Clinical applications of Behavioral Therapy
Table of Contents
- 1 What is the scientific basis for behavioral therapy?
- 2 What are the various types of clinical interventions in Behavioral therapies?
- 3 The role of behavioral therapy in the treatment of mental disorders
- 4 Overview of behavioral therapy treatment outcomes
- 5 Therapeutic advances in behavioral therapy – The third generation
- 6 Medical professionals who can provide behavioral therapy
- 7 Institutional setting for behavioral therapy
- 8 Evidence-based effectiveness of Behavioral therapy in a clinical setting
The main interventions in behavior therapy are based on functional analysis. Affection in partnerships, compassion in married people, severe pain, stress-related behavioral patterns, issues of being an adult child of an individual with an alcohol addiction, disordered eating behaviors, chronic anguish, substance misuse, depressed mood, anxiousness, sleeplessness, and weight gain are just few of several concerns that behavior therapy has qualitatively analyzed.
Functional analysis has also been used to address issues that therapists frequently face, such as patient opposition, limited engagement, and compelled patients. Clinicians now have a wide range of instruments to improve therapy success as a result of these applications. Operant conditioning or positive reinforcement is one technique to improve therapy effectiveness. Despite the fact that behavior therapy is focused on a generic learning paradigm, it can be used in a range of therapeutic packages that are especially designed to address troublesome habits.
Relaxation techniques, systematic desensitization, interactive virtual exposure, modeling, response and exposure prevention approaches, psychosocial interventions, behavioral repetition and homework, and aversion psychotherapy and punishment are several well-known therapies.
Patients are taught to lower reactivity to minimize distress by stiffening and relaxing specific muscle groups across their body during relaxation exercises. Systematic desensitization is a therapy in which the patient gradually replaces a maladaptive response with a new taught response by going up a ladder of anxiety settings. Counter conditioning is used in part of systematic desensitization. Counter conditioning is a type of discovering new ways to switch from one behavior to another, while desensitization is the process of switching from a maladaptive behavior to a more relaxing one. The basic strategy in which a psychotherapist introduces a patient to anxiety-provoking events while preventing avoidance reactions is known as exposure response prevention strategies (also referred to as flooding and response prevention).
Virtual reality treatment replicates distressing circumstances by using computer simulations. The modelling method includes an individual being exposed to other persons who exhibit behavior that is regarded adaptable and should be replicated by the client. This exposure includes not only the characteristics of the “model person,” but also the settings in which a particular behavior takes place. In this way, the relationship between the acceptability of a particular behavior and the context in which it occurs can be noticed. A patient gets a desired behavior during a therapeutic setting and then practices and records it between sessions using the behavioral rehearsing and home treatment.
Aversion treatment and punishment are two terms that refer to a technique whereby an aversive (traumatic or uncomfortable) stimuli is employed to prevent the occurrence of undesirable behaviors. It is concerned with two kinds of methods: those that reduce the occurrence of a specific behavior occurring frequently and those that decrease the attraction of certain behaviors and the triggers that activate them. The punishment component of aversion therapy occurs when an unpleasant stimulus is presented concurrently with a negative stimulus and is subsequently discontinued concurrently with the presentation of a positive stimulus or reaction. Shock treatment therapies, aversive medication therapies, and response cost conditional punishment are all forms of negative stimuli or punishment that can be utilized.
Applied behavior analysis is the application of behavioral techniques to the modification of specific behaviors deemed to be socially or personally significant. The four principal components of applied behavior analysis are as follows.
The first level of behavior analysis is primarily concerned with overt behaviors in an applied context. Treatments are intended to disrupt the link between these overt behaviors and their outcomes. Another feature of applied behavior analysis is the method by which it evaluates response to therapy. The study is focused on the individual patient; the examination is centered on the single person being treated. A third trait is that it is concerned with how the surroundings influence significant changes in behavior. Finally, applied behavior analysis employs strategies derived from classical and operant conditioning, such as reassurance, stimulus control, punishment, and any other applicable learning principle.
Social skills training instructs patients on how to gain access to extrinsic motivators and therefore reduce life consequences. In a meta-analysis, operant conditioning methods had the biggest impact factor on social skill training, trailed by modeling, mentoring, and social cognition strategies. There is some scientific backing for social skills training, notably in the case of schizophrenia. However, behavioral approaches have typically fallen out of favor in the treatment of schizophrenia.
Additionally, in behavior treatment, biofeedback, token economies, response costs, contingency contracting, and structuring and evaluating task assignments have been used.
When complex behavior needs to be taught, graded and shaping task assignments are utilized. Complicated behaviors that must be acquired are subdivided into shorter phases in which the individual can accomplish small tasks before progressing to the more complicated behavior. Each stage gets closer to the ultimate aim and assists the individual in gradually increasing their activity. This behavior is utilized when an individual believes that certain aspects of their lifestyles are unchangeable and that life’s responsibilities appear to be onerous.
