- Email: [email protected]
Behaviour therapy: Criticisms and confusions
BEHAVIOUR
THERAPY:
CRITICISMS
AND CONFUSIONS
C. G. COSTELLO Regina Psychological
Laboratory,
Regina Hospital, Saskatchewan,
Canada
Summary-An attempt will be made in this paper to show that the two most frequent crtticisms of behaviour therapy are based on confusions. These confusions, it will be shown, are not solely the responsibility of the critics. The behaviour therapists themselves, in their writings, are partly responsible for the confusions.
SYMPTOMS AND SYMPTOMS IT IS claimed by the critics that removal of a symptom without relief of the underlying problem will merely result in the appearance of a substitution symptom. The behaviour therapist replies, “There is no neurosis underlying the symptom but merely the symptom itself. Get rid of the symptom and you have eliminated the neurosis” (Eysenck, 1960). It is generally accepted that only empirical evidence will decide this issue. But such evidence is long in coming. Furthermore, opinions as strongly held and opposed as the above can act as effective filters in the face of empirical data. It may be worthwhile, therefore to consider the problem a little more closely. This disagreement over symptoms results from the lack of recognition of different types of symptoms. With such recognition it is clear that neither the antagonist nor the protagonist is wholly right or wholly wrong. Ausubel (1961) in his able defence of the concept of mental illness, distinguishes between three types of symptoms: (1) Symptoms which are “indicative of underlying pathology but are neither adaptive nor adjustive” e.g. depression. (2) Symptoms which are “adaptive and adjustive” e.g. the compulsive striving toward unrealistically high achievement goals as a type of compensatory response to basic feelings of inadequacy. (3) “Distortive psychological defences that have some adjustive value but are generally maladaptive” e.g. phobias. With regard to the first kind of symptom-a manifestation of impaired functioningneither the behaviour therapists’ position nor their critics’ position is tenable. This type of symptom is an outward sign of an inward mess but plays no role in producing the inward mess. To remove such a symptom and expect the underlying pathology to be removed would be like painting the outside of a neglected house in the hope that the neglectful owner will be automatically moved to paint the inside. Behaviour therapists may feel that this is a case of ‘tilting at straw men’ since they have not claimed that symptomatic treatment of depression solves the underlying problem. However, since depression may be a symptom of neurotic disturbance, one may mistakenly assume that the behaviour therapists, general statement regarding neurosis and symptoms applies also to depression. On the other hand, removal of such a symptom would not result in the appearance of a substitute symptom since it is not of a compensatory nature. The treatment of depression by E.C.T. or anti-depressant pharmaceutical agents may be successful in removing the depression. Because, however, the basic problem remains, the depression will almost invariably return. But it will not be replaced by a substitute symptom. This type of symptom
159
160
C. G. COSTELLO
is usually found in organic and psychotic conditions. Reactive depression, however, in so far as it is considered a symptom rather than a condition, is a neurotic symptom which falls into this first category. This is true also of anxiety as a symptom. The essential feature of these neuroses is that the condition itself is the predominant symptom. The condition is not inferred from the observation of compensatory or defensive symptoms. The removal of compensatory symptoms-the second type listed by Ausubel-would be expected to result in the emergence of a substitute symptom because of the very fact that it is compensatory. If one were to tear down the elaborate drapes, our neglectful house owner has used to hide the neglected interior, he would almost certainly find something to substitute for the drapes. It is only with regard to this kind of symptom that the critics’ position is tenable. Such symptoms, however, because of their compensatory and adaptive nature, are rarely seen in clinical practice. One critic of Eysenck’s type of behaviour therapy has recently stated that: “In spite of protestations to the contrary, many of this group hold an implicit disease conception of neuroses, in that symptoms are viewed as bad things to be gotten rid of, rather than motivated responses subserving some functions in the life goals of the person, which he may, or may not, wish to change” (Murray, 1962). It is true of the compensatory type of symptom that they are not necessarily considered bad by the owner and this is the very reason that the owners do not often come to the clinic for their removal. But symptoms of the third type to be described are generally considered bad things by their owners. The premise of the behaviour therapists that the symptom is the neurosis holds only Because of their success as defenses for the third kind of symptom-defensive