Advance report on Behavior Therapy:

A NEW, SIMPLER, FASTER WAY TO TREAT MENTAL TROUBLE

SIDNEY KATZ July 27 1963
Advance report on Behavior Therapy:

A NEW, SIMPLER, FASTER WAY TO TREAT MENTAL TROUBLE

SIDNEY KATZ July 27 1963

A NEW, SIMPLER, FASTER WAY TO TREAT MENTAL TROUBLE

Advance report on Behavior Therapy:

now attack troubles like homosexuality and alcoholism by training their patients to act normally. Their method flies in the face of all that's sacred in psychoanalysis ; and proves to some extent what laymen have suspected all along — common sense can work, too, even when the problem is mental

SIDNEY KATZ

THE ANXIOUS, disturbed people who in our century have had to choose between the long, exorbitantly expensive and uncertain help of psychotherapists and psychoanalysts on the one hand, or trying to live with their crippling habits and emotions on the other, now have a third choice. They can seek out a new kind of practitioner in psychiatry, a behavior therapist, of whom there are already a number practising in Canada.

The behavior therapists work on an almost blindingly simple principle; many people who act abnormally can be taught simply, quickly and inexpensively to act normally. Treatment by a behavior therapist doesn't always work, and the science is still very young. But many patients whose lives had been disrupted for years by tics, stuttering, phobic fears, homosexuality and other neuroses are now living normal lives after undergoing behavior therapy that in many cases lasted no longer than a few weeks or months.

Two new medical journals devoted exclusively to this new branch of mental medicine have appeared in the past year. At the Forensic Clinic, affiliated with the University of Toronto, child molesters, exhibitionists and impotent men are being successfully treated by behavior therapy. “There’s a real thirst for this kind of therapy," says Dr. Harry Hutchison. The Regina Mental Health Clinic has used behavior therapy to help homosexuals lead a normal life. The Speech and Communication Clinic in Toronto has used the new techniques to render “hopeless" stutterers fluent. Behavior therapy appears to be the most effective method yet used for the treatment of bedwetting — a distressing and embarrassing condition widely prevalent among children. Of a thousand cases treated in several countries, seven hundred and fifty were classified as “cured," most of the others “markedly improved." From various psychiatric clinics in Europe, South Africa and the United States, evidence is rapidly accumulating that behavior therapy promises new hope for the troubled.

How does behavior therapy compare, in effectiveness, with more conventional forms of treatment? As yet this question can't be answered fully.

Most comparative statistics which have been published were compiled by enthusiasts for the new therapy. Dr. Joseph A. Wolpe, a psychiatrist at the University of Witwatersrand in South Africa, published results of a hundred and twenty-two cases of assorted neuroses, showing that “ninety percent were cured or markedly improved." The average treatment was twenty-six interviews — a fraction of the time required by other forms of therapy. Another South African, Dr. Arnold A. Lazarus, claims that behavior therapy is six times as effective as older methods in the treatment of phobic fears. Dr. H. J. Eysenck, a University of London psychologist who is a leading proponent of the new method, says, “There’s ample evidence that behavior therapy produces results not inferior, and often superior, to those produced by psychotherapy.”

What exactly is behavior therapy? A much simplified explanation is that it's a system of treating human psychiatric disorders based on modern theories of learning or “conditioning.” Pavlov, the Russian physiologist, conditioned a dog to salivate when a bell rang; Watson, the American psychologist, conditioned a one-year-old child to be frightened of furry animals. This, together with the wide experimentation which followed, led to a new theory of neurosis: a person's behavior, in this view, is the result of past conditioning. If his conditioning has been deficient or defective, then he has neurotic symptoms. He learned the neurotic symptoms. Therefore, he can ////learn them.

In treating a neurotic, the behavior therapist works to get rid of the symptoms. He says, in effect, “The symptoms arc your disease. If you stutter or if you’re homosexual, that’s your problem. You’ve learned to behave in this peculiar way; your cure lies in learning to behave differently, right now.” There's no Freudian jargon, and the patient clearly understands what is being done with him and for him.

This theory flatly contradicts the Freudian teaching on which psychoanalysts and psychotherapists base their treatment. Freud held that neuroses arc caused by conflicts stored away in the unconscious mind. Bring

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There is one flaw in Freudian psychiatry, says a psychologist: The patient doesn’t get better

to light the conflicts by laboriously probing the labyrinths of the unconscious, and the neurotic symptoms vanish. Freud warned against the futility of treating symptoms, because he believed new symptoms would take their place as long as the underlying conflicts were untouched. Psychoanalysis can take two or three years or more. Psychotherapy, which calls for less probing and more discussion with the patient, as well as the possible use of drugs, electric shock or brain surgery, is somewhat less timeconsuming.

