Behavioral psychotherapy

Behavioral therapy; behavioral therapy is one of the leading areas of modern psychotherapy. Behavioral psychotherapy is based on the theory of learning as well as the principles of classical and operant conditioning. The basis of this form of psychotherapy is the idea that the symptoms of certain mental disorders owe their appearance to incorrectly formed habits. Behavioral psychotherapy has as its goal elimination of undesirable forms of behavior and development of useful skills for the client and, on their basis, useful habits of behavior. Behavioral therapy is most successfully applied for the treatment of phobias, behavioral disorders and addictions, i.e. those conditions in which it is possible to identify a particular symptom as a "target" for therapeutic intervention. The scientific basis for behavioral psychotherapy is the theory of behaviorism.

Behavioral therapy can be used either independently or in combination with cognitive psychotherapy (cognitive-behavioral psychotherapy). Behavioral psychotherapy is a directive and structured form of psychotherapy. Its stages are behavior analysis, definition of the steps necessary for the correction of behavior, gradual training and development of new behavior skills and, on their basis, correct habits of behavior in real life. The main goal of behavior therapy is not to understand the reasons for the patient's problems, but to change his or her behavior.

In behavioral therapy, improvement often occurs earlier than in other types of psychotherapy and is more concrete. Even disorders that have lasted many years (e.g., long-term alcohol addiction, eating disorders, phobias) can show rapid improvement.

Despite the fact that behavior therapy is one of the newest methods of treatment in psychiatry, the techniques used in it existed already in ancient times. It has long been known that people's behavior can be controlled by positive and negative reinforcement, that is, by rewards and punishments (the "carrot and stick" method). However, only with the emergence of the theory of behaviorism these methods were scientifically substantiated.

Behaviorism as a theoretical branch of psychology appeared and developed approximately at the same time as psychoanalysis (i.e. since the end of the 19th century). Nevertheless, the systematic application of the principles of behaviorism for psychotherapeutic purposes belongs to the late 50's - early 60's.

Behavioral therapy methods are largely based on the ideas of the Russian scientists Vladimir Mikhailovich Bekhterev (1857-1927) and Ivan Petrovich Pavlov (1849-1936). The works of Pavlov and Bekhterev were well known abroad; in particular, Bekhterev's book "Objective Psychology" had a great influence on John Watson. All the major behaviorists of the West call Pavlov their teacher. (See also: reflexology.)

Already in 1915-1918 V.M. Bekhterev proposed the method of "combination reflex therapy". I.P. Pavlov became the creator of the theory about conditioned and unconditioned reflexes and about reinforcement, by means of which behavior can be changed (due to development of desirable conditioned reflexes or "extinction" of undesirable conditioned reflexes). In his experiments with animals, Pavlov found that if feeding a dog is combined with a neutral stimulus, such as the ringing of a bell, then later this sound will cause the animal to salivate. Pavlov also described phenomena associated with the development and disappearance of conditioned reflexes:

1. Conditioned reflex extinction: If a neutral stimulus is no longer accompanied by a reinforcement for a certain period of time (for example, the ringing of a bell is not accompanied by a feed), the conditioned reflex developed earlier gradually disappears.
2. Generalization of the conditioned reflex: the reflex response can arise not only under the influence of the stimulus being supported, but also under the influence of stimuli more or less close to it. Later on, this idea was used to create a theory of phobias: for example, if a patient's phobia initially concerned only a specific situation, then later, under the influence of the generalization process, more and more situations with any resemblance to what caused the fear in the beginning will trigger the fear.

Thus, Pavlov proved that new forms of behavior can arise as a result of establishing a connection between innate forms of behavior (unconditioned reflexes) and a new (conditioned) stimulus. Pavlov's method was later called classical conditioning.

Pavlov's ideas were further developed in the works of the American psychologist John Watson (1878-1958). Watson came to the conclusion that the classical conditioning that Pavlov observed in animals also exists in humans, and it is this conditioning that causes phobias. In 1920, Watson conducted an experiment with an infant. While the child was playing with a white rat, the experimenters induced fear in him with a loud sound. Gradually the infant began to fear white rats, and later any furry animal as well.

