Behavior Therapies

• 71-1 How does the basic assumption of behavior therapy differ from the assumptions of psychodynamic and humanistic therapies? What techniques are used in exposure therapies and aversive conditioning?

The insight therapies assume that self-awareness and psychological well-being go hand in hand. Psychodynamic therapists expect people’s problems to diminish as they gain insight into their unresolved and unconscious tensions. Humanistic therapists expect problems to diminish as people get in touch with their feelings. Behavior therapists, however, doubt the healing power of self-awareness. Rather than delving deeply below the surface looking for inner causes, behavior therapists assume that problem behaviors are the problems. (You can become aware of why you are highly anxious during tests and still be anxious.) If phobias, sexual dysfunctions, or other maladaptive symptoms are learned behaviors, why not apply learning principles to replace them with new, constructive behaviors?

behavior therapy

therapy that applies learning principles to the elimination of unwanted behaviors.

A man is standing next to the car with its hood popped up, while two mechanics, one labeled “Freudian” and the other labeled “Behavior Therapist”, speak to him. The Freudian says “What’s the nature of the trouble, and where did it begin?”. The Behavior Therapist says “Let’s drive it around and see what happens.”

Classical Conditioning Techniques

One cluster of behavior therapies derives from principles developed in Ivan Pavlov’s early twentieth-century conditioning experiments (Module 26). As Pavlov and others showed, we learn various behaviors and emotions through classical conditioning. If we’re attacked by a dog, we may thereafter have a conditioned fear response when other dogs approach. (Our fear generalizes, and all dogs become conditioned stimuli.)

Could maladaptive symptoms be examples of conditioned responses? If so, might reconditioning be a solution? Learning theorist O. H. Mowrer thought so. He developed a successful conditioning therapy for chronic bed-wetters, using a liquid-sensitive pad connected to an alarm. If the sleeping child wets the bed pad, moisture triggers the alarm, waking the child. After a number of trials, the child associates bladder relaxation with waking. In three out of four cases, the treatment has been effective and the success boosted the child’s self-image (Christophersen & Edwards, 1992; Houts et al., 1994).

Can we unlearn fear responses, such as to public speaking or flying, through new conditioning? Many people have. An example: The fear of riding in an elevator is often a learned aversion to being in a confined space. Counterconditioning, such as with exposure therapy, pairs the trigger stimulus (in this case, the enclosed space of the elevator) with a new response (relaxation) that is incompatible with fear.

counterconditioning

behavior therapy procedures that use classical conditioning to evoke new responses to stimuli that are triggering unwanted behaviors; include exposure therapies and aversive conditioning.

Exposure Therapies

Picture this scene: Behavioral psychologist Mary Cover Jones is working with 3-year-old Peter, who is petrified of rabbits and other furry objects. To rid Peter of his fear, Jones plans to associate the fear-evoking rabbit with the pleasurable, relaxed response associated with eating. As Peter begins his midafternoon snack, she introduces a caged rabbit on the other side of the huge room. Peter, eagerly munching away on his crackers and drinking his milk, hardly notices. On succeeding days, she gradually moves the rabbit closer and closer. Within two months, Peter is holding the rabbit in his lap, even stroking it while he eats. Moreover, his fear of other furry objects subsides as well, having been countered, or replaced, by a relaxed state that cannot coexist with fear (Fisher, 1984; Jones, 1924).

AP^® EXAM TIP

Before you read the next several pages of this module, you may want to quickly review the material on classical and operant conditioning in Unit VI (Learning). Note that behavior therapists, like psychodynamic therapists, focus on childhood experiences, but in a different way. Behavior therapists acknowledge that conditioned responses may result from childhood experiences; psychodynamic therapists instead work on resolving unconscious conflicts stemming from childhood.

Unfortunately for many who might have been helped by Jones’ counterconditioning procedures, her story of Peter and the rabbit did not enter psychology’s lore when it was reported in 1924. It was more than 30 years before psychiatrist Joseph Wolpe (1958; Wolpe & Plaud, 1997) refined Jones’ counterconditioning technique into the exposure therapies used today. These therapies, in a variety of ways, try to change people’s reactions by repeatedly exposing them to stimuli that trigger unwanted reactions. With repeated exposure to what they normally avoid or escape, people adapt. We all experience this process in everyday life. A person moving to a new apartment may be annoyed by nearby loud traffic noise, but only for a while. The person adapts. So, too, with people who have fear reactions to specific events. Exposed repeatedly to the situation that once petrified them, with support from talk therapy, they can learn to react less anxiously (Barrera et al., 2013; Foa & McLean, 2016).

exposure therapies

behavioral techniques, such as systematic desensitization and virtual reality exposure therapy, that treat anxieties by exposing people (in imaginary or actual situations) to the things they fear and avoid.

