Behavior Therapy: History, Models and Applications

 Behavior therapy rose to prominence in the 1970’s after theorists were able to demonstrate its effectiveness (Spiegler, 2016). Instead of focusing on unconscious desires as the root of human behavior, behavior therapists focused on present conditions (Spiegler, 2016). Additionally, therapy centered on learning as the vehicle of change, rather than the psychoanalytic interview. While behavior therapy is now widely accepted among practitioners, it had quite the rocky beginning. Theorists combatted public fear and distrust of this new form of psychotherapy with scientific evidence (Bandura, 2004). Numerous variations of behavior therapy now exist; the most widely known is cognitive-behavior therapy.

 Behavior therapy developed in response to the dissatisfaction with psychoanalysis in the 1950’s, to assist client’s in reducing problematic psychological symptoms and behaviors (Spiegler, 2016). Unlike psychoanalytic therapists, behavioral therapists are able to demonstrate success through empirical evidence and observable behavioral changes (Spiegler, 2016). Where the client is a passive member of treatment in psychoanalytic therapy, behavior therapy regards the client as an active participant. The client is expected to complete therapeutic tasks, such as homework assignments, rehearsing skills, and role-playing, to alter problematic behavior (Spiegler, 2016). Behavior theorists suggest that these problematic behaviors develop through learning processes and can be adapted or replaced through new learning experiences (Spiegler, 2016).

 Spiegler (2016) proposed four characteristics specific to behavior therapy; brevity, treatment packages, stepwise progression, and individualized treatment. At the onset of therapy, a functional analysis is completed and the treatment is then tailored toward the client’s specific problems and circumstances (Spiegler, 2016). Behavior therapy usually proceeds in a stepwise progression, beginning with the easiest technique and progressing to more difficult techniques as the client adapts (Spiegler, 2016). For instance, if a client entered therapy with a fear of spiders, the therapist may begin treatment by showing her a picture of a spider. Once she is comfortable viewing the picture of the spider, she may be asked to hold the picture. Eventually, the goal would be for the client to be comfortable enough to touch the spider. Behavior therapy is rather brief in comparison with other forms of therapy as a large part of treatment occurs outside of the office. Homework assignments and self-control approaches contribute to the success of treatment over a brief period of time (Spiegler, 2016).

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 Behavior therapy is unique in that there are many techniques utilized by behavior therapists. These different techniques are often combined into treatment packages catered toward the client and their exclusive needs (Spiegler, 2016). Techniques specific to behavior therapy include positive reinforcement, self-instructional training, modeling, systematic desensitization, and token economy (Spiegler, 2016). Although there are many techniques used in behavior therapy, they are all similar in that the primary feature remains the collaboration between the client and the therapist. The rapport between the therapist and client is crucial as the client is more likely to comply with treatment if there is a positive therapeutic relationship (Spiegler, 2016).

History of Behavior Therapy

While behavioral principles such as reward and punishment have existed for thousands of years, contemporary behavior therapy originated from the experimental research of Pavlov, Watson, Jones, the Mowrer’s, Thorndike, and Jacobson (Spiegler, 2016). Ivan Pavlov, famous for his experimentation with dogs, conducted the first systematic classical conditioning experiment. Classical conditioning is a learning process that occurs when a response stimulus is repeatedly paired with a neutral stimulus, eventually producing a response with the neutral stimulus alone (Spiegler, 2016). Two learning processes, classical and operant conditioning, laid the foundation for treatment in behavior therapy.

 Although psychoanalysis was the predominant psychotherapeutic approach during the early-to-mid-20^th century, the need for a new approach became necessary when psychoanalysts could not meet the needs of soldiers returning from World War II (Spiegler, 2016). During this time, Hans Eysenck examined client improvement after insight psychotherapy and found no difference in functioning compared to those receiving no treatment. Additionally, outcome studies on psychodynamic approaches showed little improvement in clients’ behavior. Essentially, psychoanalysis produced a change in beliefs but no change in behavior (Bandura, 2004). These findings, coupled with the need for a brief treatment modality, opened the door for behavior therapy (Spiegler, 2016).