When Freudian theory was developed about sixty years ago, it was hailed as the answer to all mental ills. “Only one thing went wrong,” says Dr. H. .1. Eysenck, the London psychologist. "The patient didn't get better.” Indeed. reliable studies are lacking to prove that the psychoanalyst docs a better job with the neurotic than the general practitioner, the faith healer or for that matter, the native witch doctor. “The therapeutic efficacy of psychoanalysis is an unwarranted assumption." says Dr. Edward Glover, a leading British psychoanalyst.

By contrast, the behavior therapists already have several techniques of treatment and are now busily engaged in devising new ones. One is already fairly familiar to laymen — aversion, which discourages the symptom by creating an unpleasant association with it. Dr. S. Ci. Laverty and associates at Queen's University have been injecting alcoholics with the drug succinylcholine dihydrate at the same time that the patient takes a drink. The effect is painful and terrifying: for a full minute the patient can't breathe and lie's certain he'll die. Of fifteen patients treated in this Planner, thirteen have given up drinking, ln-

deed, for a long time they didn’t even want to talk about alcohol. Other behavior therapists have given patients an electric shock each time they took a drink, with similarly successful results.

In a British hospital, Dr. Ian Oswald uses a somewhat more elaborate program of aversion conditioning for alcoholism. To one of his patients, a thirty-one-year-old ex-sailor hopelessly addicted to beer and rum. Dr. Oswald gave, every two hours, an injection of apomorphine and then a drink of beer or rum. When the two in combination had produced a deep nausea, he turned on a tape recording. “Beer and rum and Coke make him sick,” said a female voice. Then came the sound of a man being sick, followed by male and female laughter. A female voice said, “They make him sick.” A pause, and then the recording repeated itself.

Prescribed: films of pretty women

By the end of the first day, the patient was so disturbed that he wanted to quit. He was persuaded to take the complete treatment, which lasted five days. Almost a year later the ex-sailor reports that he drinks no alcohol and that his family life was never better. Another of Dr. Oswald's patients, a confirmed alcoholic for ten years, underwent similar treatment and now confines his drinking to a monthly glass of beer.

Many forms of sexual deviation have been treated by behavior therapy. The most common of them — homosexuality — is one that seems susceptible to treatment by aversion. Fortyseven homosexuals have been so treated by Dr. K. Freund of the Karls University psychiatric clinic in Prague; it has also been used on several patients in Canada and England. "The principle of treatment,” explains Dr. Freund, “is to discourage homosexual activities and encourage heterosexual activities." Here is how this treatment works:

The patient is nauseated by an injection of apomorphine followed by

a drink of whisky. Then he is shown photographs and slides of men in various stages of undress, while the attending physicians suggest that the patient think of his past relations with men. Alternatively, the patient may be required to listen to a recording of his own voice in which he describes the erotic pleasures of his way of life. This goes on as long as the nausea lasts, usually about fifteen minutes. It is repeated every two hours, for two or three days.

After a few days phase two begins. After being given an injection of a male sexual stimulant, testosterone propionate, the patient is shown photographs or films of extremely attractive nude and semi-nude women. Delicious meals are served him. Comely nurses visit him. This continues for two days.

No general conclusions can yet be drawn about the efficacy of this treatment, but the outlook is promising. One of the first patients so handled by a Canadian clinic reports that six months later his homosexual urges have disappeared and he now has a steady girl friend. Dr. Freund reports that eighteen of his forty-seven cases have made a heterosexual adjustment for a short time or for several years. “The simplified treatment does not appear to be very different (in results) from other types of psychotherapeutic treatment.”

The aversion technique also seems to be surprisingly useful in a far different form of complaint—writer’s cramp. In many people who work with their hands, the working hand becomes useless because of trembling and seizure of the muscles. The problem can last for several years. Two doctors at the University of Manchester, England, built special “aversion” equipment that gave an electric shock to sufferers from writer's cramp when their hands seized up. Of seven people they treated, three were classified as completely cured and the remaining four as fifty to eighty-five percent better. Until their work, it had been assumed that writer’s cramp was largely emotional in origin and that the

hidden causes would have to be delved out of the unconscious before improvement could be hoped for.

