ORIGIN OF behavior THERAPY

Reward and punishment systems have been

used throughout recorded history in an

attempt to influence behavior, from child
rearing to the criminal justice system.
Modern behavioral therapy began in the
1950s with the work of B.F. Skinner and
Joseph Wolpe. Wolpe treated his patients who
suffered fromphobiaswith a technique he
developed calledsystematic desensitization.

Identifying Maladaptive Behavior & Seeks to

correct these by applying the principles of learning
derived from the following theories.
1. Classical Conditioning (Ivan Pavlov, 1936)
2. Operant Conditioning (BF Skinner, 1953)

Components of Operant Conditioning:

Some key concepts in operant conditioning:
A reinforce is any event that strengthens or
increases the behavior it follows.
There are two kinds of reinforcers:

Positive reinforcers are favorable events or

outcomes that are presented after the behavior.
In situations that reflect positive reinforcement,
a response or behavior is strengthened by the
addition of something, such as praise or a

Negative reinforces involve the

removal of an unfavourable events or
outcomes after the display of a
behavior. In these situations, a
response is strengthened by the
removal of something considered
unpleasant.
In both of these cases of
reinforcement, the behavior
increases.

Punishment on the other hand, is

the presentation of an adverse event

or outcome that causes a decrease in
the behavior it follows. There are two
kinds of punishment:

Positive punishment sometimes

referred to as punishment by
application, involves the presentation
of an unfavourable event or outcome
in order to weaken the response it
follows.

CBT: Cognitive Behavioral

therapy
Definition: CBTis

apsychotherapeuticapproa
ch that uses a combination
of behavioral & cognitive
therapies that addresses
dysfunctional emotions,
maladaptive behaviors and
cognitive processes
through goal-directed &
systematic procedures.
CBT uses practical self-help
strategies and it is based
on the assumption that the
way people behave is based
on the way they think

CBT: How is it used?

CBT aims to teach people that it is

possible to have control over their

thoughts, feelings and behaviors.
Thus it helps the person to
challenge and overcome automatic
beliefs, and use practical strategies
to change or modify their behavior.
The result is more positive
feelings, which in turn lead to more
positive thoughts and behaviors.
Thus CBT is a learning process
CBT is thought to be effective for
the treatment of a variety of
conditions including:
Phobias,
Addictions (e.g Pathological
gambling)
Schizophrenia
Depression

Cognitive Therapy
Cognitive therapy aims to change the

way the person thinks about the

triggers of their disorder.
Because it is the negative cognitions
that cause self-destructive feelings
and maladaptive behavior.
Thus the Cognitive therapy challenges
those thoughts.
It is basically a talking therapy
One approach is cognitive
restructuring which involves asking
the person to come up with evidence
to prove their maladaptive thoughts.
Thus the patient learns to firstly
identify and challenge negative
thoughts,
then replace them with more realistic
and positive thoughts.

Example of CBT for a germ

phobia
1.

2.

3.

Identifying your negative thoughts. With anxiety disorders,

situations are perceived as more dangerous than they really
are. E.g. shaking another persons hand can seem life
threatening. Identifying your own irrational, scary thoughts
can be very difficult. One strategy is to ask yourself what you
were thinking when you started feeling anxious. Your therapist
will help you with this step.
Challenging your negative thoughts. In the second step, your
therapist will teach you how to evaluate your anxietyprovoking thoughts. This involves questioning the evidence for
your frightening thoughts, analysing unhelpful beliefs, and
testing out the reality of negative predictions. Strategies for
challenging negative thoughts include conducting experiments,
weighing the pros and cons of worrying or avoiding the thing
you fear, and determining the realistic chances that what
youre anxious about will actually happen when you shake
someones hands..
Replacing negative thoughts with realistic thoughts. Once
youve identified the irrational predictions and negative
distortions in your anxious thoughts, you can replace them
with new thoughts that are more accurate and positive. Your
therapist may also help you come up with realistic, calming
statements you can say to yourself when youre facing or
anticipating a situation that normally sends your anxiety levels
soaring - I wont become ill when I shake someones hand.