Once the need for an alternate approach was realized, contemporary behavior therapy began to surface in Great Britain, South Africa, and North America (Spiegler, 2016). In the United States, Ogden Lindsley, a student of B.F. Skinner, began using the term behavior therapy to explain the treatment of psychological disorders with the use of learning processes. Lindsley researched Skinner’s principles of operant conditioning with adult psychiatric patients in an inpatient setting. Operant conditioning is a learning process that occurs with the introduction of rewards and punishment (Spiegler, 2016). Lindsley’s research was expanded upon in Canada by Teodoro Ayllon and Eric Haughton. While demonstrating the principles of operant conditioning, they challenged the psychoanalytic approach of resolving unconscious conflicts to treat a patient successfully. Ayllon and Haughton demonstrated that specific behavior, viewed as a psychiatric symptom by psychoanalysts, could be created and eliminated through reinforcement (Spiegler, 2016). The researchers conditioned a female patient with schizophrenia to hold a broom while standing. A psychiatrist, unaware of Ayllon and Haughton’s demonstration, explained the new broom-holding behavior as ritualistic, symbolizing unfulfilled desires. According to Spiegler, this “demonstration played a role in overcoming the widespread resistance to the behavioral model in the psychiatric community” (2016, p. 21).

Although Ayllon and Haughton’s broom-holding demonstration decreased the resistance to behavioral therapy within psychiatric communities, Ayllon and Azrin experienced much resistance when he later introduced the concept of the token economy(Spiegler, 2016). In a token economy, which is now commonly used in inpatient and correctional settings, patients are rewarded with tokens when they engage in positive, desired behaviors. Typically, after a designated time period, the earned tokens are then exchanged for goods, such as recreation time or snacks. In a token economy, the token serves as a substitute reinforcer, while the goods serve as the actual reinforcement for positive behavior (Spiegler, 2016). When the token economy was introduced to a psychiatric hospital in Illinois, staff was skeptical, and only referred ‘incurable’ patients as a way to resist the new behavioral approach. Luckily for Ayllon and Azrin, the token economy successfully produced desired behaviors in these ‘incurable’ patients, demonstrating that behavior therapy was an effective form of treatment (Spiegler, 2016). While behavior therapy was gaining traction in North America, Joseph Wolpe was busy developing systematic desensitization in South Africa. Systematic desensitization is used to treat anxiety disorders by combining mental images of anxious situations with progressive relaxation techniques (Spiegler, 2016). Rachman, a student of Wolpe, then introduced systematic desensitization to Great Britain in the 1960’s and became a leading behavior therapist of this period (Spiegler, 2016).

As behavior therapy spread and became more widely accepted, Albert Bandura was busy developing a theory that would combine elements of operant and classical conditioning with observational learning (Spiegler, 2016). Bandura’s theory, social learning theory, explained that an individual’s behavior could change through the process of modeling. He also offered that cognitions were essential to the development of psychopathology as well as one’s own treatment (Spiegler, 2016). Bandura renamed social learning theory to social cognitive theory to incorporate the important role of cognitions (Spiegler, 2016). Bandura theorized that “many human problems are social, not just individual”; therefore, treatment should be rendered in a natural setting, utilizing trained teachers, family members, and field therapists as “dispensers of treatment” (2004, p. 616). Social cognitive theory suggests that humans possess intentions, forethought, self-reactiveness, and self-reflectiveness. With the ability to set goals, monitor actions, and regulate behaviors, the individual has that capability to alter their own lives and the lives of those around them (Bandura, 2004).

Throughout the early years of development, society was hyperaware of civil liberty, privacy, and government control due to media influences such as the novel 1984, and the film A Clockwork Orange, which exaggerated behavioral control (Bandura, 2004). A major concern surrounded the idea that behavior therapy would be used as a form of societal control. Spiegler (2016) suggested that these fears arose most frequently when there was a misunderstanding of the uses and techniques associated with behavior therapy, as it was often erroneously referred to as behavior modification. Bandura (2004) explained that in the early days, behavior therapy was often viewed as a dangerous form of treatment, utilizing brainwashing and social control techniques. During the “height of the media frenzy”, Bandura became the president of the American Psychological Association (2004, p. 619). In response to the negative view of behavior therapy, he formed a task force including professionals from many disciplines, to investigate the ways in which behavior therapy was used. The task force published ethical standards in Ethical Issues in Behavior Modification to appease public concerns (Bandura, 2004). Around this time, there was a shift in theory and behavior therapy began to obtain public acceptance.

After gaining public acceptance, many variations of behavior therapy began to develop including, cognitive behavior therapy, rational emotive behavior therapy, and cognitive therapy. Additionally, behavioral techniques such as stress inoculation and self-instructional training were established. By the 1970’s behavior therapy was a main contender in psychological treatment and was being used to positively influence many aspects of life, including medical and environmental (Spiegler, 2016). Over the past 40 years, the field of behavior therapy has continued to advance. The field is continuing to evolve to include new techniques that will address a variety of issues (Spiegler, 2016).

