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Behaviour therapy
ICD-9-CM94.33
MeSHD001521

Behavior therapy or behaviour therapy (see American and British spelling differences) is a behavioral psychotherapy that focuses on a set of methods designed for reinforcing desired and eliminating undesired behaviors without concerning itself with the psychoanalytic state of the subject. In its broadest sense the methods focus on behaviors not the thoughts and feelings that might be causing the them. Behavioral psychotherapy breaks down into two disciplines, a more narrowly defined sense of behavior therapy and behavior modification. Within the psychological theories of learning and conditioning, behavior therapy generally treats psychopathology with pavlovian or respondent conditioning, while behavior modification makes use of operant or instrumental conditioning. These distinctions are not absolute with some crossover occuring in practice.[1]

History[edit]

Psychotherapy is the use of psychological theories and methods in the treatment of psychiatric disorders. Modern, scientific psychology is often dated to the opening of the first psychological clinic by Wilhelm Wundt in 1879. Attempts at creating methods for assessing and treating mental distress existed long before that. The earliest recorded approaches were a combination of religious, magical and/or medical perspectives.[2]

Further information: History of psychotherapy

Behavioral psychotherapy is concerned with treatments involving conditioning and modern learning theory with behaviour therapy as one of its methods. Behaviour therapy is based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. There has been a good deal of confusion on how these two conditionings are alike and differ.

Further information: /History of Behavioral Psychotherapy

Methods[edit]

By nature, behavioural therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behaviour ultimately has), probabilistic (viewing behaviour as statistically predictable), monistic (rejecting mind–body dualism and treating the person as a unit), and relational (analysing bidirectional interactions).[3] The Ninth Revision of the International Classification of Disease (ICD-9) List the following six interventions under the category of behavior therapy:

Current forms[edit]

Behavioral therapy based on operant and respondent principles has considerable evidence base to support its usage.[4] This approach remains a vital area of clinical psychology and is often termed clinical behavior analysis. Behavioral psychotherapy has become increasingly contextual in recent years.[5] Behavioral psychotherapy has developed greater interest in recent years in personality disorders[6] as well as a greater focus on acceptance[7]and complex case conceptualizations.[8]

Behavioral psychotherapy is one of two streams of thought (the other being cognitive psychotherapy) that have come together to produce cognitive behavioral therapy: a talking therapy.

One current form of behavioral psychotherapy is functional analytic psychotherapy. Functional analytic psychotherapy is a longer duration behavior therapy.[9] Functional analytic therapy focuses on in-session use of reinforcement and is primarily a relationally-based therapy.[10][11]As with most of the behavioral psychotherapies, functional analytic psychotherapy is contextual in its origins and nature.[12] and draws heavily on radical behaviorism and functional contextualism.

Functional analytic psychotherapy holds to a process model of research, which makes it unique compared to traditionalbehavior therapy and cognitive behavioral therapy.[13][14]

Functional analytic psychotherapy has a strong research support. Recent functional analytic psychotherapy research efforts are focusing on management of aggressive inpatients.[15]

Contingency management programs are a direct product of research from operant conditioning. These programs have been highly successful with those suffering from panic disorders, anxiety disorders, and phobias.[16]

Systematic desensitisation and exposure and response prevention both evolved from respondent conditioning and have also received considerable research.

Behavior avoidance test (BAT) is a behavioral procedure in which the therapist measures how long the client can tolerate an anxiety-inducing stimulus[17]. The BAT falls under the exposure-based methods of Behavior Therapy. Exposure-based methods of behavioral therapy are well suited to the treatment of phobias, which include intense and unreasonable fears (e.g., of spiders, blood, public speaking). The therapist needs some type of behavioral assessment to record the continuing progress of a client undergoing an exposure-based treatment for phobia. The simplest possible assessment approach for this is the BAT. The BAT approach is predicted on the reasonable assumption that the client’s fear is the main determinant of behavior in the testing situation. BAT can be conducted visual, virtually, or physically, depending on the clients’ maladaptive behavior. Its application is not limited to phobias, it is applied to various disorders such as Post-Traumatic Stress Disorder (PTSD) and Obsessive-Compulsive Disorder (OCD).[18]