Cognitive Vs Behavioral
therapy

Behavioral Therapy
behavioral therapy teaches the patient the
necessary skills to modify their behavior in a
way
.
that makes it adaptive rather than
maladaptive
So the negative cognitions and emotions
decrease as the patients learns that they can
function in social situations.

ASSUMPTIONS
All behaviors are learned, (Adaptive &

Maladaptive)
Human beings are passive organisms that

can be conditioned or shaped to do

anything.
Maladaptive behavior can be unlearned

and replaced by adaptive behavior if the

person receives exposures to specific

Behavior assessment is focused more on

the current behavior rather than on

historical antecedents.
Treatment strategies are individually

tailored.

Modifying Clients behavior

1.Systematic
Desensitization
Developed by Wolpe, systematic desensitization is

based on the behavioral principle of

counterconditioning, whereby a person overcomes
maladaptive anxiety elicited by a situation or an
object by approaching the feared situation gradually,
in a psychophysiological state that inhibits anxiety

The negative reaction of anxiety is inhibited by the

relaxed state, a process called reciprocal inhibition

systematic desensitization consists of three steps:

relaxation training, hierarchy construction, and

desensitization of the stimulus

Relaxation Training
Relaxation produces physiological effects opposite
to those of anxiety: slow heart rate, increased
peripheral blood flow, and neuromuscular
stability. A variety of relaxation methods have
been developed. Some of them are:
Hypnosis
Hierarchy Construction
When constructing a hierarchy, clinicians
determine all the conditions that elicit anxiety,
and then patients create a hierarchy list of 10 to
12 scenes in order of increasing anxiety.

Desensitization of the Stimulus

In the final step, called desensitization, patients
proceed systematically through the list from the
least, to the most, anxiety-provoking scene while
in a deeply relaxed state. The rate at which
patients progress through the list is determined
by their responses to the stimuli

Adjunctive Use of Drugs

Clinicians have used various drugs to hasten
relaxation, but drugs should be used cautiously
and only by clinicians trained and experienced in
potential adverse effects. Either the ultra rapidly
acting barbiturate sodium methohexital (Brevital)
or diazepam (Valium) is given intravenously in
subanesthetic doses

Indications
Systematic desensitization works best in

cases of a clearly identifiable anxietyprovoking stimulus. Phobias, obsessions,

compulsions, and certain sexual disorders
have been treated successfully with this
technique

Pairing of unpleasant stimulus with an

unpleasant response , so that even in the

absence of unpleasant response the pleasant
stimulus become unpleasant by association .
Punishment is presented immediately after
specific behavioral response & the response is
evenly inhibited.
Unpleasant is produced by electric stimulus ,
drugs, social disapproval or even fantasy.
Indications are Alcoholic abuse, paraphilias,
Homosexuality, Transvestism.

Overt sensitization- It is a type of aversion

therapy that produces unpleasant
consequences for undesirable behavior. For
e.g.,- Disulfiram (Ant abuse)
Covert sensitization -Covert sensitization is a
form of behavior therapy in which an
undesirable behavior is paired with an
unpleasant image in order to eliminate that
behavior

Positive Reinforcement:
When a behavioral response is followed by generally
rewarding event such as food , praise or gifts, it tends to
be strengthened & occurs more frequently than before
the reward.
This technique is use to increase desired behavior.

Token EconomyA token economy is a form of behavior modification

designed to increase desirable behavior and decrease
undesirable behavior with the use of tokens.
Individuals receive tokens immediately after displaying
desirable behavior.
The tokens are collected and later exchanged for a
meaningful object or privilege.

