Chapter 10: Behavioral and Cognitive-Behavioral Interventions PDF

Barry University Library Access Provided by: Current Diagnosis & Treatment: Psychiatry, 3e Chapter 10: Behavioral and Cognitive–Behavioral Interventions Travis Thomp...

Barry University Library Access Provided by: Current Diagnosis & Treatment: Psychiatry, 3e Chapter 10: Behavioral and Cognitive–Behavioral Interventions Travis Thompson; Steven D. Hollon ROOTS OF BEHAVIORAL & COGNITIVE–BEHAVIORAL INTERVENTIONS Although their roots can be found at the beginning of the twentieth century, modern behavioral and cognitive–behavioral therapies arose during the 1950s and early 1960s when the scientific study of behavior emerged as a subject with validity in its own right. Disordered behavior was no longer taken to be purely a symptom or indicator of something else going on in the mind. Of inherent concern was its relation to past and current environmental events thought to be causally related to that behavior. Methods developed in animal laboratories began to be tested—in laboratory, institutional, clinical, and school settings—with people who had chronic mental illness or intellectual disabilities and with predelinquent adolescents. Improvements in patient behavior and functioning were often striking. These changes took place against a backdrop of growing dissatisfaction with the prevailing notion that psychopathology typically arose from unobservable psychic causes that were assessed and treated using techniques that seemed to be based more on art than science. In addition, an accumulating literature of outcome studies revealed that much of psychotherapy as it had been practiced until the early 1960s engendered very modest and largely unpredictable results. Thus, contemporary behavior therapies emerged from three distinct psychological traditions: classical or Pavlovian conditioning, instrumental or operant conditioning, and cognitive–behavioral and rational–emotive therapies. CLASSICAL CONDITIONING The first major perspective within learning theory approaches is typically referred to as classical conditioning. This perspective dates to the first decade of the twentieth century and is largely attributed to the Russian neurophysiologist Ivan Pavlov. Pavlov was interested in studying the structure of the nervous system, in particular, simple reflex arcs between external events (stimuli) and an organism's behavior (response). He chose to study salivation in dogs in response to food and developed an apparatus that held the dogs suspended in a harness while a small amount of meat powder was deposited on their tongues. He would vary the amount and timing of the delivery of the meat powder and recorded the subsequent variation in the nature and amount of salivation. What happened next confounded his simple neurologic experiments but opened the way to revolutionary new insights regarding how organisms learn to adapt their behaviors in response to novel environments. Pavlov found that, after a few trials, his dogs began to salivate when strapped into the harness, well in advance of any exposure to the meat powder on a particular trial. Naïve dogs placed in the harness for the first time did not salivate; experienced dogs that had been through the procedure earlier began to salivate well in advance of the delivery of the food. In effect, the dog's response came to precede the food stimulus, something that could not be explained in terms of a simple reflex arc. Pavlov's genius lay in recognizing the importance of this observation. He shifted his attention from the study of simple reflex arcs to those conditions necessary to support changes in behavior as a consequence of prior experience, that is, learning. He sounded a bell to signal the start of a trial that was followed by the delivery of meat powder and found that he could reliably train the dogs to salivate to the sound of a bell and not to respond to other aspects of the experimental situation. In effect, he introduced a particularly salient stimulus that carried all the predictive information contained in the situation (ringing the bell predicted subsequent delivery of meat powder, whereas nothing happened until the bell was sounded), and the dogs came to salivate reliably only after the bell was rung. Once the bell was established as a particularly informative stimulus, he could occasionally omit the meat powder on subsequent trials, and the dogs continued to salivate to the sound of the bell. This simple paradigm contained the key elements of classical conditioning. The meat powder represented what Pavlov came to call the unconditioned stimulus. All dogs with intact nervous systems salivate in response to meat powder being deposited on their tongues, whether they have any experience with that stimulus or not. Salivation represented the unconditioned response. The bell (or earlier, the entire experimental apparatus) represented the conditioned stimulus. Dogs do not naturally salivate to the sound of a bell, but they come to do so if it is paired with the meat powder (the unconditioned stimulus). Salivation to the bell alone represented the conditioned response, a learned response to an originally neutral stimulus Downloaded that is not 2025­2­16 found 5:15 universally P Your IP is among all members of the species. Chapter 10: Behavioral and Cognitive–Behavioral Interventions, Travis Thompson; Steven D. Hollon Page 1 / 12 ©2025 McGraw Hill. All Rights Early Demonstrations Reserved. Terms of Use Privacy Policy Notice Accessibility in Humans J. B. Watson, one of the leading figures in American psychology, recognized the potential relevance of classical conditioning as an explanation for the This simple paradigm contained the key elements of classical conditioning. The meat powder represented what Pavlov came to call the Barry University Library unconditioned stimulus. All dogs with intact nervous systems salivate in response to meat powder being deposited on their tongues, whether they Access Provided by: have any experience with that stimulus or not. Salivation represented the unconditioned response. The bell (or earlier, the entire experimental apparatus) represented the conditioned stimulus. Dogs do not naturally salivate to the sound of a bell, but they come to do so if it is paired with the meat powder (the unconditioned stimulus). Salivation to the bell alone represented the conditioned response, a learned response to an originally neutral stimulus that is not found universally among all members of the species. Early Demonstrations in Humans J. B. Watson, one of the leading figures in American psychology, recognized the potential relevance of classical conditioning as an explanation for the development of symptoms of psychopathology. Watson and a graduate student conducted a demonstration of how the principles of classical conditioning explicated by Pavlov could be extended to humans. In this study, Watson first showed that a 3­year­old boy called Little Albert had no particular aversion to a small white laboratory rat: He would reach for it and try to pet it, as young children are inclined to do. Watson and his assistant then placed a large gong out of sight behind Little Albert and sounded it loudly every time they brought the rat into the room. Although Little Albert had shown no initial aversion to the rat, he showed a typical startle response to the sounding of the gong (again, as most young children would). Before long, he became upset and burst into tears at the sight of the rat alone and would try to withdraw whenever it was brought into the room. According to Watson, this study demonstrated that phobic reactions could be acquired purely on the basis of traumatic conditioning. Although Little Albert had previously been intrigued by the presence of the rat and showed no evidence of any fear in its presence, pairing of the rat (the conditioned stimulus) with the loud, unpredictable noise produced by the gong (the unconditioned stimulus) led him to become anxious and upset in the rat's presence (the conditioned response), just as he had naturally become upset by the sound of the gong (unconditioned response). He had not only acquired a fear response to the rat but also tried to escape from it or avoid exposure to it. According to Watson, Little Albert had acquired the two hallmarks of a phobia (unreasonable fear, and escape or avoidance behaviors) purely as a consequence of simple classical conditioning. The next major study in the sequence was conducted by Mary Cover Jones in 1924. She reasoned that, if classical conditioning could produce a phobic reaction in an otherwise healthy child, the same laws of learning could be used to eliminate that reaction. She trained a young child to have a conditioned fear response to a small animal (a rabbit) and then proceeded to feed the child in the presence of the rabbit. She found that pairing of the conditioned stimulus (the rabbit) with a second, unconditioned stimulus (food)—which produced a different unconditioned response (contentment) that was incompatible with the first (anxiety)—came to override the original learning. The child began to