American Psychological Association

113th Convention
Washington D.C., August 18-21, 2005

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Photo by Fenichel: Pioneering the Behavior Therapies---Lessons for the Future

 

PIONEERING THE BEHAVIOR THERAPIES - LESSONS FOR THE FUTURE

Cyril Franks, who I spoke with briefly before the presentation, noted that he suspected this symposium would not draw as many people as others on "practice and technique", whereas this panel was more about history and theory. True enough, as most of the panel had presented their view of behavior therapy(s) in 2002, most of the historical detail presented today (fortunately) was consistent. I'd recommend the original article on the behavior therapies. They did tell some additional anecdotes and frame some of the historical rivalries and contexts in some ways I'd not heard or read before. Just a few highlights follow.

As Dr. Franks said today, it is really these 4 panelists who are the living legacy of "behavior therapy", coming from traditions spawned by Skinner and Wolpe especially, with Hull and Tolman adding to the behavioral learning aspects, and the dominant context of the day for many years being Freud (psycho/psyche analysis) and Carl Rogers/Sullivan (conditions of worth, self-esteem, positive regard, etc) Until the 60's, when along came "the second wave" of applied behavior analysis and theory.

Nate Azrin was introduced as one of Skinner's students, who in 1956 had begun using "applied behavioral analyis" to human behavior, later to develop the "token economy". It was however, "only an experimental methodology" as there was a "disdain" for looking at human behaviors as if lower animals rather than complex (neurotic?) beings. The historical context was reflected in psych training at the time, where the emphasis was on history, Ebbinghaus' nonsense syllables, etc., "theories everywhere, while Freud was analyzing the unconscious and getting into projection".

The feuds were "entertaining... Tolstoy couldn't compare!" and it became dangerous to "analyze" a girlfriend/ boyfriend's dreams as well. Azrin shifted his attention to children, and found he had very little to offer parents. He could invoke Watson and say "leave them alone" or adopt a humanistic approach and "drown them in love and affection". As "psychology was not what I thought it was" he began a journal dealing with applications, and this, not surprisingly, was "met with antipathy", although it led to his finding a brilliant graduate student to edit the journal and who began working towards developing his own idea of "teaching machines".

It seemed there was "a total disconnect between behavioral psychology and real-world internships", making advances to a next stage impossible.

Three themes emerged as focus areas:

1. Advances in methodology
2. Types of problems we can deal with
3. procedures

"Most important", he said, is "outcome studies. Functional." Is the person being treated now functioning and contributing to society. If he is delusional, is he able to hold a job? There ws a real need in designing protocols, to look at baselines and post-tests, and not just compare treatment vs. non-treatment groups. (After all, "everything is effective" as compared to nothing, given placebo effects.)

The second focus was on identifying "what we can deal with". Maybe one cannot change being mentally retarded, but could improve functional skills.

Later he realized one doesn't need a DSM diagnosis to be subject to positive change via behavioral methods. For example, "nail biting... 50% of the population. It's not in the DSM" But meanwhile education embraced some of the notions, referring now to MR students as "trainable" vs. "educable". Often these labels changed, in fact.

General principles to guide learning-based therapies were emerging, things like shaping, successive approximation, generalization etc… but in labs, with animals, not at a human level. Does everything need a reinforcer, externally? What if one is able to get a job? Is that not a reinforcer in itself?

He concluded by stating that "behavioral analysis has done an enormous job in changing the entire field of applied psychology", and that there are several areas (e.g spousal abuse, workplace abuse, sex abuse) which are "just waiting" to see new treatments evolve using these methods.

Jumping ahead -- and I'm going to have to finish this report after some sleep -- Arnold Lazarus, who Dr. Franks described as "30 years ahead of his time" had some comments about the way in which cognition informs behavior, and Drs. Lazarus and Franks engaged in some friendly roasting of some of the others' pet ideas. Some lively comments ensued when one of Lazarus' students, a great contributor to clinical behavior in his own rite, Gerald Davison, asked a question from the audience, about "willfulness" (in the context of CBT and cognitive therapies) and again a playful debate took place about the terms and processes.

Cyril Franks, after a dig at Lazarus' seminal book, "Behavior Therapy and Beyond" (saying it was "singularly devoid of data") emphasized the importance of data and outcome research.