over-reaction. against noxious stimuli, such symptoms preclude the possibility of the disappearance of the conditioned response (usually anxiety) which can only be extinguished by repeated unreinforced evocations. The symptom itself is an essential component of the vicious circle. These symptoms maintain the emotional disturbance which is removed on removal of the symptom’ This type of emotional disturbance is maintained in relative independence of the factors which originally brought it into being. Our neglectful house owner may despair of putting the house in order because blocked sinks create such a mess. To escape his dirty house he may spend time sweeping sidewalks in his garden not knowing that he is blocking the drains with the dust. If we can clear the drain for him, his sinks will not flood, he will go back into the house, and will not block the drains any more by his compulsive sidewalk sweeping. . . . With regard to this third type of symptom, Eysenck’s statement that, “There is no neurosis underlying the symptom but merely the symptom itself” (Eysenck, 1960), has been interpreted to mean that “inferred higher mental processes, cue-producing responses of therapist various sorts and internal emotional responses” are ignored by the behaviour (Murray, 1961). But this is not so. The behaviour therapists’ position is that not all symptoms are simply manifestations of an underlying disturbance. They may be essential and maintaining links with the higher mental processes, cue-producing responses and internal emotional responses-all of which together make up the emotional disturbance of neurosis. Being personal with whom and how? Murray, speaking of the behaviour “The techniques
therapists’
offered lean heavily on classical
techniques
states :
conditioning
procedures.
hypnosis
REHAVIOUR
THERAPY
: CRITICISMS
and other authoritarian forms of control, drives” (Murray, 1962).
AND
161
CONFUSIONS
and the impersonal
manipulation
of primary
Whether or not the treatment is authoritarian or laissez-faire, personal or impersonal, is of course of little importance since the important consideration is-Does the treatment work? However, Eysenck’s statement regarding personal relations, “Personal relations are not essential for cures of neurotic disorder, although they may be useful in certain circumstances” has led critics to believe that behaviour therapists underestimate the value of personal relations to a greater extent than they actually do. The position of the behaviour therapists would be better put as follows, “Personal relations may be of great value for the cure of some neurotic disorders and are of little use in some circumstances”. Wolpe’s (1958) relation with his patient is of importance in the inducing of relaxation Murray himself has said that, “(Wolpe) appears to show considerable warmth responses. Meyer (1960) who successfully treated a woman’s excessive fear of toward his patients”. going out by accompanying her on walks wrote, “... E becomes part of the various experimental situations during treatment and, by establishing an effective relationship, he becomes a reassuring stimulus, tending to reduce anxiety”. It is important to note, however, that Meyer also writes, “Since S appeared rather dependent on E’s presence, other staff members of the ward were asked to participate without S’s knowledge of prearrangement by E”. Meyer’s avoidance of overdependency on the part of the patient illustrates an essential difference between the personal relationships developed during psychoanalysis and those developed during behaviour therapy. The personal relationships may be established between the patient and people other than the therapist who simply arranges the conditions as in group therapy and psychodrama. During the positive side of the present author’s treatment of a homosexual student, a selection of pretty nurses talked and danced with the patient during days on which he had received testosterone propionate. The relationship, according to the nurses, became on occasion quite personal. It was when one of the nurses reported that the patient had kissed her that the author began to feel treatment was progressing well. Another important difference between the relationships established by psychoanalysis and those established by behaviour therapy is that the behaviour therapist uses the situations for the learning or relearning of new personal relationships and not for the interpretation of past faulty personal relationships. There are, of course, neurotic disorders where it is felt that personal relations are of But these are only some of the conditions little value, e.g. tics, writer’s cramp, enuresis. treated by behaviour therapists. REFERENCES AIJSU~ELD. P. (1960) Amer. Psychol.
16, 69-74.
EYSENCK H. J. (Ed.) (1960) Behaviour Therapy and the Neuroses. Pergamon Press, New York. MEYER V. (1960) The treatment of two phobic patients on the basis of learnilrg principles, in Behaviour Therapy and the Neuroses (Ed. H. J. EYSENC~). MURRAY E. J. (1962) Paper read at A.P.A. Ann. Cow. St. Louis, Missouri. WOLPE J. (1958j P&horherapy by Reciprocal Inhibition. London: Oxford University Press.
