gif

 

12

 

gif
gif
gif

Behaviour therapy and
cognitive behaviour modification

The terms ‘behaviour modification’ and ‘behaviour therapy’ can be used almost interchangeably, although by and large it is the techniques used to dispel anxiety by Wolpe and the Eysenckian school that are called therapy, and the methods used by Skinnerians to try and build up new behaviours in retarded children or psychotic patients which are called modification. There is a certain amount of controversy surrounding cognitive behaviour modification, as might be expected. Much of this boils down to simple name-calling, with one side saying ‘We must wake up to reality and start to recognize that people have cognitions and beliefs’, and the other side saying ‘Oh, no, people have only private stimuli and unseen responses, as we have said all along’. But at bottom is the fundamental ambivalence of radical behaviourists faced with cognitive processes, and an important practical dispute about which methods of therapy work best.

The argument for including thoughts and cognitions as part of behaviour modification has been put forward at length by Mahoney (1974) and Meichenbaum (1977). The starting point is

145

the obvious contradiction between the early formulations of behaviour therapy, which described all clinical problems as ‘maladaptive behaviour’ and all therapeutic measures as ‘reconditioning behaviour’; and the fact that many, if not the majority, of clinical problems are best described as disorders of thought and feeling. Some of the complexities of this situation are taken into account in the three- systems model, discussed in chapter 9, but the contradiction remains.

There is still a very hard-nosed view, which pops up occasionally in some surprising quarters, that as we can never be entirely sure about the contents of someone else’s mind, we would be better off ignoring it and sticking to observable movements only. This is related to the opinion that consciousness is just ‘the smell above the factory’, which doesn’t actually do anything useful. There is also the argument that since all the most important things are unconscious anyway, we need not bother much with the conscious part directly. This applies to Freudian unconscious emotional conflicts, but also to the fact that people are said to perform very complicated motor and perceptual skills, such as those involved in driving or playing tennis, while not thinking about the details of the actions involved. In some practical cases, the lack of effect of conscious desires may be part of the problem—someone may want to give up smoking, or stop being shy, or stop being afraid of heights, but this does not seem to be enough. More generally, feelings, cognitions and actions often seem to be independent of one another.

Those who want to include cognitions in behaviour therapy say that although that may be theoretically very interesting and difficult, from a practical point of view it is foolish to ignore the commonsense idea that a person’s conscious thoughts and beliefs are among the most important determinants of their actions and behaviours, both in mental illness and in health. It may be true that some people occasionally do complicated things while unconsciously sleepwalking; chess masters do some incredibly clever computations intuitively; and some of us go back to sleep after having made firm conscious decisions to get up. But in the normal course of life many important decisions are premeditated. People have been known to get married and have babies by mistake, and others may become compulsive shop-lifters or commit murder while deranged. But there are very few reports that anyone has

146

sold their house and bought another one, or completed a degree course, during a fit of absentmindedness.

Apart from hard-nosed scepticism, there are two answers which non-cognitive behaviourists give to the claim that cognitions are important. The first is: ‘Of course thoughts and cognitions arc important, and we have said so all along, but would you please not fall back into the disgustingly mystical habit of calling thoughts thoughts, instead of calling them by their proper names of private stimuli and behaviours.’ The person who can say this with most justification is Wolpe, since from the beginning he did indeed talk extensively to his patients about their beliefs, instructed them to try to think differently, and asked them to have fantasies about things which made them anxious (see chapter 8).

With slightly less justification, Skinnerians also say that ‘self-instructional training,’ along with other kinds of cognitive restructuring, is what they have always recommended, but that these forms of therapy will only be properly scientific if we happen to describe them in terms of ‘the role of private events in controlling behaviour’ (Lowe and Higson, 1981, p. 82). Skinnerians tend to be extremely slippery customers in these arguments, since if ever they are taxed with the importance of mental events, they claim that Skinner has already included them in his system. For instance, Blackman, in his presidential address to the British Psychological Society (1982), insisted, ‘It is quite clear that behaviourists such as Skinner recognize the reality of our subjective states, and try openly to fit such states into their general schema.’ But there is a catch, since this is done ‘without attributing special status to mental events’, so that they end up being private stimuli and responses instead of thoughts and cognitions (Blackman, 1982, p. 337).

