Psych in Real Life: Behavior Therapy

Learning Objectives

  • Explain the basic process and uses of play and behavior therapy
  • Describe systematic desensitization

Psychotherapy: Play Therapy

Play therapy is often used with children since they are not likely to sit on a couch and recall their dreams or engage in traditional talk therapy. This technique uses a therapeutic process of play to “help clients prevent or resolve psychosocial difficulties and achieve optimal growth” (O’Connor, 2000, p. 7). The idea is that children play out their hopes, fantasies, and traumas while using dolls, stuffed animals, and sandbox figurines.

This photograph shows a person playing with objects in a small box filled with sand. The person is organizing these objects and small play figures in a form of treatment called sandplay.

Figure 1. This type of play therapy is known as sandplay or sandtray therapy. Children can set up a three-dimensional world using various figures and objects that correspond to their inner state (Kalff, 1991). (credit: Kristina Walter) 

Play therapy can also be used to help a therapist make a diagnosis. The therapist observes how the child interacts with toys (e.g., dolls, animals, and home settings) in an effort to understand the roots of the child’s disturbed behavior. Play therapy can be nondirective or directive. In nondirective play therapy, children are encouraged to work through their problems by playing freely while the therapist observes (LeBlanc & Ritchie, 2001). In directive play therapy, the therapist provides more structure and guidance in the play session by suggesting topics, asking questions, and even playing with the child (Harter, 1977).

Behavior Therapy

In psychoanalysis, therapists help their patients look into their past to uncover repressed feelings. In behavior therapy, a therapist employs principles of learning to help clients change undesirable behaviors—rather than digging deeply into one’s unconscious. Therapists with this orientation believe that dysfunctional behaviors, like phobias and bedwetting, can be changed by teaching clients new, more constructive behaviors. Behavior therapy employs both classical and operant conditioning techniques to change behavior.

One type of behavior therapy utilizes classical conditioning techniques. Therapists using these techniques believe that dysfunctional behaviors are conditioned responses. Applying the conditioning principles developed by Ivan Pavlov, these therapists seek to recondition their clients and thus change their behavior. Emmie is eight years old, and frequently wets her bed at night. She’s been invited to several sleepovers, but she won’t go because of her problem. Using a type of conditioning therapy, Emmie begins to sleep on a liquid-sensitive bed pad that is hooked to an alarm. When moisture touches the pad, it sets off the alarm, waking up Emmie. When this process is repeated enough times, Emmie develops an association between urinary relaxation and waking up, and this stops the bedwetting. Emmie has now gone three weeks without wetting her bed and is looking forward to her first sleepover this weekend.

One commonly used classical conditioning therapeutic technique is counterconditioning: a client learns a new response to a stimulus that has previously elicited an undesirable behavior. Two counterconditioning techniques are aversive conditioning and exposure therapy. Aversive conditioning uses an unpleasant stimulus to stop an undesirable behavior. Therapists apply this technique to eliminate addictive behaviors, such as smoking, nail biting, and drinking. In aversion therapy, clients will typically engage in a specific behavior (such as nail biting) and at the same time are exposed to something unpleasant, such as a mild electric shock or a bad taste. After repeated associations between the unpleasant stimulus and the behavior, the client can learn to stop the unwanted behavior.

Aversion therapy has been used effectively for years in the treatment of alcoholism (Davidson, 1974; Elkins, 1991; Streeton & Whelan, 2001). One common way this occurs is through a chemically based substance known as Antabuse. When a person takes Antabuse and then consumes alcohol, uncomfortable side effects result including nausea, vomiting, increased heart rate, heart palpitations, severe headache, and shortness of breath. Antabuse is repeatedly paired with alcohol until the client associates alcohol with unpleasant feelings, which decreases the client’s desire to consume alcohol. Antabuse creates a conditioned aversion to alcohol because it replaces the original pleasure response with an unpleasant one.

Exposure Therapy

In exposure therapy, a therapist seeks to treat clients’ fears or anxiety by presenting them with the object or situation that causes their problem, with the idea that they will eventually get used to it. This can be done via reality, imagination, or virtual reality. Exposure therapy was first reported in 1924 by Mary Cover Jones, who is considered the mother of behavior therapy. Jones worked with a boy named Peter who was afraid of rabbits. Her goal was to replace Peter’s fear of rabbits with a conditioned response of relaxation, which is a response that is incompatible with fear. How did she do it? Jones began by placing a caged rabbit on the other side of a room with Peter while he ate his afternoon snack. Over the course of several days, Jones moved the rabbit closer and closer to where Peter was seated with his snack. After two months of being exposed to the rabbit while relaxing with his snack, Peter was able to hold the rabbit and pet it while eating (Jones, 1924).

