Monday, January 11, 2010

Behavior Therapy

The term behavior modification and behavior therapy are often used interchangeably, but they have slightly different meanings
Behavior modification is an approach to assessment, evaluation, and behavior change that focuses on the development of adaptive, pro-social behaviors and the decrease of maladaptive behavior in daily living.  Behavior modification is used by therapists and paraprofessional workers to help individuals improve some aspect of daily life. 
Behavior therapy is a clinical approach that can be used to treat a variety of disorders, in various types of settings, and with a wide range of special population groups.
Historical Background;
The behavioral approach had its origin in the 1950s and early 1960s and it was a radical departure from the dominant psychoanalytic perspective.  Contemporary behavior therapy arose simultaneously in the U.S., South Africa, and Great Britain in the 1950s.  In spite of harsh criticism and resistance from traditional psychotherapists, the approach survived.  Its focus was on demonstrating that behavioral conditioning techniques were effective and were a viable alternative to traditional psychotherapy.
In the 1960s Albert Bandura developed social learning theory, which combined classical and operant conditioning with observational learning.  During the 1960s a number of cognitive behavioral approaches sprang up, and they still have a significant impact on therapeutic practice.
It was during the 1970s that behavior therapy emerged as a major force in psychology and made a significant impact on education, psychology, psychotherapy, psychiatry, and social work.
In the 1980s behavior therapists continued to subject their methods to empirical scrutiny and to consider the impact of the practice of therapy on both their clients and the larger society.  Increased attention was given to the role of emotions in therapeutic change, as well as the role of biological factors in psychological disorders.  Two significant developments in the field were (1) the continued emergence of cognitive behavior therapy as a major force (2) the application of behavioral techniques to the prevention and treatment of medical disorders.
By the late 1990s, there were at least 50 journals devoted to behavior therapy and its many offshoots.  Behavior therapy is marked by a diversity of views and procedures but all practitioners focus on observable behavior, current determinants of behavior, learning experiences to promote change, and rigorous assessment and evaluation.

Four Areas of Development:

(1) Classical conditioning
(2) Operant conditioning
(3) Social learning theory
(4) Cognitive behavior therapy
(1) In classical conditioning (Pavlovian) certain respondent behaviors, such as knee jerks and salivation, are elicited from a passive organism.  The focus was on experimental analysis and evaluation of therapeutic procedures.  Classical conditioning (respondent conditioning) refers to what happens prior to learning what creates a response through pairing.  Ivan Pavlov illustrated classical conditioning through experiments with dogs.  Placing food in a dog’s mouth leads to salivation, which is respondent behavior.  When food is repeatedly presented with some originally neutral stimulus, such as the sound of a bell, the dog will eventually salivate to the sound of the bell alone.  However, if a bell is sounded repeatedly, but not paired again with food, the salivation response will eventually diminish and become extinct.  Another example is Joseph Wolpe’s systematic desensitization.
(2) Operant conditioning involves a type of learning in which behaviors are influenced mainly by the consequences that follow them.  If the environmental changes brought about by the behavior are reinforcing – that is, if they provide some reward to the organism or eliminate aversive stimuli – the chances are increased that the behavior will occur again.  If the environmental changes produce no reinforcement or produce aversive stimuli, the chances are lessened that the behavior will recur.  Skinner contends that learning cannot occur in the absence of some kind of reinforcement, either positive or negative.  Reinforcement involves some kind of reward or the removal of an aversive stimulus following a response.  Reinforcement takes place when the consequences of a behavior increase the likelihood that the behavior will be repeated.  For Skinner, actions that are reinforced tend to be repeated and those that are not reinforced tend to be extinguished.
(3) The social learning approach, developed by Albert Bandura and Richard Walters, is interactional, interdisciplinary, and multimodal.  Behavior is influenced by stimulus events, by external reinforcement, and by cognitive mediational processes (thinking processes, attitudes, and values).  Social learning and cognitive theory involves a reciprocal interaction among the environment, personal factors (beliefs, preferences, expectations, self-perceptions) and individual behavior.  A basic assumption is that people are capable of self-directed behavior change.  For Bandura, self-efficacy is the individual’s belief or expectation that he or she can master a situation and bring about desired change.  The theory of self-efficacy represents one of the first major attempts to provide a unified theoretical explanation of how behavior therapy and other psychotherapy procedures work. 
(4) Cognitive behavior therapy – many techniques, particularly those developed within the last three decades, emphasize cognitive processes that involve private events such as the client’s self-talk as mediators of behavior change. 
Today, current behavior therapy tends to be integrated with cognitive therapy and is often referred to as cognitive behavior therapy.  Today there are relatively few traditional behavioral practitioners.
