Behavioral therapy

INTRODUCTION
A behavior is considered to be maladaptive when it is age inappropriate, when it interferes with adaptive
functioning, or when others misunderstand it in terms of cultural inappropriateness. The behavioral approach to
therapy is that people have become what they are through learning processes or, more correctly, through the
interaction of the environment with their genetic endowment. The basic assumption Is that problematic behaviors
occur when there has been inadequate learning and therefore can be corrected through the provision of appropriate
learning experiences. The principles of behavior therapy as we know it today are based on the early studies of
classical conditioning by Pavlov (1927) and operant conditioning by Skinner (1938). Although in this text the
Concepts are presented separately for reasons of clarification, behavioral change procedures are often combined
with cognitive procedures, and many behavior therapies are referred to as cognitive-behavioral therapies.

CLASSICAL CONDITIONING
Classical conditioning is a process of learning that was Introduced by the Russian physiologist Ivan Pavlov. In
His experiments with dogs, during which he hoped to learn more about the digestive process, he inadvertently
discovered that organisms can learn to respond in specific ways if they are conditioned to do so. In his trials he
found that, as expected, the dogs salivated when they began to eat the food that was offered to them. This was a
reflexive response that Pavlov called an unconditioned response. However, he also noticed that with time, the
dogs began to salivate when the food came into their range of view, before it was even presented to them for
consumption. Pavlov, concluding that this response was not reflexive but had been learned, called it a conditioned
response. He carried the experiments even further by Introducing an unrelated stimulus, one that had no previous
connection to the animal’s food. He simultaneously presented the food with the sound of a bell. The animal
responded with the expected reflexive salivation to the food. After a number of trials with the combined stimuli
(food and bell), Pavlov Found that the reflexive salivation began to occur when the dog was presented with the
sound of the bell in the absence of food.
This was an important discovery in terms of how learning can occur. Pavlov found that unconditioned responses
(salivation) occur in response to unconditioned stimuli (eating food). He also found that, over time, an unrelated
stimulus (sound of the bell) introduced with the unconditioned stimulus can elicit the same response alone that is,
the conditioned response. The unrelated stimulus is called the conditioned stimulus.

OPERANT CONDITIONING
The focus of operant conditioning differs from that of classical conditioning. With classical conditioning, the
focus is on behavioral responses that are elicited by specific objects or events. With operant conditioning,
additional attention is given to the consequences of the behavioral response.
Operant conditioning was introduced by B. F. Skinner (1953), an American psychologist whose work was largely
influenced by Edward Thorndike’s (1911) law of effect—that is, that the connection between a stimulus and a
response is strengthened or weakened by the consequences of the response. A Number of terms must be defined
in order to understand the concept of operant conditioning.
As defined previously, stimuli are environmental events that interact with and influence an individual’s behavior.
Stimuli may precede or follow a behavior. A Stimulus that follows a behavior (or response) is Called a reinforcing
stimulus or reinforcer. The function is called reinforcement. When the reinforcing stimulus increases the
probability that the behavior will recur, it is called a positive reinforcer, and the function Is called positive
reinforcement. Negative reinforcement is increasing the probability that a behavior will recur by removal of an
undesirable reinforcing stimulus. A stimulus that follows a behavioral response and decreases the probability that
the behavior will recur is called an aversive stimulus or punisher.
Stimuli that precede a behavioral response and predict that a particular reinforcement will occur are called
discriminative stimuli. Discriminative stimuli Are under the control of the individual. The individual is said to be
able to discriminate between stimuli and to choose according to the type of reinforcement he or she has come to
associate with a specific stimulus.

MAJOR ASSUMPTIONS OF BEHAVIOUR THERAPY

Based on above mentioned theories, the following are the assumptions of behavior therapy:
• All behavior is learned (adaptive and maladaptive)
• Human beings are passive organisms that can be conditioned or shaped to do anything if correct responses are
rewarded or reinforced
• 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
• Behavioral assessment is focused more on the current behavior rather than on historical antecedents
• 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. There is no attempt
to unearth an underlying conflict and the patient is not encouraged to explore his past

TECHNIQUES FOR MODIFYING CLIENT BEHAVIOR

Systemic decentralization: -
It was developed by Joseph Wolpe, based on the behavioral principle of counter conditioning. In this, patients 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.
1. 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
2. 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.
3. Desensitization of the stimulus: This either be done in reality or through imagination. At first, the lowest item in
hierarchy is confronted. The patient is advised to signal whenever anxiety is produced. With each signal he is asked
to relax. After a few trials, patient is able to control his anxiety gradually.
Indications:
• Phobias
• Obsessions
• Compulsions
• Certain sexual disorders.