This figure, titled “Exposure Therapy,” illustrates the exposure therapy strategy of Mary Cover Jones to rid a person of the fear of rabbits. The first of four levels depicts an image of a person and a rabbit with an equals sign between them. Under the rabbit reads “conditioned stimulus (CS),” and under the person reads “fear of rabbits.” The second level depicts an image of milk and cookies, labeled “unconditioned stimulus (US),” and on the other side of an equals sign there is a picture of the same person labeled “unconditioned response (UR).” The third level shows the milk and cookies, labeled “unconditioned stimulus (US),” and rabbit, labeled “conditioned stimulus (CS),” to the left and right of a plus sign, with the person on the other side of an equals sign. The label “unconditioned response (UR) is below the person.” The final level shows the person and the rabbit separated by an equals sign. This time the rabbit is labeled “conditioned stimulus (CS)” and the person is labeled “conditioned response (CR).”

Figure 2Exposure therapy seeks to change the response to a conditioned stimulus (CS). An unconditioned stimulus is presented over and over just after the presentation of the conditioned stimulus. This figure shows conditioning as conducted in Mary Cover Jones’ 1924 study.

Thirty years later, Joseph Wolpe (1958) refined Jones’s techniques, giving us the behavior therapy technique of exposure therapy that is used today. A popular form of exposure therapy is systematic desensitization, wherein a calm and pleasant state is gradually associated with increasing levels of anxiety-inducing stimuli. The idea is that you can’t be nervous and relaxed at the same time. Therefore, if you can learn to relax when you are facing environmental stimuli that make you nervous or fearful, you can eventually eliminate your unwanted fear response (Wolpe, 1958).

A close-up picture of a very large spider on a person’s arm is shown. The person is using its other hand to hold up two of the spider’s legs.

Figure 3This person suffers from arachnophobia (fear of spiders). Through exposure therapy he is learning how to face his fear in a controlled, therapeutic setting. (credit: “GollyGforce – Living My Worst Nightmare”/Flickr)

How does exposure therapy work? Jayden is terrified of elevators. Nothing bad has ever happened to him on an elevator, but he’s so afraid of elevators that he will always take the stairs. That wasn’t a problem when Jayden worked on the second floor of an office building, but now he has a new job—on the 29th floor of a skyscraper in downtown Los Angeles. Jayden knows he can’t climb 29 flights of stairs in order to get to work each day, so he decided to see a behavior therapist for help. The therapist asks Jayden to first construct a hierarchy of elevator-related situations that elicit fear and anxiety. They range from situations of mild anxiety such as being nervous around the other people in the elevator, to the fear of getting an arm caught in the door, to panic-provoking situations such as getting trapped or the cable snapping. Next, the therapist uses progressive relaxation. She teaches Jayden how to relax each of his muscle groups so that he achieves a drowsy, relaxed, and comfortable state of mind. Once he’s in this state, she asks Jayden to imagine a mildly anxiety-provoking situation. Jayden is standing in front of the elevator thinking about pressing the call button.

If this scenario causes Jayden anxiety, he lifts his finger. The therapist would then tell Jayden to forget the scene and return to his relaxed state. She repeats this scenario over and over until Jayden can imagine himself pressing the call button without anxiety. Over time the therapist and Jayden use progressive relaxation and imagination to proceed through all of the situations on Jayden’s hierarchy until he becomes desensitized to each one. After this, Jayden and the therapist begin to practice what he only previously envisioned in therapy, gradually going from pressing the button to actually riding an elevator. The goal is that Jayden will soon be able to take the elevator all the way up to the 29th floor of his office without feeling any anxiety.

Sometimes, it’s too impractical, expensive, or embarrassing to re-create anxiety- producing situations, so a therapist might employ virtual reality exposure therapy by using a simulation to help conquer fears. Virtual reality exposure therapy has been used effectively to treat numerous anxiety disorders such as the fear of public speaking, claustrophobia (fear of enclosed spaces), aviophobia (fear of flying), and post-traumatic stress disorder (PTSD), a trauma and stressor-related disorder (Gerardi, Cukor, Difede, Rizzo, & Rothbaum, 2010).

Link to Learning

Virtual reality exposure therapy is being used to treat PTSD in soldiers. Virtual Iraq is a simulation that mimics Middle Eastern cities and desert roads with situations similar to those soldiers experienced while deployed in Iraq. This method of virtual reality exposure therapy has been effective in treating PTSD for combat veterans. Approximately 80% of participants who completed treatment saw clinically significant reduction in their symptoms of PTSD, anxiety, and depression (Rizzo et al., 2010). Watch this Virtual Iraq video that shows soldiers being treated via simulation to learn more.

