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BEHAVIOR MODIFICATION THERAPIES

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Since the 1960s and 1970s, numerous developments have occurred in both the theory and the practice of behavior therapy. There has been a significant shift away from a reliance on models of classical and operant conditioning (derived largely from animal studies) as the theoretical basis for behavior therapy, and toward a more cognitive approach in both theory and practice. These two developments have "humanized" behavior therapy to a great extent. In addition, radical or metaphysical behaviorism has reemerged in a gradual, limited way as a basis for new therapeutic technologies and conceptual formulations. These changes imply a growing recognition by behavior therapists that human behavior is the result of a complex interaction of environmental, social, cognitive, genetic, physiological, and emotional factors (Fishman and Franks).

Criticisms of Early Behavior Therapy

Prior to 1970, behavior therapy was strongly criticized by proponents of other therapeutic schools (typically humanistic or psychodynamic) as being mechanistic and authoritarian. It was alleged, for example, that terms such as behavior control carried with them the implicit, and sometimes explicit, message that irrevocable and often involuntary behavioral changes could be induced by the selective application of conditioning techniques. The protestations of behavior therapists notwithstanding, psychosurgery, electroconvulsive therapy, and the enforced ingestion of psychotropic medications were lumped together with mainstream behavior therapy as further examples of this authoritarian approach to behavior change.

The behavior therapy of this era was also accused of attempting to impose therapy goals on unwilling or unaware clients, and of utilizing punishment and other aversion procedures to bring this about. Behavior therapists, it was believed, had the power to impose their wills upon a hapless society through a sinister manipulation of environmental responses to behavior in the form of carefully chosen rewards and punishments.

Finally, early behavior therapy was viewed by its most extreme critics as a nefarious attempt to maintain an unjust status quo, as an imposition of majority demands upon a socially deviant minority (e.g., prisoners, the developmentally disabled, chronic psychiatric patients) helpless to resist the behavioral juggernaut. Behavior therapists were viewed as willing agents of a ruling class unable to tolerate any deviation from the prevailing ethos.

While a small proportion of early behavior-therapy practice did reflect these values to some extent, most behavior therapists eschewed such methods of coercive behavior change, preferring a much more egalitarian approach to therapeutic goal setting and behavior change. Then, as now, most behavior-therapy techniques lacked the potency to bring about involuntary behavior change. Most behavior therapists, then as now, considered it unethical to "enforce" behavior changes against a client's wishes, even when such changes appeared, from the therapist's perspective, to carry with them potential client benefits. Regardless of theoretical basis, the "humanization" of behavior therapy referred to above has resulted in an increasing emphasis on teaching clients "self-control."

Cognitive Approaches in Behavior Therapy

In the early 1970s, behavior therapists began to explore the possibility of integrating cognition and self-guided behavior change (see Bandura, 1977; Beck; Lazarus; Mahoney). With the exception of those who espouse a radical perspective, most cognitive behavior therapists implicitly assume that human behavior is guided in part by an internal "self" that consists of cognitive structures called schemas. Schemas comprise learned patterns of information processing that guide both immediate behavior and general perceptions of the world. These perceptions, in turn, have a significant impact on affective states. Cognitively oriented behavior therapists believe that to change behavior one must change the schemas through which the environmental information is processed. By helping the client to alter maladaptive schemas, the therapist enables the client to engage in broader, more effective information processing, thereby producing changes in attributions that ultimately lead to changes in both behavior and affect.

Most cognitive approaches to behavior therapy still reflect a primarily linear, mechanistic view of behavior. For example, the rational emotive therapy (RET) of Albert Ellis(1962), one of the earliest attempts at integration of cognitive and behavioral approaches, affirms that emotional states occur as the result of an information-processing sequence in which an external event triggers a set of beliefs (a schema), which in turn triggers an emotional response. Thus, a rational emotive therapist would view the emotion of anger as being triggered by the patient's thoughts about the event to which the patient responded with anger, rather than by the event itself. In the view of RET, to paraphrase Shakespeare, nothing is good or bad but thinking makes it so.