THERAPY:
CRITICISMS
AND CONFUSIONS
C. G. COSTELLO Regina Psychological
Laboratory,
Regina Hospital, Saskatchewan,
Canada
Summary-An attempt will be made in this paper to show that the two most frequent crtticisms of behaviour therapy are based on confusions. These confusions, it will be shown, are not solely the responsibility of the critics. The behaviour therapists themselves, in their writings, are partly responsible for the confusions.
SYMPTOMS AND SYMPTOMS IT IS claimed by the critics that removal of a symptom without relief of the underlying problem will merely result in the appearance of a substitution symptom. The behaviour therapist replies, “There is no neurosis underlying the symptom but merely the symptom itself. Get rid of the symptom and you have eliminated the neurosis” (Eysenck, 1960). It is generally accepted that only empirical evidence will decide this issue. But such evidence is long in coming. Furthermore, opinions as strongly held and opposed as the above can act as effective filters in the face of empirical data. It may be worthwhile, therefore to consider the problem a little more closely. This disagreement over symptoms results from the lack of recognition of different types of symptoms. With such recognition it is clear that neither the antagonist nor the protagonist is wholly right or wholly wrong. Ausubel (1961) in his able defence of the concept of mental illness, distinguishes between three types of symptoms: (1) Symptoms which are “indicative of underlying pathology but are neither adaptive nor adjustive” e.g. depression. (2) Symptoms which are “adaptive and adjustive” e.g. the compulsive striving toward unrealistically high achievement goals as a type of compensatory response to basic feelings of inadequacy. (3) “Distortive psychological defences that have some adjustive value but are generally maladaptive” e.g. phobias. With regard to the first kind of symptom-a manifestation of impaired functioningneither the behaviour therapists’ position nor their critics’ position is tenable. This type of symptom is an outward sign of an inward mess but plays no role in producing the inward mess. To remove such a symptom and expect the underlying pathology to be removed would be like painting the outside of a neglected house in the hope that the neglectful owner will be automatically moved to paint the inside. Behaviour therapists may feel that this is a case of ‘tilting at straw men’ since they have not claimed that symptomatic treatment of depression solves the underlying problem. However, since depression may be a symptom of neurotic disturbance, one may mistakenly assume that the behaviour therapists, general statement regarding neurosis and symptoms applies also to depression. On the other hand, removal of such a symptom would not result in the appearance of a substitute symptom since it is not of a compensatory nature. The treatment of depression by E.C.T. or anti-depressant pharmaceutical agents may be successful in removing the depression. Because, however, the basic problem remains, the depression will almost invariably return. But it will not be replaced by a substitute symptom. This type of symptom
159
160
C. G. COSTELLO
is usually found in organic and psychotic conditions. Reactive depression, however, in so far as it is considered a symptom rather than a condition, is a neurotic symptom which falls into this first category. This is true also of anxiety as a symptom. The essential feature of these neuroses is that the condition itself is the predominant symptom. The condition is not inferred from the observation of compensatory or defensive symptoms. The removal of compensatory symptoms-the second type listed by Ausubel-would be expected to result in the emergence of a substitute symptom because of the very fact that it is compensatory. If one were to tear down the elaborate drapes, our neglectful house owner has used to hide the neglected interior, he would almost certainly find something to substitute for the drapes. It is only with regard to this kind of symptom that the critics’ position is tenable. Such symptoms, however, because of their compensatory and adaptive nature, are rarely seen in clinical practice. One critic of Eysenck’s type of behaviour therapy has recently stated that: “In spite of protestations to the contrary, many of this group hold an implicit disease conception of neuroses, in that symptoms are viewed as bad things to be gotten rid of, rather than motivated responses subserving some functions in the life goals of the person, which he may, or may not, wish to change” (Murray, 1962). It is true of the compensatory type of symptom that they are not necessarily considered bad by the owner and this is the very reason that the owners do not often come to the clinic for their removal. But symptoms of the third type to be described are generally considered bad things by their owners. The premise of the behaviour therapists that the symptom is the neurosis holds only Because of their success as defenses for the third kind of symptom-defensive over-reaction. against noxious stimuli, such