In 1924, Watson's assistant, Mary Caver Jones used a similar method to cure a child of a phobia. The child was afraid of rabbits, and Mary Jones used the following techniques:

1. The rabbit was shown to the baby from afar, while the baby was being fed.
2. The moment the child saw the rabbit, the experimenter gave him a toy or candy.
3. A child could watch other children playing with rabbits.
4. As the child became accustomed to the sight of the rabbit, the animal was brought closer and closer.

Thanks to the application of these techniques, the child's fear gradually disappeared. Thus, Mary Jones has created a method of systematic desensitization which is successfully applied for treatment of phobias. Psychologist Joseph Volpe (1915-1997) called Jones "the mother of behavior therapy.

The term "behavioral therapy" was first mentioned in 1911 by Edward Thorndike (1874-1949). In the 1940s the term was used by Joseph Volpe's research group.

Volpe did the following experiment: placing cats in a cage, he subjected them to electric shocks. The cats soon developed a phobia: they became afraid of the cage, and if they were brought close to the cage, they tried to escape and run away. Then Volpe began gradually reducing the distance between the animals and the cage and giving the cats food at a time when they were near the cage. Gradually the animals' fear disappeared. Volpe suggested that phobias and fears in humans could be eliminated using a similar method. Thus, the method of systematic desensitization was created. Volpe used this method mainly for the treatment of phobias, sociophobia and sexual disorders associated with increased anxiety.

Further development of behavioral therapy is associated primarily with the names of Edward Thorndike and Frederick Skinner, who created the theory of operant conditioning. In Pavlov's classical conditioning, behavior can be changed by modifying the initial conditions in which the behavior occurs. In the case of operant conditioning, behavior can be changed by stimuli that follow the behavior ("rewards" and "punishments").

Edward Thorndike (1874-1949), conducting experiments with animals, formulated two laws that are still used today in behavioral psychotherapy:

1. "The Law of Exercise," which states that the repetition of a certain behavior contributes to making that behavior more and more likely to occur in the future.
2. "Law of effect": if a behavior has a positive result for an individual, it is more likely to be repeated in the future. If an action has an unpleasant result, it will occur less and less frequently or disappear altogether in the future.

Frederick Skinner (1904-1990) continued Thorndike's research and made a significant contribution to the development of the theory of operant conditioning. From Skinner's point of view, in both animals and humans, the probability of the emergence of a behavior is directly related to the consequences to which this behavior has led in the past. Specifically, Skinner found that the disappearance of a pattern of behavior can lead not only to an unpleasant outcome for the individual, but also to the absence of any outcome. The only difference is that in the presence of an unpleasant outcome, the pattern of behavior disappears faster than in the absence of any outcome.

The method of classical conditioning was also used in Andrew Salter's (1914-1996) clinic of conditioned reflex therapy.

The ideas of behavioral therapy became widespread through the publications of Hans Eysenck (1916-1997) in the early 1960s. Eysenck defined behavior therapy as the application of modern learning theory to the treatment of behavioral and emotional disorders. In 1963 the first journal devoted exclusively to behavioral psychotherapy, Behavior Research and Therapy, was founded.

In the 1950s and 1960s, behavioral therapy theory developed mainly in three research centers:

The formation of behavioral psychotherapy as an independent field occurred around 1950. Growing dissatisfaction with psychoanalysis contributed to the popularity of this method because of the insufficient empirical basis of analytical methods as well as the duration and high cost of analytical therapy, while behavioral techniques proved to be effective, with the effect being achieved in only a few therapy sessions.

By the end of the 1960s, behavioral psychotherapy was recognized as an independent and effective form of psychotherapy. Currently, this area of psychotherapy has become one of the leading methods of psychotherapeutic treatment. In the 1970s, techniques of behavioral psychology began to be used not only in psychotherapy, but also in pedagogy, management and business.

Initially, methods of behavior therapy were based exclusively on the ideas of behaviorism, that is, on the theory of conditioned reflexes and on the theory of learning. But nowadays there is a tendency to considerably expand the theoretical and instrumental base of behavior therapy: any method whose effectiveness has been proven experimentally can be included in it. Arnold Lazarus has called this approach "broad spectrum behavioral therapy" or "multimodal psychotherapy. For example, relaxation techniques and breathing exercises (diaphragmatic breathing in particular) are currently used in behavior therapy. Thus, although behavior therapy is based on scientifically grounded methods, it is characterized by its eclectic character. The techniques that it uses have only one thing in common - they are all aimed at changing behavioral skills. As defined by the American Psychological Association, "Behavioral psychotherapy includes primarily the use of principles that have been developed in experimental and social psychology... The main goal of behavioral therapy is to build and strengthen the ability to act and increase self-control.

