-._._.- ..~._ ..

"

Learning Theory and

Human Behavior
John M. Beaton

The object of psychology ís to give us a totally
difierent idea oí the thing; we know best.
~AVL VALERY
L¿Mning ts but en adiunct :0 ourself
,-\nd whcre we MC our ICo~lng Iikewise ¡5.
\ v ILLIA..\r1 ~H.-\KéSPEr\~
Leve s 'Labour s Lost
le is impossible ro undersrand rhe
behavior of hurnans-or that of rnosr animals=-wirhour
knowing sornerhing about the basic principies of learning.
Two irnporranr arrributes of hurnans are cheir capuciry ro
learn ro modity their behavior ro adapr ca new siruations
and their abiliry ro rernernber che resulrs of pase experi-
ences. Humans are capable of learning a vast Jrra~- of
things ranging frorn simple behaviors ro cornplex abilities
such as language. The trearment approuches of behavior
rherapy and behavior moditicarion are based on assump-
tions abour the narure of rhis !earning process. For ex-
arnple, behavior rherapisrs assurne that many rnaladaprive
or inappropriate behaviors are che resulr or inapprcpriare
learningand .rnat rherapy requires the rnodification of be-
havior by the applicarion of basic principies of learning.
Central LO me concept of learning 'is the role of re in-
forcement and the assurnption thar rewards or punish-
menes lead ro changes in behavior, Humans encoufJge
desirable behaviors and igrrore or punish disapproved be-
haviors.
Ir is difficult ro define learning \\ime-in:- precision be-
cause learninz is never directlv observed and can onlv be--
inferred frorn observed chariges in behavior. How~Yer,
any definirion of learning rnust include the following ele-
menes.
l. Experience or pracrice rnusr be distinguished from
other influences, for instance, rnarurarion or druz
effects. Behavior can change as a result of rnarura-
rion alone (e.g., a ch.ild wal.king). Hov v·ever, many
behaviors are not rhe result of onlv learninz 070nl\"
rnarurarion, but of the interactiou' of rh~s.i-~~})-fac·-
rors.
Reinforcemem strengrhens the behavior it follows,
3. Learning 1S 3 relarively pernlanenc change in be-
havior. which allows us ro distinguish ir from those
eemporary changes in behavior caused by. drugs or
other factors."
+. Learning has ro be disringuished from perforrn-
ance. Although the only way ro know' thar learning
has occurred is bv observing performance, the per-
formance observed is nor always an accurate indi-
cator of learning.
). .vlotivarion CJn rnarkedly affecr performance.
6. \ "arious factors, such JS fatigue, brain darnage,
trauma, disease, senescence, ;\TIc! drug effeccs, infiu-
ence performance but are not exarnples of learning.
All of rhese factors lead ro the following detinition of
learning: Lea171Íng is n relmi7:ely pel7}/a7wzt ,bal7ge in a ve-
ba,,'iol'iz! tendencv OCC1l1Ti1Zgas a resuit ojreinforced practice.
Sorne controversia] aspecrs of leaming push che lirnirs
of th.is detinition, such as one-trial Iearning, irnprinring,
and critica! period learning. Ir has been observed that rats
learned, after orle exposure ro a nausea-inducing sirua-
rion, ;:0 avoid that siruation. This orie-rrial Iearning is a
function of experience but not of practice. Imprinting,
which is seen in various species, is best dernonstrated by
J young duckling prepared instinctively ro accepe and fol-
low a certain range of rnother figures. Once such a figure
has been selected, only th.is particular rnother \\;11 sarisfy
the instincrual demando Imprinting is a form of Iearning
but is dosel)' relared ro instinctive behavior and is tied ro
a particular species (e.g., fowl) and a particular age (4-6
hours after birth for ducklings), This exarnple of irnprinr-
ing, which occurs only at a particular age, is relared ro
critical p eriod Iearning. In these siruations, learning
sirnply does noc occur ir ir does not take place within a
cerrain time period or developrnenral stage.
Three main ry-pes of leaming are discussed here, fol-
lowed by exarnples relevanr ro clinical praccice. These

