32.1 Introduction
Conceptual frameworks and theories are world views. In psychiatry, various theories represent world views and are a means of thinking about people and the world. All have different explanations to account for human behavior, as well as propose interventions consistent with their tenets. Major world views having to do with the human condition can be conceptualized broadly as those in which the formation of the “self” happens via feedback from other people, and those that are more ontogenically oriented to a more individual, organic unfolding of consciousness and development.
A common mistake that clinicians make is espousing an overzealous commitment to one theoretical framework, believing that one particular way of understanding the human condition or method of therapeutic intervention is the single most effective option for all people. While commitment and fidelity to a theory is sometimes necessary, a single-minded adherence to one school of thought is not helpful, making it impossible to treat people holistically and to adhere to the principles of an integrated approach to care. Furthermore, forcing one type of approach and its related treatment interventions may make it impossible to reach and help many people who would respond better to another point of view or approach.
No one theory adequately accounts for human behavior or for psychiatric disorders; nor can one theoretical approach adequately shape interventions for the range of problems that we encounter with patients. Alternative and competing theories have dominated the field of mental health at one time or another, sometimes to the detriment of both the field and patients. For example, for decades psychoanalytic therapy was considered the gold standard, then came cognitive therapy. Then it was found that for many adolescents and others interpersonal psychotherapy was more effective. This should have come as no surprise given the importance of relationships. The take-home point is that therapeutic approaches should be tailored to the individual needs and problems of individuals. There is a great deal of data to support the position that various therapies are effective in a range of psychiatric disorders. There is almost no evidence that suggests one type of therapy is superior to another.
This chapter discusses several theories with which clinicians working in the psychiatric–mental health field should be familiar. The complexity of different approaches may not be addressed, and the approach may seem oversimplified, but it is one taken for the sake of systematic discussion. The chapter is not intended to be a tutorial on psychotherapy. It reviews a limited number of theoretical approaches that can be subsumed generally under social (environmental) and individual (internal) psychotherapeutic world views.
32.2 Behavior Theory and Therapy
32.2.1 The Behaviorist Movement
The behaviorist movement emerged in the early twentieth century as a challenge to the supremacy of psychodynamic approaches. Behavioral psychologists believed that the study of subjective experience did not provide acceptable scientific data because observations and interpretations made by psychoanalysts were not open to verification by others. In their view only the study of directly observable behavior and the stimuli and reinforcing conditions that control it could serve as a basis for formulating scientific principles of human behavior. They argued that achieving insight by way of psychoanalysis did not equate to changing behavior.
As with psychodynamics, there are many schools of thought within this perspective. All are organized around a single central theme: the role of learning in human behavior. They also all operate on the assumption that behavior is lawful.
32.2.2 General Principles and Terminology
Because behavior theory maintains that all human behavior is learned, its major scholars have concerned themselves with explaining and researching how learning occurs and focus on the question of how environmental conditions result in the acquisition, modification, maintenance, and elimination of adaptive and maladaptive behaviors. Behavior theory (or learning theory) has strong empirical support and a solid research base, although it has been criticized for neglecting the cognitive component (beliefs, assumptions) underlying people’s behaviors.
Several concepts are important within the behavioral perspective. The first is the idea of conditioning, which is a basic form of learning. There are two forms of conditioning: respondent (“classical”) and operant. Respondent conditioning happens when a response and a stimulus become connected. Unconditioned responses develop before learning and may be innate to all humans. Conditioned responses develop through the repeated pairing of stimuli and responses.
In operant conditioning, individuals respond in order to achieve a certain goal. They “operate” on their environment to achieve something that is rewarding or to avoid something that is aversive. In operant conditioning, the response precedes the stimulus. An example can be observed when patients learn that behaving in a certain way leads to certain positive events, such as praise from staff or family, more freedom, and better privileges. Thus, they increase that behavior to subsequently increase those positive events. Likewise, they also may learn that behaving in certain ways may lead to negative events and, thus, avoid behaving in those ways to prevent the negative circumstances.
A second important but frequently misunderstood concept in behavior theory is reinforcement. Contrary to what many professionals believe, a reinforcer is not a reward. A reinforcer is a stimulus that strengthens a new response by its repeated association with that response. That stimulus may be either pleasant (positive) or aversive (negative). Thus, a person may learn a certain response (behavior) either to receive a reward or to avoid a punishment. In both positive and negative reinforcement, the person is rewarded for making an appropriate response.
When positive reinforcement is used, the response happens by adding something to increase the probability of the response. Negative reinforcement involves the termination or removal of a consequence. In negative reinforcement something is removed following a desired response to increase the probability of a behavior.
Negative reinforcers are generally unpleasant or aversive so that the person is motivated to exhibit a desired target behavior to escape from the unpleasant condition. The nature of the positive or negative reinforcer can differ from person to person.
