Behavioral Therapy and Behaviorism

The definition of the behavioral model of psychotherapy is characterized by a debate on the terms behavior modification and BT. Some authors argue that the term behavior modification refers to both BT and applied behavior analysis, the latter being the study of behavior and the variables that give rise to it. In other words, behavior modification is the application of the principles and laws of learning to any setting (school, clinical, family) and carried out by any person (teachers, family, social work professionals, etc.). For its part, BT is the application of behavior modification techniques to dysfunctional behaviors in the clinical context by psychology professionals (^{Eelen, 2018}; ^{Martin & Pear, 2007}). On the other hand, other researchers defend and use both terms without distinguishing between the two (^{Ruiz et al., 2012}). During this paper, the two terms will be used as synonyms.

Having clarified the previous point, it is important to understand the origin and definition of behaviorism before fully introducing BT. Skinner defined behaviorism as the philosophy of the science of human behavior, as opposed to a general thought that categorized it as the science of human behavior. In other words, for Skinner, psychology as a science has human behavior as its object of study, and its philosophical approach is behaviorism. In his book About Behaviorism, Skinner differentiates between two types of behaviorism (^{Skinner, 1974}):

It should be noted that both types of behaviorism include the learning principles of operant and classical conditioning. It is the experimental work derived from the postulates of these two branches of conditioning that gave rise to BT. On the one hand, the experiments of ^{Watson (1913)} and, especially, Pavlov (1917) on conditioned reflexes gave rise to the theory of classical conditioning, used by Wolpe (1958) in his studies that led to the development of systematic desensitization. The latter is now recognized as the first empirically validated treatment of BT, showing particular efficacy for the treatment of specific phobias (^{Vallejo-Slocker & Vallejo, 2016}). In the same decade, the behavioral model was consolidated, and BT emerged within the clinical context as opposed to the psychoanalytic therapeutic model. The work of ^{Eysenck (1952)} is well known, in which after comparing the effects of psychoanalytic or eclectic therapy with patients who did not receive treatment, it was found that the effects of the prevailing psychotherapy at that time were no better than not receiving psychological treatment. This was a serious blow to psychoanalysis. This same author, together with his research team, examined the efficacy of behavioral techniques such as exposure for neurosis, phobias, agoraphobia, and other psychological problems (^{Ruiz et al, 2012}).

On the other hand, the contributions of operant conditioning to BT come mainly from Skinner. His major contributions are the study of conditioned operant behavior, applied behavioral analysis, functional analysis of behavior, and the pragmatic circularity between the two (^{Fuentes & Quiroga, 2004}). Today, its contributions are still latent in many problems (e.g., addictions to new technologies) and topics (e.g., behavioral economics; ^{Pérez-Álvarez, 2021}). Thus, BT was consolidated as a contextual and ideographic model, where techniques such as reinforcement, punishment, token economy, behavioral contracts, exposure techniques, etc., stand out.

BT has shown its effectiveness in the treatment of different psychological problems: specific phobia (^{Orgilés et al., 2002}), depression (^{Sanz & García-Vera, 2017}), and social anxiety disorder (^{Baeza, 2007}). A study by ^{Echeburúa et al. (2010)} highlights the effectiveness of BT and its different techniques for social phobias, specific phobias, agoraphobia, PTSD, OCD, relationship problems, sexual dysfunctions, alcoholism, and enuresis. In addition, the guide of effective psychological treatments (^{Pérez-Álvarez et al., 2003}) includes behavioral treatments such as community reinforcement approach (CRA), family and couple behavioral therapy, CRA and incentive therapy in contingency management for cocaine addiction, contingency management in methadone programs, in vivo exposure for specific phobias, exposure and response prevention for OCD, among others.

Criticism of Behavioral Therapies

One of the great generalized criticisms of BT is its "denial" or "inability" to work on the cognitive components of psychological problems. However, if one starts from radical behaviorism, behavior modification also takes cognitions into account, working on thoughts as covert behaviors. While it is true that Watson absolutely rejected the study of private events, ^{Skinner (1974)} ruled that private events should not be rejected, but that they constitute an element that is only observable by the person himself, so that it is this person, being unobservable by outsiders, who has the duty and task of recording the occurrence of that behavior. These events would be nothing more than covert behaviors that would follow the same laws of learning as visible operant behaviors. Today, radical behaviorism maintains that psychology is the science that studies human behavior, including everything that a person feels, does, and thinks (^{Froxán-Parga, 2020}).

On the other hand, ^{Upper and Cautela (1983)} show an example of how to work with covert behaviors. They propose the use and application of the principles of classical and operant conditioning in symbolic representations, working through the imagination on behavioral change in reality. This technique is inspired by systematic desensitization.

