Assumptions of Behavioral Therapy
The nice thing about Behavioral interventions is that they force practitioners to bring some degree of science and objectivity to skill training. In any kind of activity that has anything to do with psychology-- no matter how far removed -- there seems to be a constant danger of falling onto various traps of "emotional analysis". This kind of thinking leads directly into the "I'm Dysfunctional, You're Dysfunctional" syndrome that brought pride and social status to victimhood during the 1980's. Roseanne Barr epitomized the trend when she said "The fact that you cannot remember ritual sexual abuse in your childhood is a warning sign that it probably happened to you."
Behavioral interventions keep us disciplined and focused on the objective aspects of the learning process. Without it we can't really be sure about the effectiveness of our interventions, or even the behaviors the interventions are supposed to affect. In short, the value of incorporating behavioral philosophy into skills training is that it insulates our interventions from subjective expectations that each of us carries with us.
I've summarized the following seven Assumptions of Behavioral Therapy in my own words. Immediately following my summaries is an excerpt from Behavioral Therapy: Techniques and Empirical Findings, by David Rimm and John Masters that expands, in great academic detail, on the seven assumptions. Dave and John aren't much of a threat to Steven King's reputation, but give them a try anyway.
Behaviorism is practical; it concerns itself with behaviors that are incompatible with local community standards. Although there may be causative factors that underlay the target behavior, (such as emotions like anxiety or anger), behaviorism assumes they do not exist.
Behaviorism assumes that few behaviors are not learned behavior, and strives to help clients "unlearn" them, or learn new behaviors in their place.
Behaviorism is often used as a training strategy for the severely mentally handicapped, such as the mentally retarded, autistic or mentally ill. Because the ability to learn is inherent in behaviorism these populations are less likely to be lost to the "palliative care" excuse for not supplying services. ("Don't waste your time. He can't learn -- he's retarded.")
Behaviorism generates interventions based on objective measurements of observed behaviors. Therefore clearly defined goals, strategies and interventions are necessary order for interventions to maintain objectivity and validity.
One of the dangers inherent in behaviorism is the tendency for practitioners to unwittingly develop a small number of "intervention templates" that are slightly modified to meet the needs of different learners. Practitioners must discipline themselves to remember that intervention plans are individualized, and must adapt themselves to all aspects of the client.
Behaviorism is a pragmatic approach that is concerned only with how a behavior manifests itself in the present environment. Distant underlying causes of behavior, or consequences that may manifest themselves far in the future, are not relevant to behaviorism.
Behaviorism has a component of strategies and interventions that have proven to be effective in laboratory conditions and have been endorsed as being effective and ethically acceptable by academia and behavior mod organizations.
Assumptions of Behavior Therapy
Rimm and Masters
Behavior therapy approaches differ considerably with respect to the emphasis placed on underlying processes in maladaptive behavior (Yates, 1970). Operant conditioners have the strongest philosophical commitment to remaining at a purely behavioral level. We have known operant conditioners who are unfriendly to methods such as systematic desensitization that, theoretically at least, are dependent on the existence and manipulation of events below the level of overt behavior (visual imagery; anxiety). Opposition to what some label as "mentalism" is not without historical justification. (This issue is dealt with later in the chapter.)
The Wolpian methods emphasize alleviating maladaptive anxiety. Whereas the Skinnerian (that is, operant conditioner) might deal with the snake phobic simply by providing reinforcement for successively greater approach behaviors to a snake (since the problem is snake avoidance, for the Skinnerian), the Wolpian would conceptualize the problem in terms of an underlying cause, anxiety, and attempt to alleviate this internal state. It should be pointed out that while anxiety is by no means as "public" as overt avoidance behavior, for Wolpe it is a state of arousal having definite physiological referents, a state of arousal that can be detected (for instance, by the galvanic skin response). In other words, anxiety is an internal mediating response that is a good deal less obscure than underlying entities (for example, oedipal conflict and organ inferiority) typically postulated by schools of dynamic psychology.