High rates of reinforcement are necessary in early learning, with gradual tapering to maintain the response. Responses are particularly persistent when reinforcement is intermittent and therefore unpredictable. The person continually keeps responding based on past reinforcement and hoping for future reinforcement. This is why such activities as habitual gambling may be so difficult to overcome. Gamblers win intermittently and unpredictably. When gambling becomes habitual, it is extremely difficult to overcome precisely because of the intermittent and unpredictable nature of the winnings.
Punishment is a special kind of stimulus that operates in an opposite way from reinforcement. A punishing stimulus is any aversive stimulus that, when introduced after a response, decreases the future likelihood of that response. Punishing stimuli are introduced with the hope of stopping certain behaviors. Punishment is almost always ineffective. It sometimes may result in short-term compliance but is not effective in terms of long-term behavior change. Moreover, punishment can be unpredictable and self-defeating, as most people tend to react to punishment by fighting back, withdrawing into passive apathy, and avoiding the person with whom the punishment is associated.
Generalization happens when a conditioned response becomes associated with similar stimuli. For example, if a child’s response happens at home repeatedly, the child is very likely to display that behavior in other circumstances outside the home given similar conditions. Closely allied with generalization is discrimination, which occurs when a person learns to distinguish between and respond differently to similar stimuli. An example is when a child learns that he or she is expected to act a certain way within the family but that expectations for the same child may be very different within his or her peer group, because the reinforcers are different. According to behavior theory, generalization and discrimination have many important implications for the development of maladaptive behaviors. An example can be seen in people who become frightened in a given social situation who may gradually develop a social phobia in which they avoid all social situations.
Modeling involves the demonstration of desired behavior patterns to a learner. Therapists model behaviors when they teach social skills, such as assertiveness. The therapist models assertive behavior with the expectation that the learner will copy that behavior. The assertive behavior is then reinforced. Given sufficient practice of the assertive behavior paired with its reinforcement, the assertive behavior gradually becomes part of the patient’s behavioral inventory.
Shaping is a procedure that is employed when a person lacks certain behavior in his or her inventory, so that reinforcement of that behavior might take place. The fact that a behavior must occur before it can be reinforced places a therapist in something of a conundrum. In such cases it might be possible to shape behaviors in the desired direction by reinforcing very small incremental successive approximations of those behaviors.
32.2.3 Applied Behavioral Analysis
Psychotherapy and treatment based on behavior theory rests on applied behavior analysis, a systematic way of examining and analyzing the behaviors of patients as they relate to their environments and basing appropriate interventions on this analysis. The central processes of applied behavioral analysis are operationalization of behavior, functional analysis, selection of socially appropriate goals for change, and selection of appropriate behavioral change procedures. While an exhaustive description of these concepts is beyond the scope of this chapter, students should be acquainted with the ideas of operationalization of behavior and functional analysis.
Operationalization of behavior refers to precisely defining behaviors in concrete observations. Thus, a patient who uses the term “depressed” to describe how he or she feels has provided a useless description to a behavior therapist. Depression is a construct with a wide variety of meanings that may differ from person to person. Far more useful are the specific behaviors, events, actions, and stimuli associated with what the patient describes as depression. The goal of operationalization is to change vague words into observable and concrete actions that can serve as the basis for modification. Such specific actions might include withdrawing from family and friends or neglecting one’s appearance.
Functional analysis is based on the notion that a person’s behavior is directly related to environmental events and stimuli. It involves a systematic and sequential operationalization of behaviors that seek to determine the specific circumstances under which behavior occurs. Functional analysis involves examining the conditions before the behavior and the consequences that follow
32.2.4 The Evidence for Behavior Theory
Behavior theory has been praised for its precision and objectivity and for the enormous amount of empirical research that it has generated, demonstrating therapeutic efficacy in changing behavior. These are too numerous to summarize. Most recently, meta-analysis investigating the effectiveness of functional analysis of behavior-based behavioral interventions when targeting problem behaviors in various populations, especially in school-aged children, demonstrates overall very positive results for these therapeutic interventions. Behavior therapy has also been shown to be highly successful in the treatment of a variety of conditions, such as smoking cessation and insomnia, showing greater reduction in sleep latency than pharmacologic agents.
32.3 Interpersonal Psychotherapy
32.3.1 General Principles
Interpersonal psychotherapy (IPT) focuses on interpersonal rather than intrapsychic or cognitive aspects of depression. IPT uses a biopsychosocial model framing psychiatric conditions as illness occurring in a social context. IPT is grounded in interpersonal theory and the work of Sullivan and Bowlby.
The core of IPT is the central importance of relationships for human survival and adaptation. IPT integrates biologic and psychosocial approaches into a practical, patient-oriented treatment. IPT emphasizes the relational aspects of individual experience. Proponents of IPT posit that psychologic problems occur, and interpersonal relationships break down, when people’s needs for attachment are not being met. This can occur both when individuals cannot effectively communicate their needs to others and when their social support network is incapable of responding adequately to those needs.
32.3.2 Phases of Therapy
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
