What is behavior therapy?

Where behavior therapy comes from

It was not born in the consulting room but in the laboratory. From 1897 onward the Russian physiologist Ivan Pavlov showed that a dog will salivate at the sound of a bell once the sound has been paired often enough with food.¹ A learned reflex: measurable, repeatable, requiring no assumption about an inner life.

In 1913 John B. Watson declared this principle the program of an entire psychology: science could deal only with what is observable from outside; the inner life was inaccessible and therefore irrelevant to research.² Seven years later he demonstrated, in a study no ethics committee would approve today, that fear can be conditioned in a human being as readily as salivation in a dog. Many of the phobias described in psychopathology, Watson and Rayner concluded, are probably conditioned emotional reactions of just this kind, acquired either directly or by transfer.³ B. F. Skinner supplied the opposite direction: behavior followed by a reward occurs more often; behavior with no consequence dies out.⁴

Behavior therapy emerged from this physiology only late. The impetus came from Hans Jürgen Eysenck, who in 1952 disputed the effectiveness of the psychotherapies then prevailing and charged the profession with treating patients without evidence.⁵ In 1958 Joseph Wolpe presented the first fully worked-out procedure, systematic desensitization.⁶ This should not be held cheap: behavior therapy came into being as a response to a shortage of evidence. It introduced the question of effectiveness into psychotherapy — and that is the achievement that remains to it, however one judges its method.

How a course of behavior therapy proceeds

It begins with the behavioral analysis. This does not ask why someone became the way he is, but under what conditions the disturbing behavior occurs and what sustains it: which stimulus precedes it? What does the patient do? What consequence follows — and does the consequence make the behavior more likely?

The procedure follows from that. For anxiety and obsessive-compulsive disorder it is confrontation: the patient exposes himself to what he avoids and remains in the situation until the fear subsides of its own accord. That is the core. Avoidance keeps fear alive because it prevents the experience that nothing happens; confrontation returns that experience.

Alongside this stand the operant procedures: desired behavior is reinforced, undesired behavior is no longer rewarded. And the building of skills — role-play for social situations, relaxation techniques, activity scheduling in depression.

What does not occur in classical behavior therapy is the question of what the patient thinks about the situation. How he perceives the circumstances, how he judges them, and how he steers himself by that judgment goes unregarded. This is not negligence but program: Watson's black box stays shut.

That holds for the classical version only. The Psychotherapy Guideline, which governs in Germany what may be delivered as behavior therapy at the expense of the statutory health insurance system, abandoned that narrowness long ago: it expressly counts cognitive, emotional, motivational, and physiological processes as part of “behavior”, and it lists the methods of cognitive restructuring among the principal forms of intervention.⁷ By the letter of the Guideline, then, work on thinking belongs to behavior therapy today. What of it actually happens in an individual course of treatment the Guideline does not regulate.

An example

The following account is an anonymized composite of typical cases.

A woman in her early thirties has avoided every dog since an incident in childhood. She crosses to the other side of the street, she no longer goes into parks, she has declined invitations because a dog lived in the house.

Treatment begins with a hierarchy: photographs, film footage, a small dog on a leash behind glass, the same dog in the room, finally the leash in her own hand. Each stage is held until the tension has clearly dropped — not until it seems bearable, but until it has measurably subsided. After eight sessions the woman walks a strange dog through the park.

This works. It works reliably, it works quickly, and it works without anyone ever having discussed what she thinks about dogs, about loss of control, or about herself. Anyone who charges behavior therapy with being mechanical is right — and overlooks that with circumscribed fears this is precisely why it works.

Where is behavior therapy effective?

The evidence is strongest for confrontation treatment in specific phobias, in obsessive-compulsive disorder, and in post-traumatic stress disorder. For obsessive-compulsive disorder, Britain's National Institute for Health and Care Excellence lists exposure with response prevention as the treatment of first choice.⁸

One qualification is needed here, because it is readily suppressed. Klaus Grawe's large meta-analysis finds that cognitive-behavioral procedures are “highly significantly more effective than psychoanalytic therapy and person-centered psychotherapy.”⁹ That category combines pure behavior therapy and cognitive behavioral therapy. The finding therefore establishes the superiority of the group, not the superiority of the purely behavioral variant within that group. To claim it for classical behavior therapy alone is to stretch it beyond its reach.

