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".