What is behavior therapy?

Introduction

Behavior therapy is a major field of psychotherapy comprised of a wide array of therapeutic techniques (or specific behavior therapies) that directly change problem behaviors by altering the conditions that presently maintain them. At the core of behavior therapy are four defining themes.

First and foremost, behavior therapy is scientific in its commitment to precision and empirical validation. Behaviors to be changed, goals for therapy, and procedures used to assess and change the problem behaviors are defined precisely. The validity or effectiveness of assessment and therapy procedures is evaluated through controlled studies that can be independently replicated by other researchers.

Second, behavior therapy is action-oriented, in that clients engage in specific behaviors to alleviate their problems rather than just talk about them (as in traditional, verbal psychotherapies). Generally, there is a collaboration between the therapist and the client throughout therapy, and sometimes key people in a client’s life (such as a parent or a spouse) are recruited to assist in the treatment. With the guidance of the behavior therapist, clients may actively plan, implement, and evaluate their therapy in their home environments.

Third, the focus of therapy is in the present, rather than in the past. The reason is simple: Clients’ problems always occur in the present, and only present conditions can directly affect present behaviors. Although clients’ problems may have begun at some time in the past, past conditions no longer exist; if they still are in effect, they are present conditions.

Fourth, learning is a major element in behavior therapy. Clients’ problems frequently develop and are maintained by learning, and principles of learning, such as reinforcement, often are used in behavior therapy.

In addition to these defining themes, behavior therapies have four common characteristics. First, although standard treatment procedures are used, they always are individualized for each client’s unique problems and circumstances. Second, therapy often proceeds in an incremental, stepwise progression, such as beginning with easier or less threatening elements of a problem. Third, treatment plans are likely to consist of more than one therapy to increase their effectiveness and efficiency. Fourth, in general, behavior therapies result in therapeutic changes in relatively brief time frames, especially compared to many “long-term” psychotherapies.

The Behavioral Model

A simple but comprehensive theoretical model of human behavior underlies behavior therapy. It assumes that people are best understood in terms of their behaviors, both overt (actions others can directly observe) and covert (private behaviors, including thoughts and emotions). This perspective directly contrasts with the way in which people typically are viewed—namely, in terms of their personality traits. The behavioral model deals with specific behaviors, such as “working on a project until it is completed,” rather than an assumed trait of “conscientiousness.”

According to the behavioral model, the maintaining conditions, or causes of a client’s problem behaviors, are found in their present antecedents and consequences. Antecedents, which occur before a behavior is performed, set the stage for and cue a person to engage in the behavior. Consequences, which occur after a behavior is performed, determine the likelihood that the individual will perform the behavior again. The chances are greater that the person will engage in the behavior again if the consequences are positive or favorable than if they are negative or unfavorable.

For a male college student who frequently gets drunk, the antecedents might include being at places where alcohol is readily available, observing others drinking, and feeling anxious or socially inhibited. The consequences might be reduced anxiety, being able to converse easily with women, and feeling like “one of the guys.” To deal with this problem behavior, therapy would change one or more of the maintaining conditions, such as reducing the client’s anxiety (which changes a maintaining antecedent) and teaching him social interaction skills (which changes a maintaining consequence).

The Process of Behavior Therapy

Behavior therapy proceeds in a series of seven interrelated steps. First, the client’s presenting problems are clarified and, if there are multiple problems, prioritized. Second, the client and therapist establish the goals for therapy. Third, the problem is defined as a target behavior, a narrow, discrete aspect of the problem that can be unambiguously stated, can be measured, and is appropriate for the problem and the client. Behavior therapy generally involves treating just one or two target behaviors at a time; if several target behaviors are appropriate, each is dealt with successively rather than at the same time. Fourth, the current maintaining conditions of the target behavior are identified. Fifth, a treatment plan consisting of specific, individualized therapy procedures is specified to change the maintaining conditions of the target behavior, which, in turn, will change the target behavior and the client’s presenting problem. Sixth, the treatment plan is implemented. Seventh, after the treatment plan has had time to have an effect, its success is evaluated. The evaluation is based on a comparison of the client’s functioning before and after treatment. This is possible because measurement of the target behavior begins before treatment to provide a pretreatment baseline and continues throughout the treatment.

The success of behavior therapy is evaluated in terms of three criteria: The changes that occur in therapy must transfer to the client’s everyday life, make a meaningful impact on the client’s problem, and endure after the treatment ends.

Behavioral Assessment

Behavioral assessment procedures are an integral component of behavior therapy. They are used to gather information for identifying the maintaining conditions of target behaviors and measure the effectiveness of treatment. Like behavior therapy, behavioral assessment is individualized for each client; has a narrow focus (in contrast to broad, personality assessment); and focuses on assessing current (rather than past) conditions. Also like behavior therapy, there are many different behavioral assessment procedures, and more than one assessment procedure generally is employed. This practice results in a comprehensive assessment of the client’s problems. It also provides corroborative evidence from assessment procedures that tap different modes of behavior (overt actions, thoughts, emotions, and physiological responses) gathered through different methods. A brief description of eight methods of behavioral assessment follows.