View of Human Nature:
In modern behavior therapy, the current view is that the person is the producer and the product of their environment.  Behavior therapy aims to increase people’s skills so that they have more options for responding.  By overcoming debilitating behaviors that restrict choices, people are freer to select from possibilities that were not available earlier.  Thus, as behavior therapy is typically applied, it will increase individual freedom.
Basic Characteristics and Assumptions:
(1)   Behavior therapy is based on the principles and procedures of the scientific method (or a systematic adherence to precision and to empirical evaluation).  Behavior therapists state treatment goals in concrete objective terms to make replication of their interventions possible.  Treatment goals are agreed upon by the client and therapist.  Throughout the course of therapy, the therapist assesses problem behaviors and the conditions that are maintaining them.  Research methods are used to evaluate the effectiveness of both assessment and treatment procedures.  Therapeutic techniques employed must have demonstrated effectiveness.  Behavioral concepts and procedures are stated explicitly, tested empirically, and revised continually.
(2)   Behavior therapy deals with the client’s current problems and the factors influencing them.  Emphasis is on specific factors that influence present functioning and what factors can be used to modify performance.  Behavior therapists look to the current environmental events that maintain problem behaviors and help clients produce behavior change by changing environmental events.
(3) Clients involved in behavior therapy are expected to assume an active role by engaging in specific actions to deal with their problems.  They are required to do something to bring about change.  Clients monitor their behaviors both during and outside the therapy sessions, learn and practice coping skills, and role-play new behavior.  Behavior therapy is an action-oriented approach, and learning is viewed as being at the core of therapy.  It is an educational approach in which clients participate in a teaching-learning process.
(4) The behavioral approach emphasizes teaching clients skills of self-management, with the expectation that they will be responsible for transferring what they learn in the therapist’s office to their everyday lives.  Behavior therapy is generally carried out in the client’s natural environment as much as possible.
(5) The focus is on assessing overt and covert behavior directly, identifying the problem, and evaluating change.  There is direct assessment of the target problem through observation or self-monitoring to determine whether the behavior change resulted from the procedure.
(6) Behavior therapy emphasizes a self-control approach in which clients learn self-management strategies.  Therapists frequently train clients to initiate, conduct, and evaluate their own therapy.
(7) Behavioral treatment interventions are individually tailored to specific problems experienced by clients.  For ex., “What treatment, by whom, is the most effective for this individual with that specific problem and under which set of circumstances?”
(8) The practice of behavior therapy is based on a collaborative partnership between therapist and client, and every attempt is made to inform clients about the nature and course of treatment.
(9) The emphasis is on practical applications.  Interventions are applied to all facets of daily life in which maladaptive behaviors are to be decreased and adaptive behaviors are to be increased.
(10) Therapists strive to develop culture-specific procedures and obtain their clients’ adherence and cooperation.
Therapeutic Goals:
Goals occupy a place of central importance in behavior therapy.  The client, with the help of the therapist, defines specific goals at the outset of the therapeutic process.  Although assessment and treatment occur together, a formal assessment takes place prior to treatment to determine behaviors that are targets of change.  Continual assessment throughout therapy determines the degree to which identified goals are being met.  It is important to devise a way to measure progress toward goals based on empirical validation.  The therapist assists clients in formulating specific measurable goals.  Goals must be clear, concrete, understood, and agreed on by the client and the counselor.  This results in a contract that guides the course of therapy.  Behavior therapists and clients alter goals throughout the therapeutic process as needed.
• The client identifies desired outcomes.  The focus is on what the client wants to do rather than on what the client does not want to do.
• The client is the person seeking help, and only he or she can make a change.  The counselor helps the client accept the responsibility for change rather than trying to get someone else to change.
• The cost-benefit effect of all identified goals is explored, and counselor and client discuss the possible advantages and disadvantages of these goals.
Once goals have been agreed upon, a process of defining them begins.  The counselor and client discuss the behaviors associated with the goals, the circumstances required for change, the nature of sub-goals, and a plan of action to work toward these goals.
Therapist’s Function and Role:
Behavior therapists tend to be active and directive and to function as consultants and problem solvers.  They use some techniques common to other approaches, such as summarizing, reflection, clarification, and open-ended questioning.  Behavioral clinicians perform these other functions as well:
• Conduct a thorough functional assessment to identify the maintaining conditions by systematically gathering information about situational antecedents, the dimensions of the problem behavior, and the consequences of the problem.
• Formulate initial treatment goals and design and implement a treatment plan to accomplish these goals.
• Use strategies to promote generalization and maintenance of behavior change.
• Evaluate the success of the change plan by measuring progress toward the goals throughout the duration of treatment
• Conduct follow-up assessments.
Another important function of the therapist is role modeling for the client.  It is essential that therapist be aware of the crucial role they play in the therapeutic process.
