Principles of Treatment

In operant methodologies to treatment, a functional analysis is conducted to evaluate the factors that may be contributing to excesses of maladaptive behavior and/or deficits of adaptive behaviors, and interventions are designed to alter the antecedents to behaviors, and to use reinforcers to enhance adaptive behaviors and punishers or extinction to decrease maladaptive behaviors. More specifically, the functional analysis establishes the causal relations between antecedents to a behavior, the behavior, and the consequences of a behavior. For example, as described by Farmer and Chapman (2008), bulimia might involve antecedent events of conflict with significant others and proximity to a food market that precede the behavior of overeating. This behavior is positively reinforced by the immediate gratification of eating. The subsequent discomfort from overeating then becomes an antecedent to the next behavior of purging, which in turn is followed by negative reinforcement of reduction in discomfort. The positive reinforcement of immediate gratification of eating and the negative reinforcement of reduction of discomfort through purging increase the likelihood of the binging and purging cycle in the future. Understanding the “behavioral contingencies” of any given problem behavior is essential to effective treatment planning.

A behavior is said to be under stimulus control when it occurs in the presence of a particular stimulus and not in its absence. Following the previous example, the bulimic behavior may occur only in relation to conflict with a significant other. In this case, conflict with others becomes a discriminative stimulus for the behavior of overeating. Oftentimes, the discriminative stimuli are moderated by other ongoing contextual variables, such as time of day and mood state, so that the relationships become relatively complex. In the aggregate, the discriminative stimuli and associated conditions function to signal the likelihood of reinforcing or punishing consequences of the behavior. Another type of antecedent is termed establishing operations, or events or biological conditions that alter the reinforcing or punishing consequences. Continuing with the example of bulimia, having recently dieted may serve as an establishing operation that magnifies the likelihood of immediate gratification from overeating (i.e., the principle of satiation) in the presence of the cue of conflict with others. The role of discriminative stimuli and establishing operations is included in the behavioral contingency formulation, which is then used to develop a treatment plan.

Behavioral contingency management involves changing the antecedents of the target behavior, such as removing or avoiding the antecedents that typically elicit problem behaviors. This strategy is typically included in treatments for disorders related to substance use in which abusers are asked to avoid drug-associated people, places, and stimuli. Also, it may be used when self-injurious behaviors are under the control of certain antecedent stimuli. When the antecedent stimulus cannot be avoided completely, another strategy is to modify it. For example, recovered alcohol abusers may not be able to fully avoid peers with whom alcohol was previously consumed; in this case, the peers (the antecedents) may be asked to refrain from encouraging the recovered person from drinking. Another strategy involving antecedents is to use stimulus cues to encourage adaptive behaviors, such as “coping cards” to remind clients to engage in particular behaviors. In discrimination training, reinforcers for behaviors are given in certain situations but not in other situations, so that individuals learn in which situations particular behaviors are appropriate (if reinforced) or not (if not reinforced). As an example, in the context of anxiety disorders, approach behavior toward nondangerous situations (e.g., walking alone during the day in a safe park) would be reinforced whereas approach to truly dangerous situations (e.g., walking alone at night in a violent crime district) would not. Discrimination training can be applied to emotional states as well, such as learning to accurately discriminate between tension and relaxation, or anger and anxiety. Another strategy is to arrange establishing operations that change the value of reinforcers, as occurs when methadone decreases the reinforcement value of heroin use (by blocking the high from heroin) or when regulation of eating to four to six times a day decreases the reinforcement value of binging. Similarly, satiation therapy involves overdelivery of reinforcers that in turn is presumed to decrease their value. For example, smoking cessation programs sometimes include a period of oversmoking to decrease the reinforcement value of the nicotine.

Another set of principles for behavioral contingency management involves altering the consequences of behavior. Consequences are applied to either increase the likelihood of a desired behavior occurring again in the future (reinforcers) or decrease the likelihood of undesirable behaviors in the future (punishers), keeping in mind the factors already described as being influential, such as immediacy, size, and contingency of the consequence. An example of applying a positive reinforcer would be to praise a child who bravely approaches an anxiety-provoking situation. Interventions designed to decrease a target behavior may include extinction, or removing reinforcers that previously maintained the behavior. An example would be removal of parental attention from a child’s display of oppositional behavior. Alternatively, punishers may be administered, such as negative punishers in the form of response cost (e.g., time out for oppositional behavior in children) or positive punishers as in covert sensitization procedures (Cautela, 1967). In the latter, an undesired behavior is paired in imagination with aversive states, such as pairing alcohol consumption with nausea and vomiting. Covert sensitization also includes negative reinforcement in the form of relief from the aversive state as the undesired behavior is replaced by a desired behavior.

For contingency management to work, reinforcers for adaptive behaviors must exceed the reinforcers for maladaptive behaviors. Thus, if reinforcement for consuming alcohol is more potent and immediate than it is for engaging in behaviors that do not involve alcohol, such as exercising or other forms of social recreation, then the individual will devote more time and energy to consuming alcohol. Obviously, the challenge for treatment is to make the reinforcements for adaptive behavior more influential than the reinforcements for maladaptive behavior.

As outlined by Farmer and Chapman (2008), “the primary assumption underlying contingency management interventions is that the target behavior in question is under the influence of direct-acting environmental antecedents or consequences” (p 108). Contingency management procedures are not as effective for rule-governed behavior, or behavior that is not controlled by the environmental antecedents or consequences but instead is controlled by rules. Farmer and Chapman give the example of a person with anorexia who restricts intake of food based on a rule that “by not eating, I will lose weight and be more attractive to others.” This rule implies that thinness is associated with a variety of social reinforcers. However, the rule may be at odds with actual social reinforcement patterns, since others may not respond to thinness as being more attractive. Hence, the behavior of food restriction becomes more of a rule-governed behavior. In this case, behavioral contingency interventions are not useful, and direct challenges to rule governing would be more appropriate.

Another assumption of behavioral contingency programs is that the individual has the target behavior in his/her repertoire. If, for example, the target behavior is to refuse peer pressure to use drugs, and the individual is deficit in skills of assertive communication, then reliance on changes to the reinforcers and punishers of the desired behavior will have little effect. Instead, other principles would be used to develop new behaviors of assertiveness, such as response shaping and building skills. Response shaping is designed to develop behavioral skills through successive approximation to an end goal, with reinforcement for each approximation along the way. For example, in biofeedback treatment for headaches, individuals learn to lower their muscle tension. Each time their muscle tension is successfully lowered by a specified degree, an audio and/or visual signal is displayed, which reinforces the successful reduction in muscle tension. Over time, the amount by which the muscle tension has to reduce in order to be reinforced progressively increases (i.e., successive approximation). Another example of shaping is the training of communication skills in the context of severe developmental disorders; positive reinforcers are provided first for any vocalization, followed by reinforcement for vocalization of a word, then a chain of words, and so on until reinforcement applies to a full sentence. In other words, shaping involves breaking down a behavior into its components. Reinforcement is given as the client performs the initial behavior, and once that behavior is established, then reinforcement is withheld until the client performs the next behavior in the sequence.

When a certain behavior can be performed in one situation but not another, then skills training is less relevant, and instead attention may be given to response generalization. An example might be the ability to say “no” to unreasonable requests from family members but not from friends. In this case, instruction and role playing may be used to help clients perform the behavior in different contexts.