Behaviour Change – Mental Health Matters

An Overview of Cognitive Inertia

Published on 12/04/2024 by Andrew MarshallLeave a comment

Introduction

Cognitive inertia is the tendency for a particular orientation in how an individual thinks about an issue, belief, or strategy to resist change. Clinical and neuroscientific literature often defines it as a lack of motivation to generate distinct cognitive processes needed to attend to a problem or issue. The physics term inertia emphasizes the rigidity and resistance to change in the method of cognitive processing that has been used for a significant amount of time. Commonly confused with belief perseverance, cognitive inertia is the perseverance of how one interprets information, not the perseverance of the belief itself.

Cognitive inertia has been causally implicated in disregarding impending threats to one’s health or environment, enduring political values and deficits in task switching. Interest in the phenomenon was primarily taken up by economic and industrial psychologists to explain resistance to change in brand loyalty, group brainstorming, and business strategies. In the clinical setting, cognitive inertia has been used as a diagnostic tool for neurodegenerative diseases, depression, and anxiety. Critics have stated that the term oversimplifies resistant thought processes and suggests a more integrative approach that involves motivation, emotion, and developmental factors.

Brief History and Methods

Early History

The idea of cognitive inertia has its roots in philosophical epistemology. Early allusions to a reduction of cognitive inertia can be found in the Socratic dialogues written by Plato. Socrates builds his argument by using the detractor’s beliefs as the premise of his argument’s conclusions. In doing so, Socrates reveals the detractor’s fallacy of thought, inducing the detractor to change their mind or face the reality that their thought processes are contradictory. Ways to combat persistence of cognitive style are also seen in Aristotle’s syllogistic method which employs logical consistency of the premises to convince an individual of the conclusion’s validity.

At the beginning of the twentieth century, two of the earliest experimental psychologists, Müller and Pilzecker, defined perseveration of thought to be “the tendency of ideas, after once having entered consciousness, to rise freely again in consciousness”. Müller described perseveration by illustrating his own inability to inhibit old cognitive strategies with a syllable-switching task, while his wife easily switched from one strategy to the next. One of the earliest personality researchers, W. Lankes, more broadly defined perseveration as “being confined to the cognitive side” and possibly “counteracted by strong will”. These early ideas of perseveration were the precursor to how the term cognitive inertia would be used to study certain symptoms in patients with neurodegenerative disorders, rumination and depression.

Cognitive Psychology

Originally proposed by William J. McGuire in 1960, the theory of cognitive inertia was built upon emergent theories in social psychology and cognitive psychology that centred around cognitive consistency, including Fritz Heider’s balance theory and Leon Festinger’s cognitive dissonance. McGuire used the term cognitive inertia to account for an initial resistance to change how an idea was processed after new information, that conflicted with the idea, had been acquired.

In McGuire’s initial study involving cognitive inertia, participants gave their opinions of how probable they believed various topics to be. A week later, they returned to read messages related to the topics they had given their opinions on. The messages were presented as factual and were targeted to change the participants’ belief in how probable the topics were. Immediately after reading the messages, and one week later, the participants were again assessed on how probable they believed the topics to be. Discomforted by the inconsistency of the related information from the messages and their initial ratings on the topics, McGuire believed the participants would be motivated to shift their probability ratings to be more consistent with the factual messages. However, the participants’ opinions did not immediately shift toward the information presented in the messages. Instead, a shift towards consistency of thought on the information from the messages and topics grew stronger as time passed, often referred to as “seepage” of information. The lack of change was reasoned to be due to persistence in the individual’s existing thought processes which inhibited their ability to re-evaluate their initial opinion properly, or as McGuire called it, cognitive inertia.

Probabilistic Model

Although cognitive inertia was related to many of the consistency theories at the time of its conception, McGuire used a unique method of probability theory and logic to support his hypotheses on change and persistence in cognition. Utilising a syllogistic framework, McGuire proposed that if three issues (a, b and c) were so interrelated that an individual’s opinion were in complete support of issues a and b then it would follow their opinion on issue c would be supported as a logical conclusion. Furthermore, McGuire proposed if an individual’s belief in the probability (p) of the supporting issues (a or b) was changed, then not only would the issue (c) explicitly stated change, but a related implicit issue (d) could be changed as well.

This formula was used by McGuire to show that the effect of a persuasive message on a related, but unmentioned, topic (d) took time to sink in. The assumption was that topic d was predicated on issues a and b, similar to issue c, so if the individual agreed with issue c then so too should they agree with issue d. However, in McGuire’s initial study immediate measurement on issue d, after agreement on issues a, b and c, had only shifted half the amount that would be expected to be logically consistent. Follow-up a week later showed that shift in opinion on issue d had shifted enough to be logically consistent with issues a, b, and c, which not only supported the theory of cognitive consistency, but also the initial hurdle of cognitive inertia.

The model was based on probability to account for the idea that individuals do not necessarily assume every issue is 100% likely to happen, but instead there is a likelihood of an issue occurring and the individual’s opinion on that likelihood will rest on the likelihood of other interrelated issues.

Examples

Public Health

Historical

Group (cognitive) inertia, how a subset of individuals view and process an issue, can have detrimental effects on how emergent and existing issues are handled. In an effort to describe the almost lackadaisical attitude from a large majority of US citizens toward the insurgence of the Spanish flu in 1918, historian Tom Dicke has proposed that cognitive inertia explains why many individuals did not take the flu seriously. At the time, most US citizens were familiar with the seasonal flu. They viewed it as an irritation that was often easy to treat, infected few, and passed quickly with few complications and hardly ever a death. However, this way of thinking about the flu was detrimental to the need for preparation, prevention, and treatment of the Spanish flu due to its quick spread and virulent form until it was much too late, and it became one of the most deadly pandemics in history.

Contemporary

In the more modern period, there is an emerging position that anthropogenic climate change denial is a kind of cognitive inertia. Despite the evidence provided by scientific discovery, there are still those – including nations – who deny its incidence in favour of existing patterns of development.

Geography

To better understand how individuals store and integrate new knowledge with existing knowledge, Friedman and Brown tested participants on where they believed countries and cities to be located latitudinally and then, after giving them the correct information, tested them again on different cities and countries. The majority of participants were able to use the correct information to update their cognitive understanding of geographical locations and place the new locations closer to their correct latitudinal location, which supported the idea that new knowledge affects not only the direct information but also related information. However, there was a small effect of cognitive inertia as some areas were unaffected by the correct information, which the researchers suggested was due to a lack of knowledge linkage in the correct information and new locations presented.

Group Membership

Politics

The persistence of political group membership and ideology is suggested to be due to the inertia of how the individual has perceived the grouping of ideas over time. The individual may accept that something counter to their perspective is true, but it may not be enough to tip the balance of how they process the entirety of the subject.

Governmental organisations can often be resistant or glacially slow to change along with social and technological transformation. Even when evidence of malfunction is clear, institutional inertia can persist. Political scientist Francis Fukuyama has asserted that humans imbue intrinsic value on the rules they enact and follow, especially in the larger societal institutions that create order and stability. Despite rapid social change and increasing institutional problems, the value placed on an institution and its rules can mask how well an institution is functioning as well as how that institution could be improved. The inability to change an institutional mindset is supported by the theory of punctuated equilibrium, long periods of deleterious governmental policies punctuated by moments of civil unrest. After decades of economic decline, the United Kingdom’s referendum to leave the EU was seen as an example of the dramatic movement after a long period of governmental inertia.

Interpersonal Roles

The unwavering views of the roles people play in our lives have been suggested as a form of cognitive inertia. When asked how they would feel about a classmate marrying their mother or father, many students said they could not view their classmate as a step-father/mother. Some students went so far as to say that the hypothetical relationship felt like incest.

Role inertia has also been implicated in marriage and the likelihood of divorce. Research on couples who cohabit together before marriage shows they are more likely to get divorced than those who do not. The effect is most seen in a subset of couples who cohabit without first being transparent about future expectations of marriage. Over time, cognitive role inertia takes over, and the couple marries without fully processing the decision, often with one or both of the partners not fully committed to the idea. The lack of deliberative processing of existing problems and levels of commitment in the relationship can lead to increased stress, arguments, dissatisfaction, and divorce.

In Business

Cognitive inertia is regularly referenced in business and management to refer to consumers’ continued use of products, a lack of novel ideas in group brainstorming sessions, and lack of change in competitive strategies.

Brand Loyalty

Gaining and retaining new customers is essential to whether a business succeeds early on. To assess a service, product, or likelihood of customer retention, many companies will invite their customers to complete satisfaction surveys immediately after purchasing a product or service. However, unless the satisfaction survey is completed immediately after the point of purchase, the customer response is often based on an existing mindset about the company, not the actual quality of experience. Unless the product or service is extremely negative or positive, cognitive inertia related to how the customer feels about the company will not be inhibited, even when the product or service is substandard. These satisfaction surveys can lack the information businesses need to improve a service or product that will allow them to survive against the competition.

Brainstorming

Cognitive inertia plays a role in why a lack of ideas is generated during group brainstorming sessions. Individuals in a group will often follow an idea trajectory, in which they continue to narrow in on ideas based on the very first idea proposed in the brainstorming session. This idea trajectory inhibits the creation of new ideas central to the group’s initial formation.

In an effort to combat cognitive inertia in group brainstorming, researchers had business students either use a single-dialogue or multiple-dialogue approach to brainstorming. In the single dialogue version, the business students all listed their ideas. They created a dialogue around the list, whereas, in the multi-dialogue version, ideas were placed in subgroups that individuals could choose to enter and talk about and then freely move to another subgroup. The multi-dialogue approach was able to combat cognitive inertia by allowing different ideas to be generated in sub-groups simultaneously and each time an individual switched to a different sub-group, they had to change how they were processing the ideas, which led to more novel and high-quality ideas.

Competitive Strategies

Adapting cognitive strategies to changing business climates is often integral to whether or not a business succeeds or fails during economic stress. In the late 1980s in the UK, real estate agents’ cognitive competitive strategies did not shift with signs of an increasingly depressed real estate market, despite their ability to acknowledge the signs of decline. This cognitive inertia at the individual and corporate level has been proposed as reasons to why companies do not adopt new strategies to combat the ever-increasing decline in the business or take advantage of the potential. General Mills’ continued operation of mills long after they were no longer necessary is an example of when companies refuse to change the mindset of how they should operate.

More famously, cognitive inertia in upper management at Polaroid was proposed as one of the main contributing factors to the company’s outdated competitive strategy. Management strongly held that consumers wanted high-quality physical copies of their photos, where the company would make their money. Despite Polaroid’s extensive research and development into the digital market, their inability to refocus their strategy to hardware sales instead of film eventually led to their collapse.

Scenario planning has been one suggestion to combat cognitive inertia when making strategic decisions to improve business. Individuals develop different strategies and outline how the scenario could play out, considering different ways it could go. Scenario planning allows for diverse ideas to be heard and the breadth of each scenario, which can help combat relying on existing methods and thinking alternatives is unrealistic.

Management

In a recent review of company archetypes that lead to corporate failure, Habersang, Küberling, Reihlen, and Seckler defined “the laggard” as one who rests on the laurels of the company, believing past success and recognition will shield them from failure. Instead of adapting to changes in the market, “the laggard” assumes that the same strategies that won the company success in the past will do the same in the future. This lag in changing how they think about the company can lead to rigidity in company identity, like Polaroid, conflict in adapting when the sales plummet, and resource rigidity. In the case of Kodak, instead of reallocating money to a new product or service strategy, they cut production costs and imitation of competitors, both leading to poorer quality products and eventually bankruptcy.

A review of 27 firms integrating the use of big data analytics found cognitive inertia to hamper the widespread implementation, with managers from sectors that did not focus on digital technology seeing the change as unnecessary and cost prohibitive.

