J. Behav. Thcr. & Exp. Psychiar. Vol. 2, pp. 219-221. Pergamon Press, 1971. Printed in Great Britain.

THE ROLE OF BEHAVIOR THERAPY IN TEACHING MEDICAL STUDENTS

W. STEWART AGIL&

Department of Psychiatry, University of Mississippi Medical Center 2500 North State Street, Jackson, Mississippi 39216

Summary-The relationship between three behavior therapies and the experimental behavioral sciences is examined in order to define the role of this therapeutic development in teaching medical students. It is concluded that behavior therapy is one of the few media within which the relevance of the experimental behavioral sciences to clinical medicine can be demonstrated.

THERE are two ways of looking at behavior therapy which I will examine before considering the role of this newcomer in the teaching of medical students. The Crst views behavior therapy as a collection of therapeutic procedures lumped together partly due to their derivation from experiments in learning, partly for convenience, and partly because their originators felt that they belonged within this group. The second views behavior therapy as a vehicle for the application of the experimental behavioral sciences to the psychiatric clinic. These sciences at present are experimental psychology and social psychology, but may come to include others such as sociology, economics, or political science.

These two views of behavior therapy are very different and divide along the lines of applied basic science and clinical technique. Both have their problems. Basic science applied to the clinic, while correct scientifically, often leads to the investigation of increasingly irrelevant details. Myriads of Ph.D. theses attest to this. On the other hand, a technique-oriented approach often leads to a dogmatic clinical orientation not amenable to logical change, a defect which has plagued the practice of psychotherapy for years.

To clarify the situation I will examine the

relationship of three behavior therapies to the experimental behavioral sciences, namely shaping, systematic desensitization, and im- plosion. Shaping directly applies a procedure studied in the animal laboratory (selective positive reinforcement) to the clinic (Skinner, 1938). The classical animal experiment involves depriving an animal of water, food, or access to stimulation and then arranging a task which provides access to these things. The token economy (Ayllon and Azrin, 1968) is a direct extension in man except that a good deal more variability is possible in what patients will work for: food, snacks, cigarettes, candies, walks, ward privileges, visits home, money, and even access to a psychotherapist have all been used to successfully shape and maintain new and more healthy behaviors. These events can be quantified and reinforcement can be delivered promptly and on any schedule in the form of a token. A more distant analogy is in the use of social reinforcement such as praise or social attention. Evidence (Agras, Leitenberg and Barlow, 1968; Agras et al., 1969) suggests that such events are reinforcing, at least to some patients, but problems in quantifying praise are enormous as are those of controlling the more complicated social interaction in which praise must be delivered. Whether praise will be found

*Requests for reprints should be addressed to W. Stewart Agras, Department of Psychiatry, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216.

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220 W. STEWART AGRAS

to follow the rules of other reinforcing events is yet to be determined. Such questions should not of course be viewed as disappointing but as challenges to our understanding of human behavior.

Systematic desensitization is a more complex case. In his original animal experiments, Wolpe (1958) found that feeding cats in a series of situations approximating one in which the animal had been punished led to the disappear- ance of “neurotic” or escape behaviors, This was a basic experiment. Recent evidence (Nelson, 1966) suggests that the mechanism was neither the feeding nor graduated approach but exposure to the feared situation. In formulating clinical desensitization, however, Wolpe took a great conceptual leap and equated imaginary with real exposure and relaxation with feeding. This leap strained the relationship with the original animal work and made for difficulties in experimentation when treating imaginal events as stimuli. Nevertheless, these difficulties have stimulated much research into such areas as the efficacy and mechanism of action of desensitiza- tion, the defining and quantifying of relaxation, the contribution of therapeutic instructions or patient expectancy to desensitization, and the efficacy of imagined versus real exposure to feared situations. While desensitization has been shown to work better than some other forms of therapy (Gelder, Marks and Edwards, 1968; Gelder and Marks, 1968; Marks, Gelder and Edwards, 1968), how it works is still an issue at the very frontier of research. Solution of this problem may lead us to the formulation of a general principle in modifying deviant human behavior.

Finally, implosive therapy (Stampfl and Lewis, 1967) is even more difficult. It is based on the procedure of extinction where repeated presentation of a stimulus, e.g. a light that has been paired with shock, will lead to extinction of avoidance behavior associated with the light. From this, Stampfl assumed that full strength presentation of anxiety arousing cues in imagination would lead to extinction of anxiety. Moreover, in the formulation of cues which

elicit anxiety, hypotheses based on psycho- dynamic principles are used. Here then, the relationship between the original experimental procedures and the clinical procedure is even more distant, based, it seems, more upon analogy than fact and the procedure itself carried out within a very complex interpersonal situation.