SYMPOSIUM TITLE: Pioneering the Behavior Therapies---Lessons for the Future

Arthur W. Staats, PhD
Chair/Participant/1st Author
Psychological Behaviorism: Founding, Forwarding, and Futuring

Nathan H. Azrin, PhD
Participant/1st Author
Origin and Development of Applied Behavior Analysis

Cyril M. Franks, PhD
Participant/1st Author
Psychodynamic to Behavioral Therapies: Paradigm Shift, Conceptual Broadening, Future Directions

Arnold A. Lazarus, PhD
Participant/1st Author
How Behavior Therapy Became What It Is

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I'd mentioned that Cyril Franks emphasized both the importance of understanding history, as he experienced it and participated in it, and also he enjoys, as he did a few years back, his privileged position of being able to (fondly) poke fun, or even ridicule, or heap praise also, on the other living pioneers in the field of behavior therapy. Behavior therapy of course has historically encompassed evolution and revolution among several behavior therapIES (plural), and this first-hand accounting of how society and psychology reacted to new ground-breaking thinking and treating is fascinating to hear directly from those who were there, well ahead of their time....

Returning now to Cyril Franks describing the others' efforts at broadening concepts of "behavior" or even promoting an overarching "unification of psychology" around more useful conceptions of human behavior, affect, and cognition. Remember: Lazarus is universally credited by the others as being "30 years ahead of his time" as he headed towards "multi-modal" approaches, while others, alluding to Ellis, changed the name of their therapies to include aspects of cognition or affect or behavior. Franks, in his wry manner, opined that Staats, in trying for a higher order unification of psychology (or "psychological behaviorism"), was in fact "500 years ahead of his time", though he suggested Staats has abandoned that mission. (Staats immediately said he had not!) In any case, Franks noted that "Skinner was never a clinician; he worked with animals", and as I described in the last post, it was really a shocking notion at that time to seriously apply "animal" notions to human beings. He went on:

"In the UK, we had only one model, Pavlovian." They soon realized it was "unwieldy and quite impossible" to embrace as a complete model of "behavior therapy". And then along came the "cognitive revolution", a notion embracing the ancient philosophers' understanding of the centrality of cognition: "I think, therefore I am". He suggested that even his dear friend Lazarus has a tendency to confuse "behaviorism" with "behavioral", since in his estimation, it was only Watson ["the dreaded behaviorist"] who used that specific term, with "no cognition, no intervening variable. Stimulus response." What is the choice but to use efficient names, he wondered, as it is cumbersome to speak of something like "conditioning, cognition, and emotional therapy". [Hmm. I wonder if that would be acceptable to *everybody*, from Rogers through Freud and Jung….]

But at that time, returning to the actual circumstances and social context, "psychologists could not do therapy in the US or UK, only research and teaching". And here we are today with multiple therapies, and multiple ways of looking at outcome, through evidenced-based prisms, which some are better able to employ than others. Where is the future direction? As he'd said before, "there's not just one 'behavior therapy'. That doesn't cover it. 'Cognitive therapy' doesn't cover it. There's no uniformity. In closing he praised the work of Beck et al, being promoted through the Association for Cognitive Therapy (ACT), and believes that "we must continue our desperately needed efforts to help peole in this world". Now there is a common thread with great merit!

Arnold Lazarus' Reflections

Lazarus began, as he has done on other occasions, by returning the pokes at him by Dr. Franks, explaining how since the beginning of his seminal writings (e.g, "Behavioral Therapy and Beyond", 1971) Franks always gave his work back-handed compliments in praising it and then adding, "Unfortunately, Lazarus failed to mention…". This became so bothersome they had a talk and Franks agreed to stop with the "unfortunately...". The next review began, *Regrettably*, Lazarus ...."

Shifting to his own experience, what has fascinated him about the flow of history in this field is the origins, watching from Johannisburg, a "breaking away from psychoanalytic tradition. Freudian, Rogerian, Sullivanian." That was mainstream. Someone he had dated in those days, told Lazarus of a friend who was about to undergo a different kind of experimental procedure, prefrontal lobotomy. Wolpe, a physician and his mentor, and other (Rainer?) became interested in trying a different experimental approach.

