What is Relapse Prevention?

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?

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?

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.

What is Behavioural Activation?

Introduction

Behavioural activation (BA) is a third generation behaviour therapy for treating depression.

It is one functional analytic psychotherapy which are based on a Skinnerian psychological model of behaviour change, generally referred to as applied behaviour analysis. This area is also a part of what is called clinical behaviour analysis (CBA) and makes up one of the most effective practices in the professional practice of behaviour analysis. The technique can also be used from a cognitive-behaviour therapy (CBT) framework.

Overview

The Beck Institute describes BA as “getting clients more active and involved in life by scheduling activities that have the potential to improve their mood.”

Theoretical Underpinnings

Behavioural activation emerged from a component analysis of cognitive behavioural therapy. This analysis found that any cognitive component added little to the overall treatment of depression. The behavioural component had existed as a stand-alone treatment in the early work of Peter Lewinsohn and thus a group of behaviourists decided that it might be more efficient to pursue a purer behavioural treatment for the disorder. The theory holds that not enough environmental reinforcement or too much environmental punishment can contribute to depression. The goal of the intervention is to increase environmental reinforcement and reduce punishment.

The theoretical underpinnings of behavioural activation for depression is Charles Ferster’s functional analysis of depression. Ferster’s basic model has been strengthened by further development in the study of reinforcement principles which led to the matching law and continuing theoretical advances in the possible functions of depression, as well as a look at behaviour analysis of child development in order to determine long-term patterns which may lead to dysthymia.

Methods

One behavioural activation approach to depression was as follows: participants were asked to create a hierarchy of reinforcing activities which were then rank-ordered by difficulty; participants tracked their own goals along with clinicians who used a token economy to reinforce success in moving through the hierarchy of activities; participants were measured before and after by the Beck Depression Inventory (BDI) and a great effect on their depression was found as a result of their treatment. This was then compared to a control group who did not receive the same treatment. The results of those who received behavioural activation treatment were markedly superior to those of the persons in the control group. Multiple clinics have since piloted and developed the treatment.

Another behavioural activation approach utilised a different methodology: clients are asked to develop an understanding of the relationship between actions and emotions, with actions being seen as the cause of emotions. An hourly self-monitoring chart is created to track activities and the impact on the mood they create for a full week. A rating scale from 1 to 10 is used for each mood change per hour. The goal is to identify depression loops. A depression loop is when a temporary coping method reduces the overall depression, such as the temporary relief provided by alcohol or other drugs, escape or avoidance or rumination. When patterns of dysfunctional responding, or loops, are identified alternative coping responses are attempted to break the loop. This method is described with the acronym “TRAP” (Trigger, Response, Avoidance Pattern) which is to be replaced with a “TRAC” (Trigger, Response, Alternate Coping response). Particular attention is given to rumination, which is provided with its own acronym RCA (Rumination Cues Action). Rumination is identified as a particularly common avoidance behaviour which worsens mood. The client is to evaluate the rumination in terms of it having improved the thing being ruminated about, providing understanding, and its emotional effects on the client. Attending to experience is suggested as an alternative to rumination as well as other possible distracting or mood improving actions.

The general program is described with the acronym ACTION (Assess behaviour/mood, Choose alternate responses, Try out those alternate responses, Integrate these alternatives, Observe results and (Now) evaluate). The goal being the understanding of the relationship between actions and emotional consequences and a systematic replacement of dysfunctional patterns with adaptive ones. Additionally, focus is given to quality sleep, and improving social functioning.

Research Support

Depression

Reviews of behavioural activation studies for depression found that it has a robust effect and that policy makers should consider it an effective treatment. A large-scale treatment study found behavioural activation to be more effective than cognitive therapy and on par with medication for treating depression. A meta-analysis study comprising 34 Randomised Control Trials found that while Behavioural Activation treatment of adults with depression showed significantly greater beneficial effect compared with control participants, compared to participants treated with CT/CBT, at post treatment there were no statistically significant differences between treatment groups. A 2009 meta-analysis showed a medium post-treatment effect size compared to psychotherapy and other treatments.

Anxiety

A 2006 study of behavioural activation being applied to anxiety appeared to give promising results. One study found it to be effective with fibromyalgia-related pain anxiety.

In the Context of Third Generation Behaviour Therapies

Behavioural activation comes under the heading clinical behaviour analysis or what is often termed third generation behaviour therapy. Other behaviour therapies are acceptance and commitment therapy (ACT), as well as dialectical behaviour therapy (DBT) and functional analytic psychotherapy (FAP). Behavioural activation owes its basis to Charles Ferster’s Functional Analysis of Depression (1973) which developed B.F. Skinner’s idea of depression, within his analysis of motivation, as a lack of reinforcement.

Professional Organisations

The Association for Behaviour Analysis International has a special interest group for practitioner issues, behavioural counselling, and clinical behaviour analysis. The association has larger special interest groups for behavioural medicine. It also serves as the core intellectual home for behaviour analysts.

The Association for Behavioural and Cognitive Therapies (ABCT) also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis.

Doctoral level behaviour analysts who are psychologists belong to the American Psychological Association’s division 25 -Behaviour analysis. APA offers a diplomate in behavioural psychology.

BA in Virtual Reality

Due to a lack of access to trained providers, physical constraints or financial reasons, many patients are not able to attend BA therapy. Researchers are trying to overcome these challenges by providing BA via Virtual Reality. The idea of the concept is to enable especially elderly adults to participate in engaging activities that they would not attend it without VR. Possibly, the so-called “BA-inspired VR protocols” will mitigate the lower mood, life satisfaction, and likelihood of depressions.

What is Applied Behaviour Analysis?

Introduction

Applied behaviour analysis (ABA), also called behavioural engineering, is a scientific technique concerned with applying empirical approaches based upon the principles of respondent and operant conditioning to change behaviour of social significance. It is the applied form of behaviour analysis; the other two forms are radical behaviourism (or the philosophy of the science) and the experimental analysis of behaviour (or basic experimental research).

The name applied behaviour analysis has replaced behaviour modification because the latter approach suggested attempting to change behaviour without clarifying the relevant behaviour-environment interactions. In contrast, ABA changes behaviour by first assessing the functional relationship between a targeted behaviour and the environment. Further, the approach often seeks to develop socially acceptable alternatives for aberrant behaviours.

ABA has been utilised in a range of areas, including applied animal behaviour, schoolwide positive behaviour support, classroom instruction, structured and naturalistic early behavioural interventions for autism, paediatric feeding therapy, rehabilitation of brain injury, dementia, fitness training, substance abuse, phobias, tics, and organisational behaviour management.

ABA is considered to be controversial by some within the autism rights movement due to a perception that it emphasizes indistinguishability instead of acceptance and a history of, in some embodiments of ABA and its predecessors, the use of aversives such as electric shocks.

Definition

ABA is an applied science devoted to developing procedures which will produce observable changes in behaviour. It is to be distinguished from the experimental analysis of behaviour, which focuses on basic experimental research, but it uses principles developed by such research, in particular operant conditioning and classical conditioning. Behaviour analysis adopts the viewpoint of radical behaviourism, treating thoughts, emotions, and other covert activity as behaviour that is subject to the same rules as overt responses. This represents a shift away from methodological behaviourism, which restricts behaviour-change procedures to behaviours that are overt, and was the conceptual underpinning of behaviour modification.

Behaviour analysts also emphasize that the science of behaviour must be a natural science as opposed to a social science. As such, behaviour analysts focus on the observable relationship of behaviour with the environment, including antecedents and consequences, without resort to “hypothetical constructs”.

Brief History

The beginnings of ABA can be traced back to Teodoro Ayllon and Jack Michael’s study “The psychiatric nurse as a behavioural engineer” (1959) that they published in the Journal of the Experimental Analysis of Behaviour (JEAB). Ayllon and Michael were training the staff and nurses at a psychiatric hospital how to use a token economy based on the principles of operant conditioning for patients with schizophrenia and intellectual disability, which led to researchers at the University of Kansas to start the Journal of Applied Behaviour Analysis (JABA) in 1968.

A group of faculty and researchers at the University of Washington, including Donald Baer, Sidney W. Bijou, Bill Hopkins, Jay Birnbrauer, Todd Risley, and Montrose Wolf, applied the principles of behaviour analysis to instruct developmentally disabled children, manage the behaviour of children and adolescents in juvenile detention centres, and organise employees who required proper structure and management in businesses, among other situations. In 1968, Baer, Bijou, Risley, Birnbrauer, Wolf, and James Sherman joined the Department of Human Development and Family Life at the University of Kansas, where they founded the Journal of Applied Behaviour Analysis.

Notable graduate students from the University of Washington include Robert Wahler, James Sherman, and Ivar Lovaas. Lovaas established the UCLA Young Autism Project while teaching at the University of California, Los Angeles. In 1965, Lovaas published a series of articles that outlined his system for coding observed behaviours, described a pioneering investigation of the antecedents and consequences that maintained a problem behaviour, and relied upon the methods of errorless learning that was initially devised by Charles Ferster to teach nonverbal children to speak. Lovaas also described how to use social (secondary) reinforcers, teach children to imitate, and what interventions (including electric shocks) may be used to reduce aggression and life-threatening self-injury.

In 1987, Lovaas published the study, “Behavioural treatment and normal educational and intellectual functioning in young autistic children”. The experimental group in this study received an average of 40 hours per week in a 1:1 teaching setting at a table using errorless discrete trial training (DTT). The treatment is done at home with parents involved in every aspect of treatment, and the curriculum is highly individualised with a heavy emphasis on teaching eye contact, fine and gross motor imitation, and language. The use of aversives and reinforcement, were used to motivate learning and reduce non-desired behaviours. The outcome of this study indicated 47% of the experimental group (9/19) went on to lose their autism diagnosis and were described as indistinguishable from their typical adolescent peers. This included passing regular education without assistance and making and maintaining friends. These gains were maintained as reported in the 1993 study, “Long-term outcome for children with autism who received early intensive behavioural treatment”. Lovaas’ work went on to be recognised by the US Surgeon General in 1999, and his research were replicated in university and private settings. The “Lovaas Method” went on to become known as early intensive behavioural intervention (EIBI), or 30 to 40 hours per week of DTT.

The original Lovaas method focused heavily on the use of aversives; utilising shocks, beating children, ignoring children, withholding food, etc. Using shocks, ignoring children, withholding food and toys, and spraying children with water are still used today and considered ethical by the Behaviour Analyst Certification Board (BACB). Another criticism of the Lovaas Method is Lovaas’s connection with gay conversion therapy, using his own behaviour modification techniques seen in ABA in The Feminine Boy project. Similarities in gay conversion therapy to making boys indistinguishable from their heterosexual peers have been drawn with Lovaas’ belief that ABA makes “autistic children indistinguishable from their normal friends.” He infamously said “‘[Y]ou start pretty much from scratch when you work with an autistic child…they are not people in the psychological sense”.

Over the years, “behaviour analysis” gradually superseded “behaviour modification”; that is, from simply trying to alter problematic behaviour, behaviour analysts sought to understand the function of that behaviour, what antecedents promote and maintain it, and how it can be replaced by successful behaviour. This analysis is based on careful initial assessment of a behaviour’s function and a testing of methods that produce changes in behaviour.

While ABA seems to be intrinsically linked to autism intervention, it is also used in a broad range of other situations. Recent notable areas of research in JABA include autism, classroom instruction with typically developing students, paediatric feeding therapy, and substance-use disorders. Other applications of ABA include applied animal behaviour, consumer behaviour analysis, behavioural medicine, behavioural neuroscience, clinical behaviour analysis, forensic behaviour analysis, increasing job safety and performance, schoolwide positive behaviour support, and contact desensitisation for phobias.

Characteristics

Baer, Wolf, and Risley’s 1968 article is still used as the standard description of ABA. It lists the following seven characteristics of ABA.

