Behaviour Therapy Techniques based on classical conditioning

Introduction

• Behavior therapy involves changing the behavior of the patients to reduce the dysfunction and to improve the quality of life.
• The principles of behavior therapy are based on the early studies of Classical conditioning by Pavlov (1927) and operant conditioning by Skinner (1938).

• Classical conditioning is the learning of involuntary responses by pairing a stimulus that normally causes a particular response with a new, neutral stimulus after enough parings, the new stimulus will also cause the response to occur.
  
• Through classical conditioning ‘the old and undesirable responses can be replaced by the desirable ones.
  
• There are several techniques that have been developed using this type of learning to treat the disorders such as phobias, obsessive compulsive disorder, and similar anxiety disorder.
  

1. SYSTEMATIC DESENSITIZATION

• Developed by Wolpe and is based on the behavior principle of counter conditioning  for assisting the individuals to overcome their fear of phobic stimulus.
• Systematic desensitization is a behavioral therapy technique  where by a person overcomes the maladaptive anxiety elicited by a situation or an object by approaching the feared situation gradually, in a psycho physiological state that inhibits the anxiety.   
• The technique of systematic desensitization in which a therapist   guides the client through a series of steps meant to reduce the fear and anxiety
• Systematic desensitization indicated in the cases of clearly identifiable anxiety     provoking stimulus, such as:

• Phobias
  
• Obsessive compulsive disorder
  
• Sexual disorders
  
• Anxiety disorder
  

Procedure

Systematic desensitization consist of three steps

1.   Relaxation training

2.   Hierarchy construction

3.   Desensitization of stimulus

Relaxation training

This is first step of systematic desensitization. Relaxation produces physiological effects opposite to those of anxiety:

The signs of relaxation are

a. Physiological signs:  slow heart rate, increased peripheral blood flow and neuromuscular stability, pupil constriction, increased peripheral temperature, decreased oxygen consumption

b. Cognitive signs:  altered state of consciousness, heightened concentration on single mental image.

c. Behavior changes: lack of attention and concern for  the environmental stimuli, no verbal interaction, no voluntary change in the position .

Techniques used for relaxation are,

a) Jacobson progressive muscle relaxation :

• Most often used relaxation training , developed by the psychiatrist Edmund Jacobson.
• In this client must learn to relax through deep muscle relaxation training.
•  Patients relax major muscle group in a fixed order, beginning with the small muscle group of the feet and working cephal head or vice versa.

 Procedure:

I. Make the patient in a comfortable position

II. Provide light or soft music /pleasant visual cues

III. Give a brief explanation about the progressive muscle relaxation

IV. Instruct the client to tense each muscle group approximately for 10 seconds

V. Explain the tension of the muscle and uncomfortable the body part feels

VI. Ask the client to relax each muscle

VII. Make client to feel the difference between both the situation

b) Hypnosis

• Some clinicians use hypnosis to facilitate the  relaxation.

c) Mental imaginary

• it is relaxation method in which patients are instructed to imagine the selves in a place associated with the  pleasant relaxed memories.
• Such images allow the patients to enter a relaxed d state or experience the relaxation responses

d) Meditation or yoga

• present days meditation and yoga are practiced and taught by  the clinician to relax the patients. and it is an immerging trend in the relaxation therapy

2. Hierarchy construction

• Hierarchy construction when constructing a hierarchy, clinicians determine the all the conditions that elicit anxiety, and then patients create a hierarchy list t consisting of 19 to 12 scenes in order of increasing the anxiety .

Example:

An example of a hierarchy of events associated with a fesr of elevators as follows

A.   Discuss riding an elevator with the therapist

B.    Look at a picture e fof an elevator

C.   Walk in to the lobby of a building and see the elevators

D.   Push the button for the elevator

E.    Walk in to the elevator with a trusted person ,disembark before the door close

F.    Walk into a elevator with a trusted person ;allow the door to close;then open the door and walk out

G.   Rise one floor with atrud=sted person ,then walk down the stairs

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

I.     Ride the elevator alone

 3. Desensitization

Desensitization of the stimulus in the final step, patients proceed systematically through the list from the least, to the most, anxiety provoking scene while in deeply relaxed state. Under the guidance of the therapist the client begins the item on the list that causes minimal fear and looks at it, thinks about it, or actually confronts it ,all while remaining in a relaxed state. The idea is that the phobic object or the situation is conditioned stimulus that the client has learned to fear because it was originally paired with a real fearful stimulus .by paring the old conditioned s stimulus with a new relaxation response that is compatible with the emotions and the physical arousal associated with the fear, the person’s fear is reduced and relieved .the person then proceeds to the    next item on the   hierarchy until the phobia is gone.

F. Adjunctive use of the drugs

Various drugs are used to hasten the relaxation The advantage of the pharmacological desensitization are threat the preliminary training in the e relaxation can be   shortened, almost all patients can relax adequately .the drugs commonly used are, barbiturate sodium methohexital and diazepam.

3. THERAPEUTIC GRADED EXPOSURE

Therapeutic graded exposure is similar to the systematic desensitization, except the relaxation training not involved and treatment is carried out in a real life context .that is the individual must brought on contact with the warning stimulus to learn firsthand that no dangerous consequences will ensue .exposure is graded according to the hierarchy .for example the patients afraid of cats might progress from looking at a picture of a cat holding one.

4. Aversion therapy

Introduction

Aversion therapy is another way to use the classical conditioning is to reduce the frequency of the   undesirable     behavior, such as smoking or over eating, by teaching the client to pair an unpleasant stimulus that results in undesirable response.

