The Role of Behavioural Therapies in Clinical Hypnosis.

The behavioural approach to psychology was started by, amongst others, John Watson (1878-1958). This approach to psychology emphasised that psychology is a science and should be carried out in an objective manner and should not rely on introspection.

Behaviourism was, therefore, a reaction to the way in which psychology had been studied before, an attempt to limit the field of inquiry to that which is observable: namely behaviour. Ivan Pavlov (1849-1936) was a research psychologist who Watson was very impressed by, as his experiments were scientific in nature. Perhaps one of the most important behaviourist figures, though, was B. F. Skinner (1904-1990) whose major contribution was the idea that behaviour was controlled, to a large extent, by reinforcement and reward. Skinner is most associated with the idea of equipotentiality, the idea that a stimulus can be conditioned to produce any response in any situation. Like these figures, Joseph Wolpe (1915-1997) was very interested in the possibilities of a scientific psychology and carried out much revolutionary work in the treatment of patients with phobias. Edward Thorndike (1874-1949) was also heavily influenced by behaviourism and came up with the idea of the law of effect. This is the idea that the consequences of behaviour control how likely that behaviour is to be repeated. This essay will look at the contributions these figures have made to theories of behaviourism and how these theories have been used in a therapeutic context to inform the hypnobehavioural approach.

The principle on which behaviourist theories are based is that the way in which animals learn is by association. Animals learn to associate one stimulus with a particular response. While human learning is probably much more complex than animal learning, behaviourists would argue that, at the root, the basic mechanism is the same (Eysenck, 2000). The major behaviourists, in order to test these principles, carried out a variety of experiments on animals.

Classical conditioning or Pavlovian conditioning experiments were carried out by Pavlov on a dog (Eysenck, 2000). A dog which is hungry is given food over time, and each time it is given food the dog automatically salivates as a natural response. This is called an unconditioned reflex and involves the link between this, the salivation, and the unconditioned stimulus of the food. What Pavlov did was, just before the dog is given the food, a bell is rung. This sets up a conditioned reflex between the bell ringing and the salivation response. Now the dog will salivate when the bell is rung, despite the fact that there is no food present.

Within classical conditioning Pavlov also made a number of other discoveries (Eysenck, 2000). The first is the idea of generalisation, that if a bell is rung with a slightly different tone than the one used for the conditioning of the reflex, some saliva will be produced, but not as much as the original amount. The dog can also be taught to discriminate between tones. A slightly different tone to that originally used is presented to the dog, but then the original tone is also presented again with the food. This is repeated such that the original tone is always accompanied by food and the slightly different tone is never accompanied by food, eventually the dog learns to discriminate between the two tones. Experimental distinction describes the idea that over time the effect of the conditioned reflex weakens. Pavlov found that as he kept ringing the bell without giving the dog food, the dog began to salivate less and less. Despite this, however, Pavlov also discovered that after experimental distinction, when the dog was brought back into the experimental condition, there was still some salivation, which was termed spontaneous recovery.

Operant conditioning can be distinguished from classical conditioning in that instead of the stimulus occurring before the behaviour, the controlling stimulus occurs afterwards (Catlow, 2005). The behaviours that are being discussed are not those that are naturally occurring. In addition, these behaviours may be linked together into long chains in order to create complex behaviours. These types of behaviours are normally an adaptation to the particular environment in which an individual finds her or himself. The name operant conditioning comes from the idea that the behaviour that a person exhibits acts on the environment. A good example of this is the behaviour of a child, which, if it is badly behaved, may cause its parents, as part of the child's environment, to become angry or, in some way change their behaviour towards it. Skinner, in particular, used the word reinforcement rather than using the word 'reward' and stated human behaviour is controlled to a large extent by rewards. Skinner acknowledged that biology, cognition and affect were important, but believed these to be secondary to the power that reward has (Durand & Barlow, 2003).

The idea of reciprocal inhibition is most associated with Joseph Wolpe who carried out research with cats, amongst other animals (Eysenck, 2000). He found that, in carrying out these experiments it was possible to change the animal's behaviour. This was done by exposing the cats to stimuli that it was conditioned to be aversive to, for example an electric shock, along with a harmless situation. Over a period of time the cat learned to stop avoiding and fearing the electric shock.

Although behaviourism provides some important insights into why people do the things that they do, it had a major flaw. This was that behaviourists argued that people's behaviour was mostly controlled by the situation they were in. Many critics argued that this could not be true, otherwise the social world would not be the way that it is (Eysenck, 2000). The ideas and theories of behaviourism were adapted, therefore, to include a social element, which became social learning theory.

Two researchers most closely related with the development of this theory were Bandura and Rotter. Rotter (1954) emphasised the importance of expectancies - this is the idea that reward for particular actions or manifestations of our behaviour encourages us to act again the same way in the future. This is based very firmly on the ideas of behaviourism. It was extended by Rotter (1966) when he introduced the idea of locus of control. This concept included the distinction between those people who think that the punishments and rewards they receive are largely based on their own behaviour and those who think that they are not. The former have an internal locus of control, and the latter have an external locus of control.

