Techniques for Modifying Behavior

509
Behavior Therapy and Cognitive-Behavior Therapy
TA B L E
13.1
1. You are reading a newspaper and notice an ad for an airline.
A Desensitization Hierarchy
Desensitization hierarchies are lists of increasingly fear-provoking stimuli or situations that clients visualize while using
relaxation methods to remain calm. Here
are a few items from the beginning and the
end of a hierarchy that was used to help a
client overcome fear of flying.
2. You are watching a television program that shows a group of people boarding
a plane.
3. Your boss tells you that you need to take a business trip by air.
4. You are in your bedroom packing your suitcase for your trip.
.
.
.
12. Your plane begins to move as you hear the flight attendant say,“Be sure your seat
belt is securely fastened.”
13. You look at the runway as the plane is readied for takeoff.
14. You look out the window as the plane rolls down the runway.
15. You look out the window as the plane leaves the ground.
3. A therapist who acts as a kind of teacher/assistant by providing learning-based
treatments, giving “homework” assignments, and helping the client make specific
plans for dealing with problems rather than just talking about them.
4. Continuous monitoring and evaluation of treatment, along with constant
adjustments to any procedures that do not seem to be effective. (Because ineffective procedures are soon altered or abandoned, behavioral treatment tends to
be one of the briefer forms of therapy.)
Behavioral treatment can take many forms. By tradition, those that rely mainly on
classical conditioning principles are usually referred to as behavior therapy. Those
that focus on operant conditioning methods are usually called behavior modification. And behavioral treatment that focuses on changing thoughts, as well as overt
behaviors, is called cognitive-behavior therapy. These methods, especially cognitivebehavior therapy, have become increasingly influential in recent years.
LINKAGES
Can people learn their way
out of a disorder? (a link to
Learning)
Techniques for Modifying Behavior
Some of the most important and commonly used behavioral treatment methods are
those that laid the foundations of behavior therapy and behavior modification. These
include systematic desensitization, modeling, positive reinforcement, extinction, aversion conditioning, and punishment.
Joseph Wolpe (1958) developed one of the first
behavioral methods for helping clients overcome phobias and other forms of anxiety.
Called systematic desensitization, it is a treatment in which the client visualizes a
series of anxiety-provoking stimuli while remaining relaxed. Wolpe believed that this
process gradually weakens the learned association between anxiety and the feared object
until the fear disappears.
Wolpe first helped his clients learn to relax, often using the progressive relaxation training procedures described in the chapter on health, stress, and coping. While relaxed,
clients would be asked to imagine the easiest item on a desensitization hierarchy, which is
a list of increasingly fear-provoking situations (see Table 13.1). As treatment progressed,
clients imagined each item in the hierarchy, one at a time, moving to a more difficult
Systematic Desensitization
510
psychology
applying
Chapter 13 Treatment of Psychological Disorders
VIRTUAL DESENSITIZATION This client
fears heights. He is wearing a virtual reality display that creates
the visual experience of being in a glass
elevator, which, under the therapists’
careful control, seems to gradually rise
higher and higher. After learning to tolerate these realistic images without anxiety, clients are better able to fearlessly
face the situations they once avoided.
item only after learning to imagine the previous one without distress. Wolpe found that
once clients could calmly imagine being in feared situations, they were better able to
deal with them in reality later on.
Desensitization appears especially effective when it slowly and carefully presents
clients with real, rather than imagined, hierarchy items (Bouton, 2000; Marks, 2002;
McGlynn et al., 1999; Tryon, 2005). This in vivo, or “real life,” desensitization was once
difficult to arrange or control, especially in treating fear of flying, heights, or highway
driving, for example. Recently, however, virtual reality graded exposure has made it possible for clients to “experience” vivid and precisely graduated versions of feared situations without actually being exposed to them. In one study, clients who feared heights
wore a virtual reality helmet that gave the impression of standing on bridges of gradually increasing heights, on outdoor balconies at higher and higher floors, and in a glass
elevator as it slowly rose forty-nine stories (Rothbaum et al., 1995). The same
technology has been used successfully in the treatment of fears caused by spiders, dentists, air travel, social interactions, and posttraumatic stress disorder (Anderson,
Rothbaum, & Hodges, 2003; Choi et al., 2001; Dittman, 2005; Gershon et al., 2002;
Glantz, Rizzo, & Graap, 2003; Maltby, Kirsch, & Mayers, 2002; Rothbaum et al., 1999,
2000, 2002; Winerman, 2005).
Therapists often teach clients desirable behaviors by first demonstrating
those behaviors. In modeling treatments, the client learns important skills by watching other people perform desired behaviors (Bidwell & Rehfeldt, 2004). For example,
modeling can teach fearful clients how to respond fearlessly and confidently. In one
case, a therapist showed a spider-phobic client how to calmly kill spiders with a fly
swatter and then assigned her to practice this skill at home with rubber spiders (MacDonald & Bernstein, 1974). This combination of fearless demonstrations and firsthand
practice, called participant modeling, is one of the most powerful treatments for fear
(e.g., Bandura, Blanchard, & Ritter, 1969; Faust, Olson, & Rodriguez, 1991).
