Principles of learning, Evolution of Behavioral therapy, Techniques, Implications in Psychiatry

1. 1Dr. Nikhil Gupta
Junior Resident
Department of Psychiatry

2. INTRODUCTION
 The term “behavior” in behavior therapy refers to a
person's observable actions and responses.
 Behavior therapy involves changing the behavior of
patients to reduce dysfunction and to improve
quality of life.
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3.  Behavior therapy includes a methodology, referred
to as behavior analysis, for the strategic selection
of behaviors to change, and a technology to bring
about behavior change, such as modifying
antecedents or consequences or giving
instructions.
 Its a therapy based on learning principles.
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4. THEORIES OF LEARNING
 Learning is defined as relatively permanent change
in behavior that occurs as result of practice or
experience.
 Classical Conditioning.
 Operant Conditioning.
 Social learning theory.
 Cognitive learning theory.
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5. CLASSICAL CONDITIONING
 This is learning by association.
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6. OPERANT CONDITIONING
 Law of effect: reinforcement.
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7. SOCIAL LEARNING THEORY
 states that learning is a cognitive process that takes
place in social context and can occur purely
through observation or direct instruction, even in
absence of motor reproduction or direct
reinforcement.
 In addition, learning also occurs through
observation of rewards and punishments, a process
known as “Vicarious reinforcement”.
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8. COGNITIVE LEARNING THEORY
 Imitation learning: Learning occurs by imitating
other individuals in environment.
e.g: Parrot can imitate human language.
 Latent learning.
 Insight learning.
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9. MOVEMENT TOWARDS BEHAVIORAL
APPROACH:
 In 1920, case of “Little Albert” was published,
demonstrated application of classic conditioning
principles to acquisition or learning of fear.
 Similar principle was applied for deconditioning
(unlearning) of fear in another child Peter.
 Around 15 years later, “Bell-and-pad” technique (also
relied on principles of classic conditioning) was used by
researchers to treat enuresis or bed wetting.
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10.  Core concept: Maladaptive behaviors that comes
through learning or conditioning can be undone
through same process.
 Advantages are direct measurement of behavior &
change, easy to try another method if one is a
failure, less time consuming and cost effective.
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11. HISTORY
 Behavioral psychology,
or
Behaviorism,
arose in the early
20th century, in 1960.
 John Broadus Watson,
the father of Behaviorism,
had initially studied animal psychology.
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12.  Joseph Wolpe in Johannesburg, South Africa,
used Pavlovian techniques
to produce and eliminate
experimental neuroses
in cats.
 From this research,
Wolpe developed
“Systematic
desensitization.”
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13.  The other major contributors of Behavior therapy
was Harvard psychologist B. F. Skinner & Hans
Jurgen Eysenck and M. B. Shapiro, a group at the
Institute of Psychiatry, University of London.
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14. METHODS
 Instrumental or Operant conditioning techniques.
 Classical conditioning techniques.
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15. INSTRUMENTAL OR OPERANT CONDITIONING
TECHNIQUES
 Functional analysis of behavior
 Identifying +ve & -ve reinforcers
 Extinction
 Differential reinforcement
 Shaping
 Token economy
 Punishment
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16. CLASSICAL CONDITIONING TECHNIQUES
 Systematic desensitisation
 Flooding
 Aversion therapy
 Modelling
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17. FUNCTIONAL ANALYSIS OF BEHAVIOR
 ABC: Antecedents (stress)
Behavior (smoking)
Consequences (relief of stress)
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18. IDENTIFYING +VE & -VE REINFORCERS
 When a behavioral response is followed by a
generally rewarding event, such as food, or praise
(+ve reinforcer), /avoidance of shock, scouldings (-
ve reinforcer) , it tends to be strengthened and to
occur more frequently than before the reward.
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19. TOKEN ECONOMY
 Patients receive a reward for performing a desired
behavior, such as tokens, points, stars, chips that
they can use to purchase luxury items or certain
privileges like television time, play time, food, etc.
 Useful in patients with psychotic disorders,
schizophrenia.
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20. EXTINCTION
 Takes place when positive reinforcement for a
particular response is withdrawn.
 Unreinforced, the behavior weakens and usually
stops.
 Clinically, it can only be used in environments
where reinforcement can be controlled (eg: IPD
settings, classroom, etc.)
 Extinction burst may occur at first, but therapy
should be continued.
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21. OMISSION TRAINING
 or ‘Time out’.
 A place is prepared which is safe & comfortable, but
uninteresting, i.e, +ve reinforcement is at minimum.
 Used in schools, empty room.
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22. DIFFERENTIAL REINFORCEMENT
 Giving +ve reinforcement to desired behavior &
witholding it in their absence.
 Useful in extinguishing undesirable autistic
behavior.
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23. SHAPING
 Therapist provides patient with a small sample of
desired behavior , to get appropriate learning
started.
 Useful in Autism.
 If the childs early efforts are imperfect, therapist
may reward successive approximations, gradually
approaches to the desired behavior till it is right.
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24. PUNISHMENT
 The noxious event is contingent on the individuals
performing an undesirable response.
 Punishment after response.
 Use is limited to cases in which behavior threatens
physical harm and other interventions like +ve
reinforcement and extinction has been failed.
 Ethical issues.
 Useful in ruminative vomiting. 24