relax in the presence of the rabbit and no longer showed the fear response that he had acquired earlier. Thus, Jones argued, she was able to provide relief via counterconditioning. Despite these early demonstrations, it was several decades before behavioral principles were applied systematically to the treatment of psychiatric disorders. This delay resulted partly from the sense that these procedures were just too simplistic to be of practical use in the treatment of complex human problems. Required were methods based on these learning principles that could be adapted to deal with more complex problems of living. Andrew Salter provided the first such method. In a text that was ahead of its time, Salter described a series of procedures based on principles of conditioning that were suitable for addressing emotional and behavioral problems in human patients. Although that text attracted little attention when it was published in 1949, it described (in vestigial form) many of the strategies and procedures that would later be used in the clinical practice of behavior therapy. Applications to Clinical Treatment Joseph Wolpe provided the first coherent set of clinical procedures, based on principles of classical conditioning that had a major impact on the field. Wolpe had studied experimental neuroses in cats. In the course of his studies, which involved shocking animals when they tried to feed and observing the results of the conflict this produced, Wolpe replicated the essential features of Jones's earlier attempt to reduce a learned fear via the process of counterconditioning. He soon extended his work to people with phobic disorders and was able to reduce his patients' distress by pairing the object of their fear with an activity that reliably produced an incompatible response. Like Salter, he experimented with the induction of anger and sexual arousal before finally settling on a set of isometric exercises developed to help reduce stress in patients with heart conditions. This procedure, called progressive relaxation, consists of having patients alternately tense and relax different muscle groups in a systematic fashion and can lead to a state of profound relaxation. The isometric exercises could be paired with the presumably conditioned stimulus (whatever the patient feared) in order to have the new conditioned response (relaxation) override the existing arousal and distress that patients experienced in the presence of the phobic stimulus. Wolpe called his approach systematic desensitization. In progressive relaxation training, a hierarchy is developed that represents successive degrees of exposure to the feared object or stimulus. For example, a patient with fear of flying might be asked to visualize a variety of scenes that induce differing amounts of anxiety. Simply watching someone else board an airplane might induce only a minimal amount of anxiety, whereas boarding a plane oneself and flying through a thunderstorm would be expected to elicit more anxiety. Wolpe worked with the patient to develop a hierarchy of such imagined experiences and grade them on a scale from 0 to 100 in terms of how much distress they produced. He would then expose Downloaded 2025­2­16 5:15 P Your IP is the patient to these stimuli (typically in imagination). He proceeded on to the next item in the hierarchy only when the client could tolerate a particular Chapter 10: Behavioral and Cognitive–Behavioral Interventions, Travis Thompson; Steven D. Hollon Page 2 / 12 image ©2025without McGraw experiencing distress. Hill. All Rights If the patient Reserved. Termsstarted of Use to becomePolicy Privacy upset while visualizing Notice an image, Wolpe would instruct the patient to stop the Accessibility image and reinitiate the relaxation exercises until the feelings of arousal had passed. In this fashion, he systematically worked the patient through the hierarchy of representations of the feared object, proceeding as rapidly as the patient could without experiencing distress until the stimulus no longer  Barry University Wolpe called his approach systematic desensitization. In progressive relaxation training, a hierarchy is developed that represents successiveLibrary degrees of exposure to the feared object or stimulus. For example, a patient with fear of flying might be asked to visualize a variety ofProvided Access scenesby:that induce differing amounts of anxiety. Simply watching someone else board an airplane might induce only a minimal amount of anxiety, whereas boarding a plane oneself and flying through a thunderstorm would be expected to elicit more anxiety. Wolpe worked with the patient to develop a hierarchy of such imagined experiences and grade them on a scale from 0 to 100 in terms of how much distress they produced. He would then expose the patient to these stimuli (typically in imagination). He proceeded on to the next item in the hierarchy only when the client could tolerate a particular image without experiencing distress. If the patient started to become upset while visualizing an image, Wolpe would instruct the patient to stop the image and reinitiate the relaxation exercises until the feelings of arousal had passed. In this fashion, he systematically worked the patient through the hierarchy of representations of the feared object, proceeding as rapidly as the patient could without experiencing distress until the stimulus no longer elicited any anxiety. Hundreds of studies have suggested that systematic desensitization (or its variants) is effective in the treatment of phobia and related anxiety­based disorders. Systematic desensitization has been applied widely to a host of problems and represents a safe and effective way of reducing anxious arousal in both adults and children. Major variations include substituting meditation or biofeedback for progressive relaxation as a means of producing the relaxation response (some people do not respond well to muscular isometrics) or arranging experiences in a graduated fashion. The basic approach appears to be robust to these minor modifications and is one of the few examples of a treatment intervention that is truly more effective than other interventions. Extinction & Exposure Therapy Despite its evident clinical utility, systematic desensitization is based on a misperception of the laws of classical conditioning. Classical conditioning is essentially ephemeral. Organisms stop responding to the conditioned stimulus when it is no longer paired with the unconditioned stimulus. Pavlov's dogs may have learned to salivate to the ringing of the bell, but if Pavlov kept ringing the bell after it was no longer paired with the meat powder, the dogs soon stopped salivating to its ring. This is referred to as the process of extinction, in which conditioned stimuli lose their capacity to elicit a response when they are presented too many times in the absence of the unconditioned stimulus. This basic feature was considered so troublesome by early behaviorally oriented psychopathologists that they felt compelled to explain how such an ephemeral process could account for a long­lasting disorder such as a phobia (most phobias do not remit spontaneously over time). O. Hobart Mowrer solved the riddle when he postulated that phobic reactions essentially involve two learning processes: classical conditioning, to instill the anxiety response to a previously neutral stimulus; and operant conditioning, to reinforce the voluntary escape or avoidance behaviors that remove the patient from the presence of the conditioned stimulus before the anxious arousal can be extinguished. In essence, people who acquire a phobic reaction to a basically benign stimulus do not extinguish (as the laws of classical conditioning predict they should), because they do not stay in the situation long enough for classical extinction to take place. This conclusion led some behavior theorists to suggest that although systematic desensitization was undoubtedly effective, it was unnecessarily complex and time consuming. The essential mechanism of change, they suggested, was extinction, not counterconditioning, and the only procedure needed was to expose the patient repeatedly to the feared object or situation. Of course, the therapist would also have to do something to prevent the patient from running away or otherwise terminating contact with the feared situation. Thus, according to exposure theorists, it was not necessary to ensure that patients experienced no fear in the presence of the phobic stimulus (as Wolpe claimed). Rather, all that was required was to get them into the situation and to prevent them from leaving until the anxiety had diminished on its own. Several decades of controlled research have suggested that the extinction theorists were correct and that exposure (plus response prevention) is at least as effective as systematic desensitization and is more rapid in its effects. That does not necessarily mean that it is more useful than systematic desensitization in practice; many patients find exposure therapy very distressing and prefer the gentler alternative provided by systematic desensitization. Although