There are at least two reasons why it is better to be on the side of cognitions than on the side of private behaviours. The first is just clarity. If it is very often assumed that the behaviourists in question are denying the reality of thoughts and cognitions, this is largely because they persist with their taboo of special words for them. The second is that mental events surely are special, for one reason or another. Having undergone several hundred million years of evolution in order to acquire brains which are capable of thought and, in the case of most of us, decades of expensive and arduous education to help us to think, it seems very strange to

147

classify our thoughts along with the wrigglings of the amoebae, although we saw that that was just what Watson, if not his later disciples, intended to do (see pp. 10 and 24).

Therapeutic considerations

Let us now return to applied questions concerning techniques of therapy, which after all are more important than terminological wrangles. From now on we can assume that everyone agrees that patients can be dominated by obsessional thoughts, can be panic-stricken by imagined disasters, and misled by erroneous beliefs, provided that we make simultaneous translations available in the jargon of different academic sub-cultures. The argument is: should we not try to try to work directly on the patient’s obsessions, imaginings and beliefs instead of relying on the battery of behaviour therapy techniques already provided by Wolpe and others? This sounds straightforward enough, but in fact the difference between techniques called ‘behaviour therapy’ (following Ledwidge, 1978) and those called ‘cognitive behaviour modification’ is not always obvious. By and large, behaviour therapy includes the methods, used by Wolpe and others, such as assertion training and opposing anxiety by relaxation in systematic desensitization, which in theory are aimed directly at the patient’s symptoms. Cognitive behaviour modification, on the other hand, attempts to change the patient’s mind.

It may do this by rational argument and advice, emotional confrontation and brow-beating or by specialized exercises in self- instruction, self-awareness and rational analysis of problems. A patient (grown-up) who only feels secure in the company of his teddy bear may be told: ‘Don’t you think it would help your marriage if you gave up your teddy?’, ‘Don’t you realize most adults manage without teddy bears?’ ‘It is ridiculously childish to sleep with a teddy bear’, ‘Practise saying to yourself every night ‘I don’t need my teddy, I’m grown-up and I don’t need my teddy:’. In Wolpean desensitization, the same patient might over a series of interviews be helped to relax while progressively imagining: teddy is at the bottom of the bed; teddy is on the floor by the bed; teddy is just in the next room; teddy is sleeping downstairs; teddy has been given to Oxfam.

Both procedures clearly involve mental processes, so that is not

148

an issue. But often (though not always) in Wolpean procedures patients do not have to actively analyse their own problems but can passively follow the directions of the therapist. In other procedures patients are required deliberately to restructure their own thoughts or to engage in certain forms of positive thinking or otherwise helpful mental routines. I must say that it does not seem to me a hard and fast distinction and that it is just a matter of a large variety of possible procedures, all of which involve some measure of direction, persuasion, comfort and amelioration of anxiety by calming experiences. However, Ledwidge (1978) has provided a very thorough analysis of procedures, which he separates into two categories, and there remains a division between cognitive and behavioural treatments based on different theoretical traditions.

Ledwidge’s point is that attempts to ‘modify the client’s pattern of thought (faulty premises, assumptions, attitudes and the like)’ just do not work as well as methods which concentrate more directly on actions and on anxiety conceived as a bodily response. He agrees that ‘thoughts and feelings do play a critical role in human behaviour’ and that ‘changing thoughts and feelings is the aim of behaviour therapy’, but says that ten years of clinical experiences, and his extensive review of other controlled comparisons, have convinced him that ‘the best way to change thoughts and feelings is to change behaviour directly; changes in thoughts and feelings will then follow’ (1978, p. 371). There is a case to be made that the definition of a neurosis is something that does not respond to kind advice, rational discussion and self-help. Other problems such as smoking, alcoholism, drug addiction and disorders of sexuality are again usually resistant to direct appeals to the hearts and minds of the sufferers, and that is why therapists of all kinds have to resort to the more drastic or less predictable tricks of their trades. But the proof of the pudding is in the eating. Some problems may be less severe than others, not all patients (or therapists) have need of the same methods, and there is abundant evidence, as Wolpe (1978, 1981) freely admits, that some patients have cognitive problems that respond to cognitive solutions. The more cognitive methods are therefore worthy of a little further examination.