Methods similar to the techniques of behavioral therapy were used in the Soviet Union beginning in the 1920s. However, for a long time, instead of the term "behavioral psychotherapy," the term "conditionally-reflex psychotherapy" was used in Russian literature.

Behavioral psychotherapy is used for a wide range of disorders: for psychiatric and so-called psychosomatic disorders, as well as for purely somatic illnesses. It is particularly useful in the treatment of anxiety disorders, in particular panic disorders, phobias and obsessions, as well as for the treatment of depression and other affective disorders, eating disorders, sexual problems, schizophrenia, antisocial behaviour, sleep and attention disorders, hyperactivity, autism, learning difficulties and other development disorders in childhood, and also for language and conversation problems. The use of behavioral psychotherapy in the treatment of patients with chronic disorders is very significant; the primary goal of therapy is not cure, but resolution.

In addition, behavioral psychotherapy can be used to manage stress and treat the clinical manifestations of high blood pressure, headaches, asthma and some gastrointestinal diseases, particularly enteritis and chronic pain.

• A postulate of behavior therapy is the idea that behavioral patterns play a crucial role in the development of psychological disorders. For example, in depression, social isolation is not only a consequence of depression, but also a factor that aggravates the depressive state of the patient. It is assumed that behavior can be changed through the use of some or other therapeutic methods.
• Behavioral patterns may also include some or other autonomic and endocrine responses, with patterns of autonomic readiness for stress responses varying from person to person.
• In behavioral therapy, only techniques whose effectiveness has been confirmed experimentally are used, and preference is given to techniques that have an unambiguously positive effect.
• The starting point of therapy is the problem that is bothering the patient at the moment. One of the basic principles of behavior therapy is the "here and now" rule.
• "The principle of minimal intrusion" (Kafner, 1991) postulates that behavioral therapy should interfere in the patient's inner life only to the extent necessary to address the patient's actual problems.
• Relativity of the concepts of "health-disease" and "norm-deviation. The behavioral therapist does not impose his notions of what is normal and healthy behavior on the client; the goal of therapy is to develop behavior that will be optimal and desirable for that particular client.
• In behavior therapy, the therapist usually plays an active and directive role. The technique of "talking out" one's problems and experiences is not encouraged in behavior therapy. The patient mainly responds to questions that are asked and performs exercises that the therapist recommends. The therapist usually works according to a predetermined plan from which he does not deviate unnecessarily.
• One of the features of behavior therapy is that it sometimes uses help from the patient's family members (with the patient's consent), for example, to do "homework," to help with self-monitoring, to increase motivation, etc.

This procedure in behavior therapy is called "functional analysis" or "applied behavior analysis. At this stage, first of all, a list of behavioral patterns that have negative consequences for the patient is compiled. Each behavioral pattern is described according to the following scheme:

• When and how does this type of behavior manifest itself?
• How often?
• How long does it last?
• What are its implications in the short and long term?
• In behavior therapy, only what can be observed is taken into account. For example, instead of talking about the fear that he or she is experiencing, the patient should talk about the specific sensations associated with the fear (heart palpitations, breathing disturbances, etc.).

Then situations and events that cause neurotic behavioral reactions (fear, avoidance, etc.) are identified. With self-observation, the patient should answer the question: what factors might increase or decrease the likelihood of a desirable or undesirable behavioral pattern? It should also be checked to see if the undesirable behavioral pattern has any "secondary benefit" to the patient, i.e., a hidden positive reinforcement of the behavior. The therapist then determines for himself what strengths in the patient's character can be used in the therapeutic process. It is also important to find out what the patient's expectations are in relation to what psychotherapy can give him/her: the patient is asked to formulate his/her expectations in concrete terms, i.e. to indicate what behavioral patterns he/she would like to get rid of and what behaviors he/she would like to learn. It is necessary to check whether these expectations are realistic. In order to get the most complete picture of the patient's condition, the therapist gives him/her a questionnaire which the patient should fill in at home, if necessary using self-assessment techniques. Sometimes the initial assessment phase takes several weeks, because in behavioral therapy it is extremely important to get a complete and accurate description of the patient's problem.