Operant Conditioning Therapies

Some behavior therapies employ operant conditioning. Recall what you learned about operant conditioning: We have a tendency to repeat behaviors that are reinforced. What happens to behaviors that are not reinforced? They become extinguished. These principles, defined by Skinner as operant conditioning, can be applied to help people with a wide range of psychological problems. For instance, operant conditioning techniques designed to reinforce desirable behaviors and punish unwanted behaviors are effective behavior modification tools to help children with autism (Lovaas, 1987, 2003; Sallows & Graupner, 2005; Wolf & Risley, 1967). This technique is called Applied Behavior Analysis (ABA). In this treatment, a child’s behavior is charted and analyzed. The ABA therapist, along with the caregivers, determines what reinforces the child, what sustains a behavior to continue, and how best to manage a behavior. For example, Nur may become overwhelmed and run out of the room when the classroom is too noisy. Whenever Nur runs out of the classroom, the teacher’s aide chases him and places him in a special room where he can relax. Going into the special room and getting the aide’s attention are reinforcing for Nur. In order to change Nur’s behavior, he must be presented with other options before he becomes overwhelmed, and he cannot receive reinforcement for displaying maladaptive behaviors.

One popular operant conditioning intervention is called the token economy. This involves a controlled setting where individuals are reinforced for desirable behaviors with tokens, such as a poker chip, that can be exchanged for items or privileges. Token economies are often used in psychiatric hospitals to increase patient cooperation and activity levels. Patients are rewarded with tokens when they engage in positive behaviors (e.g., making their beds, brushing their teeth, coming to the cafeteria on time, and socializing with other patients). They can later exchange the tokens for extra TV time, private rooms, visits to the canteen, and so on (Dickerson, Tenhula, & Green-Paden, 2005).

Behavior Therapy in Action: How Does it Work?
Smiling picture of a college student with a pen in her mouth.

Meet Miriam. She is smart, ambitious, creative, and full of energy. She is studying at a university, majoring in business. During the next few years, after she graduates, she wants to live in interesting places and get solid training and experience with a good corporation. Her dream is to start her own company, to be her own boss, and to do things that she can take pride in. For her, financial success and doing something worthwhile must go hand-in-hand.

But Miriam has a secret. She is terrified of speaking in front of people who are not her close friends. She has fought these fears for a long time, but she has never been able to conquer them. She is also aware of the fact that she will need to be able to speak to strangers comfortably and convincingly if she is going to meet her goals in business.

Now that you and your client have agreed upon your goals, it is time to choose a particular technique for the therapy. As a behavioral therapist, you are looking for a method to allow Miriam to learn a new response to the thought of public speaking. Now the idea terrifies her. After therapy is over, she should no longer be terrified and she may even look forward to the opportunity to speak in front of other people.

You know that everyone is not the same and different problems may call for different approaches to therapy. For these reasons, you have been trained in a variety of techniques that you can use to customize Miriam’s therapy to meet her particular needs. It is time to decide how you are going to help Miriam.

Try It

Systematic desensitization works by gradually—step-by-step—exposing the person to situations that are increasingly more anxiety-producing. This is called “progressive exposure.” By learning to cope with anxiety with less-threatening situations first, the person is better prepared to handle the more-threatening situations. Even more important for treatment, the mind learns that nothing horrible happens. This retraining of the subconscious mind means that the situation actually becomes less threatening.

Same picture of the college student, Miriam, looking confused or frustrated while looking at her notebook.

The first steps in systematic desensitization is the development of a “hierarchy of fears.” This simply means that you must help Miriam create a list of situations related to her fear of public speaking. Then you create a hierarchy. This means that you have her organize the situations from the least frightening to the most frightening.

For the next step in this exercise, you will need to take on Miriam’s role as the client. Imagine that you have developed a list of frightening situations, from ones that make you only slightly uncomfortable to ones that nearly make you sick with anxiety.

Try It

Remember that systematic desensitization works by putting the person in a series of situations. The early ones are not threatening or are only mildly threatening. However, as soon as your client learns to cope with each situation, you start working on the next most frightening situation.

So we’re ready to start, right? Wrong!

Behavioral therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response. A common alternative response is relaxation. This idea is that fear and anxiety cannot coexist with relaxation—if you are relaxed, you can’t be fully afraid.

However, most people are not very good at relaxing on command. So the behavioral therapist will teach the client how to relax effectively. The techniques are ones often used in meditation—slow breathing and focus on positive thoughts. Psychologist Kevin Arnold explains a deep breathing technique in this video.

Miriam’s Treatment

Miriam is an imaginary person, but behavioral therapy is used by thousands of therapist with their clients every day. Review the following table to discover how Miriam’s therapy progressed. Her story is based on a fairly typical series of therapy sessions, though please understand that each person’s course of therapy is unique.