Effective treatment enables the client to alter irrational beliefs that lead to negative emotional states or other maladaptive behaviors. This is accomplished by directly challenging irrational beliefs in a Socratic fashion and by devising behavioral exercises to assist the client in learning that irrational beliefs are, in fact, incorrect. For example, in order to combat irrational feelings of shame and self-consciousness, which are presumably based on an irrational fear of sanction or ridicule for particular types of behavior, a rational emotive therapist might assign a client to perform the behavioral exercise of boarding a commuter train and loudly announcing each stop to the other passengers. The objective is to demonstrate that such behavior, absurd and inappropriate though it may seem to the client, does not necessarily evoke public sanction or ridicule, and that, even if it does, such responses from others are not catastrophic.

In one form or another, this combination of restructured irrational beliefs and behavioral exercises is the hallmark of most cognitive approaches to behavior therapy. Albert Bandura's social learning theory (1977), for example, aims at altering specific cognitive structures called "selfefficacy expectations" through teaching clients new behavioral skills and helping these clients practice them both in the therapist's office and in the daily world. Self-efficacy is assumed to determine, in part, whether or not a given set of environmental contingencies will be responded to with a particular behavior by the client. Therapy consists, in part, of designing graded behavioral exercises leading to both new behavior and a revision of self-efficacy expectations. Accomplishing these goals is presumed to facilitate a change in client behavior in previously problematic situations.

Research has consistently demonstrated that, in spite of the heavy emphasis by many theorists on the "cognitive" component of cognitive-behavior therapy, the most effective means of promoting both cognitive and behavioral changes is through performance-based treatments; that is, by actively engaging in new behaviors that are incompatible with older, problematic ones (see Rachman and Wilson). Engaging in new behavior, under the guidance of a therapist, seems to be an effective approach to the treatment of a variety of emotional and behavioral disorders. For example, a client who suffers from a fear of cats might be encouraged, with the therapist's assistance, to engage in closer and closer contacts with cats, moving from merely approaching a cat to actually holding one, until the fear subsides.

Radical Behaviorist Approaches to Behavior Therapy

In contrast to cognitively oriented behavior therapists, radical behaviorists reject outright the concept of "self." They view cognition as simply a form of behavior that occurs in correlation to a person's responses to environmental contingencies, but not as a cause of those responses. All behavior is presumed to be "caused" by a relationship between external events (contingencies) and behavior. According to radical behavior therapists (e.g., Hayes, 1987, 1989; Kohlenberg and Tsai), people learn sets of "rules" that guide their behavior through the experience of being rewarded or punished for particular behaviors in specific situations. Rules, considered to be verbal representations of environmental contingencies (the relationship between behavior and reward or punishment), are largely determined by an individual's cultural and linguistic milieu and prior learning history. According to radical behaviorists, rules and the linguistic milieu constitute a context that forms the causal matrix within which behavior is produced. Emotional disorders result from rigid adherence to "rules" of behavior that do not apply in a particular context, or to misattributing the causes of one's behavior to emotions rather than environmental contingencies. Thus, rules themselves are potential causes of emotional or behavioral problems.

A similar situation can arise from responding to inappropriately formed environmental contingencies, usually those derived from the structure of the individual's language. These inappropriately formed contingencies reinforce aspects of a person's subjective experience (e.g., the association of emotions with events) in a way that leads the person concerned to misattribute behavior to emotions rather than to the external contingencies that, in the radical behaviorist view, actually cause behavior.

Radical behaviorist approaches to treatment place strong emphasis on the role of an individual's linguistic community and language structure in guiding behavior. Cognition per se is irrelevant, except to the degree that thought is a part of the client's use of language. Behavior change is brought about by teaching new linguistic structures that lead to less affective upset. This is accomplished by attempting to alter the way in which clients use language to form attributions about the causes and meanings of their emotional experience. Most often, this involves teaching clients that emotions are not experiences that can or should be avoided. Rather, they are to be viewed as natural accompaniments to the process of living. Clients are taught to accept and utilize in a positive fashion affective and other inner experiences that their linguistic community has taught them should be avoided or eliminated (e.g., anxiety). Clients are also shown how to alter the contexts (contingencies) that control their behavior. Curiously, radical behaviorist approaches to behavior therapy are in some ways philosophically more similar to psychoanalysis than they are to traditional behavior or cognitive-behavior therapy, in that clients are taught that negative emotions are a natural part of life and cannot be eliminated. Eschewing mechanistic, linear views, radical behavior therapists prefer to view behavior as the product of an interaction between person and context.