149

Albert Ellis’s rational emotive therapy

Albert Ellis is a New York psychiatrist who, like Wolpe, started off as a Freudian but became disillusioned by the lack of practical effects of Freudian analysis on his patients. He originally specialized in marriage-counselling and sexual problems, and providing direct instructions and basic information in these areas could, at least in the 1950s, sometimes have very quick and very beneficial effects. Ellis turned from Freud first to Pavlov, and in a discussion of the origin of his methods includes an account of Pavlovian conditioning, partly in terms of the expectations that might have been engendered in Pavlov’s experimental dogs. But on the rational grounds that patients can be talked to with rather more result than dogs, Ellis developed a diffuse, but he believes effective, system of therapy. It is not easy to summarize, but Ellis says it is minimal as far as the personal relationship between therapist and patient goes, and maximal as regards the directive and teaching element in their verbal exchanges.

A fundamental tenet is that thinking and emotion are usually related, and especially so in psychological problems. The ancient Greek formula that ‘Man is disturbed not by events but by the opinions he forms about them’ can be taken as a slogan for cognitive therapies, and in Ellis’s bad emotions are seen as a function of irrational ideas and cures take the form of modiflying these or substituting better ideas. In the simplest form of the therapy, patients are told in no uncertain terms to look on the bright side, stop worrying and pull themselves together, but this is a fairly protracted process (several hours a week for months, but not, as in psychoanalysis, several hours a week for years). Also, Ellis is eclectic in his techniques, bringing in desensitization by familiarization with disturbing circumstances or actions, and even a certain amount of Rogerian ‘positive regard’ and respect for the patient by the therapist.

The ‘rationality’ should not be taken too literally — it is sometimes a matter of changing not unreasonable but counterproductive opinions into just as irrational but helpful ones. It is not necessarily more rational to be an optimist than a pessimist, but being pessimistic is usually less helpful, and is something to be discouraged in depressed patients. Ellis (1962) gives eleven basic irrational ideas which tend to be emotionally self-defeating

150

and are commonly associated with psychological problems. A main theme is an inability to come to terms with life’s ups and downs, and there also seems to be a lack of toleration for ambiguity and error. The first irrational idea, for example, is the belief that one must be loved and accepted by absolutely everybody —therefore rejection or loss of love is made very disturbing. The second is the perfectionist desire to be excellent in all possible respects and never to make mistakes. The third is the belief that badness should always be punished, so that blame and anger are engendered for one’s own and others’ shortcomings. Many other ideas come up in case histories, including the belief that self-discipline is impossible to achieve, that emotions cannot be controlled, that this is especially so if bad emotions have been caused by an unfortunate childhood, and so on.

The general thrust of therapy, then, is to convince the patient that nobody is perfect, everybody makes mistakes, and it is not the end of the world if X happens — ‘If I try hard enough things will get better, I can conquer my irrational fears’, etc. It is an important part of the procedure that patients practise saying to themselves statements that emerge in optimistic discussions with the therapist, or that they are explicitly directed to practise, sometimes with the help of ‘homework’ in the form of checklists and questionnaires. The patients have to break habits of saying, for example, ‘She might reject me and that would be awful’, ‘I’m no good, my parents think I’m worthless’, ‘This is never going to get any better and it’s all because I’m stupid’, and to form new mental and overt habits of saying, instead, ‘She might accept me and that would be wonderful’, ‘It’s only my parents’ opinion and I know I’m OK’, ‘There is no such thing as a stupid human being only a fallible human being, I can get better and I’m going to build new cognitive maps’.

As far as origins go, this is clearly related to an American tradition of optimism, self-improvement and self- confidencebuilding, which goes back to salesmen standing in front of a mirror in the morning saying ‘I’m going to sell, sell, sell today’, and continues in pep talks and half-time inspiration by football coaches. There is much to be said for pep talks, and selfencouragement of all kinds, but Ledwidge (1978) is entitled to his doubts as to whether these measures are universally successful in cases of severe psychological disorder.

151

A condensed version of an exchange which Ellis (1962, p. 296) says brought about the cure of a chronic psychopath goes like this:

THERAPIST Isn’t your thick skin really nourished by your corrosive hatred of others, and doesn’t that hatred in the long run corrode you?

PSYCHOPATH Hmm. . . . You’ve certainly given me something to think about.

