Article NIMHANS Journal

Recent Trends in Behaviour Therapy

Volume: 14 Issue: 04 October 1996 Page: 315-323 V Kumaraiah, P S D V Prasadarao, - Department of Clinical Psychology, National Institute of Mental Health & Neuro Sciences, Bangalore 560 029, India Abstract In this paper we have attempted to review the recent developments in Behaviour Therapy. The areas such as cognitive behaviour therapy, are discussed. Recent trends in the intervention of such clinical disorders as schizophrenia, substance use disorders, somatization disorders, panic disorder, pain and borderline personality disorder have been highlighted. In the present review, a brief account of current treads of research in India are discussed. Key words - Behaviour therapy, Cognitive behaviour therapy, Somatization, Panic disorder, Substance abuse, Recent trends In the last two decades, Behaviour therapy has made significant contributions in the area of mental health. Behaviour therapy is a structured therapy with empirical collaboration to deal with various psychiatric problems with an emphasis on functional analysis and utilization of empirically tested therapeutic techniques [1]. Behaviour therapy deals with maladaptive behaviours assuming that such behaviours are acquired through learning. Hence, principles of learning can be effectively used in the modification of such maladaptive behaviours; while intervening with various clinical disorders, behaviour therapy sets specific and well defined goals attempting at the individual's problems using an here-and-now approach [2]. According to Marlatt [3], intervention programmes aiming at behaviour change should follow certain criteria, namely, they should 1) maintain the behaviour change for a clinically significant period of time; 2) enhance and maintain the client's compliance to therapeutic programme; 3) contain a combination of techniques as well as global life style modification; 4) facilitate the development of motivation and decision making skills; 5) replace maladaptive habit patterns with alternative behaviours; 6) teach the client adaptive ways of dealing with problem situations; and 7) make use of client support systems to enhance treatment generalization effects.

Behaviour therapy, a comprehensive treatment approach, fulfils such criteria. In the present paper the attempt has been to highlight some of the recent developments in behaviour therapy. The focus of the article is not an exhaustive review of the literature in this area.

Behaviour therapy to cognitive behaviour therapy In the last few years, it was contended that a distinction between cognitive and behavioural approaches is not possible at the theoretical, practical and research levels; though behaviour therapy is used for modification of behaviours and emotions, it would ultimately act at the cognitive level. Moreover, the limits of the behaviour therapy can be expanded using various cognitive methods, as indicated by the results of various conditions such as depression [4]. Cognitive models target various clinical conditions with appropriate techniques; it is also evident that cognitive models of psychopathology have been more useful in describing the phenomenology of various clinical conditions. The appealing aspect of cognitive models is their accessibility to clients; these models are also not complex, hence, clinicians could learn and apply the cognitive models accordingly to the interventions [4]. Corrigan [4], opines that psychology benefits from augmenting classical behavioural paradigms with the cognitive models, since these latter models have more pragmatic and heuristic value and since they generate appropriate intervention strategies. More over, raprochement between the cognitive and behavioural paradigms needs to be done and the researchers should address the challenge of a combined behavioural and cognitive paradigms to deal with the questions of the present times. Accordingly, the clinicians in the recent past have realized the importance of combining the behavioural and cognitive approaches while dealing with various clinical disorders in a comprehensive manner. Such attempts have been clearly evident in the current literature, and it is one of the major developments in this area.