Behavioral Interviews

Behavioral interviews are the most widely used assessment procedure because of their efficiency in gathering data. The behavior therapist asks “what,” “where,” “when,” and “how” questions rather than “why” questions. The former questions yield specific, known information, whereas questions that ask “why” typically involve speculation. Moreover, from a behavioral perspective, the important issue of why a problem behavior is occurring (that is, what is causing it) is answered by the types of questions asked in a behavioral interview because the causes of behaviors are found in the current maintaining conditions that are tapped by those questions. For example, “where” and “when” questions concern the antecedent conditions under which the behavior is performed.

Inventories

Direct self-report inventories are short questionnaires specifically related to the type of problem experienced by the client. They are efficient means of assessment, requiring little time for clients to complete and no therapist time. Hundreds of direct self-report inventories have been developed and standardized for particular problems, including depression, anxiety, sexual dysfunctions, eating disorders, and marital discord. Because they are standardized instruments, they provide information that may not be specific to a particular client. Accordingly, direct self-report inventories primarily are used for initial screening and to provide leads that can be followed by individualized assessment procedures.

Self-Recording

Self-recording (or self-monitoring) involves clients’ observing and keeping a record of their own overt and covert behaviors. A major advantage of self-recording is that the client is the observer and thus always is present. This is especially useful for recording behaviors that occur in private settings. Additionally, self-recording can assess a client’s thoughts and emotions directly.

Checklists and Rating Scales

Interviews, inventories, and self-recording are based on clients’ self-reports, which can result in a variety of unintentional and intentional errors and biases. Thus, there are behavioral assessment procedures that employ other people to assess clients’ behaviors. The simplest of these are behavioral checklists and rating scales. Similar in format to self-report inventories, these paper-and-pencil measures are completed by someone who knows the client well, such as a parent, a teacher, or a spouse. Checklists consist of a list of behaviors related to the client’s problem, and the observer merely indicates which of them the client engages in or are problematic for the client. With rating scales, the observer evaluates each behavior on a scale, such as rating how frequently or intensely the client performs a behavior. Standard behavioral checklists and rating scales have been developed for different problems, as with direct self-report inventories.

Naturalistic Observation

Systematic naturalistic observation may be the optimal method for gathering information about clients’ overt behaviors. One or more trained individuals observe and record predetermined behaviors as clients engage in the behaviors in their natural environments. For example, a child who has difficulty interacting appropriately with other children in play situations might be observed during recess to assess aspects of the child’s peer interactions. Valid naturalistic observation requires agreement among observers (interobserver reliability) and that the observers remain as unobtrusive as possible so that they do not interfere with the client’s behaving naturally.

Simulated Observation

Naturalistic observation may require a large investment in time for observers, especially when clients perform a target behavior infrequently and observers must wait a long time to observe the client engaging in it. A more efficient, though potentially less valid way to collect data about clients’ overt actions is through simulated observation. Observations are made in contrived conditions that closely resemble the natural setting in which the client engages in the target behavior. The observations themselves are made in the same way as with systematic naturalistic observation. For example, the assessment of attention-deficit hyperactivity disorder might involve simulated observation of various predefined categories of on- and off-task behaviors as a child engages in schoolwork in a room that looks like a classroom. The simulated conditions are expected to elicit the target behavior, which means that observations are likely to be completed more quickly than with naturalistic observation. However, the key to valid simulated observation is that clients perform in the simulated conditions similarly to the way in which they perform in their natural environments.

Role-Playing

Role-playing is a form of simulated observation that is most frequently employed to assess clients’ difficulties dealing with interpersonal situations. Clients are told to imagine that they are in a problematic situation and to act “as if” they were actually in it. The therapist plays the role of the other person(s) involved. For instance, a man who has difficulty expressing his concerns and needs to his supervisor would be asked to role-play talking to his supervisor about an important issue, with the therapist responding as the man’s supervisor might. The specific ways in which the man talks and interacts with his “supervisor,” including the content of what he says as well as his tone, body language, and presentation, can provide important data about the maintaining conditions of the man’s difficulties in dealing with his supervisor.

Physiological Measures

With some problems, such as anxiety, physiological reactions are key components and may even be target behaviors. Physiological measures range from the simple and inexpensive, such as clients’ taking their own pulse, to complex electroencephalography (EEG) recordings of brain activity that require elaborate and expensive equipment. Portable physiological recording devices that clients can use in their everyday lives are becoming increasingly available, affordable, and reliable.