exposure typically works more rapidly than does systematic desensitization (and both work more rapidly than do nonbehavioral alternatives), it often takes as long to persuade a patient to try exposure techniques as it does to complete a full course of systematic desensitization. Nonetheless, it is now clear that exposure (with response prevention) is a sufficient condition for symptomatic change and that Wolpe was in error when he suggested that allowing a patient to experience anxiety in the presence of the phobic situation delayed the process of change. Although patients who already have acquired a conditioned fear response will undoubtedly experience distress when exposed to the object of their fears, the fact that they become anxious during the course of that exposure neither facilitates nor retards the extinction process. (This is why most behavior therapists no longer use the term "flooding" to refer to exposure therapy; although it may be descriptive of the level of anxiety induced, it is misleading in that it seems to imply that the induction of anxiety is itself curative in some way.) Exposure plus response prevention has a clear advantage over systematic desensitization (and virtually every other type of nonbehavioral intervention) in the treatment of more complex disorders related to anxiety. It appears to be particularly helpful in the treatment of obsessive– compulsive disorder (OCD) and severe agoraphobia. For example, treatment for a patient who has a fear of contamination and repetitive hand­ Downloaded washing rituals 2025­2­16 5:15 having might involve P Youra IP is therapy team spend a weekend locked in the patient's home, having the patient intentionally contaminate his or Chapter 10: Behavioral and Cognitive–Behavioral Interventions, Travis Thompson; Steven D. Hollon Page 3 / 12 her ©2025hands and food McGraw Hill.with dirt (byReserved. All Rights shutting off Terms the water to prevent of Use hand Privacy washing). Policy Similarly, Notice a patient with severe agoraphobia would be encouraged to Accessibility visit settings that he or she typically avoids (e.g., shopping malls or grocery stores) during the busiest times of the day and would be prevented (again by a therapy team or group) from leaving until his or her anxiety had subsided. Although systematic desensitization has had limited success with such behavior therapists no longer use the term "flooding" to refer to exposure therapy; although it may be descriptive of the level of anxiety induced, it is Barry University Library misleading in that it seems to imply that the induction of anxiety is itself curative in some way.) Access Provided by: Exposure plus response prevention has a clear advantage over systematic desensitization (and virtually every other type of nonbehavioral intervention) in the treatment of more complex disorders related to anxiety. It appears to be particularly helpful in the treatment of obsessive– compulsive disorder (OCD) and severe agoraphobia. For example, treatment for a patient who has a fear of contamination and repetitive hand­ washing rituals might involve having a therapy team spend a weekend locked in the patient's home, having the patient intentionally contaminate his or her hands and food with dirt (by shutting off the water to prevent hand washing). Similarly, a patient with severe agoraphobia would be encouraged to visit settings that he or she typically avoids (e.g., shopping malls or grocery stores) during the busiest times of the day and would be prevented (again by a therapy team or group) from leaving until his or her anxiety had subsided. Although systematic desensitization has had limited success with such severe disorders, the process of constructing and working through the literally dozens of hierarchies required typically makes the approach wildly impractical. Summary Strategies based on classical conditioning have been used in the treatment of depression, somatoform disorders, dissociative disorders, substance abuse, sexual difficulties, medical problems, and a variety of other disorders. In general, these approaches represent some of the most effective of the therapeutic interventions. As is the case with other types of behavioral strategies, they rest on a solid foundation of empirical work, much of it with nonhuman animals, and on the creative adaptation of those basic principles to human populations. Kazdin AE, Weisz JR: Evidence­Based Psychotherapies for Children and Adolescents. New York: Guilford Press, 2003. Marks IM: Fears, Phobias and Rituals. Oxford, UK: Oxford University Press, 1987. Rachman S, Hodgson RJ: Obsession and Compulsions. New York: Prentice­Hall, 1980. Wilson GT: Behavior therapy. In: Corsini RJ, Wedding D (eds). Current Psychotherapies , 5th edn. Itasca, IL: FE Peacock Publishing, 1995, pp. 197–228. Wolpe J: Psychotherapy by Reciprocal Inhibition. Palo Alto, CA: Stanford University Press, 1958. EMERGENCE OF INSTRUMENTAL & OPERANT LEARNING THEORY As a graduate student at Columbia University, Edward Thorndike began a series of experiments that set a new course in the study of processes underlying behavior change and learning. He placed a cat in an enclosed chamber and attached a vertical pole in the center of the compartment to a rope that passed over several pulleys. When the cat bumped against the pole, the pole would tilt, causing the rope to open the door. The cat could then leave the compartment and drink milk from a nearby bowl outside the cage. At first, the cat seemed to move about unpredictably each time it was returned to the compartment. The time required for the cat to tilt the pole grew shorter on successive repetitions of the task, and the cat's method for opening the door on each trial became progressively similar to the method used on the preceding trial. The trial­by­trial record of time to escape from what Thorndike called his "puzzle box" was the first instrumental learning curve published in a scientific journal. Eventually, each cat quickly approached the pole—seemingly purposively—and tilted it to one side, opening the door. Thorndike described this as an instrumental conditioning process because the pole tilting was instrumental in releasing the cat from the chamber and permitting access to a reward. Thorndike's method differed from Pavlov's classical conditioning because no specific response was elicited by a conditioned stimulus. The form of each cat's behavior that tilted the pole was idiosyncratic and variable. There was nothing fixed about the behavior, as was typical of classically conditioned behavior. Thorndike's Law of Effect described the necessary and sufficient conditions for instrumental learning to occur. Skinner & Operant Behavior Whereas Thorndike studied the process of behavior change, three decades later, B. F. Skinner, a graduate student at Harvard University, was interested in discovering a method for identifying the functional components of sequences of behavior. Skinner was drawn to the writings of the physiologists Charles Sherrington and Ernst Magnus. Skinner was particularly taken with Sherrington's notion of the reflex arc. Skinner believed that psychologists had gotten seriously off on the wrong track by focusing on unobservable phenomenological events, which no amount of experimentation could verify, rather than following the example of physiology in studying observable events. Skinner wondered whether Thorndike's Law of Effect might explain how a single component could be isolated from the continuously free­flowing activities of an organism, so that the component could be studied scientifically, much as Sherrington had done. Using a method very similar to Thorndike's, Skinner placed a rat in an enclosed chamber, and each time the rat depressed a telegraph key protruding through the wall of the chamber, a pellet of food dropped into a receptacle near Downloaded the rat. The 2025­2­16 lever­pressing 5:15 P Your IP ismethods each rat used varied: most pressed with their paws, some pushed with their muzzles, and others Chapter 10: Behavioral and Cognitive–Behavioral Interventions, held the telegraph key between their teeth and pulled Travis Thompson; down. All methods Steven produced the sameD. Hollon result—delivery Pagerat of a pellet of food that the hungry 4 / 12 ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility seized and ate. Skinner said that the rat "operated" on its environment to produce reinforcing consequences, and the type of behavior was correspondingly called operant behavior. physiologists Charles Sherrington and Ernst Magnus. Skinner was particularly taken with Sherrington's notion of the reflex arc. Skinner believed that psychologists had gotten seriously off on the wrong track by focusing on unobservable phenomenological events, which no amount Barryof University Library experimentation could verify, rather than following the example of physiology in studying observable events. Skinner wonderedAccess whether Thorndike's Provided by: Law of Effect might explain how a single component could be isolated from the continuously free­flowing activities of an organism, so that the component