25. COVERT SENSITISATION
 Alternative to Punishment.
 Unwanted behavior is imagined together with its
imaginary punishing consequences.
 Can be used anywhere, anytime.
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26. SYSTEMATIC DESENSITISATION
 Developed by Wolpe
 based on the behavioral principle of counter-
conditioning.
 a person overcomes maladaptive anxiety elicited by
a situation or an object by approaching the feared
situation gradually, in a psycho-physiological state
that inhibits anxiety.
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27.  Patients attain a state of complete relaxation and
are then exposed to the stimulus that elicits the
anxiety response.
 The negative reaction of anxiety is inhibited by the
relaxed state, a process called “reciprocal
inhibition”.
 Phobias, obsessions, compulsions, and certain
sexual disorders have been treated successfully
with this technique.
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28.  Three steps: relaxation training, hierarchy
construction, and desensitization of the stimulus.
 patients and therapists prepare a graded list or
hierarchy of anxiety-provoking scenes associated
with a patient's fears.
 Actual situations or objects that elicit fear not used.
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29.  The learned relaxation state and the anxiety-
provoking scenes are systematically paired in
treatment.
 When patients can vividly imagine the most anxiety-
provoking scene of the hierarchy with equanimity,
they experience little anxiety in the corresponding
real-life situation.
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30. THERAPEUTIC-GRADED EXPOSURE
 Individual must be brought in contact with (i.e., be
exposed to) the warning stimulus to learn firsthand
that no dangerous consequences will ensue.
 Exposure is graded according to a hierarchy.
eg: Patients afraid of cats might progress from
looking at a picture of a cat to holding one.
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31.  Useful in treatment of simple phobia, social phobia,
phobic anxiety disorders, obsessive compulsive
disorder, eating disorders, sexual dysfunctions
(especially male erectile disorder, orgasm
disorders, and premature ejaculation), shy bladder,
etc.
 Differ from systematic desensitization in that:
-relaxation training is not involved.
-treatment is usually carried out in a real-life
context. 31

32. FLOODING
 Flooding (also called implosion) involves exposing
the patient to the feared object in vivo; however,
there is no hierarchy.
 based on the principle that escaping from an
anxiety-provoking experience reinforces the anxiety
through conditioning.
 Thus, clinicians can extinguish the anxiety and
prevent the conditioned avoidance behavior by not
allowing patients to escape the situation.
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33.  variant, called Imaginal Flooding, the feared object
or situation is confronted only in the imagination, not
in real life.
 Used best in specific phobias.
 Disadvantages:
-Many patients refuse Fooding because of the
psychological discomfort involved.
-Contraindicated in those with heart diseases.
-Prematurely withdrawing from the situation which
then reinforces both the conditioned anxiety and the
avoidance behavior producing the opposite of the
desired effect. 33