Behaviour therapy to behavioural medicine Behavioural Medicine has emerged as a subspeciality of psychology, and specifically, the Behaviour therapy. Behavioural sciences contribute significantly to the field of medicine in conceptualizing the etiology and treatment of various medical illnesses such as cardiovascular and gastrointestinal disorders. In the last decade, the role of behaviour has been clearly emphasized in the acquisition and maintenance of the medical disorders and hence it is essential to use principles of behavioural change in the treatment of such disorders [5]. Moreover, the study of behaviour has been found to be important in the study of disease as certain behavioural processes influence disease process and outcome. Behavioural approaches are also found to provide a better understanding of the biological basis of the disease and influence the outcome. Consequently, behavioral medicine, a new branch, is defined as the integration of behavioural medicine, a new branch, is defined as the integration of behavioural science approaches with biomedical knowledge and techniques [6]. In the last decade, cognitive behavioural approaches have grown rapidly to handling various medical disorders such as hypertension and prevention of cardiovascular risk factors, under the rubric of Behavioural Medicine. Manual based interventions In the recent past, cognitive behavioural treatments have involved in the utilization of manual based treatment programmes. The manual based treatment research is found to be advantageous over other treatments. The manual based interventions are advantageous because in such structured programmes 1) the independent variable can be operationalized; 2) rating can be done by naive individuals; 3) treatment integrity is easier to establish; 4) definitions can be operationalized and standardization of treatments, which in turn, facilitate the replication of treatments, and comparability across different groups. Moreover, the structured and time limited nature of these treatment manuals results in focussed treatment. Such treatment manuals contribute to the development, evaluation, and dissemination of empirically validated intervention programmes with a pragmatic approach to therapy [7]. Standardized treatment manuals have been effectively utilized in the West, with both clinical and research goals. However, such approach has not yet been implemented to its fullest extent in the Indian context due to various reasons such as heterogeneity of individuals in terms of literacy, languages spoken and socioeconomic status.

Schizophrenia According to Bellack [8], schizophrenia has become "behaviour therapy's forgotten child". This was attributed to certain misconceptions such as 1) schizophrenia is a disorder which can't be treated with behaviour therapy; and 2) biological basis warrants only pharmacological intervention and precludes the psychosocial intervention. Recently, various psychosocial intervention. Recently, various psychosocial interventions are advocated to help the schizophrenics to deal with the symptoms, to cope with their illness, achieve greater self-sufficiency and ultimately leading to better quality of life. In some schizophrenics, neuroleptics do not always reduce delusions. Alford and Correia [9], reported utility of cognitive behavioural approach in such individuals. Chadwick and associates [10] reported positive results in dealing with such neuroleptic resistant delusions. Their results indicated that interventions that focus on challenging the delusions followed by empirical testing, lead to reduction in delusions. In some individuals, auditory hallucinations may fail to respond to medication. Bentall et al [11] used attribution of hallucinations to the self rather than to the external sources and suggested techniques for reducing distress associated with hearing voices. They reported positive results in the reduction of the frequency of hallucinations and associated distress. Tarrier et al [12] developed "coping strategy enhancement therapy" to teach coping strategies to deal with their symptomatology, which showed positive results. According to Liberman et al [13] the schizophrenic patients have social skills deficits because of the symptomatology, inadequate learning history before the onset of the illness, poor environmental stimulation and loss of skills due to chronic illness. Hence social skills training is advocated to train individuals in skills of interpersonal, self-care and coping demands within the environment. Such training can also equip patients with the capacity to cope with the environmental stressors and life events. Skills training has also been used to teach skills such as personal hygiene, self-directed recreation, and communication [14]. The social skills training programme may utilize moderately structured problem solving groups to highly structured curriculum based programmes [13]. Thus, the current literature clearly emphasizes the role of and need for utilizing various behavioural and cognitive strategies while dealing with delusions, hallucinations and social skills deficits among individuals with schizophrenia.

Functional somatic symptoms Funcional somatic symptoms - - the chronic and distressing physical symptoms without obvious organic pathology, are common among many patients both in the psychiatric clinics as well as in the general hospital set up. In the past decade, the significant development has occurred in the understanding and formulation ofintervention programmes to deal with the functional somatization disorders. The current cognitive behavioural formulation of somatization disorders emphasizes on the misinterpretation of the physical sensations, by the individual, as physical illness. Thus, the illness is based on the appraisal of the individual's physical sensations. It is also said that the negative thoughts and images of a threat to health are associated with anxiety of physiological arousal. This leads to the processing of external information with a cognitive bias and these further lead to avoidant behaviours, because of which the individual continues to have abnormal health concerns. Such maintaining factors lead to long-term anxiety which makes one vulnerable for misinterpretation of intrusive stimuli which results in preoccupation with health [15]. In a cognitive behavioural approach, the individuals are taught to identify these intrusive stimuli and the automatic thoughts; typically, methods of reattribution for the causes of the physical sensations and behavioural experiments are advised to evaluate the alternative explanations for their sensations. Other exposure related techniques are also used to handle the avoidance behaviours. Cognitive restructuring involves modification of dysfunctional thoughts about health [15].

