Behavior therapy

Behavior therapy techniques used for Psychiatric patient

1. BEHAVIOR therapy PREPARED BY Mrs. Divya Pancholi M.Sc. (Psychiatric Nursing) Assistant Professor SSRCN, Vapi

2. INTRODUCTION It is derived from ‘learning theories’ focused on client’s actions, not on thoughts and feelings. Behavioral approach is used frequently to control the undesirable behavior. Prominent therapists of behavioral theory/model/therapy include Joseph Wolpe , BF Skinner, Ivan Pavlov and John Watson

3. BASIC ASSUMPTIONS : Behavior is a response to stimuli from the environment. Either adaptive or maladaptive behavior is learnt . Change in behavior leads to a change in the cognitive and affective spheres . Therapist will emphasize on quantitative aspect of observable behavior. Deviations from the norm are habitual responses that can be modified through application of learning theory.

4. CONTI… Positive response is reinforced . The response is strengthened by repetition of the learning sequence. Reinforcement is essential to get the response. Positive reinforcement is a reward for selected behavior . Human beings are passive organisms that can be shaped or conditioned to do anything . If correct responses are rewarded or reinforced . Maladaptive behavior can be unlearnt and replaced with adaptive behavior, if the person receives appropriate stimuli to eliminate the maladaptive learning.

5. TECHNIQUES OF BEHAVIORAL THERAPY

6. 1. SYSTEMIC DESENSITIZATION Based on ‘Reciprocal Inhibition Behavioral Principle’ of counter conditioning. In this the clients will attain a state of complete relaxation and are then exposed to the stimulus that elicits the anxiety response . INDICATION Phobia OCD Sexual disorder

7. CONTI… 1. Relaxation training 2. Hierarchy construction 3. Desensitization to stimulus

8. 1. Relaxation training will be given, e.g. mediation, hypnosis, mental imagery, bio-feedback, Jacobson progressive relaxation. 2. Ask the client to construct a hierarchy of anxiety provoking situation in descending order of anxiety provocation. 3. Desensitization of the stimuli: patient is asked to give a signal whenever anxiety is produced with each signal; he is asked to relax, after a few trials, client is able to control his anxiety gradually.  

9. 2. FLOODING Prolonged contact with the anxiety will make the client to face the frustration and anxiety situation without much difficulty . INDICATION Specific Phobia

10. 3. AVERSION THERAPY Pairing of pleasant stimuli with an unpleasant response so that even in the absence of unpleasant response, the pleasant stimuli becomes unpleasant because of association.

11. INDICATION Alcohol abuse Paraphilias Homosexuality Transvestism .

12. 4. OPERANT CONDITIONING PROCEDURES FOR INCREASING ADAPTIVE BEHAVIOR   Positive reinforcement Token economy

13. POSITIVE REINFORCEMENT: To reinforce or improve the performance of the desirable behavior repeatedly a token. Reward material or symbolic appreciation will be given whenever the client performs an acceptable behavior ,

14. TOKEN ECONOMY: It is a positive reinforcement programme to encourage socially acceptable or desirable behavior among client; A small token will be given as an exchange for privileges. Indications- chronic hospitalized patients, children up to adolescent age.

15. 5. OPERANT CONDITIONING PROCEDURES TO TEACH NEW BEHAVIOR   Modeling Shaping Chaining

16. MODELING: Acquiring new desirable behavior through imitation or by demonstration; The client will be given an opportunity to observe ‘model behavior’ either from therapist or psychiatric team members or through other patients. The team members will exhibit a specific desirable behavior which will be observed by the client and the he will be given an opportunity to perform target behavior in desirable manner, if he does so, reward or an appreciation will be given to encourage the client to perform those act repeatedly whenever is required.

17. SHAPING : A procedure that teaches a complex behavior by reinforcing small steps towards completion of the behavior the therapist tries to shape the desired behavioral skill step by step. He positively reinforces the existing behavior and the responses which are closest for the desired behavior and ignores the other responses. Therapist will praise the client for his desired behavioral performance and if he fails no response will be given . Indication: Neurosis, Phobias, Physically handicapped, Autism, Obsession. E.g.

18. CHAINING : Training will be given to learn complex tasks in break up manner, step by step: Forward chaining: The therapist will identify the difficulty of the client in performing complex tasks. He will give training to the client to learn first step, after client achieves it, the second step and the third until client achieves the task. Backward chaining: In backward direction, step by step the client will be assisted to learn desirable tasks from last step to next step likewise, E.g For mentally disabled this training is adapted.

19. 6. OPERANT CONDITIONING PROCEDURES FOR DECREASING MALADAPTIVE BEHAVIOR Time out Response cost Punishment Ignoring/extinction Restitution/over-correction

20. TIME OUT: If the client performs undesirable acts or exhibits undesirable behavior. He will not be encouraged to perform the similar act and will be given negative reinforcement by some sort of punishment, e.g . if the child exhibits odd behavior , he is not allowed to play until he changes the behavior and adapts healthy, desirable behavior , punishment can be avoided if the caretaker is satisfied with the behavior .

21. RESPONSE COST: To teach adaptive behavior among the client token programs were activated. If those clients exhibit undesirable behavior, a fixed number of tokens or pints deducted from what the individual has got already.

22. PUNISHMENT: Whenever undesirable behavior exhibits, it has to be avoided by administering some sort of punishment with proper explanation; it will be used to decrease the undesirable behavior /maladaptive behavior.

23. IGNORING/EXTINCTION: Whenever the problematic behavior exists rewards or attention can be removed, e.g . not to have eye to eye contact or physical contact or moving away, not showing interest to talk or mingle with them.

24. RESTITUTION/OVER CORRECTION: If the client exhibits undesired or problematic behavior, it will be corrected by wide range of punishment, e.g . if the child passes stools within the dress after toilet training, to avoid the repetition of the undesirable behavior , mother will ask the child to wash his clothes by himself.

25. Examples of Restitution/Over correction:

26. 7. ASSERTIVENESS TRAINING In 1949, Salter and in 1958, Wolpe have described assertiveness training. Aims: Alleviates interpersonally based anxiety. Improves interpersonal relationship, self-esteem, self-control Improves the ability to stand up for one’s own rights Clients are assisted to identify the usual mode of behavior Brings change in emotion and other behavior pattern.  

27. Technique: The therapist will give assertive behavior training by role playing, coaching, modeling and role reversal technique and the by practicing it in real life situations. This training will help the client not to infringe on the rights of others and helps to ascertain the ability to stand for their rights, ignores passive behavior, inculcates the client for usual mode of behavior. Through assertiveness training, the client will learn social skills and improves interpersonal relationships, social behavior and social contacts. For example, eye-to-eye contact while speaking, appropriate behavior, etiquette behavior, interaction pattern, etc Indications: Chronic depression, Socially anxious person, Shy tendency

28. ROLE OF THE NURSE IN BEHAVIORAL THERAPY Nurses have to keep in mind, the principles of learning while administering behavioral therapy for the clients. Uses behavioral approaches like positive reinforcement, relaxation techniques. Involves the client and significant people in provision of care Positive responses will be reinforced.