Gerhard Lenz

med@praxis-lenz.at

In behavior therapy, there is no founder figure as in many other psychotherapy modalities . The term Behavior Therapy (USA) or Behaviour Therapy (England, South Africa) appeared independently in scientific publications in the 1950s. Here, success has been reported in the application of learning psychology principles, especially in the treatment of anxiety.

More comprehensive recent overviews can be found in Eschenröder (2019) and Margraf (2018).

Precursor of behavior therapy :

In the development of the theoretical foundations, the studies on classical conditioning by Ivan P. Pavlov at the end of the 19.Jhdts at dogs an important role. Based on these results, the theories of classical conditioning and extinction of fear responses were developed . An early practical application of these principles described in the 1920s by John.B.Watson with his case presentation of Little Albert and Mary C. Jones who investigated how to reduce children’s fears in a children’s home (for a more detailed description see Eschenröder 2019, p 15-19).

Development of behavior therapy based on learning theory: classical conditioning.

In South Africa developed JosephWolpe (1958), based on his work with experimental neuroses in cats and the subsequent possibilities of reducing fear, the principle of reciprocal inhibition: a reduction of fear is possible when fear-inducing stimuli are coupled with those that are incompatible with fear, such as food in cats or relaxation in humans. With relaxation, patients should progressively manage anxiety-provoking situations in a hierarchy (first in sensu, then in vivo). He described this procedure as “systematic desensitization” (Wolpe 1958,1972).

His circle of students included Arnold Lazarus and Stanley Rachman.

Wolpe later moved to the United States and taught at various universities there.

In England were the Institute of Psychiatry in London with Jürgen Eysenck and his student Stanley Rachman (who had come to London from South Africa) were a nucleus of the development of behavior therapy.

Jürgen Eysenck, who as a young man had emigrated to London for political reasons after graduating from high school in Berlin and studied psychology in London, became head of the Psychology Department at the Institute of Psychiatry in 1950 .

Eysenck assumed that various kinds of neurotic disorders arise from Pavlovian conditioning and can be eliminated by extinction. Under his leadership, therapies based on conditioning processes were developed and tested. Eysenck also became known for his controversy with psychoanalysis, which he accused of achieving no better results than were possible with spontaneous remission. In contrast, he placed the greatest emphasis on grounding behavioral therapy interventions in empirical psychology and the need for evidence-based practice. The paper “Learning Theory and Behaviour Therapy” (Eysenck 1959) is the first publication in which Eysenck uses the term Behaviour Therapy and presents the basic principles of the new approach.

Development of learning theory-based behavior therapy: operant conditioning:

In the USA researched Fred Skinner (1953,1973) explored the relationship between behavior and its consequences in the context of animal experiments with his Skinner box. In his experiments, he discovered that the frequency of his rats’ lever presses was not solely dependent on preceding stimuli, but primarily on stimuli that followed only after a lever press.

He referred to the process by which operant behavior is produced as “operant conditioning.” Skinner himself was never clinically therapeutic and also saw implications for his findings in broad areas of education and society . Thus he wrote a utopian novel “Walden Two” (Skinner 1948,2002) with visions of a better form of society based on operant conditioning.

Appropriate treatments in the clinical setting did not become available until the 1960s, first for children and mentally retarded adults, and later for long-term hospitalized patients and patients with chronic illnesses

performed and referred to as behavior modification. Studies on coin systems (token economies) supported the importance of social reinforcement for desired behavior.

Cognitive therapy and the convergence of cognitive and behavioral approaches:

A.Bandura’s Work on learning by imitation (Bandura & Walters 1963) drew attention to cognitive factors in behavior therapy (cognitive aspects of model learning). Michael Mahoney (1974,1977) pointed out the importance of cognitive processing. With his self-instructional training, showed Donald Meichenbaum (1975) showed that behavior change can be achieved by changing the self-talk or self-instructions that patients give themselves. In a phase of self-observation, confidence about the controllability of one’s own behavior is to be developed and it is to be learned to react to it with changed thought processes and behaviors. This is to interrupt maladaptive behaviors.

The psychoanalyst’s Aaron T. Beck based on depression therapy first developed outside the behavioral therapy movement (Beck 1967,1976) and the rational-emotive therapy of Albert Ellis (1962) are among the most important cognitive approaches today.

