Behavioral therapy is based on the assumption that changes in maladaptive behavior can occur without insight into the underlying cause. This approach works best when it is directed at specific problems and the goals are well defined. Behavioral therapy is effective in treating people with phobias, alcoholism, schizophrenia, and many other conditions. Four types of behavioral therapy
are discussed here: modeling, operant conditioning, systematic desensitization, and aversion therapy.
Modeling
In modeling, the therapist provides a role model for specific identified behaviors, and the patient learns through imitation. The therapist may do the modeling, provide another person to model the behaviors, or present a video for the purpose. Bandura, Blanchard, and Ritter (1969) were able to help people reduce their phobias about nonpoisonous snakes. They did this by having them first view closeups of filmed encounters between people and snakes that resulted in successful outcomes. Afterward they viewed live encounters between people and snakes that also had successful outcomes.
In a similar fashion, some behavior therapists use role playing in the consulting room. They demonstrate patterns of behavior that might prove more effective than those usually engaged in and then have the patients practice these new behaviors. For example, a student who does not know how to ask a professor for an extension on a term paper would watch the therapist portray a potentially effective way of making the request. The clinician would then help the student practice the new skill in a similar role-playing situation.
Operant Conditioning
Operant conditioning is the basis for behavior modification and uses positive reinforcement to increase desired behaviors. For example, when desired goals are achieved or behaviors are
performed, patients might be rewarded with tokens. These tokens can be exchanged for food, small luxuries, or privileges. This reward system is known as a token economy.
Operant conditioning has been useful in improving the verbal behaviors of mute, autistic, and developmentally disabled children. In patients with severe and persistent mental illness, behavior modification has helped increase levels of self-care, social behavior, group participation, and more.
You may find this a useful technique as you proceed through your clinical rotations.
A familiar case in point of positive reinforcement is the mother who takes her preschooler along to the grocery store, and the child starts acting out, demanding candy, nagging, crying, and yelling.
Here are examples of three ways the child’s behavior can be reinforced:
Systematic Desensitization
Systematic desensitization is another form of behavior modification therapy that involves the development of behavior tasks customized to the patient’s specific fears; these tasks are presented to the patient while using learned relaxation techniques. The process involves four steps:
1. The patient’s fear is broken down into its components by exploring the particular stimulus cues to which the patient reacts. For example, certain situations may precipitate a phobic reaction, whereas others do not. Crowds at parties may be problematic, whereas similar numbers of people in other settings do not cause the same distress.
2. The patient is exposed to the fear little by little. For example, a patient who has a fear of flying is introduced to short periods of visual presentations of flying—first with still pictures, then with videos, and finally in a busy airport. The situations are confronted while the patient is in a relaxed state. Gradually, over a period of time, exposure is increased until anxiety about or fear of the object or situation has ceased.
3. The patient is instructed in how to design a hierarchy of fears. For fear of flying, a patient might develop a set of statements representing the stages of a flight, order the statements from the most fearful to the least fearful, and use relaxation techniques to reach a state of relaxation as they progress through the list.
Aversion Therapy
Aversion therapy is used to treat behaviors such as alcoholism, paraphilic disorders, shoplifting, violent and aggressive behavior, and self-mutilation. Aversion therapy is the pairing of a negative stimulus with a specific target behavior, thereby suppressing the behavior. This treatment may be used when other less drastic measures have failed to produce the desired effects.
Simple examples of extinguishing undesirable behavior through aversion therapy include painting foul-tasting substances on the fingernails of nail biters or the thumbs of thumb suckers.
Other examples of aversive stimuli are chemicals that induce nausea and vomiting, unpleasant odors, unpleasant verbal stimuli (e.g., descriptions of disturbing scenes), costs or fines in a token economy, and denial of positive reinforcement (e.g., isolation).
Before initiating any aversive protocol, the therapist, treatment team, or society must answer the following questions:
• Is this therapy in the best interest of the patient?
• Does its use violate the patient’s rights?
• Is it in the best interest of society?
If the therapist believes aversion therapy as the most appropriate treatment, ongoing supervision, support, and evaluation of those administering it must occur.
Biofeedback
Biofeedback is also a form of behavioral therapy and is successfully used today, especially for controlling the body’s physiological response to stress and anxiety. Chapter 10 discusses biofeedback in further detail.
Implications of Behavioral Theory to Nursing
Behavior and health are inextricably linked. Consider the toll that such behaviors as smoking, overeating, alcohol and substance use problems, and inactivity take on the body and mind. A behavioral model provides a concrete method for modifying or replacing undesirable behaviors. An example of a nurse teaching a behavioral technique is smoking cessation. For example, a therapist teaches patients to modify routines to reduce smoking cues such as avoiding bars.
Nurses may work in units based on behavioral principles, particularly with children and adolescents. Token economies represent extensions of Skinner’s thoughts on learning. In a token economy, patients’ positive behaviors are reinforced with tokens. These tokens may be small plastic disks, checkmarks, or coins with no real value that can be used in exchange for materials (e.g., candy, gum, books) or services (e.g., phone calls, time off the unit, recognition).