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Two branches of behaviour therapy will, I believe, dominate the course of events in the coming decade. The cognitive interpretation of behavioural problems (and cognitive solutions) can be expected to expand and deepen. The infusion of cognitive analyses will broaden out from the established bases, the successes achieved in tackling depression and panic disorder, to encompass a wide range of psychological problems. (The need for a coherent and efficient cognitive behavioural psychology will be particularly acute when the current infatuation with biological psychiatry wanes.) This expected expansion will then merge with the other development, the slow (too slow indeed) but steady growth of behavioural medicine. In truth, behavioural medicine, conceived as the application of psychological science to medical problems additional to the psychiatric ones, has been retarded by institutional and intellectual obstacles. For economic and scientific reasons there is likely to be an acceleration of progress in the next decade, and the entire process will, or should, be enriched and enlivened by the introduction of a more cognitive approach to behavioural medicine.
The theoretical and empirical basis of commonly accepted propositions concerning the role of behaviour in the practice of behavioural psychotherapy for anxiety problems is considered. A number of problems are identified, and an alternative, more explicitly cognitive hypothesis is described. According to this cognitive account, there is both a close relationship and specific interactions between “threat cognitions” and “safety seeking behaviour”. For any individual, safety seeking behaviour arises out of, and is logically linked to, the perception of serious threat. Such behaviour may be anticipatory (avoidant) or consequent (escape). Because safety seeking behaviour is perceived to be preventative, and focused on especially negative consequences (e.g. death, illness, humiliation), spontaneous disconfirmation of threat is made particularly unlikely by such safety seeking behaviours. By preventing disconfirmation of threat-related cognitions, safety seeking behaviour may be a crucial factor in the maintenance of anxiety disorders. The implications of this view for the understanding and treatment of anxiety disorders are discussed.
The argument is presented that behavioural psychotherapy has long been infiltrated by cognitive ideas, whether at the level of underlying philosophy, assessment or practice. For example, none of the traditional laws of learning have withstood the test of time, but although modern learning theory has had to become increasingly cognitive, behaviour therapists have yet to integrate these advances into a better understanding of therapeutic techniques and practice. Examples are also presented of a range of cognitive tasks that may provide further insights into the nature of the affective disorders.
The growing sophistication of behavioural psychotherapy is indicated by the progressive easing of service delivery for anxiety disorders. This is attained by emphasis on the patient doing systematic self-exposure and recording details of tasks completed in daily exposure homework diary sheets. Therapist-accompanied exposure is now known to be largely redundant. The clinician's chief role is to assess, guide and monitor progress and teach relapse prevention, rather than to be with the patient during exposure. A similar self-management model could develop for the relief of sexual, depressive and eating disorders. Further advance is needed to shorten the time and effort needed from sufferers to help themselves.
The philosophy of radical behaviourism continues to be misunderstood and the ways in which it influences therapy are still not widely appreciated. This paper shows that radical behaviourists do not ignore peoples' thoughts and feelings; that we consider people and their behaviour as part of the context in which they live; and that clinical problems are as much our concern as broader social problems. To illustrate the influence of radical behaviourism on clinical therapies Goldiamond's constructional approach and Hayes' comprehensive distancing are described.
This paper summarizes developments in the field of classical conditioning. Attention is paid to four common misconceptions of what is classical conditioning. First, classical conditioning does not ensue as a simple result of temporal pairing of conditioned and unconditioned stimuli. Rather, conditioned reacting occurs if and to the degree that the subject is able to predict the occurrence of one stimulus from the presence of another one. Second, what is learned during classical conditioning is not necessarily a response to a cue, but rather a probabilistic relationship between various stimuli. Third, classical conditioning is not only manifested in responses mediated by the autonomic nervous system, but also in immunological parameters, in motoric behaviour and in evaluative judgments. Fourth, the nature of the conditioned and the unconditioned stimulus is (often) not a matter of indifference: particular combinations of CS and US produce more powerful conditioning effects than do other combinations. In the second part of the paper, the potential relevance of these developments is illustrated. Discussions are included about anxiety, addictions and food aversions/conditioned nausea.