Managers with high cognitive flexibility that can change the type of cognitive processing based on the situation at hand are often the most successful in solving novel problems and keeping up with changing circumstances. Interestingly, shifts in mental models (disrupting cognitive inertia) during a company crisis are frequently at the lower group level, with leaders coming to a consensus with the rest of the workforce in how to process and deal with the crisis, instead of vice versa. It is proposed that leaders can be blinded by their authority and too easily disregard those at the front-line of the problem causing them to reject remunerative ideas.

Applications

Therapy

An inability to change how one thinks about a situation has been implicated as one of the causes of depression. Rumination, or the perseverance of negative thoughts, is often correlated with the severity of depression and anxiety. Individuals with high levels of rumination test low on scales of cognitive flexibility and have trouble shifting how they think about a problem or issue even when presented with facts that counter their thinking process.

In a review paper that outlined strategies that are effective for combating depression, the Socratic method was suggested to overcome cognitive inertia. By presenting the patient’s incoherent beliefs close together and evaluating with the patient their thought processes behind those beliefs, the therapist is able to help them understand things from a different perspective.

Clinical Diagnostics

In nosological literature relating to the symptom or disorder of apathy, clinicians have used cognitive inertia as one of the three main criteria for diagnosis. The description of cognitive inertia differs from its use in cognitive and industrial psychology in that lack of motivation plays a key role. As a clinical diagnostic criterion, Thant and Yager described it as “impaired abilities to elaborate and sustain goals and plans of actions, to shift mental sets, and to use working memory”. This definition of apathy is frequently applied to onset of apathy due to neurodegenerative disorders such as Alzheimer’s and Parkinson’s disease but has also been applied to individuals who have gone through extreme trauma or abuse.

Neural Anatomy and Correlates

Cortical

Cognitive inertia has been linked to decreased use of executive function, primarily in the prefrontal cortex, which aids in the flexibility of cognitive processes when switching tasks. Delayed response on the implicit associations task (IAT) and Stroop task have been related to an inability to combat cognitive inertia, as participants struggle to switch from one cognitive rule to the next to get the questions right.

Before taking part in an electronic brainstorming session, participants were primed with pictures that motivated achievement to combat cognitive inertia. In the achievement-primed condition, subjects were able to produce more novel, high-quality ideas. They used more right frontal cortical areas related to decision-making and creativity.

Cognitive inertia is a critical dimension of clinical apathy, described as a lack of motivation to elaborate plans for goal-directed behaviour or automated processing. Parkinson’s patients whose apathy was measured using the cognitive inertia dimension showed less executive function control than Parkinson’s patients without apathy, possibly suggesting more damage to the frontal cortex. Additionally, more damage to the basal ganglia in Parkinson’s, Huntington’s and other neurodegenerative disorders have been found with patients exhibiting cognitive inertia in relation to apathy when compared to those who do not exhibit apathy. Patients with lesions to the dorsolateral prefrontal cortex have shown reduced motivation to change cognitive strategies and how they view situations, similar to individuals who experience apathy and cognitive inertia after severe or long-term trauma.

Functional Connectivity

Nursing home patients who have dementia have been found to have larger reductions in functional brain connectivity, primarily in the corpus callosum, important for communication between hemispheres. Cognitive inertia in neurodegenerative patients has also been associated with a decrease in the connection of the dorsolateral prefrontal cortex and posterior parietal area with subcortical areas, including the anterior cingulate cortex and basal ganglia. Both findings are suggested to decrease motivation to change one’s thought processes or create new goal-directed behaviour.

Alternative Theories

Some researchers have refuted the cognitive perspective of cognitive inertia and suggest a more holistic approach that considers the motivations, emotions, and attitudes that fortify the existing frame of reference.

Alternative Paradigms

Motivated Reasoning

The theory of motivated reasoning is proposed to be driven by the individual’s motivation to think a certain way, often to avoid thinking negatively about oneself. The individual’s own cognitive and emotional biases are commonly used to justify a thought, belief, or behaviour. Unlike cognitive inertia, where an individual’s orientation in processing information remains unchanged either due to new information not being fully absorbed or being blocked by a cognitive bias, motivated reasoning may change the orientation or keep it the same depending on whether that orientation benefits the individual.

In an extensive online study, participant opinions were acquired after two readings about various political issues to assess the role of cognitive inertia. The participants gave their opinions after the first reading and were then assigned a second reading with new information; after being assigned to read more information on the issue that either confirmed or disconfirmed their initial opinion, the majority of participants’ opinions did not change. When asked about the information in the second reading, those who did not change their opinion evaluated the information that supported their initial opinion as stronger than information that disconfirmed their initial opinion. The persistence in how the participants viewed the incoming information was based on their motivation to be correct in their initial opinion, not the persistence of an existing cognitive perspective.

Socio-Cognitive Inflexibility

From a social psychology perspective, individuals continually shape beliefs and attitudes about the world based on interaction with others. What information the individual attends to is based on prior experience and knowledge of the world. Cognitive inertia is seen not just as a malfunction in updating how information is being processed but as the assumptions about the world and how it works can impede cognitive flexibility. The persistence of the idea of the nuclear family has been proposed as a socio-cognitive inertia. Despite the changing trends in family structure, including multi-generational, single-parent, blended, and same-sex parent families, the normative idea of a family has centred around the mid-twentieth century idea of a nuclear family (i.e. mother, father, and children). Various social influences are proposed to maintain the inertia of this viewpoint, including media portrayals, the persistence of working-class gender roles, unchanged domestic roles despite working mothers, and familial pressure to conform.

The phenomenon of cognitive inertia in brainstorming groups has been argued to be due to other psychological effects such as fear of disagreeing with an authority figure in the group, fear of new ideas being rejected and the majority of speech being attributed to the minority group members. Internet-based brainstorming groups have been found to produce more ideas of high-quality because it overcomes the problem of speaking up and fear of idea rejection.

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An Overview of the Transtheoretical Model

Published on 08/26/2024 by Andrew MarshallLeave a comment

Introduction

The transtheoretical model of behaviour change is an integrative theory of therapy that assesses an individual’s readiness to act on a new healthier behaviour, and provides strategies, or processes of change to guide the individual. The model is composed of constructs such as: stages of change, processes of change, levels of change, self-efficacy, and decisional balance.

The transtheoretical model is also known by the abbreviation “TTM” and sometimes by the term “stages of change”, although this latter term is a synecdoche since the stages of change are only one part of the model along with processes of change, levels of change, etc. Several self-help books—Changing for Good (1994), Changeology (2012), and Changing to Thrive (2016) – and articles in the news media have discussed the model. In 2009, an article in the British Journal of Health Psychology called it “arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted exceptional criticism”.

Brief History and Core Constructs

James O. Prochaska of the University of Rhode Island, and Carlo Di Clemente and colleagues developed the transtheoretical model beginning in 1977. It is based on analysis and use of different theories of psychotherapy, hence the name “transtheoretical”. Prochaska and colleagues refined the model on the basis of research that they published in peer-reviewed journals and books.

Stages of Change

This construct refers to the temporal dimension of behavioural change. In the transtheoretical model, change is a “process involving progress through a series of stages”:

Precontemplation (“not ready”) – “People are not intending to take action in the foreseeable future, and can be unaware that their behaviour is problematic”.
Contemplation (“getting ready”) – “People are beginning to recognize that their behaviour is problematic, and start to look at the pros and cons of their continued actions”.
Preparation (“ready”) – “People are intending to take action in the immediate future, and may begin taking small steps toward behaviour change”.
Action – “People have made specific overt modifications in modifying their problem behaviour or in acquiring new healthy behaviours”.
Maintenance – “People have been able to sustain action for at least six months and are working to prevent relapse”.
Termination – “Individuals have zero temptation and they are sure they will not return to their old unhealthy habit as a way of coping”.

In addition, the researchers conceptualised “Relapse” (recycling) which is not a stage in itself but rather the “return from Action or Maintenance to an earlier stage”.

The quantitative definition of the stages of change (see below) is perhaps the most well-known feature of the model. However it is also one of the most critiqued, even in the field of smoking cessation, where it was originally formulated. It has been said that such quantitative definition (i.e. a person is in preparation if he intends to change within a month) does not reflect the nature of behaviour change, that it does not have better predictive power than simpler questions (i.e. “do you have plans to change…”), and that it has problems regarding its classification reliability.

Communication theorist and sociologist Everett Rogers suggested that the stages of change are analogues of the stages of the innovation adoption process in Rogers’ theory of diffusion of innovations.

Details of Each Stage

Stage	Precontemplation	Contempplation	Preparation	Action	Maintenance	Relapse
Standard Time	More than 6 months	In the next 6 months	In the next month	Now	At least 6 months	Any time

Stage 1: Precontemplation (Not Ready)

People at this stage do not intend to start the healthy behaviour in the near future (within 6 months), and may be unaware of the need to change. People here learn more about healthy behaviour: they are encouraged to think about the pros of changing their behaviour and to feel emotions about the effects of their negative behaviour on others.

Precontemplators typically underestimate the pros of changing, overestimate the cons, and often are not aware of making such mistakes.

One of the most effective steps that others can help with at this stage is to encourage them to become more mindful of their decision making and more conscious of the multiple benefits of changing an unhealthy behaviour.

Stage 2: Contemplation (Getting Ready)

At this stage, participants are intending to start the healthy behaviour within the next 6 months. While they are usually now more aware of the pros of changing, their cons are about equal to their Pros. This ambivalence about changing can cause them to keep putting off taking action.

People here learn about the kind of person they could be if they changed their behaviour and learn more from people who behave in healthy ways.

Others can influence and help effectively at this stage by encouraging them to work at reducing the cons of changing their behaviour.

Stage 3: Preparation (Ready)

People at this stage are ready to start taking action within the next 30 days. They take small steps that they believe can help them make the healthy behaviour a part of their lives. For example, they tell their friends and family that they want to change their behaviour.

People in this stage should be encouraged to seek support from friends they trust, tell people about their plan to change the way they act, and think about how they would feel if they behaved in a healthier way. Their number one concern is: when they act, will they fail? They learn that the better prepared they are, the more likely they are to keep progressing.

Stage 4: Action (Current Action)

People at this stage have changed their behaviour within the last 6 months and need to work hard to keep moving ahead. These participants need to learn how to strengthen their commitments to change and to fight urges to slip back.

People in this stage progress by being taught techniques for keeping up their commitments such as substituting activities related to the unhealthy behaviour with positive ones, rewarding themselves for taking steps toward changing, and avoiding people and situations that tempt them to behave in unhealthy ways.

Stage 5: Maintenance (Monitoring)

People at this stage changed their behaviour more than 6 months ago. It is important for people in this stage to be aware of situations that may tempt them to slip back into doing the unhealthy behaviour—particularly stressful situations.

It is recommended that people in this stage seek support from and talk with people whom they trust, spend time with people who behave in healthy ways, and remember to engage in healthy activities (such as exercise and deep relaxation) to cope with stress instead of relying on unhealthy behaviour.

Relapse (Recycling)

Relapse in the TTM specifically applies to individuals who successfully quit smoking or using drugs or alcohol, only to resume these unhealthy behaviours. Individuals who attempt to quit highly addictive behaviours such as drug, alcohol, and tobacco use are at particularly high risk of a relapse. Achieving a long-term behaviour change often requires ongoing support from family members, a health coach, a physician, or another motivational source. Supportive literature and other resources can also be helpful to avoid a relapse from happening.

Processes of Change

The 10 processes of change are “covert and overt activities that people use to progress through the stages”.

To progress through the early stages, people apply cognitive, affective, and evaluative processes. As people move toward Action and Maintenance, they rely more on commitments, counter conditioning, rewards, environmental controls, and support.

Prochaska and colleagues state that their research related to the transtheoretical model shows that interventions to change behaviour are more effective if they are “stage-matched”, that is, “matched to each individual’s stage of change”.