Ellis's Rational‑Emotive Therapy (Chapter X) is included in the present text because in our judgment it shares many of the assumptions common to the more traditional behavioral therapies. However, relatively speaking, Rational‑Emotive Therapy is a depth approach. Thus, our snake phobic avoids snakes because he is anxious, but the anxiety is generated by irrational thoughts (self‑verbalizations) that, themselves, follow from a faulty system of beliefs. It should be pointed out that in sharp contrast to the traditional depth approaches, the kinds of cognitive activity so essential to Ellis's theoretical position can be specified in a relatively concrete and unambiguous manner.
For the purposes of comparison, consider how a psychoanalyst might conceptualize a snake phobia. He would agree that the snake phobic does experience anxiety when confronted with a snake; but, below this anxiety might be the unconscious perception of phallic‑like properties of the snake. At a more basic level, there might be repressed thoughts of castration, and at an even more fundamental level, a sexual love of mother, also repressed. Note that whereas for Wolpe the underlying anxiety can be detected by independent means, and for Ellis, cognitions conceived of as, self‑verbalization can readily become overt verbalizations, subject to public scrutiny; many of the underlying events postulated by psychoanalysis are, according to the. theory, quite inaccessible.
Psychoanalytic and related dynamic approaches were created and have been perpetuated largely by individuals trained in the field of medicine (as the reader may know, psychiatrists are physicians who specialize in psychiatry). It is not surprising then that "models" of human maladaptive behavior associated with such approaches have tended to borrow rather heavily from concepts associated with physical illness. Hence, these dynamic conceptualizations have come to‑be identified with such labels as the "medical model," or the "disease model." In the medical model of psychological disorder, maladaptive behavior is assumed to be symptomatic of an underlying pathological state, or state of disease. it is also assumed that to cure the patient suffering from "mental illness," it is necessary to eliminate the inner state of pathology. That is, treating symptoms alone would be of no benefit and, in the long run, might be harmful, since the inner disease might be expected to intensify. It is interesting that the psychodynamic adaptation of this model of illness is considerably more stringent. on the matter of symptomatic treatment than the parent physical medicine model (witness the highly successful symptomatic treatment of cystic fibrosis, or the somewhat less successful, but very widespread, symptomatic treatment of the so‑called common cold).
A corollary of assumption I is that behavior therapy tends not to follow the medical model. Again, this is a matter of degree. Were behavior therapy limited to operant conditioning, one could fairly say, "behavior therapy rejects the medical model, and in particular, the concept of the symptom." However, when one speaks of anxiety‑mediated avoidance or self‑verbalizations that give rise to maladaptive behavior, in a sense one is treating overt behavior as symptomatic of something else. This 11 something else,'.' however, is not thought of as a disease state, related to overt behavior in some mysterious or poorly specified fashion. Instead, it refers to internal events triggered by external stimuli that serve to mediate observable responding. Another important difference that we have pointed out is that behavior therapy "internal" events are a good deal more accessible to the client, as well as to the therapist, than those of psychodynamic theory.
As many writers [see Eysenck (1959); Yates (1958); Ullmann & Krasner (1965, 1969)] have noted, psychodynamic approaches (especially psychoanalytic theory) predict that removing a symptom while ignoring the underlying cause will result in either the reoccurrence of that symptom or the appearance of a substitute symptom. It is sometimes suggested that the hypothesis of symptom substitution follows from the medical model (Ullmann & Krasner, 1965), but this requires some qualification. If, by symptom substitution, we mean the appearance of new symptoms as~ a result of removal of old ones, this doctrine is not consistent with the medical model of physical illness, which does allow for symptomatic treatment and does not ordinarily anticipate untoward consequences of this. Thus, the physician in viewing fever as a symptom of an invasion of bacteria, nevertheless, does not expect aspirin therapy or alcohol rubs to somehow cause the appearance of a new ailment. Even certain psychiatric adaptations of the medical model allow for treatment that can best be described as symptomatic. Most psychiatrists who prescribe tranquilizers or electro‑shock therapy would not argue that they are attempting to alleviate psychopathology at its most basic level, nor would they prescribe such treatment expecting new and terrible symptoms to appear.
In other words, the hypothesis of symptom substitution (we could use the term, "doctrine," because this is what it has become) does not follow from the medical model per se, but rather, from one specific psychiatric derivative of the medical model, namely, psychoanalytic theory. With respect to the psychoanalytic view of maladaptive behavior, the analogy is often made to a kind of closed hydraulic system. If something within the system gives rise to a build‑up of pressure, this may cause a surface rupture, with fluid rushing out. However, since fluids are not compressible, dealing with rupture (analogous to treating symptoms) only increases the likelihood that a rupture will occur elsewhere. Given the appropriateness of this analogy to human psychological functioning, symptom substitution is a very plausible notion.