Client’s Experience in Therapy:
Behavior therapy provides the therapist with a well-defined system of procedures to employ.  The importance of client awareness and participation in the therapeutic process is stressed.  Behavior therapy is characterized by an active role for both therapist and client.  A large part of the therapist’s role is to teach concrete skills throughout the provision of instructions, modeling, and performance feedback.  The client engages in behavioral rehearsal with feedback until skills are well learned and generally receives active homework assignments (such as self-monitoring or problem behaviors) and are expected to cooperate in carrying out therapeutic activities, both during therapy sessions and in everyday life.  They are helped to generalize and to transfer the learning acquired within the therapeutic situation to situations outside therapy.  It is clear that clients are expected to do more than merely gather insights; they need to be willing to make changes and to continue implementing new behavior once formal treatment has ended.  Clients are as aware as the therapist is regarding when the goals have been accomplished and it is appropriate to terminate treatment.
Relationship Between Therapist and Client:
A good therapeutic relationship increases the chances that the client will be receptive to therapy.  Most behavioral practitioners contend that factors such as warmth, empathy, authenticity, permissiveness, and acceptance are necessary but not sufficient for behavior change to occur.  Behavior therapists assume that clients make progress primarily because of the specific behavioral techniques used rather than because of the relationship with the therapist.
Behavioral assessment, which begins with a description of the client’s complaint, is central to behavior therapy.  The client keeps a record of the frequency and intensity of occurrences, and this becomes the tool in devising a therapeutic plan and in deciding whether the therapy is working.  There are numerous practical and easy-to-use assessment instruments, including countless self-report inventories, behavior rating scales, self-monitoring forms, and simple, observational techniques for collecting useful information on client’s problems.
The main findings produced by research in the behavioral therapies is that treatment outcomes are multifaceted.  Changes are not all or nothing.  Improvements are likely to occur in some areas but not in others.  All improvements do not emerge at one time, and gains in some areas may be associated with problems emerging in other areas.  It is clear that behavior therapists do not have to restrict themselves strictly to methods derived from learning theory.  Likewise, behavioral techniques can be incorporated into other approaches.
A sample of the approaches used in behavior therapy:
Applied Behavioral Analysis:  Operant Conditioning Techniques
In applied behavior analysis, operant conditioning techniques and methods of assessment and evaluation are applied to a wide range of problems in many different settings.  The most important contribution of applied behavior analysis is that it offers a functional approach to understanding clients’ problems and addresses these problems by changing antecedents and consequences.
Behaviorists believe we respond in predictable ways because of the gains we experience (positive reinforcement) or because of the need to escape or avoid unpleasant consequences (negative reinforcement).  The goal of reinforcement, whether positive or negative, is to increase the target behavior.  Positive reinforcement involves the addition of something of value to the individual (such as praise, attention, money, or food) as a consequence of certain behavior.  The stimulus that follows the behavior is the positive reinforcer.  When the goal of a program is to decrease or eliminate undesirable behaviors, positive reinforcement is often used to increase the frequency of more desirable behaviors, which replace undesirable behaviors.  Negative reinforcement involves the escape from or the avoidance of aversive (unpleasant) stimuli.
Extinction refers to withholding reinforcement from a previously response.  Extinction can reduce or eliminate certain behaviors but extinction does not replace those responses that have been extinguished.  Extinction is most often used in behavior modification programs in conjunction with various reinforcement strategies.
Punishment, sometimes referred to as aversive control, in which the consequences of a certain behavior result in a decrease of that behavior.  The goal of punishment is to decrease target behavior.  Positive punishment is where an aversive stimulus is added after the behavior to decrease the frequency of a behavior (such as spanking a child for misbehavior or reprimanding a student for acting out in class).  In negative punishment, a reinforcing stimulus is removed following the behavior to decrease the frequency of a target behavior (such as deducting money from a worker’s salary for missing time at work, or taking television time away from a child for misbehavior).  Punishment should be used only after non-aversive approaches have been implemented and found to be ineffective in changing problematic behavior.
The Functional Assessment Model:
A step-by-step functional assessment and treatment program:
1.  The first step is to conduct a functional assessment to gather data about the antecedents and consequences that are functionally related to the occurrence of problematic behaviors.
2.  Both indirect methods (behavioral interviews or questionnaires to gather information about the problem behavior) and direct observation methods are used.  A functional assessment yields information about antecedent events, including the time and place of the behavior and the people present when the behavior occurs.
3.  Therapists develop hypotheses about the nature of the problem behavior and the conditions contributing to this behavior.
4.  The different functions of the problem behavior is identified then treatments are devised to address the antecedents and consequences hypothesized to be maintaining the problem behaviors.
• Differential reinforcement of desirable behaviors to replace problem behaviors which may include both positive and negative reinforcement procedures.
• Extinction of problem behaviors by withholding the reinforcers (identified in the functional assessment process) found to be maintaining the problem.
