Behavioral modification therapy is as easy as ABC: antecedents, behavior, consequences” was a catchphrase we used when I was a mental health nurse preparing long-stay psychiatric patients for discharge into the local community.
Behavior modification is an early approach that used respondent and operant conditioning to change behavior. Based on methodological behaviorism,[1] overt behavior was modified with consequences, including positive and negative reinforcement contingencies to increase desirable behavior, or administering positive and negative punishment and/or extinction to reduce problematic behavior.[2][3][4] It also used Flooding desensitization to combat phobias.
Applied behavior analysis (ABA)—the application of behavior analysis—is the current term and is based on radical behaviorism, which refers to B. F. Skinner’s viewpoint that cognition and emotions are covert behavior that are to be subjected to the same conditions as overt behavior.
These patients had experienced decades of hospitalization leading to a loss of the life skills required to live independently, and the rehabilitation unit followed the principles of behavior therapy.
This article will examine the origins of behavior therapy, its development, real-life applications, and the controversies surrounding the approach. Finally, we examine the differences between behavioral therapy, Cognitive-Behavioral Therapy (CBT), and psychoanalysis, and then follow with a list of recommended books.
What Is Behavior Therapy?
Behavior therapy refers to a set of therapeutic interventions that aim to eliminate maladaptive, self-defeating behaviors and replace them with healthy, adaptive behaviors.
Behavior is learned and is a product of conditioning; therefore, during behavior therapy, the client learns constructive behaviors that overcome maladaptive behaviors and achieve their intended goals (Bambara & Knoster, 1998).
Traditional behavior therapy is still used to treat phobias and compulsions through systematic desensitization and extinction strategies. It is also used to motivate adaptive behaviors in therapeutic communities using token economies (Kazdin, 1982).
Tokens are given as rewards for adaptive behaviors leading to the acquisition of privileges, such as special food, extra leisure time, or enjoyable activities. Examples of token economies include residential communities for those with learning difficulties, rehabilitation communities for those recovering from substance abuse, and different types of correctional facilities.
Behavior therapy has developed and diversified over the years into a range of different psychological interventions when combined with other approaches. Examples include:
- Behavioral therapy and cognitive psychology, resulting in Cognitive-Behavioral Therapy
- Mindfulness and CBT, resulting in Mindfulness-Based Cognitive Therapy
- Mindfulness and contextual behavioral science, resulting in Acceptance and Commitment to Therapy
- CBT, mindfulness, and humanism, resulting in Dialectical Behavior Therapy
All these interventions have one common foundation: They aim to transform the client’s behavior so that their actions align with their desired life goals.
Most of this article will focus on behavior modification therapy, which has direct origins in behaviorism, or what is now called behavioral science.
Brief History of Behavior Therapy
Behavior therapy developed during the early 1900s and became a conventional approach to treating various mental health problems in the 1950s and 60s. It has roots in behaviorism, which emerged from the study of the relationship between stimulus, response, and reinforcement as features of the learning process (McKenna, 1995).
While John B. Watson is regarded as the father of behaviorism, he developed his ideas by exploring the discoveries of Ivan Pavlov (1927/1960).
When Pavlov was researching dogs’ digestive processes, he observed the fact that associations developed when a stimulus (food) that triggered a digestive response (salivation) was paired with a stimulus that has no response (bell). The association that dogs made between the bell and food meant that eventually, the bell triggered salivation in the absence of food. Pavlov called this type of learned response classical conditioning.
Watson used Pavlov’s classical conditioning to emphasize that all behaviors resulted from learning. He researched the origins of phobias by studying a young child named Albert. Albert was not scared of rats at first, but after Watson paired the rat with a loud noise, this frightened Albert, and after several repetitions, he became afraid of rats. His fear was extinguished when the experiment was not repeated for a month (Watson, 1924/1997).
Next, B. F. Skinner (1963) discovered that the frequency of behavior depends on the events that follow the behavior, which he called operant conditioning. For example, if a behavior is rewarded, it is positively reinforced and more likely to be repeated. Conversely, if the behavior is ignored, it will be extinguished.
Meanwhile, Dollard and Miller’s contribution to behavioral theory identified four elements in behavior: drive, cue, response, and reinforcement (Metzner, 1963). Joseph Wolpe also discovered a process known as reciprocal inhibition, when eliciting a novel response diminishes the strength of a concurrent response. This led to his development of systematic desensitization to treat phobias (Metzner, 1963).