Although formally rejecting any direct consideration of cognition, radical behaviorist and cognitive approaches to behavior therapy are consistent in other ways. For example, radical behavior therapists view the person as an active influencer of an environment that, in turn, influences the person. This is similar to Bandura's notion of reciprocal determinism (1982), a key concept in social learning theory. In addition, both radical and cognitive-behavior therapists adopt as a treatment goal the empowerment of the client to control aspects of behavior or experience that are presumed to be at the root of his or her problems. While the pathways to change are different, direct attempts to alter thoughts and behavior by cognitively oriented behavior therapists and the alteration of environmental or personal contingencies by radical behavior therapists are predicated upon the same goal: enabling people to exert more control over the causes of the problems that brought them to treatment in the first place.

Therapist–Client Relationships in Behavior Therapy

From the beginning, most behavior therapists have been intensely concerned with the ethical aspects of the application of behavior therapy, the ethical implications of the relationship between therapist and client, and the role of each in treatment. In contrast to other psychotherapeutic approaches, behavior therapy is characterized by a heavy emphasis on the responsibility of the therapist for successful treatment outcome. In behavior therapy, failure to achieve treatment goals is presumed to be the result of therapist errors or environmental hazards beyond the therapist's control, rather than of client resistance. The therapist is viewed as an "expert" guide who brings to the situation a body of teachable knowledge. In collegial fashion, as a mutual collaborative process, the patient is shown how to use this knowledge to bring about desired change. In this view, therapeutic failures result from several sources of therapist error, particularly: (1) errors in selection of therapeutic goals due to inadequate assessment; (2) errors in the selection, teaching, or application of techniques; (3) failure to consider client values in the selection of therapeutic goals, or the placing of societal or therapist values above those of the client in the process of goal selection; and (4) variables beyond the therapist's control.

While early behavior therapists tended to neglect the importance of a workable therapeutic relationship with the client, as the field has evolved such issues have become increasingly important in behavior therapy (see Wilson and Evans). Most behavior therapists recognize that without a therapeutic relationship characterized by mutual respect, empathy, trust, and equality, the first three types of therapist error noted above cannot be avoided, and treatment is unlikely to be successful. An increasing emphasis on thought and feeling leads to recognition that an adequate therapeutic relationship is essential to assessment and treatment. Changes in thoughts and emotions can, in and of themselves, be appropriate outcomes of treatment, as can changes in overt behavior. These changes can be facilitated by the establishment of a good therapeutic relationship.

Ongoing Ethical Concerns in the Practice of Behavior Therapy

Ethical practice has been a priority among behavior therapists. Nonetheless, concerns continue to arise. Particularly in cases where, at least potentially, the application of a technique can inflict pain, or where clients are relatively powerless or are involuntarily the subject of treatment, areas of ethical concern still remain.

USE OF AVERSION PROCEDURES. The use of aversion procedures (the application of subjectively unpleasant stimulation contingent upon performance of an undesirable behavior) has been, and remains, a source of criticism of behavior therapists. Particularly when procedures such as low-level electric shocks are applied to clients who lack the ability to offer informed consent to the use of such procedures, behavior therapists face a dilemma in which the desirability of treatment outcome goals has to be weighed against the rights of the client. Even when aversion therapy seems to be the best, most rapid means of suppressing other, perhaps more injurious, behavior, such as self-destructive behaviors in clients suffering from pervasive developmental disorders, behavior therapists are ethically bound to attempt to reduce the target behavior through nonaversive means before considering an aversion procedure. Only when the target behavior has been conclusively shown to be impervious to other means should aversion therapy be used.