One exposure therapy used to treat phobias is systematic desensitization. You cannot simultaneously be anxious and relaxed. Therefore, if you can repeatedly relax when facing anxiety-provoking stimuli, you can gradually eliminate your anxiety. The trick is to proceed gradually. If you fear public speaking, a behavior therapist might first help you construct a hierarchy of anxiety-triggering speaking situations. Yours might range from mildly anxiety-provoking situations (perhaps speaking up in a small group of friends) to panic-provoking situations (having to address a large audience).

systematic desensitization

a type of exposure therapy that associates a pleasant relaxed state with gradually increasing anxiety-triggering stimuli. Commonly used to treat phobias.

Next, the therapist would train you in progressive relaxation. You would learn to release tension in one muscle group after another, until you achieve a comfortable, complete relaxation. Then the therapist might ask you to imagine, with your eyes closed, a mildly anxiety-arousing situation: You are having coffee with a group of friends and are trying to decide whether to speak up. If imagining the scene causes you to feel any anxiety, you will signal by raising your finger. Seeing the signal, the therapist will instruct you to switch off the mental image and go back to deep relaxation. This imagined scene is repeatedly paired with relaxation until you feel no trace of anxiety.

The therapist will then move to the next item in your anxiety hierarchy, again using relaxation techniques to desensitize you to each imagined situation. After several sessions, you move to actual situations and practice what you had only imagined before, beginning with relatively easy tasks and gradually moving to more anxiety-filled ones. Conquering your anxiety in an actual situation, not just in your imagination, will increase your self-confidence (Foa & Kozak, 1986; Williams, 1987). Eventually, you may even become a confident public speaker. Often people fear not just a situation, such as public speaking, but also being incapacitated by their own fear response. As their fear subsides, so also does their fear of the fear.

“ The only thing we have to fear is fear itself.”

U.S. President Franklin D. Roosevelt First inaugural address, 1933

If an anxiety-arousing situation is too expensive, difficult, or embarrassing to re-create, the therapist may recommend virtual reality exposure therapy. You would don a head-mounted display unit that projects a three-dimensional virtual world. The lifelike scenes, which shift as your head turns, would be tailored to your particular fear. Experimentally treated fears include flying, heights, particular animals, and public speaking (Parsons & Rizzo, 2008). If you fear flying, you could peer out a virtual window of a simulated plane, feel the engine’s vibrations, and hear it roar as the plane taxis down the runway and takes off. In controlled studies, people participating in virtual reality exposure therapy have experienced significant relief from real-life fear (Turner & Casey, 2014).

virtual reality exposure therapy

a counterconditioning technique that treats anxiety through creative electronic simulations in which people can safely face their greatest fears, such as airplane flying, spiders, or public speaking.

Virtual reality exposure therapy Within the confines of a room, virtual reality technology exposes people to vivid simulations of feared stimuli, such as walking across a rickety bridge high off the ground.

In the first photo a man is wearing a VR headset and has a controller in his hand, while a woman wearing a mouthpiece looks on. The next photo shows a pair of legs on a bridge.

Aversive Conditioning

An exposure therapy enables a more relaxed, positive response to an upsetting harmless stimulus. It helps you accept what you should do. Aversive conditioning creates a negative (aversive) response to a harmful stimulus (such as alcohol). It helps you to learn what you should not do. The aversive conditioning procedure is simple: It associates the unwanted behavior with unpleasant feelings. To treat nail biting, the therapist may suggest painting the fingernails with a nasty-tasting nail polish (Baskind, 1997). To treat alcohol use disorder, the therapist may offer the client appealing drinks laced with a drug that produces severe nausea (recall the taste-aversion experiments with rats and coyotes in Module 29). If that therapy links alcohol with violent nausea, the person’s reaction to alcohol may change from positive to negative (Figure 71.1).

aversive conditioning

a type of counterconditioning that associates an unpleasant state (such as nausea) with an unwanted behavior (such as drinking alcohol).

Figure 71.1 Aversion therapy for alcohol use disorder

After repeatedly imbibing an alcoholic drink mixed with a drug that produces severe nausea, some people with a history of alcohol use disorder develop at least a temporary conditioned aversion to alcohol. (Remember: US is unconditioned stimulus, UR is unconditioned response, NS is neutral stimulus, CS is conditioned stimulus, and CR is conditioned response.)

Flip It Video: Counterconditioning—How It Works

The first chart consists of two text boxes connected by an arrow. The first text box reads “US (drug)”, and an arrow points from it to a second text box, which reads “UR (nausea)”. The second chart consists of three text boxes. The first two text boxes are labeled “NS (alcohol)” and ‘’US (drug)”, and are connected by a “+” sign. The NS alcohol text box includes an illustration of a martini glass, and the US (drug) text box includes an illustration of a hand using a dropper to mix something into a martini glass. An arrow points from the “US (drug)” text box to the third text box, which reads “UR (nausea)”. The third chart consists of two text boxes connected by an arrow. The first text box reads “CS (alcohol)” and an arrow points from it to a second text box, which reads “CR (nausea)”. The CS alcohol text box includes an illustration of a martini glass.

