technique occasionally employed by behaviourists. Again used for phobias and fears. The basis here is that if the person is forced to confront their fear and not be able to avoid it, their fear symptoms eventually will subside. After a number of such learning situations, it has been shown that the fear can be considerably reduced.

Unfortunately this approach is particularly unpleasant in the short term for the patient and they have to be prepared to stay in the fear provoking situation each time until the anxiety is manageable. This can take several hours for the first attempt. Each further occasion they are flooded in this way, the length of time they experience intolerable fear and anxiety reduces, until eventually it might only last for a minute or two. Morganstern (1973), however concludes that there is no convincing evidence of the effectiveness of these procedures. Nor are these techniques superior to standard desensitisation. Not only does the theoretical basis of implosion or flooding appear to be unsupported, it also raises serious ethical questions in regard to the desirability of it's clinical use. Some patients may be overwhelmed by the intensity of the fear-eliciting stimuli.

Aversion therapy is another technique. This couples the stimulus which the patient desires to avoid with an unpleasant experience. It has been used with addictions like tobacco and alcohol and also in some cases with homosexuals or sex offenders. Their use dates back to the late 19th century or earlier, tobacco, morphine and alcohol addictions being treated in this way, in Europe. Hypnosis has since been utilised and commonly hypnotic suggestions ranging from moderate disgust to nausea and vomiting were associated with the patient's contact with the addictive substance. (Bernheim 1903, Tuckey 1907, Moll 1909, Forel 1927, Grasset 1904.) Use of such techniques using hypnosis continued to the mid 20th century (Kroger 1942,1970; Hershman 1955,1956; Erickson 1954, Von Dendroth 1964,1965.). However it is recognised that there are other more effective techniques used today.

It is interesting to note that although aversion techniques have been largely superceded by other more humane and effective methods of treatment that they are still used regularly within some hospitals and many prisons. It would appear that this approach might be one of the more unpleasant experiences an individual might have, and I wonder if it is still used as it has a Victorian flavour to it.

It is traditionally used to 'help' those people who have committed crimes which society consider particularly inappropriate. Alcoholism, drug abuse, and sex offending.

There are a range of behaviours in which behaviourist techniques have proved useful in changing less acceptable behaviours for more acceptable ones.

Some of these are Obsessive compulsive disorders like compulsive handwashing, compulsive checkers.

Sexual disorders such as erectile impotence, premature ejaculation, vaginismus. Sexual deviation such as paedophilia, exhibitionism, sadism and masochism. Social skills problems like awkwardness in social situations, lack of confidence public speaking etc. Habit disorders like hairpulling, ticks, stammering, enuresis.

Using hypnosis in conjunction with behaviourist techniques such as systematic desensitisation makes more sense than using the behaviourist technique alone. For example if a patient wants help with a fear of travelling on the London underground, or a fear of flying, in order to work with the problem, it is necessary to be in the place where the fear is. In this case, the underground in London or some airport. Not only is taking the patient to those places time consuming, it is also very expensive. It makes much more sense doing the work within hypnosis and using the imagination alone. As mentioned earlier, Wolpe says that the work done within the imagination soon generalises to real life.

While there are many similarities between behaviour therapy and hypnotherapy, there are some basic differences. The primary focus of behaviour modification is to change and sustain behaviour with reinforcement, attitudes will naturally follow. Hypnotherapists traditionally attempt attitude change first and assume behavioural change will follow. The behaviourists claim you will in time come to feel the role you are playing.

The school to which most hypnotherapists have belonged, traditional psychotherapy, have argued that one must first develop insight before any change can take place. For example they felt it wrong to merely help a patient to stop smoking without first determining why he smoked. They feared that the presenting problem, in this case smoking, was merely a symptom of an underlying conflict which must first be resolved. If smoking was stopped without first understanding it's origin, they believed, another symptom would manifest in it's place. Some Behaviourists would argue that there is little evidence, however that such substitution does exist. (Kroger and Fezler1976). In my own practice I have noted that symptom substitution does occur, especially where I treat compulsive smokers rather than habit smokers, though distinguishing between the two is not always easy!

The hypnobehavioural model accepts the tenets of both schools of thought. Attitude change leads to behavioural change and behavioural change leads to attitude change. The hypnobehaviourists however attempt to change both attitude and behaviour in conjunction. It is not necessary to work on only one, hoping the other will follow; both are dealt with simultaneously. For example if an individual is driven to drink through anxiety produced by a nagging spouse, they would counsel the couple in an attempt to produce positive attitude changes to each other, but also in the meantime, begin using aversion therapy directed towards the elimination of the drinking behaviour.

A second difference is found in the therapeutic relationship. The behaviour therapist being less permissive. The psychoanalytic therapist is receptive and interested in anything said by the patient in an attempt to maximise free expression, the behaviourist pays little attention to the patient's discussion of historical information. Talk of hopelessness or despair are ignored. Behaviour therapists may be directive in encouraging positive feeling states and assist the patient in 'turning on' such feelings at will.

According to Sloan et al( 1975), behaviour therapy as opposed to psychotherapy, makes little use of interpretation of the transference, the resistances, dreams, and the lengthy recall of childhood memories. On the other hand, directive suggestions, relaxation training, desensitisation and assertive training are used by behaviour therapists. However both are similar in that they take a history, may identify the original cause or causes of the disorder, attempt to reduce anxiety, correct misconceptions, and outline objectives. They may also extend therapy to the family and other significant figures in the patient's life.

Treatment is always a mutual endeavor in which belief and faith that the method will work are involved. The universality of suggestion in any type of psychotherapy needs no reiteration. Thigpen and Cleckly (1964), in a discussion of psychoanalysis, hypnosis, and faith healing and the role of the latter in the conditioning therapies suggest;

"If we learn that we are working chiefly through the imperfectly understood but powerful effects of faith, let us admit it to be so, use it with more insight, and seek better and more straightforward means of app