could be studied scientifically, much as Sherrington had done. Using a method very similar to Thorndike's, Skinner placed a rat in an enclosed chamber, and each time the rat depressed a telegraph key protruding through the wall of the chamber, a pellet of food dropped into a receptacle near the rat. The lever­pressing methods each rat used varied: most pressed with their paws, some pushed with their muzzles, and others held the telegraph key between their teeth and pulled down. All methods produced the same result—delivery of a pellet of food that the hungry rat seized and ate. Skinner said that the rat "operated" on its environment to produce reinforcing consequences, and the type of behavior was correspondingly called operant behavior. In operant behavior, typically no stimulus was presented before an operant response that "caused" the behavior to occur (i.e., there was no conditioned stimulus). When Skinner analyzed the sequence of the rat's activities in an operant chamber, he found that after many repetitions when the rat approached the lever, depressed it, and heard the device click, which had been followed by food pellet presentation, the click sound produced by the lever press began to be rewarding without food pellet presentation. If a light were illuminated above the lever (indicating periods when food would be available), alternating with periods when the light was off (indicating lever presses would not produce food), soon the rat pressed nearly exclusively when the light was illuminated. The rat's behavior continued to be variable, changing from moment to moment even when the light was illuminated, unlike a classically conditioned reflex. Skinner called the food pellet a reinforcer and the light that signaled that operant responding would lead to reinforcer presentation a discriminative stimulus. Skinner spelled out in surprisingly accurate detail laws of operant conditioning that have stood the test of time. Immediacy, magnitude, and intermittence of reinforcement affected the pattern of behavior maintained and also determined the persistence of behavior in the absence of reinforcement. Skinner also observed that a stimulus repeatedly paired with food presentation (e.g., the "click" sound of the food pellet dispenser) came to serve as a reinforcer in its own right and would maintain considerable amounts of behavior over extended periods of time in the absence of primary reinforcement. Such previously neutral stimuli that took on reinforcing properties because of their pairing with primary reinforcers were called conditioned reinforcers or secondary reinforcers. Skinner recognized that, in most developed parts of the world, relatively limited aspects of human conduct seem to be directed toward seeking food or shelter. Instead, most human conduct seems to be governed by parent or teacher approval, threat of loss of affection, or symbols of recognition from employers or peers (e.g., paychecks, awards). Skinner reasoned that these reinforcers had developed their reinforcing properties (usually very early in an individual's life) from their repeated pairing with primary reinforcers. In short, they were powerful conditioned reinforcers. This observation led later educators, drug abuse counselors, psychologists, and psychiatrists working in applied settings to develop treatment methods based on conditioned reinforcers such as social approval or concrete objects paired with other reinforcers (e.g., check marks, stars, tokens, money). Applications to Clinical Treatment The practical utility of the operant apparatus and measurement approach was adopted quickly in experimental psychology, physiology, neurochemistry, pharmacology, and toxicology laboratories throughout the world. The methodology provided the springboard for the field of behavioral pharmacology, the study of subcortical self­stimulation, animal models of addictive behavior, and the study of psychophysics and complex human social behavior in enclosed experimental spaces. Skinner's pragmatic theory struck a popular chord with many young psychologists, special educators, and practitioners in training. In 1948, Sidney Bijou began an applied research program and experimental nursery school for children with intellectual disability at the Rainier School in Washington, applying operant principles. Bijou was joined by Donald Baer, a recent graduate of the University of Chicago, and they conducted seminal research on early child operant behavior. In 1953, Ogden Lindsley and Skinner began applying operant methods to study the behavior of patients with schizophrenia at Metropolitan State Hospital in Waltham, Massachusetts. Several major events brought the emerging field of behavior modification to the attention of psychiatry. First, Teodoro Ayllon and Nathan Azrin were granted limited funds in 1961 for an experimental program to motivate and improve the functioning of a group of severely mentally ill, mostly schizophrenic, women who were institutionalized in Illinois. The program used a token reinforcement system originally developed by Roger Kelleher, who had studied the behavior of chimpanzees in laboratory settings. Tokens resembling poker chips were given to patients immediately after they completed agreed­upon therapeutic activities. Later the tokens could be exchanged for supplementary preferred activities or commodities. The changes in patient behavior were often dramatic and included markedly increased participation in therapeutic programs such as those aimed at employment, bathing, self­care, and related daily living skills. Leonard Ullman headed a similar treatment unit in Palo Alto, California. Both programs operated on the principle that chronically mentally ill patients, primarily those with schizophrenia, had been largely unresponsive to conventional psychological therapeutic methods. Although older neuroleptic medications managed many of the florid symptoms of schizophrenia, they did little to increase the patients' general adjustment and often produced problematic side effects. These programs demonstrated that it was possible to use laboratory­based management methods to motivate patients with chronic schizophrenia, increasing their participation in hospital therapeutic programs and decreasing the amount of disturbed behavior. Although no Downloaded 2025­2­16 5:15 P Your IP is one claimed Chapter these methods 10: Behavioral andchanged the underlyingInterventions, Cognitive–Behavioral disorder, theyTravis were very effectiveSteven Thompson; tools for D.improving Hollon patient compliance and management. Page 5 / 12 ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility A less frequently cited but still important study conducted during this era was Gordon Paul and coworkers' comparison of the effectiveness of a social learning theory approach to that of a more traditional milieu therapy approach to managing the behavior of patients with chronic mental illnesses in  Barry Leonard Ullman headed a similar treatment unit in Palo Alto, California. Both programs operated on the principle that chronically University mentally Library ill patients, primarily those with schizophrenia, had been largely unresponsive to conventional psychological therapeutic methods. Although older neuroleptic Access Provided by: medications managed many of the florid symptoms of schizophrenia, they did little to increase the patients' general adjustment and often produced problematic side effects. These programs demonstrated that it was possible to use laboratory­based management methods to motivate patients with chronic schizophrenia, increasing their participation in hospital therapeutic programs and decreasing the amount of disturbed behavior. Although no one claimed these methods changed the underlying disorder, they were very effective tools for improving patient compliance and management. A less frequently cited but still important study conducted during this era was Gordon Paul and coworkers' comparison of the effectiveness of a social learning theory approach to that of a more traditional milieu therapy approach to managing the behavior of patients with chronic mental illnesses in an institutional setting. It is the single best study of its kind, demonstrating persuasively the effectiveness of a behavior therapy strategy for activating socially resistant patients who have schizophrenia. It also carefully documented reductions in schizophrenic disorganization and cognitive distortion; improvements in normal speech and social interactions; reductions in social isolation; and greatly reduced aggressive, assaultive, and other intolerable behavior. The second major event was the demonstration in 1963 by Ivar Lovaas, a clinical psychologist working at UCLA, that positive reinforcement methods could be used to teach children with autism a variety of skills. Until that time, there were no known effective treatments for autism. Lovaas worked with children who were mute and with echolalic children who had autism (labeled "schizophrenic children" at that time). These children were severely intellectually disabled, were self­injurious, displayed severe tantrums, and