The use of aversion techniques with clients for whom rapid, permanent behavior change is not essential, or for whom there may be some question as to the desire or willingness to change, raises significant ethical concerns. The application of aversion procedures to clients in powerless positions, or where the goals of the agent of behavior change seem directly counter to those of the client, requires careful assessment of the interests of all involved parties, with extra weight perhaps being given to the client's right to be free from external influence over his or her behavior. Practices such as those reported to have occurred in the former Soviet Union, including the use of aversion procedures or drugs for the subjugation of prisoners and psychiatric patients, are clearly not in keeping with the ethical application of behavior therapy or any other form of therapy. When aversion procedures are used, clear guidelines need to be established. Review by an institutional ethics board in order to set up extensive safeguards of client rights has to precede treatment.

TOKEN ECONOMIES IN INSTITUTIONAL SETTINGS. Token economies are based on the notion that behavior can be changed by systematically rewarding desired behaviors contingent upon performance. Token economies set up a microeconomy in which desired behaviors are "rewarded" by contingent distribution of tokens, or "points, " that can later be exchanged for rewards (often food or privileges). Early proponents of token economies in institutional settings frequently sought to enhance the effects of this process by withholding basic needs, which could be regained only by compliance with token-reinforced behavioral contingencies imposed by therapist fiat. This practice is now judged to be both legally and ethically unacceptable. Clients forced to reside in facilities where token economies are in effect are entitled to have basic needs for food, shelter, clothing, and social companionship met, regardless of ability to earn token reinforcers. As with the application of aversion procedures, the legitimate parameters of reinforcers need to be clearly spelled out, and the application of contingencies monitored, through continuing and independent peer review. It is the obligation of the therapist to develop effective reinforcers that are consistent with these values.

Token economies present another ethical and theoretical dilemma: the degree to which behavior changes effected through a token economy either will or should generalize to other settings in which the client may be placed in the future. Much research suggests that the sort of reinforcement contingencies that prevail in most token-economy programs do not characterize most naturally occurring reinforcers. When a client who has learned a new behavior under conditions of monitored and controlled reinforcement in a token economy moves to a setting in which different contingencies apply, there is substantial risk that the new behavior may disappear, leaving the client bereft of adequate, meaningful reinforcers.

The consequences for both the client and society of such a failure of generalization can be significant. For example, psychiatric patients who acquire workplace social skills in a consistent and regulated token-economy program and then enter a "real world" workplace where reinforcement is inconsistent may not be able to respond adequately to the new contingencies, and will therefore be unable to cope with the new setting, even though they functioned well under the token-economy conditions. This may lead to a financial inability to live independently, and even to homelessness and the need for welfare benefits that might not have been required had attention been paid to the generalization of token-economy-acquired skills to the outside world. This possibility makes it essential for behavior therapists to address the issues of generalization and maintenance of behavior change across various settings.

COMPUTER-ASSISTED AND ADMINISTERED THERAPY AND SELF-HELP BOOKS. Since the mid-1990s there has been an increasing interest among behavior and cognitivebehavior therapists in the development of computer-assisted and administered treatments, as well as in the dissemination of self-help books that detail, for the lay person, ways to cope with one's problems without the assistance of a therapist. This movement has been driven by the ready availability of computer technology and the Internet, and by a desire to bring the benefits of behavior therapy to people who might otherwise have limited access to therapists (such as those in remote rural areas).

The promulgation of treatments that involve minimal or no professional guidance, but rely instead upon the theories and techniques of behavior and cognitive-behavior therapies, as well as the claims made by these therapies in such a context, raises important ethical issues. Specifically, to what extent is a human therapist necessary to produce effective behavior change, and is it ethically responsible to promote these approaches in this way?

Many of these programs function by attempting to mimic the interaction between therapist and patient using decision tree programming that provide standardize computer responses to a variety of specific client input statements.

