44-4 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 people’s problems to diminish as they get in touch with their feelings. Behavior therapists, however, doubt the healing power of self-awareness. (You can become aware of why you are highly anxious during exams and still be anxious.) Rather than delving deeply below the surface looking for inner causes, behavior therapists assume that problem behaviors are the problems, and they view learning principles as useful tools for eliminating those behaviors. If phobias or sexual dysfunctions are learned behaviors, they reason, why not replace them with new, constructive behaviors learned through classical or operant conditioning?

One cluster of behavior therapies derives from principles developed in Ivan Pavlov’s conditioning experiments. 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. With sufficient repetition, this association of bladder relaxation with waking stops the bed-wetting. The treatment has been effective in three out of four cases and the success provides a boost to the child’s self-image (Christophersen & Edwards, 1992; Houts et al., 1994).

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Can we unlearn fear responses through new conditioning? Many people have. One example: The fear of riding in an elevator is often a learned fear response to being in a confined space. Counterconditioning pairs the trigger stimulus (in this case, the enclosed space of the elevator) with a new response (relaxation) that is incompatible with fear. Two specific counterconditioning techniques—exposure therapies and aversive conditioning—have successfully counterconditioned many people with such fears.

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 has also gone away, having been countered, or replaced, by a relaxed state that cannot coexist with fear (Fisher, 1984; Jones, 1924).

Unfortunately for many who might have been helped by Jones’ 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. With repeated exposure, the person adapts. So, too, with people who have fear reactions to specific events. Exposed repeatedly to the situation that once petrified them, they can learn to react less anxiously (Barrera et al., 2013; Foa et al., 2013).

One form of exposure therapy widely 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 ask you to make a list of anxiety-triggering speaking situations. Your list would range from situations that cause you to feel mildly anxious (perhaps speaking up in a small group of friends) to those that provoke panic (having to address a large audience).

In the next step, the therapist would train you in progressive relaxation. You would learn to relax one muscle group after another, until you achieved a comfortable, complete relaxation. The therapist might then 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 you feel any anxiety while imagining the scene, 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.

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The therapist will then move to the next item on your list, again using relaxation techniques to desensitize you to each imagined situation. After several sessions, you will move to actual situations and practice what you had only imagined before. You will begin with relatively easy tasks and gradually move 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 (for example, standing in front of an audience and being unable to speak). As their fear subsides, so also does their fear of the fear.

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 in front of your eyes. 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. You would 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).

AVERSIVE CONDITIONING Exposure therapies enable a more relaxed, positive response to an upsetting harmless stimulus. Aversive conditioning creates a negative (aversive) response to a harmful stimulus (such as alcohol). Exposure therapies help you accept what you should do. Aversive conditioning 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, one can paint the fingernails with a nasty-tasting nail polish (Baskind, 1997). To treat alcohol use disorder, an aversion therapist offers the client appealing drinks laced with a drug that produces severe nausea. By linking alcohol with violent nausea (many taste-aversion experiments were first done with rats and coyotes), the therapist seeks to transform the person’s reaction to alcohol from positive to negative (FIGURE 44.1).

Does aversive conditioning work? 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 in which alcohol was paired with sickness. At the end of that year, 63 percent were still successfully abstaining. But after three years, only 33 percent had remained abstinent.

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The problem is that in therapy (as in research), cognition influences conditioning. People know that outside the therapist’s office they can drink without fear of nausea. Their ability to discriminate between the aversive conditioning situation and all other situations can limit the treatment’s effectiveness. Thus, therapists often use aversive conditioning in combination with other treatments.

44-5 What is the main premise of therapy based on operant conditioning principles, and what are the views of its proponents and critics?

The work of B. F. Skinner and others teaches us a basic principle of operant conditioning: Voluntary behaviors are strongly influenced by their consequences. Knowing this, some behavior therapists 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 behaviors that came closer and closer to 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 treatment, only one showed similar improvement. Later studies focused on positive reinforcement—the effective aspect of this “Early Intensive Behavioral Intervention” (Reichow, 2012).

The rewards used to modify behavior vary because people differ in what they find reinforcing. For some, the reinforcing power of attention or praise is enough. Others require concrete rewards, such as food. In institutional settings, therapists may create a token economy. When people display desired behavior, such as getting out of bed, washing, dressing, eating, talking meaningfully, cleaning 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 various settings (homes, classrooms, hospitals, institutions for juvenile offenders) and among members of various populations (including disturbed children and people with schizophrenia and other mental disabilities).

Behavior modification critics express two concerns. The first is practical: How durable are the behaviors? Will people become so dependent on extrinsic rewards that the desired behaviors will stop when the 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 that the desired behaviors themselves can be rewarding. As people become more socially competent, the intrinsic satisfactions of social interaction may help them maintain the desired behaviors.

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The second concern is ethical: 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 has an authoritarian taint. Advocates reply that control already exists; people’s destructive behavior patterns are already 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.