THERAPIST Well you give it some real hard thought then. [Psychopath exits, restructuring his cognitions

 

Another success story given by Ellis (1971) concerns a couple who had been married for thirteen years without ever having had intercourse since, after initial difficulties, ‘We thought we’d wait till maybe a more convenient time to work it out.’ The therapist very quickly jumps in to tell them that their behaviour is due to (1) fear of failure and (2) sexual puritanism. They readily agree, having had strict and sheltered upbringings. They become convinced that all their guilt is irrational, but when the therapist gives them sexual exercises of the Wolpe type (see pp. 104—5) it transpires that they also have the irrational belief that all sexual relations should be spontaneous, and should not be artificially contrived. Once this error had been expunged by further instruction, the exercises did the trick, sexual relations proceeded as if they had never been absent, and the patter of tiny feet was soon heard.

An understandably less successful case concerned a graduate student who had initially had the psychotic belief that a guardian angel would protect him if he jumped in front of large trucks. Acting on this belief he received a very severe concussion, which for one reason or another dispelled his belief in the angel but which left him with a severe phobia for noises (connected with the fear that he would experience another concussion), insomnia, and remorse about his own stupidity, with suicidal depressions (Ellis, 1971, p. 179). An immediate course of rational therapy helped, but all the (post-angel) symptoms returned a year later, and protracted further therapy with much homework was necessary.

There seems no reason to doubt the value of rational argument used to change attitudes which are obviously self-destructive, but at the same time amenable to reason or to persuasion. Beck (1976) has recommended similar therapeutic techniques, especially in

152

depression. If these work, all well and good, but there are certainly limits to the number of cases of severe mental illness that are likely to respond to arguments along the lines of ‘If you examine things rationally there’s really nothing to be afraid of’ and ‘Cheer up, it’s not your fault, there’s nothing to be depressed about’.

Meichenbaum’s self-instruction

I still occasionally find myself remembering the instructions ‘Look right, look left, look right again, before you cross the road’, which were drilled into me at school as an infant. It has often been observed that children between about 2 and 5 may self-instruct or self- describe their own behaviour (e.g. ‘Now Dolly is going to bed’), and although this is by no means a universal and ever-present phenomenon, a number of Soviet theorists have argued persuasively that the development of inner speech is an important element in the child’s progress towards adult thought (Vygotsky, 1934/1962; Luria, 1961; Sokolov, 1972). Meichenbaum has suggested that artificially augmenting internal and overt self-instruction may assist in improving the behaviour of children judged to be ‘impulsive’ or ‘hyperactive’ — of which there are apparently such large numbers in North America as to almost constitute the norm (Meichenbaum, 1977). Older children (up to 10) as well as younger ones may benefit from posters and cartoons which contain such slogans as ‘Look and think before I answer’ and ‘What does the teacher want me to do?’ (cartoons may later become unnecessary, but even the most mature university students may sometimes benefit from reciting similar homilies to themselves before answering examination questions). The usual thing with young children is for an adult to model (demonstrate) the required self-control in such things as copying pictures, saying, as they unspontaneously perform the task, ‘OK, what is it I have to do? You want me to copy the picture with the different lines? I have to be slow and careful. OK, draw the line down, down, good; then to the right. Good, I’m doing fine so far.’ There is some evidence that this slows the children down and improves their performance when they do a similar task themselves, and that this is because they imitate the tactic of talking to themselves out loud. There is no evidence, however, that such procedures by themselves are a panacea for all impulsiveness and hyperactivity.

153

As Skinner certainly recognized, the area of self-control is a large one, and the day-to-day and year-by-year influence of what goes on at home and at school cannot usually be counteracted by an hour or two of isolated verbal training. More thoroughgoing intervention, sometimes with explicit retraining of parental behaviours towards their offspring, may be needed for oppositional (difficult) and hyperactive children (Wahler, 1969, 1980).