Systematic desensitization is a technique for assisting Individuals to overcome their fear of a phobic stimulus. It
is “systematic” in that there is a hierarchy of anxiety-producing events through which the individual progresses
during therapy. An example of a hierarchy of events associated with a fear of elevators may be as follows:
 1. Discuss riding an elevator with the therapist.
2. Look at a picture of an elevator.
3. Walk into the lobby of a building and see the Elevators.
4. Push the button for the elevator.
5. Walk into an elevator with a trusted person; disembark before the doors close.
6. Walk into an elevator with a trusted person; allow Doors to close; then open the doors and walk out.
7. Ride one floor with a trusted person, then walk Back down the stairs.
8. Ride one floor with a trusted person and ride the Elevator back down.
9. Ride the elevator alone.

Flooding: -
This technique, sometimes called implosive therapy, is also used to desensitize individuals to phobic stimuli. It
differs from systematic desensitization in that, instead of working up a hierarchy of anxiety-producing stimuli,
the individual is “flooded” with a continuous presentation (through mental imagery) of the phobic stimulus until
it no longer elicits anxiety. Flooding is believed to produce results faster than systematic desensitization; however,
some therapists report more lasting behavioral changes with systematic desensitization. Some questions have also
been raised in terms of the psychological discomfort that this therapy produces for the client. Flooding is
contraindicated with clients for whom intense anxiety would be hazardous (e.g., individuals with heart disease or
fragile psychological adaptation) (Sadock & Sadock, 2007).

Aversion therapy: -
Pairing of the pleasant stimulus 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.
Indications:

• Alcohol abuse
• Paraphilias
• Homosexuality
• Transvestism.

Operant conditioning procedures for increasing adaptive behavior: -

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 technique is used to increase desired behavior.

Token Economy
Token economy is a type of contingency contracting (although there may or may not be a written and Signed
contract involved) in which the reinforcers for desired behaviors are presented in the form of Tokens. Essential
to this type of technique is the prior Determination of items and situations of significance to the client that can be
employed as reinforcements. With this therapy, tokens are awarded When desired behaviors are performed and
may be Exchanged for designated privileges.
For example, A client may be able to “buy” a snack or cigarettes for 2 tokens, a trip to the coffee shop or library
for 5 tokens, or even a trip outside the hospital (if that Is a realistic possibility) for another designated number of
tokens. The tokens themselves provide immediate positive feedback, and clients should be Allowed to make the
decision of whether to spend the token as soon as it is presented or to accumulate Tokens that may be exchanged
later for a more desirable reward.

Operant conditioning procedures to teach new behavior: -

Shaping
In shaping the behavior of another, reinforcements Are given for increasingly closer approximations to the desired
response. For example, in eliciting speech from an autistic child, the teacher may first reward the child for
(a) watching the teacher’s lips, then
(b) for making any sound in imitation of the teacher, then for forming sounds similar to the word uttered by the
teacher.
Shaping has been shown to be an effective way of modifying behavior for tasks that a child has not mastered on
command or are not in the child’s repertoire (Souders, DePaul, Freeman, & Levy, 2002).

Modeling
Modeling refers to the learning of new behaviors by Imitating the behavior in others.
Role models are individuals who have qualities or Skills that a person admires and wishes to imitate (Howard,
2000). Modeling occurs in various ways. Children imitate the behavior patterns of their parents, teachers, friends,
and others. Adults and children alike model many of their behaviors after individuals observed on television and
in movies. Unfortunately, Modeling can result in maladaptive behaviors, as well as adaptive ones.
In the practice setting clients may imitate the behaviors of practitioners who are charged with their care. This can
occur naturally in the therapeutic community environment. It can also occur in a therapy Session in which the
client watches a model demonstrate appropriate behaviors in a role-play of the client’s problem. The client is then
instructed to imitate the model’s behaviors in a similar role-play and is positively reinforced for appropriate
imitation.

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.
Backward chaining is found to be more effective in training the mentally disabled.

Operant conditioning procedures for decreasing maladaptive behavior: -

Extinction
Extinction is the gradual decrease in frequency or disappearance of a response when the positive reinforcement
is withheld. A classic example of this technique Is its use with children who have temper tantrums. The tantrum
behaviors continue as long as the parent gives attention to them but decrease and often disappear when the parent
simply walks away from the child and ignores the behavior.

