Behaviorism Part III: Self-Directed Behavior Plans for Adults

Behaviorism doesn't have to be clandestine.

Many examples of behaviorism involve a scientist creating a hypothesis and implementing interventions outside of the subject's awareness. One example many students of psychology have heard is a college lecture on behaviorism - all the students agreed to look disinterested when the professor was on the right side of the lecture hall, and be overly enthusiastic when he was on the right. By the end of the class, the professor only stood on the right side - unaware both of the students' intervention and of the change in his behavior.

Likewise, in the hospital setting, where behaviorism has its most frequent use, and arguably utility, the patients frequently aren't in a place to hear and understand the behavior plan or why it is being implemented (though it is supposed to be collaborative and signed-off by the patient). In fact, many patients would intentionally go against it for various reasons. So the plan is often made behind closed doors by the treatment team.

I recall a hospital lecture by a behaviorist who talked about discussing the plan with his patients, and I recognized a feeling that somehow the "magic" would be lost. If the patient knew, would it work? Would they defy it adversarially? Or is that just a projection of my own feelings about authority?

In the outpatient setting, behavior plans are best made collaboratively. The onus is on the client to carry out the plan, and then we review in therapy, validating it's success (a form of reinforcement) and exploring why it might not have worked or what could be improved.

Behavior Planning with Adult Clients

Typically this begins with a client stating they'd like to make some behavior change, but have either been stuck or don't know how to gain momentum. A therapist may take any of several possible approaches from understanding depth related issues (psychodynamic or parts work, not particularly invested in whether the behavior change occurs), a cognitive therapist might do a walkthrough to identify distortions creating barriers, and a behavioral approach involves making a plan for reinforcement and/or punishment.

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From a behavioral perspective, I would want to know:

• What has worked, now or in the past

• What hasn't worked

• What are the barriers? A cognitive walkthrough - imagining from now to engaging in the behavior, what could pose a challenge - objectively, emotionally and cognitively.

  • Emotional barriers include depression (low mood and motivation), anxieties, and self-consciousness, embarrassment or shame. The latter could be fear about how you will look trying to run for the first time, but is often deeper: "what will people think simply that I am trying? What will they say when (if) I fail?"

  • Self-regulation: sometimes behavior change costs money, and many people don't have a forgiving budget, but most people can afford some investment in a health behavior change. So then the issue isn't budget as much as giving oneself permission to make a reasonable purchase. For example, if someone wants to take up running, they don't need top-notch running shoes, but can justify buying mid-quality ones or cross trainers (sneakers) that will do a good enough job.

  • Tangible barriers are ones to solve in therapy or planning. For example "I want to take up running, but it is objectively unsafe in my neighborhood."

• Define the goal behavior, possibly parsing this into reasonable and achievable steps

  • If these steps involve anxiety, a fear ladder may be used, rating sub-goals on a scale of 1-10, and targeting behavior change in the 4-6 out of 10 range. Last weeks 7-8 out of 10 naturally becomes next weeks 4-6 out of 10 as our anxiety decreases and confidence increases.

  • What is the frequency of the target behavior (daily? Twice a week?)

    • This might, and often should, involve some flexibility, such as saying "I'd consider it a success if I work out 5 of 7 days in a week." Often people who struggle with behavior change have paralysis by analysis, which is a side-effect or symptom of perfectionism: "if I can't do it perfectly, it is bad. If I have to do it perfectly, it is too overwhelming to start."

• Reinforcement:

  • Short term reinforcement

    • Pride in behavior change vs diminished self-respect

    • Accountabilibuddy incentivizes adherence to the plan and creates a sense of commitment or obligation, increases enjoyment by having a partner, and heightens stakes for not following through. An altered version is simply texting someone to confirm completed (or did not complete) the behavior. I've allowed clients to text me, such as "I did my morning walk today!"

  • Mid-length: This plan will be reviewed each session and people often want to present "good news" to their therapist.

  • Longer term:

    • Earning something, like each week they complete the target behavior at least 5-out-of-7 days, they allow themselves $20 toward something they wanted but wouldn't otherwise buy themselves.

    • Positive health outcomes, increased self-respect and confidence.

• Punishment: What do we do if we don't follow through with the behavioral goals?

  • Maybe not allowing a typical way we treat ourselves after a day at work, such as desert after dinner or guilty-pleasure binge-worthy TV series.

  • Referring to the longer-term reinforcement, I think of this as a wager (not that I encourage gambling!): if we don't earn $20 toward something we want to buy, then we need to donate that money to a charity.

• Tracking: a chart that lets the individual track their success (or failure) in making the identified behavior change. The nature of this chart will depend on the frequency of the behavior change (does it need to track daily behaviors, hourly behaviors?..)

References

Core Behaviorism & Operant Conditioning

• Skinner, B. F. (1938). The behavior of organisms: An experimental analysis. Appleton-Century.

• Skinner, B. F. (1953). Science and human behavior. Macmillan.

Applied Behavior Analysis (ABA) & Collaborative Planning

• Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1(1), 91–97.

• Cooper, J. O., Heron, T. E., & Heward, W. L. (2020). Applied behavior analysis (3rd ed.). Pearson.

Cognitive Walkthroughs & Emotional Barriers

• Beck, J. S. (2020). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press.

• Lewis, C., Wharton, C., Inman, C., & Rieman, J. (2005). The cognitive walkthrough method: A practitioner's guide. In Human-computer interaction (pp. 711–741). CRC Press. (Note: This methodology originated in usability engineering but aligns with clinical cognitive conceptualizations of step-by-step imagery/exposure planning).

Perfectionism, Behavioral Paralysis, & Flexibility

• Stoeber, J. (Ed.). (2017). The psychology of perfectionism: Theory, research, applications. Routledge.

• Twohig, M. P., & Levin, M. E. (2017). Acceptance and Commitment Therapy as a treatment for perfectionism. American Journal of Psychotherapy, 70(3), 273–287.

Anxiety Management & Fear Ladders (Systematic Desensitization)

• Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd ed.). Guilford Press.

• Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford University Press.

Social Accountability & Contingency Management (Reinforcement/Punishment)

• Gelkopf, M. (2017). The use of contingency management and token economies in mental health settings. International Review of Psychiatry, 29(4), 342–353.

• Higgins, S. T., Alessi, S. M., & Dantona, R. L. (2002). Contingency management in the treatment of substance use disorders: Trends in the literature. The Behavior Analyst Today, 3(3), 231–241.

• Latkin, C. A., Donnell, D., Metzger, D. S., Sherman, S., Aramrattana, A., Davis-Vogel, A., ... & Celentano, D. D. (2009). The role of social accountability and peer support in behavior change interventions. AIDS and Behavior, 13(4), 675–682.