Behavioural therapy

Behavioural therapy takes a practical, problem solving approach and it is a logical extension of behaviourism as applied to psychopathology. The therapist has three main roles; the first is to identify maladaptive learning, then to facilitate the unlearning of maladaptive responses and finally to teach the person more adaptive learning strategies. Techniques, which have been developed from classical conditioning to treat mental disorders, include systematic desensitisation, flooding and aversion therapy.

Systematic desensitisation was devised by Wolpe (1958) and aimed to treat, fears, phobias and anxieties. The therapist works with the client and the client is told to make a hierarchical list of feared situations starting with those that produce little fear and ending with those that are most frightening. Gradually over a number of sessions the client works their way up the list with graded exposure to all the situations having first been encouraged to relax. The idea behind this therapy is to replace the conditioned fear response with one of relaxation and it is therefore the pairing of relaxation with the feared stimulus that brings the desensitisation. This technique can either be used ‘in vivo’, which means the patient is actually exposed to the stimuli in real life, or ‘in vitro’ where images are used to create the fear response.

Flooding which is also known as ‘implosion’ is quicker and may be more effective then systematic desensitisation. It works around the principle that fears that are not faced will never disappear and may even grow in strength. The client is exposed to the fear stimulus and asked to remain with the fear so that they experience the full impact of their anxiety state. The therapy works because physiologically it is impossible to maintain a high anxiety state for a prolonged period of time and eventually the fear will subside. The transition that the person encounters as they go through this process shows them that they are still safe and their fear is misplaced. This treatment can be quite strenuous on a person so for ethical reasons the therapist must make sure that the client is in good health and the therapy is usually carried out ‘in vitro’ to avoid unnecessary stress.

Aversion therapy was developed from animal studies and it shows how the pairing of an unpleasant stimulus such as an electric shock with a neutral stimulus can produce an ‘aversion’ to the neutral stimulus. Aversion therapy was developed to deal with addictions and habits, so using this principal the therapist somehow attaches negative feelings to a stimulus that is considered inappropriate. An example of this may be to induce a feeling of nausea every time a person tastes tobacco, perhaps by inserting a drug into the cigarettes themselves. The idea is that the person will begin to associate nausea with cigarettes and stop smoking. There are doubts however that once the negative pairing is stopped that aversion will continue.

Token economy is a technique derived from the concept of operant conditioning and it is a behaviour modification programme developed from Skinner’s principle of behaviour shaping through positive reinforcement. If the client shows desirable behaviour they are given tokens that can be exchanged for privileges, outings or goods. The therapy has been used extensively in mental institutions, especially among those with learning difficulties or psychotic patients. It is difficult to sustain the modified behaviour outside of the institution however therapist claim that once outside there will be natural rewards from people when the patients display behaviour appropriate to the environment, maintaining the reward system even after treatment.

Social skills’ training involves behaviour rehearsal in the form of role-play or feedback. Bandura’s (1969) ‘social learning theory’ is an extension of operant conditioning, which includes learning through observing and modelling the behaviour of others. Originally Bandura used the concept of modelling to treat phobias but now it is applied in the development of social skills training, particularly in assertiveness and interpersonal skills training. People are encouraged to replace maladaptive responses to situations with more appropriate ones in a role-play situation; these responses are practiced. Skills training is very helpful to people with low self-esteem, people with high anxiety in social situations and for those who find themselves often exploited by others.

The behavioural model has been used frequently and as a result has a good scientific status. However because of ethical considerations much of the research today is carried out on animals, which may suggest validity problems. The behavioural model also overcomes the ethical problem of labelling someone as ill or abnormal and it instead views behaviour as adaptive or maladaptive. Behavioral therapies based on classical conditioning are very appropriate methods of treatment for anxiety disorders including phobias and posttraumatic stress disorder and for addictions. They are however regarded as inappropriate for psychotic disorders, such as schizophrenia. Behavioral methods are used frequently by clinical psychologists and within the NHS as the treatments only last a few months compared to those of psychodynamic therapies, which usually last several years. Behavioral methods are also very effective in group therapy as the treatment is structured, the goals are clear, and clinical progress is measurable.

The effectiveness of behavioral techniques is also quite high which researchers have shown. McGrath et al. (1990) say that systematic desensitization is effective for 75 per cent of people with specific phobias. Comer (1995) refers to a study on ‘flooding’, by Hogen and Kirchner (1967). Twenty-one people with a phobia for rats were asked to imagine themselves having their fingers nibbled and being clawed by rats. After treatment, twenty were able to open a rat’s cage and fourteen could actually pick up the rat. Menzies and Clarke (1993) claim that in vivo techniques are more effective for specific phobias than in vitro. Agoraphobia is one of the most difficult phobias to treat, but systematic desensitization has made an improvement for between 60 and 80 per cent of cases as according to Craske and Barlow (1993). However, these improvements are only partial and in 50 per cent of cases relapses occur.

Critics of behaviorist methods point out that often people with phobias have no recollection of any traumatic experience involving the object of their fear and therefore the cause remains unknown. Psychoanalytic theorists claim that this is because the phobia is merely a symptom or a conscious manifestation of the underlying cause, which is a signal from the unconscious that something is wrong. Bandura (1969) however argues that if ‘underlying’ is defined as ‘not immediately obvious’ then behavior therapists do look for underlying causes. The task is for the therapist to work with the client to find the most significant causes. According to social learning theory, phobias can develop through observing fears in others and modeling behavior upon those observations. For example if a parent reacts badly to the presence of a spider the shild will mimic that behavior.

Programmes of behavior modification like ‘token economy’, do not offer a cure for mental disorders; instead they enable patients to ‘fit’ better into their social world. For example, chronic psychiatric patients sometimes have no motivation to maintain personal hygiene and therefore tokens can be earned for washing and brushing hair for example. The intention is to give the person back some dignity.

The natural rewards that will replace the tokens to reinforce the behavior are that others will be more sympathetic towards them. It has been suggested, however, that the so-called success of this therapy may have more to do with its need for closer interaction between the patient and the nurse, which suggests that the attention is therapeutic, not the technique. Behavioral methods have given the opportunity for nursing staff to become more involved in treatment, which may have increased their investment in helping the patient. Despite its scientific status, behaviorist methods are still susceptible to the problems of evaluation that all therapeutic approaches suffer.

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