  • Applied: ABA focuses on the social significance of the behaviour studied. For example, a non-applied researcher may study eating behaviour because this research helps to clarify metabolic processes, whereas the applied researcher may study eating behaviour in individuals who eat too little or too much, trying to change such behaviour so that it is more acceptable to the persons involved.
  • Behavioural: ABA is pragmatic; it asks how it is possible to get an individual to do something effectively. To answer this question, the behaviour itself must be objectively measured. Verbal descriptions are treated as behaviour in themselves, and not as substitutes for the behaviour described.
  • Analytic: Behaviour analysis is successful when the analyst understands and can manipulate the events that control a target behaviour. This may be relatively easy to do in the lab, where a researcher is able to arrange the relevant events, but it is not always easy, or ethical, in an applied situation. Baer et al. outline two methods that may be used in applied settings to demonstrate control while maintaining ethical standards. These are the reversal design and the multiple baseline design. In the reversal design, the experimenter first measures the behaviour of choice, introduces an intervention, and then measures the behaviour again. Then, the intervention is removed, or reduced, and the behaviour is measured yet again. The intervention is effective to the extent that the behaviour changes and then changes back in response to these manipulations. The multiple baseline method may be used for behaviours that seem irreversible. Here, several behaviours are measured and then the intervention is applied to each in turn. The effectiveness of the intervention is revealed by changes in just the behaviour to which the intervention is being applied.
  • Technological: The description of analytic research must be clear and detailed, so that any competent researcher can repeat it accurately. Cooper et al. describe a good way to check this: Have a person trained in applied behaviour analysis read the description and then act out the procedure in detail. If the person makes any mistakes or has to ask any questions then the description needs improvement.
  • Conceptually Systematic: Behaviour analysis should not simply produce a list of effective interventions. Rather, to the extent possible, these methods should be grounded in behavioural principles. This is aided by the use of theoretically meaningful terms, such as “secondary reinforcement” or “errorless discrimination” where appropriate.
  • Effective: Though analytic methods should be theoretically grounded, they must be effective. If an intervention does not produce a large enough effect for practical use, then the analysis has failed
  • Generality: Behaviour analysts should aim for interventions that are generally applicable; the methods should work in different environments, apply to more than one specific behaviour, and have long-lasting effects.

Other proposed Characteristics

In 2005, Heward et al. suggested that the following five characteristics should be added:

  • Accountable: To be accountable means that ABA must be able to demonstrate that its methods are effective. This requires the repeatedly measuring the effect of interventions (success, failure or no effect at all), and, if necessary, making changes that improve their effectiveness.
  • Public: The methods, results, and theoretical analyses of ABA must be published and open to scrutiny. There are no hidden treatments or mystical, metaphysical explanations.
  • Doable: To be generally useful, interventions should be available to a variety of individuals, who might be teachers, parents, therapists, or even those who wish to modify their own behaviour. With proper planning and training, many interventions can be applied by almost anyone willing to invest the effort.
  • Empowering: ABA provides tools that give the practitioner feedback on the results of interventions. These allow clinicians to assess their skill level and build confidence in their effectiveness.
  • Optimistic: According to several leading authors, behaviour analysts have cause to be optimistic that their efforts are socially worthwhile, for the following reasons:
    • The behaviours impacted by behaviour analysis are largely determined by learning and controlled by manipulable aspects of the environment.
    • Practitioners can improve performance by direct and continuous measurements.
    • As a practitioner uses behavioural techniques with positive outcomes, they become more confident of future success.
    • The literature provides many examples of success in teaching individuals considered previously unteachable.

Concepts

Behaviour

Behaviour refers to the movement of some part of an organism that changes some aspect of the environment. Often, the term behaviour refers to a class of responses that share physical dimensions or functions, and in that case a response is a single instance of that behaviour. If a group of responses have the same function, this group may be called a response class. Repertoire refers to the various responses available to an individual; the term may refer to responses that are relevant to a particular situation, or it may refer to everything a person can do.

Operant Conditioning

Operant behaviour is the so-called “voluntary” behaviour that is sensitive to, or controlled by its consequences. Specifically, operant conditioning refers to the three-term contingency that uses stimulus control, in particular an antecedent contingency called the discriminative stimulus (SD) that influences the strengthening or weakening of behaviour through such consequences as reinforcement or punishment. The term is used quite generally, from reaching for a candy bar, to turning up the heat to escape an aversive chill, to studying for an exam to get good grades.

Respondent (Classical) Conditioning

Respondent (classical) conditioning is based on innate stimulus-response relationships called reflexes. In his famous experiments with dogs, Pavlov usually used the salivary reflex, namely salivation (unconditioned response) following the taste of food (unconditioned stimulus). Pairing a neutral stimulus, for example a bell (conditioned stimulus) with food caused the dog to elicit salivation (conditioned response). Thus, in classical conditioning, the conditioned stimulus becomes a signal for a biologically significant consequence. Note that in respondent conditioning, unlike operant conditioning, the response does not produce a reinforcer or punisher (e.g. the dog does not get food because it salivates).

Reinforcement

Reinforcement is the key element in operant conditioning and in most behaviour change programmes. It is the process by which behaviour is strengthened. If a behaviour is followed closely in time by a stimulus and this results in an increase in the future frequency of that behaviour, then the stimulus is a positive reinforcer. If the removal of an event serves as a reinforcer, this is termed negative reinforcement. There are multiple schedules of reinforcement that affect the future probability of behaviour.

Punishment

Punishment is a process by which a consequence immediately follows a behaviour which decreases the future frequency of that behaviour. As with reinforcement, a stimulus can be added (positive punishment) or removed (negative punishment). Broadly, there are three types of punishment: presentation of aversive stimuli (e.g. pain), response cost (removal of desirable stimuli as in monetary fines), and restriction of freedom (as in a ‘time out’). Punishment in practice can often result in unwanted side effects. Some other potential unwanted effects include resentment over being punished, attempts to escape the punishment, expression of pain and negative emotions associated with it, and recognition by the punished individual between the punishment and the person delivering it.

Extinction

Extinction is the technical term to describe the procedure of withholding/discontinuing reinforcement of a previously reinforced behaviour, resulting in the decrease of that behaviour. The behaviour is then set to be extinguished (Cooper et al.). Extinction procedures are often preferred over punishment procedures, as many punishment procedures are deemed unethical and in many states prohibited. Nonetheless, extinction procedures must be implemented with utmost care by professionals, as they are generally associated with extinction bursts. An extinction burst is the temporary increase in the frequency, intensity, and/or duration of the behaviour targeted for extinction. Other characteristics of an extinction burst include an extinction-produced aggression – the occurrence of an emotional response to an extinction procedure often manifested as aggression; and b) extinction-induced response variability – the occurrence of novel behaviours that did not typically occur prior to the extinction procedure. These novel behaviours are a core component of shaping procedures.

Discriminated Operant and Three-Term Contingency

In addition to a relation being made between behaviour and its consequences, operant conditioning also establishes relations between antecedent conditions and behaviours. This differs from the S-R formulations (If-A-then-B), and replaces it with an AB-because-of-C formulation. In other words, the relation between a behaviour (B) and its context (A) is because of consequences (C), more specifically, this relationship between AB because of C indicates that the relationship is established by prior consequences that have occurred in similar contexts. This antecedent-behaviour-consequence contingency is termed the three-term contingency. A behaviour which occurs more frequently in the presence of an antecedent condition than in its absence is called a discriminated operant. The antecedent stimulus is called a discriminative stimulus (SD). The fact that the discriminated operant occurs only in the presence of the discriminative stimulus is an illustration of stimulus control. More recently behaviour analysts have been focusing on conditions that occur prior to the circumstances for the current behaviour of concern that increased the likelihood of the behaviour occurring or not occurring. These conditions have been referred to variously as “Setting Event”, “Establishing Operations”, and “Motivating Operations” by various researchers in their publications.

Verbal Behaviour

B.F. Skinner’s classification system of behaviour analysis has been applied to treatment of a host of communication disorders. Skinner’s system includes:

  • Tact: A verbal response evoked by a non-verbal antecedent and maintained by generalised conditioned reinforcement.
  • Mand: Behaviour under control of motivating operations maintained by a characteristic reinforcer.
  • Intraverbals: Verbal behaviour for which the relevant antecedent stimulus was other verbal behaviour, but which does not share the response topography of that prior verbal stimulus (e.g. responding to another speaker’s question).
  • Autoclitic: Secondary verbal behaviour which alters the effect of primary verbal behaviour on the listener. Examples involve quantification, grammar, and qualifying statements (e.g. the differential effects of “I think…” vs. “I know…”)

Skinner’s use of behavioural techniques was famously critiqued by the linguist Noam Chomsky through an extensive breakdown of how Skinner’s view of language as behavioural simply can not explain the complexity of human language. This suggests that while behaviourist techniques can teach language, it is a very poor measure to explain language fundamentals. Considering Chomsky’s critiques, it may be more appropriate to teach language through a Speech language pathologist instead of a behaviourist.

For an assessment of verbal behaviour from Skinner’s system, refer to Assessment of Basic Language and Learning Skills.

Measuring Behaviour

When measuring behaviour, there are both dimensions of behaviour and quantifiable measures of behaviour. In applied behaviour analysis, the quantifiable measures are a derivative of the dimensions. These dimensions are repeatability, temporal extent, and temporal locus.

Repeatability

Response classes occur repeatedly throughout time – i.e. how many times the behaviour occurs.

  • Count is the number of occurrences in behaviour.
  • Rate/frequency is the number of instances of behaviour per unit of time.
  • Celeration is the measure of how the rate changes over time.

Temporal Extent

This dimension indicates that each instance of behaviour occupies some amount of time – i.e. how long the behaviour occurs.

  • Duration is the period of time over which the behaviour occurs.

Temporal Locus

Each instance of behaviour occurs at a specific point in time – i.e. when the behaviour occurs.

  • Response latency is the measure of elapsed time between the onset of a stimulus and the initiation of the response.
  • Inter-response time is the amount of time that occurs between two consecutive instances of a response class.

Derivative Measures

Derivative measures are unrelated to specific dimensions:

  • Percentage is the ratio formed by combining the same dimensional quantities.
  • Trials-to-criterion are the number of response opportunities needed to achieve a predetermined level of performance.

Analysing Behaviour Change

Experimental Control

In applied behaviour analysis, all experiments should include the following:

  • At least one participant.
  • At least one behaviour (dependent variable).
  • At least one setting.
  • A system for measuring the behaviour and ongoing visual analysis of data.
  • At least one treatment or intervention condition.
  • Manipulations of the independent variable so that its effects on the dependent variable may be quantitatively or qualitatively analysed.
  • An intervention that will benefit the participant in some way.

Methodologies Developed through ABA Research

Task Analysis

Task analysis is a process in which a task is analysed into its component parts so that those parts can be taught through the use of chaining: forward chaining, backward chaining and total task presentation. Task analysis has been used in organizational behaviour management, a behaviour analytic approach to changing the behaviours of members of an organization (e.g. factories, offices, or hospitals). Behavioural scripts often emerge from a task analysis. Bergan conducted a task analysis of the behavioural consultation relationship and Thomas Kratochwill developed a training program based on teaching Bergan’s skills. A similar approach was used for the development of microskills training for counsellors. Ivey would later call this “behaviourist” phase a very productive one and the skills-based approach came to dominate counselor training during 1970-1990. Task analysis was also used in determining the skills needed to access a career. In education, Englemann (1968) used task analysis as part of the methods to design the Direct Instruction curriculum.

Chaining

The skill to be learned is broken down into small units for easy learning. For example, a person learning to brush teeth independently may start with learning to unscrew the toothpaste cap. Once they have learned this, the next step may be squeezing the tube, etc.

For problem behaviour, chains can also be analysed and the chain can be disrupted to prevent the problem behaviour. Some behaviour therapies, such as dialectical behaviour therapy, make extensive use of behaviour chain analysis, but is not philosophically behaviour analytic.

Prompting

A prompt is a cue that is used to encourage a desired response from an individual. Prompts are often categorised into a prompt hierarchy from most intrusive to least intrusive, although there is some controversy about what is considered most intrusive, those that are physically intrusive or those that are hardest prompt to fade (e.g. verbal). In order to minimise errors and ensure a high level of success during learning, prompts are given in a most-to-least sequence and faded systematically. During this process, prompts are faded as quickly as possible so that the learner does not come to depend on them and eventually behaves appropriately without prompting.

Types of prompts Prompters might use any or all of the following to suggest the desired response:

  • Vocal prompts: Words or other vocalisations.
  • Visual prompts: A visual cue or picture.
  • Gestural prompts: A physical gesture.
  • Positional prompt: e.g. the target item is placed close to the individual.
  • Modelling: Modelling the desired response. This type of prompt is best suited for individuals who learn through imitation and can attend to a model.
  • Physical prompts: Physically manipulating the individual to produce the desired response. There are many degrees of physical prompts, from quite intrusive (e.g. the teacher places a hand on the learner’s hand) to minimally intrusive (e.g. a slight tap).

This is not an exhaustive list of prompts; the nature, number, and order of prompts are chosen to be the most effective for a particular individual.

Fading

The overall goal is for an individual to eventually not need prompts. As an individual gains mastery of a skill at a particular prompt level, the prompt is faded to a less intrusive prompt. This ensures that the individual does not become overly dependent on a particular prompt when learning a new behaviour or skill.

