Behavioral Therapy


Behaviorism is a school of thought that emphasizes the role of experience in governing behavior (Klein 2008). Behaviorists regard behavior as overtly displayed, measurable, learned physiological reactions to environmental stimuli, rather than of mental state. Psychological disorders are seen as causes of maladaptive learning. Behavioral therapy is one in which the basic tenets of learning theory - the elementary principles of how learning occurs - are used to change behavior (Kroger 1977).
Behaviorist’ research of the processes of learning and 'unlearning' has provided psychology with behaviorist' learning theories and models used to explain and modify behavior. Even though the mental state is an essential focus in Clinical Hypnosis, behavior therapy principles play a crucial role in clinical hypnosis. The objective of this essay is to briefly evaluate this role.

The application of behavioral therapy techniques in Clinical Hypnosis is referred to as the 'hypnobehavioral' approach. This essay focusses on the works of the main behaviorist' theorists Watson, Pavlov, Thorndike, Skinner and Wolpe, and the principles of their work relevant to hypnobehavioral techniques found within Clinical Hypnosis, in the context of the treatment of phobias, anxiety and unwanted habits. With regards to therapy, the essay will then evaluate the benefits of using either the hypno-behavioral or the behavioral approach.

Discussion
Behaviorism explains behavior and behavioral modification through a number of learning theories, of which the principle of 'conditioning' forms the basis. Conditioning is the process by which a reflexive response to a stimulus is acquired (Gross 2005). Pavlov ‘s work with dogs involved pairing certain signals (unconditioned stimuli) with the arrival of food (unconditioned stimulus). After a while, the dogs would salivate when the signal (now termed a conditioned stimulus) was given, without the presence of food; they had learned to associate the two events. Salivation became a learned involuntary response to a stimulus. Pavlov termed this learned behavior a Conditioned Reflex or Conditioned Response (CR). He termed the process Classical ‘Conditioning’. If the signal were repeated several times with the food being withheld, the dogs would eventually learn not to salivate. This process of unlearning the CR Pavlov termed ‘extinction’ (Waxman 1989). The process of counterconditioning is a more active unlearning of the CR; the intensity of the CR (f.i. anxiety) is reduced by establishing an incompatible response (relaxation) to the conditioned stimulus (a spide, f.e.), until this new S-R connection has been established.

Watson applied conditioning to the study of human behavior. He paired a loud noise when presenting a small animal to an infant, resulting in the infant learning to fear the animal. This showed evidence of classical conditioning in humans (Gross 2005). Through one of his students, Watson observed that humans can also unlearn fear towards a particular stimulus if that stimulus is paired with -in this experiment- food.

Thorndike and Skinner developed the theory of Operant Conditioning, whereby voluntary behavior is modified by the use of consequences. Thorndike theorised that behaviors that are followed by pleasant consequences are likely to be repeated in the future. Skinner researched shaping behavior through positive or negative reinforcement (the response will increase) and punishment (the response will decrease). 'Extinction’ occurs when a CR will occur with less frequency or ceases altogether as a result of 'producing' neither favorable nor unfavorable consequences. The work of Pavlov, Thorndike and Skinner is significant for behavioral and hypnobehavioral therapy as it shows how people could potentially learn anxieties, phobias and habits, and how existing behaviors could be unlearned. Wolpe is another behaviorist whose theories find their application in Clinical Hypnosis.

Wolpe (1973) stated that Behavior Therapy is relevant in syndromes that owe their existence to learning. Therefore, as one is not born with f.i. the desire to smoke, in theory, these behaviors can be unlearned. And, if phobias are, as Wolpe (1990) describes, 'a maladaptive learned habit', then, in theory, conditioning can establish a more appropriate behavior. He developed a therapy called ‘Systematic Desensitisation’, based on his theory of ‘Reciprocal Inhibition’: the inhibition of the action of one neural pathway by the activity of another (Gross 2005). This occurs when a stronger, incompatible response is introduced towards a particular stimulus, competing with and overriding the previous response. Wolpe argued that certain mental states are antagonistic to anxiety. These antagonistic mental states are relaxation, hunger, thirst and sexual arousal. A person cannot feel anxiety when experiencing any one of these antagonistic mental states. 'Desensitisation' means becoming insensitive to a stimulus.

In hypnobehavioral therapy, these principles are applied when treating maladaptive anxiety-reponses with Wolpe’s technique of ‘Systematic Desensitisation’. In imagination and in trance, the patient is gradually exposed to a hierarchy of anxiety-provoking stimuli, whilst responding with a previously learned relaxation-response, overriding the anxiety. The patient learns to associate the two; a new CR to the anxiety-provoking stimuli has been established. Before testing the responses in vivo, the patient completes the process in trance, communicating with IMR (ideomotor response) to indicate their coping limits whereupon relaxation can be deepened. This behavioral therapy lends itself well to being practiced in trance as a hypnobehavioral therapy and is known as ‘Hypno-desensitisation’ (Joseph 1994).

This therapy is very effective in the treatment of phobias and anxiety, as well as for maladaptive habits resulting from anxiety. Hurley (1976) reported a case of severe bridge and height-phobia treated by modified Systematic Desensitisation in hypnosis. In functional anxiety-responses, appropriate traces of anxiety must be left to enhance performance or protect from danger.
Learning Theory states that learning occurs through association and repetition. With this in mind, behavior modification can be achieved in hypnosis using a.o the following behavioral techniques, based on the behavioral principles discussed: Aversion Therapy, Flooding, Assertiveness Training, and Massed Practice (and Systematic Desensitisation, as already discussed), hereby applied in the Hypnobehavioral treatment of phobias, anxiety, and unwanted habits.