Rotter (1954) also developed the idea of reinforcement value. If a person has to choose between one reinforcer and another when the chances of being able to get each of them is the same, this shows which has greater value to that person. This reinforcement value is, therefore, deeply affected by our experiences in life, and as such, different people will attach different reinforcement values to different rewards. Rotter (1954) argued that this idea helped to explain why people don't always act the same in equivalent situations. By introducing this idea, Rotter helped to integrate ideas from behaviourism with a social learning perspective.

Bandura, meanwhile is also closely associated with social learning theory. While Bandura was a behaviourist he initially put forward a more complex model of behaviourism. This included the idea that three triangular factors all influenced each other. Thus behaviour, internal factors such as beliefs and expectations as well as environmental factors such as punishments and rewards all affect each other. This approach, therefore, places lower emphasis on behaviour than pure behaviourism does.

A major way in which Bandura stood aside from previous ideas on behaviourism was the way he interpreted the effect that rewards and punishments have on behaviour. While previous theorists such as Skinner thought that the link was automatic between rewards and behaviour, Bandura thought that the link was designed to provide motivation and information. Part of the strength of this approach is that it explains why people don't simply change their behaviour continually to suit the environment around them. Contrary to this, the reality is that people are often reasonably consistent across different situations.

Taking these ideas a step further, Bandura introduced the idea of observational learning. This is the learning that people can achieve while watching other people. In an experiment, Bandura, Ross & Ross (1963) had young children watch an interaction between an adult and a doll called a Bobo doll which is like a large inflatable clown with a heavy bass. One group saw an interaction characterised by aggression towards the doll while the second group saw an interaction characterised by being friendly. When the children were allowed to play with the doll they imitated the mode of interaction that they had earlier witnessed. In a second experiment (Bandura, 1965), that was similar both groups were shown the violent condition but one group was shown the adult aggressor being rewarded for their behaviour and in the second condition, the aggressor was castigated. The group that showed the most violence towards the Bobo doll, when allowed to play with it afterwards, were the group that had seen the aggressor rewarded for its behaviour. While subsequent studies have questioned the ecological validity of this experiment, the social learning perspective has certainly been influential.

These ideas from behaviourism and social learning theory have been important in developing a number of techniques in the hypnobehavioural approach. The first to be considered here is systematic desensitisation. This therapeutic approach is often associated with the work of Joseph Wolpe. This is often used in the treatment of phobias and involves introducing the object of fear to the client by a gradual process. By being done gradually, clients can continually test reality to see whether they are actually coming to any harm or not. Along with carrying this out, Wolpe introduced another element: his patients were asked to think about something that was incompatible with the fear which they were feeling. This clearly uses the idea of reciprocal inhibition described earlier. Because it was not always practical to introduce the phobic element into clients direct experience, the client was often asked by Wolpe to imagine it. Durand & Barlow (2003) provide the example of how Wolpe treated a man who had a phobia of dogs. The first stage of the process was training the man to relax and then to imagine that he was looking at a dog on the other side of a park. Then the dog was systematically brought closer and closer in the imagination until he was able to touch the dog. This particular situation is an example of working 'in vitro', or in the imagination. This can be contrasted with 'in vivo' where the client is presented with the actual situation. These findings were considered the beginning of behaviour therapy.

Classical conditioning was also important in the development of the technique of flooding. Taking the ideas of extinction from the theory, flooding involves exposing the client to the phobic situation to which they are aversive. In flooding this is sometimes carried out in vivo and sometimes in vitro. Rather than stepping up the exposure gradually either in the mind or in reality, this technique requires the client to experience the full extent of their fear and then allow this to subside as they realise that the consequences that they fear will befall them, do not actually materialise. The theory is that a person cannot maintain the same high level of fear of the phobic situation so it will naturally subside over a period of time. This differs markedly from the systematic desensitisation as it involves no relaxation technique. Carried out in vivo this technique is often much more frightening for the client but the same technique of waiting for the fear to subside is used. It is possible, however, to remove the client from the situation too soon before the fear has had a chance to subside so that the client finds the situation even more frightening in future.

The idea behind the technique of massed practice is to attempt to treat habits or tics. This is done by asking the client to actually practice the thing that they are trying to stop doing - this is called negative practice (Weeks & L'Abate, 1982). Hull (1943) uses the idea of reactive inhibition to explain how this works. Hull (1943) argues that a person does not enjoy repeating the same behaviour over and over again, so that when a person is asked to do this, they experience the period afterwards when they are relaxing as pleasurable. The theory is that this process causes the behaviours themselves to be inhibited in the future, so helping a person rid themselves of the unwanted tic or habit. Of those discussed here, this technique probably has the loosest links to behaviourism, especially as it was largely developed before the main works of behaviourism were published in the 1950s.