In behavior therapy, the data from the preliminary analysis phase is called a "baseline" or "starting point. Later on, this data is used to evaluate the effectiveness of therapy. In addition, they allow the patient to realize that his or her condition is gradually improving, which increases the motivation to continue therapy.

In behavior therapy, it is considered necessary for the therapist to stick to a certain plan when working with a patient, so after assessing the patient's condition, the therapist and the patient make a list of problems to be solved. However, it is not advisable to work with several problems at the same time. Multiple problems should be dealt with sequentially. One should not move on to the next problem until there has been a significant improvement in working with the previous problem. If there is a complex problem, it is advisable to break it down into several components. If necessary, the therapist draws up a "problem ladder," that is, a diagram that shows in what order the therapist will work with the client's problems. The pattern of behavior to be changed in the first place is chosen as the "target". The following criteria are used for the selection:

• The severity of the problem, that is, how much damage the problem causes the patient (for example, interferes with his or her professional activities) or poses a danger to the patient (for example, severe alcohol dependence);
• What causes the most unpleasant feelings (for example, panic attacks);
• "Centrality" of the problem. This criterion considers the extent to which the solution to this problem will help solve the patient's other problems.

If the patient is insufficiently motivated or lacks confidence, the therapeutic work can begin not with the most important problems, but with easy-to-reach goals, that is, with the behavioral patterns that are easiest to change or that the patient wants to change first. The transition to more difficult tasks is made only after simpler tasks have been solved. During therapy, the therapist constantly checks the effectiveness of the techniques used. If the techniques chosen initially proved to be ineffective, the therapist should change the therapy strategy and use other techniques.

The priority in choosing a goal is always agreed upon by the patient. Sometimes the therapeutic priorities can be revised in the course of therapy.

Behavioral therapy theorists believe that the more specific the goals of therapy are, the more effective the therapist's work will be. At this stage it is also necessary to find out how great the patient's motivation to change this or that type of behavior is.

In behavioral therapy, a critical success factor is how well the patient understands the meaning of the therapist's techniques. For this reason, the basic principles of the approach are usually explained to the patient in detail at the beginning of therapy, and the purpose of each particular method is explained. The therapist then uses questions to check how well the patient has understood his explanations and to answer questions if necessary. This not only helps the patient to do the exercises the therapist recommends correctly, but also increases the patient's motivation to do these exercises daily.

In behavior therapy, the use of the self-observation method and the use of "homework assignments" that the patient has to perform daily, or even, if necessary, several times a day, is widespread. The same questions that were asked of the patient in the pre-assessment phase are used for self-monitoring:

• When and how does this type of behavior manifest itself?
• How often?
• How long does it last?
• What are the "triggers" and reinforcing factors for this pattern of behavior?
• What are its consequences in the short and long term?

When giving the patient "homework," the therapist must make sure that the patient has correctly understood what he or she is supposed to do and that the patient is willing and able to do this task on a daily basis.

It should not be forgotten that behavior therapy is not limited to the elimination of undesirable behavioral patterns. From the point of view of behavioral theory, any behavior (both adaptive and problematic) always serves some function in a person's life. For this reason, when problem behavior disappears, a kind of vacuum is created in a person's life that can be filled by new problem behavior. In order to prevent this from happening, when making a behavior therapy plan, the psychologist foresees which forms of adaptive behavior must be developed to replace the problem behavior patterns. For example, phobia therapy will not be complete unless it is established which forms of adaptive behavior will fill the time that the patient devotes to phobic experiences. The therapy plan must be written in positive terms and specify what the patient should do, not what he or she should not do. This rule has been called in behavior therapy the "living person rule" because the behavior of a living person is described in positive terms (what they are capable of doing), whereas the behavior of a dead person can only be described in negative terms (e.g., a dead person cannot have bad habits, experience fear, show aggression, etc.).