Extinction of a phobia can be caused in hypnosis by the technique of ‘Flooding’: continual imagined exposure to the feared stimulus without the benefit of associated relaxation.The patient experiences the anxiety until the stimulus loses its effect both through physical exhaustion of the patient and the patient learning there are no aversive consequences (Operant Conditioning), becoming desensitised. This is a last resort-technique a.o. due to risk of further traumatising the patient.

Aversion Therapy consists of 'administering an aversive stimulus to inhibit an unwanted response, thereby diminishing the habit strength' (Wolpe 1973). Based on Classical Conditioning, the patient will associate the prodromal stimulus with the aversion, resulting in suppression of the undesired behavior. This technique should be a requested, last resort-treatment, after informed consent of the patient has been gained.

'Massed practice' eliminates a habit by continued repetition of the stimulus that triggers the bad habit, or by repeating the habit behavior until it exhausts itself (Wolpe 1973). The patient becomes desensitised to the stimulus or habit. Since imagining a habit could lead to its in vivo expression, this technique is contraindicated where there is risk of damaging the patient.

Assertiveness Training is used to treat anxiety-responses (phobias, habits such as stammering) triggered by 'social' stimuli. The patient is desensitised to the feared stimulus, and, on top, depending on behavioral type, diaphragmatic breathing influencing voice-projection and changing of physical posture is taught, which is likely to influence other people’s responses in turn, due to their conditioning.

Direct Suggestions can break or reinforce S-R connections. Cues such as 'as soon as' use the principles of Classical Conditioning as a strong association is formed between S-R, reducing risk of extinction. Suggestions for relaxation continually delivered on the exhalation may start to function as an anchor.

For all three maladaptive behaviors, hypnobehavioural therapies use 'Homework', generally incorporating 'Self-hypnosis' and 'Pseudo-Orientation in Time', to reinforce desired behavior, as well as in vivo-exposure-tasking, breaking the cycle of avoidance of the feared stimulus. Deiker and Pollock (1975) showed how pseudo-orientation in time can be effective in allowing the patient to picture themselves in the future having beaten the phobia. Regular reinforcement through pseudo-orientation in time allows the patient to visualise the goal-orientated, motivating, positive consequences of the desired behavior, based on the principles of Classical and Operant Conditioning, setting a template for success.

The most powerful reinforcement comes from experiencing the ultimate in vivo positive consequences of the modified behavior. The patient that has undergone hypnobehavioral therapy, will be thoroughly prepared.

Conclusion
It can be strongly argued that the hypno-behavioralist approach could be more effective than the behaviorist approach. Kroger (1977) stated that 'hypnosis facilitates learning'. This allows more rapid behavioral modification. As therapy is done in the unconscious mind, bypassing critical conscious interference resulting in increased suggestibility, a suggestion can be accepted in one session, while behavioral therapy relies on repetition to enable conditioning. Hypnosis achieves enhanced feelings and greater depths of relaxation, increasing effectiveness and speed of many techniques. Hypnosis is valuable at treating anxiety as the process of induction and deepening generally relieves anxiety (Hammond, 1990).

The hypnobehavioral approach allows the conditioning process to be carefully controlled, offering greater safety for the patient. IMR allows the therapist to check on progress, allowing greater control and respecting the patient's coping level, thus reducing risk of retraumatising and breaking rapport.
Other advantages of the hypnobehavioral approach include the ability to give 'post-hypnotic suggestions' to encourage behavioral responses to situations that were imagined (Deyoub and Epstein 1977), as well as enhanced scene-visualisation (Deiker and Pollock 1975), increasing effectiveness of Pseudo-orientation in time. Ego-strengthening is a vital ingredient of the hypnobehavioral approach, as it increases the patient's coping-ability, and thus success of therapy. Ego-strengthening can help prevent relapses of undesired habits (Rist & Watzl 1983).

Self-hypnosis empowers the patient by gaining control over their responses, as well as reinforcing conditioning in between sessions; all adding to preparation for in vivo exposure.
However, much depends on the patient's personality, situation and presenting symptom. Not everyone is a good hypnotic subject, and there are situations where hypnosis is contraindicated. In therapy, we can make best use of either approach when we allow them to cross over and compliment each other.

References

Carlson N and Buskist W (1997) Psychology: The science of behavior 5th edition Allyn & Bacon
Deiker TE and Pollock (1975) Integration of Hypnotic and systematic desensitization techniques in the treatment of phobias: a case report American Journal of Clinical Hypnosis 17:117
Deyoub P L & Epstein S (1977) Short term hypnotherapy for the treatment of flight phobia; A case report American Journal of Clinical Hypnosis 19, 251-254
Gross R (2005) Psychology: The Science of Mind and Behaviour Hodder Arnold

Hammond D C (1990) Handbook of Hypnotic Suggestion and Metaphors Norton
Hurley A D (1976) Unsystematic desensitization using pleasurable images to inhibit anxiety Journal of Behavioral Therapy and Experimental Psychiatry, 7
Joseph M (1994) Hypno-desensitisation European Journal of Clinical Hypnosis 1 (2): 14-20
Klein S B (2008) Learning: Principles and Applications 5th edition Sage Publications

Kroger W S (1977) Clinical and Experimental Hypnosis 2nd edition Lippincott

Rist F & Watlz H (1983) Self-assessment of relapse risk and assertiveness in relation to treatment outcome of female alcoholics Addictive Behaviours 8, 121-127
Waxman, D (Ed) (1989) Hartland's Medical and Dental Hypnosis 3rd Edition Bailliere Tindall

Wolpe J (1958) Psychotherapy by Reciprocal Inhibition Stanford University Press

Wolpe J (1973) The Practice of Behavior Therapy 4th edition Pergamon

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