Behavior therapy is a term used to describe a number of therapeutic procedures that share certain assumptions about the nature of behavioral and psychological problems and how they can best be overcome. The procedures can be classified into three main groups: fear-reduction procedures, operant conditioning procedures, and aversive techniques.
The major fear-reduction procedures consist of systematic desensitization, in which the person is trained to imagine a series of increasingly fearful images while in a state of relaxation; therapeutic modeling, in which the person observes and then imitates a therapist model engaging in increasingly close contact with the frightening object or situation; and flooding, in which the phobic person is exposed to intensely fearful stimulus situations for prolonged periods. In all of these methods, the phobic person is exposed to the real or imagined fear stimulus repeatedly and/or for prolonged periods, and in all of them attempts to escape from or avoid the fear stimulus are discouraged (response prevention). The combination of exposure and response prevention has proved to be a robust and dependable means for reducing fear, and the clinical efficacy of this combination in each of the three forms of fear-reduction procedures has been confirmed in numerous controlled clinical trials (Marks, 1987; O'Leary and Wilson, 1987).
All three methods can be traced back to the work of the Russian physiologist Ivan Petrovich Pavlov on conditioning, and especially to his research on experimental neurosis. In developing the first of the modern methods, systematic desensitization, Wolpe (1958) was influenced by the writings of Pavlov and the modern learning theorists, especially Clark Hull. Having rejected the psychodynamic approach, Wolpe attempted to apply modern learning techniques to psychological problems, particularly those in which anxiety is prominent. After completing a series of animal experiments, he concluded that graded, gradual re-exposures to a fearful stimulus are the best way to weaken or eliminate the fear. He also concluded that the fear-reduction process can be facilitated by the deliberate superimposition on the evoked fear response of a competing incompatible response (such as relaxation imposed on a fear response). Each occasion on which an incompatible response is imposed over the fear response is an instance of reciprocal inhibition. Wolpe argued that repeated instances of such reciprocal inhibition give rise to a relatively permanent form of conditioned inhibition (of fear), and that the therapeutic effects are a direct consequence of the reciprocal inhibition.
Desensitization is the earliest and best-established of the methods, but Wolpe introduced a number of other therapeutic procedures. Most attention, however, has been devoted to desensitization, which has been the subject of considerable experimental work and testing. This research advanced the therapeutic efficacy of these results and gave rise to a fresh view of fear itself.
Additions to and improvements of the clinical techniques were introduced in the early 1970s, and for certain types of anxiety disorders (such as panic disorder, agoraphobia, obsessional disorders, simple phobias), therapeutic modeling replaced desensitization as the method of choice. In most cases, therapeutic modeling and flooding are carried out in vivo, an unfortunately chosen term that here means exposure to the fear stimulus rather than to an imagined representation of the stimulus (as in the desensitization procedure). The development of therapeutic modeling, largely the result of Bandura's work (1969), consists of repeated exposures to the fear stimulus. The phobic person first watches and then imitates the approach behavior of a therapeutic model. The method is effective and well accepted by most subjects, clients, and patients. Flooding is seldom the first choice of treatment but can be used in certain cases such as extensive obsessional/compulsive problems. Systematic desensitization remains useful for numerous problems, especially those in which direct exposure is impractical or unacceptable, as in the treatment of certain sexual disorders and social phobias.
All of the fear-reduction techniques are applications of learning procedures to clinical problems, and, in common with the other forms of behavior therapy, are based on the assumption that most psychological problems can be overcome by the use of conditioning or other learning processes. In the early stages of behavior therapy, it was assumed that most psychological problems are the result of faulty learning (for instance, "Symptoms are unadaptive responses" and "Symptoms are evidence of faulty learning" [Eysenck and Rachman, 1965, p. 12]). Furthermore, it was argued that problems that are the result of faulty learning can be unlearned. In due course, more complex explanations were substituted.