As Judith Beck emphasizes, behavioral therapy does not eliminate the client's problems once and for all. The aim of therapy is only to teach how to cope with difficulties as they arise, i.e. "to become your own therapist. The well-known behavioral psychotherapist Mahoney (1976) even believes that the client should become a "research scientist" of his own personality and behavior, which will help him solve problems as they arise (in behavior therapy, this is denoted by the term self-management. For this reason, at the end of therapy, the therapist asks the client what techniques and methods have been most helpful for him or her. The therapist then recommends that these techniques be applied independently, not only when the problem arises, but also for preventive purposes. The therapist also trains the client to recognize the signs that the problem is occurring or returning, as this will allow the client to take early action to cope with the problem or at least reduce the negative effect of the problem.

• Imitative learning - when using this method, the client is invited to observe and imitate desirable patterns of behavior (for example, the therapist's or therapist's assistant's behavior). Not only a "live model" (a real person), but also a "symbolic model," which can be a character from a book or an image created by the client's own imagination, can be used for this purpose. One of the forms of learning by example is self-modeling. This technique consists in the therapist making a video recording of the client's successful moments of behavior, and then showing the client this video recording.
• Role training is a technique used to teach certain types of behavior (e.g., communication skills training) and is a type of role-playing. The effect of role-play training is based on a combination of confrontation techniques, systematic desensitization (which helps to reduce anxiety) and reinforcement of successful behavior in the form of positive feedback from the therapist. When using this technique, the patient and the therapist play out a problem situation. This technique can also be used in group therapy. Most often the patient plays himself, but sometimes the therapist or one of the members of the group does it, which allows the patient to see his problem from the outside, and to understand that in this problematic situation it is possible to act differently.
• Biofeedback is a technique that uses equipment that monitors the patient's signs of stress. As the patient manages to achieve a state of muscular relaxation, he receives positive visual or auditory reinforcement (e.g., pleasant music or an image on a computer screen).
• Weaning techniques (aversive therapy)
• Systematic desensitization
• Implosive therapy
• Shaping (behavior modeling)
• The method of autoinstructions
• Stress inoculation therapy
• The "stopping of thought" method

Methods of behavioral therapy in educational practice

Functional behavior analysis is a discipline based on the scientific views of B. F. Skinner, in particular on the concept of operant conditioning. The leading method of behavior analysis is the method of functional assessment - identification of antecedents (antecedents) and postcedents (consequences) of certain actions in order to find factors related to the manifestation of the behavior of interest to the therapist. Applied behavior analysis is a technological implementation of functional behavior analysis: methods of parsing and changing conditions in order to correct behavior. Applied behavior analysis is used in the educational system both to improve indicators - academic performance, discipline, attendance in all children, and for inclusion of children with disabilities and socialization problems (for example, with ASD) into general education classrooms.

Problems arising in the course of therapy

• The propensity for the client to verbalize verbally what he or she thinks and feels and to strive to find the reasons for his or her problems in what he or she has experienced in the past. The reason for this can be the idea of psychotherapy as a method which "allows to speak out and understand oneself. In this case, it is necessary to explain to the client that behavior therapy consists of specific exercises and that its goal is not to understand the problem, but to eliminate its consequences. Nevertheless, if the therapist sees that the client needs to express his or her experience or to find the underlying cause of his or her difficulties, it is possible to add, for example, cognitive or humanistic psychotherapy to behavioral methods.
• The client's fear that the correction of his emotional expressions will turn him into a "robot. In this case, it is necessary to explain to him that thanks to behavioral therapy, his emotional world will not become poorer, just that negative and maladaptive emotions will be replaced by pleasant ones.
• Passivity of the client or fear of the effort required to perform the exercises. In this case, it is worth reminding the client of the long-term consequences of such an attitude. At the same time, it is possible to reconsider the therapy plan and to begin work with simpler tasks, breaking them down into individual steps. Sometimes, in such cases, behavioral therapy uses the help of the client's family members.

Sometimes the client has dysfunctional beliefs and attitudes that interfere with their involvement in the therapeutic process. These attitudes include:

• Unrealistic or inflexible expectations about therapy methods and outcomes, which can be a form of magical thinking (assuming that the therapist can fix any client problem). In this case, it is especially important to find out what the client's expectations are, and then make a clear plan for therapy and discuss this plan with the client.
• The belief that only the therapist is responsible for the success of therapy, and that the client cannot and should not make any effort (external locus of control). This problem not only significantly slows down the progress of treatment, but also leads to relapses after meetings with the therapist are terminated (the client does not consider it necessary to do "homework" and follow the recommendations that were given to him at the end of therapy). In this case, it is useful to remind the client that in behavior therapy, success is impossible without the active cooperation of the client.
• Dramatization of the problem, for example: "I have too many difficulties, I will never get over it." In this case, it is useful to start therapy with simple tasks and exercises that allow for quick results, which increases the client's confidence that he or she is able to cope with his or her problems.
• Fear of judgment: The client is embarrassed to tell the therapist about some of their problems, and this prevents the development of an effective and realistic therapeutic work plan.