were extremely noncompliant. Lovaas used a combination of hugs and praise, edible reinforcers, and highly controversial aversive stimulation techniques to reduce self­destructive behavior. In 1987, Lovaas published a report in which he used an intensive behavioral treatment regimen (40 hours per week of one­to­one contact), targeting language and social skills. He reported that 47% of the experimental group (9 of 19 children) functioned similar to typical peers after 2–3 years of treatment, compared with 2% of the control group. In 1993, he published a follow­up on those children at age 12 and found that of the 9 children with best outcomes, 8 continued to function in the normal range. Lovaas was the first researcher to document such marked improvement in such a large proportion of treated children with autism; however, other interventions using similar methods of behavior analysis appear to produce similar results. The third major event that paved the way for modern behavior therapy methods was the work of Gerald Patterson and colleagues in developing a coercion model of the relationships between families and their children with conduct disorder. In the early and mid­1960s, Patterson began working with children of normal intelligence who displayed a wide array of predelinquent behavior. Some of the children displayed characteristics of attention­ deficit/hyperactivity disorder (ADHD), others seemed to have learning disabilities, and others were aggressive and noncompliant at home and school but exhibited no indications of other psychiatric or cognitive disability. On the basis of a series of laboratory and clinical studies, Patterson and his colleagues proposed that children who had conduct disorder and their families gradually learn a set of mutually coercive relationships based on interpersonal aversive stimulation and avoidance. On the basis of this model, he developed a behavioral treatment method drawing on basic operant methods (i.e., positive social and tangible reinforcement and loss of reinforcement resulting from behavior problems, both of which were based on unambiguous and consistent contingencies). He combined these techniques with what would later be called cognitive–behavioral therapy methods (i.e., the use of verbal self­instruction to mediate behavior change). Finally, in the late 1960s and early 1970s several large­scale programs were developed that applied operant behavioral principles in residential services for people with intellectual disability. These early institution­based programs paved the way for subsequent community­based service and treatment programs for people with intellectual disability, especially those with significant behavior problems. Cooper JO, Heron TE, Heward WL: Applied Behavior Analysis , 2nd edn. New York: Prentice Hall, 2006. Lord C, McGee J (eds): Educating Children with Autism. Washington DC: Commission on Behavioral and Social Sciences and Education of the National Academy of Sciences, 2001. Patterson GR, Gullion ME: Living with Children: New Methods for Parents and Teachers. Champaign, IL: Research Press, 1968. Skinner BF: Science and Human Behavior. New York: Macmillan, 1953. COGNITIVE & COGNITIVE–BEHAVIORAL INTERVENTIONS One of the major changes in behavioral approaches in the past several decades has been the emergence of the cognitive and cognitive–behavioral intervention. Based largely on social learning theory, these approaches posit that organisms are not just the passive recipients of stimuli that impinge on them but instead interpret and try to make sense out of their worlds. These approaches do not reject traditional classical and operant perspectives on learning; rather, they suggest that cognitive mediation plays a role in coloring the way those processes work in humans and other higher Downloaded 2025­2­16 5:15 P Your IP is vertebrates. Chapter 10: Behavioral and Cognitive–Behavioral Interventions, Travis Thompson; Steven D. Hollon Page 6 / 12 ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Roots of Cognitive Therapy COGNITIVE & COGNITIVE–BEHAVIORAL INTERVENTIONS Barry University Library One of the major changes in behavioral approaches in the past several decades has been the emergence of the cognitive and cognitive–behavioral Access Provided by: intervention. Based largely on social learning theory, these approaches posit that organisms are not just the passive recipients of stimuli that impinge on them but instead interpret and try to make sense out of their worlds. These approaches do not reject traditional classical and operant perspectives on learning; rather, they suggest that cognitive mediation plays a role in coloring the way those processes work in humans and other higher vertebrates. Roots of Cognitive Therapy The roots of cognitive therapy can be found in the early writings of the Stoic philosophers Epictetus and Marcus Aurelius, and in the later works by Benjamin Rush and Henry Maudsley, among others. It was Epictetus who wrote, in the first century AD, "People are disturbed not by things, but the view which they take of them." Benjamin Rush, the father of American psychiatry, wrote in 1786 that by exercising the rational mind through practice, one gained control over otherwise unmanageable passions that he believed led to some forms of madness. A century later, Henry Maudsley reiterated the notion that it was the loss of power over the coordination of ideas and feelings that led to madness and that the wise development of control over thoughts and feelings could have a powerful effect. In modern times, Alfred Adler's approach to dynamic psychotherapy was cognitive in nature, stressing the role of perceptions of the self and the world in determining how people went about the process of pursuing their goals in life. George Kelly is often accorded a central role in laying out the basic tenets of the approach, and Albert Bandura's influential treatise on learning theory provided a theoretical basis for incorporating observational learning in the learning process. Modern Approaches Modern cognitive and cognitive–behavioral approaches to psychotherapy got their impetus from two converging lines of development. One branch was developed by theorists originally trained in dynamic psychotherapy. Theorists such as Albert Ellis, the founder of rational–emotive therapy, and Aaron Beck, the founder of cognitive therapy, began their careers adhering to dynamic principles in theory and therapy. They became disillusioned with that approach and came, over time, to focus on their patients' conscious beliefs. Both subscribe to an ABC model, which states that it is not just what happens to someone at point A (the antecedent events) that determines how the person feels and what he or she does at point C (the affective and behavioral consequences), but that it also matters how the person interprets those events at point B (the person's beliefs). For example, a man who loses a relationship and is convinced that he was left because he is unlovable is more likely to feel depressed and fail to pursue further relationships than one who considers his loss a consequence of bad luck or the product of mistakes that he will not repeat the next time around. Both theorists work with patients to actively examine their beliefs to be sure that they are not making situations worse than they necessarily are. Ellis typically adopts a more philosophical approach based on reason and persuasion, whereas Beck operates more like a scientist, treating his patients' beliefs as hypotheses that can be tested and encouraging his patients to use their own behavior to test the accuracy of their beliefs. The other major branch of cognitive–behaviorism involves theorists originally trained as behavior therapists who became increasingly interested in the role of thinking in the learning process. Bandura and Michael Mahoney represent two exemplars of this tradition, as do other theorists such as Donald Meichenbaum and G. Terence Wilson. These theorists tend to stay closer to the language and tenets of traditional behavior analysis and are somewhat less likely to talk about the role of meaning in their patients' responses to events. They are also as likely to focus on the absence of cognitive mediators (i.e., covert self­statements) as on the presence of distortions. For example, Meichenbaum developed an influential approach to treatment, called self­instructional training, in which patients with impulse­control problems are trained to modulate their own behavior via the process of verbal self­regulation. These approaches focus on the role of information processing in determining subsequent affect and behavior. Beck, for example, has argued that distinctive errors in thinking can be found in each of the major types of psychopathology. For example, depression typically involves negative views of the self and the future; anxiety, an overdetermined sense of physical or psychological danger; eating disorders, an undue concern with shape and weight; and obsessions, an overbearing sense of responsibility for ensuring the safety of oneself and others. Efforts to produce change