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Behavior therapy involves changing the behavior of the patients to reduce the dysfunction and to improve the quality of life.
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The principles of behavior therapy are based on the early studies of Classical conditioning by Pavlov (1927) and operant conditioning by Skinner (1938).
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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.
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Through classical conditioning ‘the old and undesirable responses can be replaced by the desirable ones.
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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
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Developed by Wolpe and is based on the behavior principle of counter conditioning for assisting the individuals to overcome their fear of phobic stimulus.
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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.
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The technique of systematic desensitization in which a therapist guides the client through a series of steps meant to reduce the fear and anxiety
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Systematic desensitization indicated in the cases of clearly identifiable anxiety provoking stimulus, such as:
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Phobias
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Obsessive compulsive disorder
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Sexual disorders
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Anxiety disorder
Systematic desensitization consist of three steps
1. Relaxation training2. Hierarchy construction3. 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 consumptionb. 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 positionII. Provide light or soft music /pleasant visual cuesIII. Give a brief explanation about the progressive muscle relaxationIV. Instruct the client to tense each muscle group approximately for 10 secondsV. Explain the tension of the muscle and uncomfortable the body part feelsVI. Ask the client to relax each muscleVII. 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 therapistB. Look at a picture e fof an elevatorC. Walk in to the lobby of a building and see the elevatorsD. Push the button for the elevatorE. Walk in to the elevator with a trusted person ,disembark before the door closeF. Walk into a elevator with a trusted person ;allow the door to close;then open the door and walk outG. Rise one floor with atrud=sted person ,then walk down the stairsH. Ride the elevator one floor with a trusted person and ride the elevator back downI. 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
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Alcohol abuse
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Paraphillias
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Homosexuality
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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
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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.
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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).
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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
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Short duration of therapy
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Easy to train the clients
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Cot effective
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Duration of treatment is usually 6-8 weeks
APPLICATION TO THE NURSING
Widely used in mental health setting....
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Phobia
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Anxiety disorder
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Obsessive compulsive disorder
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Alcohol and drug abuse
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Certain sexual disorder such as paraphilia, transvestism
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Physical disability
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Chronic pain
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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
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Stuart GW, Laria MT. Principles and Practices of Psychiatric Nursing. IST ed. Philadelphia: Mosby Publishers; 2001.
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Mary TC. Psychiatric Mental Health Nursing –Concept of Care 3rd ed. Philadelphia :F.A. Davis Publishers ;2002
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Ahuja N .A Short Text Book of Psychiatry 5th Ed. New Delhi: Jayee Medical Brothers Publishers .2002.
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Rawlinson RP, Williams SR and Beck CK. Mental Health
Psychiatric Nursing –A Holistic Life Approach Cycle. 3rd ed.
Philadelphia: Mosby Publishers; 1992.
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Kaplan HI, Sadock BJ. Synopsis of Psychiatry, Behavioral
Sciences/ Clinical Psychiatry .9th ed. Hong Kong: William and
Wilkinson Publishers; 1998.
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Mangal SK. General Psychology. New Delhi: Sterling Publishers; 2001.
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