Substance use disorders Interventions with substance use disorders, in the past were predominantly based on conditioning principles (eg. aversive paradigm) and used various behavioural techniques utilizing these principles. However, currently, the emphasis has shifted on to the prevention of relapse using various cognitive behavioural strategies rather than on mere utilization of techniques to creating aversion. Resumption of substance use after a period of abstinence, which is called as relapse, has been of great concern to clinicians. Though some individuals with substance use disorders eventually achieve and maintain total abstinence, many may relapse. In order to deal with such individuals, various strategies have been developed, focusing on training the clients to identify, handle the causes and prevent such relapse. In the last decade Marlatt [3] has developed strategies for understanding and handling relapse of substance use disorders. One of the major relapse prevention strategies has been cognitive behavioural in nature, which provides the individuals with substance use, with the information and skills to identify and avoid/cope with emotions and situations which can create craving which may ultimately lead to relapse [16], [17], [18]. In this approach the client is taught to 1) identify cues (emotions, thoughts, behaviours) that may trigger relapse by reviewing the past relapses; 2) avoid the people, places and things that have led to relapse in the past or are likely to lead to relapse in the future; 3) learn skills to cope with unavoidable risk situations such as interpersonal conflicts, anger and frustration; 4) handle self-defeating attributions and the lapses; and 5) being honest and disclose out their lapses/cravings. Such intervention programmes have been effectively used with positive outcome [19].

Panic disorder In the last decade, research has focused on the understanding and intervention of panic disorder. Various cognitive behavioural approaches to lower physiological arousal, reduce cognitive misinterpretation of the panic related cues, and exposure to feared stimuli have been effectively used. Cognitive techniques such as panic education, guided imaginal coping, have been designed to provide adaptive coping skills, to correct catastrophic misinterpretation of somatic sensations, to identify and challenge distorted and catastrophic ideation [20].

Borderline personality disorder According to Linehan [21] Borderline Personality Disorder (BPD) occurs due to the traumatization between the individual (with constitutional vulnerability to emotion regulation) and the environment (that is prone to invalidate the expression of private experiences, beliefs and actions). Due to the biological predisposition, the BPD individual's emotional responses to environmental stimuli occur more quickly and more intense, and have as slower return to baseline compared to non BPD individuals. Hence these individuals respond strongly, and intensely to the environmental input which inturn creates a vicious feedback cycle. Further, the individual's actions and communication of private experiences are met by erratic, inappropriate, extreme responses within the environment. This would ultimately produce a need for extreme behaviours leading to intense emotional outbursts. Linehan [21] opines that the BPD individuals suffer from difficulty in affect regulation involving physiological changes, cognitions, attention to environmental events and action urges. In the Dialectical Behaviour Therapy (DBT), developed by Linehan, the clients are taught skills in attending to environmental stimuli, alter cognitive patterns, change facial and body language, and improve the quality and variety of actions one involves in. The intervention is aimed at improving the individuals ability to moderate and regulate emotional experiencing. The individuals are also taught to experience an emotion and to block the maladaptive response patterns to such emotions. DBT also uses contingencies to restrict the client's ability to respond to emotions. Thus, DBT moves the individual from a maladaptive response pattern to emotional regulation to more adaptive behaviours with physiological and cognitive changes. Further, the clients are taught to modify their rigid patterns of behaviours into flexible, more situation-person specific and to maintain adequate appropriate contact while regulating and moderating their emotions. The DBT utilizes 1) individual therapy; 2) group skills training 3) telephone consultation and 4) meetings for the therapists. In the in-patient setting other techniques such as milieu, vocational rehabilitation, dance/art therapy are utilized. The DBT has gained momentum and found go be useful in dealing with BPD individuals [22].

Pain management Cognitive behavioural programmes have been developed to deal with various pain conditions. Wilson et al [23] surveyed 435 members of the International Association for the study of pain. Of these 60% responded, 73% reported to have used cognitive behavioural strategies for the management of pain. Most of these clinicians used 1) education about the factor that influence pain perception and coping; 2) reconceptualization of the pain processes; 3) skills acquisition; and 4) increasing exercises and activity levels. Reviews on the pain management indicated positive outcome with cognitive and behavioural strategies [24], [25]. The cognitive behavioural strategies for pain management include several techniques such as reconceptualization of techniques such as reconceptualization of the pain problem, goal setting, cognitive restructuring and reconceptualization of the pain experience [26].

