Basic Behaviour Therapy
by Amy Henehan, ND
The easiest practice for a healthcare practitioner is to simply prescribe a treatment to their patient, sit back, and hope it resolves their health issue. Studies in behaviour therapy, however, suggest that we can really stand to make a long-lasting difference if we first take the time to delve a little deeper into understanding the patient’s everyday life.
Whether it’s a recommendation for a new supplement regimen, a lifestyle or a dietary change, there is more involved in creating lasting behaviour modification than simply dictating “shoulds” and “musts” regarding what to do or not to do for one’s health. Successful long-term outcomes are much more likely to result when we plan small, stepwise alterations that are integrated into the patient’s everyday life. Taking the time to implement treatment directly into the patient’s natural environment can increase the chance that healthy behaviours will continue beyond the treatment period and for the foreseeable future (1).
Going Beyond to Improve Adherence
Naturopathic doctors follow a sort-of guide that helps prioritize which types of interventions should be recommended before others. As a rule, this guide, referred to as the ‘therapeutic order’, prioritizes minimally invasive therapies that support the body’s natural healing abilities before any potentially invasive treatments, such as medication or surgery. Ultimately, no matter what type of health practitioner is providing the care, the least invasive therapy or intervention one could implement to usher in a change for one’s health, is healthy lifestyle habits – specifically diet and exercise recommendations. For the most part, we all need to eat and move our bodies, so learning how to do so optimally can really have an impact on our health outcomes.
Telling someone to eat healthy or exercise sounds simple, but the problem is this: most people already have a sense of what healthy eating looks like and know that exercising is good for them. They already know that if they did what was good for them, they would be closer to achieving their health goals. So, the question becomes “why aren’t they doing it?” and furthermore, “how can healthcare practitioners help them do it?” In cases such as this, it isn’t merely a lack of knowledge of what’s best; rather it’s a difficulty incorporating or adhering to lifestyle changes that have been recommended to them.
Some reasons why people might not do what they know is good for them:
What is behaviour therapy?
a) They feel overwhelmed with information and don’t know where to start, b) they don’t fully understand why a certain recommendation is good for them, or c) there is no one, other than themself, to hold them accountable for their actions (2, 3, 4, 5). This is why it is important that practitioners delve in and analyze where the barrier to health living actually exists. Whatever the underlying reason may be, the processes of behaviour therapy can help shed some light on the issue and elucidate the root cause of the problem (1).
An important point to make here is not to conflate this with a discussion about cognitive behaviour therapy (CBT). Behaviour therapy is a distinct psychotherapeutic approach that has distinguishable features and techniques, rendering it both practical and relevant to the practice of naturopathic medicine. It is particularly useful to guide the implementation of the minimally invasive, healthy lifestyle changes that were previously mentioned as the first step in the therapeutic order.
Although not easily defined, behaviour therapy has a number of common themes that help describe what it looks like. Mainly, behaviour therapy relies on clearly defined, observable, and measurable behaviours (1). It is not the case that thoughts and emotions are disregarded in behaviour therapy, however a discussion of how they become definable, observable and measurable is beyond the abilities of this article.
Behaviour therapy incorporates a variety of techniques including exposure therapy, modeling therapy, mindfulness, acceptance and commitment therapy (1).
What makes behaviour therapy a good match for naturopathic medicine?
Behaviour therapy is compatible with the practice of naturopathic medicine because both involve:
- an individualized process
- integrating changes directly into the patient’s lifestyle
- a collaborative and trusting relationship between the doctor and patient
- treating the underlying cause, or barrier to an individual’s healing (1)
How it works: a basic behaviour therapy outline
(To illustrate the process, we will refer to the fictional character Amanda and her experience with behaviour therapy.)
- Firstly, it is important to clarify the problem. It is best to only focus on one or two problems at a time, so as not to overwhelm.
(For example, Amanda seeks her doctor’s help because she has gained weight and cannot seem to control her eating. The clarification process reveals that Amanda is stressed about schoolwork and her eating problem first occurred when school began.)
- Secondly, the treatment goals are defined. While the patient mostly defines the goals, the doctor has an important role of ensuring that the goals are realistic, safe, and unlikely to have negative consequences.
(For example, if Amanda decided her goal was to lose 10 lbs in 2 weeks, her doctor would advise her that this is unhealthy and unrealistic, and perhaps recommend a goal of 1.5 lbs/week over 6 weeks instead.)
- The third step is to narrowly define a “target behaviour”, which is a measurable aspect of the overall problem. It is only a component of the problem that gets focused on at one time. The target behaviour may be one that needs to be increased (eg. exercise) or decreased (eg. eating cookies). It is best to begin with a target behaviour that is the least anxiety-provoking.
(For example, Amanda’s target behaviour is her consumption of chocolate bars, which we need to decrease.)
- Next, one must measure the target behaviour at baseline and throughout the therapy, to ensure the treatment is having the desired effect. Measurements may include duration, intensity, frequency, or amount of byproduct (1).
(For example, Amanda must tally her candy bar wrappers at the end of each day.)
- Then, one must carefully consider everything that precedes and follows the target behaviour. Events that precede the behaviour are called “antecedents” and those that follow are called “consequences”. Antecedents are broken down into categories, including “prerequisites”, “setting events” and “prompts”. Setting events refer to the environment that sets the stage for a behaviour to occur (1, 6).
(For example, Amanda’s binge eating is preceded by stress and her walking to the store to buy candy bars. The prerequisites include: having transportation to the store, knowledge of how to get there and money to purchase the candy. She is triggered when she overhears classmates discussing upcoming assignment deadlines (setting events). She is prompted by a candy bar advertisement she sees posted at a bus stop. The consequences of eating candy bars are that, most immediately, she feels a burst of energy and satisfaction. Soon after that, she feels a drop in energy, a sense of guilt and a tummy ache.)
- One of the most important steps involves deciding which antecedents and consequences are actually causing the target behaviour to continue. These are called the “maintaining conditions”.
(For Amanda, the consequence of feeling satisfaction and energy immediately after consuming candy bars is far more likely to be a maintaining condition than is her feeling a tummy ache afterwards.)
Ultimately, you want good behaviours to be easy to perform and the consequences of performing good behaviours to be desirable, so that the behaviour is more likely to occur again later. Vice versa for bad behaviours.
- With all the previously gathered information, it is time to design and implement the treatment plan. This is accomplished by deciding which maintaining conditions are exerting the most control over the target behaviour, and which lend themselves to being altered. This step involves deciding on a behavioural therapy technique that’s most appropriate for the individual patient and the problem, and applying it in order to alter the maintaining conditions. (Note: in behaviour therapy, the maintaining conditions are considered the root cause of the problem, while the target behaviour is considered a symptom of the maintaining conditions) (1).
(In Amanda’s case, the stress she feels before she binges is definitely a maintaining condition for the behaviour of eating candy bars. It would be beneficial to decrease her stress. To do so, her doctor may suggest mindfulness techniques where she practices being fully present in the moment without judgment or attempting to change what is happening.)
- Once treatment is implemented, it is important to continue to measure the target behaviour. If the desired effect does not occur, then a re-assessment of the target behaviour and maintaining conditions may be necessary.
The above is merely a glimpse into some of the techniques that behaviour therapy offers. Whether the goal is to increase a good behaviour, decrease a bad behaviour, or simply change how one responds to their distress over an existing problem, behaviour therapy and naturopathic medicine can potentially work together to alleviate the issue. For patients and practitioners alike, it is worth exploring the possibility of incorporating behaviour therapy into your treatment plan.