involve having the patient first monitor fluctuations in mood and relate those changes to the ongoing flow of automatic thoughts, subsequently using one's own behavior to test the accuracy of these beliefs. For example, a depressed patient who believes that he or she is incompetent will be asked to provide an example of something he or she should be able to do but cannot. The patient is then invited to list the steps that anyone else would have to do to carry out the task. The patient is then encouraged to carry out those steps just to determine whether he or she is as incompetent as he or she believes (typically, the patient is not). Similarly, patients with panic disorder often misinterpret innocuous bodily sensations as signs of impending physical or psychological catastrophe, such as having a heart attack or "going crazy." The therapist provides a rationale that stresses the role of thinking in symptom formation and encourages the patient to test his or her belief in the imminence of the impending catastrophe by inducing a panic attack right in the office. As the patient experiences extreme states of arousal and panic with no subsequent consequences (i.e., neither dying nor "going crazy"), he or she comes to recognize that the initial arousal is not a harbinger of impending doom (as first believed), and the patient no longer begins to panic at the occurrence Downloaded 2025­2­16 5:15 P Your IP is of arousal. Chapter 10:InBehavioral essence, like andthe behavioral approaches Cognitive–Behavioral based on classical Interventions, conditioning, Travis Thompson; modern Steven D. cognitive Hollon and cognitive–behavioral interventions Page 7 / 12 emphasize ©2025 the curative McGraw Hill. Allprocess of exposing oneself Rights Reserved. Terms oftoUse the things onePolicy Privacy most fears as a way Notice of dealing with irrational or unrealistic concerns. Accessibility These approaches are well established in the treatment of unipolar depression, panic disorder, social phobia, generalized anxiety disorder, and  Barry University Similarly, patients with panic disorder often misinterpret innocuous bodily sensations as signs of impending physical or psychological Library catastrophe, such as having a heart attack or "going crazy." The therapist provides a rationale that stresses the role of thinking in symptom formation and Access Provided by: encourages the patient to test his or her belief in the imminence of the impending catastrophe by inducing a panic attack right in the office. As the patient experiences extreme states of arousal and panic with no subsequent consequences (i.e., neither dying nor "going crazy"), he or she comes to recognize that the initial arousal is not a harbinger of impending doom (as first believed), and the patient no longer begins to panic at the occurrence of arousal. In essence, like the behavioral approaches based on classical conditioning, modern cognitive and cognitive–behavioral interventions emphasize the curative process of exposing oneself to the things one most fears as a way of dealing with irrational or unrealistic concerns. These approaches are well established in the treatment of unipolar depression, panic disorder, social phobia, generalized anxiety disorder, and bulimia. For these disorders, cognitive and cognitive–behavioral interventions appear to be at least as effective as other competing alternatives (including medications) and quite possibly more enduring. There are consistent indications that cognitive–behavioral therapy produces long­lasting change that reduces the likelihood that symptoms will return after treatment ends. The evidence is mixed with respect to substance abuse, marital distress, and childhood conduct disorder, although at least some indications are promising. Cognitive and cognitive–behavioral interventions are typically not thought to be particularly effective in patients who have formal thought disorder, although recent studies suggest that such interventions may reduce delusional thinking in psychotic patients who receive neuroleptic drugs. Beck AT: Cognitive Therapy and the Emotional Disorders. Madison, CT: International Universities Press, 1976. Ellis A: Reason and Emotion in Psychotherapy. New York: Lyle Stuart, 1962. Hollon SD, Beck AT: Cognitive and cognitive behavioral therapies. In: Lambert MJ (ed). Garfield and Bergin's Handbook of Psychotherapy and Behavior Change: An Empirical Analysis , 5th edn. New York: Wiley, 2004, pp. 447–492. Meichenbaum D: Cognitive­Behavior Modification: An Integrative Approach. New York: Plenum, 1977. O'Donohue WO, Fisher JE, Hayes SC: Cognitive Behavior Therapy: Applying Empirically Supported Techniques in Your Practice. New York: Wiley, 2003. FUNDAMENTAL ASSUMPTIONS OF THERAPIES BASED ON LEARNING THEORY Several basic assumptions are common to most learning­based interventions. Perhaps most fundamental is that the behavior of the individual who has been referred for psychiatric treatment is of concern in its own right. Behavior is not necessarily an indication of pathology at some other level of analysis (e.g., brain chemical or psychic). Pathologic behavior is often seen as the result of the demands of the environment in which the person is living, working, or going to school (or, in the case of the cognitive approaches, the person's perception of the environment). What appears to be pathologic may be a person's best adaptation to an impossible situation given the person's cognitive or personality limitations (e.g., living with alcoholic parents, residing in an abusive institutional or community residential setting, interacting with people who do not use the same communication system). Although major mental illnesses have neurochemical substrates, much of the pathologic behavior observed by psychiatrists has been learned in much the same way that normal behavior is learned. Pathologic behavior generally follows the same scientific laws as normal behavior. Vulnerability to learning pathologic behavior is shaped by the biological substrate of inherited traits and neurochemical predispositions upon which the collective history of experiences is imposed. Individual differences in normal and pathologic behavior are attributable to dispositions created by variations in genetic makeup or differences in histories that predispose an individual to differences in motivation. Some people, by virtue of their genetic and associated neurochemical makeup, are prone to respond to mild, negative comments by other people as though such comments were aversive and to be avoided at all costs. Others, with different genetic makeup and correspondingly different neurochemical predisposition, may be largely impervious to similar negative reinforcers and cues. The former individuals are prone to develop avoidant behavior and extreme anxiety, whereas the latter individuals tend to be insensitive to aversive social situations. In the early days of behavior modification and behavior therapy treatments, targets of treatment were often circumscribed responses (e.g., nail­biting, failing in school, encopresis). Since then, researchers have recognized that narrowly defined instances of pathologic behavior (i.e., presenting symptoms) are usually members of larger classes of problematic responses. The treatment task is not to treat the isolated behavior (e.g., arguing with parents or making self­deprecating remarks) but rather to identify the factors that determine the likelihood that any one of an entire class of responses may occur. Such factors could include, for example, the child having no legitimate mechanism for determining what is going on in his or her life, combined with parental submission to unpleasant, coercive responses. Failure to assess properly the full breadth of the members composing a Downloaded 2025­2­16 functional response class5:15 P lead could YourtoIP is symptom substitution. For example, the successful reduction of arguing by a defiant teenager by implementing Chapter 10: Behavioral and Cognitive–Behavioral Interventions, Travis Thompson; Steven D. Hollon Page 8 / 12 a behavioral contract limited to arguing will, in most instances, lead to the emergence of other defiant behaviors (e.g., staying out beyond curfew, ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility experimenting with alcohol). The task is to identify a broader class of problem behavior, develop hypotheses concerning the purposes served by that class of behavior, and then develop an intervention plan that makes the entire class of behavior ineffective and unnecessary. In the early days of behavior modification and behavior therapy treatments, targets of treatment were often circumscribed responses (e.g., nail­biting, Barry failing in school, encopresis). Since then, researchers have recognized that narrowly defined instances of pathologic behavior (i.e., University Library presenting symptoms) are usually members of larger classes of problematic responses. The treatment task is not to treat the isolated behavior Access(e.g., arguing Provided by: with parents or making self­deprecating remarks) but rather to identify the factors that determine