Thinning a Reinforcement Schedule

Thinning is often confused with fading. Fading refers to a prompt being removed, where thinning refers to an increase in the time or number of responses required between reinforcements. Periodic thinning that produces a 30% decrease in reinforcement has been suggested as an efficient way to thin. Schedule thinning is often an important and neglected issue in contingency management and token economy systems, especially when these are developed by unqualified practitioners (refer to professional practice of behaviour analysis).

Generalisation

Generalisation is the expansion of a student’s performance ability beyond the initial conditions set for acquisition of a skill. Generalisation can occur across people, places, and materials used for teaching. For example, once a skill is learned in one setting, with a particular instructor, and with specific materials, the skill is taught in more general settings with more variation from the initial acquisition phase. For example, if a student has successfully mastered learning colours at the table, the teacher may take the student around the house or school and generalise the skill in these more natural environments with other materials. Behaviour analysts have spent considerable amount of time studying factors that lead to generalisation.

Shaping

Shaping involves gradually modifying the existing behaviour into the desired behaviour. If the student engages with a dog by hitting it, then they could have their behaviour shaped by reinforcing interactions in which they touch the dog more gently. Over many interactions, successful shaping would replace the hitting behaviour with patting or other gentler behaviour. Shaping is based on a behaviour analyst’s thorough knowledge of operant conditioning principles and extinction. Recent efforts to teach shaping have used simulated computer tasks.

One teaching technique found to be effective with some students, particularly children, is the use of video modelling (the use of taped sequences as exemplars of behaviour). It can be used by therapists to assist in the acquisition of both verbal and motor responses, in some cases for long chains of behaviour.

Interventions Based on an FBA

Critical to behaviour analytic interventions is the concept of a systematic behavioural case formulation with a functional behavioural assessment or analysis at the core. This approach should apply a behaviour analytic theory of change (see Behavioural change theories). This formulation should include a thorough functional assessment, a skills assessment, a sequential analysis (behaviour chain analysis), an ecological assessment, a look at existing evidenced-based behavioural models for the problem behaviour (such as Fordyce’s model of chronic pain) and then a treatment plan based on how environmental factors influence behaviour. Some argue that behaviour analytic case formulation can be improved with an assessment of rules and rule-governed behaviour. Some of the interventions that result from this type of conceptualisation involve training specific communication skills to replace the problem behaviours as well as specific setting, antecedent, behaviour, and consequence strategies.

Use in the Treatment of Autism Spectrum Disorders

ABA-based techniques are often used to teach adaptive behaviours or to diminish behaviours associated with autism, so much that ABA itself is often mistakenly considered to be synonymous with therapy for autism. According to a paper from 2007, it was considered to be an effective “intervention for challenging behaviours” by the American Academy of Paediatrics. A 2018 Cochrane review of five studies that compared treatment vs. control showed that ABA may be effective for some autistic children. However, the quality of the evidence was weak; the number of subjects in the studies was small, and only one study randomised subjects into control and treatment groups. ABA for autism may be limited by diagnostic severity and IQ.

Efficacy

Recent reviews of the efficacy of ABA-based techniques in autism include:

  • A 2007 clinical report of the American Academy of Paediatrics concluded that the benefit of ABA-based interventions in autism spectrum disorders (ASDs) “has been well documented” and that “children who receive early intensive behavioural treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behaviour as well as some measures of social behaviour”.
  • Researchers from the MIND Institute published an evidence-based review of comprehensive treatment approaches in 2008. On the basis of “the strength of the findings from the four best-designed, controlled studies”, they were of the opinion that one ABA-based approach (the Lovaas technique created by Ole Ivar Løvaas) is “well-established” for improving intellectual performance of young children with ASD.
  • A 2009 review of psycho-educational interventions for children with autism whose mean age was six years or less at intake found that five high-quality (“Level 1” or “Level 2”) studies assessed ABA-based treatments. On the basis of these and other studies, the author concluded that ABA is “well-established” and is “demonstrated effective in enhancing global functioning in pre-school children with autism when treatment is intensive and carried out by trained therapists”. However, the review committee also concluded that “there is a great need for more knowledge about which interventions are most effective”.
  • A 2009 paper included a descriptive analysis, an effect size analysis, and a meta-analysis of 13 reports published from 1987 to 2007 of early intensive behavioural intervention (EIBI, a form of ABA-based treatment with origins in the Lovaas technique) for autism. It determined that EIBI’s effect sizes were “generally positive” for IQ, adaptive behaviour, expressive language, and receptive language. The paper did note limitations of its findings including the lack of published comparisons between EIBI and other “empirically validated treatment programmes”.
  • In a 2009 systematic review of 11 studies published from 1987 to 2007, the researchers wrote “there is strong evidence that EIBI is effective for some, but not all, children with autism spectrum disorders, and there is wide variability in response to treatment”. Furthermore, any improvements are likely to be greatest in the first year of intervention.
  • A 2009 meta-analysis of nine studies published from 1987 to 2007 concluded that EIBI has a “large” effect on full-scale intelligence and a “moderate” effect on adaptive behaviour in autistic children.
  • A 2009 systematic review and meta-analysis by Spreckley and Boyd of four small-n 2000-2007 studies (involving a total of 76 children) came to different conclusions than the aforementioned reviews. Spreckley and Boyd reported that applied behaviour intervention (ABI), another name for EIBI, did not significantly improve outcomes compared with standard care of preschool children with ASD in the areas of cognitive outcome, expressive language, receptive language, and adaptive behaviour. In a letter to the editor, however, authors of the four studies meta-analysed claimed that Spreckley and Boyd had misinterpreted one study comparing two forms of ABI with each other as a comparison of ABI with standard care, which erroneously decreased the observed efficacy of ABI. Furthermore, the four studies’ authors raised the possibility that Spreckley and Boyd had excluded some other studies unnecessarily, and that including such studies could have led to a more favourable evaluation of ABI. Spreckley, Boyd, and the four studies’ authors did agree that large multi-site randomised trials are needed to improve the understanding of ABA’s efficacy in autism.
  • In 2011, investigators from Vanderbilt University under contract with the Agency for Healthcare Research and Quality performed a comprehensive review of the scientific literature on ABA-based and other therapies for autism spectrum disorders; the ABA-based therapies included the UCLA/Lovaas method and the Early Start Denver Model (the latter developed by Sally Rogers and Geraldine Dawson). They concluded that “both approaches were associated with … improvements in cognitive performance, language skills, and adaptive behaviour skills”. However, they also concluded that “the strength of evidence … is low”, “many children continue to display prominent areas of impairment”, “subgroups may account for a majority of the change”, there is “little evidence of practical effectiveness or feasibility beyond research studies”, and the published studies “used small samples, different treatment approaches and duration, and different outcome measurements”.
  • A 2019 review article concluded ABA proponents have utilised predominantly non-verbal and neurologically different, children who are not recognised under this paradigm to have their own thought processes, basic needs, preferences, style of learning, and psychological and emotional needs, for their experiment. This also indicates a missing voice of children and nonverbal people who cannot express their view on ABA.
  • A preliminary study indicates that there might be a publication bias against single-subject research studies that show that ABA is ineffective. Publication bias could lead to exaggerated estimates of intervention effects observed by single-subject studies.

Opposition to the Use in Treatment of Autism Spectrum Disorder

The Autistic Community

The value of eliminating autistic behaviours is disputed by proponents of neurodiversity, who claim that it forces autistics to mask their true personalities on behalf of a narrow conception of normality. Autism advocates contend that it is cruel to try to make autistic people “normal” without consideration for how this may affect their well-being. Instead, these critics advocate for increased social acceptance of harmless autistic traits and therapies focused on improving quality of life. Julia Bascom of the Autistic Self Advocacy Network (ASAN) has said, “ASAN’s objection is fundamentally an ethical one. The stated end goal of ABA is an autistic child who is ‘indistinguishable from their peers’ – an autistic child who can pass as neurotypical. We don’t think that’s an acceptable goal. The end goal of all services, supports, interventions, and therapies an autistic child receives should be to support them in growing up into an autistic adult who is happy, healthy, and living a self-determined life.” A recent study examined perspectives of autistic adults that received ABA as children and found that the overwhelming majority reported that “behaviourist methods create painful lived experiences”, that ABA led to the “erosion of the true actualising self”, and that they felt they had a “lack of self-agency within interpersonal experiences.”

Professional Concerns

Professionals against ABA have voiced concerns over it’s evolution from Radical behaviourism. Radical behaviourism when applied views the individual as nothing more than a stimulus-response, that all of their experience can be reduced to a set of behavioural functions and manipulated through operant conditioning which only addresses “the surface level” and may only temporarily subdue aggressive behaviour under the guise that it is addressed because the subject appears content. Other concerns have focused on the “ideological zealotry” surrounding it, where ABA journals and websites have claimed that it “cures” autism and is “the only evidence based autism therapy” which has restricted access to other therapies that are also evidence based like TEACCH. The rhetoric surrounding the virtues of ABA has concerning effects including parents and professionals that claim that ABA “cured” their child’s autism, like one parent who “…claims that ABA had saved her children’s lives, likening it to chemotherapy as a treatment for cancer.”

Researchers have critiqued the leniency of the ABA ethical code, discussing how it does not restrict or clarify the “appropriate use of aversives”, it does not require competency so ABA therapists are “not required to take even a single class on autism, brain function or child development” , and its view of the client as the parent so requiring “client consent” only requires parental consent, not the person receiving services. Similarly, because the parent is seen as the client, the goals that are set under the ethical code are according to the client’s needs, which means focusing on changing autistic behaviours for the benefit of the parent and not the child is considered ethical.

Besides ethics, scientists also have concerns over the methodological issues rampant through the evidence that ABA claims supports the therapy. Early ABA research regularly employed poor methodology, including the initial study by Lovaas that supposedly supported the use of the therapy. The study by Lovaas used a self-selected sample of autistic children with high IQ and many early and present studies also employed this poor sampling with a lack of randomization, researcher-selected samples, samples pulled from researchers’ own clinics, and funding by ABA organizations with a clear conflict of interest for proving ABA is effective. Another concern is that ABA research only measures behaviour as a means of success, which has led to a lack of qualitative research about autistic experiences of ABA, a lack of research examining the internal effects of ABA and a lack of research for autistic children who are non-speaking or have comorbid intellectual disabilities (which is concerning considering this is one of the major populations that intensive ABA focuses on). Research is also lacking about whether ABA is effective long-term and very little longitudinal outcomes have been studied.

Use of Aversives

Some embodiments of applied behaviour analysis as devised by Ole Ivar Lovaas used aversives such as electric shocks to modify undesirable behaviour in their initial use in the 1970s, as well as slapping and shouting in the landmark 1987 study. Over time the use of aversives lessened and in 2012 their use was described as being inconsistent with contemporary practice. However, aversives have continued to be used in some ABA programs. In comments made in 2014 to the US Food and Drug Administration (FDA), a clinician who previously worked at the Judge Rotenberg Educational Centre claimed that “all textbooks used for thorough training of applied behaviour analysts include an overview of the principles of punishment, including the use of electrical stimulation.” In 2020, the FDA banned the use of electrical stimulation devices used for self-injurious or aggressive behaviour and asserted that “Evidence indicates a number of significant psychological and physical risks are associated with the use of these devices, including worsening of underlying symptoms, depression, anxiety, posttraumatic stress disorder, pain, burns and tissue damage.”

Major Journals

Applied behaviour analysts publish in many journals. Some examples of “core” behaviour analytic journals are:

  • Journal of Applied Behaviour Analysis.
  • Journal of the Experimental Analysis of Behaviour.
  • Behaviour Analysis: Research and Practice.
  • The Behaviour Analyst Today.
  • Perspectives on Behaviour Science (formerly The Behaviour Analyst until 2018).
  • The Psychological Record.
  • The Journal of Speech-Language Pathology and Applied Behaviour Analysis.
  • Journal of Early and Intensive Behaviour Interventions.
  • The International Journal of Behavioural Consultation and Therapy.
  • The Journal of Behavioural Assessment and Intervention in Children.
  • The Behavioural Development Bulletin.
  • Behaviour and Social Issues.
  • Journal of Behaviour Analysis of Sports, Health, Fitness, and Behavioural Medicine.
  • Journal of Behaviour Analysis of Offender and Victim: Treatment and Prevention.
  • Behavioural Health and Medicine.
  • Applied Animal Behaviour Science.
  • Behaviour Therapy.
  • Behaviour and Philosophy.

What is Psychical Inertia?

Introduction

Psychical inertia is a term introduced by Carl Jung to describe the psyche’s resistance to development and change.

