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The following points highlight the top twelve techniques of behaviour therapy. The techniques are: 1. Systematic Desensitization 2. Flooding 3. Shaping 4. Modelling 5. Response Prevention and Restraint 6. Aversion 7. Self-Control Techniques 8. Contingency Management 9. Assertiveness Training 10. Negative Practice 11. Contracts 12. Meditation and Yoga.
Technique # 1. Systematic Desensitization:
It is based on the principle of reciprocal inhibition, which holds that prior establishment of an appetitive physiological response can prove capable of blocking a conditioned avoidance response.
Systematic desensitization as given by Wolpe (1958) involve the following three stages;
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i. Training the patient to relax
ii. Constructing with the patient a hierarchy of anxiety-arousing situation.
iii. Presenting phobic items from the hierarchy (a sequence of phobic stimuli in an increasing order) in a graded way, whilst the patient inhibited the anxiety by relaxation.
(a) Relaxation Techniques:
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There are many methods of relaxation which are used before starting desensitization e.g., Jacobson’s muscular relaxation techniques (e.g., successful tensing and then relaxing various pairs of muscles throughout the body) or Yoga or use of Methohexitone. The advantages of using these techniques are that firstly they are useful for those patients who are unable to relax, secondly all anxiety techniques are that firstly they are useful for those patients who are unable to relax, secondly all anxiety disappears and lastly, they make the technique of systematic desensitization as more economical in time.
(b) Hierarchy:
It is a sequence of phobic-stimuli from the least to the most phobic one. In systematic desensitization, it is started from the least phobic to the most phobic stimuli in sequence.
(c) Systematic Desensitization:
It is based on the pairing of a pleasurable physiological state such as relaxation, sexual arousal or eating, with progressive hierarchical exposure to the feared situation or object. The elicitation of anxiety requires return to a prior step (in hierarchy). The basic mechanism at work appears to be the phenomenon of extinction i.e. the gradual elimination of a response such as anxiety, when it is no longer reinforced.
When the sensitization is being done in imagination, the length of the session is generally about 40 minutes, depending on how long it takes to get the patient relaxed; moving up steps in the hierarchy rarely extends beyond 30 minutes. The number of sessions required varies from say, 10 to 100 depending on the complexity of the problem and on the number of hierarches to be worked through. Patients are expected to practise at home what they have learned in the clinical session.
When the desensitization is carried out in vivo, the patient is instructed how to relax and how and when to use relaxation beforehand in the consulting room but the actual desensitization is done in the real relaxation. Most of this ‘homework’ will actually be done while the patient is accompanied by a relative.
The main use of desensitization in vivo is that when the patients have difficulty in imagining situations or do not feel anxious or they fail to relax. But the main disadvantages are that it is tedious, time consuming, impossible to device situations precisely as represented in hierarchy and in certain situations e.g., crowded streets, it is difficult to remove the patient.
Systematic desensitization is one of the most intensively investigated of all kinds of psychological therapy. In phobic neurosis, it is extensively used.
Technique # 2. Flooding:
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Stampf and Lewis (1967) first reported the use of flooding in phobias.
Flooding involves exposing patients to a phobic object or situation in a non-graded manner with no attempt to reduce anxiety. Unlike systematic desensitization, no prior relaxation techniques are taught to the patient and it is usually given in a non- graded manner or in reverse hierarchy (starting from most phobic to least phobic stimulus). It can be conducted in imagination (Implosion) or in vivo.
Implosion:
In this therapy, there is exposure to phobic ideas or scenes in fantasy, for quite long periods (for 40 to 60 minutes in comparison to 10 to 20 seconds used in desensitization). The patient’s anxiety is raised to an almost maximal level during the presentation e.g., the patient is placed alone in a room with the phobic object say a cat and is required to stay there until the fear has diminished.
It is believed that if a avoidance is not allowed, the fear will diminish due to emotional exhaustion or habituation. Another likely reason for success is the patient’s reality testing of the situation whereby he discovers that he is less afraid of the phobic object than he had expected to be.
Flooding and systematic desensitization is used in the treatment of phobias but is also effective in obsessive compulsive neurosis. Flooding can be used in groups (as it increases sociability by reducing inhibitions).
Flooding is avoided in patients with cardiovascular disorders or uncooperative patients or those who continue to have panic attacks.