symptoms preclude the possibility of the disappearance of the conditioned response (usually anxiety) which can only be extinguished by repeated unreinforced evocations. The symptom itself is an essential component of the vicious circle. These symptoms maintain the emotional disturbance which is removed on removal of the symptom’ This type of emotional disturbance is maintained in relative independence of the factors which originally brought it into being. Our neglectful house owner may despair of putting the house in order because blocked sinks create such a mess. To escape his dirty house he may spend time sweeping sidewalks in his garden not knowing that he is blocking the drains with the dust. If we can clear the drain for him, his sinks will not flood, he will go back into the house, and will not block the drains any more by his compulsive sidewalk sweeping. . . . With regard to this third type of symptom, Eysenck’s statement that, “There is no neurosis underlying the symptom but merely the symptom itself” (Eysenck, 1960), has been interpreted to mean that “inferred higher mental processes, cue-producing responses of therapist various sorts and internal emotional responses” are ignored by the behaviour (Murray, 1961). But this is not so. The behaviour therapists’ position is that not all symptoms are simply manifestations of an underlying disturbance. They may be essential and maintaining links with the higher mental processes, cue-producing responses and internal emotional responses-all of which together make up the emotional disturbance of neurosis. Being personal with whom and how? Murray, speaking of the behaviour “The techniques
therapists’
offered lean heavily on classical
techniques
states :
conditioning
procedures.
hypnosis
REHAVIOUR
THERAPY
: CRITICISMS
and other authoritarian forms of control, drives” (Murray, 1962).
AND
161
CONFUSIONS
and the impersonal
manipulation
of primary
Whether or not the treatment is authoritarian or laissez-faire, personal or impersonal, is of course of little importance since the important consideration is-Does the treatment work? However, Eysenck’s statement regarding personal relations, “Personal relations are not essential for cures of neurotic disorder, although they may be useful in certain circumstances” has led critics to believe that behaviour therapists underestimate the value of personal relations to a greater extent than they actually do. The position of the behaviour therapists would be better put as follows, “Personal relations may be of great value for the cure of some neurotic disorders and are of little use in some circumstances”. Wolpe’s (1958) relation with his patient is of importance in the inducing of relaxation Murray himself has said that, “(Wolpe) appears to show considerable warmth responses. Meyer (1960) who successfully treated a woman’s excessive fear of toward his patients”. going out by accompanying her on walks wrote, “... E becomes part of the various experimental situations during treatment and, by establishing an effective relationship, he becomes a reassuring stimulus, tending to reduce anxiety”. It is important to note, however, that Meyer also writes, “Since S appeared rather dependent on E’s presence, other staff members of the ward were asked to participate without S’s knowledge of prearrangement by E”. Meyer’s avoidance of overdependency on the part of the patient illustrates an essential difference between the personal relationships developed during psychoanalysis and those developed during behaviour therapy. The personal relationships may be established between the patient and people other than the therapist who simply arranges the conditions as in group therapy and psychodrama. During the positive side of the present author’s treatment of a homosexual student, a selection of pretty nurses talked and danced with the patient during days on which he had received testosterone propionate. The relationship, according to the nurses, became on occasion quite personal. It was when one of the nurses reported that the patient had kissed her that the author began to feel treatment was progressing well. Another important difference between the relationships established by psychoanalysis and those established by behaviour therapy is that the behaviour therapist uses the situations for the learning or relearning of new personal relationships and not for the interpretation of past faulty personal relationships. There are, of course, neurotic disorders where it is felt that personal relations are of But these are only some of the conditions little value, e.g. tics, writer’s cramp, enuresis. treated by behaviour therapists. REFERENCES AIJSU~ELD. P. (1960) Amer. Psychol.
16, 69-74.
EYSENCK H. J. (Ed.) (1960) Behaviour Therapy and the Neuroses. Pergamon Press, New York. MEYER V. (1960) The treatment of two phobic patients on the basis of learnilrg principles, in Behaviour Therapy and the Neuroses (Ed. H. J. EYSENC~). MURRAY E. J. (1962) Paper read at A.P.A. Ann. Cow. St. Louis, Missouri. WOLPE J. (1958j P&horherapy by Reciprocal Inhibition. London: Oxford University Press.