(A) ModellingModelling refers to the learning of new behaviors by

imitating the behavior in others. Role models are the

individuals who have qualities or skills that a person
admires & wishes to imitate.
Modelling occurs in various ways. Children imitate the
behavior pattern of the patient, teacher, friends & others.
Adults & children alike model many of their behaviors
after individuals observed on television & in movies .
Unfortunately , modelling can result in maladaptive
behavior , as well as adaptive

In shaping the behavior of others ,

reinforcements are given for increasingly closer

approximations to the desired response.
For e.g.- In eliciting speech from an autistic
child, the teacher may first reward the child for
(a) Watching the teachers lips , then (b) for
making my sound in imitation of the teacher ,
then (c) for forming sounds similar to the word
uttered by the teacher .

It is used when a person failed to perform a

complex task.
The complex task is broken it to number of
small steps & each step is taught to the
patient .
In forward chaining- one start with the first
step & accomplishes the task.
In backward chaining starts with the last step
& accomplishes.

(A) ExtinctionIn behavior modification, extinction eliminates the

incentive for unwanted behavior by withholding the

expected response.
A widespread parenting technique based on extinction
is the time-out, in which a child is separated from the
group when he or she misbehaves.
This technique removes the expected reward of
parental attention.
This is commonly used when patient exhibits odd
behavior.

Aversive stimulus is presented contingent

upon undesirable response.

The punishment procedure should be
administered immediately & consistently
following the undesirable behavior with clear
explanation

It is an aversive stimulus or punishment

during which client is removed from the

environment where the unacceptable behavior
is being exhibited .
The client is usually isolated so that
reinforcement from the attention of others is
absent.

This technique named for its originator states

that a frequently occurring response (R1)can
serve as a positive response for response (R2)
that occurs less frequently (Premark, 1959).
Those is accomplished by allowing R1 to occur
only after R2 has been performed. For e.g.. 13
yr old Jennie has been neglecting her homework
for the past few weeks. She spends great deal
of time on telephone talking to her friends.
Applying the Premark principle being allowed to
talk on the phone to her friends could serve as a
positive reinforcement for completing her home
work.

It means restoring the disturbed situation to a

state that is much better than what it was

before the occurrence of the problem behavior.
For e.g.- If the patient passes urine in the ward
he would be required to not only to clean the
dirty area but also mop the entire/ larger area
of the floor in the ward

This procedure used with individuals who are

on token programs for teaching adaptive

behavior .
When undesirable behavior occurs , a fixed
number of tokens or points deducted from
which individual has already earned .

A contract is drawn up among all parties

involved .The behavior change that is desired is

stated explicitly in writing .
The contract specifies the behavior change
desired & the reinforcers to be given for performing
desired behaviors.
The negative consequences or punishers that will
be rendered for not fulfilling the terms of the
contract are also delineated.
The contract is specific about how reinforcers &
the punishment will be presented, However ,
flexibility is important so that renegotiations can

Assertiveness training is a behavior therapy

technique in which the patient is given training

to bring about change in the emotional & other
behavioral pattern by being assertive.
Client is encouraged not be afraid of showing

an appropriate response , negative or positive,

to an idea or suggestion. Assertive behavior
training is given by the therapist , first by role
play & then by practice in a real life situation.

Social Skills Training

Social skills training programs for patients with

schizophrenia cover skills in the following areas:

conversation, conflict management, assertiveness,
community living, friendship and dating, work and
vocation, and medication management.
Negotiating and compromising, for example,

involves the following steps:

Explain one's viewpoint briefly.
Listen to the other person's viewpoint.
Repeat the other person's viewpoint.
Suggest a compromise

Some Common Clinical Applications of

behavior Therapy
Disorder
Agoraphobia

Comments
Graded exposure and flooding can reduce the fear of being
in crowded places. About 60% of patients so treated
improve. In some cases, the spouse can serve as the model
while accompanying the patient into the fear situation;
however, the patient cannot get a secondary gain by
keeping the spouse nearby and displaying symptoms.
Alcohol
Aversion therapy in which the alcohol-dependent patient is
dependence
made to vomit (by adding an emetic to the alcohol) every
time a drink is ingested is effective in treating alcohol
dependence. Disulfiram (Antabuse) can be given to alcoholdependent patients when they are alcohol free. Such
patients are warned of the severe physiological
consequences of drinking (e.g., nausea, vomiting,
hypotension, collapse) with disulfiram in the system.
Anorexia
Observe eating behavior; contingency management; record
nervosa
weight
Bulimia nervosa Record bulimic episodes; log moods