In general, for people to progress they need:

A growing awareness that the advantages (the “pros”) of changing outweigh the disadvantages (the “cons”) – the TTM calls this decisional balance.
Confidence that they can make and maintain changes in situations that tempt them to return to their old, unhealthy behaviour – the TTM calls this self-efficacy.
Strategies that can help them make and maintain change – the TTM calls these processes of change.

The ten processes of change include:

Consciousness-raising (Get the facts) — increasing awareness via information, education, and personal feedback about the healthy behaviour.
Dramatic relief (Pay attention to feelings) — feeling fear, anxiety, or worry because of the unhealthy behaviour, or feeling inspiration and hope when hearing about how people are able to change to healthy behaviours.
Self-re-evaluation (Create a new self-image) — realising that the healthy behaviour is an important part of who they want to be.
Environmental re-evaluation (Notice your effect on others) — realizing how their unhealthy behaviour affects others and how they could have more positive effects by changing.
Social liberation (Notice public support) — realising that society is supportive of the healthy behaviour.
Self-liberation (Make a commitment) — believing in one’s ability to change and making commitments and re-commitments to act on that belief.
Helping relationships (Get support) — finding people who are supportive of their change.
Counterconditioning (Use substitutes) — substituting healthy ways of acting and thinking for unhealthy ways.
Reinforcement management (Use rewards) — increasing the rewards that come from positive behaviour and reducing those that come from negative behaviour.
Stimulus control (Manage your environment) — using reminders and cues that encourage healthy behaviour and avoiding places that do not.

Health researchers have extended Prochaska’s and DiClemente’s 10 original processes of change by an additional 21 processes. In the first edition of Planning Health Promotion Programmes, Bartholomew et al. (2006) summarised the processes that they identified in a number of studies; however, their extended list of processes was removed from later editions of the text, perhaps because the list mixes techniques with processes. There are unlimited ways of applying processes. The additional strategies of Bartholomew et al. were:

Risk comparison (Understand the risks) – comparing risks with similar dimensional profiles: dread, control, catastrophic potential and novelty
Cumulative risk (Get the overall picture) – processing cumulative probabilities instead of single incident probabilities
Qualitative and quantitative risks (Consider different factors) – processing different expressions of risk
Positive framing (Think positively) – focusing on success instead of failure framing
Self-examination relate to risk (Be aware of your risks) – conducting an assessment of risk perception, e.g. personalisation, impact on others
Re-evaluation of outcomes (Know the outcomes) – emphasising positive outcomes of alternative behaviours and re-evaluating outcome expectancies
Perception of benefits (Focus on benefits) – perceiving advantages of the healthy behaviour and disadvantages of the risk behaviour
Self-efficacy and social support (Get help) – mobilising social support; skills training on coping with emotional disadvantages of change
Decision making perspective (Decide) – focusing on making the decision
Tailoring on time horizons (Set the time frame) – incorporating personal time horizons
Focus on important factors (Prioritise) – incorporating personal factors of highest importance
Trying out new behaviour (Try it) – changing something about oneself and gaining experience with that behaviour
Persuasion of positive outcomes (Persuade yourself) – promoting new positive outcome expectations and reinforcing existing ones
Modelling (Build scenarios) – showing models to overcome barriers effectively
Skill improvement (Build a supportive environment) – restructuring environments to contain important, obvious and socially supported cues for the new behaviour
Coping with barriers (Plan to tackle barriers) – identifying barriers and planning solutions when facing these obstacles
Goal setting (Set goals) – setting specific and incremental goals
Skills enhancement (Adapt your strategies) – restructuring cues and social support; anticipating and circumventing obstacles; modifying goals
Dealing with barriers (Accept setbacks) – understanding that setbacks are normal and can be overcome
Self-rewards for success (Reward yourself) – feeling good about progress; reiterating positive consequences
Coping skills (Identify difficult situations) – identifying high risk situations; selecting solutions; practicing solutions; coping with relapse

While most of these processes and strategies are associated with health interventions such as stress management, exercise, healthy eating, smoking cessation and other addictive behaviour, some of them are also used in other types of interventions such as travel interventions. Some processes are recommended in a specific stage, while others can be used in one or more stages.

Decisional Balance

This core construct “reflects the individual’s relative weighing of the pros and cons of changing”. Decision making was conceptualised by Janis and Mann as a “decisional balance sheet” of comparative potential gains and losses. Decisional balance measures, the pros and the cons, have become critical constructs in the transtheoretical model. The pros and cons combine to form a decisional “balance sheet” of comparative potential gains and losses. The balance between the pros and cons varies depending on which stage of change the individual is in.

Sound decision making requires the consideration of the potential benefits (pros) and costs (cons) associated with a behaviour’s consequences. TTM research has found the following relationships between the pros, cons, and the stage of change across 48 behaviours and over 100 populations studied.

The cons of changing outweigh the pros in the Precontemplation stage.
The pros surpass the cons in the middle stages.
The pros outweigh the cons in the Action stage.

The evaluation of pros and cons is part of the formation of decisional balance. During the change process, individuals gradually increase the pros and decrease the cons forming a more positive balance towards the target behaviour. Attitudes are one of the core constructs explaining behaviour and behaviour change in various research domains. Other behaviour models, such as the theory of planned behaviour (TPB) and the stage model of self-regulated change, also emphasise attitude as an important determinant of behaviour. The progression through the different stages of change is reflected in a gradual change in attitude before the individual acts.

Due to the use of decisional balance and attitude, travel behaviour researchers have begun to combine the TTM with the TPB. Forward uses the TPB variables to better differentiate the different stages. Especially all TPB variables (attitude, perceived behaviour control, descriptive and subjective norm) are positively show a gradually increasing relationship to stage of change for bike commuting. As expected, intention or willingness to perform the behaviour increases by stage. Similarly, Bamberg uses various behaviour models, including the transtheoretical model, theory of planned behaviour and norm-activation model, to build the stage model of self-regulated behaviour change (SSBC). Bamberg claims that his model is a solution to criticism raised towards the TTM. Some researchers in travel, dietary, and environmental research have conducted empirical studies, showing that the SSBC might be a future path for TTM-based research.

Self-Efficacy

This core construct is “the situation-specific confidence people have that they can cope with high-risk situations without relapsing to their unhealthy or high risk-habit”. The construct is based on Bandura’s self-efficacy theory and conceptualises a person’s perceived ability to perform on a task as a mediator of performance on future tasks. In his research Bandura already established that greater levels of perceived self-efficacy leads to greater changes in behaviour. Similarly, Ajzen mentions the similarity between the concepts of self-efficacy and perceived behavioural control. This underlines the integrative nature of the transtheoretical model which combines various behaviour theories. A change in the level of self-efficacy can predict a lasting change in behaviour if there are adequate incentives and skills. The transtheoretical model employs an overall confidence score to assess an individual’s self-efficacy. Situational temptations assess how tempted people are to engage in a problem behaviour in a certain situation.

Levels of Change

This core construct identifies the depth or complexity of presenting problems according to five levels of increasing complexity. Different therapeutic approaches have been recommended for each level as well as for each stage of change. The levels are:

Symptom/situational problems: e.g., motivational interviewing, behaviour therapy, exposure therapy
Current maladaptive cognitions: e.g., Adlerian therapy, cognitive therapy, rational emotive therapy
Current interpersonal conflicts: e.g., Sullivanian therapy, interpersonal therapy
Family/systems conflicts: e.g., strategic therapy, Bowenian therapy, structural family therapy
Long-term intrapersonal conflicts: e.g., psychoanalytic therapies, existential therapy, Gestalt therapy

In one empirical study of psychotherapy discontinuation published in 1999, measures of levels of change did not predict premature discontinuation of therapy. Nevertheless, in 2005 the creators of the TTM stated that it is important “that both therapists and clients agree as to which level they attribute the problem and at which level or levels they are willing to target as they work to change the problem behavior”.

Psychologist Donald Fromme, in his book Systems of Psychotherapy, adopted many ideas from the TTM, but in place of the levels of change construct, Fromme proposed a construct called contextual focus, a spectrum from physiological microcontext to environmental macrocontext: “The horizontal, contextual focus dimension resembles TTM’s Levels of Change, but emphasizes the breadth of an intervention, rather than the latter’s focus on intervention depth.”

Outcomes of Programmes

The outcomes of the TTM computerised tailored interventions administered to participants in pre-Action stages are outlined below.

Stress Management

A national sample of pre-Action adults was provided a stress management intervention. At the 18-month follow-up, a significantly larger proportion of the treatment group (62%) was effectively managing their stress when compared to the control group. The intervention also produced statistically significant reductions in stress and depression and an increase in the use of stress management techniques when compared to the control group. Two additional clinical trials of TTM programmes by Prochaska et al. and Jordan et al. also found significantly larger proportions of treatment groups effectively managing stress when compared to control groups.

Adherence to Antihypertensive Medication

Over 1,000 members of a New England group practice who were prescribed antihypertensive medication participated in an adherence to antihypertensive medication intervention. The vast majority (73%) of the intervention group who were previously pre-Action were adhering to their prescribed medication regimen at the 12-month follow-up when compared to the control group.

Adherence to Lipid-Lowering Drugs

Members of a large New England health plan and various employer groups who were prescribed a cholesterol lowering medication participated in an adherence to lipid-lowering drugs intervention. More than half of the intervention group (56%) who were previously pre-Action were adhering to their prescribed medication regimen at the 18-month follow-up. Additionally, only 15% of those in the intervention group who were already in Action or Maintenance relapsed into poor medication adherence compared to 45% of the controls. Further, participants who were at risk for physical activity and unhealthy diet were given only stage-based guidance. The treatment group doubled the control group in the percentage in Action or Maintenance at 18 months for physical activity (43%) and diet (25%).

Depression Prevention

Participants were 350 primary care patients experiencing at least mild depression but not involved in treatment or planning to seek treatment for depression in the next 30 days. Patients receiving the TTM intervention experienced significantly greater symptom reduction during the 9-month follow-up period. The intervention’s largest effects were observed among patients with moderate or severe depression, and who were in the Precontemplation or Contemplation stage of change at baseline. For example, among patients in the Precontemplation or Contemplation stage, rates of reliable and clinically significant improvement in depression were 40% for treatment and 9% for control. Among patients with mild depression, or who were in the Action or Maintenance stage at baseline, the intervention helped prevent disease progression to Major Depression during the follow-up period.

Weight Management

Five-hundred-and-seventy-seven overweight or moderately obese adults (BMI 25-39.9) were recruited nationally, primarily from large employers. Those randomly assigned to the treatment group received a stage-matched multiple behaviour change guide and a series of tailored, individualized interventions for three health behaviours that are crucial to effective weight management: healthy eating (i.e. reducing calorie and dietary fat intake), moderate exercise, and managing emotional distress without eating. Up to three tailored reports (one per behaviour) were delivered based on assessments conducted at four time points: baseline, 3, 6, and 9 months. All participants were followed up at 6, 12, and 24 months. Multiple Imputation was used to estimate missing data. Generalized Labour Estimating Equations (GLEE) were then used to examine differences between the treatment and comparison groups. At 24 months, those who were in a pre-Action stage for healthy eating at baseline and received treatment were significantly more likely to have reached Action or Maintenance than the comparison group (47.5% vs. 34.3%). The intervention also impacted a related, but untreated behaviour: fruit and vegetable consumption. Over 48% of those in the treatment group in a pre-Action stage at baseline progressed to Action or Maintenance for eating at least 5 servings a day of fruit and vegetables as opposed to 39% of the comparison group. Individuals in the treatment group who were in a pre-Action stage for exercise at baseline were also significantly more likely to reach Action or Maintenance (44.9% vs. 38.1%). The treatment also had a significant effect on managing emotional distress without eating, with 49.7% of those in a pre-Action stage at baseline moving to Action or Maintenance versus 30.3% of the comparison group. The groups differed on weight lost at 24 months among those in a pre-Action stage for healthy eating and exercise at baseline. Among those in a pre-Action stage for both healthy eating and exercise at baseline, 30% of those randomised to the treatment group lost 5% or more of their body weight vs. 16.6% in the comparison group. Coaction of behaviour change occurred and was much more pronounced in the treatment group with the treatment group losing significantly more than the comparison group. This study demonstrates the ability of TTM-based tailored feedback to improve healthy eating, exercise, managing emotional distress, and weight on a population basis. The treatment produced the highest population impact to date on multiple health risk behaviours.

