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The Medical Model versus Behavior Therapy

Behavior therapies are based on conditioning procedures such as we discussed in Chapter 5. In the late 1960s, behavior therapies gained credibility and influence largely because of one procedure: desensitization.

Desensitization worked better than existing therapies for treating phobias and anxiety disorders. It did this by treating the anxiety disorder as a learned response that could be unlearned.

Behavior therapy introduced therapists to an alternative set of assumptions about the nature of "mental illness." Many disorders were not illnesses at all; they were learned patterns of behavior that could be modified.

What is the "medical model" and what does it imply?

Freud, Jung, and most other early thera­pists were MD's. They treated psycholog­ical problems like medical problems. In medicine, visible symptoms indicate a hidden problem such as infection.

Rather than simply treating symptoms (a sore throat) a doctor is better off treating the underlying problem (an infection). If symptoms were treated but the under­lying cause was not, new symptoms might appear, and the patient would remain sick. That set of assumptions became known as the medical model.

The medical model implied that a good therapist should look for underlying causes of any problem. That was what Freud did, in proposing that the family drama was underlying all forms of neurosis.

Through the lens of behavioral psych­ology, such speculations were irrelevant. The problem a client brought to therapy usually involved a behavior. From a behavioral point of view, the symptoms were the problem.

If a person is unable to fly in airplanes because of a phobia about flying, the origins of the problem might (or might not) go back to some childhood trauma. The behaviorist would not address that. A behavior therapist would try to make the person comfortable flying in planes again, and that would be considered successful therapy.

If you think that sounds a bit like Ellis demanding that clients not blame their problems on the past, you are right. After behavior therapies became popular, Ellis decided that his rational-emotive therapy was in fact a behavior therapy, modifying the behavior of speech or self-talk.

Like other behavior therapists, Ellis believed that behavior change was the objective of therapy. Like other behavior therapists, he felt it was counter-productive to engage in a search for underlying causes beyond the "activating situation" that caused negative emotions.

Traditional psychotherapists and psychiatrists, faced with the arguments of behavior therapists, predicted that behavior therapies would merely result in new problems. They suggested symptom substitution would occur.

Because the underlying cause of a problem was not treated by behavior therapy (the argument went) a new problem was likely to pop up, as a behavior therapist addressed an old problem and made it go away. This would continue unless the underlying cause, the root of the problem, was addressed in psychotherapy.

What argument did behavior therapists make against the medical model?

Behavior therapists countered that there was, in fact, no evidence for symptom substitution. On the contrary, when a problem behavior was eliminated, the client was pleased, and no new problems appeared. Therefore it made sense to treat behaviors directly without specu­lating about underlying causes.

The Broom Lady

A famous study from 1965 symbolized the skepticism of behaviorists toward the medical model. The study took place in Saskatchewan Mental Hospital.

Theodoro Ayllon and colleagues found a 54 year old female mental patient who was severely disabled. She spent most of the day standing in the ward doing nothing, but she loved cigarettes.

Ayllon, Haughton, and Hughes (1965) were trained in operant conditioning and knew cigarettes would function as a powerful reinforcer. If so, cigarettes should raise the frequency or probability of a behavior they followed (see Chapter 5, Conditioning).

Ayllon, Haughton, and Hughes picked an arbitrary behavior–holding a broom–and reinforced it. They gave the woman cigarettes whenever she held a broom. Soon she held a broom all the time.

How did Ayllon and colleagues get the "broom lady" to hold her broom?

Next Ayllon and colleagues invited two psychiatrists to observe the woman's behavior through a one-way mirror. Each was invited to analyze or explain the patient's behavior.

Dr. X. described the patient as follows:

"The broom represents to this patient some essential perceptual element in her field of conscious­ness...rather analogous to the way small children or infants refuse to be parted from some favorite toy, piece of rag, etc."

Dr. Y made these comments about the same patient:

"Her constant and repetitive pacing, holding the broom in the manner she does, could be seen as a ritualistic procedure, a magical action....Her broom would be then: (1) a child that gives her love and she gives him in return her devotion, (2) a phallic symbol, (3) the sceptre of an omnipotent queen..." (Ayllon, Haughton, and Hughes, 1965)

This made the psychiatrists look ridi­culous, and that was the point. Ayllon and colleagues knew the underlying reason the lady was carrying the broom. She had been reinforced with cigarettes.

This demonstration, published in the mid-1960s, symbolized (depending on your point of view) (1) the hostility of behavioral psychologists toward psychiatrists or (2) the absurdity of old theories that looked for symbolic underlying causes of abnormal behavior (and the superiority of behavioral analysis).

There is a third angle to consider. The lady was probably suffering from a psychosis, and we now have good evidence psychosis is due to alterations in brain circuits.

So the lady's willingness to stand holding a broom was, indeed, sympto­matic of an underlying disorder. If the broom-holding was extinguished, the woman's quality of life would not be improved.

On the other hand, she might have benefitted tremendously from some of the psychiatric medications available 50 years later. Perhaps, given clozapine or a similar medication, she would have returned to near-normal.

So the broom lady example cuts both ways. It does show the absurdity of symbolic interpretations, in a case where there is a direct incentive for a behavior. It also shows the importance of recognizing underlying disorders when they exist, and using appropriate medical treatments when they are available.

Write to Dr. Dewey at

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