Albert Ellis was also originally a psychoanalyst, and his new approach to therapy focused on making patients aware of unrealistic and self-harming thoughts, challenging them, and replacing them with realistic and constructive alternatives. In his Rational-Emotive Therapy RET (Ellis 1962, 2012), he identifies 11 irrational ideas that cause and maintain mental disorders, and later three basic irrational beliefs that are contrasted with unconditional acceptance as a positive alternative.

Therapeutic methods consist of cognitive methods, behavioral methods, emotive-evocative methods, and active-directive therapy.

Aaron T. Beck described a cognitive triad of negative views of self, environment, and future in depressed patients, which would be based on early experiences and reactivated by trigger situations in the present. He listed a number of dysfunctional automatic thoughts, conditional assumptions, and basic assumptions that would play a role in the development of negative emotions and problematic behaviors (link between thoughts, feelings, behaviors, and physical sensations).

In cognitive therapy, patients are guided to identify and modify negative automatic thoughts (what speaks for the thought, what speaks against it, what would be a more adequate view).In a similar way, dysfunctional basic assumptions are also replaced by more adequate new basic assumptions. Behavioral tasks and behavioral experiments are used to find evidence for the new views. In addition, activity planning plays an important role, especially at the beginning of therapy for depressed patients.

Arnold Lazarus was one of the first to publish on behavior therapy (Lazarus 1958) and criticized the concepts derived from animal experiments by Wolpe and Eysenck as insufficient to understand and treat human problems and developed in his approach of a broad spectrum behavior therapy (Lazarus 1971) an integration of learning theory and cognitive methods.

Kanfer (Kanfer & Karoly 1972, Kanfer et al 1990) emphasized in his self-management approach the self-regulatory organization of humans with feedback processes of self-observation, self-assessment, and self-reinforcement. His scheme of behavior analysis (S-O-R-K-C model) became of great importance for the practice of behavior therapy.

Integrating emotion-focused concepts:

In describing his differential theories of emotion, Izard (1977,1994) replaced the view that emotional experience is a mere product of arousal and cognitive attribution of meaning. From research on the role of emotions in the psychotherapeutic change process emerged the

emotion-focused therapy by L.Greenberg (1997, 2011) whose techniques also found their way into behavior therapy (Sulz & Lenz 2000).

Behavioral medicine :

In accordance with the biopsychosocial model, behavioral medicine, as a counterpart to psychosomatics with its depth psychology connotations, is concerned with the interactions between physical illnesses and psychosocial factors. Behavioral therapy strategies are often highly relevant for change and influence, especially in chronic physical illnesses, and also have implications for reducing health care costs. As an example, the textbook “Behavioral Medicine” ( Ehlert 2003, 2016 ) should be mentioned.

Development of behavior therapy in German-speaking countries:

The emergence took place in the late 1960s and early 1970s in parallel in several places (overview in Margraf 2018 and Lenz 2019): First and foremost, the Psychology Department of the Max Planck Institute of Psychiatry in Munich (Johannes C. Brengelmann) , the University of Konstanz (Rudolf Cohen), and the Clinical Psychology Department of the University of Münster (Lily Kemmler). Fred Kanfer from Illinois (who was born in Vienna and fled to the USA to escape the Nazis) made a great contribution to the spread of behavioral therapy in German-speaking countries through his lecturing activities and by helping to establish behavioral therapy-oriented psychosomatic clinics.

In 1968 the Society for the Promotion of Behavior Therapy (GVT) was founded in Munich, in 1971 the German Professional Association of Behavior Therapists (DBV) was founded in Münster, and in 1976 the GVT and DBV merged to form the German Society for Behavior Therapy (DGVT).

The Austrian Society for Behavior Research, Behavior Modification and Behavior Therapy (ÖGVT) was founded in 1971 by H.G.Zapotoczky, Peter Berner and Giselher Guttmann.

In 1974 Zapotoczky founded and directed a behavior therapy ward (and a behavior therapy outpatient clinic) at the University Hospital for Psychiatry in Vienna.

1973 also saw the first training course in Vienna with lecturers from Germany and England.

In addition to the ÖGVT in Vienna, the Arbeitsgemeinschaft für Verhaltensmodifikation (AVM) was founded in Salzburg in 1976 by Hans Reinecker, Herbert Mackinger, and Gerhard Crombach (Lenz 2019).