He considered it one of the main reason for the neurotic opposing, or shrinking from, his or her age-appropriate tasks in life.

Refer to Repetition Compulsion.

Freudian and Other Developments

Freud argued that such psychic inertia played a part in the lives of the normal, as well as of the neurotic, and saw its origins in fixation between early instincts and their first impressions of significant objects. As late as Civilization and its Discontents (his 1930 book), he considered as a major obstacle to cultural development “the inertia of the libido, its disinclination to give up an old position for a new one”.

Later Jungians have seen psychic inertia as a force of nature reflecting both internal and outer determinants; while others have seen it as a product of social pressures, especially in relation to ageing.

What is Applied Behaviour Analysis?

Introduction

Applied Behaviour Analysis (ABA), also called behavioural engineering, is a scientific technique concerned with applying empirical approaches based upon the principles of respondent and operant conditioning to change behaviour of social significance.

It is the applied form of behaviour analysis; the other two forms are:

  • Radical behaviourism (or the philosophy of the science); and the
  • Experimental analysis of behaviour (or basic experimental research).

The name “applied behaviour analysis” has replaced behaviour modification because the latter approach suggested attempting to change behaviour without clarifying the relevant behaviour-environment interactions. In contrast, ABA changes behaviour by first assessing the functional relationship between a targeted behaviour and the environment. Further, the approach often seeks to develop socially acceptable alternatives for aberrant behaviours.

ABA has been utilised in a range of areas, including applied animal behaviour, schoolwide positive behaviour support, classroom instruction, structured and naturalistic early behavioural interventions for autism, paediatric feeding therapy, rehabilitation of brain injury, dementia, fitness training, substance abuse, phobias, tics, and organisational behaviour management.

ABA is considered to be controversial by some within the autism rights movement due to a perception that it emphasizes indistinguishability instead of acceptance and a history of, in some embodiments of ABA and its predecessors, the use of aversives such as electric shocks.

Definition

ABA is an applied science devoted to developing procedures which will produce observable changes in behaviour. It is to be distinguished from the experimental analysis of behaviour, which focuses on basic experimental research, but it uses principles developed by such research, in particular operant conditioning and classical conditioning. Behaviour analysis adopts the viewpoint of radical behaviourism, treating thoughts, emotions, and other covert activity as behaviour that is subject to the same rules as overt responses. This represents a shift away from methodological behaviourism, which restricts behaviour-change procedures to behaviours that are overt, and was the conceptual underpinning of behaviour modification.

Behaviour analysts also emphasize that the science of behaviour must be a natural science as opposed to a social science. As such, behaviour analysts focus on the observable relationship of behaviour with the environment, including antecedents and consequences, without resort to “hypothetical constructs”.

Brief History

The beginnings of ABA can be traced back to Teodoro Ayllon and Jack Michael’s study “The psychiatric nurse as a behavioural engineer” (1959) that they published in the Journal of the Experimental Analysis of Behaviour (JEAB). Ayllon and Michael were training the staff and nurses at a psychiatric hospital how to use a token economy based on the principles of operant conditioning for patients with schizophrenia and intellectual disability, which led to researchers at the University of Kansas to start the Journal of Applied Behaviour Analysis (JABA) in 1968.

A group of faculty and researchers at the University of Washington, including Donald Baer, Sidney W. Bijou, Bill Hopkins, Jay Birnbrauer, Todd Risley, and Montrose Wolf, applied the principles of behavior analysis to instruct developmentally disabled children, manage the behaviour of children and adolescents in juvenile detention centres, and organise employees who required proper structure and management in businesses, among other situations. In 1968, Baer, Bijou, Risley, Birnbrauer, Wolf, and James Sherman joined the Department of Human Development and Family Life at the University of Kansas, where they founded the Journal of Applied Behaviour Analysis.

Notable graduate students from the University of Washington include Robert Wahler, James Sherman, and Ivar Lovaas. Lovaas established the UCLA Young Autism Project while teaching at the University of California, Los Angeles. In 1965, Lovaas published a series of articles that outlined his system for coding observed behaviours, described a pioneering investigation of the antecedents and consequences that maintained a problem behaviour, and relied upon the methods of errorless learning that was initially devised by Charles Ferster to teach nonverbal children to speak. Lovaas also described how to use social (secondary) reinforcers, teach children to imitate, and what interventions (including electric shocks) may be used to reduce aggression and life-threatening self-injury.

In 1987, Lovaas published the study, “Behavioural treatment and normal educational and intellectual functioning in young autistic children”. The experimental group in this study received up to 40 hours per week in a 1:1 teaching setting at a table using errorless discrete trial training (DTT). The treatment is done at home with parents involved in every aspect of treatment, and the curriculum is highly individualized with a heavy emphasis on teaching eye contact, fine and gross motor imitation, and language. ABA principles were used to motivate learning and reduce non-desired behaviours. The outcome of this study indicated 47% of the experimental group (9/19) went on to lose their autism diagnosis and were described as indistinguishable from their typical adolescent peers. This included passing regular education without assistance, making and maintaining friends, and becoming self-sufficient as adults. These gains were maintained as reported in the 1993 study, “Long-term outcome for children with autism who received early intensive behavioural treatment”. Lovaas’ work went on to be recognised by the US Surgeon General in 1999, and his research were replicated in university and private settings. The “Lovaas Method” went on to become known as early intensive behavioural intervention (EIBI), or 30 to 40 hours per week of DTT.

Over the years, “behaviour analysis” gradually superseded “behaviour modification”; that is, from simply trying to alter problematic behaviour, behaviour analysts sought to understand the function of that behaviour, what antecedents promote and maintain it, and how it can be replaced by successful behaviour. This analysis is based on careful initial assessment of a behaviour’s function and a testing of methods that produce changes in behaviour.

While ABA seems to be intrinsically linked to autism intervention, it is also used in a broad range of other situations. Recent notable areas of research in JABA include autism, classroom instruction with typically developing students, paediatric feeding therapy, and substance-use disorders. Other applications of ABA include applied animal behaviour, consumer behaviour analysis, behavioural medicine, behavioural neuroscience, clinical behaviour analysis, forensic behaviour analysis, increasing job safety and performance, schoolwide positive behaviour support, and contact desensitisation for phobias.

Characteristics

Baer, Wolf, and Risley’s 1968 article is still used as the standard description of ABA. It lists the following seven characteristics of ABA.

  • Applied:
    • ABA focuses on the social significance of the behaviour studied.
    • For example, a non-applied researcher may study eating behaviour because this research helps to clarify metabolic processes, whereas the applied researcher may study eating behaviour in individuals who eat too little or too much, trying to change such behaviour so that it is more acceptable to the persons involved.
  • Behavioural:
    • ABA is pragmatic; it asks how it is possible to get an individual to do something effectively.
    • To answer this question, the behaviour itself must be objectively measured.
    • Verbal descriptions are treated as behaviour in themselves, and not as substitutes for the behaviour described.
  • Analytic:
    • Behaviour analysis is successful when the analyst understands and can manipulate the events that control a target behaviour.
    • This may be relatively easy to do in the lab, where a researcher is able to arrange the relevant events, but it is not always easy, or ethical, in an applied situation.
    • Baer et al. outline two methods that may be used in applied settings to demonstrate control while maintaining ethical standards.
    • These are the reversal design and the multiple baseline design.
    • In the reversal design, the experimenter first measures the behaviour of choice, introduces an intervention, and then measures the behaviour again.
    • Then, the intervention is removed, or reduced, and the behaviour is measured yet again.
    • The intervention is effective to the extent that the behaviour changes and then changes back in response to these manipulations.
    • The multiple baseline method may be used for behaviours that seem irreversible.
    • Here, several behaviours are measured and then the intervention is applied to each in turn.
    • The effectiveness of the intervention is revealed by changes in just the behaviour to which the intervention is being applied.
  • Technological:
    • The description of analytic research must be clear and detailed, so that any competent researcher can repeat it accurately.
    • Cooper et al. describe a good way to check this: Have a person trained in applied behaviour analysis read the description and then act out the procedure in detail.
    • If the person makes any mistakes or has to ask any questions then the description needs improvement.
  • Conceptually Systematic:
    • Behaviour analysis should not simply produce a list of effective interventions.
    • Rather, to the extent possible, these methods should be grounded in behavioural principles.
    • This is aided by the use of theoretically meaningful terms, such as “secondary reinforcement” or “errorless discrimination” where appropriate.
  • Effective:
    • Though analytic methods should be theoretically grounded, they must be effective.
    • If an intervention does not produce a large enough effect for practical use, then the analysis has failed
  • Generality:
    • Behaviour analysts should aim for interventions that are generally applicable; the methods should work in different environments, apply to more than one specific behaviour, and have long-lasting effects.

Other Proposed Characteristics

In 2005, Heward et al. suggested that the following five characteristics should be added:

  • Accountable:
    • To be accountable means that ABA must be able to demonstrate that its methods are effective.
    • This requires the repeatedly measuring the success of interventions, and, if necessary, making changes that improve their effectiveness.
  • Public:
    • The methods, results, and theoretical analyses of ABA must be published and open to scrutiny.
    • There are no hidden treatments or mystical, metaphysical explanations.
  • Doable:
    • To be generally useful, interventions should be available to a variety of individuals, who might be teachers, parents, therapists, or even those who wish to modify their own behaviour.
    • With proper planning and training, many interventions can be applied by almost anyone willing to invest the effort.
  • Empowering:
    • ABA provides tools that give the practitioner feedback on the results of interventions.
    • These allow clinicians to assess their skill level and build confidence in their effectiveness.
  • Optimistic:
    • According to several leading authors, behaviour analysts have cause to be optimistic that their efforts are socially worthwhile, for the following reasons:
      • The behaviours impacted by behaviour analysis are largely determined by learning and controlled by manipulable aspects of the environment.
      • Practitioners can improve performance by direct and continuous measurements.
      • As a practitioner uses behavioural techniques with positive outcomes, they become more confident of future success.
      • The literature provides many examples of success in teaching individuals considered previously unteachable.

Concepts

Behaviour

Behaviour refers to the movement of some part of an organism that changes some aspect of the environment. Often, the term behaviour refers to a class of responses that share physical dimensions or functions, and in that case a response is a single instance of that behaviour. If a group of responses have the same function, this group may be called a response class. “Repertoire” refers to the various responses available to an individual; the term may refer to responses that are relevant to a particular situation, or it may refer to everything a person can do.

Operant Conditioning

Operant behaviour is the so-called “voluntary” behaviour that is sensitive to, or controlled by its consequences. Specifically, operant conditioning refers to the three-term contingency that uses stimulus control, in particular an antecedent contingency called the discriminative stimulus (SD) that influences the strengthening or weakening of behaviour through such consequences as reinforcement or punishment. The term is used quite generally, from reaching for a candy bar, to turning up the heat to escape an aversive chill, to studying for an exam to get good grades.

Respondent (Classical) Conditioning

Respondent (classical) conditioning is based on innate stimulus-response relationships called reflexes. In his famous experiments with dogs, Pavlov usually used the salivary reflex, namely salivation (unconditioned response) following the taste of food (unconditioned stimulus). Pairing a neutral stimulus, for example a bell (conditioned stimulus) with food caused the dog to elicit salivation (conditioned response). Thus, in classical conditioning, the conditioned stimulus becomes a signal for a biologically significant consequence. Note that in respondent conditioning, unlike operant conditioning, the response does not produce a reinforcer or punisher (e.g. the dog does not get food because it salivates).

Environment

The environment is the entire constellation of stimuli in which an organism exists. This includes events both inside and outside of an organism, but only real physical events are included. A stimulus is an “energy change that affects an organism through its receptor cells”.

A stimulus can be described:

  • Topographically by its physical features.
  • Temporally by when it occurs.
  • Functionally by its effect on behaviour.

Reinforcement

Reinforcement is the key element in operant conditioning and in most behaviour change programmes. It is the process by which behaviour is strengthened. If a behaviour is followed closely in time by a stimulus and this results in an increase in the future frequency of that behaviour, then the stimulus is a positive reinforcer. If the removal of an event serves as a reinforcer, this is termed negative reinforcement. There are multiple schedules of reinforcement that affect the future probability of behaviour.

The use of punishments, especially those that inflict sensory or physical pain, is an area of controversy.

Punishment

Punishment is a process by which a consequence immediately follows a behaviour which decreases the future frequency of that behaviour. As with reinforcement, a stimulus can be added (positive punishment) or removed (negative punishment). Broadly, there are three types of punishment: presentation of aversive stimuli (e.g. pain), response cost (removal of desirable stimuli as in monetary fines), and restriction of freedom (as in a ‘time out’). Punishment in practice can often result in unwanted side effects. Some other potential unwanted effects include resentment over being punished, attempts to escape the punishment, expression of pain and negative emotions associated with it, and recognition by the punished individual between the punishment and the person delivering it.