The effectiveness of the use of this model in weight management interventions (including dietary or physical activity interventions, or both, and also combined with other interventions) for overweight and obese adults was assessed in a 2014 systematic review. The results revealed that there is inconclusive evidence regarding the impact of these interventions on sustainable (one year or longer) weight loss. However, this approach may produce positive effects in physical activity and dietary habits, such as increased in both exercise duration and frequency, and fruits and vegetables consumption, along with reduced dietary fat intake, based on very low quality scientific evidence.

Criticisms

In 2009, an article in the British Journal of Health Psychology called the TTM “arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted exceptional criticism”, and said “that there is still value in the transtheoretical model but that the way in which it is researched needs urgently to be addressed”. Depending on the field of application (e.g. smoking cessation, substance abuse, condom use, diabetes treatment, obesity and travel) somewhat different criticisms have been raised.

In a systematic review, published in 2003, of 23 randomized controlled trials, the authors found that “stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour”. However, it was also mentioned that stage based interventions are often used and implemented inadequately in practice. Thus, criticism is directed towards the use rather the effectiveness of the model itself. Looking at interventions targeting smoking cessation in pregnancy found that stage-matched interventions were more effective than non-matched interventions. One reason for this was the greater intensity of stage-matched interventions. Also, the use of stage-based interventions for smoking cessation in mental illness proved to be effective. Further studies, e.g. a randomised controlled trial published in 2009, found no evidence that a TTM based smoking cessation intervention was more effective than a control intervention not tailored to stage of change. The study claims that those not wanting to change (i.e. precontemplators) tend to be responsive to neither stage nor non-stage based interventions. Since stage-based interventions tend to be more intensive they appear to be most effective at targeting contemplators and above rather than pre-contemplators. A 2010 systematic review of smoking cessation studies under the auspices of the Cochrane Collaboration found that “stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents”. A 2014 Cochrane systematic review concluded that research on the use of TTM stages of change “in weight loss interventions is limited by risk of bias and imprecision, not allowing firm conclusions to be drawn”.

Main criticism is raised regarding the “arbitrary dividing lines” that are drawn between the stages. West claimed that a more coherent and distinguishable definition for the stages is needed. Especially the fact that the stages are bound to a specific time interval is perceived to be misleading. Additionally, the effectiveness of stage-based interventions differs depending on the behaviour. A continuous version of the model has been proposed, where each process is first increasingly used, and then decreases in importance, as smokers make progress along some latent dimension. This proposal suggests the use of processes without reference to stages of change.

West claimed that the model “assumes that individuals typically make coherent and stable plans”, when in fact they often do not. However, the model does not require that all people make a plan: for example, the SAMSHA document Enhancing Motivation for Change in Substance Use Disorder Treatment, which uses the TTM, also says: “Don’t assume that all clients need a structured method to develop a change plan. Many people can make significant lifestyle changes and initiate recovery from SUDs without formal assistance”.

Within research on prevention of pregnancy and sexually transmitted diseases, a systematic review from 2003 comes to the conclusion that “no strong conclusions” can be drawn about the effectiveness of interventions based on the transtheoretical model. Again this conclusion is reached due to the inconsistency of use and implementation of the model. This study also confirms that the better stage-matched the intervention the more effect it has to encourage condom use.

Within the health research domain, a 2005 systematic review of 37 randomized controlled trials claims that “there was limited evidence for the effectiveness of stage-based interventions as a basis for behaviour change. Studies with which focused on increasing physical activity levels through active commute however showed that stage-matched interventions tended to have slightly more effect than non-stage matched interventions. Since many studies do not use all constructs of the TTM, additional research suggested that the effectiveness of interventions increases the better it is tailored on all core constructs of the TTM in addition to stage of change. In diabetes research the “existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model” as related to dietary interventions. Again, studies with slightly different design, e.g. using different processes, proved to be effective in predicting the stage transition of intention to exercise in relation to treating patients with diabetes.

TTM has generally found a greater popularity regarding research on physical activity, due to the increasing problems associated with unhealthy diets and sedentary living, e.g. obesity, cardiovascular problems. A 2011 Cochrane Systematic Review found that there is little evidence to suggest that using the transtheoretical model stages of change (TTM SOC) method is effective in helping obese and overweight people lose weight. There were only five studies in the review, two of which were later dropped due to not being relevant since they did not measure weight. Earlier in a 2009 paper, the TTM was considered to be useful in promoting physical activity. In this study, the algorithms and questionnaires that researchers used to assign people to stages of change lacked standardisation to be compared empirically, or validated.

Similar criticism regarding the standardisation as well as consistency in the use of TTM is also raised in a 2017 review on travel interventions. With regard to travel interventions only stages of change and sometimes decisional balance constructs are included. The processes used to build the intervention are rarely stage-matched and short cuts are taken by classifying participants in a pre-action stage, which summarises the precontemplation, contemplation and preparation stage, and an action/maintenance stage. More generally, TTM has been criticised within various domains due to the limitations in the research designs. For example, many studies supporting the model have been cross-sectional, but longitudinal study data would allow for stronger causal inferences. Another point of criticism is raised in a 2002 review, where the model’s stages were characterised as “not mutually exclusive”. Furthermore, there was “scant evidence of sequential movement through discrete stages”. While research suggests that movement through the stages of change is not always linear, a study of smoking cessation conducted in 1996 demonstrated that the probability of forward stage movement is greater than the probability of backward stage movement. Due to the variations in use, implementation and type of research designs, data confirming TTM are ambiguous. More care has to be taken in using a sufficient amount of constructs, trustworthy measures, and longitudinal data.

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What is Habit Reversal Training?

Published on 03/26/2024 by Andrew Marshall1 Comment

Introduction

Habit reversal training (HRT) is a multicomponent behavioural treatment package originally developed to address a wide variety of repetitive behaviour disorders.

Behavioural disorders treated with HRT include tics, trichotillomania, nail biting, thumb sucking, skin picking, temporomandibular disorder (TMJ), lip-cheek biting and stuttering. It consists of five components: awareness training, competing response training, contingency management, relaxation training, and generalisation training.

Research on the efficacy of HRT for behavioural disorders have produced consistent, large effect sizes (approximately 0.80 across the disorders). It has met the standard of a well-established treatment for stuttering, thumb sucking, nail biting, and TMJ disorders. According to a meta-analysis from 2012, decoupling, a self-help variant of HRT, also shows efficacy.

Refer to Decoupling for Body-Focused Repetitive Behaviours.

For Tic Disorders

In case of a tic, these components are intended to increase tic awareness, develop a competing response to the tic, and build treatment motivation and compliance. HRT is based on the presence of a premonitory urge, or sensation occurring before a tic. HRT involves replacing a tic with a competing response—a more comfortable or acceptable movement or sound—when a patient feels a premonitory urge building.

Controlled trials have demonstrated that HRT is an acceptable, tolerable, effective and durable treatment for tics; HRT reduces the severity of vocal tics, and results in enduring improvement of tics when compared with supportive therapy. HRT has been shown to be more effective than supportive therapy and, in some studies, medication. HRT is not yet proven or widely accepted, but large-scale trials are ongoing and should provide better information about its efficacy in treating Tourette syndrome. Studies through 2006 are “characterized by a number of design limitations, including relatively small sample sizes, limited characterisation of study participants, limited data on children and adolescents, lack of attention to the assessment of treatment integrity and adherence, and limited attention to the identification of potential clinical and neurocognitive mechanisms and predictors of treatment response”. Additional controlled studies of HRT are needed to address whether HRT, medication, or a combination of both is most effective, but in the interim, “HRT either alone or in combination with medication should be considered as a viable treatment” for tic disorders.

Comprehensive Behavioural Intervention for Tics

Comprehensive Behavioural Intervention for Tics (CBIT), based on HRT, is a first-line treatment for Tourette syndrome and tic disorders. With a high level of confidence, CBIT has been shown to be more likely to lead to a reduction in tics than other supportive therapies or psychoeducation. Some limitations are: children younger than ten may not understand the treatment, people with severe tics or ADHD may not be able to suppress their tics or sustain the required focus to benefit from behavioural treatments, there is a lack of therapists trained in behavioural interventions, finding practitioners outside of specialty clinics can be difficult, and costs may limit accessibility. Whether increased awareness of tics through HRT/CBIT (as opposed to moving attention away from them) leads to further increases in tics later in life is a subject of discussion among TS experts.

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What is Decoupling for Body-Focused Repetitive Behaviours?

Published on 03/26/202403/26/2024 by Andrew Marshall1 Comment

Introduction

Decoupling is a behavioural self-help intervention for body-focused and related behaviours (DSM-5) such as trichotillomania, onychophagia (nail biting), skin picking and lip-cheek biting.

Outline

The user is instructed to modify the original dysfunctional behavioural path by performing a counter-movement shortly before completing the self-injurious behaviour (e.g. biting nails, picking skin, pulling hair). This is intended to trigger an irritation, which enables the person to detect and stop the compulsive behaviour at an early stage.

A systematic review from 2012 suggested some efficacy of decoupling, which was corroborated by Lee et al. in 2019.

Whether or not the technique is superior to other behavioural interventions such as habit reversal training awaits to be tested. Decoupling is a variant of habit reversal training.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Decoupling_for_body-focused_repetitive_behaviors >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Covert Conditioning?

Published on 03/25/2024 by Andrew MarshallLeave a comment

Introduction

Covert conditioning is an approach to mental health treatment that utilises the principles of applied behaviour analysis, or cognitive-behaviour therapies (CBTs) to help individuals improve their behaviour or inner experience. This method relies on the individual’s ability to use imagery for purposes such as mental rehearsal. In some populations, it has been found that an imaginary reward can be as effective as a real one. The effectiveness of covert conditioning is believed to depend on the careful application of behavioural treatment principles, including a comprehensive behavioural analysis.

Some clinicians include the mind’s ability to spontaneously generate imagery that can provide intuitive solutions or even reprocessing that improves people’s typical reactions to situations or inner material. However, this goes beyond the behaviouristic principles on which covert conditioning is based.

Therapies and self-help methods have aspects of covert conditioning. This can be seen in focusing, some neuro-linguistic programming methods such as future pacing, and various visualisation or imaginal processes used in behaviour therapies, such as CBTs or clinical behaviour analysis.

Therapeutic Interventions

“Systematic desensitisation” associates an aversive stimulus with a behaviour that the client wishes to reduce or eliminate. This is achieved by imagining the target behaviour followed by imagining an aversive consequence. “Covert extinction” attempts to reduce a behaviour by imagining the target behaviour while imagining that the reinforcer does not occur. “Covert response cost” seeks to reduce a behaviour by associating the loss of a reinforcer with the target behaviour that is to be decreased.

“Contact desensitisation” intends to increase a behaviour by imagining a reinforcing experience in connection with modelling the correct behaviour. “Covert negative reinforcement” attempts to increase a behaviour by connecting the termination of an aversive stimulus with increased production of a target behaviour.

“Dialectical behaviour therapy” (DBT) and “Acceptance and commitment therapy” (ACT) uses positive reinforcement and covert conditioning through mindfulness.

Effectiveness

Previous research in the early 1990s has shown covert conditioning to be effective with sex offenders as part of a behaviour modification treatment package. Clinical studies continue to find it effective with some generalisation from office to natural environment with this population.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Covert_conditioning >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Behaviour Management?