Finally, Bandura (1977) applied the principles of classical and operant conditioning to develop social learning theory. Bandura discovered how people learn through the observation of others’ behavior or modeling. All these principles of behaviorism have informed the development of behavior therapy.
What Does It Focus On?
Behavioral therapy focuses on behavioral modification by reinforcing adaptive behaviors and extinguishing unwanted behaviors.
Behavioral extinction is often achieved by simply ignoring the behavior or through aversive conditioning (Bambara & Knoster, 1998).
Aversive conditioning can be used to help a client give up drinking alcohol. They can choose to be prescribed medication that makes them nauseous when they sip an alcoholic drink (Elkins, 1975). Soon, they will come to associate drinking alcohol with feeling ill, and this is likely to change their behavior. The intention is that they will develop an aversion to drinking alcohol.
Meanwhile, extinction strategies are often recommended to parents seeking to change a child’s behavior.
Often, parents unwittingly reinforce challenging behavior by paying the child more attention when they misbehave, and while this attention may be corrective or even punitive, this can lead to reinforcement of the behavior, especially if the child gets less attention when behaving well. Parents may be instructed to ignore their child’s tantrums or use a timeout to remove all reinforcement (Ducharme & Shecter, 2011).
Timeout is a behavioral modification strategy used to extinguish unwanted behavior and provide a child with the opportunity to self-soothe. Meanwhile, appropriate behavior is rewarded when the timeout has ended. The video below describes this popular behavior management tool.
Behavioral therapy in clinical settings usually begins by conducting a functional behavioral assessment by conducting a systematic observation of antecedents, behaviors, and consequences (ABC), using the ABC checklist (Maag, 1995).
The contextual elements surrounding a behavior have termed the contingencies that shape behavior and determine its function. The ABC checklist is often used to monitor and implement behavior modification strategies, especially to manage challenging behavior in therapeutic communities, in-patient mental health facilities, forensic settings, and correctional facilities.
3 Interesting Theories and Research Findings
1. Changing your brain
Behavioral scientists have found that learning new behavior can change the neural pathways in the brain due to neuroplasticity (Voss et al., 2017). This has many implications for behavior therapy interventions that require a client to take action by learning new skills.
One well-documented example is taking up mindfulness meditation as a stress management tool and its impact on neurophysiology (Bremner et al., 2017).
2. Enhanced learning
New research teaching adult stroke patients how to play entertainment-based video games has shown that this behavioral intervention has the potential to reactivate dormant neuromodulators, helping to develop new neural pathways in the brain (Bavelier et al., 2010).
This behavioral therapy approach uses environmental enrichment to reactivate the neuromodulators that enable developing brains to learn more quickly and deeply than mature brains.
3. Virtual reality
Action-Centered Exposure Therapy (ACET) is a new behavior therapy-oriented approach that uses an interactive virtual reality environment to treat patients with post-traumatic stress disorder (PTSD) and reduce psychological distress (Kamkuimo Kengne et al., 2018).
ACET uses interactive gamification techniques that place the user in an active learning environment to stimulate new, unproblematic associations to previously traumatizing stimuli through graded levels of indirect and direct exposure. ACET is a new approach to treating PTSD, and more experiments are needed.
3 Real-Life Examples of Behavior Therapy
How is this applied in real life? Let’s take a look.
1. Behavioral parent training (BPT)
BPT is an evidence-based behavioral therapy for parents with children that display challenging behavior (Tucker et al., 1998).
BPT equips parents with the skills required to change their behavior in a way that evokes behavioral changes in their children.
Parents are trained in behavioral management practices that reinforce their child’s prosocial behavior and extinguish disruptive behavior.
Parental training is usually required when treating a range of children’s behavioral issues, including attention deficit hyperactivity disorder (ADHD), aggression, hyperactivity, impulsive behavior, irritability, and school refusal.
Misbehaving children may not remember a therapist’s suggestion for more prosocial, adaptive behaviors or remain motivated to enact them when experiencing intense negative emotions in their domestic or school setting. Parents must be also involved.
This video by the CHOPS Research Institute describes how BPT is used to support the caregivers of children with ADHD.
