BEHAVIORAL THERAPY

Prepared by: Isha Bhusal

MN 1st Year
Roll no. 18
 Behaviour

• Adaptive

• Maladaptive- when it is age inappropriate, interferes with adaptive

functioning or others misunderstand it in terms of cultural

inappropriateness.
• Behaviorism see psychological disorders as the result of maladaptive
learning.

• Basic assumption is that the maladaptive behavior can be corrected

through the provision of adequate learning experiences.
 Behavioral therapy

• It is a form of psychotherapy, which focuses on modifying faulty

behavior rather than basic changes in the personality.

• Behaviour therapy is the systematic application of scientific principles of

learning and a form of psychotherapy, aims at changing maladaptive
behaviour by substituting it with adaptive behaviour.
• Behaviour therapy is a form of treatment for problems in which a trained
person deliberately establishes a professional relationship with the client,
with the objective of removing or modifying existing symptoms and
promoting positive personality, growth and development.
 Principles of Behavioral Therapies

• Theory of Classical conditioning: involves learning by association and

is usually the cause of most phobias.

• Theory of Operant conditioning: involves learning by reinforcement (e.g.

rewards) and punishment, and can explain abnormal behavior should as
eating disorders.

• Social Learning Theory

• Cognitive Behavioral Approach

Ivan Pavlov Theory of Classical conditioning
Thorndike’s Trial & Error Theory
Social Learning Theory
10 Key Characteristics of Behavioural Therapy
1. Based on principles & procedures of scientific method

2. Deals with client’s current problems & factors influencing them &
factors that can be used to modify performance

3. Clients expected to assume an active role by engaging specific actions

to deal with their problems
4. Emphasizes teaching clients skills of self-management, with
expectation they’re responsible for transferring what’s learned in office to
everyday lives

5. Focus on assessing overt & covert behaviors directly, identifying

problem, & evaluating change

6. Emphasizes a self-control approach in which clients learn self-

management strategies
7. Interventions individually tailored to specific problems “What treatment,
by whom, is the most effective for this individual with that specific problem
& under which set of circumstances?”

8. Based on collaborative partnership between therapist & client (clients

informed about nature & course of Rx)
9. Emphasis on practical application Interventions applied to ALL
facets of daily life in which maladaptive behaviors are to be deceased &
adaptive behaviors are to be increased

10. Therapists strive to develop culture-specific procedures & obtain

clients’ adherence & cooperation
Purpose of Behavioural Therapy

• To bring permanent change in behavior as a result of practice and

experience

• To correct the abnormal psychodynamic which are contributing to the

illness

• To manage those conditions which are refractory to other types of

therapy.
 Indications of Behavioral therapy

• Obsessive-compulsive disorder (OCD)

• Post-traumatic stress disorder (PTSD)

• Generalized anxiety disorder (GAD)

• Depression

• Social phobia

• Bipolar disorder
• Schizophrenia

• Autism

• Personality disorders

• Substance abuse

• Eating disorders

• Sexual deviations/dysfunctions
 Criteria for behavioral treatment:

1. The problem can be defined in terms of observable and measurable

behaviour.

2. The problem is current and generally predictable.

3. Therapist and patient can agree on already defined behavioural goals.

4. Patient understands the treatment offered and accepts it.

Therapist’s Function & Role
• Active & directive

• Consultants & problem-solvers

• Pay attention to clues presented by client

• Follow their clinical hunches

• Use some techniques common to other approaches ( e.g., summarizing,

reflection, clarification, & open-ended questioning)

• Role-modeling for the client

 Behavioral Therapy Techniques

1. Shaping

2. Modeling

3. Premack Principle

4. Extinction

5. Contingency Contracting

6. Token Economy
7. Time-Out

8. Reciprocal Inhibition

9. Overt Sensitization

10. Covert Sensitization

11. Systematic Desensitization

12. Flooding
 Shaping

• In shaping the components of a particular skill, behavior is reinforced

step-by-step. The therapist starts shaping by reinforcing the existing
behavior.

• Reinforcements are given to the responses which are closest to the

desired behavior.
• For example, in eliciting speech from an autistic child, the teacher may
first reward the child for

(a) watching the teacher’s face/lips, then

(b) for making any sound in imitation of the teacher, then

(c) for forming sounds similar to the word uttered by the teacher.
 Modeling

• Modeling refers to the learning of new behaviors by imitating the

behavior in others.

