Behavioral Therapy

Behavioral therapy uses behavior modification for the treatment of health problems. It makes a distinction between disease and illness, the latter referring to the sick role, that is, the socially determined behaviors that go with a disease and which may be as debilitating as the disease. Thus, therapy is focused on changing the sick role behaviors. A behavioral therapy known as systematic desensitization, introduced by Wolpe (1958), has become one of the most common treatments of phobias. Other examples of behavioral therapy include aversion therapy (Panconesi, Gallassi, Sarti et al., 1999) as well as the development of problem-solving skills, stress inoculation (Beck and Fernandez, 1998), social skills training, marital therapy, and reinforcement (Bowers and Clum, 1988).

The expected outcome of behavioral therapy is documented changes in actual behavior (Lipsey and Wilson, 1993). Frequently, behavioral therapy is focused on behavioral risk factors, such as smoking, that are thought to be causally related to illness (Garrick and Loewenstein, 1989). A clean definition of behavioral therapy is complicated by the fact that it is frequently combined with cognitive approaches and will include relaxation and biofeedback.

Biofeedback

Biofeedback provides information to a patient about a targeted physiologic process that enables the individual to control that process (Wald, 1981) through mental activity (Stamatiadis and Polimeneas, 1997). Consequently, the patient gains voluntary control over processes that may not be consciously monitored. A form of psychophysiological self-regulation (Green and Shellenberger, 1999), biofeedback usually provides a patient with visual or auditory signals that can supply information about minute physiologic changes and the intensity of functions. These signals also give instant feedback to the patient on their efforts to control or alter the target function. Biofeedback has been used to teach muscle control and to modify autonomic dysfunction associated with blood pressure, pulmonary, and vascular disease (van der Plas, Benninga, Buller et al., 1996). Biofeedback is frequently used as an adjunct to other therapies. For at least one author (Olson, 1995), biofeedback excludes physiological self-regulation that does not use external instrumentation and feedback (such as relaxation therapy, hypnosis, meditation, and imagery).

Schwartz and Schwartz (1993) describe five different types of biofeedback:

1. Electromyographic (EMG) biofeedback -- measures muscle tension.
2. Thermal biofeedback -- measures temperature of skin.
3. Electrodermal activity (EDA) -- measures minute changes in sweat activity..
4. Finger pulse -- measures pulse rate and force.
5. Breathing -- measures breathing rate, volume, rhythm, and location (chest vs. abdomen).

Cognitive Therapy

Cognitive therapy is based on the principles of cognitive psychology. Cognition refers to people's thoughts -- in particular, to the way people think about their illness -- which can have a profound effect on their physical state. Cognitive therapy involves such techniques as cognitive preparation and cognitive reframing through the use of cognitive self-statements (Beck and Fernandez, 1998). It is most frequently combined with behavioral therapy -- and as such often identified as cognitive-behavioral therapy (CBT) -- but it is also combined with relaxation and guided imagery.

An example of cognitive therapy might involve a patient identifying triggers for anger, using cognitive training to redefine the triggers, and then practicing this cognitively until the response becomes automatic. These techniques lead to a cognitive reappraisal or restructuring of how a patient thinks about the problem and, it is hoped, about the negative behavior. This therapy is based on the premise that behavior is rooted in a person's cognitive appraisal (i.e., one's definition) of events. Once the meaning of an event has been established, it becomes associated with an emotional reaction and a behavior (Schrodt and Tasman, 1999). Cognitive changes are seen as necessary for behavioral changes. Assessing risk and benefits and then initiating an action, for example, would constitute cognitive activity. By identifying the cognitive schema by which an individual gives meaning to an event, the therapy can attempt to alter the cognition. For example, to view illness fatalistically lessens the concept of self-efficacy; that is, the ability to act on things and change outcomes, a quality needed for illness prevention. Much of cognitive therapy involves enhancing the patient's ability to monitor his or her thinking and to develop alternative ways of thinking about an issue.

Guided Imagery

The most common form of imagery used in therapy is guided imagery, where a patient is asked to deliberately focus on a particular image to either “relax, manage stress, or alleviate a specific symptom” (Sobel and Ornstein, 1996). Key to this therapy is that the patient is in control of the image and can redirect it. The image does not have to be physiologically true, as in the case of a cancer patient imagining being free of cancer, or even real in the sense that the patient has or would ever experience what the image depicts. Imagery may be just simple visualization or sensory perceptions such as smell, touch, and sound (Rossman and Bresler, 2000). Although imagery uses the conscious mind, it may also be utilized to tap into the unconscious or less conscious mind.

Hypnosis

It is difficult to define hypnosis partly because it “remains exceedingly vague and continues to be used in contradictory ways by different investigators” (Spanos, 1991, p. 644). Furthermore, the term hypnotherapy has been applied to a wide range of therapies. Hypnosis is characterized by an “artificially induced state” of mind (Benson, 1989) and increased suggestibility, and it usually includes suggestion of relaxation and drowsiness. Hypnosis may be either self-induced or brought on by the therapist. The psychological state associated with hypnosis is referred to as a trance state (Spanos, 1991). This is a “waking state in which the subject's attention is detached from his immediate environment and is absorbed by inner experiences such as feelings, thoughts and imagery” (Heap, 1996, p. 515).