The second form of behavior therapy, consisting of the application of operant conditioning ideas and procedures to clinical problems, was engineered in the United States and applied mainly to the psychological problems of children and adults with severe handicaps (e.g., mentally retarded people in or out of institutions and people with chronic and serious psychiatric disturbances, especially chronic schizophrenia). The fear-reduction techniques, developed mainly in Britain, are still used predominantly in dealing with adult neurotic problems, especially anxiety disorders such as obsessional disorders, panic disorders, social phobias, and circumscribed phobias.
The clinical application of operant conditioning later referred to as reinforcement therapy was a direct application of Skinnerian ideas, with emphasis on the consequences of behavior. Behavior that is followed by a reward will be strengthened and behavior that is followed by nonreward will be weakened.
The first application consisted of a series of attempts to treat schizophrenic problems in laboratory settings, but only limited success was achieved until the methods were applied, often with considerable ingenuity, to the maladaptive behavior of institutionalized patients with chronic psychiatric disorders (e.g., Ayllon and Azrin, 1968). Notable advances were made by the selective reinforcement of desirable behavior (e.g., self-care, eating) and the withholding of (social) reinforcement after undesirable behavior. Many of these useful advances were later incorporated into an institutional program that Ayllon and Azrin, two pioneers of this work, called the token economy (exchangeable tokens having replaced tangible rewards). The fact that the large ambitions of the earlier workers who expected reinforcement therapy to eliminate these psychiatric problems were never achieved does not detract from the contribution that this form of therapy continues to make. It is widely used to modify the maladaptive behavior of retarded children and adults, patients with chronic psychiatric disorders, children with speech or other behavioral deficits, and in educational settings.
Aversion therapy is a direct application of Pavlovian conditioning to appetitive but maladaptive behavior such as the excessive use of alcohol and was originally prompted by the discovery that laboratory animals can develop conditioned nausea reactions to the stimuli that are associated with the administration of drugs that induce nausea. In order to convert the aberrant stimuli (such as inappropriate sexual stimuli or alcohol) into conditioned stimuli for nausea or other unpleasant responses, the alcohol or sexual stimuli are contingently followed by aversive stimulation. The earlier and still most common form of aversion therapy consists of pairing an alcohol-conditioned stimulus with aversive nausea induced by drugs. This form of chemical aversion therapy is used mainly in the treatment of alcoholism; the other technique, electrical aversion therapy, in which the aversive stimulus is an electric shock, is used mainly in the treatment of aberrant sexual behavior such as pedophilia. Although aversion therapy appears to make a useful contribution to dealing with alcohol and sexual problems, it is rarely sufficient and nowadays is used as part of a wider therapeutic program that typically includes counseling, group therapy, and family therapy. This insufficiency, the ethical problems involved in the deliberate application of aversive stimuli, and the fact that the precise nature of the conditioning processes involved in aversion therapy is not fully understood have combined to limit its use.
The other two forms of behavior therapy also have their limitations, so clinicians have been receptive to the growing influence of cognitive analyses of psychological and clinical phenomena. Behavior therapy has been expanded to include the influence of cognitive factors, and most practitioners now favor cognitive behavior therapy, which combines the original forms of behavior therapy with cognitive analyses of the problem and cognitive procedures for helping to deal with them. Cognitive behavior therapy appears to have achieved most success in the treatment of depression (Beck, 1976; O'Leary and Wilson, 1987).
Ayllon, T., and Azrin, N. (1968). The token economy. New York: Appleton.
Bandura, A. (1969). Principles of behavior modification. New York: Holt.
Beck, A. (1976). Cognitive therapy and the emotional disorders. New York: International University Press.
Eysenck, H., and Rachman, S. (1965). The causes and cures of narcosis. London: Routledge and Kegan Paul.
Marks, I. (1987). Fears, phobias, and rituals. Oxford: Oxford University Press.
O'Leary, K., and Wilson, G. T. (1987). Behavior therapy, 2nd edition. Englewood Cliffs, NJ: Prentice-Hall.