Extinction

Extinction is the technical term to describe the procedure of withholding/discontinuing reinforcement of a previously reinforced behaviour, resulting in the decrease of that behaviour. The behaviour is then set to be extinguished. Extinction procedures are often preferred over punishment procedures, as many punishment procedures are deemed unethical and in many states prohibited. Nonetheless, extinction procedures must be implemented with utmost care by professionals, as they are generally associated with extinction bursts. An extinction burst is the temporary increase in the frequency, intensity, and/or duration of the behaviour targeted for extinction. Other characteristics of an extinction burst include an:

  • Extinction-produced aggression: the occurrence of an emotional response to an extinction procedure often manifested as aggression; and
  • Extinction-induced response variability: the occurrence of novel behaviours that did not typically occur prior to the extinction procedure.

These novel behaviours are a core component of shaping procedures.

Discriminated Operant and Three-Term Contingency

In addition to a relation being made between behaviour and its consequences, operant conditioning also establishes relations between antecedent conditions and behaviours. This differs from the S-R formulations (If-A-then-B), and replaces it with an AB-because-of-C formulation. In other words, the relation between a behaviour (B) and its context (A) is because of consequences (C), more specifically, this relationship between AB because of C indicates that the relationship is established by prior consequences that have occurred in similar contexts. This antecedent-behaviour-consequence contingency is termed the three-term contingency. A behaviour which occurs more frequently in the presence of an antecedent condition than in its absence is called a discriminated operant. The antecedent stimulus is called a discriminative stimulus (SD). The fact that the discriminated operant occurs only in the presence of the discriminative stimulus is an illustration of stimulus control. More recently behaviour analysts have been focusing on conditions that occur prior to the circumstances for the current behaviour of concern that increased the likelihood of the behaviour occurring or not occurring. These conditions have been referred to variously as “Setting Event”, “Establishing Operations”, and “Motivating Operations” by various researchers in their publications.

Verbal Behaviour

B.F. Skinner’s classification system of behaviour analysis has been applied to treatment of a host of communication disorders. Skinner’s system includes:

  • Tact: A verbal response evoked by a non-verbal antecedent and maintained by generalized conditioned reinforcement……
  • Mand: Behaviour under control of motivating operations maintained by a characteristic reinforcer.
  • Intraverbals: Verbal behaviour for which the relevant antecedent stimulus was other verbal behaviour, but which does not share the response topography of that prior verbal stimulus (e.g. responding to another speaker’s question).
  • Autoclitic: Secondary verbal behaviour which alters the effect of primary verbal behaviour on the listener. Examples involve quantification, grammar, and qualifying statements (e.g. the differential effects of “I think…” vs. “I know…”).

Measuring Behaviour

When measuring behaviour, there are both dimensions of behaviour and quantifiable measures of behaviour. In applied behaviour analysis, the quantifiable measures are a derivative of the dimensions. These dimensions are repeatability, temporal extent, and temporal locus.

  • Repeatability:
    • Response classes occur repeatedly throughout time – i.e. how many times the behaviour occurs.
    • Count is the number of occurrences in behaviour.
    • Rate/frequency is the number of instances of behaviour per unit of time.
    • Celeration is the measure of how the rate changes over time.
  • Temporal extent:
    • This dimension indicates that each instance of behaviour occupies some amount of time – i.e. how long the behaviour occurs.
    • Duration is the period of time over which the behavior occurs.
  • Temporal locus:
    • Each instance of behaviour occurs at a specific point in time – i.e. when the behaviour occurs.
    • Response latency is the measure of elapsed time between the onset of a stimulus and the initiation of the response.
    • Interresponse time is the amount of time that occurs between two consecutive instances of a response class.
  • Derivative measures:
    • Derivative measures are unrelated to specific dimensions.
    • Percentage is the ratio formed by combining the same dimensional quantities.
    • Trials-to-criterion are the number of response opportunities needed to achieve a predetermined level of performance.

Analysing Behaviour Change

Experimental Control

In applied behaviour analysis, all experiments should include the following:

  • At least one participant.
  • At least one behaviour (dependent variable).
  • At least one setting.
  • A system for measuring the behaviour and ongoing visual analysis of data.
  • At least one treatment or intervention condition.
  • Manipulations of the independent variable so that its effects on the dependent variable may be quantitatively or qualitatively analysed.
  • An intervention that will benefit the participant in some way.

Methodologies developed through ABA Research

Task Analysis

Task analysis is a process in which a task is analysed into its component parts so that those parts can be taught through the use of chaining: forward chaining, backward chaining and total task presentation. Task analysis has been used in organisational behaviour management, a behaviour analytic approach to changing the behaviours of members of an organisation (e.g. factories, offices, or hospitals). Behavioural scripts often emerge from a task analysis. Bergan conducted a task analysis of the behavioural consultation relationship and Thomas Kratochwill developed a training programme based on teaching Bergan’s skills. A similar approach was used for the development of microskills training for counsellors. Ivey would later call this “behaviourist” phase a very productive one[58] and the skills-based approach came to dominate counsellor training during 1970-1990. Task analysis was also used in determining the skills needed to access a career. In education, Englemann (1968) used task analysis as part of the methods to design the Direct Instruction curriculum.

Chaining

The skill to be learned is broken down into small units for easy learning. For example, a person learning to brush teeth independently may start with learning to unscrew the toothpaste cap. Once they have learned this, the next step may be squeezing the tube, etc.

For problem behaviour, chains can also be analysed and the chain can be disrupted to prevent the problem behaviour. Some behaviour therapies, such as dialectical behaviour therapy, make extensive use of behaviour chain analysis, but is not philosophically behaviour analytic.

Prompting

A prompt is a cue that is used to encourage a desired response from an individual. Prompts are often categorized into a prompt hierarchy from most intrusive to least intrusive, although there is some controversy about what is considered most intrusive, those that are physically intrusive or those that are hardest prompt to fade (e.g. verbal). In order to minimise errors and ensure a high level of success during learning, prompts are given in a most-to-least sequence and faded systematically. During this process, prompts are faded quickly as possible so that the learner does not come to depend on them and eventually behaves appropriately without prompting.

Types of prompts Prompters might use any or all of the following to suggest the desired response:

  • Vocal prompts: Words or other vocalisations.
  • Visual prompts: A visual cue or picture.
  • Gestural prompts: A physical gesture.
  • Positional prompt: For example, the target item is placed close to the individual.
  • Modelling: Modelling the desired response.
    • This type of prompt is best suited for individuals who learn through imitation and can attend to a model.
  • Physical prompts: Physically manipulating the individual to produce the desired response.
    • There are many degrees of physical prompts, from quite intrusive (e.g. the teacher places a hand on the learner’s hand) to minimally intrusive (e.g. a slight tap).

This is not an exhaustive list of prompts; the nature, number, and order of prompts are chosen to be the most effective for a particular individual.

Fading

The overall goal is for an individual to eventually not need prompts. As an individual gains mastery of a skill at a particular prompt level, the prompt is faded to a less intrusive prompt. This ensures that the individual does not become overly dependent on a particular prompt when learning a new behaviour or skill.

Thinning a Reinforcement Schedule

Thinning is often confused with fading. Fading refers to a prompt being removed, where thinning refers to an increase in the time or number of responses required between reinforcements. Periodic thinning that produces a 30% decrease in reinforcement has been suggested as an efficient way to thin. Schedule thinning is often an important and neglected issue in contingency management and token economy systems, especially when these are developed by unqualified practitioners (see professional practice of behaviour analysis).

Generalisation

Generalisation is the expansion of a student’s performance ability beyond the initial conditions set for acquisition of a skill. Generalisation can occur across people, places, and materials used for teaching. For example, once a skill is learned in one setting, with a particular instructor, and with specific materials, the skill is taught in more general settings with more variation from the initial acquisition phase. For example, if a student has successfully mastered learning colours at the table, the teacher may take the student around the house or school and generalise the skill in these more natural environments with other materials. Behaviour analysts have spent considerable amount of time studying factors that lead to generalisation.

Shaping

Shaping involves gradually modifying the existing behaviour into the desired behaviour. If the student engages with a dog by hitting it, then they could have their behaviour shaped by reinforcing interactions in which they touch the dog more gently. Over many interactions, successful shaping would replace the hitting behaviour with patting or other gentler behaviour. Shaping is based on a behaviour analyst’s thorough knowledge of operant conditioning principles and extinction. Recent efforts to teach shaping have used simulated computer tasks.

One teaching technique found to be effective with some students, particularly children, is the use of video modelling (the use of taped sequences as exemplars of behaviour). It can be used by therapists to assist in the acquisition of both verbal and motor responses, in some cases for long chains of behaviour.

Interventions Based on an FBA

Critical to behaviour analytic interventions is the concept of a systematic behavioural case formulation with a functional behavioural assessment or analysis at the core. This approach should apply a behaviour analytic theory of change. This formulation should include a thorough functional assessment, a skills assessment, a sequential analysis (behaviour chain analysis), an ecological assessment, a look at existing evidenced-based behavioural models for the problem behaviour (such as Fordyce’s model of chronic pain) and then a treatment plan based on how environmental factors influence behaviour. Some argue that behaviour analytic case formulation can be improved with an assessment of rules and rule-governed behaviour. Some of the interventions that result from this type of conceptualization involve training specific communication skills to replace the problem behaviours as well as specific setting, antecedent, behaviour, and consequence strategies.

Use in the Treatment of Autism Spectrum Disorders

ABA-based techniques are often used to teach adaptive behaviours or to diminish behaviours associated with autism, so much that ABA itself is often mistakenly considered to be synonymous with therapy for autism. According to a paper from 2007, it was considered to be an effective “intervention for challenging behaviors” by the American Academy of Paediatrics, though this has been refuted by more recent papers. ABA for autism may be limited by diagnostic severity and IQ.

Efficacy

Recent reviews of the efficacy of ABA-based techniques in autism include:

  • A 2007 clinical report of the American Academy of Paediatrics concluded that the benefit of ABA-based interventions in autism spectrum disorders (ASDs) “has been well documented” and that “children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior”.
  • Researchers from the MIND Institute published an evidence-based review of comprehensive treatment approaches in 2008. On the basis of “the strength of the findings from the four best-designed, controlled studies”, they were of the opinion that one ABA-based approach (the Lovaas technique created by Ole Ivar Løvaas) is “well-established” for improving intellectual performance of young children with ASD.
  • A 2009 review of psycho-educational interventions for children with autism whose mean age was six years or less at intake found that five high-quality (“Level 1” or “Level 2”) studies assessed ABA-based treatments. On the basis of these and other studies, the author concluded that ABA is “well-established” and is “demonstrated effective in enhancing global functioning in pre-school children with autism when treatment is intensive and carried out by trained therapists”. However, the review committee also concluded that “there is a great need for more knowledge about which interventions are most effective”.
  • A 2009 paper included a descriptive analysis, an effect size analysis, and a meta-analysis of 13 reports published from 1987 to 2007 of early intensive behavioural intervention (EIBI, a form of ABA-based treatment with origins in the Lovaas technique) for autism. It determined that EIBI’s effect sizes were “generally positive” for IQ, adaptive behaviour, expressive language, and receptive language. The paper did note limitations of its findings including the lack of published comparisons between EIBI and other “empirically validated treatment programs”.
  • In a 2009 systematic review of 11 studies published from 1987 to 2007, the researchers wrote “there is strong evidence that EIBI is effective for some, but not all, children with autism spectrum disorders, and there is wide variability in response to treatment”. Furthermore, any improvements are likely to be greatest in the first year of intervention.
  • A 2009 meta-analysis of nine studies published from 1987 to 2007 concluded that EIBI has a “large” effect on full-scale intelligence and a “moderate” effect on adaptive behaviour in autistic children.
  • A 2009 systematic review and meta-analysis by Spreckley and Boyd of four small-n 2000-2007 studies (involving a total of 76 children) came to different conclusions than the aforementioned reviews. Spreckley and Boyd reported that applied behaviour intervention (ABI), another name for EIBI, did not significantly improve outcomes compared with standard care of preschool children with ASD in the areas of cognitive outcome, expressive language, receptive language, and adaptive behaviour. In a letter to the editor, however, authors of the four studies meta-analysed claimed that Spreckley and Boyd had misinterpreted one study comparing two forms of ABI with each other as a comparison of ABI with standard care, which erroneously decreased the observed efficacy of ABI. Furthermore, the four studies’ authors raised the possibility that Spreckley and Boyd had excluded some other studies unnecessarily, and that including such studies could have led to a more favourable evaluation of ABI. Spreckley, Boyd, and the four studies’ authors did agree that large multi-site randomised trials are needed to improve the understanding of ABA’s efficacy in autism.
  • In 2011, investigators from Vanderbilt University under contract with the Agency for Healthcare Research and Quality performed a comprehensive review of the scientific literature on ABA-based and other therapies for autism spectrum disorders; the ABA-based therapies included the UCLA/Lovaas method and the Early Start Denver Model (the latter developed by Sally Rogers and Geraldine Dawson). They concluded that “both approaches were associated with … improvements in cognitive performance, language skills, and adaptive behavior skills”. However, they also concluded that “the strength of evidence … is low”, “many children continue to display prominent areas of impairment”, “subgroups may account for a majority of the change”, there is “little evidence of practical effectiveness or feasibility beyond research studies”, and the published studies “used small samples, different treatment approaches and duration, and different outcome measurements”.
  • An October 2019 report by the United States Department of Defence found that “76 percent of TRICARE beneficiaries in the ACD had little to no change in symptom presentation over the course of 12 months of applied behavior analysis (ABA) services, with an additional 9 percent demonstrating worsening symptoms.”
  • Controversy regarding ABA persists in the autism community. A 2017 study found that 46% of people with autism spectrum undergoing ABA appeared to meet the criteria for post-traumatic stress disorder (PTSD), a rate 86% higher than the rate of those who had not undergone ABA (28%). According to the researcher, the rate of apparent PTSD increased after exposure to ABA regardless of the age of the patient. However, the quality of this study has been disputed by other researchers.
  • A 2019 review article concluded ABA proponents have utilised predominantly non-verbal and neurologically different, children who are not recognised under this paradigm to have their own thought processes, basic needs, preferences, style of learning, and psychological and emotional needs, for their experiment. This also indicates a missing voice of children and nonverbal people who cannot express their view on ABA.