The European Association for Behaviour Therapy (EABT) was formally founded in 1976, but had its origins 5 years earlier when groups in Germany, England and Holland joined forces to initiate a Europe-wide movement. In 1992, EABT was renamed EABCT (European Association for Behavioural and Cognitive Therapies www.eabct.eu ) and includes member organizations from 44 different countries with over 25000 members.

Continuous developments in behavior therapy :

According to Margraf (2018), the most important new developments include mindfulness-based practices and schema therapy, the expansion of therapy programs for children and adolescents, and the development of standardized materials for therapeutic practice.

Despite many successes of Cognitive Behavioral Therapy, there have often been difficulties in treating certain groups of patients, such as those with personality disorders or patients with self-injury or patients with chronic depression.

Promoting mindfulness and acceptance is not about challenging and changing dysfunctional cognitions, but rather developing an accepting, observing, and detached attitude toward these thoughts.

Marsha Linehan developed for patients with borderline personality disorder and self-injurious behavior the Dialectical-Behavioral Therapy DBT (Linehan 1993, 1996). Here, in an interplay between acceptance and change (dialectic), a wide variety of therapeutic strategies are used in addition to the therapeutic relationship, such as behavior analysis, cognitive techniques, emotion exposure, skills training, contingency management . DBT proceeds in several treatment phases (preparatory phase, first therapy phase for working on suicidal and parasuicidal behavior as well as behavior threatening therapy and a skills training, second therapy phase for working on post-traumatic stress syndrome, and a third therapy phase for stabilization and building self-esteem).

James McCullough developed a new method for the treatment of chronically depressive patients.

patients the Cognitive-Behavioral Analysis System of Psychotherapy (CBASP) (Mc Cullough 2000). The goals are the learning of new behavioral and thinking strategies as well as the transparent learning or experiencing of new

corrective relational experiences to heal traumatizing relational experiences from childhood. Social problem situations are analyzed and new ways of thinking and behaving are developed.

Segal,Williams and Tesadale developed the “Mindfulness-Based Cognitive Therapy” ( Mindfulness-Based Cognitive Therapy MBCT, Segal et al 2002,2015) for relapse prevention in depressive disorders.

The therapy consists of a combination of mindfulness exercises, psychoeducation, cognitive elements, and behavioral elements.

The acceptance and commitment therapy developed by Steven Hayes Acceptance and Commitment Therapy (ACT, Hayes et al 1999, 2004 ) includes cross-disorder strategies. Rather than eliminating “symptoms” and correcting “disorders,” ACT aims to develop greater psychological flexibility through learning mindful acceptance and a focus on engaged life-goal oriented action….

The schema therapy of Jeffrey Young (2003,2005) is a further development of Beck’s Cognitive Therapy for more effective treatment of patients with personality disorders. Young describes early maladaptive schemas (trait variables) that develop when specific basic emotional needs are not adequately met in childhood. In the mode model (state variables), the modes represent current activated experience states including their behavioral tendency, which, for example, can change rapidly in borderline patients in a trigger-dependent manner, while the schemas remain stable in the background. For the therapeutic relationship, the principle of limited parental care plays an important role. After diagnostic and information phase, cognitive, emotion-focused and behavioral methods are applied in therapy. The patient is also confronted very clearly with his interpersonal patterns in the therapy relationship through empathic confrontation.

Furthermore the Metacognitive Therapy by Adrian Wells (Wells 2000, 2011): Metacognitive therapy postulates that mental disorders are based on metacognitions that exist separately from the beliefs and thoughts that play such an important role in cognitive-behavioral therapy. The term metacognition refers to the factors of thinking that direct, control, and evaluate thinking. The therapist’s task is to work on changing metacognitions that result in the dysfunctional persistent thinking styles.

Transdiagnostic treatment of emotional disorders (Barlow et al 2017, 2019): Drawing on recent concepts about various anxiety and affective disorders , which emphasize their similarities more than their differences, and the fact of the high comorbidity of emotional disorders, Barlow et al have developed a principled treatment approach that is applicable to a wide range of problems and patients.

In contrast to disorder-specific treatment, transdiagnostic treatment of emotional disorders addresses the core emotional processes that maintain symptoms across disorder boundaries.

This approach reduces the burden on therapists in that they only need to learn one type of intervention to provide evidence-based therapy for most common disorders.

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