Applied Behavior Analysis in the Treatment of Mental Health Disorders

Applied Behavior Analysis (ABA) is used in the field of mental health to treat patients with psychological disorders using the theories and techniques associated with operant conditioning, focusing on observable behavioral cues and symptoms.

The evolution of mental health treatment has gone from ignoring it, to imprisonment of the afflicted, to radical surgery, to shock therapy, to drug therapies. Each of these has, in their own way, been both incomplete and dehumanizing to patients. Applied behavior analysis, for mental health professionals, represents a more humane and sometimes more effective treatment modality.

Most of the basic research B.F. Skinner and other early behaviorists conducted focused primarily on animal subjects and revolved around operant training techniques that could be used to alter behaviors for teaching, rather than therapeutic, purposes. But it wasn’t long before practitioners understood that techniques rooted in the same theories could prove equally useful in treating human patients in a therapeutic setting.

Behaviorists went directly from animal training to mental hospitals, implementing ABA techniques such as token economies, reinforcement procedures, and shaping. Experiments in the early 1960s revealed that an applied behavioral approach could work successfully with schizophrenics.

But behavior analysis in mental health treatment went into decline in the 1970s and 1980s. The number of research papers in the domain dropped precipitously, and behavior-based approaches such as token economies in mental institutions were dropped in favor of psychotropic medicines.

Applied behavior analysis is making a comeback in mental health treatment, however, thanks to new research and a link between mental issues and the overwhelming specter of the autism epidemic in the United States.

Mental Health Issues Emerge from the Shadows of Autism

Since the early 1990s, treatment of Autism Spectrum Disorder (ASD) has dominated both the practice of applied behavior analysis in mental health, and applied behavior analysis generally. According to a 2015 survey commissioned by the Behavior Analyst Certification Board (BACB), more than half of all job postings for ABAs involved positions working with ASD patients.

Although ASD itself is not considered a mental disorder, research has shown that individuals with ASD are also at higher risk for experiencing a co-occurring mental disorder than other individuals in their age range. ABAs working primarily with autistic individuals are certain to encounter such issues frequently in the course of their careers, including:

  • Attention Deficit/Hyperactivity Disorder
  • Depression
  • Anxiety

Those conditions can easily merge and overlap with ASD-issues.

Fortunately, the functional aspects of applied behavior analysis render the distinctions irrelevant. An ABA approaches treatment by beginning with a Functional Behavior Analysis (FBA) that focuses on environments and actual behaviors, and the consequences that reinforce those behaviors. This evaluation makes use of the so-called ABCs of applied behavior analysis:

  • Antecedent – The prompt, or initial situation, leading to a behavior.
  • Behavior – The action or behavior in response to the antecedent.
  • Consequence – The reinforcement mechanism associated with the behavior.

In making these observations, ABAs effectively quantify emotional or psychological issues in terms of the behaviors that they are expressed through. The underlying disorder has important implications, but the treatment devised for a patient who, for example, exhibits violent and socially unacceptable outbursts as a result of an inoperable brain tumor could be identical to that used for a patient exhibiting the same behaviors as a symptom of schizophrenia.

For an ABA, these behaviors are learned and are reinforced by environmental conditions. The underlying causes are a part of the environment, but an ABA holds that behaviors can be altered by systematically altering the consequences for engaging in the behavior.

Some psychologists push back against this type of treatment, protesting that functional approaches do not address underlying psychological issues.

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Cognitive Behavioral Therapy Combines ABA and Cognitive Treatment Techniques

A combination of these approaches has resulted in perhaps the most scientifically validated mental health therapy available today, cognitive behavioral therapy, or CBT.

CBT merges behavioral analytic techniques rooted in operant conditioning with cognitive therapy approaches designed to alter the thoughts and emotions of the patient. By approaching the issue from both angles, CBT provides an avenue to address both troubling behaviors resulting from mental health issues, and the underlying mental issues themselves.