Use of Aversives

Some embodiments of applied behaviour analysis as devised by Ole Ivar Lovaas used aversives such as electric shocks to modify undesirable behaviour in their initial use in the 1970s, as well as slapping and shouting in the landmark 1987 study. Over time the use of aversives lessened and in 2012 their use was described as being inconsistent with contemporary practice. However, aversives have continued to be used in some ABA programs. In comments made in 2014 to the FDA, a clinician who previously worked at the Judge Rotenberg Educational Centre claimed that “all textbooks used for thorough training of applied behavior analysts include an overview of the principles of punishment, including the use of electrical stimulation.” In 2020, the FDA banned the use of electrical stimulation devices used for self-injurious or aggressive behaviour and asserted that “Evidence indicates a number of significant psychological and physical risks are associated with the use of these devices, including worsening of underlying symptoms, depression, anxiety, posttraumatic stress disorder, pain, burns and tissue damage.”

Controversy

The value of eliminating autistic behaviours is disputed by proponents of neurodiversity, who claim that it forces autistics to mask their true personalities on behalf of a narrow conception of normality. Autism advocates contend that it is cruel to try to make autistic people “normal” without consideration for how this may affect their well-being. Instead, these critics advocate for increased social acceptance of harmless autistic traits and therapies focused on improving quality of life. Julia Bascom of the Autistic Self Advocacy Network (ASAN) has said, “ASAN’s objection is fundamentally an ethical one. The stated end goal of ABA is an autistic child who is ‘indistinguishable from their peers’ – an autistic child who can pass as neurotypical. We don’t think that’s an acceptable goal. The end goal of all services, supports, interventions, and therapies an autistic child receives should be to support them in growing up into an autistic adult who is happy, healthy, and living a self-determined life.”

It has been suspected that there might be a publication bias against those research articles share a controversial account of ABA. Publication bias could lead to exaggerated estimates of intervention effects.

What is Behaviour Therapy?

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 learning theory, such as 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 felt to be 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 behaviour”. 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 “behaviour 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 programme 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. 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 (CBT). 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 strengthen or weaken certain behaviours.

Contingency management programmes 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 persons 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 desensitisation, 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 desensitisation 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 programmes 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 indicates that both behaviour therapy and cognitive-behavioural therapy (CBT) are equally effective for OCD. CBT has 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 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. 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 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 doesn’t 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 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, therapists are 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 don’t consider the success an accomplishment. Generally, in those not suffering from 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

The third-generation behaviour therapy movement has been called clinical behaviour analysis because 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), behavioural activation (BA), dialectical behavioural 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.

ACT may be the most well-researched of all the third-generation behaviour therapy models. It is based on relational frame theory. 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.

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 (1969) 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.

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 Behaviour Therapy 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 an 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 the 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.

Methods

  • Behaviour management.
  • Behaviour modification.
  • Clinical behaviour analysis.
  • Contingency management.
  • Covert conditioning.
  • Decoupling.
  • Exposure and response prevention.
  • Flooding.
  • Habit reversal training.
  • Matching law.
  • Modelling.
  • Observational learning.
  • Operant conditioning.
  • Professional practice of behaviour analysis.
  • Respondent conditioning.
  • Stimulus control.
  • Systematic desensitisation.

Reference

Skinner, B.F. (1969). Contingencies of Reinforcement: A Theoretical Analysis. New York: Meredith Corporation.

What is Learned Helplessness?

Introduction

Learned helplessness is behaviour exhibited by a subject after enduring repeated aversive stimuli beyond their control. It was initially thought to be caused from the subject’s acceptance of their powerlessness: discontinuing attempts to escape or avoid the aversive stimulus, even when such alternatives are unambiguously presented. Upon exhibiting such behaviour, the subject was said to have acquired learned helplessness.

Over the past few decades, neuroscience has provided insight into learned helplessness and shown that the original theory actually had it backwards: the brain’s default state is to assume that control is not present, and the presence of “helpfulness” is what is actually learned.

In humans, learned helplessness is related to the concept of self-efficacy; the individual’s belief in their innate ability to achieve goals. Learned helplessness theory is the view that clinical depression and related mental illnesses may result from such real or perceived absence of control over the outcome of a situation.

Refer to Learned Optimism.

Foundation of Research and Theory

Early Experiments

American psychologist Martin Seligman initiated research on learned helplessness in 1967 at the University of Pennsylvania as an extension of his interest in depression. This research was later expanded through experiments by Seligman and others. One of the first was an experiment by Seligman & Maier:

  • In Part 1 of this study, three groups of dogs were placed in harnesses.
    • Group 1 dogs were simply put in a harness for a period of time and were later released.
    • Groups 2 and 3 consisted of “yoked pairs”.
    • Dogs in Group 2 were given electric shocks at random times, which the dog could end by pressing a lever.
    • Each dog in Group 3 was paired with a Group 2 dog; whenever a Group 2 dog got a shock, its paired dog in Group 3 got a shock of the same intensity and duration, but its lever did not stop the shock.
    • To a dog in Group 3, it seemed that the shock ended at random, because it was their paired dog in Group 2 that was causing it to stop.
    • Thus, for Group 3 dogs, the shock was “inescapable”.
  • In Part 2 of the experiment the same three groups of dogs were tested in a shuttle-box apparatus (a chamber containing two rectangular compartments divided by a barrier a few inches high).
    • All of the dogs could escape shocks on one side of the box by jumping over a low partition to the other side.
    • The dogs in Groups 1 and 2 quickly learned this task and escaped the shock.
    • Most of the Group 3 dogs – which had previously learned that nothing they did had any effect on shocks – simply lay down passively and whined when they were shocked.

In a second experiment later that year with new groups of dogs, Overmier and Seligman ruled out the possibility that, instead of learned helplessness, the Group 3 dogs failed to avert in the second part of the test because they had learned some behaviour that interfered with “escape”. To prevent such interfering behaviour, Group 3 dogs were immobilised with a paralysing drug (curare), and underwent a procedure similar to that in Part 1 of the Seligman and Maier experiment. When tested as before in Part 2, these Group 3 dogs exhibited helplessness as before. This result serves as an indicator for the ruling out of the interference hypothesis.

From these experiments, it was thought that there was to be only one cure for helplessness. In Seligman’s hypothesis, the dogs do not try to escape because they expect that nothing they do will stop the shock. To change this expectation, experimenters physically picked up the dogs and moved their legs, replicating the actions the dogs would need to take in order to escape from the electrified grid. This had to be done at least twice before the dogs would start wilfully jumping over the barrier on their own. In contrast, threats, rewards, and observed demonstrations had no effect on the “helpless” Group 3 dogs.

Later Experiments

Later experiments have served to confirm the depressive effect of feeling a lack of control over an aversive stimulus. For example, in one experiment, humans performed mental tasks in the presence of distracting noise. Those who could use a switch to turn off the noise rarely bothered to do so, yet they performed better than those who could not turn off the noise. Simply being aware of this option was enough to substantially counteract the noise effect. In 2011, an animal study found that animals with control over stressful stimuli exhibited changes in the excitability of certain neurons in the prefrontal cortex. Animals that lacked control failed to exhibit this neural effect and showed signs consistent with learned helplessness and social anxiety.

Expanded Theories

Research has found that a human’s reaction to feeling a lack of control differs both between individuals and between situations, i.e. learned helplessness sometimes remains specific to one situation but at other times generalises across situations. Such variations are not explained by the original theory of learned helplessness, and an influential view is that such variations depend on an individual’s attributional or explanatory style. According to this view, how someone interprets or explains adverse events affects their likelihood of acquiring learned helplessness and subsequent depression. For example, people with pessimistic explanatory style tend to see negative events as permanent (“it will never change”), personal (“it’s my fault”), and pervasive (“I can’t do anything correctly”), and are likely to suffer from learned helplessness and depression.

Bernard Weiner proposed a detailed account of the attributional approach to learned helplessness. His attribution theory includes the dimensions of globality/specificity, stability/instability, and internality/externality:

  • A global attribution occurs when the individual believes that the cause of negative events is consistent across different contexts.
    • A specific attribution occurs when the individual believes that the cause of a negative event is unique to a particular situation.
  • A stable attribution occurs when the individual believes the cause to be consistent across time.
    • An unstable attribution occurs when the individual thinks that the cause is specific to one point in time.
  • An external attribution assigns causality to situational or external factors,
    • while an internal attribution assigns causality to factors within the person.

Research has shown that those with an internal, stable, and global attributional style for negative events can be more at risk for a depressive reaction to failure experiences.

Neurobiological Perspective

Research has shown that increased 5-HT (serotonin) activity in the dorsal raphe nucleus plays a critical role in learned helplessness. Other key brain regions that are involved with the expression of helpless behaviour include the basolateral amygdala, central nucleus of the amygdala and bed nucleus of the stria terminalis. Activity in medial prefrontal cortex, dorsal hippocampus, septum and hypothalamus has also been observed during states of helplessness.

In the article, “Exercise, Learned Helplessness, and the Stress-Resistant Brain”, Benjamin N. Greenwood and Monika Fleshner discuss how exercise might prevent stress-related disorders such as anxiety and depression. They show evidence that running wheel exercise prevents learned helplessness behaviours in rats. They suggest that the amount of exercise may not be as important as simply exercising at all. The article also discusses the neurocircuitry of learned helplessness, the role of serotonin (or 5-HT), and the exercise-associated neural adaptations that may contribute to the stress-resistant brain. However, the authors finally conclude that:

“The underlying neurobiological mechanisms of this effect, however, remain unknown. Identifying the mechanisms by which exercise prevents learned helplessness could shed light on the complex neurobiology of depression and anxiety and potentially lead to novel strategies for the prevention of stress-related mood disorders”.

Health Implications

People who perceive events as uncontrollable show a variety of symptoms that threaten their mental and physical well-being. They experience stress, they often show disruption of emotions demonstrating passivity or aggressiveness, and they can also have difficulty performing cognitive tasks such as problem-solving. They are less likely to change unhealthy patterns of behaviour, causing them, for example, to neglect diet, exercise, and medical treatment.

Depression

Abnormal and cognitive psychologists have found a strong correlation between depression-like symptoms and learned helplessness in laboratory animals.

Young adults and middle-aged parents with a pessimistic explanatory style often suffer from depression. They tend to be poor at problem-solving and cognitive restructuring, and also tend to demonstrate poor job satisfaction and interpersonal relationships in the workplace. Those with a pessimistic style also tend to have weakened immune systems, having not only increased vulnerability to minor ailments (e.g. cold, fever) and major illness (e.g. heart attack, cancers), but also poorer recovery from health problems.