The Behavioral Model

 The behavioral model serves as the foundation for behavior therapy. In order to understand the behavioral model, it is important to distinguish between human behavior and traits (Spiegler, 2016). There are four modes of behavior that a therapist must consider during treatment; physiological responses, emotions, cognitions, and overt behaviors. It is crucial for the therapist to be able to distinguish between overt and covert behaviors (Spiegler, 2016). These behaviors can be explained by the ABC model, which describes the sequence of events leading to specific behaviors. Learning also influences our behavior, and contemporary researchers have suggested that conditioning involves both automatic and higher-level cognitive processes (Kirsch, Lynn, Vigorito, and Miller, 2004).

 According to Spiegler, the behavioral model suggests that, “each of us is defined by our behaviors…We are what we do” (2016, p.30). Behavior can be separated into two categories; overt and covert. Overt behaviors are observable, while covert behaviors are unobservable. These unobservable covert behaviors fall into three categories; emotions, cognitions, and physiological responses (Spiegler, 2016). Since covert behaviors are unobservable, a therapist must infer these behaviors from a client’s observable, overt behaviors (Spiegler, 2016). For example, if a client is staring into the distance (overt behavior), the therapist could infer that the client is thinking of a memory (covert behavior). An individual’s covert behaviors, environment, and overt behaviors all influence and are influenced by one another (Spiegler, 2016).

 Behavior therapists are tasked with the ability to distinguish between behaviors and traits. Traits differ from behaviors in that they are personality characteristics that are theoretical in nature. Similar to covert behaviors, we often infer traits from observable behavior (Spiegler, 2016). For example, if a client is talkative and reports having many friends, the therapist may infer that the client is outgoing (trait). Since traits are theoretical, they do not provide much information about the client (Spiegler, 2016). The behavioral model, suggests that an individual’s behavior is caused by events leading up to the behavior and events occurring after the behavior. The events occurring prior to a behavior are referred to as antecedents, while the events that occur after a behavior, as a result of the behavior, are known as consequences (Spiegler, 2016).

 The ABC model outlines the process of behavior development and maintenance in terms of antecedents and consequences (Spiegler, 2016). According to the model, antecedents set the condition for a behavior to occur, and the consequences are a result of the behavior, and determine whether or not the behavior will occur again. The specific antecedents and consequences that influence behavior are referred to as maintaining conditions (Spiegler, 2016). The model suggests that prerequisites must be met before an individual is able to engage in a specific behavior. Prerequisites include motivation, knowledge, skills, and resources. For instance, if an individual is going on a camping trip, a desire to go camping (motivation), (knowledge) of a camping location, being able to commute to the camping location (skills), and a tent (resources), are all required (Spiegler, 2016). Other conditions that set the scene for an individual to engage in a behavior are referred to as stimulus control, which includes prompts and setting events (Spiegler, 2016). An example of a prompt would be a teacher asking a question in class. This prompt would cue the individual to raise their hand to answer the question. Environmental conditions that provoke a behavior are referred to as setting events (Spiegler, 2016). For example, an individual in a bar with friends is more likely to have a drink than if they were at home alone. Behaviors are often situation specific, as some behaviors would be viewed as acceptable in one setting but not in another. In order to change problematic behaviors, therapists alter setting events and prompts (Spiegler, 2016).

 Maintaining consequences, on the other hand, are the outcome of a behavior. These events determine whether or not an individual will repeat the behavior (Spiegler, 2016). If the resulting event is negative or unfavorable, the individual is less likely to engage in the behavior in the future. The individual will anticipate the negative consequence as they have already been exposed to it and will refrain from the behavior. Since these consequences may prohibit a future behavior, they are also referred to as antecedents. As Spiegler stated, “maintaining consequences for today’s actions are the maintaining antecedents for tomorrow’s actions” (2016, p. 37). In behavior therapy, the therapist alters problematic behaviors through maintaining conditions, rather than manipulating the behavior itself (Spiegler, 2016).

 Behaviors are developed and maintained in the context of biological and environmental factors (Spiegler, 2016). Environmental factors include all external variables which influence behavior through the process of learning (Spiegler, 2016). Reciprocal determinism states that overt behaviors, covert behaviors, and environment influence and are influenced by one another. Although behavior is partially developed through biological influences, learning is crucial in the development, maintenance, and alteration of behaviors. Two types of learning that are synonymous with behavior theory are classical and operant conditioning (Kirsch et al., 2004). Previously, classical conditioning was regarded as an automatic learning process, while operant conditioning was viewed as learning resulting in voluntary responses (Kirsch et al., 2004). Kirsch et al., (2004) relay that contemporary learning theorists assume cognitive involvement in classical and operant conditioning. The idea that conditioning is purely mechanistic has been rejected as, “there is now virtually universal agreement that conditioning involves the production of expectancies” (Kirsch et al., 2004, p. 371). Cognitive theorists suggest that expectancies are a higher-order cognitive functioning, not simply associations. For example, in classical conditioning, the individual expects that a specific stimuli will follow another stimuli, and in operant conditioning, the individual expects that a specific behavior will result in a specific outcome (Kirsch et al., 2004).

