CURRENT PRACTICES AND FUTURE

TRENDS – BEHAVIOUR THERAPY

Submitted by : Hudha
Submitted to : Rasheeda mam
Submitted on : 25/01/24
 Behaviour Therapy
The term “behavior” in behavior therapy is defined as anything a person does. Behavior
therapy involves changing what patients do, to improve their health. Behavior therapy includes a
methodology, referred to as behavior analysis, for the strategic selection of behaviors to change
and a technology to bring about behavior change, such as modifying antecedents or
consequences or giving instructions. Today, behavior therapy has not only pervaded mental
health care but under the rubric of behavioral medicine it has also made inroads into other
medical specialties.
Behavior therapy represents clinical applications of principles developed in behavioral
science. Behavioral psychology, or behaviorism, arose a decade after the turn of the century, in
reaction to the method of introspection that dominated psychology at the time. John B. Watson,
the father of behaviorism, had initially studied animal psychology. This background made it a
smaller conceptual leap to argue that psychology should concern itself only with publicly
observable phenomena (i.e., overt behavior). According to behavioristic thinking, since mental
content is not publicly observable, it cannot be subjected to rigorous scientific inquiry.
Consequently, behaviorists developed a focus on overt behaviors and their environmental
influences.
Today different behavioral schools continue to share a focus on verifiable behavior.
Behavioral views differ from cognitive views in holding that physical rather than mental events
control behavior. However, current behavioral orientations differ in how mental phenomena are
accommodated. For example, according to methodological behaviorism, mental phenomena or
speculations about them have no scientific interest. According to molar or teleologic
behaviorism, what seems mental becomes public once the context is considered. Such contexts
can be appreciated after the individual has been observed over long enough time. Radical
behaviorism treats verbal behavior as a class of behaviors with unique properties; mental events
such as thinking are equivalent to the verbal behaviors that describe them.
As new behavioral principles are discovered, new clinical behavioral applications follow,
and existing clinical applications may need to be reconceptualized. For example, developments
in Pavlovian conditioning require evaluation of treatments developed from earlier Pavlovian
models. Advances in the understanding of verbal behavior led to new approaches to treatment
and increased the interface with both philosophy and social psychology. Philosophy has a long
tradition in the study of logic, which is self-conscious verbal behavior. Social psychology has
examined our verbal conventiens with respect to goal setting and emotions.
Behavior therapy uses a precise terminology and represents a specific view of how
behavior is influenced. To understand and employ behavioral techniques, the reader needs to
learn how to think in a behavioral mode. This mode supplements the normal diagnostic and
psychopharmacological mode in which psychiatrists usually function.
 Current Trends

Because behavior therapy can be applied across the full age spectrum from in- fants
through the elderly, many varied problems have been addressed. Ad- vances in research and
application bring new ideas. Many have been documented and illustrated in treatment manuals.
New applications such as eye-movement desensitization, acceptance and commitment therapy,
and dia- lectical behavior therapy are being developed.
Eye-Movement Desensitization and Reprocessing
Relatively new, eye-movement desensitization and reprocessing (EMDR) was developed
by Francine Shapiro in 1987 (1997, 1999, 2001; Shapiro & Forrest, 2004; Shapiro, Kaslow, &
Maxfield, 2007). It was first designed for individuals with posttraumatic stress disorder, but it
has been applied more broadly since then. This method uses a combination of cognitive and
behavioral techniques. First a behavioral assessment is done, imaginal flooding is used, and
cognitive restructuring, somewhat similar to that of Meichenbaum, follows..

In explaining EMDR, Shapiro (2001; Leeds & Shapiro, 2000; Shapiro & Forrest, 2004)
describes eight phases. Luber (2009) provides a variety of scripted protocols for work with
different psychological disorders, age groups, couples, and group work. EMDR and the Art of
Psychotherapy with Children (Adler-Tapia & Settle, 2008) is a comprehensive approach to
applying EMDR to children. The first three phases are an introduction to behavioral assessment.
In the first phase, the therapist takes a client history and tries to determine if the client will be
able to tolerate the stress that EMDR may bring about. In the second phase, the therapist explains
how EMDR works and how the client may feel between sessions as a result of EMDR. In the
third phase, the therapist gathers baseline data before desensitizing the client. Typically, the client
is asked to select a memory and to assign a subjective unit of discomfort (SUD) in which 10 is
the highest distress possible and 0 is the lowest.