Social learning theory has provided the field of substance misuse with a solid base from which to generate hyotheses and develop treatments. The emphasis during the last decade has been upon outcome and efficacy expectancies, relapse prevention and stages of change. Helping people to move through these stages of change (motivational interviewing) has been a particularly strong focus. The literature on alcohol dependence provides reasonable evidence to support the effectiveness of the following treatment approaches: antidepressant medication, behavioural contracting, brief interventions, behavioural marital therapy, behavioural self-control training, community reinforcement approach, covert sensitization, Disulfiram (Antabuse), social skills training and stress management training. It is also suggested that interest in cue exposure will develop in the future. During the next decade self-regulation theory will turn out to be a rich source of ideas as well as a useful conceptual framework that integrates a range of treatment approaches.
Behavioural psychotherapy is being applied to an ever increasing range of children's problems. Well established techniques continue to be used by an increasing range of people from different professions. There is a slight danger that the techniques are so widely used that they are outstripping their data base and some thought needs to be given about the level of training necessary to ensure that new approaches are encouraged and critically evaluated.
Over the past few years, there has been increasing availability of effective behavioural psychotherapies for use with elderly people. Notably, procedures developed with younger adults have been found effective with elderly clients. However, the needs of people with dementia are still only partially met. Some therapies are used that are of questionable benefit, while possibilities based on sound theoretical bases have been largely ignored. Given that the targets of intervention for people with dementia are likely to be wide ranging, and certainly include the needs of families and of other caring systems, and of their effective functioning, behavioural interventions must address these wider issues, which may well include behavioural methods applied to systemic change.
Three typical areas of application of behavioural medicine are described: biofeedback, relaxation training, and various cognitive behavioural procedures. It is argued that biofeedback has led to few useful clinical treatments but both relaxation and more complex procedures and methods of analysis can contribute to the prevention and treatment of disease. This is illustrated with examples from the literature on headache and the prevention and treatment of coronary heart disease and cancer.
“Of all the contributions made by psychologists to the education and training of the mentally retarded in recent years, pride of place must surely be accorded to behaviour modification” (Clarke and Clarke, 1987). This is a significant claim and one that may be disputed by those who work in other areas (as indeed do the Clarkes themselves) but there is little doubt that behavioural methods have made a major contribution to the teaching and management of people with learning difficulties. This paper will divide the, necessarily selective, review of recent research into two main areas: first, that concerned with skill development and second, that concerned with behaviour reduction and the management of what has become known as Challenging Behaviour.
Behavioural therapists have been involved with the management of schizophrenia since the emergence of the discipline in the 1950s. It has been stated recently that behaviour therapists have lost interest in serious mental illness. However, in the last few years great advances have been made in behavioural approaches to the management of schizophrenia. Controlled trials of family management methods have indicated that: relapse rates can be reduced, the patient's social functioning increased and family burden decreased. These approaches also have economic benefits over traditional services. Furthermore, other methods, such as early signs monitoring followed by early intervention and self-management of drug resistant residual symptoms, have also shown promise. The development of these innovative behavioural approaches is especially important in an era of community based mental health services.
The introduction of sex therapy two decades ago was accompanied by largely uncritical enthusiasm, with the result that too few careful evaluative studies were conducted. Those that were indicated that a weekly or twice weekly schedule of treatment sessions was best and that treatment by individual therapists was as effective as co-therapy. Some of the major prognostic factors and the long-term results of sex therapy have now been elucidated. Low sexual desire has emerged as a problem for which our now traditional methods of treatment are often inadequate and new therapeutic approaches are required. Current efforts to explore the beliefs and cognitive processes associated with erectile dysfunction are proving rewarding and are likely to enrich therapeutic interventions in the future. Attention should now be paid to the beliefs and cognitions associated with other sexual dysfunctions, both male and female.