Current Medical Diagnosis & Treatment in Psychiatry

Fundamental Assumptions of Learning Theory-Based Therapies

Several basic assumptions are common to most learning-based interventions. Perhaps most basic is that the behavior of the individual who has been referred for psychiatric treatment is of concern in its own right. Behavior is not necessarily an indication of pathology at some other level of analysis (eg, brain chemical or psychic). Moreover, pathologic behavior is often seen as the result of the demands of the environment in which the person is living, working, or going to school (or, in the case of the cognitive approaches, the person’s perception of the environment). What appears to be pathologic behavior may be a best-effort adaptation to an impossible situation given the person’s cognitive or personality limitations (eg, living with alcoholic parents, residing in an abusive institutional or community residential setting, interacting with people who don’t use the same communication system).

Although major mental illnesses have neurochemical substrates, much of the pathologic behavior observed by psychiatrists has been learned in much the same way that more normal-appearing behavior is learned, and pathologic behavior generally follows the same scientific laws as normal behavior. Vulnerability to learning pathologic behavior is shaped by the biological substrate of inherited traits and neurochemical predispositions upon which the collective history of experiences is imposed. Individual differences in normal and pathologic behavior are attributable to dispositions created by variations in genetic makeup or differences in histories that predispose an individual to differences in motivation. Some people, by virtue of their genetic and associated neurochemical makeup, are prone to respond to a wide range of mild, negative comments by other people as though such comments are aversive and are to be avoided at all costs. Others, with different genetic makeups and correspondingly different neurochemical predispositions, may be largely impervious to similar negative reinforcers and cues. The former individuals are prone to develop avoidant behavior patterns characterized by extreme anxiety problems, whereas the latter individuals will tend to be insensitive to aversive social situations.

In the early days of behavior modification and behavior therapy treatments, targets of treatment were often circumscribed responses (eg, nail-biting, failing in school, encopresis). Since then, researchers have recognized that narrowly defined instances of pathologic behavior (ie, presenting symptoms) are usually members of larger classes of problematic responses. The treatment task is not to treat the isolated behavior (eg, arguing with parents or making self-deprecating remarks) but rather to identify factors that determine the likelihood that any member of an entire class of responses may occur. Such factors could include, for example, the child having no legitimate mechanism for determining what is going on in his or her life, combined with parental submission to a variety of unpleasant, coercive responses. Failure to properly assess the full breadth of the members composing a functional response class will tend to lead to symptom substitution. For example, successful reduction of arguing by a defiant teenager by implementing a behavioral contract limited to arguing will, in most instances, lead to emergence of other defiant behaviors (eg, staying out beyond curfew, experimenting with alcohol). The task is to identify a broader class of problem behavior, develop hypotheses concerning the purposes served by that class of behavior, and then develop an intervention plan that makes that class of behavior ineffective and unnecessary.

Most of the causes of pathologic behavior are found in the relation between the individual and the environmental antecedents and consequences of his or her actions. An individual’s history creates the context within which current environmental circumstances serve as either discriminative stimuli (eg, a spouse coming home late from work) or conditioned negative reinforcers (eg, threatened disapproval). An individual’s history could also establish the motivational framework that governs most of the individual’s actions. As a result, assessment usually requires obtaining information from the individual or other informants about events taking place in the individual’s natural environment in order to obtain valid data concerning the circumstances surrounding the pathologic behavior. The meaning of an environmental cue or a putative motivating consequence is determined contextually. Whether a social stimulus is alarming, neutral, or positive will depend on the person’s history and the circumstance in which the stimulus is being experienced. Similarly, a consequence can be positive, neutral, or negative depending on the individual’s history and the circumstance in which the consequence is encountered. Thus Thorndike’s original Law of Effect has been contextualized. Whether this contextualization is conceptualized as residing in the cognitive domain or in the observable environment is a matter of some theoretical dispute, but the learning-based approaches emphasize the role of idiosyncratic experience in shaping the behavioral proclivities of any given individual.

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