Paraphilias

Schizophrenia

Electric shocks or other noxious stimuli can be applied at

the time of a paraphilic impulse, and eventually the
impulse subsides. Shocks can be administered by either
the therapist or the patient. The results are satisfactory but
must be reinforced at regular intervals.
The token economy procedure, in which tokens are
awarded for desirable behavior and can be used to buy
ward privileges, has been useful in treating inpatients with
schizophrenia. Social skills training teaches patients with
schizophrenia how to interact with others in a socially
acceptable way so that negative feedback is eliminated. In
addition, the aggressive behavior of some patients with
schizophrenia can be diminished through those methods.

GOALS OF BEHAVIOR THERAPY

It is fundamental to behavior therapy that the
client should have the major say in setting
treatment goals, it is important that the client is
fully informed, and consents to and participates in
setting goals.
Provide a direction to counseling
Provide a basis for selecting and using

strategies & interventions.

Provide a framework for evaluating the outcome.

Process of Setting Goals

1.
2.
3.
4.
5.

Counselor explains the purpose of goals.

Client specifies the positive changes desired as a
result of counseling.
Together they explore whether the goals are realistic.
They discuss advantages and disadvantages of the
goals.
On the basis of the information obtained about clientstated goals, the counselor and the client make one
of the following decisions: to continue counseling, to
reconsider the clients goals, or the seek a referral.

Advantages of goal setting

It increases the chances of making the

counselor/client alliance operational.

It emphasizes the importance of their active

participation in the process, rather than fostering

an attitude of being a passive spectator.
It is the basic link between whatever therapeutic

procedures or techniques are used and the

concrete goals of the client.

Therapists Function and Role

Behavior therapists must assume an

active, directive role in treatment.

Behavior therapists function as teacher,

director, and expert in prescribing curative

procedures that will lead to improved
behavior.

Use techniques such as summarization,

reflection, clarification, and open-ended

questions.
They focus on specifics, systematically
getting information about specific
antecedents, the dimensions of the
problem behavior, and the consequences
of the problem. (Goldried & Davison, 1976)

Relationship between Therapist

and Client
Exemplified by warmth, empathy,

authenticity, permissiveness, and

acceptance as necessary but not sufficient
conditions for behavioral change.
Behavior therapists are more self-

disclosing when it benefits the motivation

of the client.

There are three basic roles for the nurse

involved in behavioral therapy. Each of these

roles can be performed by all nurses at various
levels of expertise
Providing direct patient care
Planning treatment programmes
Teaching others the use of behavioral
techniques

Psychiatric nurses provide direct patient care in both

inpatient & community settings, & the value of

cognitive behavioral therapy is evident throughout the
continuum of the care. Most treatments are ideally
suited to community settings, & they can include the
interventions across the continuum of coping
responses- from promoting health , to intervening in
acute illness, to fostering rehabilitation
Nurses may also function as planners & co-ordinators
of complex treatment programmes , consultants , &
teachers of other nurses , professionals, patients, &
their families. It is clear that with the current emphasis
on cost- effective treatment & documented outcomes
of care , behavioral therapy will be growing area of
expertise for all psychiatric nurses in next decade

behavior therapy is a combination of the

systematic application of principles of learning
theory to the analysis and treatment of behavior. It
involves more than principles of learning and
conditioning, however, and uses the empirical
findings of social and experimental psychology.
The emphasis is placed upon the observable and
confront able and not inferred mental states or
constructs. The doctors seeks to relate
problematic behaviors (symptoms) to other
observable physiological and environmental
events. This involves behavioral analysis of what is

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