The
Meaning of Behaviour Therapy – Part 1
Several
randomised trials have shown that psychological intervention of a particular
type can increase survival and increase quality of life of people with cancer.
This intervention is behaviour therapy.
It is one of the many possible treatments for neurotic problems.
(More serious psychotic problems require different treatment). What is
behaviour therapy and how does it differ from other forms of psychological
intervention?
The
following explains some of the terms.
Interpretive therapy (eg Freudian): Relies on verbal and symbolic
methods, such as "free
association". Observed disorders are symptoms of an underlying "complex",
often related to sexual factors. Both
of these terms were coined by Carl Jung who in 1914 parted company with Freud.
Uses several methods including interpretation of dreams. Complete cure requires
removal of this underlying complex. The patient learns that the anxiety etc is a
transformation of sexual tension (libido) not discharged through normal sexual
activity.
Behaviour
Modification Based on instrumental conditioning (eg a particular reaction to
a stimulus such as anger might reduce the continuation of the anger.
Thus the individual becomes conditioned to always respond the same way in
later conditions of anger, even if no longer appropriate. Therapy relies on
using different rewards or punishments to modify behaviour. Used also for
treatment of psychotic conditions. The neurotic person learns to act
differently.
Behaviour
Therapy based on Pavlovian or classical conditioning - Relies on direct
manipulation of motor and autonomic behaviour (emotions). (eg as a result of a
traumatic emotional event one stimulus becomes linked or associated with a
second (say, fear-producing) stimulus. Future
events of the first kind then trigger a reaction of fear- a conditioned
emotional response. Symptoms are
the disorder. There is no
underlying complex. Aim of therapy
is to eliminate symptoms, i.e. the reaction to a neutral stimulus with fear, by
extinction of the conditioned response. Therapy includes:
Desensitisation, Flooding, Modelling
Thus
psychotherapy is a general term used
to describe a wide range of approaches to treating neurotic disorders.
Until the 1950s when the term behaviour
therapy was coined by Hans Eysenck, most psychotherapy was one or other
forms of psychoanalysis (developed from Freudian analysis) or behaviour
modification (developed by Watson and Skinner). Freud had developed
psychoanalysis to replace hypnosis as a primary therapy of psychotherapy.
Behaviour
therapy has slowly replaced the other two main therapies for the treatment of
neurotic conditions. The term
Cognitive Behaviour Therapy is sometimes used but Eysenck believes the cognitive
conditioning aspect is only a very minor modification of the behaviour therapy
and adds little or nothing to the efficacy of the treatment.
Two
major studies have been carried out to evaluate the relative efficacy of 18
different psychotherapies. One by Smith et al (1980)1 found most of
such therapies had an efficacy of about 0.6 (not very much but there is an
effect). Placebo treatment (No 18) also scored about 0.6. In contrast the
behaviour therapies generally scored above 1.
The second study by Paul Grawe2 confirmed behaviour therapy to
be by far the most impressive and successful.
1.
Smith, ML et al.
The benefits of psychotherapy. Johns
Hopkins University Press, Baltimore, 1980.
2.
Grawe, K et al. Psychotherapie im
Wandel, Gottingen, Hogrete, 1995.
The
Meaning of Behaviour Therapy – Part 2
In the July/August 1998 CISS Newsletter was an article
entitled Psychotherapy – The Most Effective Cancer Therapy in which I
summarised the results of randomised trials of behaviour therapy.
In the January/February 2001 Newsletter I described
briefly the way Behaviour Therapy differs from Psychotherapy on the one hand (a
label generally used to describe Freudian therapies based on theories of dreams
and childhood sexuality) and Behaviour Modification on the other (based on
Watson and Skinner’s instrument conditioning).
In contrast to both of these, Behaviour Therapy relies on direct
manipulation of emotions to eliminate symptoms by extinguishing the conditioned
(eg Pavlovian) response. It uses
densensitisation, flooding and modelling. The
“symptoms” are considered as the problem, not symptoms of an
underlying problem.
Behaviour Therapy differs from these other forms of
Psychotherapy in ten major ways:
1.