Conditioning by aversion has also helped people stay on diets. A thirtysix-year-old woman found it impossible to avoid some tasty foods. Her physician. Dr. Joseph Wolpe of Witwatersrand University, South Africa, fitted electrodes on her left arm and told her to raise her right arm as soon as she had a clear image in her mind of one of the succulent foods denied hei. At the very second her arm went up. the electricity was turned on and remained on until the patient indicated she could no longer endure the discomfort. Ten such sessions were conducted. The end result'’ “The patient reported,” says Dr. Wolpe, “that on imagining any of the delectable foods she immediately had a feeling of fear and revulsion, accompanied by an image of the shock situation. The tendency to think of food diminished.”

Dr. Wolpe is the foremost exponent and practitioner of a behavior therapy technique known as reciprocal inhibition. The way it works can be simply explained: The patient’s neurotic

symptoms are triggered by a certain kind of anxiety-producing situation he encounters in his life. If at the same moment of the “triggering" incident you can present him with a different kind of situation, he will respond in a new and non-neurotic way. Using this procedure, in time the patient can be taught to substitute normal for neurotic behavior. Reciprocal inhibition has already successfully treated exhibitionists, child molesters, impotent men, and men and women with a variety of phobic fears.

The treatment of exhibitionists by

Dr. Henry Hutchison of the Forensic Clinic, Toronto, illustrates one way of applying this technique. The exhibitionist is a basically insecure personality: in the presence of women, under certain circumstances, tension steadily mounts within him until he can no longer endure it. The tension is only dissipated when he exposes himself and observes the terrified reaction of the woman. Dr. Hutchison says to each patient. “Recall the scenes or situations which so disturb you that you expose yourself.” Then, Hutchison induces a state of deep relaxation in the patient and has him visualize these "exposure - prompting” scenes. With repeated practice the patient can contemplate them calmly. Later, he can encounter situations in real life which formerly triggered him off and not react to them.

Relaxation also plays an important part in the behavior therapy approach to phobic fears — a neurotic condition where the individual has an abnormal terror of a situation, an animal or an object. It is estimated that some 250,000 Canadians suffer from this disability. The most frequent objects of such fear are high places, closed rooms, dogs and cats and snakes. Dr. Arnold A. Lazarus of Witwatersrand University has been getting remarkable results with phobics by treating them with relaxation, accompanied by a process of desensitization.

Dealing with acrophobia (fear of high places) Dr. Lazarus will have the patient prepare an anxiety hierarchy, which is to say a list of frightening situations going from the least to the most terrifying. A typical anxiety hierarchy for an acrophobic would read: Looking down from ten

feet . . . Looking down from twenty feet . . . Sitting on a thirty-foot ledge . . . Looking down a well . . . Seeing somebody dive from a fifty-foot board . . . Looking down from sixty-foot balcony, etc.

Lessons in relaxation now follow. After the patient has been helped to reach a state of deep relaxation he's asked to visualize the weakest item on the hierarchy and to put up his hand when he feels distress. When he can imagine any given scene tor ten seconds and remain unperturbed he’s allowed to proceed to the next item. In about three sessions, most patients manage to complete the entire list and are then ready to expose themselves to real life situations. D r. L a z a r u s claims that fifteen months after he had treated eighteen adult phobic patients in this way, ten of them were still cured, and that of a similar number of phobics treated by conventional group psychotherapy, none were cured.

Another form of reciprocal inhibition ( i.e. getting a non-neurotic response from the patient by providing a different stimulus) used by behavior therapists is assertiveness. Many patients display their neurotic symptoms when they're pressured by other people. They're driven to desperation by a domineering wife or a hypercritical boss but, previously trained not to talk back, they simply harbor their resentment. As a consequence, their anxiety level rises and ultimately erupts in the form of a nervous tic. a stammer, impotence or any one of a countless number of symptoms.

Recently, Dr. Harry Hutchison of the Forensic C linic was approached by a rather passive Englishman, thirty years old. He stated that he had been impotent for several months. A review of his home life suggested the cause: his mother disliked his wife, constantly belittled her and provoked quarrels between the couple. “Why don't you tell your mother to mind her own business?" Hutchison suggested. The Englishman was taken aback. He had always been afraid of his mother; it had never occurred to him to contradict her. Dr. Hutchison pointed out that the wife had every reason to be disappointed; that a man’s primary loyalty was to his wife, not his mother. “You must learn to stand up for yourself.” said the doctor. The patient was then given exercises in asserting himself in situations which were not too threatening. He was told to begin insisting on good service from elevator operators, bank tellers, store clerks, etc., even if it meant getting into arguments. He did so. Bolstered by his successes in self-assertion and supported by Dr. Hutchison behind the scenes, in time the patient was able to manage his mother. His anxiety vanished and his sexual ability was restored.