Naturally, the critical question from our point of view pertains to whether or not symptom substitution is likely to occur. As Bandura (1969) cogently pointed out, it is not really possible to disprove this doctrine once and for all, because therapists who apparently believe in symptom substitution have specified neither the nature of the substitute symptom nor the circumstances under which it should occur. On the other hand, it is possible for the behavior therapist to state his own version of the hypothesis (Cahoon, 1968) and test it on the chance that symptomatic treatment may indeed prove to be harmful. Generally, efforts in this direction (and there have been many) have involved employing behavior therapy to eliminate or weaken an undesirable behavior, waiting some reasonable period of time, and then querying the individual as to whether or not he has experienced some new symptom. Reviews of empirical findings (including case histories and controlled experiments) indicate that the evidence is overwhelmingly against symptom substitution (see Bandura, 1969; Lazarus, 1971; Paul, 1969b,c; Wolpe, 1969; Wolpe & Lazarus, 1966).
As other writers (for example, Bandura, 1969; Ullmann & Krasner, 1969) have noted, there are circumstances in which one maladaptive response may substitute for another. Bandura (1969, p. 51) cites the example of antisocial behavior that has been suppressed by punishment. If the individual is lacking in a socially acceptable response which could serve the same end, he is likely to engage in some other antisocial response. Wolpe (1969) notes that symptom substitution may occur when a particular overt act is eliminated but the underlying autonomic (emotional) response remains. For example, if so‑called compulsive hand‑washing is suppressed, the individual might conceivably learn another maladaptive anxiety‑reducing response. Thus, there is no axiom of behaviorism which precludes the substitution of one maladaptive behavior for another. But from a practical point of view, it is a phenomenon only rarely observed.
No currently popular theory of human behavior or personality would take issue with the view that human beings are, to a large extent, products of their environment. However, behavior therapy specifies rather precisely how the environment may influence people, in terms of established learning principles (for example, classical and operant conditioning, modeling).
It must be stressed that while maladaptive behavior differs from adaptive behavior in terms of its impact on the individual and those around him, "healthy" and "unhealthy" ways of responding are generally viewed as fundamentally alike in other respects. Both ways of responding directly reflect the individual's learning history and follow from the same general principles of learning (Ullmann & Krasner, 1969).
Clearly, no modern behaviorist would take the position that all maladaptive behavior is merely a consequence of an unfortunate learning history. One would be hard pressed to argue that the immediate behavioral deterioration following a traumatic central nervous system accident arises from the sudden acquisition of a large number of new habits (that is, learned responses). Similarly, few therapists would maintain that mental retardation (for example, associated with microcephaly, mongolism, cretinism, or hydrocephaly) arises exclusively, or even primarily, from unusual learning experiences.
It seems reasonable to assume some correspondence between the degree to which a particular response was learned (as opposed to having been genetically determined) and the ease with which it can be modified. On the other hand, as Davison (1968) has observed, the fact that a response can be modified through learning does not prove it was acquired through learning. For example, it is likely that certain components of human sexual arousal are innate. Yet everyday experience suggests that we can learn to be aroused (and later inhibit such arousal; see Chapter IX) in the presence of stimuli that initially were "neutral" (articles of clothing or pornographic literature).
The degree to which people in a position of social control are aware of the importance of relatively straightforward learning principles can be expected to have a major bearing on the welfare of their charges. Consider the case of a child who very early in life is diagnosed as severely mentally deficient (for instance, mongoloidism). This child has two serious strikes against him. First, assuming the diagnosis correct, there is something wrong with the way his brain functions, and it is unlikely that he will ever behave in a totally normal manner, no matter what kind of treatment he receives. Second, once he has been labeled severely mentally deficient, the child may automatically be assumed by a great many el people (including some professionals) totally incapable of learning. As a result, rather than devoting the extra attention necessary to teach him things such as elementary speech, the child is treated in a custodial manner and fails to acquire many basic skills that he may be quite capable of acquiring. That certain rudimentary skills may be taught to such individuals has become abundantly clear in recent years (see Garcia, Baer, & Firestone, 197 1; O'Brien, Azrin, & Bugle, 1972; O'Brien, Bugle, & Azrin, 1972).
