BEHAVIOUR THERAPY

INTRODUCTION:
✓ Every individual is best understood and evaluated by the way he thinks, feels, and
behaves.
✓ Behaviour, according to the psychologists, is a learnt activity, and can be unlearned and
relearned.
✓ Thus, there is a hope for the psychiatric patients whom we know have an alteration in
behaviour more towards a maladaptive type.
✓ Thus, this maladaptive behaviour may be unlearned and adaptive behaviour may be
relearned.
✓ Thus, comes the role of behaviour therapy and therapists.
✓ Behaviour therapy involves identifying maladaptive behaviors and seeking to correct
these by applying the Principles of Learning derived from the following theories:
• Classical Conditioning Model by Ivan Pavlov (1936)
• Operant Conditioning Model by BF Skinner (1953)

DEFINITION:
“It is a form of psychotherapy/treatment for problem in which a trained person deliberately
establishes a professional relationship with the patient, with the objective of removing or
modifying existing symptoms and promoting positive personality, growth and development.”
“Behaviour therapy or behaviour modification is the attempt to alter human behaviour and
emotions in a beneficial way according to the laws of modern learning theory.”
- Eysenck’s
GOAL OF BEHAVIOUR THERAPY: To identify and help an individual to change
potentially self-destruction or unhealthy behaviour.

MAJOR ASSUMPTIONS OF BEHAVIOUR THERAPY:

1) All behavior is learned (adaptive and maladaptive).

2) Human beings are passive organisms that can be conditioned or shaped to do anything
if correct responses are rewarded or reinforced.
3) Maladaptive behavior can be unlearned and replaced by adaptive behavior if the person
receives exposure to specific stimuli and reinforcement for the desired adaptive
behavior.
4) Behavior assessment is focused more on the current behavior rather than on historical
antecedents.
5) Treatment strategies are individually tailored.
• Behavior therapy is a short duration therapy, therapists are easy to train and it is cost-
effective.
• The total duration of therapy is usually 6-8 weeks.
• Initial sessions are given daily, but the later sessions are spaced out.
• Unlike psychoanalysis where the therapist is a shadow person, in behavior therapy both
the patient and therapist are equal participants.
BEHAVIOUR TECHNIQUES

1. SYSTEMIC DESENSITIZATION:
 It was developed by Joseph Wolpe, based on the behavioral principle of counter
conditioning.
In this, patient attain a state of complete relaxation and are then exposed to the stimulus
that elicits the anxiety response.
The negative reaction of anxiety is inhibited by the relaxed state, a process called
reciprocal inhibition.
It consists of three main steps:
A) Relaxation training
B) Hierarchy construction
C) Desensitization of the stimulus

A) Relaxation training:
There are many methods which can be used to induce relaxation. Some of them are:
❑ Jacobson’s progressive muscle relaxation
❑ Hypnosis
❑ Meditation or yoga
❑ Mental imagery
❑ Biofeedback
B) Hierarchy construction:
✓ Here the patient is asked to list all the conditions which provoke anxiety.
✓ Then he is asked to list them in a descending order of anxiety provocation.

C) Desensitization of the stimulus:

✓ This can either be done in reality or though imagination.
✓ At first, the lowest item in hierarchy is confronted.
✓ The patient is advised to signal whenever anxiety is produced.
✓ After a few trials, patient is able to control his anxiety gradually
FOR EXAMPLE; A child is having fear of crossing the road. For a few days the mother
can take the child to the road & just stand & talk about other thing. The child keeps
observing people crossing the road. Then after 2-3 days mother & child cross the road while
they are talking. This may reduce the anxiety in a child as he is allowed to cross the road
in a relaxed manner. Therapy is very useful for patient who have developed certain fears
specially to domestic animals like dog.
Indications: Phobias, Obessions, Compulsions, Certain sexual disorders
2. FLOODING (IMPLOSIVE THERAPY)
✓ The patient is directly exposed to the phobic stimulus, but escape is made impossible.
✓ By prolonged contact with the phobic stimulus, the therapist’s guidance and
encouragement and his modeling behavior reduce anxiety.
Indication: Specific phobias
For Examples; He has developed intense phobia of a lizard. During psychotherapy session
suddenly the therapist puts a rubberized lizard on the table. For a minute the patient may
get scared but gradually may start handling a rubberized lizard while taking.

3. AVERSION THERAPY:
✓ Pairing of the pleasant with an unpleasant response, so that even in absence of the
unpleasant response the pleasant stimulus becomes unpleasant by association.
 ✓ Punishment is presented immediately after a specific behavioral response and the
response is eventually inhibited.
✓ Unpleasant response is produced by electric stimulus, drugs, social disapproval or even
fantasy.
✓ Such as putting a bitter taste on nails or tongue for nail biting, giving drug like
apomorphine which cause nausea & vomiting on taking alcohol or an electric shock to
treat a child with enuresis and eating unhealthy food.
✓ Typically, 20-40 session are given, with each session lasting about 1 hour.
✓ After completion of treatment, booster session may be given.
Indications: Alcohol abuse, Paraphilias, Homosexuality, Transvestism

