ORIGINS AND TRADITIONAL TECHNIQUES OF BEHAVIOR THERAPY

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Clinical Psychology (PSY401)

Lecture 33

ORIGINS AND TRADITIONAL TECHNIQUES OF BEHAVIOR THERAPY

Traditionally, the behavioral approach allies itself with

(1) A scientific emphasis and

(2) A deemphasis of the role of inferred variables.

The behaviorists are likely to trace their origins to the "science" of Skinner or Pavlov rather than the

"rnentalism" of Freud. The focus is on stimuli and responses rather than variables that are presumed to

mediate-them. However, behavior therapy over the years has broadened its scope to include techniques that

address cognitive and other mediation processes (Goldfried & Davison, 1994). Nevertheless, it is instructive

to review behavior therapy's historical roots.

A BRIEF HISTORY:

Beginning by presenting the groundbreaking work of Watson and Rayner (1920), who conducted the

widely cited laboratory study of Albert and the laboratory rat. This study was in effect, a demonstration of

how a "neurosis" can develop in a child. In the tradition of Pavlovian conditioning, Albert was given a

laboratory rat to play with. But each time the rat was introduced, loud noise was introduced simultaneously.

After a few such trials, the rat (previously a neutral stimulus) elicited a fearful response that also generalized

to similar furry objects.

Mary Cover Jones (1924) demonstrated how such learned fears can be removed. A 3-year-old boy,-Peter,

was afraid of rabbits, rats,-and other such objects. To eradicate the fear, Jones brought a caged rabbit closer

and closer as the boy was eating. The feared object thus became associated with food, and after a

few months Peter's fear of the rabbit disappeared entirely. It is important, however, to recall Jones's

admonition that the fear of the rabbit must not be so intense that the child will develop an aversion to food.

Watson's conditioning of fears and Jones's 'reconditioning" of them were erect antecedents of the

development of Wolpe's (1958) therapy by reciprocal inhibition, which arrived on the scene some 30 years

later.

As the foregoing experiences of Albert and Peter suggest, the major theoretical underpinnings of the

behavior therapy movement were Pavlovian conditioning and Hullian learning theory. In the 1950s. Joseph

Wolpe and Arnold Lazarus in South Africa and Hans Eysenck at Maudsley Hospital in London began to

apply the results of animal research to the acquisition and elimination of anxiety in humans. Wolpe began to

experiment with the reduction of fears in humans by having patients, while in a state of heightened

relaxation, imagine the situations in which their tears occurred. Wolpe's technique of systematic

desensitization, like Jones's reconditioning work, provided a practical demonstration of how principles of

learning could be applied in the clinical setting. In his work on conditioned reflex therapy, Salter (1949)

also attempted to develop a method of therapy that was derived from the Pavlovian tradition.

It is important to note that these investigators did not merely introduce new techniques. They also argued

vigorously that their techniques were derived from the framework of a systematic experimental science. In

addition, they took pains to point out that their demonstrations of the origins and treatment of neurotic fears

proved that it was unnecessary to subscribe to the "mentalistic demonology" of Freudianism or to the

"psychiatric pigeonholing" practiced by Kraepelinians

At about the same time that Wolpe, Lazarus, and Eysenck were developing their conditioning procedures,

the operant tradition was beginning to have an impact. Skinner and his colleagues (Lindsley & Skinner,

1954; Skinner, 1953) were demonstrating that the behavior of hospitalized psychotic patients could be

modified by operant procedures. By establishing controlled environments to ensure that certain responses of

the patient would be followed by specific consequences, significant behavioral changes were produced.

At first, there was a radical quality to behavior therapy .The inner world of the patient was largely ignored

in the rush to focus on behavior. Whether in reaction to the mentalism of psychoanalysis or out of an overly

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provincial view of what should be the subject matter of science, the early behavior therapists studiously

avoided anything of a cognitive nature.