Perhaps to a lesser extent, persons labeled as autistic, schizophrenic, or even epileptic are frequently victimized by significant others who severely underestimate the ability of these individuals to learn. When this happens, a major learning deficit may be expected, fulfilling the misguided prophecy.
Behavior therapy does not conceptualize maladaptive responding as emanating from a "disturbed personality" (a term that would have little meaning for most behaviorists). Obviously, then, the goal of the therapist and client would not be to facilitate the reorganizing or restructuring of the client's personality. Instead, the aim would be to help alleviate the specific problems that are interfering with the client's functioning, often by treating these problems in a relatively discrete manner. For this reason, certain writers (see Breger & McGaugh, 1965) have criticized behavior therapy for ignoring states such as general unhappiness. The behavior therapist's preference is to determine the specific events that lead to broad statements such as "I'm unhappy all the time," or, "Life isn't worth living." The analogy may be made to physical medicine, wherein the patient who feels "generally poor" is asked to indicate specific ailments that are often treated separately. The criticism that the physician is thereby ignoring his patient's "general health" would not seem to be justified.
The Importance of Stimulus Control.
The term stimulus‑response (S‑R) is often associated with behavioristic psychology. We prefer to avoid its usage, because for many it has a highly simplistic connotation that does not do modern behavior theory justice. On the other hand, a fundamental precept is that behavior is under stimulus control and, when the behavior therapist establishes his objectives, they are conceived of in terms of specific responses occurring lawfully in the presence of specific stimuli. Thus, the therapist using systematic desensitization is not trying to free his client from "fearfulness," but rather from specific fears (for example, of high places or certain animals). And the operant conditioner would not attempt to increase the likelihood of all types of behavior in all circumstances, but, rather, specific responses to specific stimuli. Even Rational‑Emotive Therapy (see Chapter X), which is not usually thought of as exemplifying S‑R psychology, does postulate lawful stimulus response relationships, with S and R bridged by the thoughts the patient has.
Behavior Therapy and Trait Psychology.
The position of most behavior therapists is that behavior is highly situation‑specific. That is, by and large what people learn are specific ways of reacting to, or dealing with, specific situations. No one would argue that what we learn in one situation does not carry over (that is, generalize or transfer) in some measure to other situations. However, the behaviorist would argue that this occurs far, far less than is suggested by traditional theorists (and by the layman, as well). The opposite point of view is that people acquire traits that give rise to similar responses in a wide variety of situations. For example, the individual who is labeled as aggressive is expected to be unusually aggressive in most situations; the liar is more likely to prevaricate than a nonliar, no matter where he is; and the schizophrenic to emit more "crazy" behaviors than the "normal" person in any situation. Mischel (1968) has carefully examined the psychological research literature pertinent to traits. His general conclusion may be stated as follows: A person's behavior in one set of circumstances is generally a rather poor indicator of how he will respond in situations that are markedly different. In other words, different behavioral manifestations Of the same "trait" do not intercorrelate very highly. The behaviorists' position is that a far better predictor of future behavior in a given set of circumstances is past behavior in the same or similar circumstances.
Many forms of traditional psychotherapy provide essentially one method of treatment, regardless of the specific nature of the client's presenting complaint. While it is true that the psychodynamic therapist may occasionally opt to provide "support," rather than attempt to get at the deep‑seated roots of the problem, this is usually seen as a stopgap procedure. If one assumes, as in the case of psychoanalytic and related approaches, that present difficulties usually stem from a lack of insight into critical childhood experiences, a single approach, aimed at achieving such insight, seems to be plausible. Similarly, if an individual's present problems are usually symptomatic of a need for "unconditional positive regard" (Rogers, 1961), client‑centered therapists are quite justified in providing this as the principal mode of treatment.