There is also little evidence that self-instructional training has any very profound effect on the thought and speech of chronic schizophrenics, which is often weird, delusional and over-inclusive (rambling). Behavioural techniques of reward and persuasion (see pp. 142—3) have been used in attempts to change these particular symptoms, among others, and Meichenbaum (1977) observed that patients who had been instructed to ‘Give healthy talk, be coherent and relevant’ began to repeat this exhortation to themselves. Further examples are given by Meichenbaum (1977, p. 75) of schizophrenic patients being explicitly encouraged to repeat to themselves ‘I must not talk sick talk’, ‘Don’t talk crazy’, ‘Stay on the topic, stay on the topic’ and ‘Don’t ramble on, don’t ramble on’. The effect this expedient has on the long-term prognosis of the patients involved appears to be extremely limited, but the last two suggestions may again come in handy for students writing essays (and for lecturers giving lectures, I know). The anecdote which expresses the difficulties as far as schizophrenics are concerned is about a paranoid person who believed he was Napoleon. He was arduously persuaded by the giving of tokens and by advice as regards self- instruction to say that he was John Brown, born in Chicago in 1940, rather than N. Bonaparte, born in Corsica in 1769, but after this achievement he pocketed his tokens, put his hand inside his jacket and asked all in the corridor as he left not to pay any attention to the John Brown nonsense, as he was really Napoleon (Wincze et al., 1972). Verbal expression is not always the same thing as belief, and words may often disguise thoughts in many less extreme cases.

Stress inoculation and imagery

Meichenbaum (1977) also suggests that forms of self-instruction can be used to prepare those who know they have difficulties such as reacting with excessive anger or anxiety to certain personal

154

interactions (e.g. personal strains at work, or visits to parents or in-laws). These appear to be fairly elaborate, including advance preparations, on-the-spot self-warnings and self-debriefings afterwards, such as ‘I can work out a plan for this, it won’t be too bad’, ‘Stay calm, stay calm, keep control’, ‘There was no need to take it personally, I don’t have to be upset by that’, ‘It will all be the same in a hundred years, it isn’t the end of the world’. It is surely true that time-honoured maxims and proverbs, and more recent slogans and self-instructions, play a role in some people’s lives, and may occasionally be helpful in therapy, especially for mild sorts of personal emotional control. But equally Wolpe (1978) is not only whistling to keep up his own courage when he claims that self- instructions and simple maxims are not very much use in severe cases of anxiety. As an old proverb has it, ‘panic fear is beyond all arguments’. As Wolpe says, many strong neurotic fears are triggered by things that the patient already knows to be harmless, and telling oneself to keep calm and that there’s nothing to worry about is unlikely to be very much help during a panic attack. If it was, there wouldn’t be such a need for therapies.

Behavioural treatment of obsessions and compulsions

The incidence of incapacitating obsessional and/or compulsive disorders is not high — certainly less than 5 per cent of psychiatric patients are classified in this way, although obsessional symptoms (or possession of an ‘obsessional personality’) may be fairly common in those who see no reason to seek professional help. Considerable attention, however, has been given to these disorders by behaviour therapists. That fact is particularly interesting in the context of this discussion, since a frequent feature of obsessive- compulsive disorder and, indeed, according to earlier writers, the defining feature of the syndrome, is the presence of obtrusive thoughts, which the patient tries hard to resist because he or she believes they are irrational, and does not like them. ‘The religious person who is continually tormented by sacrilegious thoughts and who may, to his great consternation, even feel himself forced to make blasphemous statements; the woman who experiences thoughts related to injuring her husband or children; men who continually fight against thoughts of homosexual activities, all fall into this category’ (Malamud, 1944).

155

Not surprisingly, such patients are also often depressed, but the category, though small, is very varied: patients who are obsessed by cleanliness, or by particular sources of contamination, or by the dangers of things left undone, and have compulsions like incessant washing of hands or objects, or repeated ‘checking rituals’, such as testing locks or taps or making sure the electricity is turned off, do not always struggle against the illogicality of their concerns as much as they are supposed to. The onset of these syndromes is usually gradual, and by the time a patient has attracted clinical attention, the prognosis is generally poor — the patients are extremely resistant to psychotherapy and are occasionally recommended (by psychiatrists, not behaviour therapists) for electroconvulsive treatment and leucotomies (brain operations).

Obsessional patients may thus clearly have irrational thoughts as a main symptom, but it does not follow that cognitive methods can easily be used, in the sense of rationally arguing the patient out of the obsession. A number of procedures, of greater or lesser forcefulness than reasonable discussion, have been used by behaviour therapists in the treatment of obsessions and compulsions.