Taste aversion learning has been a successful alternative to killing predators in some animal protection programs (Dingfelder, 2010; Garcia & Gustavson, 1997). After being sickened by eating a contaminated sheep, wolves may avoid sheep. Does aversive conditioning also transform humans’ reactions to alcohol? In the short run it may. In one classic study, 685 hospital patients with alcohol use disorder completed an aversion therapy program (Wiens & Menustik, 1983). Over the next year, they returned for several booster treatments that paired alcohol with sickness. At the end of that year, 63 percent were not drinking alcohol. But after three years, only 33 percent were alcohol free.

In therapy, as in research, cognition influences conditioning. People know that outside the therapist’s office they can drink without fear of nausea. Just as animals learn to expect how often they will experience an unconditioned stimulus (Rescorla & Wagner, 1972), people can learn a probability that drinking will lead to nausea. This ability to discriminate between the therapy situation and all others can limit aversive conditioning’s effectiveness. Thus, therapists often combine aversive conditioning with other treatments.

Operant Conditioning Techniques

• 71-2 What is the main premise of therapy based on operant conditioning principles, and what are the views of its proponents and critics?

If you have learned to swim, you learned how to put your head under water without suffocating, how to pull your body through the water, and perhaps even how to dive safely. Operant conditioning shaped your swimming. You were reinforced for safe, effective behaviors. And you were naturally punished, as when you swallowed water, for improper swimming behaviors.

Pioneering researcher B. F. Skinner helped us understand the basic principle of operant conditioning (Modules 27 and 28): Consequences strongly influence our voluntary behaviors. Knowing this, behavior therapists can practice behavior modification. They reinforce behaviors they consider desirable, and they fail to reinforce—or sometimes punish—behaviors they consider undesirable.

Using operant conditioning to solve specific behavior problems has raised hopes for some seemingly hopeless cases. Children with intellectual disabilities have been taught to care for themselves. Socially withdrawn children with autism spectrum disorder (ASD) have learned to interact. People with schizophrenia have been helped to behave more rationally in their hospital ward. In such cases, therapists used positive reinforcers to shape behavior. In a step-by-step manner, they rewarded closer and closer approximations of the desired behavior.

In extreme cases, treatment must be intensive. One study worked with 19 withdrawn, uncommunicative 3-year-olds with ASD. For two years, 40 hours each week, the children’s parents attempted to shape their behavior (Lovaas, 1987). They positively reinforced desired behaviors and ignored or punished aggressive and self-abusive behaviors. The combination worked wonders for some children. By first grade, 9 of the 19 were functioning successfully in school and exhibiting normal intelligence. In a group of 40 comparable children not undergoing this effortful treatment, only one showed similar improvement. Later studies focused on positive reinforcement—the effective aspect of this early intensive behavioral intervention (Reichow, 2012).

Rewards used to modify behavior vary. For some people, the reinforcing power of attention or praise is sufficient. Others require concrete rewards, such as food. In institutional settings, therapists may create a token economy. When people display a desired behavior, such as getting out of bed, washing, dressing, eating, talking coherently, cleaning up their rooms, or playing cooperatively, they receive a token or plastic coin. Later, they can exchange a number of these tokens for rewards, such as candy, TV time, day trips, or better living quarters. Token economies have been used successfully in homes, classrooms, and detention facilities, and among people with various disabilities (Matson & Boisjoli, 2009).

token economy

an operant conditioning procedure in which people earn a token for exhibiting a desired behavior and can later exchange tokens for privileges or treats.

Behavior modification critics express two concerns:

• How durable are the behaviors? Will people become so dependent on extrinsic rewards that the desired behaviors will stop when reinforcers stop? Behavior modification advocates believe the behaviors will endure if therapists wean people from the tokens by shifting them toward other, real-life rewards, such as social approval. Further, they point out, the desired behaviors themselves can be rewarding. As people become more socially competent, the intrinsic satisfactions of social interaction may sustain the behaviors.
• Is it right for one human to control another’s behavior? Those who set up token economies deprive people of something they desire and decide which behaviors to reinforce. To critics, this whole process feels too authoritarian. Advocates reply that control already exists: People’s destructive behavior patterns are being maintained and perpetuated by natural reinforcers and punishers in their environments. Isn’t using positive rewards to reinforce adaptive behavior more humane than institutionalizing or punishing people? Advocates also argue that the right to effective treatment and an improved life justifies temporary deprivation.

Check Your Understanding

Ask Yourself

• Have you had any experience with behavior therapy techniques in your own life, perhaps to eliminate some childhood behavior problem or to shape some good behavior? Were they effective?

Test Yourself

• What might a psychodynamic therapist say about Mowrer’s therapy for bed-wetting? How might a behavior therapist defend it?
• Some maladaptive behaviors are learned. What hope does this fact provide?
• Exposure therapies and aversive conditioning are applications of ______________ conditioning. Token economies are an application of ______________ conditioning.

Answers to the Test Yourself questions can be found in Appendix E at the end of the book.