34. AVERSION THERAPY
 Aim is to induce unpleasant feeling, specifically in
relation to stimuli that trigger unwanted behavior.
 electric shocks, substances that induce vomiting,
corporal punishment, and social disapproval.
 The negative stimulus is paired with the behavior,
which is thereby suppressed.
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35.  Aversion therapy has been used for alcohol abuse,
paraphilias, and other behaviors with impulsive or
compulsive qualities.
 Controversy: AT does not always lead to the
expected decreased response and can sometimes
be positively reinforcing.
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36. MODELLING
 Desired behavior is performed by therapist and
patients made to learn by imitation, primarily by
observation, without having to perform the behavior
until they feel ready.
 Principle: Just as irrational fears can be acquired by
learning, they can be unlearned by observing a
fearless model confront the feared object.
 A hierarchy of activities is established, with the
least anxiety-provoking activity being dealt with first.
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37.  used in treating phobias by encouraging patients to
expose themselves to feared situations, in social skills
training in disorders such as schizophrenia, marital
counseling, training in better parenting skills, reducing
fear in children before medical procedure.
 In a variant of the procedure, called behavior
rehearsal, real-life problems are acted out under a
therapist's observation or direction.
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38. EXPOSURE TO STIMULI PRESENTED IN
VIRTUAL REALITY
 Advances in computer technology have made it
possible to present environmental cues in virtual
reality for exposure treatment.
 Beneficial effects have been reported with virtual
reality exposure of patients with height phobia, fear
of flying, spider phobia, and claustrophobia.
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39. ASSERTIVENESS TRAINING
 Assertive behavior enables a person to act in his or
her own best interest, to stand up for herself or
himself without undue anxiety, to express honest
feelings comfortably, and to exercise personal rights
without denying the rights of others.
 Two types of situations frequently call for assertive
behaviors:
(1) setting limits on pushy friends or relatives
and
(2) commercial situations, such as when returning
defective merchandise.
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40. SOCIAL SKILLS TRAINING
 Includes analyzing social skills deficit (avoiding eye
contact, inappropriate body language or speaking too
softly, etc.)
and then gradually developing appropriate behaviors
and practicing them in environment.
 Useful in depression ,schizophrenia, social phobia etc.
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41.  Cover skills in conversation, conflict management,
assertiveness, community living, friendship and dating,
work and vocation, and medication management.
 Eg: conflict management includes skills in negotiating,
compromising, tactful disagreeing, responding to
untrue accusations, and leaving overly stressful
situations.
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42. EMDR
 Eye Movement Desensitization and Reprocessing.
 Saccadic eye movements are rapid oscillations of
the eyes that occur when a person tracks an object
that is moved back and forth across the line of
vision.
 Studies show that inducing saccades while a
person is imagining or thinking about an anxiety-
producing event can yield a positive thought or
image that results in decreased anxiety.
 Used in PTSD and phobias.
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43. BEHAVIORAL MEDICINE
 Behavioral medicine uses the concepts and methods
described above to treat a variety of physical
diseases.
 Emphasis is placed on the role of stress and its
influence on the body, particularly on the endocrine
system.
 Attempts to relieve stress are made with the
expectation that either the disease state will lessen
or the patient's ability to tolerate the disease state
will strengthen.
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44. CASE 1
 Seema, 7 years old girl, would go to school if her mother took her
but would cry inconsolably when her mom left. Lately the school
had been calling her mother to come and take Seema home, as
she “would not stop crying”.
 School therapist developed program in which Seema received
stickers as reward ( 1 sticker for five minutes) and if she cried or
disturbed the class, she would go out of class and not earn any
stickers. She was not allowed to go home until the school day
ended.
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45.  Mom takes Seema to class and stays 5 minutes to help her settle down.
 Mom takes Seema to class and stands at the door for 1 minute.
 Mom takes Seema inside school, and she walks to class alone.
 Mom takes Seema to school but only to front of building.
 Mom takes Seema to school and drops her off but stays in the car.
 Mom takes Seema to the bus stop and rides the bus with her.
 Mom takes Seema to the bus stop but Seema rides alone.
 Mom watches Seema walk to the bus.
 Mom says good bye to Seema at the door of their home.
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46. CASE 2
 Mr. Kumar, 23 yrs. old, presented with severe symptoms of OCD,
and he is no longer able to go to his work because of his
compulsive checking, repeating, hoarding. He worried constantly
that he has done something wrong and disappointed his parents.
He is depressed and has significant social anxiety, making difficult
to make and keep friends.
 After forming case conceptualization (to understand the nature,
onset, course and severity of symptoms, precipitating factors and
relationship between different symptoms and dysfunction caused);
rating scales (YBOCS, HAM-D, HAM-A) were used to assess baseline
severity.
 Mr. Kumar was told to keep record of how the symptoms occurred
during his daily life, to form treatment plan.
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48. REFERENCES
 Morgan & King Introduction to Psychology.
 Kaplan and Sadock’s Comprehensive Textbook of
Psychiatry.
 JN Vyas Essentials of Postgraduate Psychiatry.
 Internet Sources (Goggle Scholar, TiPPS, etc.)
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