• Antecedent control procedures in which antecedents are manipulated in an attempt to prevent the occurrence of problem behaviors and to promote desirable alternative behaviors to replace the problem behaviors.
6.  After treatment methods have been used, it is very important to develop strategies to promote the generalization and maintenance of behavioral changes that have occurred.
Relaxation Training and Related Methods:
Relaxation training involves several components that typically require from 4 to 8 hours of instruction.  Clients are given a set of instructions that asks them to relax.  They assume a passive and relaxed position in a quiet environment while alternately contracting and relaxing muscles.  Deep and regular breathing is also associated with producing relaxation.  At the same time clients learn to mentally “let do,” perhaps by focusing on pleasant thoughts or images.  Clients are encouraged to actually feel and experience the tension building up, to notice their muscles getting tighter and study this tension, and to hold and fully experience the tension.  Also, it is useful for clients to experience the difference between a tense and a relaxed state.  Relaxation becomes a well-learned response.
Systematic Desensitization:
Clients imagine successively more anxiety-arousing situations at the same time that they engage in a behavior that competes with anxiety.  Gradually, or systematically, clients become less sensitive (desensitized) to the anxiety-arousing situation.  This procedure can be considered a form of exposure therapy because clients are required to expose themselves to anxiety-arousing images as a way to reduce anxiety.  The core of systematic desensitization is repeated exposure in the imagination to anxiety-evoking situations without experiencing any negative consequences.
Self-Management Programs and Self-Directed Behavior:
Self-management programs teach people the skills they need to manage their own lives effectively.  An advantage of self-management techniques is that treatment can be extended to the public in ways that cannot be done with traditional approaches to therapy.  Another advantage is that costs are minimal.  Because clients have a direct role in their own treatment, techniques aimed at self-change tend to increase involvement and commitment to their treatment.
Self-management strategies include, but are not limited to, self-monitoring, self-reward, self-contracting, stimulus control, and self-as-model.  The basic idea of self-management assessments and interventions is that change can be brought about by teaching people to use coping skills in problematic situations.
1. Selecting goals.
2. Translating goals into target behaviors.
3. Self-monitoring
4. Working out a plan for change
5. Evaluating an act6ion plan
Successful self-change efforts begin with setting realistic goals and providing a concrete plan for achieving behavioral change.
Multimodal Therapy:  Clinical Behavior Therapy:
Multimodal therapy is a comprehensive, systematic, holistic approach to behavior therapy developed by Arnold Lazarus.  It is grounded in social learning and cognitive theory and applies diverse behavioral techniques to a wide range or problems.  This model implies that we are social beings who move, feel, sense, imagine, and think.  This contemporary approach is particularly important as it serves as a major link between some behavioral principles and the cognitive behavioral approach that has largely replaced traditional behavioral psychology.  Multimodal therapists recognize that many clients come to therapy needing to learn skills, and therapists are willing to teach, coach, train, model, and direct their clients.
The essence of Lazarus’s multimodal approach is the premise that the complex personality of human beings can be divided into seven major areas of functioning:
B = behavior
A = affective responses
S = sensations
I = images
C = cognitions
I = interpersonal relationships
D = drugs, biological functions, nutrition, and exercise
Multimodal therapy begins with a comprehensive assessment of the seven modalities of human functioning and the interaction among them.  A complete assessment and treatment program must account for each modality of the BASIC I.D., which is the cognitive map linking each aspect of personality.  Multimodal therapists tend to be very active during therapy sessions, functioning as trainers, educators, consultants, and role models.  They provide information, instruction, and feedback as well as modeling assertive behaviors, challenging self-defeating beliefs, offering constructive criticism and suggestions, offering positive reinforcements, and being appropriately self-disclosing.
Contributions to Multicultural Counseling:
Behavioral counseling does not place emphasis on experiencing catharsis.  Rather, it stresses changing specific behaviors and developing problem-solving skills.  Clients who are looking for action plans and behavioral change are likely to cooperate with this approach because they can see that it offers them concrete methods for dealing with their problems of living.
Behavior therapy focuses on environmental conditions that contribute to a client’s problems.  Social and political influences can play a significant role in the lives of people of color through discriminatory practices and economic problems.  A strength of behavioral procedures is that they take into consideration the social and cultural dimensions of the client’s life.
Limitations and Criticisms of Behavior Therapy:
1,  Behavior therapy may change behaviors, but it does not change feelings.
2.  Behavior therapy ignores the important relational factors in therapy.
3.  Behavior therapy does not provide insight.
4.  Behavior therapy treats symptoms rather than causes.   – Behavioral therapists may acknowledge that deviant responses have historical origins, but they contend that history is seldom important in the maintenance of current problems.

Dr. Rebecca Curtis