However, in 1954, Julian Rotter published his book Social Learning and Clinical Psychology. In it he

demonstrated convincingly that a motivation reinforcement approach to psychology could be coupled with

a cognitive-expectancy approach. Thus, behavior was regarded as being determined both by the value of

reinforcements and by the expectancy that such reinforcements would occur following the behavior in

question. What is more, Rotter's novel views were supported by a series of laboratory studies that left no

doubt that one could be clinical, oriented toward both learning theory and cognitive theory, and

scientifically respectable, all at the same time.

Also significant in this context was the application of Albert Bandura's (1969) social learning contributions

to e modification of a behavior. It was theorists such as Rotter and Bandura who led the way to the current

cognitive emphasis, giving behavior therapy a wider ranging and serviceable character.

It is important to point out that the "mentalism" of psychoanalysis or other psychodynamic approaches is

not the same as the "cognitive processes" concepts that are used today. Freud's references to thinking

processes were never defined operationally. They were vague notions incapable of objective measurement,

poorly anchored either to antecedent conditions or consequent outcomes. More often than not, Freud

viewed thinking processes as irrational, distorting processes rather than problem-solving processes.

For Freud, mentalism seemed to function largely in the service of the reified ego, id, and superego----little

people who ran about the mind distorting, projecting, condemning, or figuring out ways of fooling one

another. In contrast, current notions of cognition emphasize such concepts as expectancies, cognitive

schemas, or memory processes. These are concepts that can be measured and quantified. They can be objec-

tively defined in ways that lead to reliable understanding among separate- investigators.

TRADITIONAL TECHNIQUES OF BEHAVIORAL THERAPY:

Behavior therapists use a variety of specific techniques-not only for different patients but for the same

patient at different points in the overall treatment process. Lazarus (1971a) refers to this as a broad

spectrum behavior therapy. Each technique can serve a specific purpose but that, in reality, they are

complementary.

For example, a woman who has trouble coping with a domineering husband may undergo assertiveness

training to team specific behaviors. But when she uses these behaviors, other sets of fears about their

relationship may begin to worry her. Therefore, she may also require therapeutic sessions that will help her

restructure her beliefs about the marriage that are illogical and tend to perpetuate her submissive behavior.

She might also participate in modeling or observational learning to help her cope.

A comprehensive behavioral assessment is conducted before behavioral treatments or techniques are

selected and implemented-.-For example, a functional analysis of the presenting problem helps to identify

(1) The stimulus or antecedent conditions that bring on the problematic behavior;

(2) The Organismic variables (such as cognitive biases) that are related to the problematic behavior;

(3) The exact description of the problem; and

(4) The consequences of the problematic behavior.

By completing such a detailed analysis, behavior and cognitive-behavioral therapists can prescribe ap-

propriate treatments.

Now we will go through some behavioral techniques.

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Clinical Psychology (PSY401)

SYSTEMATIC DESENSITIZATION:

This technique is typically applied when a patient has the capacity to respond adequately to a particular

situation (or class of situations), yet reacts with anxiety, fear, or avoidance. Basically, systematic

desensitization is a technique to reduce anxiety. Developed by Salter (1949) and Wolpe (1958), it is based

on reciprocal inhibition the apparently simple principle that one cannot be relaxed and anxious

simultaneously. The idea is to teach Patients to relax and then, while they are in a relaxed state, to' introduce

a gradually increasing series of anxiety-producing stimuli. Eventually, the patient becomes desensitized to

the feared stimuli by virtue of having experienced them in a relaxed state. Systematic desensitization has

been shown to be efficacious for animal phobias, public speaking anxiety, and social anxiety (Chambless et

al., 1998).

TECHNIQUES AND PROCEDURES:

Systematic desensitization begins with the collection of a history of the patient's problem. This includes

information both about specific precipitating conditions and about developmental factors. Collecting a his-

tory may require several interviews, and it often includes the administration of questionnaires. The principal

reason for all of this is to pinpoint the locus of the patient's anxiety. It is also part of assessment to determine

whether systematic desensitization is the proper treatment. In a patient with adequate coping potential who

nevertheless reacts to certain situations with severe anxiety, desensitization is often appropriate.