2. Applied behavioral analysis (ABA) therapy
ABA therapy for children with autism spectrum disorders (ASD) addresses behavioral excesses and deficits unique to each child.
Behavior analysts are not concerned with theories of the causes of autism. Their focus on behavior alone has led to the steady development and refinement of their approach, making modern ABA programs flexible, functional, and fun for the child (Alberto & Troutman, 1999).
Research shows that ABA therapy (also known as early intensive behavioral intervention) is most effective when used intensively (30–40 hours per week). However, specific ABA techniques that target one type of behavior only can also be very helpful without an intensive program.
The video below by the Hopebridge Autism Therapy Centers explains how ABA therapy works and has roots in the work of behavioral psychologist B. F. Skinner.
3. Exposure-based behavior therapy
Exposure-based behavioral therapies expose phobic clients to the stimuli that frighten them and have a strong evidence base demonstrating their effectiveness (Böhnlein et al., 2020).
From a behavioral perspective, specific phobias are maintained by the avoidance of phobic stimuli. This avoidance prevents the phobic client from learning new, adaptive behavioral responses to the feared stimuli. Exposure therapies support a phobic client’s re-engagement with feared stimuli or situations (either in reality, virtual reality, or imaginal exercises) to desensitize them over time.
Typically, exposure-based behavioral therapy follows an individually tailored fear hierarchy that starts with mildly anxiety-provoking stimuli and builds up to panic-inducing situations, stage by stage.
Exposure-based behavioral therapy is also accruing an evidence base demonstrating its efficacy for treating PTSD, anxiety, and depression. The video below by licensed counselor Justin K. Hughes explains more.
Behavior Modification Techniques
There are several methods by which behavior modification therapy functions. Basically, desired behavior is rewarded and negative behavior is punished. But because humans are nuanced, it’s not always so simple to practice behavioral therapy.
Positive reinforcement
Positive reinforcement is the practice of offering a reward for good behavior. The reward, or reinforcer, strengthens a positive association with the action, thus making it more attractive. You might give your child extra screen time when they do their homework directly after school. This expected reward gives the child motivation to complete a chore they may not otherwise be eager to tackle. Talkspace therapist Liz Kelly, LICSW says, “A helpful behavior modification strategy is positive reinforcement. I encourage my clients to think of healthy ways to treat themselves when they have completed a challenging task or reach a goal. That could be something like going out for a cup of coffee after tackling a difficult work project or buying yourself new workout gear as a reward for consistent physical activity.”
It’s important to vary this technique, however. Reinforcers can lose their value over time. For example, if you were to give your child candy every time they made their bed, the sweet reward would lose its novelty, and over time, the child would begin to neglect the chore. Positive reinforcement works best when it’s both consistent and unexpected. If your child knows they may get a reward if they make their bed, they’re still going to be more likely to keep making their bed than if there was no expectation of a reward.
Negative reinforcement
On the flip side, negative reinforcement occurs when a behavior is reinforced by the absence of something negative. In my example above with the alarm clock, my behavior was reinforced because the negative consequences of wasting time and being late for work were removed. In the classroom, you may see teachers reinforcing positive behavior by eliminating a homework assignment when students do well on a test. Negative reinforcement can be a useful behavior modification technique that supports behavior change within individuals.
Positive punishment
Positive punishment is a common behavior modification technique used to stop unwanted behavior. But this can be a confusing one — how can punishment be positive? But just as with reinforcement, “positive” and “negative” mean “adding” and “taking away.” So a positive punishment technique involves adding something punitive to a situation as a consequence of negative behavior. For example, some people may add an extra mile to their run if they ate a pint of ice cream the night before, or a student may be told to stay after school if they’re caught texting during class.
Negative punishment
Negative punishment is the act of removing something as a consequence in order to stop bad behavior. For example, a parent may take away a child’s favorite doll if they won’t share it with a friend or withhold dessert if a child won’t eat all their vegetables at dinner.
Tips for Successful Behavior Modification Therapy
In order for behavior modification therapy to be truly successful, it’s important to keep several things in mind:
- Be consistent. It’s important to maintain particular practices, especially with children, across the board. This means everyone in the family (parents, siblings, grandparents, and other caretakers), babysitters or childcare providers, and teachers should be made aware of any expectations you’ve put into place for your child and agree to follow that same system. This applies to both reinforcements and punishments.