With this preparation done, the therapist moves to the desensitization phase, which is the
longest one. At this point, the therapist asks the client to think of the traumatic image and to
notice feelings attached to it as the therapist moves her hand. The client concentrates on the
image and feelings as the therapist moves her hand back and forth as rapidly as possible. Usually
the therapist holds two fingers up with her palm facing the client about 12 inches from the
client’s face. About 15 to 30 bilateral eye movements make a set. After the set, the therapist tells
the client to let go and take a breath. Then the client describes his feelings, images, sensations, or
thoughts. The therapist may ask, “What are you experienceing now?” Although the most
common approach, eye movements are not the only way of activating this information-
processing system. Therapists may use hand taps or repeat verbal cues. This desensitization
process continues until

Near the end of the session or when the SUD rating drops to 0 or 1. After the client has
been desensitized, the fifth phase is to increase the positive cognition. This stage is called
installation because a new positive thought is installed. In this phase, the positive cognition is
linked to the original memory by asking the individual to focus on the positive cognition and the
desired target behavior. At this point, eye movements are done to enhance the connection.

When the positive cognition is installed, the client moves to the sixth phase and performs
a body scan. Here, he scans his body from head to toe, trying to find any tension or discomfort. If
discomfort is located, it is targeted with successive sets of eye movements until the tension is
diminished. Emotional equilibrium. Between

In the last two phases, the client returns to an sessions, the client is asked to maintain a
log of distressing thoughts, images, or dreams. If they occur, the client is told to apply the self-
soothing or relaxation exercises he has learned. Then the entire process is re-evaluated and
reviewed. Typically EMDR takes four to six sessions for a single target to be reached, but the
sessions usually run 90 to 120 minutes.
Acceptance and Commitment Therapy

A relatively new approach, acceptance and commitment therapy (ACT) uses behav- ioral
techniques in combination with an emphasis on clients’ use of language to al- leviate client
distress (Blackledge, Ciarrochi, & Deane, 2009; Eifert & Forsyth, 2005; Hayes & Strosahl,
2005). Hayes and his colleagues believe many emotional pro- blems develop as clients use
ineffective methods, such as avoidance, to control their emotions. Rather than having clients
focus on avoiding a feeling, they help clients accept a feeling, event, or situation. Clients can
then look at their thoughts and feel- ings rather than look from them. They help clients clarify
values and commit to be- haviors that fit with these values. Manuals (Luoma, Hayes, & Walser,
2007) and transcripts (Twohig & Hayes, 2008) are helpful to those wishing to learn ACT.
 To illustrate their approach, Blackledge and Hayes (2001) use the case of Mark, a young
college student who has had a history of problems that affect his dating relationships with
women. As a therapeutic goal, they want the client to accept and experience fearful or painful
thoughts, clarify his values, and commit to changing behaviors. In Mark’s case, he “needed to
learn to recognize his negative self-evaluations simply as words rather than truths, and to stop
avoiding the anxiety and fear he experienced in response to intimacy” (p. 248).

One of the first steps in ACT is “creative hopelessness.” The therapist re- views with the
client the ways the client has taken to solve the problem and ex- amines why they have not
worked. This helps the client be open to suggestions the therapist makes that may not seem, at
first, to make sense to the client. Mark describes solutions he has tried, such as not asking
women out anymore to avoid anxiety about being rejected. The therapist responds by suggesting
that anxiety is

Not the problem. Therapy then continues by focusing on aspects of the client’s
experience other than the feeling of anxiety. For example, Mark is asked to close his eyes and
focus on the physical sensations in his body for several minutes, repeating this several times. His
physical feelings are identified as “mind stuff” by the ther- apist rather than the “truth” about
how he feels. Then Mark sees his thoughts as thoughts rather than the truth about how he fears
dating women. In this way the negative emotion is defused.

Other defusion strategies may be used as well. For example, Mark feels ashamed because
of his lack of sexual experience. The therapist does not attempt to talk Mark out of these
thoughts but instead says, “Thank your mind for that thought” or “Those are interesting words”
(p. 251). Later in therapy, when Mark has a disturbing thought, he is asked to picture himself in
front of a stream. He then is asked to place the thought on a leaf and focus on his breathing.

Another diffusion exercise is used when Mark says, “I’m worthless” (p. 251). The
therapist and Mark repeat the phrase over and over until the phase has no meaning. You may
want to try this yourself with a similar phrase, saying it out loud. Notice how the phrase sounds
different the first time as compared to the 30th time you say it. Mark noted that the phrase had
lost its literal meaning after many repetitions.
 In the fifth and final session, Mark reports his commitment to the behavior. He has asked
out two women and has experienced little anxiety asking them out on the date or being with them
on the date.
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) was developed by Marsha Linehan in the 1980s as a
result of her work with patients with suicidal intentions. She later de- veloped it into a therapy
that has been used primarily with patients diagnosed with borderline disorder (Linehan, 1993a,
1993b; Linehan & Dexter-Mazza, 2008). These patients present difficulties that challenge
therapists more than al- most any other psychological disorder. Patients with borderline disorder
present with severe mood swings and impulsive behavior such as drug abuse, sexual acting out,
and self-damaging behavior. They may see relationships as either all good or all bad, including
the relationship with the therapist. To work with these patients using DBT requires at least a year
of both individual and group therapy, as well as phone consultations. Furthermore, therapeutic
work needs to be comprehensive and sophisticated to accomplish what other therapies have not.