Social skills training teaches clients skills to access reinforcers and lessen life punishment. Operant conditioningprocedures in meta-analysis had the largest effect size for training social skills, followed by modelling, coaching, and social cognitive techniques in that order.[19] Social skills training has some empirical support particularly for schizophrenia.[20][21]However, with schizophrenia, behavioural programs have generally lost favour.[22]

Applied to problem behaviour[edit]

Behaviour therapy based its core interventions on functional analysis. Just a few of the many problems that behaviour therapy have functionally analysed include intimacy in couples relationships,[23][24][25] forgiveness in couples,[26] chronic pain,[27] stress-related behaviour problems of being an adult child of an alcoholic,[28] anorexia,[29]chronic distress,[30]substance abuse,[31]depression,[32] anxiety,[33] and obesity.[34]

Functional analysis has even been applied to problems that therapists commonly encounter like client resistance, particially engaged clients and involuntary clients.[35][36] Applications to these problems have left clinicans with considerable tools for enhancing therapeutic effectiveness. One way to enhance therapeutic effectiveness is to use positive reinforcement or operant conditioning.

Many have argued that behaviour therapy is at least as effective as drug treatment for depression, ADHD, and OCD.[37] Although, two large studies done by the Faculty of Health Sciences at Simon Fraser University indicates that both behaviour therapy and cognitive-behavioural therapy(CBT) are equally effective for OCD. CBT has been proven to perform slightly better at treating co-occurring depression.[38]

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy (habit reversal training) has been found to be highly effective for treating tics.

Behavioural therapy develops, adds and provides behavioural intervention strategies and programs for clients, and training to people who care to facilitate successful lives in the communities.

Third wave Approaches[edit]

  • Wave two - Behaviorism & Cognitivism
  • verbal behaviour
Acceptance and Commitment Therapy (ACT)
cognitive behavioural therapy (CBT)
Dialectical Behavior Therapy (DBT)
Functional Analytic Psychotherapy (FAP)

Of particular interest, in behaviour therapy today are the areas often referred to as Third Generation Behaviour Therapy.[39]This movement has been called clinical behavior analysis because it represents a movement away from cognitivism and back toward radical behaviourism and other forms of behaviourism, in particular functional analysis and behavioural models of verbal behaviour. This area includes Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Analysis System of Psychotherapy (CBASP) (McCullough, 2000), behavioural activation (BA), Kohlenberg & Tsai'sFunctional Analytic Psychotherapy, integrative behavioural couples therapyand dialectical behavioural therapy. These approaches are squarely within theapplied behaviour analysis tradition of behaviour therapy.

Acceptance and Commitment Therapy is probably the most well-researched of all the third generation behaviour therapy models. It is based on Relational Frame Theory.[40]

Functional Analytic Psychotherapy is based on a functional analysis of the therapeutic relationship.[41] It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement.[42] In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.[43]

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component.[44] Behavioural activation is based on a matching model of reinforcement.[45] A recent review of the research, supports the notion that the use of behavioural activation is clinically important for the treatment of depression.[46]

Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1966) for the difference between contingency-shaped and rule-governed behaviour.[47] It couples this analysis with a thorough functional assessment of the couple's relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness.[48]

Behavior modification[edit]

is the use of empirically demonstrated behavior change techniquesto increase or decrease the frequency of behaviors, such as altering an individual's behaviors and reactions to stimuli through positive and negative reinforcement of adaptive behavior and/or the reduction of behavior through itsextinction, punishment and/or satiation. Most behavior modification programs currently used are those based on Applied behavior analysis (ABA), formerly known as the experimental analysis of behavior which was pioneered by B. F. Skinner.