Published on 03/21/2024 by Andrew MarshallLeave a comment

Introduction

Behaviour management, similar to behaviour modification, is a less-intensive form of behaviour therapy. Unlike behaviour modification, which focuses on changing behaviour, behaviour management focuses on maintaining positive habits and behaviours and reducing negative ones. Behaviour management skills are especially useful for teachers and educators, healthcare workers, and those working in supported living communities. This form of management aims to help professionals oversee and guide behaviour management in individuals and groups toward fulfilling, productive, and socially acceptable behaviours. Behaviour management can be accomplished through modelling, rewards, or punishment.

Research

Influential behaviour management researchers B.F. Skinner and Carl Rogers both take different approaches to managing behavio.

Skinner claimed that anyone can manipulate behaviour by identifying what a person finds rewarding. Once the rewards are known, they can be given in exchange for good behaviour. Skinner called this “Positive Reinforcement Psychology.”

Rogers proposed that the desire to behave appropriately must come before addressing behavioural problems. This is accomplished by teaching the individual about morality, including why one should do what is right. Rogers held that a person must have an internal awareness of right and wrong.

Many principles and techniques are the same as in behaviour modification. However, they are considerably different and administered less often.

In the Classroom

Behaviour management is often applied by a classroom teacher as a form of behavioural engineering, in order to raise students’ retention of material and produce higher yields of student work completion. This also helps to reduce classroom disruption and places more focus on building self-control and self-regulating a calm emotional state.

American education psychologist, Brophy (1986, p.191) writes:

Contemporary behavior modification approaches involve students more actively in planning and shaping their own behavior through participation in the negotiation of contracts with their teachers and through exposure to training designed to help them to monitor and evaluate their behavior more actively, to learn techniques of self-control and problem solving, and to set goals and reinforce themselves for meeting these meetings.

In general, behaviour management strategies are effective at reducing classroom disruption. Recent efforts have focused on incorporating principles of functional assessment.

Such strategies can come from a variety of behavioural change theories, although the most common practices rely on using applied behaviour analysis principles such as positive reinforcement and mild punishments (like response cost and child time-out). Behavioural practices like differential reinforcement are often used. These may be delivered in a token economy or a level system. In general, the reward component is considered effective. For example, Cotton (1988) reviewed 37 studies on tokens, praise, and other reward systems and found them to be effective in managing student classroom behaviour. A comprehensive review of token procedures to match children’s level of behavioural severity is found in Walker’s text “The Acting Out Child.”

Behaviour management systems have three main parts:

Whole group;
Table group; and
Individual.

Examples may include marble jars for the class, prize charts for tables, and a grid chart with 25 spaces for individual students. Many types of charts can be found to use in each situation.

Effective behaviour management depends on using tools that are appropriate to each situation. One effective tool is the High Card/Low Card system. To use a high card, the educator or instructor uses strong intervention to address the issue. Some examples of High Cards are:

Sending a student to the office.
Keeping a student after school hours.
Calling home to the student’s parent.

A Low Card approach is a less invasive way to address a behavioural issue and may include:

Speaking to a student privately.
Making eye contact during the issue.
Changing the seating arrangement.

Some student behaviours must be addressed immediately and could cause a teacher to interrupt teaching in order to resolve the issue. This is known as a direct cost situation. This typically arises in extreme behaviour situations like physical disputes between students, loud outbursts in class, or disrupting the class disrespectfully.

Purkey proposed a visualisation way to keep track of the methods used to manage student behaviour. He called it the “Blue-card, orange-card theory”. Blue cards help reinforce good behaviour and ways to encourage a student. Orange cards, in contrast, are things that may be critical, discouraging, or demeaning. Some examples of blue cards might be bringing up the good things a student has done before focusing on the behaviour that needs to change, therefore reminding the student that they have worth and causing them to feel encouraged. An orange card could list ways to critique a student’s work in front of the class, which would lower their feelings of self-worth, providing an example of what to avoid. Teachers can be aware and provide students with required critique and feedback, while reinforcing their self-image. Purkey’s theory helps teachers understand how they can edit behavioural management specifically in the classroom.

In Supported Living

When bringing behavioural management in relation with supported living the purpose of this is to keep a person’s dignity. Most of the time, residents have some behaviour that is meant to be improved in order for them to live a more normal life. Our main goal of the behavioural management is to help them become as independent as possible. Of course, it is important to recognise that not every resident will be back to being completely independent.

There are a lot of ways to help residents be more independent and we will look at some of those here.

It is important we first take a look at each resident’s history. Many of them will have gone through an experience that may have started the behaviour change in the first place. Some examples of these are child abuse, trauma, anxiety, depression, etc.

Once a person is in the behaviour management process, we have to consider their behaviour daily. We should also be meeting with them regularly in order to keep accurate data of their behaviour. In this way we can look back and make modifications to what they need during the behaviour management process.

Each resident will be different and need a variety of attention. But it is important to consider what will be needed in order to get to their success. The main goal of the behaviour management is to address the behaviour issue in order to keep them independent.

When with a resident there are a variety of behaviours you may come into contact with. You will not only need to know what to do in each situation but also how to act. Your behaviour is crucial to the progress of their behaviour. There may be situations when yourself can not handle the behaviour and will need to lead to a bigger solution. Redirecting them to a psychologist, psychiatrist, hospital, or a behaviour management centre may be beneficial.

Building Prosocial Behaviour

Behavioural management principles have used reinforcement, modelling, and punishment to foster prosocial behaviour. This is sometimes referred to as behavioural development, a sub-category of which is behaviour analysis of child development. The “token economy” is an example of behavioural management approach that seeks to develop prosocial behaviour. In this model, socially appropriate behaviours are encouraged and reinforced since these are equivalent to points that can be exchanged for rewards. Examples of situations and behaviours where tokens can be earned include attending groups, taking medication, and refraining from aggressive behaviours, among others.

Several studies have been done in this area to discover effective methods of building prosocial behaviour. Midlarsky and colleagues (1973) used a combination of modelling and reinforcement to build altruistic behaviour. Two studies exist in which modelling by itself did not increase prosocial behaviour; however, modelling is much more effective than instruction-giving (such as “preaching”). The role of rewards has been implicated in the building of self-control and empathy. Cooperation seems particularly susceptible to rewards. Sharing is another prosocial behaviour influenced by reinforcement. In a Harvard study, it was proven that acts of kindness and expressing gratitude in the classroom can cause better behaviour and increased mood overall.

Reinforcement is particularly effective in the learning environment if context conditions are similar. Recent research indicates that behavioural interventions produce the most valuable results when applied during early childhood and early adolescence. Positive reinforcement motivates better than punishment. Motivation to behaviour change is also less damaging to the relationship.

More controversy has arisen concerning behaviour management due to the role of punishment in forming prosocial behaviour. However, one study found that sharing rates of children could be increased by removing factors that caused a failure to share. The socialisation process continues by peers with reinforcement and punishment playing major roles. Peers are more likely to punish cross-gender play and reinforce play specifically to gender.

Positive reinforcement, negative reinforcement, positive punishment, and negative punishment are all forms of operant conditioning. Reinforcements are an attempt to change behaviour, either positively or negatively. Positive reinforcement attempts to increase a behaviour by adding something the target wants (e.g. awarding good behaviour with a treat). Negative reinforcement is attempting to increase behaviour by removing something unwanted from the target. (e.g. a child’s room is messy and their mother nags them to clean it up, they will eventually try to keep it clean to stop the mother from nagging them). Punishment is trying to decrease behaviour, either by using negative or positive stimuli. Positive punishment is when one adds an unwanted stimulus to decrease the target’s behaviour (e.g. spanking a child when they behave badly). Here, spanking is being added to decrease undesired behaviour. Negative punishment is when one removes something the target enjoys or likes to decrease their undesired behaviour. (e.g. a child comes home past curfew every weekend, so if their mother bans them from watching TV when they are past curfew, the child will eventually try to come home on time). This is negative punishment because the child likes to watch TV, so when the mother takes that away from them, they dislike the consequence. Thus, they will be more likely to come home in time to avoid having that privilege taken away.

Abraham Maslow is a very well-known humanist psychologist, known for his work on the hierarchy of needs, in which he states that humans must have one level of needs satisfied before attaining the next level. There are five needs that are being satisfied in sequence: physiological, safety, social, esteem, and self-actualisation. Maslow also claims that humans’ needs are never completely fulfilled and that this affects how people behave (e.g. if a person’s needs are never fully satisfied, then they might not always behave well, even if they do receive a treat for good behaviour). A related concept, the “Hawthorne Effect”, involves the manipulation of behaviour of somebody being observed. For example, if someone is being studied in an experiment, that person might perform better or work harder because they are aware of the attention they are receiving. It is this effect of observation that is called the “Hawthorne Effect”. This is interesting because if a child who is behaving very poorly, no matter what, is put in an experiment, they might increase their good behaviour. After all, they are receiving attention from the researcher. The point of operant conditioning in behaviour modification is to regulate the behaviour. This method uses different techniques and ties them all together to monitor behaviour. It can lead to problems, however, when talking about Maslow’s Hierarchy of needs because in this model Maslow goes on to explain how no one’s needs are fully met. The highest point on Maslow’s pyramid is self-actualisation which Maslow argues is the goal in which we do not reach. This can pose a problem when it comes to behaviour modification because one might think if that individual can not reach that ultimate goal, why try at all. Self-actualisation is the goal in which humans have this sense of belonging or accomplishment. Humans have an inherent need to achieve goals and attain self-satisfaction; when we do not attain those goals and needs, we feel dissatisfied. When a person does not meet that top goal, that person might feel a void, discouraged because they cannot seem to reach that ultimate step. Using these behavioural modifications or techniques, people can teach themselves how to better attain these goals.

Managing Defensive Behaviour

Understanding and dealing with defensiveness is an important personal skill. Following are some of the strategies:

Recognize that defensive behaviour is normal, as “defensive behaviours are intended to reduce a perceive threat or avoid an unwanted threat,” It is normal for one to be defensive when they feel that something is their fault. These actions are attempted in order to avoid blame or change of action.
Never attack a person’s defences. Do not try to “explain someone” to themselves by saying things like, “you know the real reason you are using that excuse is that you cannot bear to be blamed for anything.” Instead, try to concentrate on the act itself rather than on the person.
Postpone action. Sometimes it is best to do nothing at all. People frequently react to sudden threats by instinctively closing off and hiding their feelings. When given time the person will be able to give a more composed reaction or answer. These feelings often come from being overloaded, especially in the workplace where overload can have a taxing effect on a person’s ability to meet task expectations.
Recognize human limitations. Do not expect to be able to solve every problem that comes up, especially the human ones. More importantly, remember that a layman should not try to be a psychologist. Offering employees understanding is one thing; trying to deal with deep psychological problems is another matter entirely.
Knowing personal limits and expectations is important in helping others with defensive behaviour. Being able to have effective self-observation is important because if there is no solid idea of one’s feelings, then trying to help others will come across as too aggressive or too reserved. A smart way to start this change is by asking oneself a couple of different questions, such as “what am I feeling”, “what am I thinking”, “how else can I think about that,” etc. Then proceed to automatically notice if the feelings are winding up or down to act accordingly.

An effective strategy to dealing with defensiveness is the SCARF model which was developed by an Australian neuroscientist named David Rock. The five letters stand for status, certainty, autonomy, relatedness, and fairness. Understanding each domain will help explain the fight or flight response when someone is faced with a stressful situation; and focus on each individuals’ skills.

Status threats relate to how important the threat is to others and ourselves, looking at how the situation will help lift or put down the other people involved and forget about ego(s).

Certainty threats deal with predicting the future such as when someone says “I never get told anything in this company.” It is actually them asking to be kept in the loop about decisions that are being made.

Autonomy threats are based on the control throughout a situation; if someone is having this threat they will feel like they have not had any say or input and become frustrated as a result. In these situations, giving that person a choice is the best option.

Relatedness threats deal with how comfortable someone feels around other people. In this case, the leader of the group needs to make sure that everyone is feeling included and important. Making sure that everyone’s voice is heard and they are important individuals.