In terms of the problems with which he is confronted, the behavior therapist is willing to assume a more varied etiology, although, obviously, learning is stressed. However, there is nothing in present learning formulations that suggests that maladaptive responses are acquired very early in life, or that they necessarily are mediated by the same pervasive mental state (for example, a low self‑concept). As we shall see later in the chapter, behavior therapy does not require that the precise learning conditions giving rise to present difficulties be known. The point is that the behavior therapy conceptualization of how psychological disorders develop simply does not justify the use of what Bandura (1969, p. 89) has called an "all‑purpose, single method" therapy. Instead, the therapist will employ different procedures, depending upon the nature of the problem. A person fearful of flying may be desensitized; a male who is timorous in the presence of attractive females may receive assertive training; the alcoholic may be offered aversive conditioning; the parent whose child frequently throws tantrums may be instructed in operant principles; the obese person may be taught principles of self-control; and so on.
If a practitioner tends to view all psychological disorders as emanating from a common internal state or process, and especially if the state is said to be "unconscious," he will be most unlikely to interpret the client's "presenting" complaint as the client's real problem. The client, who is ruled by powerful, but unconscious, thoughts and impulses, is considered not competent to portray what ~is troubling him in anything but a superficial and distorted manner. In fact, the authors have known psycho dynamically oriented therapists who universally assume that the client's true thoughts and feelings are, in fact, diametrically opposed to what he expresses during initial therapy sessions.
Behavior therapists, on the other hand, are considerably more likely to accept the client's presenting complaints as valid (if he did not suffer from these complaints, he would not have sought professional help). Naturally, one not need be an experienced professional practitioner to know that in any initial encounter, people are not always candid. The therapist, after all, is a stranger and, regardless of his formal credentials, time is required to establish an atmosphere of trust and confidence. Any experienced clinician will recall many cases involving clients who after a few sessions, readily admitted to problems that were of far greater concern to them than problems initially presented. It is also very common to deal with clients presenting initial complaints who report other unrelated problems during the course of therapy. Thus, the experienced behavior therapist does not assume that he has "a complete picture" of his client after I hour with him. At the same time, the client is generally viewed as an essentially competent source of pertinent information, whose basic problems may be specified without. the necessity of hundreds of hours of some form of "uncovering" therapy.
The reader may wonder how a behavior therapist might deal with the more bizarre complaints of the hospitalized psychotic patient. In part, this would depend on the nature of the overall treatment program. In Chapter ‑ VI, ward programs based upon operant principles are described. Programs of this nature stress methodically ignoring bizarre, inappropriate behavior, on the expectation that it will extinguish, while, at the same time, reinforcing constructive, appropriate ways of behaving. The assumption is that if certain of the patient's complaints (for example, "I'm fearful because the Romans are going to crucify me.") are not very credible, this is at least partly a result of the attention he has received for such behavior. Individual treatment may readily be incorporated into operant programs. When this is done, the therapist's approach to the validity, of presenting complaints would be qualitatively the same as that for outpatients in a consulting room office. Most individuals with a diagnosis of "psychosis" exhibit relatively normal behavior much of the time (especially if the ward program does not implicitly discourage this). The mere fact that a patient occasionally exhibits bizarre forms of behavior in no way implies that he possesses a "trait" of incompetence and that his complaints are in general not to be taken seriously.
Individuals beginning therapy often have the expectation that they will be asked to delve into their early childhood experiences in minute detail. In fact, psychoanalytic and related approaches, which have predominated in the United States throughout most of this century, do strongly emphasize the importance of uncovering (that is, "working through") early events assumed to be critical The assumption is that the attainment of "insight" into these experiences (Fenichel, 1945) is of curative value. Associated with this assumption are two critical questions. First, how can we be sure that the content of such insights adequately describe actual childhood events? As has been frequently pointed out (see Bandura, 1969), insights presented to the therapist represent a particular class of verbal behaviors, subject to the same principles of learning that influence other behaviors. Verbal conditioning (Greenspoon, 1955, 1962), wherein an experimenter is able to increase certain types or classes of verbal response by selective reinforcement, has been repeatedly demonstrated in the laboratory; and given the presumably higher levels of motivation of most clients, influences of this nature might be expected to be even more potent in the therapeutic situation. A combination of selective reinforcement and verbal modeling could easily account for findings (see Heine, 1953) wherein clients tend to characterize their own behavior in terms of the orientation of their particular therapist. The situation is analogous to a student adopting the idiosyncratic language of a favorite professor or of an admired friend. Considerations of this nature have led Bandura to suggest that what has been labeled "insight" in the therapeutic interview might better be characterized as "social conversion."