Rachman, S. (1990). Fear and courage, 2nd edition. New York: W. H. Freeman.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press.
A goal-oriented, therapeutic approach that treats emotional and behavioral disorders as maladaptive learned responses that can be replaced by healthier ones with appropriate training.
In contrast to the psychoanalytic method of Sigmund Freud (1856-1939), which focuses on unconscious mental processes and their roots in the past, behavior therapy focuses on observable behavior and its modification in the present. Behavior therapy was developed during the 1950s by researchers and therapists critical of the psychodynamic treatment methods that prevailed at the time. It drew on a variety of theoretical work, including the classical conditioning principles of the Russian physiologist Ivan Pavlov (1849-1936), who became famous for experiments in which dogs were trained to salivate at the sound of a bell, and the work of American B.F. Skinner (1904-1990), who pioneered the concept of operant conditioning , in which behavior is modified by changing the response it elicits. By the 1970s, behavior therapy enjoyed widespread popularity as a treatment approach. Over the past two decades, the attention of behavior therapists has focused increasingly on their clients' cognitive processes, and many therapists have begun to use cognitive behavior therapy to change clients' unhealthy behavior by replacing negative or self-defeating thought patterns with more positive ones.
As an initial step in many types of behavioral therapy, the client monitors his or her own behavior carefully, often keeping a written record. The client and therapist establish a set of specific goals that will result in gradual behavior change. The therapist's role is often similar to that of a coach or teacher who gives the client "homework assignments" and provides advice and encouragement. Therapists continuously monitor and evaluate the course of the treatment itself, making any necessary adjustments to increase its effectiveness.
A number of specific techniques are commonly used in behavioral therapy. Human behavior is routinely motivated and rewarded by positive reinforcement . A more specialized version of this phenomenon, called systematic positive reinforcement, is used by behavior-oriented therapists. Rules are established that specify particular behaviors that are to be reinforced, and a reward system is set up. With children, this sometimes takes the form of tokens that may be accumulated and later exchanged for certain privileges. Just as providing reinforcement strengthens behaviors, withholding it weakens them. Eradicating undesirable behavior by deliberately withholding reinforcement is another popular treatment method called extinction . For example, a child who habitually shouts to attract attention may be ignored unless he or she speaks in a conversational tone.
Aversive conditioning employs the principles of classical conditioning to lessen the appeal of a behavior that is difficult to change because it is either very habitual or temporarily rewarding. The client is exposed to an unpleasant stimulus while engaged in or thinking about the behavior in question. Eventually the behavior itself becomes associated with unpleasant rather than pleasant feelings. One treatment method used with alcoholics is the administration of a nausea-inducing drug together with an alcoholic beverage to produce an aversion to the taste and smell of alcohol by having it become associated with nausea. In counter conditioning , a maladaptive response is weakened by the strengthening of a response that is incompatible with it. A well-known type of counterconditioning is systematic desensitization , which counteracts the anxiety connected with a particular behavior or situation by inducing a relaxed response to it instead. This method is often used in the treatment of people who are afraid of flying. Modeling , another treatment method, is based on the human tendency to learn through observation and imitation . A desired behavior is performed by another person while the client watches. In some cases, the client practices the behavior together with a model, who is often the therapist.
Ammerman, Robert T. and Michel Hersen, eds. Handbook of Behavior Therapy with Children and Adults: A Developmental and Longitudinal Perspective. New York: Allyn and Bacon, 1993.
Craighead, Linda W. Cognitive and Behavioral Interventions: An Empirical Approach to Mental Health Problems. Boston: Allyn and Bacon, 1994.
O'Leary, K. Daniel and G. Terence Wilson. Behavior Therapy: Application and Outcome. Englewood Cliffs, NJ: Prentice-Hall, 1975.
Wolpe, Joseph. The Practice of Behavior Therapy. Tarrytown, NY: Pergamon Press, 1996.
Association for the Advancement of Behavior Therapy. 15 W. 36th St., New York, NY 10018, (212) 647-1890.