Thus, at one end of a spectrum we have the direct application of a procedure derived from animal experiments and at the other a clinical procedure with a hypothesized relationship to basic research. In the middle seem to lie applied psychology and research into the mode of action of psychotherapy.

Now what of all this should we teach to medical students and in what way? Most important, in my opinion, is to teach the application and relevance of the experimental behavioral sciences to the clinic. This fits well with teaching in other medical school depart- ments, and in this model behavior therapy becomes a medium for the teaching of applied basic science. A very important medium, how- ever for it is one of the very few demonstrable applications of the basic behavioral sciences to the clinic. I suggest then, that we can firstly teach medical students the relevant findings of the experimental behavioral sciences as they increase our understanding of both normal and deviant human behavior. Here principles and procedures derived from classical conditioning, operant conditioning, cognitive psychology, and social psychology such ’ as modeling procedures have great relevance. These may be taught in conjunction with principles from other behavioral sciences such as sociology, e.g. where the development of role behavior is being considered.

Secondly, we can teach methods of observing and measuring deviant human behavior. Here the establishment of reliability of observation is important, as are methods of increasing reliability such as precision of response definition. This can be taught either theoretically or within a practicuum, or both, and again parallels methods from other disciplines in

medicine while demonstrating that behavioral observations can be made with high reliability under some circumstances.

Thirdly, and most important to psychiatry, is the application of the experimental behavioral sciences to changing deviant human behavior. Here I believe that the experimental analysis of the individual case can be taken as a clinical paradigm. In this procedure a variable modifying a particular behavior is introduced, removed and reintroduced, while objective and reliable measures are being taken. This pulls together the theoretical experiences of the first two approaches and teaches a particular technique of observation and behavioral analysis, making the point that therapeutic progress can be checked even in the individual patient and teaching the student inquiring behavior rather than acceptance of traditional therapeutic dogmas, an important attitude for students of medicine to acquire, for dogma is the basis of much that we do.

Finally, behavior therapy provides research opportunities for medical students during electives or summers, an excellent opportunity for the more interested student to become engaged in relevant inquiry. For there is no doubt that the field of behavior modification is now at the frontier of research in psychotherapy.

The timing and the details of such a syllabus are matters of choice, but I trust that I have made the point that application of the behavioral sciences to the clinic is the message while behavior therapy is the medium.

REFERENCES AGRAS W. S., LEITENBERG H. and BARLOW D. H. (1968)

Social reinforcement in the modification of agora- phobia, Arch. Gen. Psychiur. 19,423427.

AGRA~ W. S., L~TENBERG H., BARLOW D. H. and THOMSON L. E. (1969) Instructions and reinforcement in the modification of neurotic behavior, Am. J. Psychiut. 125, 1435-1439.

AYLLON T. and AZR~N N. (1968) The Token Economy. Appleton-Century-Crofts, New York.

GELDER M. G., MARKS I. M. and WOLFF H. H. (1967) Desensitization and psychotherapy in the treatment of phobic states: A controlled enquiry, Brit. J. Psychiat. 113, 53-73.

GELDER M. G. and MARKS I. M. (1968) Desensitization and phobias: A crossover study, Brit. J. Psychiat. 114, 323-328.

MARKS I. M., GELDER M. G. and EDWARDS J. G. (1968) Hypnosis and desensitization for phobias: A con- trolled prospective trial, Brit. J. Psychiut. 114, 1263-1274.

NELSON F. (1966) Effects of two counterconditioning procedures on the extinction of fear, J. Comp. Physiol. Psychol. 62,208-213.

SKINNER B. F. (1938) The Behavior of Organisms. Appleton-Century-Crofts, New York.

STAMFL T. G. and L~vrs D. J. (1967) Essentials of implosive therapy: A learning theory based psycho- dvnamic behavioral therauy. J. Abnorm. Ps~chol. 7i,496-503.

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WOLPE J. (1958) Psychotherapy by Reciprocal Inhibition. Stanford Univ. Press, Stanford.

THE ROLE OF BEHAVIOR THERAPY IN TEACHING MEDICAL STUDENTS 221

(Received 28 May 1971)