Aversion training is often described as a therapy of last resort because part of therapy involves exposing the client to an extremely unpleasant stimulus. A useful example is aversion therapy for alcoholics - in this case alcoholics are given their favourite alcoholic beverage with an emetic added. An emetic drug causes feelings of nausea and vomiting. A stimulus that is, therefore, aversive - vomiting - is linked in the mind with the behaviour that the person wants to avoid. Perhaps the most obvious problem with this type of therapy is that, other than the fact it is extremely unpleasant, it also relies on an automatic connection being made in the brain. After all, the client knows that, outside of the therapeutic setting, they are unlikely to encounter alcohol that has been laced with an emetic. A further example of aversion therapy is provided by Vogler, Weissbach, Compton & Martin (1977) who, in treating alcoholics, used electric shocks to the hand just as the client was taking a first sip. The point should be made that, while this treatment is extreme, people have been known to volunteer for it as they see it as their only way out to make a recovery.

Assertiveness training is used when a client is found to behave maladaptively in certain situations. It is normally only used when a client behaves in a characteristic way when in a certain situation, rather than in any situation. In the latter case, a different form of therapy is required. Assertiveness training is based on ideas set out by Wolpe & Lazarus (1966) and involves attempting to replace the client's current automatic responses to a situation with those seen as more adaptive. This will usually comprise the client expressing their thoughts and feelings clearly in a situation in which they would normally disguise them in some way. These ideas are based on both the social learning theories described above and operant conditioning. Assertiveness training often involves a variety of stages to help change the desired behaviour. Response acquisition learning helps the client to model the required behaviour. Cognitive, verbal and nonverbal aspects are considered during this process. Once the responses are acquired, the technique moves on to practice. The client can, for example, role-play the responses back to the therapist. The responses that are made are shaped so that small adjustments are made to improve the communication. Cognitive elements are tackled that tend to stop or hinder the process of being assertive. Assertiveness training is normally carried out first in vitro with the therapist role-playing and helping the client through the process. Afterwards, once the desired responses and behaviours have been learned, the client sets themselves a number of goals to take their new skill and use it in vivo.

Hypnobehavioural approaches to the treatment of pathological anxiety have been shown to be effective (Frankel, 1976). In the treatment of anxiety, hypnobehavioural approaches use a variety of factors to help tackle the undesired anxiety. Normally the technique of exposing the patient to the anxiety making situation, either in vivo or in vitro will be used (Voit, 2003). In vitro, under hypnosis, the patient can be encouraged to be desensitised to the situation, to become habituated to it and therefore deconditioned. Along with this approach, the therapist will often examine what personal significance the threat has for the patient, as well as attempting to get the client to think again, or re-evaluate, the situation and see it from a different angle. Finally, the therapist will attempt to increase the client's self-efficacy so that they feel able to personally cope with the anxiety inducing situation in the future. One of the most useful aspects of hypnosis is the ability to train the client to rapidly relax and then apply this to the problem situation (Voit, 2003).

A common type of phobia often treated with a hypnobehavioural approach is agoraphobia. Hypnosis is used, again, to help teach the client to relax and to learn to relax rapidly. One of the first steps in treating agoraphobia is for the therapist to teach the client how to have control over their own thoughts and feelings. The ability to relax rapidly, when practiced, allows the client to experience having control over themselves (Voit, 2003). From having this control over themselves, this allows them to feel more confident to cope with their own thoughts and feelings in a more stressful situation, such as being outside in the open. As part of these relaxation sessions, the client is often encouraged, while they are relaxing, to imagine themselves to be outside and to notice that they are still remaining relatively relaxed. The idea is to connect the relaxed state with being outside and supplant the conditioned response of panic. This work with hypnosis can be combined with breathing techniques and positive self-talk to allow the client to face their fear in vivo. Again, the fearful situation is introduced to the client in stepped phases until they feel able to cope with it.

Hypnobehavioural approaches are often used in the treatment of habit disorders. Some of the most common of these are breaking the habit of eating to promote weight loss and stopping smoking (Voit, 2003). To attack the problem of smoking, a two-stage approach is sometimes taken. The first stage tries to attack the association between the smoking and other activities that are basically unrelated. This can include, for example, the link that some people have between getting up in the morning and having a cigarette. Sometimes it is recommended that this 'bad' habit of the connection between smoking and getting up, is replaced by another habit that isn't so injurious to health. The actual automatic behaviours are therefore redirected away from smoking. Secondly, the therapist will try to target the emotional impact of smoking. Smoking may sometimes be used as a way to avoid feeling in a particular way, for example smokers often say that it helps them feel calm. The smoking is therefore used as an emotional crutch and it can be hard to break this connection. Hypnotherapy is then used to redirect this connection. Like the approaches to other problem behaviours, self-hypnosis can be taught to the client to help them continue free of the damaging behaviour.

Hypnobehavioural approaches have some clear advantages over the use of behavioural methods used on their own. We each create our own reality by the way in which we interpret the world around us. Hypnosis helps the client to change the way in which they see reality. Hypnosis also helps to cut-out extraneous detail and distraction in the process of teaching a client to imagine that which is required for effective therapy. The use of self-hypnosis is in helping the client to maintain the gains that they have made during therapeutic sessions. Hypnosis allows the client to become more involved in the situation in which they want to change their behaviour while in vitro, so that when they come to face the situation in vivo the practice will not have been too far from the reality. This helps to promote self-efficacy in the client.