4. OPERANT CONDITIONING PROCEDURES FOR INCREASING ADAPTIVE

BEHAVIOUR
a) Positive reinforcement: When a behavioral response is followed by a generally
rewarding event such as food, praise or gifts, it tends to be strengthened and occurs more
frequently than before the reward. This used to increase desired behavior. Examples; as
soon as the infants gets up & walks, the mother claps & gives the infant a piece of chocolate
to enjoy.

b) Token economy: This program involves giving token rewards for appropriate or desired
target behaviors performed by the patient. The token can later be exchanged for other
rewards. For example, in inpatient hospital wards, patients receive a reward for performing
a desired behaviour, such as tokens which they may use to purchase luxury items or certain
privileges.
e.g., a patient with schizophrenia does not maintain personal hygiene. The day he maintains
he gets a token as reinforcer that he can watch T.V. when he desires. Like this he is able to
collect many tokens & adapt behaviors which is socially acceptable. Like maintaining
personal hygiene. Sometimes in return of tokens the patient may exchange then by asking
for PAROLE.

5. OPERANT CONDITIONING PROCEDURES TO TEACH NEW BEHAVIOUR

A) Modeling: Modeling is a method of teaching by demonstration, wherein the therapist
shows how a specific behavior is to be performed. In modeling, the patient observes other
patients indulging in target behaviors and getting rewards for those behaviors. This will make
the patient repeat the same behavior and earn rewards in the same manner.

b) Shaping: In shaping, the components of a particular skill, the behaviour is reinforced step-
by-step. The therapist starts shaping by reinforcing the existing behavior. This technique is
used in a behavior problem or mental retardation. For example; Shubam, 14, has an
intelligence level of a five years old child. He had never done any of these activities such as
washing hands before eating, wearing shoes & socks. The therapist trained the family member
to encourage Shubam to wear his socks & shoes. When he wears them, he should be taken for
a ride (car) which he enjoys the maximum. In this way he can be encourage to learn those
behaviors which he has never learnt.
C) Chaining: Chaining is used when a person fails to perform a complex task. The complex
task is broken into a number of small steps and each step is taught to the patient. In forward
chaining, one starts with the first step, goes on to the second step, then to the third and so on.
In backward chaining, one starts with the last step and goes on to the next step in a backward
fashion.
6. OPERANT CONDITIONING PROCEDURES FOR DECREASING
MALADAPTIVE BEHAVIOR
a) Extinction: It means removal of attention rewards permanently, following a problem
behavior. This includes actions like not looking at the patient, not talking to the patient, or
having no physical contact with the patient, etc. following the problem behaviour. This is
commonly used when patients exhibit odd behaviour. For Example;
Every time Sonu, a nine-year-old girl bites her nails, her mother gives her an angry look. Sonu
understand the mother anger & tries not to repeat the bad habit. A maladaptive behavior is
gradually removed. Mother anger is a punishment for Sonu.
Reward is also provided to reduce the maladaptive learning. Rishi, 11-year-old boy, is told
that if he studies one hour regularly on his own in class VI, he could be allowed to buy a cricket
set of his choice.
b) Punishment: The punishment procedure should be administered immediately and
consistently following the undesirable behavior with clear explanation. Differential
reinforcement of an adaptive or desirable punishment should always be added when a
punishment is being used for decreasing an undesirable behavior.
c) Time out: Timeout method includes removing the patient from the reward or the reward
from the patient for a particular period of time following a problem behavior. This is often
used in the treatment of childhood disorders. For e.g., the child is not allowed to go out of the
ward to play if he fails to complete the given work.
d) Restitution (over correction): Restitution means restoring the disturbed situation to a state
that is much better than what it was before the occurrence of the problem behavior. For e.g.,
if a patient passes urine in the ward, he would be required to not only clean the dirty area but
also mop the entire area of the floor in the ward.
e. Response cost: This procedure is used with individuals who are on token programs for
teaching adaptive behavior. When undesirable behavior occurs, a fixed number of tokens or
points are deducted from what the individual has already earned.
7. ASSERTIVENESS AND SOCIAL SKILL TRAINING
Assertive training is a behavior therapy technique in which the patient is given training to bring
about change in emotional and other behavioral pattern by being assertive. Patient is
encouraged not to be afraid of showing an appropriate response, negative or positive, to an
idea or suggestion. Assertive behavior training is given by the therapist, first by role play and
then by practice in a real-life situation. Social skills training helps to improve social manners
like encouraging eye contact, speaking appropriately, observing simple etiquette and relating
to people.
CONTRAINDICATIONS OF BEHAVIOUR THERAP
• Patients with severe mood disorder.
• Individuals with very limited intellectual functioning.
• Patients who are actively suicidal.

NURSES' ROLE BEHAVIOR THERAPY

➢ Devises (plan) behavioral objectives with the client.
➢ Identifies the behavior that is to be changed and breaks them down in to small and
manage able segments.
➢ Advocates for client’s identification behaviors that are appropriate, constructive and
amenable to change whatever the treatment setting.
➢ Observe, documents and outline behavior targeted for change.
➢ Teaches and reinforces behavior techniques particularly in inpatient or community
setting with a behavioral orientation.
➢ Teaches progressive relaxation to the client with anxiety, models, shapes and reinforces
appropriate behavior.
➢ Initiates and leads groups that focus on developing social skills and assertive behavior.
➢ Refers the clients for cognitive behavior therapy.
➢ As a member of the interdisciplinary team, conducts 6-20 sessions for effective
outcome.