In the presence of such dysfunctional beliefs, it makes sense to apply methods of cognitive psychotherapy to help the client revise his or her attitudes.

One of the obstacles to success is insufficient motivation of the client. As stated above, strong motivation is a prerequisite for successful behavioral therapy. For this reason, motivation to change should be assessed at the very beginning of therapy and then, as the work with the client progresses, its level should be constantly checked (it should not be forgotten that sometimes the client's demotivation takes hidden forms. For example, he can stop therapy, assuring himself that his problem is solved. In behavior therapy, this is called "escape to recovery"). To increase motivation:

• The importance and usefulness of the techniques used in therapy must be clearly and concisely explained;
• Specific therapeutic goals should be chosen, coordinating your choice with the desires and preferences of the client;
• It has been noticed that clients often focus on problems that have not yet been solved and forget about the successes already achieved. In this case, it is useful to periodically evaluate the client's condition, showing him/her the progress made thanks to his/her efforts (this can be demonstrated, for example, with the help of diagrams).
• A peculiarity of behavioral therapy is the focus on quick, concrete, observable (and measurable) results. Therefore, if there is no significant progress in the client's condition, the client's motivation may disappear. In this case, the therapist should immediately reconsider the chosen tactic of work with the client.
• Since in behavior therapy the therapist works in collaboration with the client, it should be explained that the client is not obliged to blindly follow the therapist's recommendations. Objections on his part are welcome, and any objection should be immediately discussed with the client and, if necessary, changes should be made to the work plan.
• To increase motivation, it is recommended to avoid monotony in work with the client; it is useful to use new methods that arouse the client's greatest interest.

At the same time, the therapist must not forget that the failure of therapy may be related not to the client's dysfunctional attitudes, but to the therapist's own hidden dysfunctional attitudes and errors in the application of behavioral therapy methods. For this reason, self-monitoring and peer assistance should be used at all times to identify which distorted cognitive attitudes and problem behaviors are preventing the therapist from succeeding in their work. Behavioral therapy is characterized by the following errors:

• The therapist gives the client "homework" or a self-observation questionnaire, but then forgets about it or does not take the time to discuss the results. This approach can significantly decrease the client's motivation and trust in the therapist.
• Inexperienced behavioral therapists are characterized by deviations from the pre-established therapy plan: the therapist may proceed to eliminate a new problem without having completed work on the previous problem. All of this reduces the effectiveness of therapy and decreases the client's motivation. For this reason, in behavior therapy, it is recommended that a clear and realistic work plan be drawn up in advance; the therapist should follow this plan as far as possible and not change it without consulting the client. If it is necessary to change the plan, the therapist should not improvise - together with the client, work out a new work plan.
• Sometimes the therapist works only with individual symptoms and problems to which particular techniques correspond. This does not take into consideration and does not analyze the entire picture of disorders, which inevitably reduces the effectiveness of work and can even lead to the opposite, negative effect. For this reason, the behavioral psychotherapist should possess in-depth knowledge of the clinical picture and the psychological mechanisms of various syndromes and pathologies and in his work should always strive to understand the meaning behind a particular problem.

Contraindications to the use of behavioral psychotherapy

Behavioral psychotherapy should not be used in the following cases:

In these cases, the main problem is that the patient is unable to understand why he or she should perform the exercises the therapist recommends.

If the patient has a personality disorder, behavioral therapy is possible, but it may be less effective and more time-consuming, since the therapist will find it more difficult to obtain active cooperation from the patient. An insufficient level of intellectual development is not an obstacle for behavioral therapy, but in this case, it is preferable to use simple techniques and exercises, the purpose of which the patient is able to understand.

Third Generation Behavioral Psychotherapy

New directions in behavioral psychotherapy are grouped under the term "third generation behavioral therapy.