Miriam’s Treatment

Therapy Sessions Session Description
Miriam’s therapy: Preparation Prior to starting progressive exposure, Miriam created her hierarchy of fears. She spent several session working on relaxation. She practiced relaxation at home several times a day until she and you, her therapist, agreed that she was ready to start treatment.
Miriam’s therapy: Exposure Session 1 The bottom (lowest anxiety) of Miriam’s fear hierarchy was chatting with friends about everyday topics. When asked to rate the fear level associated with doing this on a 1 to 10 scale, Miriam said 1: No fear at all.

Miriam brought two friends with her to the therapy session today. You had them sit in a comfortable part of your office, drinking tea and chatting for 15 minutes. Afterwards Miriam reported her fear level during the chat as a 1 on a ten-point scale: no fear.

You then had her sit in a comfortable chair and think about giving a talk about the challenges of her job to a small, friendly audience. At the beginning of this task, she rated her anxiety as 3 on a 10-point scale. As she thought about it—with helpful suggestions from you—she also relaxed, using her relaxation training. After about 10 minutes, she reported her anxiety had dropped to 1, the lowest level of anxiety on your scale.

You gave Miriam “homework”—to repeat this exercise twice a day until the next session.

Miriam’s therapy: Exposure Session 2 At the beginning of today’s session, you had Miriam repeat the task from the previous session of thinking about talking about her job to a small, friendly group. At the beginning she rated her fear at 2, but it dropped to 1 within a few minutes.

Now you took Miriam to the next level. You had her imagine telling a large audience of company executives about some technical problem she was working on at her job. At the beginning, just thinking about doing this led to a fear level of 5. After 10 minutes, her fear level dropped to 2. You repeated the exercise with a different topic and a different group, with similar results. Relaxation was practiced throughout the session.

You gave Miriam homework again—to practice a similar situation at home.

Miriam’s therapy: Exposure Session 3 You started this situation with a new scenario similar to the one Miriam did in the last session and practiced at home. She was quickly able to drop her anxiety level to 1.

You had a professional photography group create a video of someone very similar in appearance and manner to Miriam giving a talk in from of a small friendly audience on a topic similar to one Miriam might give. You asked her to watch this video and imagine herself in the place of the real speaker. She rated this a 6 on the anxiety scale. Over several repetitions, her rating dropped to 2.

For homework, Miriam watched the video several times a day. You instructed her in ways to make the video seem MORE REAL, so she could really feel the anxiety of being in front of people.

Miriam’s therapy: Exposure Session 4 You have had Miriam arrange to give a talk NEXT SESSION to a small group of Miriam’s co-workers. You also had Miriam prepare the talk. Today you practiced the talk with her. At the start of the practice session, with only you there, Miriam rated her anxiety level at 9 out of 10. Over the course of the hour, her anxiety level dropped to 5.

Her homework was to continue to practice the talk and to work on relaxation.

Miriam’s therapy: Exposure Session 5 Today, Miriam gave the talk to the small group. Her anxiety rating before she went in front of them was 10. Except for a little stumbling at the start, the 20-minute presentation went well. Miriam reported an anxiety level of 4 after the talk.
We’ll skip a few sessions. We hope you have the basic idea.
Miriam’s therapy: Exposure Session 6 In this last session, you have arranged for Miriam to be the introductory speaker at a literacy tutoring volunteer organization nearby. Miriam has done a small amount of volunteer work with the organization, but she knows very little about it. With the help of the staff, she prepares a talk during the week before this session.

The audience is composed of 45 people, all interested in doing literacy tutoring, who have come to the literacy center for an information session. Miriam knows none of them and none of them has ever heard of her.

Miriam’s introductory comments take about 15 minutes. She rates her anxiety level before going out at 8. After the talk, she rates her anxiety at 2. In fact, she said it was almost fun.

After Therapy Miriam continues to see you for a few more sessions. You give her additional homework and you help her develop a plan that includes arranging to give professional presentations for her job and continuing to give talks at the literacy volunteer organization. Miriam reports that none of these ideas create an anxiety level above 3 when she thinks about doing them.

You just learned about Systematic Desensitization, a form of exposure therapy. Flooding is another type of exposure therapy. To understand how it works, let’s review a few points from Systematic Desensitization.

Try It

In flooding therapy, you would skip the earliest situations described in systematic desensitization and you would move directly to highly threatening situations. Right after Miriam had mastered relaxation, your first session would require Miriam to give an actual talk. You would probably not start with the most extreme situation, but your goal would be to start Miriam in situations that she would immediately rate as 9 or 10 on the anxiety scale.

Flooding has the potential to be more traumatic for Miriam (for your client), so it must be arranged carefully. But the same principles of learning work for flooding that work for systematic desensitization:

  • The person consciously works to replace anxiety and fear with relaxation.
  • The unconscious parts of the mind learn that the situation does not result in horrible outcomes. New expectations replace old fears.
  • Learning does not just happen immediately. Homework and repeated practice reinforce the new positive response to situations that once produced fear.

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