Punishment
Aversive stimulus is presented contingent upon the undesirable response. The punishment procedure should be administered
immediately and consistently following the undesirable behavior with clear explanation. Differential reinforcement of an
adaptive or desirable behavior should always be added when a punishment is being used for decreasing an undesirable
behavior. Otherwise, the problem behaviors tend to get maintained because of the lack of adaptive behaviors and skill defect.
Time-Out
Time-out is an aversive stimulus or punishment during which the client is removed from the environment where
the unacceptable behavior is being exhibited. The client is usually isolated so that reinforcement from the attention
of others is absent.

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 example, if a patient passes urine in the ward, he would be required to not only clean the dirty
area but also mop the entire/larger area of the floor in the ward.

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.

Assertiveness and social skills training: -

Assertive training is a behavior therapy s 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. Attention is focused on more effective interpersonal skills. Social skills training
helps to improve social manners like encouraging eye contact, speaking appropriately, observing simple etiquette, and
relating to people.

Other techniques: -
Premack Principle
This technique, named for its originator, states that a frequently occurring response (R1) can serve as a positive
reinforcement for a response (R2) that occurs less frequently (Premack, 1959). This is accomplished by allowing
R1 to occur only after R2 has been performed.
For example, 13-year-old Jennie has been neglecting her homework for the past few weeks. She spends a lot of
time on the telephone talking to her friends. Applying the Premack principle, being allowed to talk on the
telephone to her friends could serve as a positive reinforcement for completing her homework.

Contingency Contracting
In contingency contracting, a contract is drawn up among all parties involved. The behavior change that is desired
is stated explicitly in writing. The contract specifies the behavior change desired and the reinforcers to be given
for performing the desired behaviors. The negative consequences or punishers that will be rendered for not
fulfilling the terms of the contract are also delineated. The contract is specific about how reinforcers and
punishment will be presented; however, flexibility is important so that renegotiations can occur if necessary.

Reciprocal Inhibition
Also called counter-conditioning, reciprocal inhibition decreases or eliminates a behavior by introducing a more
adaptive behavior, but one that is incompatible with the unacceptable behavior (Wolpe, 1958).
An example is the introduction of relaxation exercises to an individual who is phobic. Relaxation is practiced in
the presence of anxiety so that in time the individual is able to manage the anxiety in the presence of the phobic
stimulus by engaging in relaxation exercises. Relaxation and anxiety are incompatible behaviors.

Overt Sensitization
Overt sensitization is a type of aversion therapy that produces unpleasant consequences for undesirable behavior.
For example, disulfiram (Antabuse) is a Drug that is given to individuals who wish to stop drinking alcohol. If an
individual consumes alcohol while on Antabuse therapy, symptoms of severe nausea and vomiting, dyspnea,
palpitations, and headache Will occur. Instead of the euphoric feeling normally experienced from the alcohol (the
positive reinforcement for drinking), the individual receives a severe punishment that is intended to extinguish
the unacceptable behavior (drinking alcohol).

Covert Sensitization
Covert sensitization relies on the individual’s imagination to produce unpleasant symptoms rather than on
medication. The technique is under the client’s control and can be used whenever and wherever it Is required.
The individual learns, through mental imagery, to visualize nauseating scenes and even to induce a mild feeling
of nausea. This mental image Is visualized when the individual is about to succumb to an attractive but undesirable
behavior. It is most Effective when paired with relaxation exercises that Are performed instead of the undesirable
behavior. The primary advantage of covert sensitization is that the individual does not have to perform the
undesired behaviors but simply imagines them.

ROLE OF THE NURSE IN BEHAVIOR THERAPY

The nursing process is the vehicle for delivery of Nursing care with the client requiring assistance with behavior
modification.
1. Devises (plan) behavioural objectives with the client.
2. Identifies the behaviour that is to be changed and breaks them down in to small and manage able segments.
3. Advocates for client’s identification behaviours that are appropriate, constructive and amenable to change
whatever the treatment setting.
4. Observe, documents and outline behaviour targeted for change.
5. Teaches and reinforces cognitive – behaviour techniques particularly in inpatient or community setting
with a behavioural orientation.
6. Teaches progressive relaxation to the client with anxiety, models, shapes and reinforces appropriate
behaviour.
7. Initiates and leads groups that focus on developing social skills and assertive behaviours.
8. Refers the clients for cognitive behaviour therapy.
9. As a member of the interdisciplinary team, conducts 6-20 sessions for effective outcome.