Meaning

It is form of behavior therapy in which an undesirable behavior i s paired with an aversive stimulus to reduce the frequency of the behavior.

Indication

• Alcohol abuse
  
• Paraphillias
  
• Homosexuality
  
• Tranvestism
  

Types of Aversion therapy

1. Overt sensitization

It is a type of aversion therapy that produces unpleasant consequences for undesirable behavior.  For example if an individual consumes alcohol while on Antabuse therapy, symptoms of severe nausea, vomiting, dyspnoea, palpitation and  headache. Instead of euphoria feeling normally experienced from the alcohol, the individual receives a punishment that is intended to extinguish the unacceptable behavior.

2. Covert sensitization

It relies on the individual produce symptoms rather than on medication.  The technique is under clients control and can be used whenever and whenever it is required. The individual learns through mental imagery to visualize nauseating scenes and even to induce a mild feeling of nausea. It is most effective when paired with relaxation exercises that are performed instead of the undesirable behavior.

Preparation

Depending upon his/her customary practice, a therapist administering aversion therapy may establish a behavioral contract defining the treatment, objectives, expected outcome, and what will be required of the patient. The patient may be asked to keep a behavioral diary to establish a baseline measure of the behavior targeted for change. The patient undergoing this type of treatment should have enough information beforehand to give full consent for the procedure. Patients with medical problems or who are otherwise vulnerable to potentially damaging physical side effects of the more intense aversive stimuli should consult their primary care doctor first.

Aftercare

Patients completing the initial phase of aversion therapy are often asked by the therapist to return periodically over the following six to twelve months or longer for booster sessions to prevent relapse.

Risks

Patients with cardiac, pulmonary, or gastrointestinal problems may experience a worsening of their symptoms, depending upon the characteristics and strength of the aversive stimuli. Some therapists have reported that patients undergoing aversion therapy, especially treatment that uses powerful chemical or pharmacological aversive stimuli, have become negative and aggressive.

Example

• Someone who wants to stop smoking might go to the therapist who uses a rapid smoking techniques, in which the client is allowed to smoke but must take the puff on the cigarette every five or six seconds. As nicotine is a poison, such rapid smoking produces nausea and dizziness, both unpleasant responses.
  
• Cigarette including the e act of putting in to the mouth, lighting up (CS) which leads to a Pleasurable stimulation response (CR), then Rapid smoking (US) which leads to Nausea and dizziness (UR). Repeated practice lead to the unconditioned response (UR) to a conditioned response (CR).
  
• Use of a drug called disulfiram to treat the alcoholism is another example for the aversion therapy. This medicine is properly prescribed and monitored results in several aversive reactions when combined with the alcohol. The person may experience nausea, vomiting and anxiety, and even more serious symptoms making this drug an effective deterrent for drinking for people who are unable to quit by other means.
  

5. FLOODING

Introduction

Flooding was invented by a psychologist named Thomas Stampfl. Flooding is an effective form of treatment for phobias amongst other psychopathologies. It works on the behaviorist principles of classical conditioning.

Meaning

It is behavior therapy technique in which the person is rapidly and intensely exposed to the fear provoking situation or object and prevented from making the usual avoidance or escape response.

Indication

• Phobias
  
• Post traumatic stress disorder
  
• Obsessive compulsive disorder
  

Procedure

Flooding is based on the premise that   escaping from an anxiety provoking reinforces the anxiety through conditioning .client is prevented from the conditioned avoidance of the behavior by not allowing the patient to escape the situation .no relaxation therapy is used and patient experiences fear. Which gradually subsides after some time. The success of the procedure depends on having the patients remain in the fear generating situation until they are calm and feel a sense of mastery.

ADVANTAGE OF CLASSICAL CONDITIONING TECHNIQUES

• Short duration of therapy
  
• Easy to train the clients
  
• Cot effective
  
• Duration of treatment is  usually 6-8 weeks
  

APPLICATION TO THE NURSING

Widely used in mental health setting....

1. Phobia
   
2. Anxiety disorder
   
3. Obsessive compulsive disorder
   
4. Alcohol and drug abuse
   
5. Certain sexual disorder  such as paraphilia, transvestism
   
6. Physical disability
   
7. Chronic pain
   
8. Rehabilitation center
   

CONCLUSION

Behavior therapy is based on the theories of operant conditioning by Skinner and classical conditioning by Pavlov. Beahviour therapy techniques has contributed to education and treatment of psychiatric and medical disorders.

REFERENCES

1. Stuart GW, Laria MT. Principles and Practices of Psychiatric Nursing. IST ed. Philadelphia: Mosby Publishers; 2001.
   
2. Mary TC. Psychiatric Mental Health Nursing –Concept of Care 3rd ed. Philadelphia :F.A. Davis Publishers ;2002
   
3. Ahuja N .A Short Text Book of Psychiatry 5th Ed. New Delhi: Jayee Medical Brothers Publishers .2002.
   
4. Rawlinson   RP, Williams SR and Beck CK. Mental Health Psychiatric Nursing –A Holistic Life Approach Cycle. 3rd ed. Philadelphia: Mosby Publishers; 1992.
   
5. Kaplan HI, Sadock BJ. Synopsis of Psychiatry, Behavioral Sciences/ Clinical Psychiatry .9th ed. Hong Kong: William and Wilkinson Publishers; 1998.
   
6. Mangal SK. General Psychology. New Delhi: Sterling Publishers; 2001.
   

Posted in: Mental Health Nursing,Psychology