Dr. Joseph Wolpe used a similar approach in treating an extremely attractive woman of twenty-eight who came for help after a succession of unsuccessful romances. She was disturbed and tense, explaining. "All my men treat me with contempt and leave me." Dr. Wolpe soon found out why. Since childhood, she had been a habitually subservient person. In her affairs, she did exactly as she was asked to do. even though this often

led to resentment on her part. Starting with minor situations, in the course of thirteen interviews Dr. Wolpe coached her in how to be firm and independent in her dealing with others. His prescription worked. Within three months, she was married. A year later she reported that the relationship was highly satisfactory.

Perhaps the most revolutionary technique used by the behavior therapist is negative practice, by which is meant the active, conscious practising of habits which the patient wants to get rid of. While this procedure seems to defy common sense, it produces good results in such conditions as tics and stuttering. Theoretically, negative practice breaks up a habit by making the patient conscious of the deliberate steps involved in its execution. This makes it possible for him, ultimately, to voluntarily control it.

Eye - blinking tics are particularly susceptible to treatment by negative practice. At the clinic, the patient is seated in front of a mirror and told to blink in an exaggerated form for ten minutes or so. He is asked to repeat this procedure at home, two or three times a day. Gradually, the periods of deliberate blinking are increased until they reach a full hour. Following this program, Canadian patients have recently rid themselves of long - standing eye - blink tics in the course of a few weeks.

The beginning of a genuine science

Even more remarkable results have been obtained by Dr. A. J. Yates of the University of New England, New South Wales, Australia. One of his patients w'as an intelligent twenty-fiveyear-old woman whose life was being ruined by four tics of ten years’ standing: an eye-biink tic, a coughing tic, a nasal (“explosion") expiration tic and a complex stomach-contraction breathing tic. The patient attended three hundred and fifteen sessions during the next months, during which she practised one or another of her unwanted habits. At the end of this first period she wrote, “The nasal tic has almost vanished . . . The eyeblink tic and throat tic are sharply reduced in frequency. Only the stomach tic has changed little. I have improved in all departments of living. I am able to relax on a bus or train; 1 can now read and do crossword puzzles. Now that I have had a taste of success, I am not tired of treatment.’’

Negative practice is an integral part of the cure for stuttering. For some years Ernest Douglass, a University of Toronto speech therapist and director of the Speech and Communication Clinic, has encouraged stutterers to practise their habit freely and to carefully observe it. To help the patient discover the exact pattern of his stutter. Douglass has used practice in front of a mirror; slow-motion films of the stutterer struggling to speak. He has also paired off stutterers so that they could report on each other’s difficulty. “Stuttering voluntarily and knowing exactly w hat he’s doing, helps the stutterer exercise some control over his habit." says Douglass.

While practising in England, Douglass was the co-inventor of a piece of apparatus which is widely used by

behavior therapists in the treatment of bet wetting. Using the Davidson and Douglass invention, behavior therapists have been conspicuously successful in curing bedwetters. The apparatus is an electrically wired pad placed over the mattress. As soon as tw'o or three square inches of the pad become moist, a bell starts ringing and wakes the sleeper. Within two or three months, using this apparatus, most children cease wetting their beds, largely because they’ve learned not to.

It is much too early to make a definite statement about the future usefulness of behavior therapy or its efficacy compared to psychoanalysis and psychotherapy. But Dr. Cyril Franks of the New Jersey Neuro-Psychiatric Institute says, “The behaviorist approach must be taken seriously. No clinician can afford to dismiss it in a cavalier fashion." Behavior therapy appears to be a superior method of treatment in enuresis, stuttering and phobic fears. It shows promise in the handling of sexual deviations, tics, writer's cramp. It is now also being applied to psychosomatic illnesses — asthma, skin diseases, and hysterical blindness and deafness.

Psychoanalysis or psychotherapy can only help a small fraction of the people who have — or wdll have — severe emotional trouble. There will never be enough practitioners; it takes too long to train them. The treatment is too lengthy and too expensive, the results too uncertain. Furthermore, psychoanalysts can’t really help people who have trouble talking or understanding their language — and there are many, many of these.

The next step in finding out just how' much good behavior therapy can do, according to Dr. H. J. Eysenck, is to introduce new research on a massive scale. “We have the beginning," he says, “of a genuinely scientific system of treatment for behavioral disorders." And this, most scientists and many disturbed people agree, is a good deal more than we've ever had before. ★