Linehan views borderline personality disorder as having biological and envi- ronmental
components (Linehan, 1993a, b; Linehan, McDavid, Brown, Sayrs, & Gallop, 2008). Her
biosocial theory examines genetics, prenatal conditions, and other factors that may influence how
people regulate their emotions and respond to problems in their environment. Her theory
suggests that individuals with bor- derline personality disorder experience a great deal of
emotional vulnerability, resulting in intense emotional reactions that are difficult for the
individual to manage. Individuals with borderline personality disorder generally also have
experienced invalidating environments. These may include neglect from parents or other
caregivers, abuse, or abandonment. Such experiences may lead to people having a poor self-
image, being self-critical, lacking trust in others, and having poor problem-solving skills.
Linehan theorizes that borderline personality disor- der arises from the interaction between
emotional vulnerability and invalidating environments.

Dialectical behavior therapy may be best described by the title words: dialec- tical and
behavior. Dialectical refers to the fact that in an argument there is an as- sertion and a position
that opposes the assertion. To resolve the argument, a synthesis that incorporates the assertion
and the opposition will help to move past the argument and resolve it (Spiegler & Guveremont,
2010). For patients with borderline symptoms, this provides a way to reduce symptoms and find
meaning in their lives by balancing acceptance and change. Behavior refers to the need to use
behavioral methods to change self-destructive behaviors (such as careless driving or cutting
one’s arms). Different therapeutic methods are ap- plied in individual and group therapy.
Additionally, phone consultations are made with individuals in crisis.
 Individual therapy. The first part of individual therapy in DBT is to assess the client’s
problems and to assess her ability to follow through in meeting therapeu- tic goals. Both therapist
and client must agree on the goals, target behaviors, and techniques to be used. The client must
agree to attend individual and group ses- sions. This is important, as dropout from treatment of
borderline personality dis- order has a reputation for being high. The therapist may also disclose
supervision arrangements and issues dealing with availability to the client in a crisis. The
therapist then decides which of four stages to start with.

In DBT, the four stages are in order of degree of importance to the goal of keeping the
client alive. Therapists may change from one stage to another de- pending on the nature of the
problems the patient presents. Since patients with borderline symptoms often experience crises,
changing stages can be frequent. The stages are described here.
Stage 1. Life-threatening behaviors such as suicide attempts, risk-taking behaviors such
as driving recklessly, and intent to harm self or others must be the first priority. Assuring safety is
important because self-destructive behaviors are common in individuals with a borderline
personality disorder.
Stage 2. Attention is paid to behaviors that may interfere with therapy. Because of the
difficulty of treatment and the lack of success of treatment for many in- dividuals with borderline
personality disorder, it is important to keep the pa- tient in therapy. In Stage 2, clients work on
experiencing strong emotions with less and less disturbance. They also learn to deal with
problems in their environment in a more effective way.
Stage 3. Clients work on ways to increase their quality of life and decrease their
problematic responses to daily events. For example, they try to reduce symp- toms of anxiety and
depression. Dealing with substance abuse may be an is- sue in Stages 1 and 2, but making
reductions in drug dependence continues
In Stage 3. Attention is paid to relationships with family, friends, and coworkers.
Stage 4. Clients make changes in their lives to adapt to problems around them. Attention
is paid to finding more happiness, a greater sense of freedom, and the development of
spirituality. Work is done to develop skills in handling problems with others and with
unanticipated events.
 Therapeutic skills. In DBT, certain skills are used in individual therapy but may be used
in group as well when appropriate. These skills include validation and acceptance strategies,
problem-solving and change strategies, and dialectical persuasion.

Validation and acceptance strategies. Clients with borderline personality disorder often
present behaviors that may be harmful to themselves. The therapist should communicate
empathy toward the client rather than point out the harmfulness of the behavior. The therapist
can point out to the client that the behavior serves a function to reduce stress or to help in some
way, even if the behavior causes other problems. For example if a client drinks alcohol to the
point that she gets sick and can’t walk, the therapist may say to her: “When you are very upset,
drinking seems to help you relax, and it would be helpful to reduce your stress, which you do by
drinking. Perhaps there are other ways to achieve the goal of relaxation.” In this response, the
client’s behavior is accepted, and a suggestion is made to examine possible changes.