But, even assuming the "validity" of insights obtained in psychotherapy, does it follow that they will necessarily lead to reduction in maladaptive responding? Consider the so‑called "war neurotics" (Grinker & Spiegel, 1945), who in our experience are quite able to describe traumatic combat experiences that relate to their presenting complaints in a manner far too plausible to discount. Yet despite their apparent insights, their problems seem to remain. For example, Rimm treated a World War 11 veteran who had served as bombardier through some 50 combat missions and who, some 20 years later, was still fearful of loud noises resembling the sounds of exploding flack or machine gun fire and of high places (prior to the war he had experienced neither fear). Whereas such insight appeared to be of little value, both fears were alleviated through systematic desensitization. We are not suggesting that every phobic person is able to recall precipitating traumatic events [Lazarus (197 1) has presented data to the contrary 6]. But persons who can, would, nevertheless, seem to remain phobic.
It should be obvious at this point that behavior therapy rejects the notion that the attaining of what might be labeled "historical insight" is curative. The necessity for detailed explorations of the client's childhood is also rejected, although a certain amount of biographical information is usually considered helpful. (This is dealt with when intake interviews are discussed later in this chapter.)
As Kanfer and Phillips (1970) have noted, behavior therapy is very "self‑conscious" when it comes to scientific validation of its techniques. As we see in the section to follow, empirical evidence may come in more than one form, with greater degrees of scientific control providing greater degrees of certainty. The behavior therapist does not assume that a technique is effective because it is derived from a widely held theory, or because an authority has labeled it effective in the absence of supporting evidence, or because common sense suggests its effectiveness. Naturally, our thinking is affected by factors of this nature that may serve as the source for hypotheses about human behavior. The essential point, however, is that these hypotheses must then be‑ put to test.
It may seem quite obvious to the reader that any accepted mode of treatment ought to be based upon established scientific findings, rather than upon authority, convention, or suppositions bordering on folklore. It should be stressed, however, that this has not been the prevailing attitude throughout most of the history of psychotherapy. In the writings of orthodox analysis (for example, Fenichel, 1945) it is common practice to cite the edicts of Freud and other prominent analysts, much the way medieval scholastics cited Aristotelian proclamations as incontrovertible proof for their positions. Frequently, when cases are cited in the psychodynamic literature, no mention whatsoever is made of outcome, as if this were simply not an issue (see Astin, 1961).
Today clinical psychologists usually hold doctoral degrees awarded through academic departments of psychology. Most departments, ostensibly at least, adhere to the so‑called "Boulder Model" of training (see Cook, 1966), wherein the clinical psychologist is assumed to possess critical scientific, as well as practical, skills. A fair portion of his training is devoted to statistics, learning theory, research design, etc., with his instructors repeatedly stressing the virtues of a "hard‑nosed," rigorous approach in dealing with the subject matter of psychology. On the other hand, not infrequently in the same department (and often on internships), he finds himself exposed to other instructors or supervisors who may pay lip service to scientific rigor, but who clearly take a prescientific approach in dealing with clinical problems. Consider the student who questions his professor as to the value of clinical interpretations on the grounds that the interpretation is based upon a personality test that substantial research has shown to be of questionable validity. The professor's response might be that his own personal experience has provided him with a special "feel" for the test in question, or that one should approach such tests "intuitively." The student may receive the same sort of response when he poses questions concerning particular therapy tactics. What he is being told, implicitly, may be stated as follows: "While there may be a place for scientific psychology in the laboratory, when you get down to actual clinical cases, forget rigor. Instead, rely on the authority of experienced clinicians and, later, on personal experience, intuition, 'gut' reactions, etc."
Training of this nature is likely to produce a professional "dual personality," wherein the clinician pays due homage to the ethic of science, but, perhaps somewhat smugly, believes that in terms of clinical practice, doing one's "own thing" is the superior approach.
We are by no means advocating that the practitioner ignore his personal experience, or that of others. During any given therapy session, the clinician will be required to make many on‑the‑spot decisions pertaining to issues which have not been researched in a manner that would prove to be helpful. At such choice points, he can rely only on experience. On the other hand, the clinician who is confronted with a problem that has been well researched, but who pays such findings no heed, is clearly doing his client a disservice.