On the other hand, if a patient lacks certain skills and then becomes anxious in situations that require those

skills, desensitization could be inappropriate and counterproductive, For example, if a man becomes

seriously anxious in social situations that involve dancing, it would seem more efficient to see that he learns

to dance rather than desensitize him to what is, in fact, a behavioral deficit.

Next, the problem is explained to the patient. This explanation is normally elaborated to include examples

from the patient's life and to cover the manner in which the patient acquired and maintains the anxieties.

Following this, the rationale for systematic desensitization is also explained. The explanations and the

illustrations should be in language that the patient can understand-free from scientific jargon. In a sense, the

clinician uses this phase to "sell" the patient on the efficacy of systematic desensitization. It should be added

that the entire process of interviewing, assessment, and explanation is conducted with warmth, acceptance,

and understanding.

The next two phases involve training in relaxation and the establishment of an anxiety hierarchy. While

work is begun on the anxiety hierarchy, training in relaxation is also started.

Relaxation:

Behavior therapists frequently use the progressive relaxation methods of Jacobson (1938). Te patient is first

taught to tense and relax particular muscle groups and then to distinguish between sensations of relaxation

and tensing. The instructions for relaxation can easily be taped and played at home for practice. Generally,

about six sessions are devoted to relaxation training. In some instances, hypnosis may be used to induce

relaxation. In other instances, the patient may be asked to imagine relaxing scene still other instances,

breathing exercises are used to enhance relaxation.

The Anxiety Hierarchy:

In discussions about specific problems, the situations in which they occur, and their development, the

patient and the therapist work together to construct a hierarchy. The recurrent themes in the patient's diffi-

culties and anxieties are isolated and then ordered in terms of their power to induce anxiety (from situations

that provoke very low levels of anxiety through situations that precipitate extreme anxiety reactions). A

typical anxiety hierarchy consists of 20 to 25 items in approximately equal intervals from low through

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Clinical Psychology (PSY401)

moderate to extreme. The following anxiety hierarchy was that of a 24-year old female student who

experienced severe examination anxiety (Wolpe, 1973):

1. Four days before an examination.

2. Three days before an examination.

3. Two days before an examination.

4. One day before an examination.

5. The night before an examination.

6. The examination paper lies face down before her.

7. Awaiting the distribution of examination papers.

8. before the unopened doors of the examination room.

9. In the process of answering an examination paper.

10. on the way to the university on the day of the examination.

This hierarchy illustrates two points: First, it is organized largely along spatial-temporal lines. Second, the

items are not exactly organized in a logical fashion.

One might expect item 10 (the most anxiety-provoking item) to be placed near the middle of the hierarchy.

This suggests how idiosyncratic hierarchies can be-after all, it is the patient's anxiety, not the clinician's!

In the desensitization procedure, the patient is asked to imagine the weakest item in the hierarchy (the item

that provokes the least anxiety) while being completely relaxed. The therapist describes the scene, and the

patient imagines (for about 10 seconds) being in the scene. Therapist moves the patient up the hierarchy

gradually (between two and five items per session). However, if at any time the level of anxiety begins to

increase, the patient is instructed to signal, where upon the therapist requests that the patient stop visualizing

that scene. The therapist then helps the patient to relax once more. After a few minutes, the procedure can

be started again. Ideally, over a period of several sessions, the patient will be able to imagine the highest

item in the hierarchy without discomfort.

Rationale:

Although Wolpe's explanation for the success of systematic desensitization is based on the principle of

counter conditioning (the substitution of relaxation for anxiety), others are not so sure (Davison & Wilson,

1973). Some have argued that the operative process is really extinction. That is, when the patient repeatedly

visualizes anxiety-generating situations but without ensuing bad experiences, the anxiety responses are

eventually extinguished (Wilson & Davison, 1971). Alternatively, Mathews (1971) argues on behalf of a

habituation hypothesis. Emmelkamp (1982) has reviewed the empirical support for these and other

theoretical explanations.

The standard method of desensitization is to present scenes in a graduated ascending fashion in order to

avoid premature arousal of anxiety that would disrupt the procedure. However, some clinician have found

that presenting the hierarchy in the reverse order (most anxiety-provoking items first) is also effective in

reducing various phobias. Richardson and Suinn (1973) also report positive results when participants are

exposed only to the three highest hierarchy scenes.

Systematic desensitization involves a number of components. The instructions suggest that a positive

outcome is likely. Consequently, the Patient's expectations for improvement may affect the process.

Another crucial element may be positive reinforcement from the therapist follow, in, the patient's reports of

lessened anxiety, improvement outside the consulting room, or the successful completion of anxiety

hierarchies.

For example, Leitenberg, Agras, Barlow, and Oliveau (1969) observed that, with snake phobias, the effects

of systematic desensitization are best when the therapist uses reinforcing comments, such as "Good,"

"Excellent," and "You're doing fine," when participants (1) visualize a scene without reporting anxiety, (2)

complete a hierarchy item, and (3) report progress in approaching a snake during practice. Goldfried (1971)

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Clinical Psychology (PSY401)

argues that systematic desensitization is far from a passive process that is applied to patients to reduce their

fears. Rather, it represents the acquisition of a skill that the patients can use to reduce their own fear.

In that sense, Goldfried regards systematic desensitization as training in self control. From a cognitive

viewpoint, Valins and Ray (1967) explain the effectiveness of systematic desensitization in terms of

patients' belief that they are relaxed. Others, such as Sullivan and Denney (1977), emphasize the importance

of getting the patient to expect improvement.

All of the foregoing suggests that systematic desensitization is hardly the simple mechanical or conditioning

process that it was once thought to be. A number of relationship variables seem implicated, as well as

beliefs or expectations--on the part of the patient. In general, systematic desensitization has proven to be a

moderately effective form of psychological intervention for a variety of clinical conditions. As might be ex-

pected, research suggests that it is most effective when used to treat anxiety disorders particularly specific

phobias. Social anxiety, public speaking anxiety, and generalized anxiety disorder.

Exposure Therapy:

The term exposure therapy is used to describe a behavior therapy technique that is a refinement of a set of

procedures originally known as flooding or implosion. The roots of exposure therapy can be traced to

Masserman (1943), who studied anxiety reactions and avoidance behaviors in cats. Masserman's studies in-

volved inducing "neurotic behaviors" in cats by administering shock under certain environmental

conditions. He subsequently discovered that the avoidance behavior could be extinguished if the cats were

forced to remain in the situation in which they had previously been shocked (that is, no escape or avoidance

was possible). These 'findings were the basis for developing anxiety treatments for humans There is

empirical support for the efficacy of exposure treatments for specific phobias, panic disorder, agoraphobia,,

social phobia, post traumatic stress disorder, and obsessive-compulsive disorder.

In exposure therapy, patients expose themselves to those stimuli or situations that were previously feared

and avoided. The "exposure" can be in real life (in vivo) or in fantasy (in-imagino). In the latter version,

patients are asked to imagine themselves in the presence of the feared stimulus (such as a spider) or in the

anxiety-provoking situation (such as speaking in front of an audience). Several researchers suggest that

certain features must be present in exposure treatments in order for the patient to achieve maximum benefit

(Barlow & Cerny, 1988):

1. Exposure should be of long rather than short duration.

2. Exposure should be repeated until all fear/anxiety is eliminated.

3. Exposure should be graduated, starting with low-anxiety stimuli/situations and progressing to high-

anxiety stimuli/situations.

4. Patients must attend to the feared stimulus and interact with it as much as possible.

5. Exposure must provoke anxiety.

Like the other behavioral therapies exposure treatment can be used as a self-contained treatment or as one

component of a multimodal treatment.

What is especially ingenious about their version of exposure treatment is that they have patients expose

themselves to interoceptive cues---internal physiological stimuli such as rapid breathing and dizziness. This

modification was necessary because individuals suffering from panic disorder typically report that their

panic attacks are unpredictable and "come out of the blue." In such cases, no external anxiety provoking

stimulus or situation is apparent. In contrast, individuals with other, non-panic anxiety disorders report acute

anxiety primarily in the face of certain external stimuli or situations.

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Clinical Psychology (PSY401)

Researchers recently compared the effectiveness of two forms of treatment for panic disorder with

agoraphobia: one that included interoceptive exposure and one that incorporated breathing retraining

instead of interoceptive exposure. Although both forms of treatment were effective, results indicated that

panic disorder patients who received the interoceptive exposure component reported less impairment and

fewer panic attacks at post treatment and at follow-up. Thus, the addition of the interoceptive exposure

component had beneficial effects.

Behavior Rehearsal:

Included under this broad heading are a variety of techniques whose aim is to enlarge the patient's repertoire

of coping behaviors. Clearly, behavior rehearsal is not a new concept, it has been around in one form or

another for many years. For example, Moreno (1947 developed psychodrama, a form of role playing, to

help solve patients' problems, and Kelly (1955) used fixed-role therapy.

However, it is important to note that such forms of role playing or behavior rehearsal have purposes that

depart from behavioral goals. For Moreno, role playing provided a therapeutic release of emotions that was

also diagnostic-in identifying the causes of the patient's problems. For Kelly, role playing was a method of

altering the patient's cognitive structure. Again, we are reminded that specific therapeutic techniques are not

the exclusive province of one theoretical frame of reference. Different theorists may use similar techniques

for vastly different reasons.

The Technique:

According to Goldfried and Davison (1994), the use of behavior rehearsal involves four stages.

The first stage is to prepare the patient by explaining the necessity for acquiring new behaviors, getting the

patient to accept for rehearsal as a useful device, and reducing any initial anxiety over the prospect of role

playing.

The second stage involves the selection of target situations. At this point many therapists draw up a

hierarchy of role playing or rehearsal situations. This hierarchy should relate directly to those situations in

which the patient has been having difficulty. A sample hierarchy of target situations (ranked in order of the

increasingly complex behavioral skills required) might be as follows:

1. You ask a secretary for information about a class.

2. You ask a student in class about last week's assignment.

3. After class, you approach the instructor with a question about the lecture.

4. You go to the instructor's office and engage her in conversation about a certain point.

5. You purposely engage another student, who you know disagrees with you, in a minor debate about some

issue.

The third stage is the actual behavior rehearsal. Moving up the hierarchy, the patient plays the appropriate

roles, with the therapist providing both coaching and feedback regarding the adequacy of the patient's

performance. Sometimes videotaped replays are used as, an aid. In other instances the "therapist (or a

therapeutic aide) exchanges roles with the patient in order to provide an appropriate model. When patients

develop proficiency in one target situation, they move up the hierarchy.

The final stage is the patient's actual utilization of newly acquired skills in real-life situations. After such in

vivo experiences, the patient and the therapist discuss the patient's performance and feelings about the

experiences. Sometimes patients are asked to keep the records describing the situations they were in, their

behavior, and its consequences.

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Clinical Psychology (PSY401)

Assertiveness Training:

One application of behavioral rehearsal is assertiveness training. Wolpe regarded assertive responses as an

example of how reciprocal inhibition works. That is, it is impossible to behave assertively and to be passive

simultaneously. Situations that once evoked anxiety will no _longer do so because the assertive behavior

inhibits the anxiety

Originally, assertiveness training was designed as a treatment for persons whose anxiety seemed to stem

from their timid mode of coping with situations (Wolpe, 1958; Wolpe & Lazarus, 1966). A variety of

assertiveness training programs have been developed specifically for individuals seeking to overcome

destructive passivity. But assertiveness training has also been used in treating sexual problems, depression,

and marital conflicts. It is important to note that cognitive self-statements (for example, "I was thinking that

I am perfectly free to say no") may enhance the effects of assertiveness training. Infact many procedures

can be used to increase assertiveness. Behavior rehearsal is perhaps the most obvious one.

Lack of assertiveness may stem from a variety of sources. In some cases, the cause may be a simple lack of

information, in which case the treatment might center largely on information giving. In other instances, a

kind of anticipatory anxiety may prevent persons from behaving assertively. In such cases, the treatment

may involve desensitization. Yet other individuals may have unrealistic (negative) expectations about what

will ensue if they become assertive. Some clinicians would deal with such expectations through

interpretation or rational-emotive techniques.

Similar techniques might be applied to patients who feel that assertiveness is wrong. Finally, there are

patients whose lack of assertiveness involves a behavioral deficit they do not know how to behave

assertively, for such patients, behavior rehearsal, modeling, and related procedures would be used.

Assertiveness training is not the same as trying to teach people to be aggressive. It is really a method of

training people to express how they feel without trampling on the rights of other in the process (Wolpe &

Lazarus, 1966). Take the spectator at a basketball game that cannot see because the person in front

constantly jumps up. To react by saying "If you don't sit down, I'm going to knock you down" is aggressive.

But saying "Please, I wish you would sit down; I just can't see anything" is an assertive response. Indeed,

assertiveness training has been useful in teaching overly aggressive persons gentler and more effective ways

of meeting their needs.

Contingency Management:

A variety of Skinnerian or operant techniques are all referred to as contingency management procedures.

They share the common goal of controlling behavior by manipulating its consequences.

Techniques:

Contingency management can take many forms, of which the following are just a few examples.

1. Shaping: A desired-behavior is developed by first rewarding any behavior that approximates it.

Gradually, through selective reinforcement of behavior more and more closely resembling the desired

behavior, the final behavior is shaped. This technique is sometimes called successive approximation.

2. Time Out: Undesirable behavior is extinguished by removing the person temporarily from a situation in

which that behavior is reinforced. A child who disrupts the class is removed so that the disruptive behavior

cannot be reinforced by the attention of others.

3. Contingency Contracting: A formal agreement or contract is-struck between therapist and patient,

specifying the consequences of certain behaviors on the part of both.

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Clinical Psychology (PSY401)

4. "Grandma's Rule'':

The basic idea is akin to Grandma's exhortation, "First you work, then you play!" It means that desired

activity is reinforced by allowing the individual the privilege of engaging in a more attractive behavior. For

example, the child is allowed to play bail after the music lesson is completed. This method is sometimes

referred to as the Premack principle (Premark, 1959).

Token Economies:

The operant approach is most commonly used in environments in which a therapist or other institutional

staff can exert significant control over the- reinforcement contingencies relative to patient behavior. The

principles of operant conditioning are especially apparent in token economy programs that are designed to

modify the behavior of institutionalized populations; such as those with mental retardation-or chronic

mental illness (Kazdin, 1977; Liberman, 1972). Such programs can make an institution a more livable place

that ultimately is more conducive to therapeutic gains. Many of the social skills that are "shaped" will also

facilitate a smoother transition to a non institutional setting.

In establishing a token economy, there are three major considerations (Krasner, 1971).

First, there must be a clear and careful specification of the desirable behaviors that will be reinforced.

Second, a clearly defined reinforcer for medium of exchange-for example, colored poker chips, cards, or

coins) must be decided upon.

Third, backup reinforcers are established. These may be special privileges or other things desired by the

patient. Thus, two tokens, each worth 10 points, might be exchanged for permission to watch TV n extra

hour, or one token worth 5 points might be exchanged for a small piece of candy. It goes without saying

that a token economy also requires a fairly elaborate system of record keeping and a staff that is very

observant and committed to the importance of the program.

Token economies are used to promote desired behavior through the control of reinforcements. Whether the

desired behavior is increased neatness, greater social participation, or improved job performance, the

probability of its occurrence can be enhanced by the award of tokens of varying value. But why use tokens

at all? Why not reinforce proper bed making directly? The reason is essentially that the effect of rein-

forcement is greater if the reinforcement occurs immediately after the behavior occurs. If the reward of

attending a movie occurs ten hours after a patient sweeps out his or her room, it is not likely to be nearly so

effective as a token given immediately. That token will come to signify reward and will assume much of the

effectiveness of the backup reward for which it may be exchanged.

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