Technique # 3. Shaping:
The successive approximations to the required behaviour with contingent positive reinforcement. By praising the patient, each time the patient takes a step in hierarchy. It is useful in many other types of situations e.g., rehabilitation of physically handicapped children with neurotic behaviour or autism, etc.
Technique # 4. Modelling:
It refers to the acquisition of new behaviours by the process of imitation. In this form of treatment, the patient observes someone else (may be the therapist) carrying out an action which the patient currently finds difficult to perform. Results are better if the patient can realistically identify with the person serving as the model.
Modelling is often used with other techniques such as flooding and role playing, particularly in the treatment of phobic and obsessive compulsive disorders, but is widely used to develop social skills or to increase self-assertiveness. Participant Modelling is the general technique or modelling demonstration and client participation.
Technique # 5. Response Prevention and Restraint:
When combined with flooding, it is the treatment of choice in obsessive compulsive neurosis. The technique involves exposing the patient to a contaminating object, such as soiled towel and subsequently preventing him from carrying out his usual cleansing ritual. Modelling (e.g., touching the contaminated object by therapist and then eating something) may also be combined.
Sometimes response prevention can be more directly achieved through physical restraint e.g., wearing gloves or plaster by thumb suckers. Thought stopping is sometimes used in the control of obsessional thoughts by arranging a sudden intrusion (e.g., snapping an elastic band on the wrist). The effects are merely those of distraction.
Technique # 6. Aversion:
It involves producing an unpleasant sensation in the patient, usually by inflicting pain in association with a stimulus. One alternative to aversion is the withdrawal of reinforcement, either known or presumed, or removal of the patient from all possible sources of reinforcement.
It is useful in treatment of cases where the patient’s behaviour has serious consequences for himself or for others and which cannot be tolerated even for a short period e.g., self-injuring patients or those who sexually abuse children.
Aversion therapy has been used for alcoholism where the sight, smell and taste of alcohol are linked by classical conditioning with nausea and vomiting induced by apomorphine. Later, mild electric shock was used as the aversive stimulus. The conditioned and unconditioned stimuli are associated at precise intervals. It produces longer lasting changes in behaviour. Aversion has technical (patient may become aversive to therapist) and ethical problems.
Aversion techniques have been used in the treatment of sexual perversions. Covert sensitization is an alternative to aversion therapy, here the mental images of the unwanted behaviour (e.g., fantasies about cross dressing) are associated with mental images of situations that the patient finds unpleasant or disgusting.
Technique # 7. Self-Control Techniques:
All behavioural treatments encourage patients to learn to control their own behaviour and feelings. In self-control techniques such learning is the principal aim. These treatments lack specific procedures directed to individual symptoms. Instead they attempt to increase the patient’s ability to make common sense efforts at altering his behaviour. Over-eating and excessive- smoking are examples.
It consists of two stages:
i. Self-Monitoring:
It refers to keeping daily records of the problem behaviour and the circumstances in which it appears, e.g., a patient with bulimia nervosa would be asked to record the frequency of binge eating and subsequent vomiting and to note any association between overeating and events experienced at stressful.
Once the problem behaviour has been identified, self- reinforcement is tried e.g., the patient rewards himself in some way when he has controlled behaviour successfully.
ii. Self- Evaluation:
It refers to making records of progress and this also helps to bring about change. Premack Principle. Any frequently performed piece of behaviour can be used as a positive reinforcer of the desired behaviour.
Technique # 8. Contingency Management:
This group of procedure is based on the principle that if behaviour persists, it is being reinforced by certain of its consequences and if these consequences can be altered, the behaviour should change. It is assumed in treatment that the relevant positive reinforcers are usually social. They include expressions of approval and disapproval by other people, and actions that are enjoyable and rewarding for the patient.
Contingency management has four stages:
i. The behaviour to be changed is defined and another person (e.g., a nurse in case of a schizophrenic patient) is trained to record it.
ii. The events that immediately follow (and presumably reinforce) the behaviour are identified e.g., a nurse paying more attention to a schizophrenic patient when he shouts than when he is quiet.
iii. Alternative reinforcements are devised e.g., tokens that can be exchanged for privileges (e.g., weekend leaves), signs of approval by other people.
iv. Staff or relatives must be trained to provide these reinforcements immediately after the desired behaviour and withhold them at other times.
Contingency management may be used for individual patients, couples or families (i.e., behavioural, marital or family therapy) or for a group.
Token Economy:
When reinforcement is mainly by tokens to be exchanged for privileges the system is called token economies e.g., depriving a patient of some amenity (which can be earned with tokens) for an undesired behaviour.