Thought stopping

Wolpe (1958) notes that obsessional thoughts and behaviours are often variable in detail, and that although in a given patient various symptoms tend to lead to one or other kind of result, obsessions can be either anxiety-elevating (exhibitionism of all kinds and intrusive thoughts) or (in the short term) anxiety-reducing (checking, washing, tidying, collecting, list-making). Other symptoms include excessive slowness (sixty minutes over shaving) and indecisiveness, and so the analysis of the causes of obsessions is complicated. As far as treatment goes, Wolpe has ‘correcting misconceptions’ as ‘often an essential precondition to psychotherapeutic success’ (1958, p. 200), but does not set much store by it and has as another subsidiary method ‘thought stopping’. This is a direct and symptomatic treatment of obtrusive ruminations. The patient indicates when he is having one of these and the therapist then yells ‘Stop!’ and perhaps bangs the table. The patient then himself does the yelling, eventually sub-vocally, and if this is practiced assiduously, it sometimes works. The patient can also be

156

encouraged just to ‘think of something else’ when unwanted ideas occur, but Beech and Vaughan (1978) and Rachman and Hodgson (1980) conclude that the results obtained by these methods have usually been unreliable in clinical practice.

Exposure, flooding and response prevention

For the treatment of patients with severe and incapacitating behavioural symptoms associated with obsessions, behaviour therapists have evolved procedures in which strict and demanding requirements are imposed on those involved (mainly on the patient, but also on the therapists and their assistants, and sometimes on relatives as well). All the treatments involve exposure to disturbing circumstances, and most require the patient not to do the things he or she normally does when disturbed. In the most thorough method, that of response- prevention as used by Meyer at the Middlesex Hospital,. patients are taken off all medication and put under the constant round-the-clock supervision of nursing staff and volunteers, with the aim of completely preventing them from indulging in their rituals over a period of days or weeks. Reassurance, social pressure and encouragement by the supervisors, and of course the patients’ own efforts at self-control, are necessary. It is curious that Meyer (1966) originally referred to this procedure as ‘modification of expectations’ since the idea was to demonstrate to the patients that they were capable of surviving without their rituals, and that neither the imagined exterior events, of disease, plagues and dire accidents, often expected to affect both the patients and others in the absence of their rituals, nor any unacceptable increase in their own anxiety, would befall them. Subsequently Meyer has come to believe that rigorous prevention of symptomatic behaviours is, by itself, the main point to concentrate on (Meyer et al., 1974).

This treatment was apparently successful and long-lasting, for during follow-ups, depression, anxiety and ability to work all showed improvements in the absence of rituals, although sexual problems tended not to show any improvement. However, it is costly in time and effort. Home visits, and homework by the patients themselves, are used by the Middlesex team, and others have reported some success with less direct attempts to prevent unwanted responses.

157

Absence of cleaning, checking and avoiding rituals is usually the main goal, but exposure to exaggerated or normal circumstances with less supervisory effort is often beneficial. For normal conditions the patient is simply told to ‘practise therapeutic tasks in his natural environment’ (Emmelkamp, 1982). They have to go home and try not to clean their hands a hundred times a day. The subtleties of this are that the therapist may assist in constructing a sequence of goals according to difficulty (90 the first day, 8o the second) and may enlist the help of family members, who are often bound up in the obsession (doing the dirty jobs, or having to wash their own hands excessively to pacihj the patient). For exaggerated conditions, a patient obsessed with the possibility of contamination from animals may be required to endure the company of several dogs and cats for long periods, without subsequent decontaminatory rituals. It has been found that initially just as great an effect is obtained if the patient watches a therapist playing with dogs and cats, or putting hamsters in his or her hair, or touching doorknobs, leaving taps running or handling raw meat. This is termed ‘modelling’ by the therapists and appears to be a benign alternative to ‘flooding’ or ‘satiation’, in which it is the patient who must put up with excesses of this kind.