Researchers have also validated a number of computerassisted and administered treatments using "virtual reality" and computer-assisted interviewing to treat panic disorder (Newman, Kenardy, Herman, and Taylor), anger (Timmons, Oehlert, Sumerall, Timmons, et al.), acrophobia (Vincelli), and problem drinking (Hester and Delaney). To the extent that these treatments have been found to be as effective as their human-delivered counterparts, they pose no more ethical concerns than do other behavioral therapies. However, there is a danger that untested approaches and methods will be used, possibly to the detriment of patients, and it is incumbent upon all behavior therapists to insure that computer or Internet-based treatments are subjected to thorough research testing prior to full dissemination.

Similar issues adhere to the publication of self-help books. As with computer- and Internet-based applications, it is incumbent upon the authors of these books to insure that they have reasonable research evidence for their efficacy.

Authors and users of both computer-assisted and administered applications of behavior therapy and self-help books need to be attentive to possible misapplication of these techniques, particularly by persons whose problems may be more complex and difficult than such approaches can address. Clear disclaimers and cautions to potential users with respect to the limitations of these approaches are necessary to insure their ethical dissemination and use. On the positive side, these approaches are entirely consistent with the traditional emphasis in behavior therapy on active client participation in treatment.

The Image of Behavior Therapy

As noted, the image of early behavior therapy among nonbehavioral professionals and the lay public was often extremely negative. Grossly inaccurate notions about the nature of behavior therapy were commonplace, and behavior therapy was lumped with such alien procedures as psychosurgery and Erhard Seminar Training. Such misconceptions are now infrequent. This is due largely to the incorporation of behavior therapy into the mental health mainstream, to increased sophistication and greater acceptance of behavior therapy by the general public, and, perhaps above all, to the concerted attempts of behavior therapists, both as individuals and as members of professional organizations, to correct these misconceptions and thereby improve the image of behavior therapy.

There is a continuing need to modify misconceptions through well-planned public education. Behavior therapists also need continuing educational training in the maintenance of good ethical practice. Measures of consumer satisfaction are the rule rather than the exception in both clinical research and treatment. Behavior therapists must increasingly think in terms of public relations and the necessity for keeping patients informed at all stages of the intervention process. For example, behavior therapists in private practice are beginning to make available written descriptions of the treatment procedures and policies for discussion and review before treatment begins (Franks).

Conclusion

Contemporary behavior therapy is characterized by an emphasis on client participation in therapeutic goal setting and a balancing of client rights (particularly when the client is relatively powerless) against societal needs, values, and expectations. Even in institutional settings the application of techniques is much less mechanistic and intrusive, and behavior therapists are trained to apply their techniques with stringent safeguards of client rights.

An increasing awareness of the roles of thoughts and feelings in the production and maintenance of behavior has led to behavior therapists' becoming more client-centered and humanistic in their approaches to behavior change. This awareness has also produced an increasing emphasis on teaching clients self-control techniques rather than "applying techniques to clients" without consideration of the active role the client should play in the process of changing behavior.

By virtue of the inclusion of cognitive and contextual variables in theory and application, contemporary behavior therapy is a considerably advanced over early behavior therapy, which was based largely on animal models of learning. Behavior therapy is unique among current psychotherapeutic schools in that practitioners rely on repeated, data-based, objective assessments of client behaviors, thoughts, and feelings to aid in the establishment of therapeutic goals and the continuous assessment of therapeutic progress. Contemporary behavior therapy is a diverse field in which theoretical progress and practice are based on demonstrable advances in scientific knowledge, rather than on the pronouncements of authorities or "gurus." Although not yet fully integrated into behavior-therapy practice, developments in basic psychology, human rule-governed behavior (Hayes), cognitive sciences, and computer science all hold promise for enhancing both treatment efficacy and sensitivity to ethical constraints. As practitioners of a discipline and through organizations such as the Association for Advancement of Behavior Therapy, behavior therapists are learning how to apply these rigorous standards to themselves and to their personal interactions with clients, colleagues, students, and society at large.

frederick rotgers

cyril m. franks (1995)

revised by authors

SEE ALSO: Autonomy; Behaviorism; Coercion; Freedom and Free Will; Informed Consent; Mental Health Therapies; Mental Illness; Neuroethics; Patients' Rights: Mental Patients' Rights; Psychiatry, Abuses of; Psychoanalysis and Dynamic Therapies

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