Behavior Therapy

In psychoanalysis, therapists help their patients look into their past to uncover repressed feelings and resolve internal personality conflicts. 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, but it is important to note that establishing a relationship of trust and empathy with the client (or the parents of the child being treated) is still an important element of successful treatment.

Behavior therapy begins with careful assessment of the person, through a scientifically based process. It is important to determine what the target behavior(s) of treatment will be and to understand how frequently the behavior occurs at the present time. This rate is called the baseline and enables the therapist to evaluate whether the treatment is working by increasing a constructive behavior or decreasing a problematic behavior compared to baseline. It also may involve careful evaluation of the situations in which the behavior occurs in order to understand what cues or stimuli may be associated with the behavior and the context in which the behavior occurs; it may be possible to influence the rate of the behavior by making changes to the environment as well as more direct classical or operant conditioning methods. It is also important to note that for operant conditioning situations, that consequences that may be reinforcing or punishing may be idiosyncratic or unique to the person. While many common consequences are generally perceived as reinforcing (for example money, attention, pleasure) this may not be true for all persons, and behaviors that are often thought of as punishers (such as restriction of privileges or freedom, fines, or other additional costs of the behavior) may not function the same way for all persons, for a variety of reasons.

As an example, a sixteen-year-old girl in a psychiatric inpatient unit suddenly began to increase her frequency of assaults on peers and staff. This behavior resulted in the use of seclusion and sometimes restraints to try and manage her behavior and to provide safety to others. The young woman had a repeated history of sexual abuse that had occurred in her family when she was much younger. This situation was baffling because despite the use of these punishment methods (seclusion, restraints, loss of privileges) aimed at reducing assaultive behavior, her assault rate was increasing. The fact that the target behavior (physical assault on others) was increasing suggested that she was in fact being reinforced for that behavior. Careful analysis suggested the possibility that, given her history, she was finding some comfort or possibly pleasure in being touched and handled by young male staff involved in the restraint procedures in addition to the attention given to her by those checking on her to make sure she was physically unharmed. The treatment involved the creation of specific protocols for her in which only female staff intervened and direct attention was minimized (no eye contact, minimal conversation necessary) during these procedures. In addition, a behavior modification program was put in place to encourage prosocial behaviors for which staff would give her more attention, encouragement, and recognition for prosocial behaviors (social reinforcement). This resulted in a successful reduction in assault-related behaviors and gradually improving relationships with staff and peers, although these processes took some time. This example also demonstrates the importance of genuinely understanding these behavior principles rather than relying on common interpretations of behavior or misunderstandings of the meaning and use of reinforcers and punishers. If the target behavior is increasing, it is being reinforced regardless of assumptions people make about the consequences of the 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 coming weekend.

Another 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 a bad taste, or a repulsive odor. 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 use of a medication called Antabuse. When a person takes Antabuse and then consumes alcohol, they experience uncomfortable side effects 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 order to understand the value of exposure therapy, think back to the discussion regarding extinction. Extinction is the gradual disconnection of the relationship between the unconditioned stimuli and the conditioned (learned) stimuli, or in operant conditioning, the disconnection between the operant behavior and a reinforcer (e.g., people would not go to work if they were not being paid). All forms of exposure therapy aim to reduce or eliminate the undesired behavior through these behavioral processes. Exposure therapy is especially useful in treating anxiety disorders and has been widely used in a variety of these disorders.

In exposure therapy, a therapist seeks to treat clients’ fears or anxiety by presenting them with the object or situation that causes their anxiety with the idea that due to extinction 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 three-year-old 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; Figure 1).

Figure 1. Exposure 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; Figure 2).

Figure 2. This 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 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).

Operant Conditioning Therapies

Some behavior therapies employ operant conditioning. As noted above, if a behavior is no longer reinforced, it will 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 applied behavior analysis (ABA) therapist, along with the caregivers, determines what reinforces the child, what encourages 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. Instead, more productive and effective coping strategies need to be identified and then implemented along with specific teaching of the behaviors and reinforcement, including gradual shaping, of the new behaviors which will replace the maladaptive behaviors.

Operant conditioning also plays a significant role in the formation and treatment of anxiety disorders. When a person develops an anxiety disorder, one of the key features is avoidance; the person engages in behaviors in an attempt to avoid confronting the situation or stimulus that creates the anxiety or fear, such as a person afraid of snakes avoiding the houses of friends with pet snakes, movies with snakes, or places where snakes may be found. This leads to a sense of relief or of escaping a danger, and this emotional response is a very powerful form of negative reinforcement. Recall that reinforcers increase a behavior, so when a person engages in avoidance and feels relieved, they are *more* likely to do so again. The public frequently confuses negative reinforcement with punishment (probably because the common association of the word negative means something one doesn’t like), but remember that negative reinforcement and punishment are opposites. This is precisely why exposure is important. If the anxiety or fear is to be reduced, the avoidant behavior must be reduced through extinction, which comes through exposure.

Aggressive behavior also frequently involves interdependent aspects of positive and negative reinforcement. For example, the bully at school threatens a target peer; the fear reaction by the peer or giving in to the bully’s demands are positively reinforcing to the bully. However, the victim’s reaction and watching the bully leave without causing them harm also generates feelings of relief or escape and so may negatively reinforce the victim’s behavior making it more likely they may give in again to the bully’s demands in the future. This is seen in abusive family environments, and unfortunately sometimes in residential or inpatient treatment settings as well as on the playground. Making progress in these areas may also involve punishment for the bully as well as attempts to eliminate positive reinforcers, but also needs to address the needs of the victim and teaching and reinforcing behaviors that increase or restore their sense of competence and self-esteem.

Operant conditioning methods and procedures are also involved in many other forms of mental disorders ranging from eating disorders, mood disorders like depression, and sexual dysfunctions as well as other disorders.

Another popular operant conditioning intervention is called the token economy. This involves a controlled setting such as an inpatient unit or residential treatment setting where individuals are reinforced for desirable behaviors with tokens, such as a poker chip or points, 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).