The approaches are mutually reinforcing and provide an objective mechanism for assessing the effectiveness of the treatment: if negative behaviors decrease, the patient is making progress. By addressing cognitive biases, patients have the antecedents of their behavior addressed; by addressing the consequences, motivation for the negative behaviors is reduced.

Practicing Applied Behavior Analysis as a Mental Health Professional

In addition to ABAs who deal with mental health issues as a part of ASD treatments, more and more behavior analysts are finding work treating mental illnesses. In 2012, according to the 2015 BACB employment survey, only 4 percent of ABA listing were for positions in mental health. But by 2014, that had crept up to 9 percent.

ABAs working in private practice or for social services are likely to end up working with some clients who have mental health issues. These patients are typically functional enough to be candidates for outpatient therapy, so the ABA may see them only a few times a month for direct therapy.

But their influence on the patient’s treatment will extend further into their lives. After conducting an FBA, the analyst will create a behavior intervention plan (BIP) that governs how the patient’s environment should be altered, or behaviors rewarded, that must be implemented consistently in all facets of the patient’s life.

The ABA will probably work with family or caregivers, and possibly other health care professionals, in order to implement the BIP and monitor the patient’s progress. Changes are typically made through the course of treatment as new issues rise or old ones disappear.

ABAs working in mental health will rely heavily on CBT techniques, usually in coordination with a practicing psychologist. Other techniques, such as behavioral activation (an off-shoot of CBT that discards the cognitive component), may be used to treat specific conditions (depression, in the case of behavioral activation) where they have been found to be particularly effective. Other such specific therapies include:

  • Dialectical behavior therapy – A skill-based therapy extending CBT with coping techniques, frequently used in the treatment of borderline personality disorder (BPD)
  • Acceptance and commitment therapy – A mindfulness training technique combined with commitment and behavior reinforcement techniques.
  • Functional analytic psychotherapy – A psychotherapeutic treatment that relies on generalization and behavioral reinforcement.

Other ABAs end up working in mental health through employment in institutions, whether schools or long-term residential care facilities or hospitals. The focus of practice there will include one-on-one therapy in the traditional manner, but likely also addressing issues of managing larger groups of patients with diverse mental issues. The complexities of coping with a variety of conditions and the interactions that arise from them represents a challenge.

In addition to managing these group with traditional techniques such as token economies, ABAs may make use of group contingencies, which use reward and reinforcements made contingent on the overall performance of the group. For instance, a dining cohort in a group home might be promised a special treat as a reward if they are able to collectively meet certain behavior standards consistently for a week.

Preparing for a Career in Mental Health as an Applied Behavior Analyst

The best route into a mental health career as an applied behavior analyst will run through an advanced degree in psychology or advanced behavior analysis.

Most practitioners in the field are, in fact, licensed psychologists who make use of applied behavior analysis as part of their practice. ABA represents only one tool in their box of treatment techniques.

When selecting a degree program, you should look for master’s or doctoral programs in psychology include a focus or concentrate in applied behavior analysis techniques. Check the licensing laws for the state where you plan to practice to ensure that you degree will qualify you for the appropriate credentials.

It is also possible to find position in mental health working exclusively as an applied behavior analyst. Again, some states require licenses to practice in these positions. Most such positions will also require that you hold a Board Certified Behavior Analyst (BCAB) certification from the BACB.

You can gain experience in the field before obtaining a degree by volunteering in agencies that offer services to populations with mental health issues. Although most specialized mental health treatment facilities do not use volunteers, many social service agencies are grateful for such help.

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Further Reading on Applied Behavior Analysis in Mental Health

Association for Behavioral and Cognitive Therapies – A non-profit professional association dedicated to the advancement of scientific, evidence-based therapeutic treatments in mental health care.

American Psychological Association’s Division 25 – Division 25 of the APA is dedicated to the study of behavioral analysis in the practice of psychology.

National Association of Cognitive Behavioral Therapists – A national associate of CBT practitioners.

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