Social Impact

Learned helplessness can be a factor in a wide range of social situations.

  • In emotionally abusive relationships, the victim often develops learned helplessness.
    • This occurs when the victim confronts or tries to leave the abuser only to have the abuser dismiss or trivialise the victim’s feelings, pretend to care but not change, or impede the victim from leaving.
  • The motivational effect of learned helplessness is often seen in the classroom.
    • Students who repeatedly fail may conclude that they are incapable of improving their performance, and this attribution keeps them from trying to succeed, which results in increased helplessness, continued failure, loss of self-esteem and other social consequences.
  • Child abuse by neglect can be a manifestation of learned helplessness.
    • For example, when parents believe they are incapable of stopping an infant’s crying, they may simply give up trying to do anything for the child.
  • Those who are extremely shy or anxious in social situations may become passive due to feelings of helplessness.
    • Gotlib and Beatty (1985) found that people who cite helplessness in social settings may be viewed poorly by others, which tends to reinforce the passivity.
  • Aging individuals may respond with helplessness to the deaths of friends and family members, the loss of jobs and income, and the development of age-related health problems.
    • This may cause them to neglect their medical care, financial affairs, and other important needs.
  • According to Cox et al., Abramson, Devine, and Hollon (2012), learned helplessness is a key factor in depression that is caused by inescapable prejudice (i.e. “deprejudice”).
    • Thus: “Helplessness born in the face of inescapable prejudice matches the helplessness born in the face of inescapable shocks.”
  • According to Ruby K. Payne’s book A Framework for Understanding Poverty, treatment of the poor can lead to a cycle of poverty, a culture of poverty, and generational poverty.
    • This type of learned helplessness is passed from parents to children.
    • People who embrace this mentality feel there is no way to escape poverty and so one must live in the moment and not plan for the future, trapping families in poverty.

Social problems resulting from learned helplessness may seem unavoidable to those entrenched. However, there are various ways to reduce or prevent it. When induced in experimental settings, learned helplessness has been shown to resolve itself with the passage of time. People can be immunized against the perception that events are uncontrollable by increasing their awareness of previous experiences, when they were able to effect a desired outcome. Cognitive therapy can be used to show people that their actions do make a difference and bolster their self-esteem.

Extensions

Cognitive scientist and usability engineer Donald Norman used learned helplessness to explain why people blame themselves when they have a difficult time using simple objects in their environment.

The UK educationalist Phil Bagge describes it as a learning avoidance strategy caused by prior failure and the positive reinforcement of avoidance such as asking teachers or peers to explain and consequently do the work. It shows itself as sweet helplessness or aggressive helplessness often seen in challenging problem solving contexts, such as learning to use a new computer programming language.

The US sociologist Harrison White has suggested in his book Identity and Control that the notion of learned helplessness can be extended beyond psychology into the realm of social action. When a culture or political identity fails to achieve desired goals, perceptions of collective ability suffer.

Emergence under Torture

Studies on learned helplessness served as the basis for developing enhanced interrogation techniques. In CIA interrogation manuals, learned helplessness is characterised as “apathy” which may result from prolonged use of coercive techniques which result in a “debility-dependency-dread” state in the subject, “If the debility-dependency-dread state is unduly prolonged, however, the arrestee may sink into a defensive apathy from which it is hard to arouse him.”

What is Motivational Interviewing?

Introduction

Motivational interviewing (MI) is a counselling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. It is a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. Compared with non-directive counselling, it is more focused and goal-directed, and departs from traditional Rogerian client-centred therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than engaging in non-directive therapeutic exploration. The examination and resolution of ambivalence is a central purpose, and the counsellor is intentionally directive in pursuing this goal. MI is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship.

Core concepts evolved from experience in the treatment of problem drinkers, and MI was first described by Miller (1983) in an article published in the journal Behavioural and Cognitive Psychotherapy. Miller and Rollnick elaborated on these fundamental concepts and approaches in 1991 in a more detailed description of clinical procedures.

Overview

Motivational interviewing (MI) is a person-centred strategy. It is used to elicit patient motivation to change a specific negative behaviour. MI engages clients, elicits change talk and evokes patient motivation to make positive changes. For example, change talk can be elicited by asking the patient questions such as: “How might you like things to be different?” or “How does __ interfere with things that you would like to do?”

Unlike clinical interventions and treatment, MI is the technique where the interviewer (clinician) assists the interviewee (patient) in changing a behaviour by expressing their acceptance of the interviewee without judgement. By this, MI incorporates the idea that every single patient may be in differing stages of readiness levels and may need to act accordingly to the patient’s levels and current needs. Change may occur quickly or may take considerable time, depending on the client. Knowledge alone is usually not sufficient to motivate change within a client, and challenges in maintaining change should be thought of as the rule, not the exception. The incorporation of MI can help patients resolve their uncertainties and hesitancies that may stop them from their inherent want of change in relation to a certain behaviour or habit. At the same time, it can be seen that MI ensures that the participants are viewed more as team members to solve a problem rather than a clinician and patient. Hence, this technique can be attributed to a collaboration that respects sense of self and autonomy.

To be more successful at motivational interviewing, a clinician must have a strong sense of “purpose, clear strategies and skills for such purposes”. This ensures that the clinician knows what goals they are trying to achieve prior to entering into motivational interviewing. Additionally, clinicians need to have well-rounded and established interaction skills including asking open ended questions, reflective listening, affirming and reiterating statements back to the patient. Such skills are used in a dynamic where the clinician actively listens to the patient then repackages their statements back to them while highlighting what they have done well. In this way, it can improve their self-confidence for change.

Furthermore, at the same time the clinician needs to keep in mind the following five principles when practicing MI.

Express Empathy

This means to listen and express empathy to patients through the use of reflective listening. In this step, the clinician listens and presents ideas the patient has discussed in a different way, rather than telling the patient what to do. This hopes to ensure that the patient feels respected and that there are no judgments given when they express their thoughts, feelings and experiences but instead, shows the patient that the clinician is genuinely interested about the patient and their circumstances. This aims to strengthen the relationship between the two parties and ensures it is a collaboration, and allows the patient to feel that the clinician is supportive and therefore will be more willing to be open about their real thoughts.

Develop Discrepancy

This means to assist patients in developing discrepancies between the current self and what they want to be like in the future after a change has taken place. The main goal of this principle is to increase the patient’s awareness that there are consequences to their current behaviours. This allows the patient to realize the negatives aspects and issues the particular behaviour that MI is trying to change can cause. This realisation can help and encourage the patient towards a dedication to change as they can see the discrepancy between their current behaviour and desired behaviour. It is important that the patient be the one making the arguments for change and realise their discrepancies themselves. An effective way to do this is for the clinician to participate in active reflective listening and repacking what the patient has told them and delivering it back to them.

Avoid Arguments

During the course of MI the clinician may be inclined to argue with a patient, especially when they are ambivalent about their change and this is especially true when “resistance” is met from the patient. If the clinician tries to enforce a change, it could exacerbate the patient to become more withdrawn and can cause degeneration of what progress had been made thus far and decrease rapport with the patient. Arguments can cause the patient to become defensive and draw away from the clinician which is counterproductive and diminishes any progress that may have been made. When patients become a little defensive and argumentative, it usually is a sign to change the plan of attack. The biggest progress made towards behaviour change is when the patient makes their own arguments instead of the clinician presenting it to them.

Roll with Resistance

“Rolling with resistance” is now an outdated concept in MI; in the third edition of Miller & Rollnick’s textbook Motivational Interviewing: Helping People Change, the authors indicated that they had completely abandoned the word “resistance” as well as the term “rolling with resistance”, due to the term’s tendency to blame the client for problems in the therapy process and obscure different aspects of ambivalence. “Resistance”, as the idea was previously conceptualised before it was abandoned in MI, can come in many forms such as arguing, interrupting, denying and ignoring. Part of successful MI is to approach the “resistance” with professionalism, in a way that is non-judgmental and allows the patient to once again affirm and know that they have their autonomy and that it is their choice when it comes to their change.

Support Self-Efficacy

Strong self-efficacy can be a significant predictor of success in behaviour change. In many patients there is an issue of the lack of self-efficacy. They may have tried multiple times on their own to create a change in their behaviour (e.g. trying to cease smoking, losing weight, sleep earlier) and because they have failed it causes them to lose their confidence and hence lowers their self-efficacy. Therefore, it is clear to see how important it is for the patient to believe that they are self-efficient and it is the clinician’s role to support them by means of good MI practice and reflective listening. By reflecting on what the patient had told them, the clinician can accentuate the patient’s strengths and what they have been successful in (e.g. commending a patient who had stopped smoking for a week instead of straining on the fact they failed). By highlighting and suggesting to the patient areas in which they have been successful, this can be incorporated into future attempts and can improve their confidence and efficacy to believe that they are capable of change.

While there are as many differences in technique, the underlying spirit of the method remains the same and can be characterized in a few key points:

  • Motivation to change is elicited from the client, and is not imposed from outside forces.
  • It is the client’s task, not the counsellor’s, to articulate and resolve the client’s ambivalence.
  • Direct persuasion is not an effective method for resolving ambivalence.
  • The counselling style is generally quiet and elicits information from the client.
  • The counsellor is directive, in that they help the client to examine and resolve ambivalence.
  • Readiness to change is not a trait of the client, but a fluctuating result of interpersonal interaction.
  • The therapeutic relationship resembles a partnership or companionship.

Ultimately, practitioners must recognize that motivational interviewing involves collaboration not confrontation, evocation not education, autonomy rather than authority, and exploration instead of explanation. Effective processes for positive change focus on goals that are small, important to the client, specific, realistic, and oriented in the present and/or future.

Four Processes

There are four steps used in motivational interviewing. These help to build trust and connection between the patient and the clinician, focus on areas that may need to be changed and find out the reasons the patient may have for changing or holding onto a behaviour. This helps the clinician to support and assist the patient in their decision to change their behaviour and plan steps to reach this behavioural change. These steps do not always happen in this order.

Engaging

In this step, the clinician gets to know the patient and understands what is going on in the patient’s life. The patient needs to feel comfortable, listened to and fully understood from their own point of view. This helps to build trust with the patient and builds a relationship where they will work together to achieve a shared goal. The clinician must listen and show empathy without trying to fix the problem or make a judgement. This allows the patient to open up about their reasons for change, hopes, expectations as well as the barriers and fears that are stopping the patient from changing. The clinician must ask open ended questions which helps the patient to give more information about their situation, so they feel in control and that they are participating in the decision-making process and the decisions are not being made for them. This creates an environment that is comfortable for the patient to talk about change. The more trust the patient has towards the clinician, the more likely it is reduce resistance, defensiveness, embarrassment or anger the patient may feel when talking about a behavioural issue. Overall, the patient is more likely to come back to follow up appointments, follow an agreed plan and get the benefit of the treatment.

Focusing

This is where the clinician helps the patient find and focus on an area that is important to them, where they are unsure or are struggling to make a change. This step is also known as the “WHAT?” of change. The goal is for the clinician to understand what is important to the patient without pushing their own ideas on the patient. The clinician needs to ask questions to understand the reasons if and why the patient would be motivated to change and choose a goal to reach together. The patient must feel that they share the control with the clinician about the direction and agree on a goal. The clinician will then aim to help the patient order the importance of their goals and point out the current behaviours that get in the way of achieving their new goal or “develop discrepancy” between their current and desired behaviours. The focus or goal can come from the patient, situation or the clinician. There are three styles of focusing; directing, where the clinician can direct the patient towards a particular area for change; following, where the clinician let the patient decide the goal and be led by the patient’s priorities, and; guiding, where the clinician leads the patient to uncover an area of importance.

Evoking

In this step the clinician asks questions to get the patient to open up about their reasons for change. This step is also known as the “WHY?” of change. Often when a patient puts this into words it reinforces their reasons to change and they find out they have more reasons to change rather than to stay the same. Usually, there is one reason that is stronger than the others to motivate the patient to change their behaviour. The clinician needs to listen and recognise “change talk”, where the patient is uncovering how they would go about change and are coming up with their own solutions to their problems. The clinician should support and encourage the patient when they talk about ways and strategies to change, as the patient is more likely to follow a plan they set for themselves. When the patient is negative or is resisting change the clinician should “roll with resistance” where they do not affirm or encourage the negative points but highlight the ways and reasons the person has come up with to change. The clinician must resist arguing or the “righting reflex” where they want to fix the problem or challenge the patient’s negative thoughts. This comes across as they are not working together and causes the patient to resist change even more. The clinician’s role is to ask questions that guide the patient to come up with their own solution to change. The best time to give advice is if the patient asks for it, if the patient is stuck with coming up with ideas, the clinician can ask permission to give advice and then give details, but only after the patient has come up with their own ideas first. If the clinician focuses more on their own reasons they believe the patient should change this would not come across as genuine to the patient and this would reduce the bond they made in the engaging process.