Being based on a properly formulated
and testable theory it is more scientific;
2.
Where psychotherapy is derived from
clinical observations, behaviour therapy derives from experimental studies
designed to test basic theories and deductions made from them;
3.
Where psychotherapy sees particular
neurotic behaviour as symptoms of an underlying problem, behaviour therapists see
the “symptoms” as simply unadaptive conditioned responses, i.e. the
problem, not symptoms.
4.
Where psychotherapy sees symptoms as
evidence of repression, behaviour therapists see them as evidence of faulty
learning or conditioning;
5.
Where psychotherapy sees symptoms as
defence mechanisms against repressed, unconscious material trying to get into
the conscious, behaviour therapists sees them as individual differences in the
degree of difficulty in which the person acquires conditioned responses;
6.
Where psychotherapy sees the problem
as historically based, for behaviour therapists treatment is concerned with
habits existing at present. The historical development of the behaviour
is of theoretical interest only.
7.
To psychotherapists cures are
achieved by handling the underlying (unconscious) dynamics, whereas the
behaviour therapist cures by treating the symptom itself directly, by
extinguishing unadaptive conditioned responses and establishing desirable
conditioned responses.
8.
For the psychotherapist
interpretation of symptoms, dreams, acts etc are an important element of
treatment, whereas the behaviour therapist interpretation is irrelevant.
9.
For the psychotherapist, treating
symptoms leads to either a relapse or to the appearance of new symptoms
(substitution), whereas the behaviour therapist sees extinguishment of symptoms
as permanent recovery.
10. Psychotherapists need to establish personal relations
with the patient in order to revive unconscious memories through transference
of the accompanying emotions to the therapist.
Behaviour therapist see such personal relationships as not essential,
although they can be useful in certain circumstances.
With Desensitisation the patient with specific
fears or anxieties is given graduated tasks, starting with relatively easy tasks
producing little anxiety, and working up to more difficult ones.
The patient is also taught relaxation to minimise the anxiety produced by
the task.
With Flooding (or response prevention)
the patient is exposed to the conditioned stimulus in its full
strength right from the beginning. Although
apparently contradicting the principle of (gradual) desensitisation, it has been
found that, provided the duration of flooding is relatively lengthy, the
original enhancement of the anxiety reaction is followed by a gradual decrease.
With this approach the patient is prevented from carrying out the usual
response to the anxiety. This approach is particularly useful with patients with
obsessive-compulsive disorders.
In Modelling the patient is shown other persons,
as mush as possible like the patient, not reacting to the situation that
produces the anxiety, such as handling snakes, touching dirty items, etc.
So this is often used together with Flooding.
How is this relevant to cancer patients?
The two major personality traits that have been
traditionally linked with cancer have been
(1) the repression of emotions, such as anger and anxiety,
and the inability to show these emotions;
(2) failure to cope with stress and feelings of
hopelessness-helplessness and depression in response to interpersonal stress,
leading to an inability to find appropriate coping mechanisms to deal with the
problems involve.
The
essence of this type of temperament is the absence of autonomy, i.e. emotional
dependence, which prevents such people from making independent decisions in the
light of their own best interests. The
patient has become object-dependent and makes decisions involving
needs-satisfaction and problem solving that are totally dependent on the
behaviour of particular persons or objects, themselves persisting in a passive
role. The patient’s own needs are blocked and remain unsatisfied with the
result that symptoms like depression, hopelessness, anxiety, excite-ment and
self-aggression appear. It is this
passivity in the face of stressful stimulation from the outside that consti-tutes
the essential personality feature of the cancer-prone (Type 1 or Type C)
individual. Their social relationships arouse conflict and they develop
behaviours that are detrimental to their health, manifesting as cancer.
The
aim of therapy is therefore to increase the patient’s autonomy, i.e. his/her
independence and ability to make rational decisions that lead to long-term
positive consequences, even though this might involve some short-term negative
consequences. The aim is to teach
the patient to avoid behaviours that lead to long-term negative consequences,
even where these may be associated with short-term positive consequences.