Wolpe was a physician with no direct study of psychology, "but a voracious reader". He agreed to take on this case, experimentally, and utilized some new approaches behind a one-way mirror, where others (including psychiatrists) could watch. Wolpe was given feedback like, "You're supposed to be analyzing the transference! Why are you not getting into the unconscious?" But utilizing his relaxation/imagery techniques (later to emerge as systematic desensitization), after 6 or 7 months the patient was clearly "doing very well". Was this success recognized as dramatic? No, "people said it was transference cure". In another early case, a man who was traumatized when a companion was killed falling off a building developed agoraphobia. The treatment began and was succeeding, but people asked, "what about early childhood?".

Wolpe chaired Lazarus' dissertation, which was an experiment in using desensitization in groups. Comparing a desensization group with a psychodynamic group, "the first was superior". In retrospect he can see weak design and controls, as he was both therapist and researcher, and subtle bias, etc, might have had some role. But in any case the results and discussion were so compelling that he "caught the eye of Bandura", who invited Lazarus to teach at Stanford as a visiting professor. He accepted. While at Stanford, a student of his was Gerald Davison (sitting next to me, and smiling as this story is told). Davison and others would of course come to integrate various dimensions of cognitive and behavioral functioning, as did Lazarus, though for a while, recalled Lazarus, "I had named Wolpe the king, and we would begin each class bowing to the East". Funny, he reminisced, how they all ended up in the States.

In those early days Lazarus had been working with "basic desensitization", arriving at a starting point of "some anxiety" and teaching the patient to relax, "deeper, deeper… and when you feel anxious just raise a finger. [As an example of an anxiety-provoking image.] There are 5 people you are going to speak to. Visualize it. If you're anxious, lift your finger. Breathe deeply..." And then one day he had "an epiphany. I realized people could think and talk, and elaborate about the context for the anxiety." As he was reflecting on this, "for some strange reason" he (Lazarus) suddenly remembered his grandmother's funeral. No matter how he tried to understand this in terms of stimulus-response channel, it was not sufficient. So, he thought, "why not talk about the experience rather than just lifting a finger?" Why should this not be an additional part of treatment? And he went to Wolpe with his new revelation. Wolpe in turn dismissed this as "analytic B.S." Moreover, the act of talking about the anxiety would interfere with the pairing of relaxation with the image. "Joe Wolpe didn't get frustrated; he just argued why it wouldn't be productive". He offered this while noting that at the time "rumors flied" of a growing feud between them. Meanwhile, there was no single explanation acceptable to everyone: "Beck's theory was challenged, and reciprocal inhibition is not the case". And then, "one comes full circle. Behavior really is the sine non quon [sp?] ".

Wow.

And now Arthur Staats presented his vision of a unified "psychological behaviorism" (PB). As Dr. Franks had described, "In 1950 behavior therapy did not exist. It was animal research. I became a behaviorist in 1953 from reading papers by Hall and Spence" and then becoming interested in human behavior. He saw two processes happening: 1) classical conditioning of emotion; and 2) reinforcement of motor responses. Like Lazarus, he recalled a specific key event which was transformational for him. He was working with an OT, trying to help a boy cope after having lost his hand and forearm. The boy refused to accept a prosthesis, and the task for him was to develop a reinforcement which led to the prosthetic itself becoming a reinforcer. It hit home, in working closely with this devastated boy, that "basic conditioning principles applied to complex human behavior….Behaviors are learned differently, with individual emotion playing a role."

In 1956 a journal study described a patient who said the opposite of what he meant. In Staats' estimation (analyzing behavior) the "psychoanalytic doctors" were all reinforcing this continued behavior rather than eliminating it. They'd ask, want a cigarette? He'd say no, so that meant yes, they'd give him a cigarette, and of course had just reinforced his "opposite talk". By 1963, psychotherapy was being legitimized as a book referred to "verbal learning psychotherapy" and "language behavior therapy".

"PB provided one foundation for behavior therapy, behavior analysis. PB is a 3rd generation behavior theory. Many people still use 2nd generation."