If this amenity is something the patient should have by right, there is ethical problem. Contingency management has been used in schizophrenic patients, mentally handicapped adults, behaviour disorders in children etc.
Technique # 9. Assertiveness Training:
Used in chronically depressed, socially anxious and inhibited in the expression of warm feelings of anger. It is also based on the principle of reciprocal inhibition (as discussed with systematic desensitization). It is designed to encourage the direct but socially-appropriate expression of thoughts and feelings.
Technique # 10. Negative Practice:
Some problems e.g., tics, stammering, thumb- sucking, nail-biting etc. can be reduced when the patient deliberately repeated the behaviour. The support for this idea is provided by experiments showing that inhibition accumulates during massed practice. On repetition, reactive inhibition becomes associated with behaviour which is then reduced.
Technique # 11. Contracts:
It is often the case that the reinforcing consequences of a patient’s behaviour are under the control of another person e.g., a parent who wishes a child to behave in a certain manner can state quite precisely what rewards will be given if the child behaves in that way.
The therapist may act as a neutral arbitrator when the contract is being drawn up and when there are difficulties about its implementation e.g., in marital problems. Seidner and Kirschenbaum (1980) have indicated the use of contracts in behaviour change.
Technique # 12. Meditation and Yoga:
The meaning of meditation and its phenomenological characteristics. Meditation means the creation of a special state of consciousness that differs from the medium every-day-consciousness by higher arousal, attention and concentration, with a withdrawal from the outside world (environment) and with an altered experience of one’s self.
The egocentric experience of the world is given up. Narcissistic needs are not any longer urgent. The ego-bound characteristics of everyday-existence are dissolved.
This is the basis of the ‘unio mystica’: The ego has merged into an all common transcendent being, the experience of atma brahma identity, the experience of ego-lessness (anatta as it is called in Theravada Buddhism).
The body feelings are altered or even suspended. Perception hallucination, imagination in various sensory fields flow together. The senses of time and space are lost. The basic feeling is often a quiet peaceful concentration and openness.
Psychological and psychophysiological effects of meditation:
(a) Psychological effects of meditation commonly reported are: achieving relaxation, calmness, quietness, peacefulness, equal activity and wakefulness, improving one’s self-concept and autonomy of personality with less need for defensive attitude and with more tolerance.
(b) Emotions are harmonized and often a joyful tranquility is reported.
(c) The ability to cope with struggles of life is improved.
(d) In some cases a person may become more active and creative.
(e) Communicating with other people may sometimes be less problematic due to the better self-experience.
(f) Experimental psychology has reported functional improvement on a series of psychological tests, especially perception- tests. Some found a reduction in the orienting reflexes, a shortening of reaction time. In the field-independence test higher scores of independency were found among meditators.
(g) Physiologically the meditative state is characterized by a higher functional level of the trophotropic parasympathetic nervous system.
Meditation as an Aid in Psychotherapy:
The patient himself is the meditator; the therapist may act as a meditation teacher or supervisor or may perform psychotherapy parallel to the meditative exercises of his client. This is the way meditation is mostly practised in treating numerous psychosomatic disorders, nonpsychotic psychological problems, neurotic troubles, life-crises etc.
This type of meditation is an aid in psychotherapy-the patient being meditator himself:
Psychosomatic disorders:
Hypertension, bronchial asthma, gastric, duodenal ulcer, multiple autonomic dysfunctions.
Neurotic troubles:
Anxiety, restlessness, sleep disorders, phobias, obsessive compulsive tendencies, multiple neuroses especially depressive neuroses.
There are various theoretical interpretations of its effects: as a behaviour changing technique, as a bio-feedback therapy, as an operant conditioning of autonomic functions and as an influence in biological rhythmicity.
Psychoanalytically it may also be interpreted as a change in the libidinal loading of object representatives and ego-structures. Or it may be interpreted by the concept of vital energy identical with cosmic energy, called Kundalini. Strictly speaking, there are no indicators as to what kinds of patients are able to meditate with therapeutic profit.
A completely different way of applying meditation in psychotherapy is in the treatment procedures for schizophrenics. Here the therapist is the meditator and the patient is passively included into the atmosphere created by the meditating therapist. It seems that a relatively solid ego-structure is a prerequisite for successful meditation without causing disintegration of the meditator.