Problem-solving and change strategies. Many different behavioral and problem- solving
techniques can be used so that patients with borderline personality disorder can change behavior
that has interfered with their life goals. Sometimes the therapist may wish to use positive
reinforcement or modeling techniques to help clients achieve their goals. Meichenbaum’s self-
instructional training and stress inoculation (pp. 299-300) provide a means for accomplishing
cognitive restructuring. For certain problems, especially related to phobias or obsessive-
compulsive dis- orders, therapists may wish to use exposure and ritual prevention (p. 306). Other
behavioral and cognitive techniques can be used as well.

Dialectical persuasion. Dialectical was explained above as trying to find a resolution

between two extremes. Using dialectical persuasion, the therapist accepts the client but gently
tries to persuade the client to use a more effective method to bring about change. This is done by
pointing out inconsistencies in actions, beliefs, and values. The client is helped to change
behavior to fit with values and beliefs. In the following example, dialectical persuasion is used
with a 23- year-old woman who cuts her arms to relieve stress.

Group skills training. Along with individual therapy, clients participate in 2 to 3 hours of
group skills training per week for a year or more. The group leader would not be the client’s
individual therapist. The group leader follows a manual that includes handouts for clients. The
group focuses, especially at first, on Stages 1 and 2: life-threatening behaviors and behaviors that
interfere with individual therapy. Although some of the techniques described above may be used
by the group leader, the skills that are taught are core mindfulness, interpersonal effec- tiveness,
emotional regulation, and distress tolerance.
The Future
The behavior therapies have provided simple, direct, and relatively inexpensive help to
many people, including some for whom other approaches are inapplicable or unavailable. With
the amount of dedicated interest, many clinicians and experimentalists will surely continue to
investigate and sharpen techniques and concepts. At present, evidence of their value rests on a
relatively narrow base of individual case studies, clinical surveys, and some analog experiments,
but the amount and quality of research is bound to increase. As the field matures, hope- fully
some of the present polarization between behaviorists and dynamic or humanistic psychologists
will diminish. Clinicians of other persuasions can then utilize behavioral methods for those
problems for which it is best suited, while behavior therapists can focus their activities with these
same patients and, at the same time, expand their understanding of clinical process and human
personality; ultimately, with the patient’s needs rather than the clinician’s bias determining the
interventive approach.

A. A. Lazarus' "broad spectrum" behavior’ therapy is a move in this direction,

as evidenced in the following passage:
The achievement of profound insights will frequently fail to eliminate tics, phobias,
compulsions, or perversions, whereas operant conditioning, desensitization, or straightforward
hypnotic suggestion may often quell these “symptoms” with neither relapse or substitution.
Should we then abandon the quest for self-knowledge in favor of conditioning techniques?
Indeed, if one’s goal is to overcome enuresis or to teach an autistic child to speak, or to instigate
prosocial behaviors among schizophrenic in mates, the clinical and research evidence suggests
that it would be foolhardy to bypass direct behavioral approaches. While even here, more
attention to the patient’s interpersonal relationships may well enhance the effects of specific
reconditioning, it is obvious that instruction or training in a specific area will probably lead to
improved performance in that area. Stutterers will usually find fluency exercises more helpful
than introspection for their speech; phobic patients will usually respond better to desensitization
than to psychoanalysis; social skills are more readily acquired through behavior for rehearsal
(modelling and role playing) than through advice or nondirective inter- views. Since it is not
always so easy to determine when limited problems of function of dysfunction become entagled
with far-reaching problems of meaning, therapists should try to determine what they are dealing
with before plunging ahead with deconditioning or reconditioning techniques. The basic question
to be asked is whether one
Is dealing with a problem or a symptom. To desensitize a phobic patient, for without first
establishing whether his phobia is a straightforward avoidance or a psychotic manifestation, or a
symbolic retreat or a face saving or attention-seeking device, or a weapon in family of marital
strife violates the cardinal rule “diagnosis before therapy.” It may seem ridiculous to keep
asserting the obvious. After all, what self-respecting therapist would apply desensitization (or
any other technique) without first conducting a thorough evaluation of the patient’s problem The
answer, regret ably, is all too many

Reference:
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Korchin S.J. (1986), Modern Clinical Psychology. Delhi: CBS Publishers and Distributers.
Sharf, R.S. (2012). Theories of psychotherapy and counseling. (5th ed).cengage learning.