Achieving the trance state, referred to as hypnotic induction, is often accomplished through a series of exercises, such as relaxation exercises, eye closure, induced drowsiness, etc. While in the trance state, the patient is thought to be more responsive to suggestions made by the therapist or, in the case of self-hypnosis, to self-direction. Suggestions may take effect immediately or at some later time. Hypnosis may also cause involuntary changes in perception, memory, and mood, and these changes have both biological and behavioral consequences (Wickramasekera, 1999). Those successfully hypnotized show distinct EMG patterns, and some individuals may be able to recall data not easily accessed by the conscious mind (Saichek, 2000).

In general, there are two major groups of therapists that employ hypnosis. The authoritarian hypnotist imposes both the trance state and the resolution of a problem on the patient using prepared inductions (Saichek, 2000). The Erickson hypnotist does not believe the trance state alone will create changes and does not seek to impose changes on the patient; instead, the patient retains the power and the resources to solve his or her problems.

For most of its history, hypnosis has been surrounded with controversies and disputes. For some writers there is no scientific definition of hypnosis that would distinguish it from a “relaxed but aware state” (Logue and Edwards, 1998). Hypnosis is clearly related to relaxation exercises and makes extensive use of imagery.

Meditation

Harvard's Herbert Benson, M. D., was the first to report the physical effects of meditation (Benson, Beary, et al., 1974). He observed that after 20 minutes of meditation, a participant's heart rate, breathing rate, blood pressure, and oxygen consumption decreased, while skin resistance increased and blood flow was altered. For some adherents, meditation therapy is a technique for emptying the mind; for others, it is “the intentional self-regulation of attention, a systematic focus on particular aspects of inner or outer experience” (Astin, Shapiro, and Schwartz, 2000, p. 73). Meditation often involves arresting “awareness in the present moment without struggle or wandering” (Baime, 1999).

There are two general forms of concentration methods. The first focuses the mind on a specific thing or act, such as breathing and posture, as exemplified by yoga. The second is known as “mindfulness practices,” a meditation technique that empties the mind. Attention is not restricted to any one object or act “but rather attends to any and all sensations, perceptions, cognitions, and emotions as they arise moment to moment in the field of awareness” (Astin, Shapiro, and Schwartz, 2000, p. 73). Mindfulness meditation is achieved in a variety of ways, but it usually involves intense concentration on such things as breathing or on a mantra, which is a sound repeated over and over (Vickers and Zollman, 1999). Mindfulness meditation has its origins in Buddhist meditation and was introduced into the medical setting in 1979 by Jon Kabat-Zinn, founder of the Stress Reduction Clinic at the University of Massachusetts Medical Center (Kabat-Zinn, 1993; 1996). The goal of this technique is to have the participant become more aware, more in touch with what is happening within one's body and mind in the present moment. This modality has been used to treat anxiety (Kabat-Zinn, Massion, Kristeller et al., 1992) and pain (Kabat-Zinn, Lipworth, and Burney, 1985).

Mindfulness meditation is one of several recognized forms of meditation; another is transcendental meditation. Practically all forms induce a state of deep relaxation (Baime, 1999). Although meditation was historically associated with religious or spiritual movements, this is no longer always the case.

Placebo Therapy

A placebo is defined as an inert or innocuous treatment that works not because of the therapy itself but because of its suggestive effect. It is considered a mind-body modality, but with some distinct differences. Placebo therapy depends on the power of a patient's belief that the therapy will be effective (Goleman and Gurin, 1993). The fact that placebos work at all is strong evidence in favor of mind-body therapies, particularly when the outcome measures are not subjective, for example, urinary flow rate or blood glucose levels. However, placebo poses another challenge for mind-body therapies: the extent to which they provide any effect beyond that provided by placebo.

Mind-body therapy attempts to harness the same forces that make placebos work. The difference is that placebos are generally considered to have nonspecific effects. For researchers, the placebo effect is viewed as experimental static (Goleman and Gurin, 1993), a form of background noise. It can simply result from the impact of the therapeutic encounter; from the interpersonal relationship between the patient and the practitioner (Bowers and Clum, 1988); or from the patient's awareness of being in a clinical situation (Garcia-Alonso, Guallar, Bakke et al., 1998). The distinction between other kinds of mind-body therapies and placebo, therefore, is that the former intend a specific result, the latter a nonspecific one. However, both interventions rely on the same mechanism -- the mind -- for effect.

Placebo can be considered in two distinct ways. First, it can be seen as something inherently present in all interventions and the result simply of an intervention being made (similar to the Hawthorne effect whereby observing behavior causes the behavior to change). Second, placebo can be used intentionally as a therapy when, for example, a practitioner gives a patient an inert substance known to the practitioner but not to the patient. This is the classic sugar pill that results in a surprisingly large number of recoveries, usually around 30 percent, for a wide range of conditions (Goleman and Gurin, 1993). In this review, we focused on placebo in the second sense; that is, as a deliberate mind-body intervention.

Relaxation Therapy

The object of relaxation therapy is to help the patient enter a relaxed state through the use of specified techniques, such as imaging, breathing exercises, biofeedback, and yoga. Relaxation is primarily directed at muscles, either muscles in general or a specific set of muscles. It may also be achieved by inducing physical sensations, such as warmth, in different parts of the body (Vickers and Zollman, 1999).

Relaxation therapy takes advantage of the body's natural relaxation response, which is the opposite of the fight-or-flight response that causes stress (Sobel and Ornstein, 1996). By refocusing the mind, an individual can induce the relaxation response and trigger physiological changes, including slower heart rate, slower breathing, lower blood pressure, and lower metabolism, as well as muscle relaxation (Sobel and Ornstein, 1996).