An additional behavior therapy strategy is to hold a patient or client responsible for their behaviors in order to modify them. This is referred to as a contingency contract, which is a formalized written agreement between two or more parties that describes the particular expected behaviors that you desire to change, as well as the associated rewards and sanctions. A contingency contract must contain five characteristics in order to be considered legitimate. To begin, it must specify what each individual will receive if they effectively do the required behavior. Second, those participating must keep an eye on their behavior. Third, if the target behavior is not carried out according to the contract’s terms, the contract’s penalties must be carried out. Fourth, if the parties adhere to the deal, they must get incentives. The final part entails recording adherence and non – compliance when utilizing this treatment in order to provide consistent feedback about the goal behavior and the allocation of reinforcers to the individuals involved.
Token economies are a sort of behavior treatment strategy in which patients are rewarded with tokens that function as a means of payment and may be used to acquire desired incentives, such as watching television or eating a snack, for performing desirable behaviors.
Token economies are most frequently utilized in organizational and rehabilitative contexts. To be successful, a token economy must be administered consistently by the rest of the staff. Protocols must be clearly specified to avoid patient misinterpretation. Rather than seeking ways to punish individuals or deprive them of incentives, staff must encourage positive behaviors in order to boost the frequency of the desired behavior. Over time, the tokens should be phased out and replaced with less extrinsic incentives such as compliments, so that the patient is ready when they leave the organization and does not expect to receive something for every positive behavior.
A method called reaction costs is closely linked to token economies. This strategy can be used in conjunction with or in lieu of token economies. Response costs are punishment aspects in token economies, where somebody loses a prize or permission for engaging in undesired behavior. As is the case with token economies, this strategy is most frequently applied in organizational and rehabilitative settings.
Behavioral perspectives on many forms of psychopathology have had significant policy ramifications. A particular type of behavior therapy, behavior reversal training, has been shown to be extremely helpful in the treatment of tics (involuntary movements).
Both behavior therapy and cognitive-behavioral treatment (CBT) are equally beneficial for obsessive-compulsive disorder (OCD), according to two large studies conducted by Simon Fraser University’s Faculty of Health Sciences. CBT has been demonstrated to be marginally more effective in the treatment of co-existing depression.
Behavioral perspectives on many forms of mental illness have had significant policy ramifications. For managing tics, one type of behavior therapy (behavior reversal training) has been shown to be very helpful.
There has also been a shift in the treatment of psychiatric conditions by combining various therapy methods. Better established behavioral therapies based on classical and operant conditioning are utilized to improve the impact of cognitive interventions. There has also been a greater emphasis on the interpersonal environment in which a certain behavior manifests itself.
Behavior therapy can be used to treat a variety of mental diseases, and it is often more beneficial for certain disorders than for others. Any phobias that an individual may have can be treated through behavioral therapy procedures. Desensitization has also been used to treat other concerns such as anger management, sleeping problems, and certain speech impairments. Desensitization by itself doesn’t happen overnight; it is a therapeutic procedure. Desensitization is performed in a series of treatments and is done in a sequence. From events that make people feel less nervous or tense to things that are considered excessive for the patient, the scale progresses.
Apprehensions and phobias have been treated via modeling. Phobia of snakes, as well as a fear of heights, have both been treated using modeling. Sexual perversions and alcohol consumption problems have both been treated with aversive therapy approaches. People with anxiety issues, as well as other mood concerns or phobias, might benefit from the exposure and preventative strategies.
These techniques have also been utilized to assist people with rage issues and compulsive grievers. Fear of flying, height phobia, and a range of other anxiety disorders are treated with virtual reality treatment (VRT). VRT has also been used to help individuals with substance misuse issues lower their sensitivity to certain triggers that make them want to use drugs.
Suicide prevention and depressed or inhibited individuals have benefited from work assignment shaping and grading. This is utilized when a patient feels hopeless and unable to change their circumstances. This pessimism is exacerbated by how the person behaves and reacts to others and specific situations, as well as their felt impotence to change things. It is critical for an individual with suicidal ideation to take little action at first. Because that individual may consider everything as a large step, the smaller you start, the easier each step will be for them to master. This method has also been used to help people who suffer from agoraphobia, or a dread of being seen in public or doing something humiliating.
Contingency contracting has been utilized to deal with miscreants’ behavior issues as well as on-task behavior in kids. Token economies are usually prevalent in psychiatric facilities and are employed in restricted contexts. They could be used to assist patients with various mental diseases, but the focus is on the patient’s behavioral elements rather than the therapy of the mental condition. The response cost method has been used to treat a wide range of behaviors, including tobacco smoke, binge-eating, stammering, and schizophrenic speech.