Finally, the fairness threat is the perception of both parties that the exchange of content and relation is fair and equal. No one wants to feel like they are putting in 80 percent while the other side is only putting in 20%.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Behavior_management >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Behaviour Therapy?

Published on 03/11/2024 by Andrew Marshall1 Comment

Introduction

Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or other people’s mental states, influences those behaviours, and consists of techniques based on behaviourism’s theory of learning: respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method, but it has a wide range of techniques that can be used to treat a person’s psychological problems.

Behavioural psychotherapy is sometimes juxtaposed with cognitive psychotherapy. While cognitive behavioural therapy integrates aspects of both approaches, such as cognitive restructuring, positive reinforcement, habituation (or desensitisation), counterconditioning, and modelling.

Applied behaviour analysis (ABA) is the application of behaviour analysis that focuses on functionally assessing how behaviour is influenced by the observable learning environment and how to change such behaviour through contingency management or exposure therapies, which are used throughout clinical behaviour analysis therapies or other interventions based on the same learning principles.

Cognitive-behavioural therapy views cognition and emotions as preceding overt behaviour and implements treatment plans in psychotherapy to lessen the issue by managing competing thoughts and emotions, often in conjunction with behavioural learning principles.

A 2013 Cochrane review comparing behaviour therapies to psychological therapies found them to be equally effective, although at the time the evidence base that evaluates the benefits and harms of behaviour therapies was weak.

Brief History

Precursors of certain fundamental aspects of behaviour therapy have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Wolpe and Lazarus wrote,

While the modern behavior therapist deliberately applies principles of learning to this therapeutic operations, empirical behavior therapy is probably as old as civilization – if we consider civilization as having started when man first did things to further the well-being of other men. From the time that this became a feature of human life there must have been occasions when a man complained of his ills to another who advised or persuaded him of a course of action. In a broad sense, this could be called behavior therapy whenever the behavior itself was conceived as the therapeutic agent. Ancient writings contain innumerable behavioral prescriptions that accord with this broad conception of behavior therapy.

The first use of the term behaviour modification appears to have been by Edward Thorndike in 1911. His article Provisional Laws of Acquired Behaviour or Learning makes frequent use of the term “modifying behavior”. Through early research in the 1940s and the 1950s the term was used by Joseph Wolpe’s research group. The experimental tradition in clinical psychology used it to refer to psycho-therapeutic techniques derived from empirical research. It has since come to refer mainly to techniques for increasing adaptive behaviour through reinforcement and decreasing maladaptive behaviour through extinction or punishment (with emphasis on the former). Two related terms are behaviour therapy and applied behaviour analysis. Since techniques derived from behavioural psychology tend to be the most effective in altering behaviour, most practitioners consider behaviour modification along with behaviour therapy and applied behaviour analysis to be founded in behaviourism. While behaviour modification and applied behaviour analysis typically uses interventions based on the same behavioural principles, many behaviour modifiers who are not applied behaviour analysts tend to use packages of interventions and do not conduct functional assessments before intervening.

Possibly the first occurrence of the term “behavior therapy” was in a 1953 research project by B.F. Skinner, Ogden Lindsley, Nathan Azrin and Harry C. Solomon. The paper talked about operant conditioning and how it could be used to help improve the functioning of people who were diagnosed with chronic schizophrenia. Early pioneers in behaviour therapy include Joseph Wolpe and Hans Eysenck.

In general, behaviour therapy is seen as having three distinct points of origin: South Africa (Wolpe’s group), the United States (Skinner), and the United Kingdom (Rachman and Eysenck). Each had its own distinct approach to viewing behaviour problems. Eysenck in particular viewed behaviour problems as an interplay between personality characteristics, environment, and behaviour. Skinner’s group in the United States took more of an operant conditioning focus. The operant focus created a functional approach to assessment and interventions focused on contingency management such as the token economy and behavioural activation. Skinner’s student Ogden Lindsley is credited with forming a movement called precision teaching, which developed a particular type of graphing program called the standard celeration chart to monitor the progress of clients. Skinner became interested in the individualising of programs for improved learning in those with or without disabilities and worked with Fred S. Keller to develop programmed instruction. Programmed instruction had some clinical success in aphasia rehabilitation. Gerald Patterson used programme instruction to develop his parenting text for children with conduct problems. (see Parent management training.) With age, respondent conditioning appears to slow but operant conditioning remains relatively stable. While the concept had its share of advocates and critics in the west, its introduction in the Asian setting, particularly in India in the early 1970s and its grand success were testament to the famous Indian psychologist H. Narayan Murthy’s enduring commitment to the principles of behavioural therapy and biofeedback.

While many behaviour therapists remain staunchly committed to the basic operant and respondent paradigm, in the second half of the 20th century, many therapists coupled behaviour therapy with the cognitive therapy, of Aaron Beck, Albert Ellis, and Donald Meichenbaum to form cognitive behaviour therapy. In some areas the cognitive component had an additive effect (for example, evidence suggests that cognitive interventions improve the result of social phobia treatment.) but in other areas it did not enhance the treatment, which led to the pursuit of third generation behaviour therapies. Third generation behaviour therapy uses basic principles of operant and respondent psychology but couples them with functional analysis and a clinical formulation/case conceptualisation of verbal behaviour more inline with view of the behaviour analysts. Some research supports these therapies as being more effective in some cases than cognitive therapy, but overall the question is still in need of answers.

Theoretical Basis

The behavioural approach to therapy assumes that behaviour that is associated with psychological problems develops through the same processes of learning that affects the development of other behaviours. Therefore, behaviourists see personality problems in the way that personality was developed. They do not look at behaviour disorders as something a person has, but consider that it reflects how learning has influenced certain people to behave in a certain way in certain situations.

Behaviour therapy is based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. Classical conditioning happens when a neutral stimulus comes right before another stimulus that triggers a reflexive response. The idea is that if the neutral stimulus and whatever other stimulus that triggers a response is paired together often enough that the neutral stimulus will produce the reflexive response. Operant conditioning has to do with rewards and punishments and how they can either increase or decrease certain behaviours.

Contingency management programs are a direct product of research from operant conditioning.

Current Forms

Behavioural therapy based on operant and respondent principles has considerable evidence base to support its usage. This approach remains a vital area of clinical psychology and is often termed clinical behaviour analysis. Behavioural psychotherapy has become increasingly contextual in recent years. Behavioural psychotherapy has developed greater interest in recent years in personality disorders as well as a greater focus on acceptance and complex case conceptualisations.

Functional Analytic Psychotherapy

One current form of behavioural psychotherapy is functional analytic psychotherapy. Functional analytic psychotherapy is a longer duration behaviour therapy. Functional analytic therapy focuses on in-session use of reinforcement and is primarily a relationally-based therapy. As with most of the behavioural psychotherapies, functional analytic psychotherapy is contextual in its origins and nature. and draws heavily on radical behaviourism and functional contextualism.

Functional analytic psychotherapy holds to a process model of research, which makes it unique compared to traditional behaviour therapy and cognitive behavioural therapy.

Functional analytic psychotherapy has a strong research support. Recent functional analytic psychotherapy research efforts are focusing on management of aggressive inpatients.

Assessment

Behaviour therapists complete a functional analysis or a functional assessment that looks at four important areas: stimulus, organism, response and consequences. The stimulus is the condition or environmental trigger that causes behaviour. An organism involves the internal responses of a person, like physiological responses, emotions and cognition. A response is the behaviour that a person exhibits and the consequences are the result of the behaviour. These four things are incorporated into an assessment done by the behaviour therapist.

Most behaviour therapists use objective assessment methods like structured interviews, objective psychological tests or different behavioural rating forms. These types of assessments are used so that the behaviour therapist can determine exactly what a client’s problem may be and establish a baseline for any maladaptive responses that the client may have. By having this baseline, as therapy continues this same measure can be used to check a client’s progress, which can help determine if the therapy is working. Behaviour therapists do not typically ask the why questions but tend to be more focused on the how, when, where and what questions. Tests such as the Rorschach inkblot test or personality tests like the MMPI (Minnesota Multiphasic Personality Inventory) are not commonly used for behavioural assessment because they are based on personality trait theory assuming that a person’s answer to these methods can predict behaviour. Behaviour assessment is more focused on the observations of a person’s behaviour in their natural environment.

Behavioural assessment specifically attempts to find out what the environmental and self-imposed variables are. These variables are the things that are allowing a person to maintain their maladaptive feelings, thoughts and behaviours. In a behavioural assessment “person variables” are also considered. These “person variables” come from a person’s social learning history and they affect the way in which the environment affects that person’s behaviour. An example of a person variable would be behavioural competence. Behavioural competence looks at whether a person has the appropriate skills and behaviours that are necessary when performing a specific response to a certain situation or stimuli.

When making a behavioural assessment the behaviour therapist wants to answer two questions: (1) what are the different factors (environmental or psychological) that are maintaining the maladaptive behaviour and (2) what type of behaviour therapy or technique that can help the individual improve most effectively. The first question involves looking at all aspects of a person, which can be summed up by the acronym BASIC ID. This acronym stands for behaviour, affective responses, sensory reactions, imagery, cognitive processes, interpersonal relationships and drug use.

Clinical Applications

Behaviour therapy based its core interventions on functional analysis. Just a few of the many problems that behaviour therapy have functionally analysed include intimacy in couples relationships, forgiveness in couples, chronic pain, stress-related behaviour problems of being an adult child of a person with an alcohol use disorder, anorexia, chronic distress, substance abuse, depression, anxiety, insomnia and obesity.

Functional analysis has even been applied to problems that therapists commonly encounter like client resistance, partially engaged clients and involuntary clients. Applications to these problems have left clinicians with considerable tools for enhancing therapeutic effectiveness. One way to enhance therapeutic effectiveness is to use positive reinforcement or operant conditioning. Although behaviour therapy is based on the general learning model, it can be applied in a lot of different treatment packages that can be specifically developed to deal with problematic behaviours. Some of the more well known types of treatments are: Relaxation training, systematic desensitization, virtual reality exposure, exposure and response prevention techniques, social skills training, modelling, behavioural rehearsal and homework, and aversion therapy and punishment.

Relaxation training involves clients learning to lower arousal to reduce their stress by tensing and releasing certain muscle groups throughout their body. Systematic desensitisation is a treatment in which the client slowly substitutes a new learned response for a maladaptive response by moving up a hierarchy of situations involving fear. Systematic desensitization is based in part on counter conditioning. Counter conditioning is learning new ways to change one response for another and in the case of desensitisation it is substituting that maladaptive behaviour for a more relaxing behaviour. Exposure and response prevention techniques (also known as flooding and response prevention) is the general technique in which a therapist exposes an individual to anxiety-provoking stimuli while keeping them from having any avoidance responses.

Virtual reality therapy provides realistic, computer-based simulations of troublesome situations. The modelling process involves a person being subjected to watching other individuals who demonstrate behaviour that is considered adaptive and that should be adopted by the client. This exposure involves not only the cues of the “model person” as well as the situations of a certain behaviour that way the relationship can be seen between the appropriateness of a certain behaviour and situation in which that behaviour occurs is demonstrated. With the behavioural rehearsal and homework treatment a client gets a desired behaviour during a therapy session and then they practice and record that behaviour between their sessions. Aversion therapy and punishment is a technique in which an aversive (painful or unpleasant) stimulus is used to decrease unwanted behaviours from occurring. It is concerned with two procedures: 1) the procedures are used to decrease the likelihood of the frequency of a certain behaviour and 2) procedures that will reduce the attractiveness of certain behaviours and the stimuli that elicit them. The punishment side of aversion therapy is when an aversive stimulus is presented at the same time that a negative stimulus and then they are stopped at the same time when a positive stimulus or response is presented. Examples of the type of negative stimulus or punishment that can be used is shock therapy treatments, aversive drug treatments as well as response cost contingent punishment which involves taking away a reward.