Another dynamic was that post-Watson, "constructs such as intelligence and personality have been tossed out as 'mentalistic'. That is unfortunate, and the fields were demeaned. For example, intelligence. Traditional IQ tests are predictive of behavior, but don’t' address the causes of intelligence,or types of behavior. Different learning conditions determine how well repertoires are learned… The learned basic behavioral repertoires include language repertoire. How to make a child intelligent. Wouldn't it be valuable to tell traditional psychology what intelligence is? To teach parents using psychological behavioralism? These things are possible. PB Opens new avenues for the behavior therapies." He noted, incidentally, that it was not Skinner who applied principles on his own children, but he. [Reading/language enrichment]

The audience was invited at the end to ask questions. Gerald Davison asked what Lazarus (his former professor) thought about "acceptance and mindfulness", central notions in the work of Linehan and the DBT proponents. Lazarus reflected a moment and said, "I'm trying to find out what this mindfulness is. I attended a symposium and spent 1/2 hour studying a raisin and felt like I was in a back ward. What am I missing?... I see nothing new." A little back and forth about ACT (Acceptance/commitment therapy, used with OCD especially), and they seemed to agree that success rates -- for example lower hospitalization rates -- might be a function of the hospitals' policies and not lessened symptomology. Dr. Davison reflected how "it's a complex package. It can include behavior activation. Moving from application to principles is a different way of approaching the whole clinical enterprise". The two agreed to argue over lunch about what is or isn't "radical behaviorism".

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Enough behaviorism? OK, onto online applications....

 

CLINICAL TOPICS ON THE INTERNET -- Working in the Online Medium

[Photo]

Last asynchronously live report for today coming up(on the day of the event before it's not fresh, and weeks/months before you read of it in journals)...

The big event for online mental health watchers, this meaning all aspects of online mental health, from counseling to consultation, supervision, support groups, information web sites, etc. etc. It was another all-ISMHO panel, and this year I was not presenting so could enjoy being in the audience as a very able panel spoke.

The panel was chaired by John Grohol (first webmaster of mentalhealth.net; owner of PsychCentral.com); presenters included Kate Anthony, who trains online counselors and is active in U.K. counseling organizations, and a published author on the topic; Dr. Ron Kraus, founder of onlineclinic.com and developer of ethics guidelines; DeeAnna Merz, ISMHO president and a leader in presenting online supervision via the Internet; and Michelle Davis, who hosts an online support/advice page, and on this occasion discussed 3 different potential suicide notes she received, and how she responded to each of them. Ms. Anthony began with an overview of text-based communication in general: use of emoticons, the look of different chat environments, and the nature of explicit and implicit online communication, with a look at how disinhibition (as described by John Suler) and other factors actually facilitate, along with anonymity, clients speaking from the heart and soul rather than hidden by defenses. (Self consciousness about physical presence was also discussed).

Again, I can add some of the data and additional quotes from notes, as I prepare web articles. Photos too. I'd just add for now that in reflecting on Anthony's look at therapeutic versus casual email, it occurs to me that there are many dimensions which might be explored here, as continuums -- from accuracy/distortion, to comfort/discomfort with typing, formality/disinhibition, and other dimensions which contribute to unique client-therapist communication dynamics. Food for thought in future research, which would be a ripe area for doctoral studies!

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[Part 2]

Again, I gave a brief summary already, but here are some more of the details, using the powerpoint slides and my own notes.

*As always, if I've incorrectly quoted a person or statistic, please let me know and I'll immediately correct it; to the best of my knowledge it is accurate*

Kate Anthony, a trainer and supervisor of online counselors, and President-elect of ISMHO, began the presentation with a discussion of "The Therapeutic Relationship between Counsellor and Client Online". She presented an overview of the "therapeutic relationship", and how this is a central component not only face to face but online as well. She cited some compelling reasons why sometimes technology-mediated relationships may be possible or desirable, while f2f might not be.

What is therapeutic email? Well, as distinct from business email, it is both "a personal communication because of the nature of the content and purpose" and "a professional transaction between workplace counsellor and client", thus: a therapeutic intervention.