Systematic desensitization has been demonstrated to be effective in treating phobias of heights, bugs, and arthropods (e.g. cockroaches), driving, and any other type of anxiety. Anxiety can manifest itself in a variety of ways, including social nervousness, anxiety over speaking in public, and exam or assessment anxiety. It has been demonstrated that systematic desensitization is an efficient method that may be used to address a variety of issues that a person may encounter.
When modeling approaches are used, this method is frequently likened to another type of behavioral therapy. When contrasted with desensitization, it appears as though the modeling approach is less effective. However, it is self-evident that the more the involvement between the client and the subject he is modeling, the more effective the intervention will be.
An individual normally requires 5 sessions of exposure therapy to determine the treatment’s success. After 5 sessions, it has been demonstrated that exposure therapy benefits the patient. However, therapy should be continued beyond the initial 5 sessions. Fear of heights has been demonstrated to be beneficial with virtual reality therapy (VRT).
Additionally, it has been demonstrated to aid in the treatment of a range of anxiety disorders. Due to the high expense of VRT, practitioners are still waiting for the results of randomized trials to determine which uses achieve the best benefits.
Suicidal thoughts are treated differently depending on the severity of the individual’s sadness and sense of despair. If these factors are extreme, the individual’s reaction to achieving tiny steps will be irrelevant, as they will not consider the result achievement. Generally, this strategy has proved helpful in people who do not suffer from severe depression or dread, as completing basic activities develops their confidence and helps them to advance to more complicated scenarios.
Contingency contracts have been shown to be helpful at changing individuals’ undesirable behaviors. It has been shown to be beneficial in treating miscreants’ behavioral issues regardless of the contract’s exact features.
Token economies have been demonstrated to be useful in the treatment of chronic schizophrenia patients admitted to mental facilities. The findings indicated that contingent tokens exerted control over the patients’ behavior.
Response costs have been demonstrated to be effective in inhibiting a variety of behaviors including tobacco smoke, disordered eating, and stammering in a varied range of clinical settings ranging from sociopaths to school kids. These restricted behaviors frequently do not rebound after the punishment condition is removed. Additionally, the negative consequences associated with punishment are rarely observed when the response cost technique is used.
Ever since the 1980s, a plethora of innovative behavioral therapies have been devised. These were eventually termed “the third generation” of behavioral therapy by Steven C. Hayes. The 1st generation of behavioral therapy is defined as that pioneered independently by Joseph Wolpe, Ogden Lindsley, and Hans Eysenck in the 1950s, while the 2nd generation is defined as that established by Aaron Beck in the 1970s.
Other researchers opposed the terms “third-generation” or “third wave” and instead designate the many “third wave” treatment procedures as advanced cognitive-behavioral therapies.
This “third wave” of behavioral therapy has been referred to as clinical behavior analysis since it is considered to represent a retreat from cognitive science and a return to behavioral psychology and other forms of behaviorism, most notably functional analysis and behavioral models of verbal behavior.
Metacognitive training, metacognitive therapy, integrative behavioral couples therapy, functional analytic psychotherapy (FAP), dialectical behavioral therapy, behavioral activation (BA), cognitive behavioral analysis system of psychotherapy (CBASP), and Acceptance and commitment therapy (ACT) are all included in this category. These methods are fully within the tradition of behavior therapy centered on applied behavior analysis.
ACT is likely the most thoroughly investigated approach to third-generation behavior treatment. It is premised on the idea of relational frameworks. However, psychologist James C. Coyne noted manipulation with data in a clinical trial of ACT that alleged to prove that ACT is successful in preventing psychotic patients’ readmission rates in a 2012 blog post discussing “disappointments and embarrassments in the branding of psychotherapies as evidence-supported”. Coyne explained that after he raised these concerns, the APA Division 12 website lowered the ACT ranking for psychotic illnesses from “strong evidence” to “modest research support.” Additionally, William O’Donohue and coauthors evaluated multiple ACT trials and identified over 30 ways in which they were “weak or pseudo-tests.” O’Donohue and colleagues contended, using notions from Karl Popper’s scientific method and Popper’s criticism of psychoanalysis is difficult to verify, that such weaker ACT trials created false positive outcomes in support of ACT.
Functional analytic psychotherapy is focused on an examination of the therapeutic alliance from a functional perspective. It reintroduces in-session reinforcement and puts a bigger emphasis on the therapy setting. In general, forty years of study supports the notion that in-session rewarding can result in behavioral change.
Behavioral activation was identified as a feature of cognitive behavior therapy via a component analysis. The cognitive element had no additional effect in this study. Behavioral activation is centered on a reinforcement matching approach. A new assessment of the data establishes the clinical significance of behavioral activation in depression treatment.