Rachman and Hodgson (1980) report success rates of between 70 and 8o per cent with procedures like this, in which patients are directly encouraged not to engage in rituals, and some success is also reported in chivvying methods of speeding up obsessive slowness. Although Meyer’s rigorous response-prevention methods have been very effective, Rachman and Hodgson (1980) suggest that in future developments ‘The methods of cognitive behaviour therapy are likely to be helpful’. Their clinical experience has led them to conclude that they should attempt to ‘deflate the significance of obsessions’ and ‘try to modify the person’s definition of unacceptable thoughts and impulses’ (1980, p. 278). Thus, although direct methods of behaviour control have so far seemed most effective even in controlling the subjective part of obsessive-compulsive disorders, it may be that further efforts at ‘cognitive restructuring’ will also be useful. Checkers tend to believe that they are rational, while cleaners are more likely to admit to illogicality, and so the correcting of misconceptions in these cases may not take the same form. However it is probable that the direction of theory in behaviour therapy in both will move

158

further in the direction of modifyjing expectancies, as opposed to modifying response rituals. The trinity of subjective, physiological and behavioural factors in Rachman’s three-systems model already takes the theory well beyond that of simple stimulus-response alterations (Rachman and Hodgson, 1980).

Conclusion: the learning theory and behaviour modification of the future

It should be clear enough from this and previous chapters that there has in the past been a strong connection between theories of animal learning and the development of clinical and educational methods, as a matter of historical fact. Whether this was logically necessary is a different, and unanswerable, question. Perhaps Wolpe could have come up with his procedures for alleviating human anxiety without first reading Watson and Hull and doing his experiments on cats — but he didn’t. It seems even less likely that the attitudes which underlie the more blinkered forms of behaviour modification would be the same if Skinner’s boxes, and Skinner’s writings, did not exist. Whether this historical relationship has been a good thing, or a bad thing, I leave for the reader to decide; there are many points to be made both for and against.

In my view the best single thing which practitioners in applied fields have inherited from their connection with the experimental work and scientific pretensions (to give them the least possible status) of learning theorists is their willingness to measure their successes objectively, to admit errors and to entertain new ideas. Of all forms of psychological therapy, behaviour therapy is the one where writers seem most likely to record therapeutic failures, to express doubts about their underlying theories, and to look forward to different methods which may result from new evidence and new hypotheses. This is by no means universal, of course, but I refer the reader to Rachman and Hodgson (1980) as an example. It is a necessary part of scientific pretensions that new evidence should be sought, and that old theories should be overturned, and this distinguishes the behaviour-therapy tradition from traditions based on dogmas handed down by founding gurus.

It is obvious that the main trend over the past decade has been for theories and methods of therapy to become more cognitive,

159

that is the thoughts and feelings of both patients (or clients, or pupils) and therapists (and to a lesser extent, trainers) receive more attention. There are still arguments about this — not anymore over whether thoughts and feelings matter, but about whether they are best taken into account directly or indirectly; about whether the new approaches are as new as they seem; and about the precise way in which thoughts and feelings can be theoretically and practically related to physiological and behavioural reactions. Physiological and behavioural factors are certainly not going to disappear from the scene altogether. But in all strands of applied practice influenced by learning theory, there are hopeful anticipations of a more coherent and useful inclusion of human intellectual and emotional faculties in therapeutic methods (Rachman and Hodgson, 1980; Craighead et al., 1981; Rimm and Masters, 1979; Lowe and Higson, 1981). This is in some cases long overdue, and in all cases much to be welcomed. Irrational and counter- productive ideas, evaluations, attributions and attitudes are important components of many psychological problems, and the careful incorporation of techniques of attitude change into more behavioural techniques, which Wolpe (1958) did not ignore, will no doubt continue. Also, the principle of positive regard and human warmth towards other persons (Rogers, 1951), as well as being interpretable in terms of general encouragement and specific social reward, has much else to recommend it.

Where does this leave the connection between therapeutic methods and theories of learning which in principle apply to animal behaviour as well? To some extent, it undoubtedly leaves the connection weakened, for the future, if not for the past. But some at least of the questions and criticisms within the world of behaviour therapy were in fact thrown up first by learning theorists, not therapists (Seligman, 1970; Rachman and Seligman, 1976). These were criticisms of the over-simplified principles of conditioning as independent of species differences and independent of the detailed circumstances of individual experience. Further, just as thoughts and feelings have been surfacing in the theories of therapists, so have expectancies, evaluations and cognitive representations come to be included in theories of animal learning (Mackintosh, 1974; Dickinson, 1980; Walker, 1983). One cannot say to what degree one theoretical change has

160

been caused by the other, but at least the changes have been occurring in synchrony which, in the separate-systems model of neurosis, is usually taken to be a healthy sign.

161

End of Chaper 12 (last) | Contents