Another major criticism is that its application is not very effective beyond anxiety disorders, especially for problems such as depression. However, there are multiple studies that dismantle these criticisms. On the one hand, BT could be at least as effective as CBT for the treatment of depression (^{Echeburúa, 1998}).

Finally, Albert ^{Bandura and Richard Walters (1977)} indicated that the learning principles of behaviorism are insufficient to explain the acquisition of completely new behaviors and that some behaviors are learned without being directly experienced by the person. In this sense, he proposed his theory of social learning, and with it his main technique, modeling, based on the same principles of reinforcement and punishment proposed by operant conditioning, but with the inclusion of a new element: a model. His proposal is that learning can be consolidated on the basis of the observation of the reinforcers or punishments that a model receives for his/her behaviors and, on the basis of these, the individual will decide whether or not to carry them out. From the theory of social learning various relevant techniques in current psychotherapy are derived such as, for example, modeling and training in social skills. Furthermore, it was an important revolution for two reasons. On the one hand, it introduced cognitive variables (attention, memory, and motivation) and highlighted their importance in acquiring and developing new behaviors. On the other hand, it was a relevant reference for the development of cognitive-behavioral therapies.

Third Generation Therapies and Functional Contextualism

The criticisms and limitations of CBT, despite its undoubted quality and efficacy in the treatment of many psychological disorders, led to the emergence of what has been called a new "wave" or generation of BT. Contextual therapies combine strategies from first-generation therapies, more oriented towards the history and circumstances of the person, and second-generation therapies, with greater emphasis on the cognitive component (^{Hayes & Hofmann, 2021}). In fact, the greatest exponent of these, acceptance and commitment therapy (ACT), focuses on the functional analysis of verbal behavior, and has its origin in radical behaviorism. ACT is based on relational frame theory, which is based on Skinner's studies on verbal behavior and considers thoughts as behavior.

Third generation therapies are based on functional contextualism as a philosophical model (^{Hayes, 1993}). This philosophy of science arises from the postulates raised about behavior in the radical behaviorism of Skinner and other authors. This new approach is based on the idea of incorporating more optimally the empirical emphasis in the analysis of behavior, being more "contextual" than, for example, radical behaviorism itself as it does not contemplate the pragmatic component that describes it (^{Gifford & Hayes, 1999}; ^{González-Terrazas, 2021}).

Within this group are encompassed: ACT, dialectical behavioral therapy, behavioral activation therapy, functional analytic psychotherapy, integrative behavioral couple therapy, and mindfulness-based cognitive therapy (^{Luciano & Valdivia-Salas, 2006}; ^{Mañas, 2007}). The word context takes on a different meaning depending on the selected therapy. Thus, ACT and mindfulness-based cognitive therapy focus on change in the socio-verbal context, that is, the person as a subject who learns to control and experience his or her feelings according to the rules of language. On the other hand, the context of the therapeutic relationship (functional analytic psychotherapy) refers to the clinical space in which the patient and the psychologist develop the therapy as a source of experience and learning. Finally, the context as environment (behavioral activation therapy and integral behavioral couple therapy) is that in which the individual and his/her behaviors develop with his/her environment (^{Pérez-Álvarez, 2006}). Because it focuses the axis of psychological change in the context, these therapies have been called "contextual therapies".

The efficacy of this type of therapy varies depending on the problem presented by the patient. For example, behavioral activation therapy has shown efficacy for the treatment of depression (^{Barraca, 2016}) as well as for depressive and anxious symptomatology in cancer patients (^{Fernández et al., 2011}). For its part, ACT is effective for the treatment of social phobia, being equally as or more effective than CBT (^{García-Pérez & Valdivia-Salas, 2018}). It has also been shown to be effective for depression, work stress management, psychotic symptomatology, obsessive-compulsive patterns, anxiety disorders, drug and tobacco use, multiple sclerosis, psycho-oncology, trichotillomania, fears and worries, diabetes, epileptic episodes, chronic pain, and self-injurious acts (^{Luciano & Valdivia-Salas, 2006}). Dialectical behavior therapy shows efficacy for the treatment of borderline personality disorder (^{Soler et al., 2016}). Integral couple therapy is effective for the marital clinic, assuming an improvement in emotional acceptance with respect to classical BT. Some of these therapies, such as ACT and dialectical behavior therapy, include mindfulness in some of their cases, which-while it seems to be an effective complementary technique for depression and anxiety (^{Pérez-Álvarez, 2014})-has not yet proven its efficacy on its own (^{Martín-Orgilés & Sevilla, 2014}).