Types of Behavior Therapy

Behavior therapies can be classified into four categories. One category, often referred to as behavior modification, primarily changes the consequences of behaviors. Reinforcement and punishment are employed to increase desirable behaviors and to decrease undesirable behaviors, respectively. For example, token economies employ token reinforcers (such as points or poker chips) that are earned for adaptive behaviors and can be exchanged for desirable goods and access to activities. Contingency contracts set up a written agreement detailing the target behaviors that the client is expected to perform and the consequences for performance and nonperformance. The responsibilities of the therapeutic agents (such as the therapist or parents) are spelled out, and all participants in the treatment plan sign the contract.

A second category of behavior therapies consists of exposure therapies for alleviating fear and anxiety-related disorders. In exposure therapies, clients confront previously threatening situations or engage in threatening behaviors without incurring negative consequences, which has the result of reducing or eliminating the fear or anxiety. The exposure can occur in a variety of ways. Joseph Wolpe, a South African psychiatrist, developed the first exposure therapy, systematic desensitization. Clients briefly and repeatedly imagine anxiety-evoking scenes while relaxed (which counteracts muscle tension associated with anxiety). The exposure begins with scenes that elicit little anxiety, and progressively more anxiety-evoking scenes are presented gradually. In contrast, in vivo flooding
involves exposure to the actual anxiety-evoking stimuli for a prolonged period without any response that competes with the anxiety.

A third category consists of modeling therapies, in which clients observe other people engaging in adaptive behaviors that they need to learn or perform. Modeling therapies are used to teach clients adaptive skills (such as assertive behaviors) and to reduce debilitating fears and anxiety.

The fourth category, which represents the most widely practiced type of behavior therapy, is cognitive behavioral therapy. A wide array of techniques is used to directly and indirectly change maladaptive cognitions (thoughts, beliefs, or expectations) associated with psychiatric disorders. Cognitive restructuring changes maladaptive cognitions directly, such as when a client who views life crises as threats comes to view crises as opportunities. Stress inoculation training provides clients with coping skills to handle stressors in their lives, which indirectly changes their perceptions of what is stressful.

Clients in behavior therapy are treated individually and in groups. The latter includes behavioral couples therapy and family therapy. Beyond the treatment of psychiatric disorders, behavior therapy principles and procedures have been harnessed for other practical ends. Prominent among these has been their widespread use in behavioral medicine, the interdisciplinary field devoted to the assessment, treatment, and prevention of physical disease. Behavioral procedures sometimes are employed to treat medical disorders less intrusively and less expensively than physical medical treatments, such as medication, and without negative side effects. Behavioral therapy is used to increase patients’ adherence to medical treatments, such as engaging in physical exercises and maintaining a prescribed diet; to help patients cope with debilitating medical tests and treatments, such as chemotherapy; and to prevent physical disease by increasing healthful behaviors, such as eating low-fat foods, and decreasing unhealthful behaviors, such as unprotected sexual activity. Other applications of behavior therapy principles and procedures beyond therapy have included classroom management, child rearing, coping with problems of aging, enhancing athletic performance, and solving community-related problems, such as safety and ecology.

Historical Roots of Behavior Therapy

The inspiration for behavior therapy came from behaviorism, the school of psychology that emphasized the influence of the environment on observable behaviors, and the experimental work on learning in the early nineteenth century by Russian physiologist Ivan Petrovich Pavlov and in the twentieth century by American psychologists Edward Thorndike and John B. Watson. The modern practice of behavior therapy began simultaneously in South Africa, Great Britain, and North America in the 1950s. It developed, in part, as a reaction and alternative to psychoanalysis, the predominant psychotherapy at the time.

In South Africa, Wolpe, arguably the founder of behavior therapy, was disenchanted with psychoanalysis, and he developed treatments based on Pavlovian conditioning, such as systematic desensitization. Similar reactions to psychoanalysis and experimentation with learning approaches to therapy occurred in Great Britain. In the United States, Ogden Lindsley and Nathan Azrin, students of Harvard operant-conditioning researcher B. F. Skinner, began to apply principles of operant conditioning to the treatment of severe psychiatric disorders, as did Teodoro Ayllon in Canada. These early applications were met by skepticism, criticism, and resistance from the established mental health community, which was still firmly ensconced in psychoanalysis.

In the 1960s, as empirical evidence supporting behavioral treatment methods mounted, behavior therapy began to be accepted. Also in this period, the idea of dealing with cognitions began to take root. Independently, psychiatrist Aaron T. Beck and psychologist Albert Ellis developed the first cognitive behavioral therapies—cognitive therapy and rational emotive therapy, respectively. The advent of cognitive behavioral therapies, which broadened the domain of the field, increased acceptance of behavior therapy in general. Professional journals devoted exclusively to behavior therapy, including Behaviour Research and Therapy, Journal of Applied Behavior Analysis, and Behavior Therapy, commenced publication. The Association for Advancement of Behavior Therapy, the major professional organization in the field, was established. Behavior therapy was on its way to becoming the prominent field of psychotherapy that it is today.

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