Applied behaviour analysis is using behavioural methods to modify certain behaviours that are seen as being important socially or personally. There are four main characteristics of applied behaviour analysis. First behaviour analysis is focused mainly on overt behaviours in an applied setting. Treatments are developed as a way to alter the relationship between those overt behaviours and their consequences.

Another characteristic of applied behaviour analysis is how it (behaviour analysis) goes about evaluating treatment effects. The individual subject is where the focus of study is on, the investigation is centred on the one individual being treated. A third characteristic is that it focuses on what the environment does to cause significant behaviour changes. Finally the last characteristic of applied behaviour analysis is the use of those techniques that stem from operant and classical conditioning such as providing reinforcement, punishment, stimulus control and any other learning principles that may apply.

Social skills training teaches clients skills to access reinforcers and lessen life punishment. Operant conditioning procedures in meta-analysis had the largest effect size for training social skills, followed by modelling, coaching, and social cognitive techniques in that order. Social skills training has some empirical support particularly for schizophrenia. However, with schizophrenia, behavioural programs have generally lost favour.

Some other techniques that have been used in behaviour therapy are contingency contracting, response costs, token economies, biofeedback, and using shaping and grading task assignments.

Shaping and graded task assignments are used when behaviour that needs to be learned is complex. The complex behaviours that need to be learned are broken down into simpler steps where the person can achieve small things gradually building up to the more complex behaviour. Each step approximates the eventual goal and helps the person to expand their activities in a gradual way. This behaviour is used when a person feels that something in their lives can not be changed and life’s tasks appear to be overwhelming.

Another technique of behaviour therapy involves holding a client or patient accountable of their behaviours in an effort to change them. This is called a contingency contract, which is a formal written contract between two or more people that defines the specific expected behaviours that you wish to change and the rewards and punishments that go along with that behaviour. In order for a contingency contract to be official it needs to have five elements. First it must state what each person will get if they successfully complete the desired behaviour. Secondly those people involved have to monitor the behaviours. Third, if the desired behaviour is not being performed in the way that was agreed upon in the contract the punishments that were defined in the contract must be done. Fourth if the persons involved are complying with the contract they must receive bonuses. The last element involves documenting the compliance and noncompliance while using this treatment in order to give the persons involved consistent feedback about the target behaviour and the provision of reinforcers.

Token economies is a behaviour therapy technique where clients are reinforced with tokens that are considered a type of currency that can be used to purchase desired rewards, like being able to watch television or getting a snack that they want when they perform designated behaviours. Token economies are mainly used in institutional and therapeutic settings. In order for a token economy to be effective there must be consistency in administering the program by the entire staff. Procedures must be clearly defined so that there is no confusion among the clients. Instead of looking for ways to punish the patients or to deny them of rewards, the staff has to reinforce the positive behaviours so that the clients will increase the occurrence of the desired behaviour. Over time the tokens need to be replaced with less tangible rewards such as compliments so that the client will be prepared when they leave the institution and won’t expect to get something every time they perform a desired behaviour.

Closely related to token economies is a technique called response costs. This technique can either be used with or without token economies. Response costs is the punishment side of token economies where there is a loss of a reward or privilege after someone performs an undesirable behaviour. Like token economies this technique is used mainly in institutional and therapeutic settings.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy, habit reversal training, has been found to be highly effective for treating tics.

In Rehabilitation

Currently, there is a greater call for behavioural psychologists to be involved in rehabilitation efforts.

Treatment of Mental Disorders

Two large studies done by the Faculty of Health Sciences at Simon Fraser University indicate that both behaviour therapy and cognitive-behavioural therapy (CBT) are equally effective for OCD. CBT is typically considered the “first-line” treatment for OCD. CBT has also been shown to perform slightly better at treating co-occurring depression.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy (habit reversal training) has been found to be highly effective for treating tics.

There has been a development towards combining techniques to treat psychiatric disorders. Cognitive interventions are used to enhance the effects of more established behavioural interventions based on operant and classical conditioning. An increased effort has also been placed to address the interpersonal context of behaviour.

Behaviour therapy can be applied to a number of mental disorders and in many cases is more effective for specific disorders as compared to others. Behaviour therapy techniques can be used to deal with any phobias that a person may have. Desensitisation has also been successfully applied to other issues such as dealing with anger, if a person has trouble sleeping and certain speech disorders. Desensitisation does not occur over night, there is a process of treatment. Desensitisation is done on a hierarchy and happens over a number of sessions. The hierarchy goes from situations that make a person less anxious or nervous up to things that are considered to be extreme for the patient.

Modelling has been used in dealing with fears and phobias. Fears are thought to develop through observational learning, and so positive modelling, when a person’s behaviour is imitated, can used to counter these effects. In a systematic review of 1,677 papers, positive modelling was found to lower fear levels. Modelling has been used in the treatment of fear of snakes as well as a fear of water.

Aversive therapy techniques have been used to treat sexual deviations, as well as alcohol use disorder.

Exposure and prevention procedure techniques can be used to treat people who have anxiety problems as well as any fears or phobias. These procedures have also been used to help people dealing with any anger issues as well as pathological grievers (people who have distressing thoughts about a deceased person).

Virtual reality therapy deals with fear of heights, fear of flying, and a variety of other anxiety disorders. VRT has also been applied to help people with substance abuse problems reduce their responsiveness to certain cues that trigger their need to use drugs.

Shaping and graded task assignments has been used in dealing with suicide and depressed or inhibited individuals. This is used when a patient feel hopeless and they have no way of changing their lives. This hopelessness involves how the person reacts and responds to someone else and certain situations and their perceived powerlessness to change that situation that adds to the hopelessness. For a person with suicidal ideation, it is important to start with small steps. Because that person may perceive everything as being a big step, the smaller you start the easier it will be for the person to master each step. This technique has also been applied to people dealing with agoraphobia, or fear of being in public places or doing something embarrassing.

Contingency contracting has been used to effectively deal with behaviour problems in delinquents and when dealing with on task behaviours in students.

Token economies are used in controlled environments and are found mostly in psychiatric hospitals. They can be used to help patients with different mental illnesses but it does not focus on the treatment of the mental illness but instead on the behavioural aspects of a patient. The response cost technique has been used to successfully address a variety of behaviours such as smoking, overeating, stuttering, and psychotic talk.

Treatment Outcomes

Systematic desensitisation has been shown to successfully treat phobias about heights, driving, insects as well as any anxiety that a person may have. Anxiety can include social anxiety, anxiety about public speaking as well as test anxiety. It has been shown that the use of systematic desensitisation is an effective technique that can be applied to a number of problems that a person may have.

When using modelling procedures this technique is often compared to another behavioural therapy technique. When compared to desensitisation, the modelling technique does appear to be less effective. However it is clear that the greater the interaction between the patient and the subject he is modelling the greater the effectiveness of the treatment.

While undergoing exposure therapy, a person typically needs five sessions to assess the treatment’s effectiveness. After five sessions, exposure treatment has been shown to provide benefit to the patient. However, it is still recommended treatment continue beyond the initial five sessions.

Virtual reality therapy (VRT) has shown to be effective for a fear of heights. It has also been shown to help with the treatment of a variety of anxiety disorders. Due to the costs associated with VRT in 2007, therapists were still awaiting results of controlled trials investigating VRT, to assess which applications demonstrate the best results.

For those with suicidal ideation, treatment depends on how severe the person’s depression and sense of hopelessness is. If these things are severe, the person’s response to completing small steps will not be of importance to them, because they do not consider the success an accomplishment. Generally, in those without severe depression or fear, this technique has been successful, as completion of simpler activities builds their confidences and allows them to progress to more complex situations.

Contingency contracts have been seen to be effective in changing any undesired behaviours of individuals. It has been seen to be effective in treating behaviour problems in delinquents regardless of the specific characteristics of the contract.

Token economies have been shown to be effective when treating patients in psychiatric wards who had chronic schizophrenia. The results showed that the contingent tokens were controlling the behaviour of the patients.

Response costs has been shown to work in suppressing a variety of behaviours such as smoking, overeating or stuttering with a diverse group of clinical populations ranging from sociopaths to school children. These behaviours that have been suppressed using this technique often do not recover when the punishment contingency is withdrawn. Also undesirable side effects that are usually seen with punishment are not typically found when using the response cost technique.

“Third Generation”

Since the 1980s, a series of new behavioural therapies have been developed. These have been later labelled by Steven C. Hayes as “the third-generation” of behavioural therapy. Under this classification, the first generation of behavioural therapy is that independently developed in the 1950s by Joseph Wolpe, Ogden Lindsley and Hans Eysenck, while the second generation is the cognitive therapy developed by Aaron Beck in the 1970s.

Other authors object to the term “third generation” or “third wave” and incorporate many of the “third wave” therapeutic techniques under the general umbrella term of modern cognitive behavioural therapies.

This “third wave” of behavioural therapy has sometimes been called clinical behaviour analysis because it has been claimed that it represents a movement away from cognitivism and back toward radical behaviourism and other forms of behaviourism, in particular functional analysis and behavioural models of verbal behaviour. This area includes acceptance and commitment therapy (ACT), cognitive behavioural analysis system of psychotherapy (CBASP) (McCullough, 2000), behavioural activation (BA), dialectical behaviour therapy, functional analytic psychotherapy (FAP), integrative behavioural couples therapy, metacognitive therapy and metacognitive training. These approaches are squarely within the applied behaviour analysis tradition of behaviour therapy.

Acceptance and Commitment Therapy (ACT) may be the most well-researched of all the third-generation behaviour therapy models. It is based on relational frame theory. As of March 2022, there are over 900 randomised trials of Acceptance and Commitment Therapy and 60 mediational studies of the ACT literature. ACT has been included in over 275 meta-analyses and systematic reviews. As the result of multiple randomised trials of ACT by the World Health Organisation (WHO) now distribute ACT-based self-help for “anyone who experiences stress, wherever they live, and whatever their circumstances.” As of March 2022, a number of different organizations have stated that Acceptance and Commitment Therapy is empirically supported in certain areas or as a whole according to their standards. These include: American Psychological Association, Society of Clinical Psychology (Div. 12), The WHO, The United Kingdom National Institute for Health and Care Excellence (NICE), Australian Psychological Society, Netherlands Institute of Psychologists: Sections of Neuropsychology and Rehabilitation, Sweden Association of Physiotherapists, SAMHSA’s National Registry of Evidence-based Programs and Practices, California Evidence-Based Clearinghouse for Child Welfare, and the US Veterans Affairs/Department of Defence.

Functional analytic psychotherapy is based on a functional analysis of the therapeutic relationship. It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement. In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component. Behavioural activation is based on a matching model of reinforcement. A recent review of the research, supports the notion that the use of behavioural activation is clinically important for the treatment of depression.

Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1966) for the difference between contingency-shaped and rule-governed behaviour. It couples this analysis with a thorough functional assessment of the couple’s relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness.

A review study published in 2008, concluded that at the time, third-generation behavioural psychotherapies did not meet the criteria for empirically supported treatments.

Organisations

Many organisations exist for behaviour therapists around the world. In the United States, the American Psychological Association’s Division 25 is the division for behaviour analysis. The Association for Contextual Behavioural Science is another professional organisation. ACBS is home to many clinicians with specific interest in third generation behaviour therapy. Doctoral-level behaviour analysts who are psychologists belong to American Psychological Association’s Division 25 – behaviour analysis. APA offers a diploma in behavioural psychology.

The Association for Behavioural and Cognitive Therapies (formerly the Association for the Advancement of Behaviour Therapy) is for those with a more cognitive orientation. The ABCT also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis. In addition, the Association for Behavioural and Cognitive Therapies has a special interest group on addictions.

Characteristics

By nature, behavioural therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behaviour ultimately has), probabilistic (viewing behaviour as statistically predictable), monistic (rejecting mind–body dualism and treating the person as a unit), and relational (analysing bidirectional interactions).

