54-4 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?

663

The insight therapies assume that many psychological problems diminish as self-awareness grows. Psychodynamic therapists expect problems to subside as people gain insight into their unresolved and unconscious tensions. Humanistic therapists expect problems to diminish as people get in touch with their feelings. Proponents of behavior therapies, however, doubt the healing power of self-awareness. (You can become aware of why you are highly anxious during exams and still be anxious.) They assume that problem behaviors are the problems, and the application of learning principles can eliminate them. Rather than delving deeply below the surface looking for inner causes, behavior therapists view maladaptive symptoms—such as phobias or sexual dysfunctions—as learned behaviors that can be replaced by constructive behaviors.

One cluster of behavior therapies derives from principles developed in Ivan Pavlov’s early twentieth-century conditioning experiments. As Pavlov and others showed, we learn various behaviors and emotions through classical conditioning. Could maladaptive symptoms be examples of conditioned responses? If so, might reconditioning be a solution? Learning theorist O. H. Mowrer thought so and developed a successful conditioning therapy for chronic bed-wetters. The child sleeps on a liquid-sensitive pad connected to an alarm. Moisture on the pad triggers the alarm, waking the child. With sufficient repetition, this association of bladder relaxation with waking up stops the bed wetting. In three out of four cases the treatment is effective, and the success provides a boost to the child’s self-image (Christophersen & Edwards, 1992; Houts et al., 1994).

Another example: If a claustrophobic fear of elevators is a learned aversion to being in a confined space, then might one unlearn that association by reconditioning to replace the fear response? 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 therapy and aversive conditioning—have successfully counterconditioned people with such fears.

Exposure TherapiesPicture this scene reported in 1924 by behaviorist psychologist Mary Cover Jones: Three-year-old Peter is petrified of rabbits and other furry objects. Jones plans to replace Peter’s fear of rabbits with a conditioned response incompatible with fear. Her strategy is to associate the fear-evoking rabbit with the pleasurable, relaxed response associated with eating.

As Peter begins his midafternoon snack, Jones 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 tolerating 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).

Unfortunately for those who might have been helped by her counterconditioning procedures, Jones’ story of Peter and the rabbit did not immediately become part of psychology’s lore. It was more than 30 years later that psychiatrist Joseph Wolpe (1958; Wolpe & Plaud, 1997) refined Jones’ technique into what are now the most widely used types of behavior therapies: exposure therapies, which expose people to what they normally avoid or escape (behaviors that get reinforced by reduced anxiety). Exposure therapies have them face their fear, and thus overcome their fear of the fear response itself. As people can habituate to the sound of a train passing their new apartment, so, with repeated exposure, can they become less anxiously responsive to things that once petrified them (Barrera et al., 2013; Foa et al., 2013).

664

One widely used exposure therapy is systematic desensitization. Wolpe assumed, as did Jones, that you cannot be simultaneously 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. Imagine yourself afraid of public speaking. A behavior therapist might first ask for your help in constructing 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, such as having to address a large audience.

Next, using progressive relaxation, the therapist would train you to relax one muscle group after another, until you achieve a blissful state of complete relaxation and comfort. Then the therapist would 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 would signal your tension by raising your finger, and the therapist would 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 would progress up the constructed anxiety hierarchy, using the relaxed state 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, raises 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.

When an anxiety-arousing situation is too expensive, difficult, or embarrassing to recreate virtual reality exposure therapy offers an efficient middle ground. Wearing a head-mounted display unit that projects a three-dimensional virtual world, you would view a lifelike series of scenes that would be tailored to your particular fear and that shift as your head turns. Experiments led by several research teams have treated many different people with many different fears—flying, heights, particular animals, and public speaking (Parsons & Rizzo, 2008). People who fear flying, for example, can peer out a virtual window of a simulated plane, feel vibrations, and hear the engine roar as the plane taxis down the runway and takes off. In studies comparing control groups with people experiencing virtual reality exposure therapy, the therapy has provided relief from real-life fear (Gonçalves et al., 2012; Opris et al., 2012).

665

Aversive ConditioningIn systematic desensitization, the goal is substituting a positive (relaxed) response for a negative (fearful) response to a harmless stimulus. In aversive conditioning, the goal is substituting a negative (aversive) response for a positive response to a harmful stimulus (such as alcohol). Thus, aversive conditioning is the reverse of systematic desensitization—it seeks to condition an aversion to something the person should avoid.

The 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 of these 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 54.1).

Does aversive conditioning work? In the short run it may. Arthur Wiens and Carol Menustik (1983) studied 685 hospital patients with alcohol use disorder who completed an aversion therapy program. One year later, after returning for several booster treatments of alcohol-sickness pairings, 63 percent were still successfully abstaining. But after three years, only 33 percent had remained abstinent.

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.

54-5 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 desired behaviors, and they withhold reinforcement for undesired behaviors. Using operant conditioning to solve specific behavior problems has raised hopes for some otherwise 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 use positive reinforcers to shape behavior in a step-by-step manner, rewarding 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. Each participated in a 2-year program in which their parents spent 40 hours a week attempting to shape their behavior (Lovaas, 1987). The combination of positively reinforcing desired behaviors, and ignoring or punishing aggressive and self-abusive behaviors, worked wonders for some. By first grade, 9 of the 19 children 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. (Ensuing studies focused on the effective aspect—positive reinforcement.)

666

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 appropriate 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 as a positive reinforcer. Later, they can exchange their accumulated tokens for various rewards, such as candy, TV time, trips to town, or better living quarters. Token economies have been successfully applied 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).

Critics of behavior modification express two concerns. The first is practical: How durable are the behaviors? Will people become so dependent on extrinsic rewards that the appropriate behaviors will stop when the reinforcers stop? Proponents of behavior modification believe the behaviors will endure if therapists wean patients from the tokens by shifting them toward other, real-life rewards, such as social approval. They also point out that the appropriate behaviors themselves can be intrinsically rewarding. For example, as a withdrawn person becomes more socially competent, the intrinsic satisfactions of social interaction may help the person maintain the behavior.

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 some patients request the therapy. Moreover, control already exists; rewards and punishers are already maintaining destructive behavior patterns. So why not reinforce adaptive behavior instead? Treatment with positive rewards is more humane than being institutionalized or punished, advocates argue, and the right to effective treatment and an improved life justifies temporary deprivation.