That is helpful in some cases is of primary importance for our conceptualizing of the nature of schizophrenic ego-disease. In severe catatonic schizophrenia, meditation by the therapist may have a calming effect on the frightened patient, diminishing his psychotic behaviour and abolishing all his symptomatology for the period of time of meditation.
It terms of Western psychotherapeutic language this kind of meditative therapy, is a type of preverbal empathic therapy. In the duality therapist-patient, the latter finds security and a rest for his threatened ego which allows him gradually to recollect himself as a being with his own vitality, activity, consistency, demarcation and identity.
During the meditation of the therapist there is no intention towards the patient — both therapist and patient are included in an individual-transcending and transpersonal process of consciousness. During successful meditation the ego-consciousness of the therapist is not prominent and is replaced by an “impersonal pure presence”.
Therefore there is no protopathic-intuitive perception of the patient and no realization of counter transference, no participation and on acceptance during meditation. In meditation there is neither intimacy nor distance, neither intensity nor emptiness of existence. In meditative consciousness the alternative dimension is transcended.
Meditation may be seen as pure “letting be”. The ego-consciousness of the schizophrenic is suspended as long as the patient takes part in meditative process.
In this stage of “prae-ego, in the communication in the nil”, as one of the patients called it, the “negative existence” of the schizophrenic may be replaced by the birth of a new positive existence. This may be called ego-synthesis or reconstruction.
The therapist has to accompany the patient out of the meditative stage of consciousness, proceeding step by step to the concrete problems of the day.
Dangers of Meditation:
There are potential dangers-without mentioning the teacher’s economic and erotic misuse of his influence:
1. Meditation can be misused as an escape from the concrete tasks of every-day-life, it may then lead to an even more severe inability to cope with life.
2. Narcissistic personalities may be threatened by feelings of being lost, of being overwhelmed by the chaos of ‘samsara’, some suffer from isolation and anxiety, experiencing themselves as bottomless existences.
3. The Task Force on Meditation of the American Psychiatric Association (1977) has given a warning of “acute dis-organizational states”, as sometimes manifested by meditators with weak ego structure, without a capable leader or forced by overmedication or if the meditation of the patient is used to escape the concrete life situations as in drug abuse. “Meditation is a classical way of developing a receptive attitude. It is the practice in the skill of being quiet and paying attention.”
Yoga:
Yoga which literally means ‘union’, stands for a union of the individual consciousness with cosmic consciousness. Although, truly speaking, yoga was not devised as a therapeutic system in the narrower sense, it has been copiously employed for that purpose both at home, in India and abroad. Yoga has evolved into a variety of cults.
Yet, Patanjali’s ‘ Ashtang Yoga’ (Eightfold Yoga) remains of central importance. Of the eight kinds of observance it prescribes (i.e., Yam, Niyam, Pratyahar, Asana, Pranayam, Dharna, Dhyan and Samadhi), the first three are concerned with ethical purification; the middle two with psychophysical control; and the last three with progressive control of the psychic apparatus culminating in Samadhi or the highest form of meditation, wherein contents of consciousness are fully emptied and an absolute single-pointedness (ekagrata) is attained. The resulting experience of contentless consciousness (shunya = void) is, in essence, a fully deconditioned state of mind, hence also called liberation or ‘moksha’.
The attainment of this state requires the highest integration of psychophysical functioning, for every stimulus, external or internal, tends to produce a disturbance (vikshepa) of the inner harmony.
Disease (vyadhi) is considered an important psychophysical disturbance (vikshepa) and requires to be dealt without through methods that would quell this disturbance. ‘Samadhi’ literally means putting together or integration; ‘vyadhi’ by contrast means disconcertment or disintegration which produces a feeling of being ‘ill at ease’ (‘dukkha’) and hence is a ‘dis-ease’ producing process. It is, therefore, a ‘vikshepa’, and needs to be remedied for ‘samadhi’ to be properly maintained. Hence the interest of yoga in therapeutic practices.
Yogic practices have also been adopted as therapeutic cults. The ‘asanas’ or physical postures have been adopted by ‘Hatha Yoga’ as an independent cult, and has found much popularity, even in the West, as a mode of physical culture and attaining physical^ and mental relaxation.
‘Mantra Yoga’ or concentration (Sanskrit Dhyana, Pali Jhana, and Japanese Zen are equivalent words) over a verbal formula has more recently, come out in an abbreviated form called Transcendental Meditation and found considerable therapeutic application even to merit a mention in some textbooks of psychiatry.