Martin and Pear indicate that there are seven characteristics to behavior modification,[49] They are:

  • There is a strong emphasis on defining problems in terms of behavior that can be measured in some way.
  • The treatment techniques are ways of altering an individual's current environment to help that individual function more fully.
  • The methods and rationales can be described precisely.
  • The techniques are often applied in everyday life.
  • The techniques are based largely on principles of learning
    specifically operant conditioning and respondent conditioning
  • There is a strong emphasis on scientific demonstration that a particular technique was responsible for a particular behavior change.
  • There is a strong emphasis on accountability for everyone involved in a behavior modification program.

Organisations[edit]

Many organisations exist for behaviour therapists around the world. The World Association for Behavior Analysis offers a certification in behaviour therapy [20]. In the United States, the American Psychological Association's Division 25 is the division for behaviour analysis. The Association for Contextual Behavior Therapy is another professional organisation. ACBS is home to many clinicians with specific interest in third generation behaviour therapy. The Association for Behavioral and Cognitive Therapies (formerly the Association for the Advancement of Behavior Therapy) is for those with a more cognitive orientation. Internationally, most behaviour therapists find a core intellectual home in the International Association for Behavior Analysis (ABAI)[21].

Techniques[edit]

Therapy and consultation cannot be effective unless the behaviors to be changed are understood within a specific context.[50][51] The process of understanding behavior in context is called functional behavioral assessment.[52] One of the most simple yet effective methods of functional behavioral assessment is called the "ABC" approach, where observations are made onAntecedents, Behaviors, and Consequences. In other words, "What comes directly before the behavior?", "What does the behavior look like?", and "What comes directly after the behavior?" Once enough observations are made, the data are analyzed and patterns are identified. If there are consistent antecedents and/or consequences, an intervention should target those to increase or decrease the target behavior. This method forms the core of positive behavior support for schoolchildren in both regular and special education.

In recent years, the concept of punishment has had many critics, though these criticisms tend not to apply to negative punishment (time-outs) and usually apply to the addition of some aversive event. The use of positive punishment by board-certified behavior analysts is restricted to extreme circumstances when all other forms of treatment have failed and when the behavior to be modified is a danger to the person or to others (see professional practice of behavior analysis). In clinical settings positive punishment is usually restricted to using a spray bottle filled with water as an aversive event. When misused, more aversive punishment can lead to affective (emotional) disorders, as well as to the receiver of the punishment increasingly trying to avoid the punishment (i.e., "not get caught").

Behavior modifiers like to employ a variety of evidence-based techniques. These techniques intervene at all levels of context. For example, given specific setting events for a behavior, a behavior modifier may develop a neutralizing routine to eliminate that setting. If a behavior pattern has a specific antecedent, or trigger, then an antecedent control strategy can be developed to train new behavior in the presence of the trigger. If a problem behavior readily occurs because it achieves some function, then an alternative behavior can be instructed and trained to occur in the context of the trigger.[50][51] If a behavior is particularly complex it may be task-analyzed and broken into its component parts to be taught through chaining. While all these methods are effective, when the behavior problem gets difficult or when all else fails many turn to contingency management systems.[53] Complex and comprehensive contingency management systems have been developed and represent effective ways to eliminate many problem behaviors (see applied behavior analysis and positive behavior support). Collaborative goal setting with the client enhances treatment effects.[49]

Some areas of effectiveness[edit]

Functional behavior assessment forms the core of applied behavior analysis and thus forms the core of behavior modification. Many techniques in this therapy are specific techniques aimed at specific issues. Interventions based on behavior analytic/modification principles have been extremely effective in developing evidence-based treatments.[54]