Theoretical issues While rejecting the disease model, the modern behaviour therapy has adopted an educational model, with an emphasis on teaching skills for individual life problems. Behaviour therapy emphasizes on more than mere planning of symptom reduction. Prophylaxis has become a part of intervention. Efforts are also being made on the prevention of various disorders utilizing behavioural and cognitive strategies. As Goldfried and Castonguay [27] put it, there is now a healthy recognition that the behavioural techniques have a modest impact and the behaviour therapists are now open to the failures and learn from them. This they consider as a positive trend in the growth and development of behaviour therapy. The focus of behaviour therapists is on specific determinants of the behaviour rather than the global aspects of an individual; consequently the clinicians started looking into the thoughts, feelings and behaviours in specific life situations and efforts are being made to develop assessment methods and procedures of change [27]. The clinicians with cognitive behavioural orientation have also become more sensitive to the implicit intrapersonal and interpersonal aspects of the individuals [28]. Goldfried and Castonguay [27] opine that the cognitive behaviour therapists have begun integrating the views of Messer [29] that exploration, regulation and integration of the client's inner reality(eg. conflicts, emotions) would be beneficial.

Developments in India The Behavioural Medicine unit of the Department of Clinical Psychology, National Institute of Mental Health & Neuro Sciences, Bangalore, India has been a centre actively involved in providing clinical services, human power development and in conducting research in the areas of behaviour therapy and behavioural medicine. Intervention programmes have been developed and efficacy of such programmes evaluated in various clinical conditions namely, Biofeedback in pain [30], autogenic training [31] in tension headache, EMG feedback [32], [33], EMG Biofeedback and SIT [34] in generalized anxiety disorder, Behaviour modification in mental retardation [35], [36], [37], and multimodal intervention in alcohol dependence [38], [39]. In the recent past the research has begun to focus on various general medical disorders and cognitive behavioural approaches have been used in such conditions as hypertension [40], duodenal ulcer [41], menstrual distress [42], cancer [43], Coronory Heart Disease [44], [45] and Diabetes mellitus [46] with positive outcome. As it can be seen, the work done in the recent past at this center in India, has shifted its focus from the initial psychiatric disorders to the most recent research showing the application and utilization of various cognitive behavioural strategies in general medical disorders where the psychobiosocial factors play a significant role and which need to be handled in order to have a better compliance for other interventions as well as to handling various psychological issues involved in these physical disorders. Accouding to Kapur [47], the research on behaviour therapy in India during the last decade showed a significant improvement; Kapur points out that the current research started utilizing more group comparison research rather than individual case studies; the therapists have started utilizing interventions for wider range of psychological, psychosomatic and medical conditions; the intervention programmes tend to be comprehensive with utilization of multiple techniques rather than single technique therapies. Now, more and more involvement of significant others is sought for broader and better generalization of treatment gains. There is also an increasing trend of utilizing multiple parameters for outcome evaluation.

Conclusion In the recent past, the behaviour therapists have developed various innovative and specific intervention strategies to deal with a wide range of clinical disorders. In some disorders (eg. anxiety, OCD), behaviour therapists have provided definitely successful comprehensive intervention programmes. In the last decade, the emphasis has been on the understanding, assessment and intervention of various general physical illnesses under the rubric of behaviour medicine. Moreover, the behaviour therapists have also attempted to focus on various methodological issues. Understanding and further developing the theories of behaviour therapy is an important area that needs further attention from the clinicians as progress in the interventions would depend on the basic theoretical formulations underlying such programmes. Advancement of theoretical issues would also lead to refinement of various intervention programmes and in formulating specific strategies and their effective utilization. In the coming years, the attention of Behaviour therapists needs to be focused on the interaction between the treatment strategies and intra- and extra-individual variables. It is also essential to determine the role of environmental factors in the utilization and efficacy of intervention strategies. Since some specific behaviours are unique to some cultures, though certain behaviours are common across cultures, one needs to keep in mind, while theorizing and developing specific intervention programmes, these "etic" (shared, universality of behaviours) and "emic" (features unique in meaning, significance and manifestation to a given culture) aspects of behaviour. 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