 In their 2004 article, Kirsch et al. review data indicating higher-order cognition in conditioning as well as data indicating automatic conditioning. The authors then offer a theory that combines both automatic and cognitive processes in conditioning (Kirsch et al., 2004). In their research with rats navigating a maze, Tolman and colleagues found that rats had formed cognitive maps through the expectation of finding food in certain locations of the maze (Bolles as cited in Kirsch et al., 2004). As Tolman and colleagues continued to research the hypothesis that rats formed cognitive maps in the maze, they found that the rats learned the location of the food, rather than navigation responses that were reinforced (Kirsch et al., 2004). Based on his review of 200 studies, Brewer concluded, “that there is not and never has been any convincing evidence for unconscious, automatic mechanisms in the conditioning of adult human beings” (as cited in Kirsch et al., 2004, p. 374). Other studies showed that expectancies and information pairing strengthened responses, suggesting higher-order cognitive processes are involved in conditioning in conjunction with automatic processes (Kirsch et al., 2004). Interestingly, in a study on placebo effects, Montgomery and Kirsch found that verbal information reversed the effects of conditioning (Kirsch et al., 2004). According to Kirsch et al. (2004), responses can be developed through the classical and operant conditioning, but also through observation and information-pairing.

 While Albert Bandura was writing Principles of Behavior Modification, he began to realize that conditioning processes were in fact, influenced by cognitive processes. Much of his early work is based on the theory that the environment is an important influence on behavior (Bandura, n.d.). He found that social influences were creating problematic behaviors and in order to adapt the behavior, the social practices would need to be altered. Bandura’s social cognitive theory incorporates aspects of conditioning and cognition in the development and maintenance of behavior. According to social cognitive theory, behavioral changes occur as a result of modeling, self-efficacy and self-regulatory mechanisms (Bandura, n.d.). Bandura explained that through the process of modeling in guided mastery treatment, functioning was able to be restored in clients with phobias. Through modeling, clients are able to learn behaviors by watching others engage in them, while also witnessing the outcome of the specific behavior. Bandura (n.d.) suggests that in order to produce successful outcomes through modeling, support must exist in the environment. It is also crucial for individuals to develop a strong self-efficacy. Self-efficacy is the “belief that one has the power to effect change by one’s action” (Bandura, n.d.). If an individual does not believe in their own capabilities, then they will not succeed in changing problematic behaviors.

Bandura’s theories of human behavior apply to both the individual and societal levels and translate perfectly into today’s world. Societal problems such as women’s rights can be addressed through modeling and collective-efficacy (Bandura n.d.). For example, Bandura explained that television dramas which model behaviors that will provide women with a voice, have been broadcasted in countries where women’s rights are non-existent. Through the viewing of these dramas, women can witness the behavior and positive outcome associated with the behavior and will be more likely to believe that they can make a change in their own lives. This collective-efficacy has influenced societal behavior in the past, for example, during the suffragette movement. These ideas are extremely relevant in today’s society, where women are being stripped of their right to abortion. Perhaps social cognitive theory can be used to address these societal issues.

Both Bandura (2004) and Spiegler (2016) provide an excellent synopsis of the history of behavioral therapy as it developed in an unwelcoming time. Bandura (2004) specifically addresses the issues that he held with psychodynamic theory, which caused him to develop an alternate theory of human behavior. He takes the reader on his journey through the paradigm shift from a psychodynamic perspective to a behavioral perspective.

References

• Bandura, A. (n.d.). Behavior therapy, self-efficacy, & modeling . Available from http://www.psychotherapy.net.fgul.idm.oclc.org/stream/fielding/video?vid=269.
• Bandura, A. (2004). Swimming against the mainstream: the early years from chilly tributary to              transformative mainstream. Behavior Research and Therapy, 42, 613-630.
• Kirsch, I., Lynn, S. J., Vigorito, M., & Miller, R. R., (2004). The role of cognition in classical and operant conditioning. Journal of Clinical Psychology, 60(4), 369-392.
• Spiegler, M. D. (2016). Contemporary Behavior Therapy (6^th ed.). Wadsworth/Centage: Belmont, CA.