Where it reaches its limits

First, an objection that does not land: psychoanalysis reproached behavior therapy for decades with removing only the symptom, whereupon another would take its place. That prediction has largely failed to be confirmed in research. Treat a dog phobia successfully and you do not receive a cat phobia in exchange. The reproach was a theoretical assumption, not a finding.

The documented limits lie elsewhere, and they are more serious. Insofar as behavior therapy proceeds in purely behavioral fashion, it operates on the physiological level, the level at which Pavlov's dogs already responded. The errors that generate human fear in the first place lie one level above that: at the level of thinking, which is what distinguishes a human being from a dog. There it does not intervene.

The fear can return. Fear extinguished in the treatment room is not erased but overlaid. When the context changes — a different place, a different dog, a difficult period of life — it can reappear.¹⁰ Confrontation creates a new experience; it does not delete the old one.

Its reach is narrow. It treats what can be circumscribed. If behind the dog phobia stands a general sentence — that the world is unmanageable, say, and that one is not equal to it — then after eight sessions the woman is finished with dogs and not with the sentence. That is not symptom substitution but simply an untreated subject.

Many do not see it through. Confrontation treatments carry comparatively high rates of dropout and refusal. A procedure that consists in enduring the fear demands a willingness not everyone brings.

Whether that demand is necessary at all is a question seldom asked. In my clinical observation it is not. Patients who first have explained to them the thinking errors that generate their fear no longer have to endure the fear, because it does not arise in the feared situation to begin with. They then seek that situation out of their own accord — not as an exercise to be got through, but because the recovered freedom from fear gives them pleasure. To withhold this preparatory work from a patient is to impose on him suffering that could have been avoided. I regard that as indefensible. That the majority of the field judges otherwise is known to me; my view would be refuted only by a demonstration that the cognitive preparatory work spares the patient nothing.

The question of cause remains open. This is the point at which classical behavior therapy acknowledged its own limit: the cognitive turn of the 1960s was the recognition that the black box can after all be opened, and that what is inside it is what produces fear and panic in the first place. And for anyone who has understood how cognitive errors generate fear and panic, the feared situation loses its terror before he next enters it. Confrontation does not thereby become superfluous — it happens anyway, as soon as the patient resumes his daily life. It becomes something else: an experience he seeks rather than endures, and one for which he no longer needs a therapist at his side. What that looks like in detail is shown by this cognitive psychotherapy for agoraphobia in Zurich.¹¹

Behavior therapy, cognitive behavioral therapy, cognitive psychotherapy

Pure behavior therapy is now rarely encountered in practice; what is billed to payers under that heading is often, though not always, already cognitive behavioral therapy — behavioral practice plus a greater or lesser amount of work on thinking.

Only cognitive psychotherapy carries the step consistently through to the end: it corrects the thinking and leaves the changed behavior to the patient, who practices it of his own accord as soon as he no longer believes the sentence that held him back and frightened him.

Set out at length in: What is cognitive psychotherapy?¹² and Cognitive Behavioral Therapy and Cognitive Psychotherapy — The Difference.¹³

Readers who wish to know the internal obstacles on the road to the most effective psychotherapy should also read this article: Why Cognitive Psychotherapy Is Demonstrably the Most Effective — and Helps the Fewest People.¹⁴

Frequently asked questions about behavior therapy

Is behavior therapy the same as cognitive behavioral therapy?

No, but the line has grown indistinct. Classical behavior therapy works on behavior alone. Cognitive behavioral therapy adds the work on thinking. By the letter of the German Psychotherapy Guideline that work belongs to behavior therapy in any case, and in today's practice “behavior therapy” usually means the cognitive variant.⁷ It is worth asking before treatment begins how much work on thinking is actually planned.

How long does behavior therapy take?

For circumscribed phobias often a few sessions; for obsessive-compulsive disorder and more complex presentations considerably longer. In any case it belongs among the shorter procedures.

What is its effectiveness best established for?

For specific phobias, obsessive-compulsive disorder, and post-traumatic stress disorder.⁸

Do I really have to expose myself to my fear?

In behavioral confrontation treatment, yes — that is its operating principle. It proceeds in stages and at an agreed pace, but it cannot be circumvented without abandoning the procedure. Cognitive psychotherapy starts earlier: it first clarifies the thinking errors that generate the fear. Those who return to the situation afterwards do so, in clinical observation, mostly without the fear they would otherwise have had to steel themselves against.¹¹

What is the difference from cognitive psychotherapy?

Behavior therapy changes behavior through practice. Cognitive psychotherapy changes thinking and leaves the behavior to the patient. One trains; the other explains.

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