the likelihood that any one of an entire class of responses may occur. Such factors could include, for example, the child having no legitimate mechanism for determining what is going on in his or her life, combined with parental submission to unpleasant, coercive responses. Failure to assess properly the full breadth of the members composing a functional response class could lead to symptom substitution. For example, the successful reduction of arguing by a defiant teenager by implementing a behavioral contract limited to arguing will, in most instances, lead to the emergence of other defiant behaviors (e.g., staying out beyond curfew, experimenting with alcohol). The task is to identify a broader class of problem behavior, develop hypotheses concerning the purposes served by that class of behavior, and then develop an intervention plan that makes the entire class of behavior ineffective and unnecessary. Most of the causes of pathologic behavior are found in the relation between the individual, the environmental antecedents, and the consequences of his or her actions. An individual's history creates the context within which current environmental circumstances serve as either discriminative stimuli (e.g., a spouse coming home late from work) or conditioned negative reinforcers (e.g., threatened disapproval). An individual's history could also establish the motivational framework that governs most of the individual's actions. As a result, assessment usually requires obtaining information from the individual or other informants about events taking place in the individual's natural environment in order to obtain valid data concerning the circumstances surrounding the pathologic behavior. The meaning of an environmental cue or a putative motivating consequence is determined contextually. Whether a social stimulus is alarming, neutral, or positive will depend on the person's history and the circumstance in which the stimulus is being experienced. Similarly, a consequence can be positive, neutral, or negative depending on the individual's history and the circumstance in which the consequence is encountered. Thus, Thorndike's original Law of Effect has been contextualized. Whether this contextualization is conceptualized as residing in the cognitive domain or in the observable environment is a matter of some theoretical dispute, but the learning­based approaches emphasize idiosyncratic experience as the shaper of behavioral proclivities. Bandura A: Principles of Behavior Modification. Austin, TX: Holt, Rinehart & Winston, 1969. Craighead WE, Craighead LW, Ilardi SS: Behavior therapies in historical perspective. In: Bonger BM, Buetler LE (eds). Comprehensive Textbook of Psychotherapy: Theory and Practice. Oxford, UK: Oxford University Press, 1995. Kazdin AE: History of Behavior Modification: Experimental Foundations of Contemporary Research. Baltimore, MD: University Park Press, 1978. Krasner L: History of behavior modification. In: Bellack AS, Hersen M, Kazdin AE (eds): International Handbook of Behavior Modification and Therapy , 2nd edn. Springer, 1990, pp. 3–25. COMBINATIONS WITH MEDICATION Many of the disorders treated with behavioral or cognitive–behavioral therapy can also be treated pharmacologically, although some cannot. In some disorders, a combination of drugs and behavioral (or cognitive–behavioral) therapy is more effective than either alone. For example, stimulant medication and cognitive–behavioral therapy produces greater behavioral improvements than either treatment alone among many children with ADHD. Combined treatment for depression retains the rapidity and robustness of the medication response and the enduring effects of cognitive or behavioral treatment. Despite the theoretically based concerns of advocates for each approach, one modality rarely interferes with the other, although such interference sometimes occurs. For many disorders, there simply are not adequate data to guide clinical practice; we often know that both modalities are effective in their own right but do not know whether their combination enhances treatment response. Drugs and other somatic interventions appear to be essential to the treatment of the more severe disorders, particularly those that involve psychotic symptoms. Nonetheless, behavioral and cognitive–behavioral interventions can often play an important adjunctive role. Recent studies indicate that D­ cycloserine administered during exposure therapy for phobias facilitates extinction of the exaggerated fear response to the phobic stimulus. Antipsychotic medications remain the most effective means of reducing the more florid symptoms of psychosis, and the newer, atypical antipsychotics show promise in relieving the negative symptoms of schizophrenia. Rehabilitation programs based on behavioral skills training appear to help redress impairments in psychosocial functioning in such patients and may allow the use of newer low­dose neuroleptic medications (see Chapter 15). Lithium and anticonvulsants provide the most effective means of treatment of the bipolar disorders, but cognitive–behavioral therapy can enhance compliance with drug therapy (see Chapter 17). The relative importance of pharmacotherapy is less pronounced among even the more severe, nonpsychotic disorders and quite possibly is nonexistent among the less severe disorders. Cognitive therapy appears to be about as effective as pharmacotherapy for all but the most severe nonbipolar depressions and may be more enduring in its effect (see Chapter 17). Exposure­based therapies are quite helpful in reducing compulsive Downloaded rituals in OCD2025­2­16 (see Chapter 5:15 20)Pand Your IP is behavioral avoidance in severe agoraphobia (see Chapter 18). Such therapies are often combined with medication Chapter 10: Behavioral and Cognitive–Behavioral Interventions, Travis Thompson; Steven D. Hollon Page 9 / 12 to treat McGraw ©2025 these disorders. Hill. All Cognitive–behavioral Rights Reserved. Termstherapy appears of Use to bePolicy Privacy at least Notice as effective and possibly longer­lasting than pharmacotherapy in the Accessibility treatment of panic disorder and social phobia (see Chapter 18), and the same can be said with respect to the treatment of bulimia (see Chapter 25). Exposure­based treatment is clearly superior to pharmacotherapy (or any other form of psychotherapy) in the treatment of social phobia. There is little and anticonvulsants provide the most effective means of treatment of the bipolar disorders, but cognitive–behavioral therapy can enhance compliance Barry University Library with drug therapy (see Chapter 17). Access Provided by: The relative importance of pharmacotherapy is less pronounced among even the more severe, nonpsychotic disorders and quite possibly is nonexistent among the less severe disorders. Cognitive therapy appears to be about as effective as pharmacotherapy for all but the most severe nonbipolar depressions and may be more enduring in its effect (see Chapter 17). Exposure­based therapies are quite helpful in reducing compulsive rituals in OCD (see Chapter 20) and behavioral avoidance in severe agoraphobia (see Chapter 18). Such therapies are often combined with medication to treat these disorders. Cognitive–behavioral therapy appears to be at least as effective and possibly longer­lasting than pharmacotherapy in the treatment of panic disorder and social phobia (see Chapter 18), and the same can be said with respect to the treatment of bulimia (see Chapter 25). Exposure­based treatment is clearly superior to pharmacotherapy (or any other form of psychotherapy) in the treatment of social phobia. There is little evidence that drugs are particularly helpful in the treatment of the personality disorders (see Chapter 29); however, a dialectic­type behavior therapy appears to reduce the frequency of self­destructive behavior in patients with borderline personality disorder. In general, the more severe the psychopathologic disorder, the greater the relative efficacy of pharmacotherapy and the more purely behavioral the psychosocial intervention should be. Medications are often useful to control disruptive symptoms, but behavioral interventions (especially operant ones) are uniquely suited to promoting new skills or restoring those that have been lost to illness or institutionalization. Behavioral interventions based on classical conditioning are particularly helpful in reducing undesirable states of arousal and affective distress; cognitive interventions reduce the likelihood of subsequent relapse by correcting the erroneous beliefs and attitudes that contribute to recurrence. These strategies rarely interfere with one another. It is often useful to combine them in practice to achieve multiple ends. Klerman GL, Weissman MM, Makkowitz JC, et al.: Medication and psychotherapy. In: Bergin AE, Garfield SL (eds). Handbook of Psychotherapy and Behavior Change , 4th edn. Hoboken, NJ: Wiley, 1994, pp. 734–782. Panksepp J: Textbook of Biological Psychiatry. New York: Wiley­Liss, 2003. Reiff MI, Tippin S: ADHD: A Complete and Authoritative Guide. Elk Grove Village, IL: American Academy