Planning

In this step the clinician helps the patient in planning how to change their behaviour and encourages their commitment to change. This step is also known as the “HOW?” of change. The clinician asks questions to judge how ready the patient is to change and helps to guide the patient in coming up with their own step by step action plan. They can help to strengthen the patient’s commitment to changing, by supporting and encouraging when the patient uses “commitment talk” or words that show their commitment to change. In this step the clinician can listen and recognise areas that may need more work to get to the core motivation to change or help the patient to overcome uneasiness that is still blocking their behavioural change. In doing this, they help to strengthen the patients motivation and support that they are capable of achieving this goal on their own. The clinician should help the patient to come up with SMART goals which are; Specific, Measurable, Achievable, Relevant and Time bound. This helps to set benchmarks and measure how their behaviour has changed towards their new goal.

Adaptations

Motivational Enhancement Therapy

Motivational enhancement therapy is a time-limited four-session adaptation used in Project MATCH, a US-government-funded study of treatment for alcohol problems and the Drinkers’ Check-up, which provides normative-based feedback and explores client motivation to change in light of the feedback.

Motivational interviewing is supported by over 200 randomised controlled trials across a range of target populations and behaviours including substance abuse, health-promotion behaviours, medical adherence, and mental health issues.

Motivational Interviewing Groups

MI groups are highly interactive, focused on positive change, and harness group processes for evoking and supporting positive change. They are delivered in four phases:

  1. Engaging the group.
  2. Evoking member perspectives.
  3. Broadening perspectives and building momentum for change.
  4. Moving into action.

Behaviour Change Counselling

Behaviour change counselling (BCC) is an adaptation of MI which focuses on promoting behaviour change in a healthcare setting using brief consultations. BCC’s main goal is to understand the patient’s point of view, how they’re feeling and their idea of change. It was created with a “more modest goal in mind”, as it simply aims to “help the person talk through the why and how of change” and encourage behaviour change. It focuses on patient-centred care and is based on several overlapping principles of MI, such as respect for patient choice, asking open-ended questions, empathetic listening and summarizing. Multiple behaviour change counselling tools were developed to assess and scale the effectiveness of behaviour change counselling in promoting behaviour change such as the Behaviour Change Counselling Index (BECCI) and the Behaviour Change Counselling Scale (BCCS).

Behaviour Change Counselling Scale


The Behaviour Change Counselling Scale (BCCS) is a tool used to assess lifestyle counselling using BCC, focusing on feedback on the skill achieved. “Items of BCCS were scored on 1-7 Likert scales and items were tallied into 4 sub-scales, reflecting the 3 skill-sets: MI and readiness assessment, behaviour modification, and emotion management”.

The data obtained is then presented on: item characteristics, sub-scale characteristics, interrater reliability, test-retest reliability and construct validity.

Based on a study conducted by Vallis, the results suggest that BCCS is a potentially useful tool in assessing BCC and aid to training practitioners as well as assessing training outcomes.

Behaviour Change Counselling Index

The Behaviour Change Counselling Index (BECCI) is a BCC tool that assesses general practitioner behaviour and incites behaviour change through talking about change, encouraging the patient to think about change and respecting the patient’s choices in regards to behaviour change. BECCI was developed to assess a practitioner’s competence in the use of Behaviour Change Counselling (BCC) methods to elicit behaviour change. Used primarily for the use of learning practitioners in a simulated environment to practice and learn the skills of BCC. It “provides valuable information about the standard of BCC that practitioners were trained to deliver in studies of BCC as an intervention”. Rather than the result and response from the patient, the tool emphasizes and measures the practitioner’s behaviours, skills and attitude. Results from the study show that after receiving training in BCC, practitioners show great improvement based on BECCI. However, as BECCI has only been used in a simulated clinical environment, more study is required to assess its reliability in a real patient environment. Furthermore, it focuses heavily on practitioner behaviour rather than patient behaviour. Therefore, BECCI may be useful for trainers to assess the reliability and effectiveness of BCC skills but further research and use is required, especially in a real consultation environment.

Technology Assisted Motivational Interview

Technology Assisted Motivational Interview (TAMI) is “used to define adaptations of MI delivered via technology and various types of media”. This may include technological devices and creations such as computers, mobile phones, telephones, videos and animations. A review of multiple studies shows the potential effectiveness of the use of technology in delivering motivational interviewing consultations to encourage behaviour change. However, some limitations include: the lack of empathy that may be expressed through the use of technology and the lack of face-to-face interaction may either produce a positive or negative effect on the patient. Further studies are required to determine whether face-to-face consultations to deliver MI is more effective in comparison to those delivered via technology.

Limitations

Underlying Mental Health Conditions

Patients with an underlying mental illness present one such limitation to motivational interviewing. In a case where the patient suffers from an underlying mental illness such as depression, anxiety, bipolar disease, schizophrenia or other psychosis, more intensive therapy may be required to induce a change. In these instances, the use of motivational interviewing as a technique to treat outward-facing symptoms, such as not brushing teeth, may be ineffective where the root cause of the problem stems from the mental illness. When working with these patients, it is important to recognise that only so much can be done at certain levels. The treating therapists should, therefore, ensure the patient is referred to the correct medical professional to treat the cause of the behaviour, and not simply one of the symptoms.

Pre-Contemplation

Patients in the pre-contemplation stage of the stages of change present a further limitation to the model. If the patient is in this stage, they will not consider they have a problem and therefore are unlikely to be receptive to motivational interviewing techniques. It is important that motivational interviewers are well trained in the approach to be taken when handling these patients. Well intended messages can have the opposite effect of pushing the patient away or causing them to actively rebel. In these instances discussing how the issue may be affecting the patient must be handled very delicately and introduced carefully. Suggesting less harmful ways of dealing with the client’s issue and helping them recognize danger signs may be a better approach to plant the seed aiding their progression to the contemplation stage.

Motivation

Professionals attempting to encourage people to make a behavioural change often underestimate the effect of motivation. Simply advising clients how detrimental their current behaviour is and providing advice on how to change their behaviour will not work if the client lacks motivation. Many people have full knowledge of how dangerous smoking is yet they continue the practice. Research has shown that a client’s motivation to alter behaviour is largely influenced by the way the therapist relates to them.

Therapist/Client Trust

Clients who do not like or trust their health care professionals are likely to become extremely resistant to change. In order to prevent this, the therapist must take time to foster an environment of trust. Even when the therapist can clearly identify the issues at hand it is important to have the patient feels the session is collaborative and that they are not being lectured to. Confrontational approaches by well-meaning therapists will inhibit the process.

Time Limitations

Time limits placed on therapists during consultations also have the potential to impact significantly on the quality of motivational interviewing. Appointments may be limited to a brief or single visit with a patient; for example, a client may attend the dentist with a toothache due to a cavity. The oral health practitioner or dentist may be able to broach the subject of a behaviour change, such as flossing or diet modification but the session duration may not be sufficient when coupled with other responsibilities the health practitioner has to the health and wellbeing of the patient. For many clients, changing habits may involve reinforcement and encouragement which is not possible in a single visit. Some patients, once treated, may not return for a number of years or may even change practitioners or practices, meaning the motivational interview is unlikely to have sufficient effect.

Training Deficiencies

While psychologists, mental health counsellors, and social workers are generally well trained and practiced in delivering motivational interviewing, other health-care professionals are generally provided with only a few hours of basic training. Although perhaps able to apply the underpinning principles of motivational interviewing, these professionals generally lack the training and applied skills to truly master the art of dealing with the patient’s resistant statements in a collaborative manner. It is important that therapists know their own limitations and are prepared to refer clients to other professionals when required.

Group Treatment

Although studies are somewhat limited, it appears that delivering motivational interviewing, in a group may be less effective than when delivered one-on-one. Research continues into this area however what is clear is that groups change the dynamics of a situation and the therapist needs to ensure that group control is maintained and input from group members does not derail the process for some clients.

Applications

Motivational interviewing was initially developed for the treatment of substance abuse, but MI is continuously being applied across health fields and beyond that. The following fields have used the technique of MI.

Brief Intervention

Brief intervention and MI are both techniques used to empower behavioural change within individuals. Behavioral interventions “generally refer to opportunistic interventions by non-specialists (e.g. GPs) offered to patients who may be attending for some unrelated condition”. Due to speculation in the health industry the use of brief intervention has been deemed to be used too loosely and the implementation of MI is increasing rapidly.

Classroom Management

Motivational interviewing has been incorporated into managing a classroom. Due to the nature of MI where it elicits and evokes behavioural change within an individual it has shown to be effective in a classroom especially when provoking behaviour change within an individual. In association with MI, the classroom check-up method is incorporated which is a consultation model that addresses the need for classroom level support.

Coaching

Motivational interviewing has been implemented in coaching, specifically health-based coaching to aid in a better lifestyle for individuals. A study titled “Motivational interviewing-based health coaching as a chronic care intervention” was conducted to evaluate if MI had an impact on individuals health who were assessed as chronically ill. The study’s results showed that the group that MI was applied to had “improved their self-efficacy, patient activation, lifestyle change and perceived health status”.

Environmental Sustainability

Initially motivational interviewing was implemented and formulated to elicit behavioural change in individuals suffering from substance abuse. However, MI has been reformed and has multiple uses. One of these uses include of stabilising the surrounding environment of an individual. This is completed by allowing the individual to evoke behavioural change within themselves and elicit motivation to change certain habits, for example substance abuse. By motivating the individual, it allows them to maintain the environment surrounding them to eliminate factors of temptation. However, if relapse occurs it is normal and is bound to happen.

Mental Disorders

Motivational interviewing was originally developed by William R. Miller and Stephen Rollnick in the 1980s in order to aid people with substance abuse disorders. However, it has also been implemented to help aid in established models with mental disorders such as anxiety and depression. Currently an established model known as cognitive behavioural therapy (CBT) is being implemented to aid in these issues. Research suggests that with collaborating motivational interviewing and CBT has proved to be effective as they have both shown to be effective. A study was conducted as a randomised cluster trial that suggests that when MI was implemented it “associated with improved depressive symptoms and remission rate”. There is currently insufficient research papers to prove the effect of MI in mental disorders. However, it is increasingly being applied and more research is going into it.

Dual Diagnosis

Dual diagnosis can be defined as a “term that is used to describe when a person is experiencing both mental health problems and substance misuse”. Motivational interviewing is used as a preventative measure for individuals suffering from both a mental health issue and substance misuse due to the nature of MI eliciting behavioural change in individuals.

Problem Gambling

Gambling issues are on the rise and it is becoming a struggle for therapists to maintain it. Research suggests that many individuals “even those who actively seek and start gambling treatment, do not receive the full recommended course of therapy”. Motivational interviewing has been widely used and adapted by therapists to overcome gambling issues, it is used in collaboration with cognitive behavioural therapy and self-directed treatments. The goal of using MI in an individual who is having issues with gambling is to recognize and overcome those barriers and “increase overall investment in therapy by supporting an individual’s commitment to changing problem behaviours”.

Parenting

Motivational interviewing is implemented to evoke behavioural change in an individual. Provoking behavioural change includes the recognising of the issue from an individual. A research was conducted by utilising motivational interviewing to help promote oral regime and hygiene within children under the supervision of a parent. In this research the experimental group which was parents who received MI education in the form of a “pamphlet, watched a videotape, as well as received an MI counselling session and six follow-up telephone calls”. The mothers who had received the MI counselling session showed that “children in the MI group exhibited significantly less new caries (decayed or filled surfaces)” in contrast to the children in the control group. This suggests that the application of MI with parenting can significantly impact outcomes regarding the children of the parent.

Substance Dependence

Motivational interviewing was initially developed in order to aid people with substance abuse, specifically alcohol. Due to the results it displayed MI can be implemented into any substance abuse or dependence treatment. Research that was conducted utilised MI with a cocaine-detoxification programme. This research had found that out of the 105 randomly assigned patients, the randomly assigned group that underwent MI treatment indicated that “completers who received MI increased use of behavioural coping strategies and had fewer cocaine-positive urine samples on beginning the primary treatment”. This evidence suggests that the application of MI in substance dependent individuals has a positive impact in aiding the individual to overcome this issue.

A 2016 Cochrane review focused on alcohol misuse in young adults in 84 trials found no substantive, meaningful benefits for MI for preventing alcohol misuse or alcohol-related problems.