In addition to the above, a growing list of research-based interventions from the behavioral paradigm exist. With children with attention deficit hyperactivity disorder (ADHD), one study showed that over a several year period, children in the behavior modification group had half the number of felony arrests as children in the medication group.[55][56] These findings have yet to be replicated, but are considered encouraging for the use of behavior modification for children with ADHD. There is strong and consistent evidence that behavioral treatments are effective for treating ADHD. A recent meta-analysis found that the use of behavior modification for ADHD resulted in effect sizes in between group studies (.83), pre-post studies (.70), within group studies (2.64), and single subject studies (3.78) indicating behavioral treatments are highly effective.[57]

Behavior modification programs form the core of many residential treatment facilityprograms. They have shown success in reducing recidivism for adolescents with conduct problems and adult offenders. One particular program that is of interest is teaching-family homes (see Teaching Family Model), which is based on a social learning model that emerged from radical behaviorism. These particular homes use a family style approach to residential treatment, which has been carefully replicated over 700 times.[58] Recent efforts have seen a push for the inclusion of more behavior modification programs in residential re-entry programs in the U.S. to aid prisoners in re-adjusting after release.

One area that has repeatedly shown effectiveness has been the work of behaviorists working in the area of community reinforcement for addictions.[59] Another area of research that has been strongly supported has been behavioral activation for depression.[60]

One way of giving positive reinforcement in behavior modification is in providing compliments, approval, encouragement, andaffirmation; a ratio of five compliments for every one complaint is generally seen as being effective in altering behavior in a desired manner[61]and even in producing stable marriages.[62]

Of notable interest is that the right behavioral intervention can have profound system effects. For example, Forgatch and DeGarmo (2007) found that with mothers who were recently divorced, a standard round of parent management training (a program based on social learning principles that teaches rewarding good behavior and punishing bad behavior combined with communication skills) could help elevate the divorced mother out of poverty.[63] In addition, parent management training programs, sometimes referred to as behavioral parent training programs, have shown relative cost effectiveness for their efforts[64] for the treatment of conduct disorder. Thus, such intervention can have profound effects on socializing the child in a relatively cost effective fashion and help get the parent out of poverty. This level of effect is often looked for and valued by those who practice behavioral engineering and results of this type have caused the Association for Behavior Analysis International to take a position that those receiving treatment have a right to effective treatment[65] and a right to effective education.[66]

Criticism[edit]

Behavior modification is critiqued in person-centered psychotherapeutic approaches such as Rogerian Counseling and Re-evaluation Counseling,[67] which involve "connecting with the human qualities of the person to promote healing", while behaviorism is "denigrating to the human spirit".[68] B.F. Skinner argues in Beyond Freedom and Dignity that unrestricted reinforcement is what led to the "feeling of freedom", thus removal of aversive events allows people to "feel freer".[69] Further criticism extends to the presumption that behavior increases only when it is reinforced. This premise is at odds with research conducted by Albert Bandura at Stanford University. His findings indicate that violent behavior is imitated, without being reinforced, in studies conducted with children watching films showing various individuals "beating the daylights out of Bobo". Bandura believes that human personality and learning is the result of the interaction between environment, behavior and psychological process. There is evidence, however, that imitation is a class of behavior that can be learned just like anything else. Children have been shown to imitate behavior that they have never displayed before and are never reinforced for, after being taught to imitate in general.[70]

Several people have criticized the level of training required to perform behavior modification procedures, especially those that are restrictive or use aversives, aversion therapy, or punishment protocols. Some desire to limit such restrictive procedures only to licensed psychologists or licensed counselors. Once licensed for this group, post-licensed certification in behavior modification is sought to show scope of competence in the area through groups like the World Association for Behavior Analysis [22]. Still others desire to create an independent practice of behavior analysis through licensure to offer consumers choices between proven techniques and unproven ones (seeProfessional practice of behavior analysis). Level of training and consumer protection remain of critical importance inapplied behavior analysis and behavior modification.

While behavior analysis continues to grow as a science by including more environmental factors and behaviorism grows as a philosophy, some continue to criticize it for being reductionist.

Methods[edit]

See also[edit]

References[edit]

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