• Role models are individuals who have qualities or skills that a person
admires and wishes to imitate (Howard, 2000).

• In the practice setting clients may imitate the behaviors of practitioners

who are charged with their care. This can occur naturally in the
therapeutic community environment.
• It can also occur in a therapy session in which the client watches a model
demonstrate appropriate behaviors in a role-play of the client’s problem.
The client is then instructed to imitate the model’s behaviors in a similar
role-play and is positively reinforced for appropriate imitation.

• The patient also observes other patients indulging in target behaviors and
getting rewards for those behaviours. This will make the patient repeat the
same behavior and earn rewards in the same manner.
 Premack Principle

This technique, named for its originator, states that a frequently occurring
response (R1) can serve as a positive reinforcement for a response (R2)
that occurs less frequently (Premack, 1959). This is accomplished by
allowing R1 to occur only after R2 has been performed.
• For example, 13-year-old Jennie has been neglecting her homework for the
past few weeks. She spends a lot of time on the telephone talking to her
friends.
• Applying the Premack principle,
R1 – Telephone talking with friends
R2- Completing homework

Therefore, being allowed to talk on the telephone to her friends could serve as
a positive reinforcement(incentive) for completing her homework
 Extinction

• Extinction is the gradual decrease in frequency or disappearance of a

response when the positive reinforcement (attention) is withheld.

• A classic example of this technique is its use with children who have
temper tantrums.

• The tantrum behaviors continue as long as the parent gives attention to

them but decrease and often disappear when the parent simply walks
away from the child and ignores the behavior.
 Contingency Contracting

In contingency contracting, 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 and the
reinforcers to be given for performing the 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 and punishment will be presented;
however, flexibility is important so that renegotiations can occur if
necessary.
 Token economy

• Token economy involves giving token rewards (reinforcers) for

appropriate or desired target behaviours performed by the patient.

• Essential to this type of technique is the prior determination of items

and situations of significance to the client that can be employed as
reinforcements.
• With this therapy, tokens are awarded when desired behaviors are
performed and may be exchanged for luxury items or certain privileges.

• For example, a client may be able to “buy” a snack for 2 tokens, a trip to
the coffee shop or library for 5 tokens, or even a trip outside the hospital
(if that is a realistic possibility) for another designated number of tokens.
• The tokens themselves provide immediate positive feedback, and clients
should be allowed to make the decision of whether to spend the token as
soon as it is presented or to accumulate tokens that may be exchanged
later for a more desirable reward.
 Time-Out

• Time-out is an aversive stimulus or punishment during which the client is

removed from the reward or reward from the client for a particular
period of time following a problem behavior.

• This is often used in the treatment of childhood disorders.

• For example, the child is not allowed to go out of the ward to play if he
fails to complete the given work.
 Reciprocal Inhibition

• Also called counter-conditioning.

• Reciprocal inhibition decreases or eliminates a behavior by introducing a

more adaptive behavior, but one that is incompatible with the unacceptable
behavior (Wolpe, 1958).

• An example is the introduction of relaxation exercises to an individual who

is phobic.
• Relaxation is practiced in the presence of anxiety so that in time the
individual is able to manage the anxiety in the presence of the phobic
stimulus by engaging in relaxation exercises. Reaxation and anxiety are
incompatible behaviors.
 Overt sensitization

• Overt sensitization is a type of aversion therapy that produces

unpleasant consequences for undesirable behavior.

• For example, disulfiram (Antabuse) is a drug that is given to individuals

who wish to stop drinking alcohol.
• If an individual consumes alcohol while on Antabuse therapy, symptoms
of severe nausea and vomiting, dyspnea, palpitations, and headache will
occur. Instead of the euphoric feeling normally experienced from the
alcohol (the positive reinforcement for drinking), the individual receives a
severe punishment that is intended to extinguish the unacceptable behavior
(drinking alcohol).
 Covert Sensitization

• Covert sensitization relies on the individual’s imagination to produce

unpleasant symptoms rather than on medication.

• The technique is under the client’s control and can be used whenever and
wherever it is required.