Behavioural therapy develops, adds and provides behavioural intervention strategies and programs for clients, and training to people who care to facilitate successful lives in various communities.

Training

Recent efforts in behavioural psychotherapy have focused on the supervision process. A key point of behavioural models of supervision is that the supervisory process parallels the behavioural psychotherapy provided.

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What is Relapse Prevention?

Published on 02/16/2022 by Andrew MarshallLeave a comment

Introduction

Relapse prevention (RP) is a cognitive-behavioural approach to relapse with the goal of identifying and preventing high-risk situations such as unhealthy substance use, obsessive-compulsive behaviour, sexual offending, obesity, and depression.

It is an important component in the treatment process for alcohol use disorder, or alcohol dependence.

Underlying Assumptions

Relapse is seen as both an outcome and a transgression in the process of behaviour change. An initial setback or lapse may translate into either a return to the previous problematic behaviour, known as relapse, or the individual turning again towards positive change, called prolapse. A relapse often occurs in the following stages: emotional relapse, mental relapse, and finally, physical relapse. Each stage is characterised by feelings, thoughts, and actions that ultimately lead to the individual’s returning to their old behaviour.

Relapse is thought to be multi-determined, especially by self-efficacy, outcome expectancies, craving, motivation, coping, emotional states, and interpersonal factors. In particular, high self-efficacy, negative outcome expectancies, potent availability of coping skills following treatment, positive affect, and functional social support are expected to predict positive outcome. Craving has not historically been shown to serve as a strong predictor of relapse.

Efficacy and Effectiveness

Carroll et al. conducted a review of 24 other trials and concluded that RP was more effective than no treatment and was equally effective as other active treatments such as supportive psychotherapy and interpersonal therapy in improving substance use outcomes. Irvin and colleagues also conducted a meta-analysis of RP techniques in the treatment of alcohol, tobacco, cocaine, and polysubstance use, and upon reviewing 26 studies, concluded that RP was successful in reducing substance use and improving psychosocial adjustment. RP seemed to be most effective for individuals with alcohol problems, suggesting that certain characteristics of alcohol use are amenable to the RP. Miller et al. (1996) found the GORSKI/CENAPS relapse warning signs to be a good predictor of the occurrence of relapse on the AWARE scale (r = .42, p < .001).

Prevention Approaches

General Prevention Theories

Some theorists, including Katie Witkiewitz and G. Alan Marlatt, borrowing ideas from systems theory, conceptualize relapse as a multidimensional, complex system. Such a nonlinear dynamical system is believed to be able to best predict the data witnessed, which commonly includes cases where small changes introduced into the equation seem to have large effects. The model also introduces concepts of self-organisation, feedback loops, timing/context effects, and the interplay between tonic and phasic processes.

Rami Jumnoodoo and Dr. Patrick Coyne, in London UK, have been working with National Health Service users and carers over the past ten years to transfer RP theory into the field of adult mental health. The uniqueness of the model is the sustainment of change by developing service users and carers as ‘experts’ – following RP as an educational process and graduating as Relapse Prevention Practitioners. The work has won many national awards, been presented at many conferences, and has resulted in many publications.

Terence Gorski MA has developed the CENAPS (Centre for Applied Science) model for relapse prevention including Relapse Prevention Counselling (Gorski, Counselling For Relapse Prevention, 1983) and a system for certification of Relapse Prevention Specialists (CRPS).

Depression

For the prevention of relapse in Major Depressive Disorder (MDD), several approaches and intervention programmes have been proposed. Mindfulness-based Cognitive Therapy is commonly used and was found to be effective in preventing relapse especially in patients with more pronounced residual symptoms. Another approach often used in patients who wish to taper down antidepressant medication is Preventive Cognitive Therapy, an 8-weeks lasting psychological intervention programme delivered in individual or group sessions that focuses on changing dysfunctional attitudes, enhancing memories of positive experiences and helping patients to develop personal relapse prevention strategies. Preventive Cognitive Therapy has been found to be equally effective in preventing a return of depressive symptoms as antidepressant medication use alone in the long-term treatment of MDD. In combination with pharmaceuticals, it was found to be even more effective than antidepressant use alone.

What is Body-Focused Repetitive Behaviour?

Published on 12/10/2021 by Andrew Marshall1 Comment

Introduction

Body-focused repetitive behaviour (BFRB) is an umbrella name for impulse control behaviours involving compulsively damaging one’s physical appearance or causing physical injury.

Body-focused repetitive behaviour disorders (BFRBDs) in ICD-11 is in development.

BFRB disorders are currently estimated to be under the obsessive-compulsive spectrum.

Cause(s)

The cause of BFRBs is unknown.

Emotional variables may have a differential impact on the expression of BFRBs.

Research has suggested that the urge to repetitive self-injury is similar to a BFRB but others have argued that for some the condition is more akin to a substance abuse disorder.

Researchers are investigating a possible genetic component.

Onset

BFRBs most often begin in late childhood or in the early teens.

Diagnosis

Types

The main BFRB disorders are:

Skin:
- Dermatillomania (excoriation disorder), skin picking.
- Dermatophagia, skin nibbling.
Mouth:
- Morsicatio buccarum, cheek biting.
- Morsicatio labiorum, inner lip biting.
- Morsicatio linguarum, tongue biting.
Hands:
- Onychophagia, nail biting.
- Onychotillomania, nail picking.
Nose:
- Rhinotillexomania, compulsive nose picking.
Hair:
- Trichophagia, hair nibbling.
- Trichotemnomania, hair cutting.
- Trichotillomania, hair pulling.
Eyes:
- Mucus fishing syndrome – compulsion to remove or “fish” strands of mucus from the eye.

Treatment

Psychotherapy

Treatment can include behaviour modification therapy, medication, and family therapy. The evidence base criteria for BFRBs is strict and methodical. Individual behavioural therapy has been shown as a “probably effective” evidence-based therapy to help with thumb sucking, and possibly nail biting. Cognitive behavioural therapy was cited as experimental evidence based therapy to treat trichotillomania and nail biting; a systematic review found best evidence for habit reversal training and decoupling. Another form of treatment that focuses on mindfulness, stimuli and rewards has proven effective in some people. However, no treatment was deemed well-established to treat any form of BFRBs.

Pharmacotherapy

Excoriation disorder, and trichotillomania have been treated with inositol and N-acetylcysteine.

Prevalence

BFRBs are among the most poorly understood, misdiagnosed, and undertreated groups of disorders. BFRBs may affect at least 1 out of 20 people. These collections of symptoms have been known for a number of years, but only recently have appeared in widespread medical literature. Trichotillomania alone is believed to affect 10 million people in the United States.

What is the Association for Behaviour Analysis International?

Published on 12/01/2021 by Andrew MarshallLeave a comment

Introduction

The Association for Behaviour Analysis International (ABAI) is a professional association of psychologists, educators, and practitioners whose scholarship and practice derive from the work of B.F. Skinner.

ABAI organises conferences in the US and abroad, publishes journals, and offers accreditation programs for behaviour analysis training programmes. As of March 2021, ABAI has 97 regional associate chapters both in the United States and abroad, many of which offer their own annual conferences. As of 2019, ABAI had over 9,000 members and membership in its affiliate chapters was greater than 28,000.

Refer to Clinical Behaviour Analysis, Applied Behaviour Analysis, and Licensed Behaviour Analyst.

Brief History

The Association for Behaviour Analysis International (ABAI) was founded in 1974 as the MidWestern Association for Behaviour Analysis (MABA) to serve as an interdisciplinary group of professionals, paraprofessionals, and students. Behaviour analysis was well-represented in the Midwest of the US, but many behaviour analysts were disappointed with the level of support their relatively new field received at the existing psychology conferences. Gerald Mertens and Israel Goldiamond organised the first two-day conference, which was held at the University of Chicago, and speakers included, Sidney Bijou, James Dinsmoor, Roger Ulrich and Goldiamond.

MABA’s first headquarters were located on the campus of Western Michigan University (WMU) in Kalamazoo, Michigan. By 1977, the annual conference was extended four days and included 550 events, and MABA had grown to 1,190 members from 42 states and five foreign countries.

In 1978, MABA began publishing its first journal, The Behaviour Analyst (renamed Perspectives in Behavioural Science in 2018), and in 1979, the organisation changed its name to the Association for Behaviour Analysis (ABA), subsequently adopting the name Association for Behaviour Analysis International (ABAI). In 2001, it sponsored its first international meeting in Venice, Italy.

Association for Behaviour Analysis (ABA) began offering APA credits for the first time in 1994, at their 20th Annual Convention in Atlanta, GA. While the BACB solidified itself in the field, ABA offered its first BACB credits in 2000 at their 26th Annual Convention in Washington, DC.

Activities

Conferences

ABAI organises conferences related to the theory and practice of behaviour analysis. In addition to the annual conference, which is held at a location in the US or Canada, every other year, ABAI hosts an international conference. The association also holds an annual autism conference and has hosted several single-track conferences on topics of special interest to behaviour analysts, such as theory and philosophy, climate change, behavioural economics, and education.

Many conference sessions offer approved continuing education credits (CEUs) for practitioners who wish to maintain their professional certification. Among the organisations that approve ABAI presentations for CEU credit are the American Psychological Association, the National Association of School Psychologists, and the Behaviour Analyst Certification Board.

Accreditation Programme

ABAI operates an accreditation programme for universities offering master’s and doctoral degrees in behaviour analysis. Degree programs that achieve ABAI accreditation meet the organization’s standards of training and will satisfy the Behaviour Analyst Certification Board requirements to achieve certification as a behaviour analyst.

Society for the Advancement of Behaviour Analysis

ABAI is supported by the Society for the Advancement of Behaviour Analysis (SABA), a 501(c)(3) organisation that accepts tax-exempt charitable contributions. SABA maintains a number of funds to support research in child development, international development, public awareness of behavioural science, and diversity, equity, and inclusion. SABA also provides grants to support student research, student travel to the annual ABAI conference, and graduate research focused on issues of diversity, equity, and inclusion.

Position Statements

As of 2021, ABAI had released six policy statements on: right to effective behavioural treatment (1989), student’s right to effective education (1990), facilitated communication (1995), restraint and seclusion (2010), sexual harassment (2019), and commitment to equity (2020).

Awards

SABA administers an awards programme at the annual convention of ABAI that recognises distinguished service to behaviour analysis, scientific translation, international dissemination of behaviour analysis, effective presentation of behaviour analysis in the mass media, and enduring programmatic contributions to behaviour analysis. Past recipients of the award for distinguished service to behaviour analysis include Sidney Bijou, James Dinsmoor, A. Charles Catania, Jack Michael and Murray Sidman.

Journals

The Association of Applied Behaviour Analysis International publishes six peer-reviewed journals.

Perspectives on Behaviour Science, is ABAI’s first journal, published from 1978-2017 as The Behaviour Analyst. It is a semiannual journal publishing articles on theoretical, experimental, and applied topics in behaviour analysis, including literature reviews, re-interpretations of published data, and articles on behaviourism as a philosophy.
The Analysis of Verbal Behaviour is a collection of experiments and theoretical papers regarding verbal behaviour and applied behaviour analysis.
Behaviour Analysis in Practice is a peer-reviewed journal that includes articles on how to efficiently practice applied behaviour analysis.
The Psychological Record includes articles concerning behavioural analysis, behavioural science, and behaviour theory. It was founded in 1937 by Jacob Robert Kantor. Its first experimental area editor was B.F. Skinner. After being published most recently at Southern Illinois University at Carbondale, the journal was adopted as an official publication of ABAI. The Psychological Record publishes empirical and conceptual articles related to the field of behaviour analysis, behaviour science, and behaviour theory.
Behaviour and Social Issues, is an interdisciplinary journal publishing articles analysing human social behaviour, particularly with regard to understanding and influencing significant social problems such as social justice, human rights, and sustainability.
Education and Treatment of Children.