Modeling is also a major part of assertiveness training and social skills training,
which help clients learn how to deal with people more comfortably and effectively.
Social skills training has been used to help children interact more effectively with peers,
to help social-phobic college students make conversation on dates, and to help rebuild
mental patients’ ability to have normal conversations with people outside the hospital
(McQuaid, Granholm, et al., 2000; Spence, 2003; Spence, Donovan, & BrechmanToussaint, 2000; Trower, 1995; Wong et al., 1993). In assertiveness training, the therapist helps clients learn to express their feelings and stand up for their rights in social
situations (Alberti & Emmons, 1986; Ballou, 1995). Assertiveness training is often done
in groups and involves both modeling and role playing of specific situations. For example, group assertiveness training has helped wheelchair-bound adults and learningdisabled students more comfortably handle the socially awkward situations in which
they sometimes find themselves (Gleuckauf & Quittner, 1992; Weston & Went, 1999).
Modeling
Behavior therapists also use positive reinforcement to
alter problematic behaviors and to teach new skills in cases ranging from childhood
tantrums and juvenile delinquency to schizophrenia and self-starvation. Employing
operant conditioning principles, they set up contingencies, or rules, that specify the
behaviors to be strengthened through reinforcement. In one study, children with autistic disorder, who typically speak very little, were given grapes, popcorn, or other items
they liked in return for saying “please,” “thank you,” and “you’re welcome” while
exchanging crayons and blocks with a therapist. After the therapist modeled the desired
behavior by saying the appropriate words at the appropriate times, the children began
to say these words on their own. Their use of language also began to appear in other
situations, and, as shown in Figure 13.1, the new skills were still evident six months
later (Matson et al., 1990).
When working with severely retarded or disturbed clients in institutions or with
unruly juveniles in residential facilities, behavior therapists sometimes establish a
Positive Reinforcement
modeling A behavioral therapy
method in which desirable behaviors
are demonstrated for clients.
assertiveness training A set of methods for helping clients learn to express
their feelings and stand up for their
rights in social situations.
positive reinforcement Presenting a
positive reinforcer (reward) after a desired response.
511
Behavior Therapy and Cognitive-Behavior Therapy
FIGURE
13.1
Baseline
Positive Reinforcement for an
Autistic Child
Follow-up
Please
100
0
100
Thank you
Percentage of target behaviors
applying
0
You’re welcome
psychology
During each pretreatment baseline period,
an autistic child rarely
said “please,” “thank you,” or “you’re
welcome,” but these statements began to
occur once they were demonstrated, then
reinforced. Did modeling and reinforcement actually cause the change? Probably,
because each type of response did not
start to increase until the therapist began
demonstrating it.
Treatment package
100
0
5
10
15
20
25
30
35
40
45
50
Sessions
Source: Matson et al. (1990).
token economy, which is a system for reinforcing desirable behaviors with points or
coin-like tokens that can be exchanged later for snacks, access to television, or other
desired rewards (Ayllon, 1999; Ayllon & Azrin, 1968; Field et al., 2004; LePage et al.,
2003; Paul & Lentz, 1977; Seegert, 2003). The goal is to shape more adaptive behavior patterns that will persist outside the institution (Moore et al., 2001; Paul, 2000;
Paul, Stuve, & Cross, 1997).
Just as reinforcing desirable behaviors can make them more likely to
occur, failing to reinforce undesirable behaviors can make them less likely to occur,
a process known as extinction. Treatment methods that use extinction change behavior slowly but offer a valuable way of reducing inappropriate behavior in children
and adolescents and in retarded or seriously disturbed adults. For example, a client
who gets attention by disrupting a classroom, damaging property, or violating hospital rules might be placed in a quiet, boring “time out” room for a few minutes to
eliminate reinforcement for misbehavior (e.g., Kee, Hill, & Weist, 1999; Reitman &
Drabman, 1999).
Extinction is also the basis of a fear-reduction treatment called flooding, in which
clients are kept in a feared but harmless situation and not permitted to use their normally rewarding escape strategies (O’Donohue, Hayes, & Fisher, 2003). The client is
flooded with fear at first, but after an extended period of exposure to the feared stimulus (a frog, say) without experiencing pain, injury, or any other dreaded result, the
association between the feared stimulus and the fear response gradually weakens, and
the conditioned fear response is extinguished (Basoglu, Livanou, & Salcioglu, 2003;
Harris & Goetsch, 1990; Öst et al., 2001). In one study, twenty clients who feared
needles were exposed for two hours to the sight and feel of needles, including mild
finger pricks, harmless injections, and blood samplings (Öst, Hellström, & Kåver,
1992). Afterward, all except one client were able to have a blood sample drawn
without experiencing significant anxiety. (Because they continuously expose clients
Extinction
token economy A system for improving the behavior of clients in institutions by rewarding desirable behaviors
with tokens that can be exchanged for
various rewards.
extinction The gradual disappearance
of a conditioned response.
flooding
A procedure for reducing
anxiety that involves keeping a client in
a feared but harmless situation.