Dissatisfaction with standard behavioral couples treatment prompted the development of integrative behavioral couples treatment therapies. Integrative behavioral couples therapy draws its distinction between rule-governed and contingency-shaped behavior from Skinner (1966). This examination is supplemented with a comprehensive evaluation of the marriage or relationship. Recent attempts have been devoted to analyzing a variety of clinical events, including reconciliation, using radical behavioral principles.
In 2008, a systematic analysis indicated that third-generation behavioral types of psychotherapy did not meet the requirements for empirically validated treatments at that moment.
Mental health professionals and other clinicians, psychologists, nurses, counselors, social workers, and marriage and family therapists are all medical professionals who can offer behavioral therapy. They may work in personal and social mental health practices and health centers, or in departments of mental health, psychology, or psychiatry in medical centers or outpatient clinics.
Clinicians often need specific training in order to provide systematic, evidence-based therapy; the type of treatment a clinician gives cannot be determined only by their specialty. Therapists should give information about the type of therapy they perform and the training they have obtained if asked by a patient or referring physician.
Primary care — In the United States, the proportion of patients with nonpsychotic psychiatric disorders are treated in primary care instead of being in the mental health specialized sectors. When compared to mental health specialty care, general practice mental health care has certain distinguishing qualities, including:
When contrasted with mental health specialized settings, individuals in general practice are far more likely to get the medication than therapy. In primary care, patients individuals are more likely to be managed for anxiety and depression disorders, and less likely to be treated for psychotic disorders.
Many treatment measures have been proposed and evaluated to improve or widen mental health care in primary care since people with psychiatric problems regularly report in primary care and mental health specialized care may be inaccessible or inappropriate for the individual. Educating primary healthcare practitioners to offer evidence-based therapy, as well as structural improvements to primary care termed integrated care, are examples of these systems. Despite the fact that many systems have been researched, they are not frequently utilized.
Systematic trials have demonstrated that primary care practitioners and clinicians who receive training in evidence-based therapy can achieve better outcomes than those who get a control intervention, especially when working with people with serious depression or heavy alcohol use.
Due to conflicting demands and time restrictions faced by primary care practitioners, researchers are striving to discover population subgroups that can be treated successfully with shorter forms of evidence-based psychotherapies (shorter session lengths and fewer sessions). Referral to mental health specialized care may be more appropriate for individuals with severe, complex, or refractory disorders.
In general care, short psychological interventions typically consist of two to ten regular sessions. The majority of these treatments are variants of cognitive-behavioral therapy, which is commonly used to treat anxiety and depression disorders.
Integrated primary and specialty care — The availability of mental health specialized care in the setting of primary care is referred to as integrated or collaborative care. Integration can take many forms, but at its most basic level, it may entail the co-location of doctors. Observational studies, on the other hand, imply that integrated models may be more effective if primary care and mental health professionals communicate and coordinate in a systematic way.
In the primary care context, teams of primary care practitioners and mental health professionals provide collaborative care. Collaborative care’s structure and effectiveness are examined separately.
The effectiveness of behavioral therapy is dependent on several factors, including the type of treatment utilized and the problem being treated. In general, research indicates that roughly 67 percent of persons who attempt psychotherapy benefit in some way.
This is not to say that cognitive-behavioral therapy or other behavioral techniques are the only sorts of therapy that can be used to treat mental illness. Additionally, this does not indicate that behavior therapy is the best option in every scenario.
For instance, anxiety disorders such as post-traumatic stress disorder (PTSD), panic disorder, obsessive-compulsive disorder (OCD), and phobias frequently respond well to behavioral therapy.
However, studies discovered that the efficacy of behavioral therapy, specifically CBT, in treating substance abuse varies according to the drug being abused.
CBT was also found to be useful for a subset of schizophrenia symptoms but had no impact on recurrence or hospitalization when matched to other kinds of therapy.
Another RCT involving individuals with anxiety problems yielded promising outcomes. When compared to standard care, a complex intervention that includes supported computer-based CBT and/or pharmacotherapy with medication compliance had robust impacts on all end measures.
Thirty-four percent of patients in the intervention group chose only CBT, 9% chose only medicine, and 57 percent got both. As a result, the intervention effects could be mediated by either better pharmaceutical treatment or greater rates of quality CBT in the intervention group, as measured by the amount and regularity of CBT components in psychotherapy sessions.
The findings reveal that individuals in the intervention group who had at least one CBT session (n = 261; average 7.63 sessions) showed a significant reduction in depressive and anxiety symptoms that was not modified by the administration of medication. Even though the relative proportions of the CBT and medicine components cannot be assessed with certainty, these findings suggest that the CBT element added to the intervention’s overall beneficial outcomes.
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