Based on BT, a new perspective for the development of psychotherapy, process-based therapy (PBT), has been described (^{Hayes & Hofmann, 2018}). PBT consists of employing evidence-based procedures in accordance with processes that operate in a specific way in the context of each individual, aiming to solve problems and promote well-being. In this way, a series of common processes are proposed that interact with each other and give rise to the different problems observed in the clinic. Motivational, attentional, and emotional processes, the self (understood as the individual identity emphasizing its language), the behavioral repertoire of coping and cognitive defusion constitute the core processes of PBT (^{Hayes et al., 2021}). These processes could serve as common bridges between different perspectives within CBT (^{Hofmann & Hayes, 2019}). PBT represents a paradigm shift from the previous paradigm based on diagnostic labeling and symptom enumeration (^{Hayes et al., 2021}).

Discussions and Conclusions

It is important for a science to have a clear object of study, just as in medicine it is the health and illness of the human being. However, in psychology, this is not the case. The great debate about cognitivism (introspective psychology, focused on internal processes and more attached to the medical model) and behaviorism (empirical psychology, focused on the observable and in favor of a contextual model), which seemed buried in favor of cognitivism and mental processes (^{Zumalabe, 2012}) is beginning to resurface, thanks, in part, to those known as contextual or third-generation therapies (^{Pérez-Álvarez, 2014}). However, as long as this debate persists, it seems that it will be complicated to unify psychology under a single theoretical framework. This can be both positive and negative. On the one hand, it is positive that psychology is not reduced to a single explanatory theoretical framework. However, the non-delimitation of its field of study, and thus of its basic theoretical frameworks, can lead to problems due to psychological treatments that are not empirically validated. There is no doubt that CBT is currently the psychological technology that has the most empirical evidence, and this is confirmed in the most important guides to effective psychological treatment (^{Fonseca-Pedrero, 2021a}, ^2021b; ^{Pérez-Álvarez et al., 2003}). In other guidelines (APA, NICE, Cochrane, etc.) there is a notable presence of behavioral therapies, and every day contextual therapies increase their empirical evidence. BT, with its three generations, seems to be positioning itself as the psychotherapy with the most empirical evidence, above others derived from psychoanalytic, humanistic, and systemic models (^{Fonseca-Pedrero, 2021a}, ^2021b; ^{Moriana et al., 2017}).

However, some authors would strongly disagree with this statement, and the fact is that in the world of psychology there is what’s known as the "Dodo bird enigma" which, taking the story of Alice in Wonderland, argues that none of the major psychological therapies can be discarded, as they all have a similar level of efficacy (^{Fernández-Hermida & Pérez-Álvarez, 2001}; ^{Pérez-Álvarez, 2019}). However, not all psychology professionals agree with this metaphor, with some being neutral (^{González-Blanch & Carral-Fernández, 2017}) and others totally against it (^{Hofmann & Lohr, 2010}). Although it is important to defend a psychology that is different from the medical model, characterized by diagnosis and the elimination of symptoms, it is important to recognize the contributions that such a model could make within psychology, such as, for example, the development of guidelines for effective psychological treatments (e.g., ^{Fonseca-Pedrero, 2021a}, ^2021b; ^{Pérez-Álvarez et al., 2003}). Although psychology should not be based purely on the diagnosis and elimination of symptoms, it should take an example from other disciplines in knowing how to differentiate between what is effective and what is not, and also why it is effective, and it should make this information available to the professionals in the field.

Although the philosophy of BT is contextual, in its first and third generation, it has been proven to be effective for the treatment of various psychological problems, appearing in numerous guides of effective psychological treatment. Therefore, it should not be understood that effective treatment guides, as well as evidence-based psychological treatments (EBPT), are allies of the medical model. Rather, they should be considered allies of science-whether contextualist or natural-and, therefore, of public health.

In short, and to conclude the paper, psychology should perhaps be a little more rigid and adhere to EBPT, discarding or minimizing the visibility of those psychotherapeutic interventions that do not have sufficient scientific evidence or that are developed based on questionable theoretical frameworks. Therefore, and in response to the title of the paper, there seems to be evidence that BT, and its three generations, are the ones that have demonstrated the most scientific evidence, any one of them constituting EBPTs for different problems. As far as behaviorism is concerned, it seems that after a long lethargy under the dominance of the cognitive, the behaviorist movement within psychology has begun to re-emerge, led by contextualist therapies. However, first generation behavioral therapists are also claiming the validity of behavioral theories and techniques in the clinical context (^{Froxán-Parga, 2020}). This paper does not aim to give an answer or position any of the generations of BT above the others, while as a whole it is the therapeutic model with the greatest empirical background in psychotherapy. The aim is simply to establish links between the different generations of behavior therapy, to reflect on the validity of behavioral theory, which was the basis and origin of behavior therapy, in the current clinical context.