1. Chapter 18
Behavior Therapy

2. Introduction A behavior is considered to be maladaptive when:
It is age-inappropriate
Interferes with adaptive functioning
It is misunderstood by others in terms of cultural inappropriateness

3. Introduction (cont.)
The behavioral approach to therapy is that people have become what they are through learning processes or through the interaction of the environment with their genetic endowment.
The basic assumption is that problematic behaviors occur when there has been inadequate learning and therefore can be corrected through the provision of appropriate learning experiences.

4. Classical Conditioning
It was introduced by Russian physiologist Pavlov in his experiments with dogs.
Pavlov found that dogs salivated when presented with food (unconditioned response).
He learned that dogs salivated when food came into view (conditioned response).

5. Classical Conditioning (cont.)
He introduced an unrelated stimulus (the sound of a bell) with presentation of food.
He learned that the dogs soon began salivating (conditioned response) at the sound of the bell alone (conditioned stimulus).
When a similar response is elicited from similar stimuli, it is called stimulus generalization.

6. Operant Conditioning Introduced by American psychologist B. F. Skinner
The basic assumption is that the connection between a stimulus and a response is strengthened or weakened by the consequences of the response.
A stimulus that follows a behavior (or response) is called a reinforcer.

7. Operant Conditioning (cont.)
When the reinforcing stimulus increases the probability that the behavior will recur, it is called a positive reinforcer.
When the reinforcing stimulus increases the probability that a behavior will recur by removal of an undesirable reinforcing stimulus, it is called a negative reinforcer.

8. Operant Conditioning (cont.)
A stimulus that follows a behavioral response and decreases the probability that the behavior will recur is called an aversive stimulus or punisher.

9. Techniques for Modifying Client Behavior
Shaping. In shaping the behavior of another, reinforcements are given for increasingly closer approximations to the desired response.
Modeling. Modeling refers to the learning of new behaviors by imitating the behavior of others.

10. Techniques for Modifying Client Behavior (cont.)
Premack Principle. This principle states that a frequently occurring response can serve as a positive reinforcement for a response that occurs less frequently.
Extinction. The gradual decrease in frequency or disappearance of a response when the positive reinforcement is withheld.

11. Techniques for Modifying Client Behavior (cont.)
Contingency Contracting. A contract for behavioral change is developed. Positive and negative reinforcers for performing the desired behaviors, as well as aversive reinforcers for failure to perform, are stated explicitly in the contract.
Token Economy. A token economy is a type of contingency contracting in which the reinforcers for desired behaviors are presented in the form of tokens. The tokens may then be exchanged for designated privileges.

12. Techniques for Modifying Client Behavior (cont.)
The nurse is encouraging a child, diagnosed with autism, to verbalize needs. Which nursing intervention reflects the behavior therapy of shaping?
A. The nurse provides no rewards to the child to encourage independence.
B. The nurse rewards the child regardless of speech improvement.
C. The nurse rewards the child at the conclusion of the therapy.
D. The nurse rewards the child incrementally as improvement in speech occurs.

13. Techniques for Modifying Client Behavior (cont.)
Correct answer: D
In shaping the behavior of another, reinforcements are given for increasingly closer approximations to the desired response. In this situation, the nurse is providing rewards incrementally as the child’s speech begins to improve.

14. Techniques for Modifying Client Behavior (cont.)
Time Out. An aversive stimulus or punishment whereby the client is removed from the environment where the unacceptable behavior is being exhibited; the client is usually isolated so that reinforcement from the attention of others is absent.
Reciprocal Inhibition. Also called counterconditioning, this technique serves to decrease or eliminate a behavior by introducing a more adaptive behavior but one that is incompatible with the unacceptable behavior.

15. Techniques for Modifying Client Behavior (cont.)
Overt Sensitization. Overt sensitization is an aversion therapy that produces unpleasant consequences for undesirable behavior.
Covert Sensitization. This is a mental imagery of an aversive stimulus to divert an individual from an undesirable behavior.
Systematic Desensitization. This is a technique to assist an individual to overcome fear of a phobic stimulus; a systematic hierarchy of events associated with the phobic stimulus is used to gradually desensitize the individual.

16. Techniques for Modifying Client Behavior (cont.)
Flooding. Sometimes called implosive therapy, this technique is used to desensitize an individual to a phobic stimulus. It differs from systematic desensitization in that instead of working through a hierarchy of anxiety-producing stimuli, the individual is “flooded” with a continuous presentation of the phobic stimulus until it no longer elicits anxiety.

17. Techniques for Modifying Client Behavior (cont.)
A client diagnosed with alcoholism has recently been prescribed disulfiram (Antabuse). The nurse recognizes this as which type of behavior therapy?
A. Overt sensitization
B. Flooding
C. Reciprocal inhibition
D. Systematic desensitization

18. Techniques for Modifying Client Behavior (cont.)
Correct answer: A
The nurse recognizes the use of Antabuse as overt sensitization behavior therapy. This is a type of aversion therapy that produces unpleasant consequences for undesirable behavior. Instead of the euphoric feeling normally experienced from alcohol (the positive reinforcement for drinking), an individual taking Antabuse will experience nausea, vomiting, palpitations, and headache if alcohol is consumed. The client receives a severe punishment that is intended to extinguish the unacceptable behavior (drinking alcohol).

19. Role of the Nurse
The nursing process is the vehicle for delivery of nursing care to clients requiring assistance with behavior modification.
An assessment is conducted to identify behaviors that are unacceptable because of age or cultural inappropriateness.

20. Role of the Nurse (cont.)
Nursing diagnoses are formulated, and outcome criteria are established.
A plan for behavior modification is devised, using techniques thought to be most appropriate for the client.
The plan may be devised by the nurse alone, the physician alone, the nurse and physician together, or with input from the client and various members of the treatment team.

21. Role of the Nurse (cont.)
All members of the treatment team must be made aware of the behavior modification plan.
Consistency among all staff is required for implementation to be successful.
Evaluation of care is based on achievement of the outcome criteria.

22. Role of the Nurse (cont.)
A nurse is using covert sensitization to help a client control compulsive overeating. Which nursing intervention reflects this behavior therapy?
A. Asking the client to visualize and imagine smelling a rotting potato
B. Encouraging the client to practice relaxation exercises when tempted to eat
C. Introducing the client to a peer who has overcome obesity
D. Providing small rewards for periodic weight loss

23. Role of the Nurse (cont.)
Correct answer: A
Covert sensitization relies on the individual’s imagination to produce unpleasant symptoms as negative stimuli. The mental image (rotting potatoes) is visualized when the individual is about to succumb to an attractive (ice cream sundae) but undesirable behavior (compulsive eating). The technique is under the client’s control and can be used whenever and wherever it is required.