- Maintain the habit. Unfortunately, the behavior modification process doesn’t stop once a good habit is established with the desired behavior or a negative pattern is broken. The work is ongoing in order to make sure the behaviors don’t recur. Once a pattern of desired behavior has been established, think about varying the schedule. While you’re establishing the pattern, you may give your child a reward or praise every time they complete the target behavior. Over time, however, that incentive fades, so you should modify its frequency to maintain the value, or change the reward to keep things interesting.
- Customize the method. As with most things in life, there is no one-size-fits-all approach to behavior modification. You know your child and yourself better than anyone else. If you find a particular approach isn’t working, try something else!
- Be patient and realistic. Behavior modification can take time and a good dose of patience, both with yourself and with those around you. Falling back on harmful habits is common, and it’s not the end of the world. Keep at it and you’ll be back on track.
Behavior Modification Examples
Here are some examples of behavior modification strategies. Behavior modification can change undesirable behaviors in people into more desirable behaviors (chewing gum instead of smoking cigarettes). Or it can help increase desirable behaviors (paying attention in class) and decrease undesirable behaviors (temper tantrums). Another example of behavior modification is children getting rewards for positive behavior. Such as doing chores or controlling their temper; in this way, the positive behavior of doing chores would continue, and the negative behavior of having a hard-to-control temper would decrease or stop happening (become extinct).
The goal of behavior modification in the educational setting is to teach the student different ways of behaving by making changes to the educational environment, changing emotional and cognitive processes, and helping the child learn new skills. Therapists/teachers using behavior modification use operant conditioning, classical conditioning, and modeling for behavior problems, problematic emotional responses, and psychological disorders in children.
A teacher might use behavior modification in a classroom to get a student with ADHD who has problems focusing and being disruptive to pay better attention, do his work, and reduce disruptiveness. The teacher might do this by providing the student with positive reinforcement. When he demonstrates the desired behaviors, she could praise him, which is positive reinforcement. Hopefully, her praise of him would help him to continue and increase these desired behaviors.
Another educational example is providing a student who has some behavior issues with a daily report card; this would provide daily feedback to parents on their child’s behavior (operant conditioning). They can give their child positive reinforcement (rewards) for meeting specific behavioral goals, such as staying in an assigned seat and not interrupting others.
Another example of behavior modification is its use to help someone overcome a fear. With the help of a therapist, a client might try to overcome his fear of riding on an escalator. The therapist could use exposure therapy, one type of behavior modification therapy, to help the client. After learning about the client’s fears, thoughts, and reactions to escalators, the therapist might gradually expose the client to escalators. She might first show him pictures of escalators, gauging his emotional response and asking his thoughts. Then she might ask him to imagine and describe riding one. Next, she might give him the assignment to visit an escalator nearby but not ride it. And she might show him videos of people riding escalators and not getting hurt. Finally, she might ask him to ride an escalator. The design of this gradual exposure would decrease and eliminate his anxiety about riding an escalator. The goal would be for the stimulus of riding an elevator not to cause a negative reaction.
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Parents might use behavior modification on their 3-year-old child who was having frequent temper tantrums. One way to strengthen the likelihood of temper tantrums would be to reinforce and thus increase the behavior by yelling, giving the child attention when she was throwing a tantrum, or even giving her what she wants so that the fit stops. The way to use behavior modification is to ignore the behavior; this may cause extinction or eliminate the undesirable behavior as the child realizes she will not get the attention she seeks or get what she wants by pitching a fit.
The Goals of a Behavior Therapy Session
In short, behavior therapists help their clients achieve their personal and professional goals by collaborating with them on the following:
- Setting mutually agreed goals
- Eliminating maladaptive behaviors that prevent goal achievement
- Replacing maladaptive behaviors with constructive behaviors that meet the agreed goals (Haynes & O’Brien, 2000).
6 Pros and Cons of Behavior Therapy
As with so many things in life, one has to look at it from all angles and consider the negatives as well as the positives. Let’s take a look at the pros and cons of behavior therapy.
3 Advantages
- Behavioral modification therapy in token economies, such as rehabilitation centers and correctional institutions (Kazdin, 1982), applies instant rewards for behavioral compliance and pro-social behavior. This has very effective results in the short term.
