The Principles of Behavioral Therapy

Behavioral therapies are based on the theory of classical conditioning. The principle of behavioral therapy is all behavior is learned. Faulty learning (i.e. conditioning) is the cause of anomalous behavior. The aim of the behavioral therapy is to focus on current behavioral issues and on efforts to remove the undesirable behaviors. Behavioral therapy has clear distinctions from psychodynamic therapy (re: Freud) who emphasizes on uncovering unresolved conflicts from childhood (i.e. the cause of abnormal behavior). Skinner and A. Bandura are well known behavioral theorists Skinner developed a theory of operant conditioning. Operant conditioning is a method of learning that occurs through rewards and punishments for behavior. Through operant conditioning, an individual makes an association between a particular behavior and a consequence (Skinner, 1938). The main principle of operant conditioning is changing environmental events that are related to a person's behavior.

For example, the reinforcement of desired behaviors and ignoring or punishing undesired ones. Unlike Skinner, Bandura believed that humans are active information processors and think about the relationship between their behavior and its consequences. Observational learning could not occur unless cognitive processes were at work. These mental factors mediate in the learning process to determine whether a new response is acquired. Therefore, individuals do not automatically observe the behavior of a model and imitate it. There is some thought prior to imitation, and this consideration is called mediational processes. This occurs between observing the behavior (stimulus) and imitating it or not (response) (Bandura, 1977)

Examples of behavior therapy include: Systematic Desensitization, Aversion Therapy and Flooding. The theory of classical conditioning suggests a response is learned and repeated through immediate association. Behavioral therapies based on classical conditioning aim to break the association between stimulus and undesired response (e.g. phobia, additional etc.) Systematic desensitization Systematic desensitization was developed by South African psychologist Joseph Wolpe. In the 1950s. Wolpe discovered that the cats of Wits University could overcome their fears through gradual and systematic exposure.

The therapy is based on the principles of classical conditioning. The goals of systematic desensitization are to remove the fear response of a phobia and substitute a relaxation response to the conditional stimulus gradually using counter conditioning. (Wolpe, 1958) Treatment contains 3 phases: Phase 1 Learning a deep muscle relaxation technique and breathing exercises (control over breathing, muscle de tensioning or meditation). This step is very important because of reciprocal inhibition, where once response is inhibited because it is incompatible with another. For example in phobias, fears involves tension and tension is incompatible with relaxation. Phase 2 Forming a fear ladder starting at stimuli that create the least anxiety (fear) and building up in stages to the most fear-provoking images. The list is vital for building a therapy structure.

For example, define the ultimate level-10 scary Phase 3 Working the way up the fear ladder starting at the least unpleasant stimuli with relaxation techniques. Once comfortable and no longer afraid with the step 1 of the fear ladder, gradually move on to the step 2. If the client becomes upset, they can return to an earlier stage and regain their relaxed state. The client repeatedly imagines (or is confronted by) this situation until it fails to evoke any anxiety at all, indicating that the therapy has been successful. This process is repeated while working through all of the situations in the anxiety ladder until the most anxiety-provoking. Exposure can be done in two ways:

1. In vitro “ the client imagines exposure to the phobic stimulus.
2. In vivo “ the client is actually exposed to the phobic stimulus. Research has found that in vivo techniques are more successful than in vitro (Menzies & Clarke, 1993).

Whether the fear is of elevators or public speaking, the basic principles of systematic desensitization are the same: 1. Define the ultimate level-10 scary 2. Define level-1 scary 3. Brainstorm and rank all points in between. 4. Assign the level-1 scariest as homework. 5. In a week, review the homework and assign level 2. Depending on the severity of the phobia, number of sessions can vary from 4 to 12. Once therapeutic goals are met (not necessarily when the person's fears have been completely removed), the therapy is considered to be successful. Practical Issues In vitro exposition depends on patient's ability to to imagine the fearful object or situation. Some people cannot create a vivid image and thus systematic desensitization is not always effective Systematic desensitization is highly effective where the problem is a learned anxiety of specific objects/situations, e.g. phobias. It is not effective in treating serious mental disorders like depression and schizophrenia.

Systematic desensitization treats only the observable and measurable symptoms of phobia, not symptoms not the causes of the phobia. It's a substantial weakness because cognitions and emotions are often the motivators of behavior and so the treatment is only dealing with symptoms not the underlying causes. Systematic desensitization may not work on social phobias and agoraphobia due to the fact that it's usually originates from other psychological/biological issues vs learned behavior. (Lang, et.al., 1963) Flooding (Total Immersion) Flooding in its purest form involves forced, prolonged exposure to the actual stimulus that provoked the original trauma. (Wolpe, 1969) The idea of treatment phobia by exposure in feared situation was originally proposed by Freud in 1919.

In the mid-1960s, Thomas Stampfl, pioneered a technique called 'implosion therapy' to treat phobias, currently known as flooding. He discovered that after six to nine hours of detailed description of fearful situations, patients with phobia would most likely lose their fear. Stampfl's research was later refined by Zev Wanderer, who used biofeedback machines to monitor patients listening to verbal descriptions of what they most feared. Using phrases that provoked the most intense phobic reactions, he was able to reduce session time to about two hours for the first session and half an hour of exposure during the second session. Tape recording of the sessions were used for daily homework. Systematic research on flooding under its current name pioneered in the late 1960's by Wolpe.

According to Wolpe, flooding may in fact be the most rapid and effective of all available methods for treating phobias. (Wolpe, 1969) Skinner and Bandura are well known theorists . Skinner believes that behavior is Flooding works by exposing the patient directly to the phobic object or situation for an extended period of time in a safe and controlled environment. Unlike systematic desensitization which might use in vitro or virtual exposure, flooding generally involves in vivo exposure. The theory is based on the fact that fear is the time limited response, therefore, the patient may experience panic and extreme anxiety at first, but ultimately anxiety decreases due to exhaustion and patient has no choice but confront their fears. Subsequently, the fear which is anticipatory in the most cases is extinguished.

Prolonged intense exposure eventually creates a new association between the feared object and something positive like a sense of calm and lack of anxiety. It also prevents reinforcement of phobia through escape or avoidance behaviors. ( Wolpe, 1969) Considering the fact that not all the patients are able to tolerate high levels of anxiety flooding can lead to re-traumatization and reinforcement of fear avoidance response. There is a narrow therapeutic window between facing fears and reaching anxiety limits. Flooding is not an appropriate treatment for every phobia. Wolpe (1960) reported the case of a client whose anxiety intensified to such as degree that flooding therapy resulted hospitalization. Its successfully used for aquaphobia, claustrophobia, PTSD and agoraphobia. The success of the method confirms the hypothesis that phobias are so persistent because the object is avoided in real life and is therefore not extinguished by the discovery that it is harmless. (McLeod, 2010)

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