• The individual learns, through mental imagery, to visualize nauseating

scenes and even to induce a mild feeling of nausea.
• This mental image is visualized when the individual is about to succumb
(fail to resist pressure) to an attractive but undesirable behavior i.e.
alcohol craving.

• The primary advantage of covert sensitization is that the individual does

not have to perform the undesired behaviors but simply imagines
them.
 Systematic desensitization

Systematic desensitization is a technique for assisting individuals to

overcome their fear of a phobic stimulus. It is “systematic” in that there is
a hierarchy of anxiety- producing events through which the individual
progresses during therapy.
An example of a hierarchy of events associated with a fear of elevators
may be as follows:

1. Discuss riding an elevator with the therapist.

2. Look at a picture of an elevator.

3. Walk into the lobby of a building and see the elevators.

4. Push the button for the elevator.

5. Walk into an elevator with a trusted person; disembark before the doors
close.

6. Walk into an elevator with a trusted person; allow doors to close; then
open the doors and walk out.

7. Ride one floor with a trusted person, then walk back down the stairs.

8. Ride one floor with a trusted person and ride the elevator back down.

9. Ride the elevator alone.

• As each of these steps is attempted, it is paired with relaxation exercises
as an antagonistic behavior to anxiety.

• Generally, the desensitization procedures occur in the therapy setting by

instructing the client to engage in relaxation exercises.

• When relaxation has been achieved, the client uses mental imagery to
visualize the step in the hierarchy being described by the therapist.
anxiety.
• If the client becomes anxious, the therapist suggests relaxation exercises
again, and presents a scene that is lower in the hierarchy.

• Therapy continues until the individual is able to progress through the

entire hierarchy with manageable
 Flooding

• This technique, sometimes called implosive therapy.

• Patient is exposed to the phobic stimulus, but escape is made impossible.

• It differs from systematic desensitization in that, instead of working up a

hierarchy of anxiety-producing stimuli, the individual is “flooded” with a
continuous presentation (through mental imagery) of the phobic stimulus
until it no longer elicits anxiety.
• Flooding is believed to produce results faster than systematic
desensitization; however, some therapists report more lasting behavioral
changes with systematic desensitization.

• Some questions have also been raised in terms of the psychological

discomfort that this therapy produces for the client.
• Flooding is contraindicated with clients for whom intense anxiety
would be hazardous (e.g., individuals with heart disease or fragile
psychological adaptation) (Sadock & Sadock, 2007).
 Role of The Nurse in Behavioural Therapy

Assessment
• Assessment of appropriate/inappropriate behaviors present in the
patient,
• Antecedent, Behaviour and Consequences Analysis
• Obtaining relevant history : Time, frequency, duration of both
adaptive and maladaptive behavior
 Nursing Diagnosis –

• Noncompliance with therapy

• Impaired Social Interaction related to speech deficiency
• Defensive coping related to negative role model
• Risk for self directed or other directed violence related to low
tolerance of frustration etc.
 Intervention
• Providing positive and negative reinforcement;
• Modeling adaptive behaviour
• Assessment of efficacy of behavioural therapy,
• Collaborating with multidisciplinary treatment team
• Monitoring Patient’s behavior and assisting the behavioural therapist
to provide prescribed behavioural therapy like time out.
• Maintaining consistency in behavior while dealing with the clients.
• Evaluation – Outcomes (as planned) & maintaining, additional
change (if needed).
 References
• Townsend MC. Psychiatric mental health nursing- concepts of care in evidence-based
practice. 8th ed. Philadelphia: F.A. Davis Company, 2015. 567-68pp.

• Reddemma S. A guide to mental health and psychiatric nursing. 4th ed. New Delhi: Jaypee
Brothers: Medical Publishers (P) Ltd, 2018. 150-52pp.

• Ahuja N. A short textbook of psychiatry.7th ed. India: Jaypee Brothers Medical Publishers
(P) Ltd, 2011. 214-15pp.

• Sadock BJ, Sadock VA, Ruiz P. Kaplan & sadock's synopsis of psychiatry: behavioral
sciences/clinical psychiatry. 11th ed. ebook, New York: Wolters Kluwer, 2015. 877-83pp. [
Weblink]