Ms. Anthony outlined the various types of technology-assisted communication, from telephone to test-based communication. In some cases, the focus on the written word might help facilitate pure, meaningful communication. Citing John Suler here, "Sights and sounds are but extraneous noise that clogs the pure expression of mind and soul". Dr. Suler has also described the "disinhibition effect", which Anthony subscribes to as a force to be harnessed for the good: "My argument is that without physical presence you get to that place much more quickly", getting around defenses to the real feelings and self-observations. She noted how she had become aware of how using one's fantasy of the other can eventually converge upon having accurate perceptions of the other, as she learned through her early (late 90's) work with Gary Stofle. [Stofle]was one of the original members of ISMHO's Clinical Case Study Group, and one of the first to engage in text-based online counseling.] Some of "facilitating factors" seen online include the opportunity for anonymity, and also an informed consumer who "can explore you and get involved, or just click away", which helps "equalize the power" from the beginning.

In Anthony's model, components of online counseling experience include rapport/presence, quality of written communication, and fantasy/visual representation, along with the catalysts of anonymity and opportunity. Many people value the ability to communicate directly, but not f2f.

Reviewing some of the ways in which effective text communication can help be more natural and spontaneous and clear, Anthony spoke about emoticons -- American and Asian -- and some common acronyms, such as LOL (laugh out loud), byb ("be right back"), and a new favorite, yyr(w) -- well known to those who spend time working or living with teens -- "yeah yeah right (whatever)"

Continuing an overview of online communication, basics of netiquette were reviewed as well, ranging from use of CAPITALIZATION and blind copies to multiple exclamation marks.

She emphasized that online work is not "the poor cousin" of f2f work. She spoke about use of color and font [an early focus of the Case Study Group, one of my own interests], and after describing some useful tools also reminded us that online work is "not suitable for all". [See article by Suler et al on "Suitability..."] Meanwhile, in any event, client demand is growing.

In closing, Ms. Anthony noted 3 points for consideration:

• Online work will not be suitable for all and many organisations and individuals will decide against this modality...
• ...but clients are demanding it globally, and this seems likely to grow
• How long could anyone have avoided using the telephone "because it is 'new' technology?"

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Ron Kraus presented next, on Teaching Clinicians about Online Counseling.

Dr. Kraus, began by focusing on the potential turning point for mainstream online counseling, with the recent acceptance of CPT code 0074T, which essentially authorizes reimbursal for online [follow-up] sessions. In his estimation this has legitimized and legalized such services, while the political tide seems poised to embrace it as a means of simultaneously improving service and reducing costs.

Not long ago, 1999 to 2000 at the peak, online entities were poised for a boom, but then the Internet bubble went bust, and we witnessed the "dot com crash". Many mental health sites disappeared, "some without declaring they were disappearing". Now there is finally a resurgence of sorts. Most clinicians are already familiar with software like Therapist Helper and other management/database tools. Meanwhile there are movements to require computer-entered prescription-writing, as discussion and debate grow concerning the digital storage of medical records. From continuing ed to self-help, billing, and many other activities, technology can help reduce office visits, and cost. How does the future look? Healthcare will likely become "a whole different game". Yet still there is slow movement, and paradoxically, while "over 95% of clinicians have email", many are still unfamiliar with the potential of the Internet beyond that. Some are skeptical too, about text-based counseling especially, as they've not been trained in it and may not have a comfort level either. Education is clearly one key need: "Nothing like this exists in our schools". And until recently there was a dearth of resources such as training manuals and textbooks. Now both he and Ms. Anthony have edited such texts, and Dr. Kraus feels "it's time" to start referencing such manuals.

DeeAnna Merz

Ms Merz, current President of ISMHO, has built a consulting company with a staff of 70 professionals and paraprofessionals, utilizing a "HIPAA-compliant environment" to allow for distance counseling and supervision. She is well aware of all the regulatory and ethical issues, serving as ethics chair for her state licensing board. She also noted the APA ethical mandate to supervise trainees adequately across modalities. (Interestingly, her first client wrote to her via "snail mail" and gradually moved to email.)

Some of the benefits of distance technology:

time constraints

logistical constraints

more efficient

cost effective

accommodating

Concerns about providing effective instruction/supervision:

• Establishment of rapport
• Confidentiality
• potential for misinterpretation of the written world
• compatibility of platforms/computer literacy

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And from here, a small gathering for food and drink and talk, and a new day Friday...