of Pediatrics, 2004. COMBINED INTERVENTIONS IN DEVELOPMENTAL DISABILITIES Behavioral interventions can be highly effective in improving the quality of life for people who have developmental disabilities and display serious behavior problems. Sometimes behavioral methods are insufficient by themselves. Psychopharmacologic treatments can control psychopathologic symptoms and behavior in some people with intellectual and related disabilities (e.g., ADHD, major depression, bipolar disorder, anxiety disorder, schizophrenia) in non–developmentally delayed individuals. In elucidating how psychotropic drugs reduce problem behavior, it is helpful to examine the behavioral as well as the neurochemical mechanisms of drug action. Behavioral mechanisms refer to psychological or behavioral processes altered by a drug. Neurochemical mechanisms refer to the receptor­level events that are causally related to those changed behavioral processes. Some psychopathologic problems are associated so frequently with specific developmental disabilities that pharmacotherapy is among the first treatments to be explored. Anxiety disorder, especially OCD, is commonly associated with autism and Prader­Willi syndrome. Anxiety disorder manifests itself as ritualistic, repetitive stereotypic motor responses (e.g., rocking or hand­flapping) and rigidly routinized activities (e.g., repeatedly lining up blocks, insisting that shoelaces be precisely the same length) that, if interrupted, provoke behavioral outbursts or tantrums. Selective serotonin reuptake inhibitors alleviate agitation, anxiety, and ritualistic behavior, such as skin­picking and self­injurious behavior. At times, aggression results from an anxiety disorder. For example, a patient with autism who has severe anxiety may strike out against others who are crowding too closely, in order to keep them at a distance. Fluvoxamine reduces anxiety and the need for increased social distance, thereby diminishing the need to strike out against others to keep them at a distance. Aggression, in this example, serves as a social avoidance response that fluvoxamine renders unnecessary. The behavioral mechanism of action is the reduction of anxiety and associated avoidance. The neurochemical mechanism is thought to be mediated by inhibition of serotonin reuptake with increased binding to the serotonin­2 receptors. An individual with autism or intellectual disability who strikes his or her head in intermittent bouts throughout the day may do so because head blows cause the release of β­endorphin, which binds to the μ­opiate receptor, thereby reinforcing self­injury. In this way, a self­addictive, vicious cycle is established and maintained and through years of repetition becomes a firmly entrenched behavioral pattern. An opiate antagonist, such as naltrexone, blocks the reinforcing effects consequent to the binding of β­endorphin to the opiate receptor. Naltrexone reduces self­injurious behavior in approximately 40% of patients, primarily in those engaging in high­frequency, intense self­injury directed at the head and hands. Evidence indicates that elevated baseline levels of plasma β­endorphin after bouts of self­injury are predictive of a therapeutic response to naltrexone. Downloaded 2025­2­16behavior, Repetitive self­injurious 5:15 P Your suchIP asishead banging and self­biting, can be treated effectively with complementary behavioral and pharmacologic Chapter 10: Behavioral and Cognitive–Behavioral Interventions, Travis Thompson; Steven D. Hollon strategies, as described in the following case example. Page 10 / 12 ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility A 13­year­old boy with autism and severe intellectual disability had no communication system at baseline. An observational functional assessment of the boy's self­injurious behavior in his natural environment (a special education classroom) indicated that approximately two thirds of this behavior cause the release of β­endorphin, which binds to the μ­opiate receptor, thereby reinforcing self­injury. In this way, a self­addictive, vicious cycle is established and maintained and through years of repetition becomes a firmly entrenched behavioral pattern. An opiate antagonist, Barrysuch as University Library naltrexone, blocks the reinforcing effects consequent to the binding of β­endorphin to the opiate receptor. Naltrexone reducesAccess self­injurious Provided by: behavior in approximately 40% of patients, primarily in those engaging in high­frequency, intense self­injury directed at the head and hands. Evidence indicates that elevated baseline levels of plasma β­endorphin after bouts of self­injury are predictive of a therapeutic response to naltrexone. Repetitive self­injurious behavior, such as head banging and self­biting, can be treated effectively with complementary behavioral and pharmacologic strategies, as described in the following case example. A 13­year­old boy with autism and severe intellectual disability had no communication system at baseline. An observational functional assessment of the boy's self­injurious behavior in his natural environment (a special education classroom) indicated that approximately two thirds of this behavior was motivated by the desire to obtain attention or to escape from situations he did not like or found disturbing. Self­injury dropped 50% from baseline during the first naltrexone treatment phase. Next the patient was taught to use pictorial icons to make requests and indicate basic needs to others around him (Figure 10–1). His self­injury dropped subsequently by another 50% (i.e., a reduction of a total of 75% from baseline) when communication treatment was initiated. On follow­up 1 year later, during which time naltrexone treatment had continued, the boy's self­injurious behavior had dropped to nearly zero. In this case, naltrexone blocked the neurochemical reinforcing consequences of self­injury, and communication training provided an appropriate behavioral alternative to indicate basic needs and wants. In short, combined treatment produced complementary, additive salutary effects. Figure 10–1 Efficacy of treatment for self­injurious behavior. Nal, naltrexone. Emerson E, Hatton C, Parmeter T, Thompson T (eds): International Handbook of Applied Research in Intellectual Disabilities. Chichester, UK: Wiley, 2004. Kelley ME, Fisher WW, Lomas JE, et al.: Some effects of stimulant medication on response allocation: A double­blind analysis. J Appl Behav Anal 2006;39:243–247. [PubMed: 16813046] Thompson T, Moore T, Symons F: Psychotherapeutic medications and positive behavior support. In: Odom S, Horner R, Snell M, Blacher J (eds). Handbook on Developmental Disabilities. New York: Guilford Press, 2007. CONCLUSION Modern behavioral and cognitive–behavioral interventions emphasize the role of learning and adaptation to the environment in shaping and maintaining normal life functions and in the emergence of maladaptive symptomatology. These interventions treat behavior as important in its own right and often seek to change instances of disordered behavior by the application of clearly articulated, basic principles of learning. There are three fundamental, interrelated perspectives: classical conditioning, which emphasizes the learning of associations between classes of stimuli; operant conditioning, which emphasizes the learning of relations between behaviors and their consequences; and the cognitive perspective, which emphasizes the role of idiosyncratic beliefs and misconceptions in coloring each of the two earlier perspectives. Learning­based approaches have sparked a major revolution in the treatment of psychiatric disorders. Each perspective can point to notable gains. Behavioral approaches can often be combined beneficially with Downloaded medication 2025­2­16 5:15and should P Your IPbe is part of the armamentarium of any well­trained clinician. Chapter 10: Behavioral and Cognitive–Behavioral Interventions, Travis Thompson; Steven D. Hollon Page 11 / 12 ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility right and often seek to change instances of disordered behavior by the application of clearly articulated, basic principles of learning. There are three Barry University Library fundamental, interrelated perspectives: classical conditioning, which emphasizes the learning of associations between classes of stimuli; operant Access Provided by: conditioning, which emphasizes the learning of relations between behaviors and their consequences; and the cognitive perspective, which emphasizes the role of idiosyncratic beliefs and misconceptions in coloring each of the two earlier perspectives. Learning­based approaches have sparked a major revolution in the treatment of psychiatric disorders. Each perspective can point to notable gains. Behavioral approaches can often be combined beneficially with medication and should be part of the armamentarium of any well­trained clinician. Downloaded 2025­2­16 5:15 P Your IP is Chapter 10: Behavioral and Cognitive–Behavioral Interventions, Travis Thompson; Steven D. Hollon Page 12 / 12 ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility