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SEMINAR
Behaviour therapy
Subhashish Nath
Introduction
The term “behaviour” in behaviour therapy refers to a person’s observable actions and responses. The principles and techniques of behaviour therapy are anchored in learning theories. A behavioural approach involves thinking about clinical symptoms as learned behaviours and developing treatment programs that help patients to learn new ways of behaving (and sometimes thinking) to reduce symptoms and improve quality of life.
A key component of a behavioural approach involves identifying outcome measures that can be assessed over time to evaluate treatment efficacy and extent of change. Behavioural therapy has not only influenced mental health care but under the rubric of behavioural medicine, it has also made inroads into other medical specialties. Today different behavioural schools continue to share a focus on verifiable behaviour.
History of behaviour therapy
Behavioural treatments for psychiatric symptoms have existed since at least the first century, when Pliny the Elder used a type of aversion therapy to modify drinking behaviour. In early nineteenth century, Alexander Maconochie set up a Token Economy in which prisoners were awarded points for positive behaviours in a penal colony at Norfolk Island, Australia. The formal application of learning principles and the movement towards a behavioural approach to the treatment of abnormal behaviour emerged in the 1920’s following the publication of the classic case of “Little Albert” in 1920.
In mid 1950’s, principles of operant conditioning studied by B.F. Skinner and his colleagues were beginning to be applied to the treatment of psychiatric disorders. In 1960’s, behaviour therapy emerged as a systematic and comprehensive approach to psychiatric disorders. Joseph Wolpe developed systematic desensitisation. A classic article was published by Hans Jurgen Eysenck challenging the effectiveness of traditional psychotherapy based on psychoanalytic model. First scientific journal focused on behavioural procedures and treatments, “Behaviour Research and Therapy (BRAT)” and first national professional association, “Association for the Advancement of Behaviour Therapy” came into existence.
In 1970’s, behaviour therapy had another surge in growth with the addition of attention to cognition and the development of cognitive behaviour therapy (CBT). By this time behaviour therapy had become a major force in psychology and was beginning to have an impact also in the fields of psychiatry and social work.
Principles of behaviour therapy
1. Maladaptive behaviours are acquired through learning according to the same principles that govern the learning of adaptive behaviours.
2. It is not necessary to identify an underlying cause or motive for maladaptive behaviours.
3. Learning principles can be used to modify maladaptive behaviours.
4. The focus of treatment is on factors that maintain current behaviour rather than on historical issues.
5. Therapists should be knowledgeable about scientific literature relevant to the patients they treat.
6. It is important to set specific, measurable treatment goals and measure outcomes.
Basic steps of behaviour therapy
Behaviour therapy encompasses a range of assessment and treatment procedures.
Assessment and conceptualisation: A thorough assessment and case conceptualisation are required before a behavioural treatment plan can be developed. The primary goals of an initial behavioural assessment are to identify and define target behaviours and the variables that maintain them and to develop a functional analysis.
Methods of behavioural assessment:
A. Behavioural observation — Naturalistic behavioural observation and analogue behavioural observation.
Tools used are Child Behaviour Checklist Direct Observation Form, Revised Edition of the School Observation Coding System, Marital Interaction Coding System.
B. Behavioural rating scales — Completed by individuals who are either familiar with a client’s behaviour or have the opportunity to directly observe a client’s behaviour.
Tools used are Child Behaviour Checklist, Motivation Assessment Scale.
C. Self monitoring – Systematic self-observation and recording of parameters of targeted behaviours, environmental events, cognition and/or mood states. Self monitoring forms are usually individually tailored to an individual’s target behaviour problems.
D. Psychophysiological assessment— Measurement of physiological and motoric components of behaviour problems using a variety of measurement devices, especially electroencephalogram (EEG), electromyographic (EMG), cardiovascular, and electrodermal measures.
E. Self report
Behavioural interview — A structured or semistructured interview that assesses dimension’s of a client’s behaviour, behaviour–environment interactions, behavioural contexts and the functional relation of the behaviour with other controlling variables.
Behavioural questionnaire — A measurement instrument completed by the client, or individuals that know the client well. Assesses – (a) Behavioural dimensions and (b) Functional relations of behaviours with cognitions, emotional states, and other controlling variables.
Case conceptualisation: Functional analysis of target problems and investigation of the patient’s history provide the base for development of a case conceptualisation or working hypothesis. Case conceptualisation ties together information from the assessment and provides a road map for developing an integrated intervention based on behavioural principles. To develop a case conceptualisation, the therapist hypothesises about core difficulties that tie together the full set of problems presented by the patient and perceived by the therapist.
Goals of behaviour therapy
Identifying behaviours to be changed and working towards changing them. The action, on the part of the patient, toward change is the primary goal of treatment.
Treatment techniques
1. Relaxation
Relaxation technique was introduced by Edmund Jacobson’s book “Progressive Relaxation” in 1938. It serves two functions – first, relaxation exercises increase parasympathetic nervous system activity. Second, the tension-reduction cycle teaches patients to discriminate feelings of tension within their bodies. The therapeutic effects become evident only after 4-5 sessions.
It is used as a competing stimulus during systematic desensitization, as a primary intervention for stress and some medical disorders, as a part of a comprehensive intervention strategy for the reduction of anxiety.
Negative side effects are muscle soreness or strain, depersonalization, relaxation induced panic attacks.
Relaxation approaches: Progressive deep muscle relaxation, autogenic training, meditation, biofeedback assisted relaxation, mindfulness practice, applied relaxation, applied tension.
Progressive deep muscle relaxation (PDMR)
It is the most popular relaxation approach. Patients are taught to tense and relax various muscles in their bodies. The act of tensing before relaxing serves to help patients identify tension and facilitate relaxation. There is also a focus on diaphragmatic breathing, which actually can be used as a standalone relaxation training procedure. Sessions typically last 20-30 minutes and patients are often given a tape at the end of the session to continue the practice at home.
Autogenic training
It is a method of self suggestion that originated in Germany. It involves the patients directing their attention to specific bodily areas and having they think certain phrases reflecting a relaxed state. Uses repeated suggestions of warmth and heaviness, with suggestions first spoken by the therapist and then repeated by the patient. Autogenic relaxation is the American modification of autogenic training. Particularly used for the treatment of migraine headache.
Meditation
It is primarily a cognitive procedure. Uses words on which people focus their attention. It produces physiological changes, including decreased metabolic rate, increased skin resistance and decreased heart rate.
Biofeedback assisted relaxation
Biofeedback involves the recording and display of small changes in the physiological levels of the feedback parameter. The display may be visual or auditory and patients are instructed to change the levels of the parameter, using the feedback from the display as a guide. The most common biofeedback modalities used – Frontalis EMG feedback or feedback to increase finger temperature.
Mindfulness practice
The purpose of this approach is to ensure generalisation of the effects generated during a relaxation session to the patient’s everyday life. Practitioners of mindfulness meditation cultivate nonjudging, patience, beginner’s mind, self trust, nonstriving, acceptance (of what is already a fact) and letting go.
Applied relaxation
Used for generalisation of the effects of relaxation session to the patient’s everyday life. It involves eliciting a relaxation response in the stressful situation itself. Establishing the relaxation response in the patient’s natural environment consists of seven phases of one to two sessions each – progressive relaxation, release only relaxation, cue-controlled relaxation, differential relaxation, rapid relaxation, application training and maintenance.
Applied tension
A technique opposite to relaxation used for patients with blood and injury phobia. The treatment extends over four sessions.
2. Exposure therapies
They are sometimes known as programmed practice. One of the most investigated and frequently used therapies in the treatment of phobias, including agoraphobia based on the premise that fears are acquired through associative learning (classical or operative conditioning). Interventions to eliminate fear use the conditioning principles, and the elimination of maladaptive fears requires exposure with the feared object, event or situation. Two basic theoretical and applied models of exposure treatment – counterconditioning model pairs a feared object with an incompatible response and extinction model is based on habituation of the feared response.
Counterconditioning: The basic concept is substitution of one response for another. The theoretical and scientific basis for counterconditioning is contiguity theory. In theory, any positive stimulus that inhibits the expression of a reaction by another stimulus constitutes counterconditioning. The most prominent method of counterconditioning in the clinical arena is systematic desensitisation.
Systematic desensitisation: The roots of systematic desensitisation can be found in Joseph Wolpe’s book “Psychotherapy by Reciprocal Inhibition”.
Reciprocal inhibition – Permanent weakening of the ability of a stimulus to evoke anxiety if a response antagonistic to anxiety occurs in the presence of anxiety evoking stimuli so that it is accompanied by a complete or partial suppression of the anxiety response. Systematic desensitisation consists of two components, relaxation therapy (usually PDMR) and the presentation of fear producing stimuli arranged within a hierarchy. The hierarchy consists of a series of situations (real or imagined) that represent successive approximations to the feared object, situation or event.
The hierarchy is created and PDMR is taught. A state of relaxation is then paired with the presentation of the feared object, event or situation in a gradual fashion and using imagery. Systematic desensitisation is preferable when anxiety and fear are extreme, when there is a complicated fear structure, when the fear stimuli cannot easily be reproduced.
In vivo desensitisation is based on the same principle as systematic desensitisation. The stimuli are presented entirely in “real life”. PDMR is not typically used in conjunction with the presentation of the stimulus because complete muscle relaxation is not possible when the patient is using muscles in real life situations. It is preferable when there is a need to obtain quicker results and when the stimulus is readily available.
Extinction model: The exposing process involves exposing the patient to the fear stimuli (conditioned stimulus) in an unreinforced fashion. Over repeated trials, the conditioned stimulus ceases to be a feared stimulus.
Flooding is an exposure procedure that harnesses the extinction process and reduces anxiety. The objective of flooding is to expose the patient immediately to the fear producing stimulus at its full strength. No physiological alternative state incompatible with anxiety is used. For exposure to produce extinction, avoidance behaviours that typically reduce fear need to be prevented.
Interoceptive exposure: Patients are exposed to internal sensations that characterise panic attacks. Interoceptive stimuli are created by maneuvers such as deliberately hyperventilating, spinning in an office chair, or performing jumping attacks. The therapist discourages subtle avoidance behaviours detected during these exercises. Interoceptive exposure is part of many treatment programmes for panic disorder.
Implosion: A type of exposure therapy which uses horrific, frightening and psychodynamic cues to maximise anxiety arousal which in turn was presumed to enhance rapid extinction.
Eye movement desensitisation and reprocessing: The exposure component involves attending to a recalled traumatic event. During exposure, therapists move their fingers back and forth in front of the patients. The patients keep their eyes open and follow the therapist’s fingers with their eyes. During the desensitisation part of the treatment, patients concentrate on the images, emotions, body sensations and negative thoughts associated with a traumatic event. At the same time they perform the rapid eye tracking movements.
3. Operant strategies for the acquisition of new behaviours
Interventions based on operant strategies are powerful methods by which to acquire new behaviours. In this learning model behaviour is not elicited or evoked but occurs independently, and environmental responses influence whether the behaviour is continued or stopped. Changes in behaviour occur as a result of consequences that reinforce or punish emitted responses.
Positive reinforcement increases the frequency of a particular response by giving something favourable immediately after the response.
Negative reinforcement increases the frequency of a particular response by removing an aversive event immediately after the response.
Punishment decreases the frequency of a response by either presenting an aversive event following a response or the removal of a positive event following a response.
Behavioural interventions for acquisition of new behaviours consist of shaping and chaining.
Shaping is a process of reinforcing successive approximations that come increasingly close to a desired behavioural goal. Shaping uses a process of slow, small steps to reach the final goal. At each stage the patient is reinforced for behaviour that more closely resembles the final behaviour.
Chaining: One response produces the conditions for the next response, and so on, and at the end of the chain, the individual is reinforced. There may be forward chaining and backward chaining. Backward chaining is more effective when teaching complex behaviours.
4. Contingency management
It is defined as general application of operant principles in the process of behaviour change. It adheres to the same rules of reinforcement and punishment. Clarify behavioural expectations, and teach people how to bargain and compromise rather than resort to coercive procedures and how to define and clarify what they want and expect.
Token economy: Token economy programmes are a formalised method of contingency management. Often used in child inpatient settings, day treatment programmes and classrooms. Clearly spell out a series of behaviours that are expected and the contingencies for compliance/ noncompliance with these behavioural goals. The achievement of behavioural goals leads to the acquisition of tangible rewards or privileges.
Response cost – Removal or withdrawal of reward/reinforcer following inappropriate or problem behaviour.
Child management training: Most empirically established form of contingency management. It teaches basic disciplinary skills to parents. Most commonly used approaches are positive reinforcement training, how to attend to desirable behaviour and how to ignore undesirable behavior, how to give commands, how to use time outs, how to use response costs.
5. Aversion based approaches
Punishment procedures: Punishment decreases the frequency of a response by either presenting an aversive event following a response or the removal of a positive event following a response. Time out, response cost, application of a noxious stimuli or event are various punishment procedures that the decrease the probability of target behaviours. To be effective, punishment needs to be of high intensity, immediate and continuous. There is a direct relation between the strength of the punishing stimulus and the recovery of a previously suppressed behaviour. The weaker the punishing stimulus, the more likely it is that the negative behaviour will recur.
Token economy: Punishment by the removal of positive reinforcement. The therapist must consider the duration of the timeout interval, the location where the timeout occurs and what behaviour the child is required to exhibit before timeout can be concluded.
Aversion therapy: An aversive procedure based on classical conditioning. An aversive physical or emotional state is paired with cues that elicit undesirable behaviour. Aversive conditioning stimuli are chemical aversion, electrical aversion and verbal aversion. Uses are sexual deviations and substance abuse.
6. Skills training
Social skills training: Designed to teach a wide variety of social skills that can be fitted to the particular needs of individuals. It is divided into two components – social environment awareness and interpersonal skill enhancement.
Problem solving skills training: Teaches patients the skills necessary to discover effective solutions.
Goal – Teach patients to solve problems in a productive, positive fashion.
7. Self control approaches
They are defined by the use of stimuli, behaviours, and consequences with oneself to achieve a desired outcome. It is usually administered by patient to oneself. Generally involve three processes – self monitoring, self evaluation, self reinforcement.
8. Habit reversal training
It is designed to reduce repetitive behaviours: awareness training, habit control motivation, competing response training, relaxation training, reinforcement.
Behaviour therapy in various psychiatric and medical conditions
Anxiety disorders
1. Agoraphobia: Exposure therapy (category 1)
2. Blood and injury phobia: Applied tension (category 2).
3. Specific phobia: Exposure (category 1).
4. Social phobia: Cognitive behavioural therapy (CBT) (category 1), systematic desensitisation (category 2).
5. Avoidant personality disorders: Social skills training (category 1).
6. Obsessive-compulsive disorder (OCD): Exposure and response prevention.
7. Posttraumatic stress disorder (PTSD): Exposure therapy, CBT (category 1).
8. Panic disorder: Interoceptive exposure therapy (category 2).
Mood disorders
1. Major depression: Problem solving, self-control therapy.
Schizophrenia: Social skills training, token economy (Category 1).
Addictive disorders: Aversion therapy, Cue exposure therapy.
Childhood disorders
1. Conduct disorder: Parent training, CBT.
2. Attention-deficit/hyperactivity disorder (ADHD): Token economy, time out.
3. Autistic disorder: Reinforcement approaches.
Medical disorders
1. Hypertension: Meditation, EMG biofeedback.
2. Raynaud’s syndrome: Skin temperature biofeedback, various other relaxation procedures.
3. Headache: Relaxation training.
Bibliography
1. Comprehensive Textbook of Psychiatry. 9th Edition. Vol 2. Sadock & Sadock.
2. Comprehensive Textbook of Psychiatry. 8th Edition. Vol 2. Sadock & Sadock.
3. Synopsis of Psychiatry. 10th Edition. Kaplan & Sadock.
4. Textbook of Clinical Psychiatry. 4th Edition. Vol 2. Hales & Yudofsky.
5. Textbook of Postgraduate Psychiatry. 2nd Edition. Vol 2. Vyas & Ahuja.
6. Encyclopedia of Psychotherapy. Vol 1-A.
Author is Postgraduate Trainee of Psychiatry at Silchar Medical College Hospital, Silchar.
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