- Because of the instantaneous feedback provided by behavior modification techniques, researchers found these interventions to be very effective with students who may struggle with longer-term memory and delayed gratification, such as children with ADHD, ASD, and other learning difficulties (Nowacek & Mamlin, 2007).
- Behavior-based exposure therapies for PTSD and systematic desensitization through gradual exposure to phobic stimuli are very cost-effective treatments that have positive long-term results (Resick et al., 2012).
3 Disadvantages
- The effects of token economies have very little application outside the institution where they are applied, such as rehabilitation and correctional facilities. In the absence of other therapeutic modalities, relapse and recidivism rates remain high (Kazdin, 1982).
- Behavioral therapy needs to be very consistently implemented, which requires a high degree of skill. Those without the necessary skills may revert to punishment when managing challenging behavior, which can arouse defensiveness and further behavioral problems (Maag, 1995).
- Behavior therapy can overlook the fact that people have different learning styles and learn in different ways (Bandura, 1977). It can seriously underestimate the complexity of human development and learning, especially the biological components of neurodiversity and personality, the impact of the socio-political environment (e.g., class, race, gender, and sexuality) on learning, and the impact of early childhood experiences on neuroplasticity and learning ability (Bavelier et al., 2010).
Behavior Therapy vs CBT and Psychoanalysis
As explained above, behavioral therapy does not attend to the psychological causes of the problem under consideration and instead focuses on behavioral change (Skinner, 1963).
Meanwhile, CBT investigates the relationship between a client’s thoughts, feelings, and behavior and how they reinforce each other in terms of repetitive internal scripts. CBT challenges these maladaptive scripts and replaces them with activities that reinforce adaptive behavior by attending to a client’s cognition, affect, and behavior simultaneously (Carr et al., 2009).
Finally, psychoanalysis attends to the root causes of psychological problems in early childhood experiences that are often repeated unconsciously in the relational patterns of adult life. Psychoanalysis focuses on interpreting the client’s internal world to dissolve unconscious linkages between repressed early experiences and adult psychological functioning to improve a client’s mental health and overall quality of life (Nash, 1999).
3 Books on the Topic
We suggest picking any one of the following recommended reads, to learn and understand more about behavior therapy.
1. Science and Human Behavior – B. F. Skinner
This book is considered a psychology classic and is a seminal text in the field of behavioral therapy.
Skinner’s theory of human behavior influenced a generation of psychologists and inspired many of the strategies used in behavioral therapy today.
Find the book on Amazon.
2. Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences – Edna B. Foa, Elizabeth A. Hembree, Barbara Olasov Rothbaum, and Sheila A. M. Rauch
This book provides therapists with all the tools they need to treat PTSD clients with prolonged exposure therapy, a scientifically tested behavior therapy intervention used to treat victims of trauma, including war veterans, abuse survivors, and survivors of accidents and natural disasters.
This treatment exposes clients to imagery associated with their traumatic memories, as well as real-life situations related to the traumatic event in carefully staged phases. Breathing retraining is taught as a method for helping the client manage anxiety in daily life.
The book is a manual designed to help clinicians help their clients reclaim their lives from PTSD.
Find the book on Amazon.
3. Exposure Therapy for Anxiety: Principles and Practice – Jonathan S. Abramowitz, Brett J. Deacon, and Stephen P. H. Whiteside
This book describes how exposure therapy focuses on changing the behaviors that maintain anxiety rather than investigating its causes.
While anxiety appears to be mediated by both environmental and biological variables, psychological treatments cannot “undo” historical events or change biological predispositions.
The book explains the theoretical basis of exposure therapy in behavioral science and how to conduct the intervention, presents a series of case study examples and discusses its application from a variety of behavioral perspectives, including Acceptance and Commitment Therapy.
Find the book on Amazon.
Conclusion
Behavior therapy has a history in the earliest foundations of psychological science. Behavior therapy does not attend to the inner world of the client but aims to change observable behavior only.
The overall objective is to replace maladaptive behaviors with healthy behaviors that will enable a client to achieve their life goals.
Behavior therapy has inspired a diverse range of contemporary psychological therapies, including CBT and the third wave of mindfulness-based behavioral therapies. However, it remains the intervention of choice for specific behavioral problems, especially in therapeutic communities. Behavior therapy requires total consistency from the behavior therapist to be effective – and a high degree of skill.