271

• __ • ---- -_ - -_._ ••• o

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.-...::-~. ';--:-:-.~' __.¡.- ~ ••."!.r._ .•.. :._._~'.; •. :'.' - __
 rhree are often regarded as me simplesr forms of Iearning:
classical conditioning, operant condirioning, and model-
ing. In classical condirionirig che organisrn leams an as-
sociarion berween two srimuli (S-S), whereas in operant
·con:d..i.tionirig· che associarion learned is berweeri a re-
sponse and a srimulus (R"S). Modeling is a third kind of
learning in which che subjecr Iearns by observing another
persono However, che general premise of all theories of
learning is that behavior can be changed: che various che-
ories of learning simply describe those siruations under
which behavior can be changed.
CLASSICAL CONDITIONINCi
han Pavlov (1849-1936) was a famous Russian phvsiol-
ogiSt who accidentally discovered classical (Pavlovian)
conditioning. Pavlov was srudying me physiologv of che
digestive sysrem, and sorne of his experirnents involved
measuring che produccion of saliva in dogs when certain
focds were placed in their rnouths. Before che experirnenr
.each dog underwent surger\· [Q move che openings of che
salivarv ducrs from che rnouth ro che ourside skin so che
saliva produced could be measured easily. ;\.11dogs wer e
restrained in harnesses and kepr in soundproofed rooms.
Ivan P. Pavlov (1H~9-19~6') Courtcsy of thc National Library or
Medicine ..
272 Assessrnenr of Parients
"2
Pavlov found thar when he prescnted mear powder arid
observed che autornatic, unleamed response of salivario..
other stimuli occurring shortly before chis srirnulus (sigh:
of food and sighc or sound of experirnenrer) also began
ro elicit salivarion. \Vhen salivation was elicited by these
other stimuli, ir was called a condicioned or condicional
response (CR). Pavlov called che normal eiiciting SU¡:1-
ulus (che presentation of food) che unconditioned or un-
condicional stimulus (CCS, or sornetimes abbr eviared
l.~S).He named che response that inevitablv follows chis
stimulus (salivation) che uncondicioned response (L'CR.
or L"R).
"nen classical condirioning tales place, che organisrn
learns a new association berween tWO previously unrelared
srimuli, that is. rhe conditioned stimulus (GS i now siznals
che onset of che unconditioned stirnulus (es:. Once this
s-s pairins has been learned, che organism resporids to
me condicioned signal iust as if it were me original. in-
stigating stirnulus (e.g .. food or elecrric shock). The re- 1
¡
larionship berween che various conditiorrs is shown in Fig-
ure 19-1.
A merronome was used as me es in one of Pavlov's
classic experirnents .. Afrer checking thar ene merronorne
. was a neutral stirnulus (e.g .. ir did not induce salivation
when presenred alone). Pavlov paired the clicking of [he
rnerronorne (CS) with che presentarion oi rhe food (es)
and beg3n che acquisirion phase of the srudv .. -\her severa!
pairings of che srirnuli. Pavlov rested for :1 change in the
dog's behavior. He pr esented the rnerroriorne 310ne and
measured increase d salivation (or increased CR). P~I"!O\'
had dernonstrare d learning. a change in oehavior that re-
sulted from experirnenrer manipulation. (1, should be
nored thar rhis ~"pe of learning can be testeó onlv during
cxti ncri on , rhat is. the presenration of the es in th::: .1::-
serice of the CS. because there is no \\"3,· o: resrirur for
learning ifthe l.-S is pr esented.) . -
If the es is ornirted for a periodo rhc animal will even-
Before conditioning
es No CR
During co-iduioning
es us UR
IM~lronOfTIt"' IMea: cowcen
Aiter conditioning (testingl
es CR
FICiVRE 19·1
The relat:ionship bcrween stimuli and responses in the various stazes or'
classical condirioning. -
,
~
....i~A
I •

cually srop salivaring, and rhe result is experimental ex- rato Before rhe experirnent Watson and Rayner derer-
rincrion. However, if the animal is res red again on rhe mined that no fear was presenc, because Albert played
subsequenr day with only the CS, ir will again salivare ro wirh me raro They also dererrnined thar Albert was afraid
rhe metronorne: this is known as spontaneous recovery. of the loud clang rnade when a metal bar was hit with a
The CR will not be as srrong or as incense, and after hamrner beca use rhe noise made Albert cry and crawl
severa! sessions of the presentution of the CS alone, the awav,
animal will no longer exhibir the CR and rrue exrinction To condirion Albert, me experimenrer paired che
wil! hove occurred -(i.e .. rhe rnerronorne is azain 01 neutral whire rar (CS) wirh che loud noise (US). Euch rime Albert
stirnulus for rhe subjecr and elicirs no sali\·a-rion). couched rhe rat, Watson and Rayner hit me bar with me
Two othcr phenornena are associated wirh classicnl harnrner. After only seven pairings. Albert cried at me
conditioning: generalization und discrirninarion, If the sighr of the rar ulone. The researchers had dernonsrrared
dog is crained using a rnetronorne with 60 beats per min- char Albert had been condirioned, or had Iearned, ro rear
ure and then tested wirh vurious rnetronorne sertings. a rats. This fear becarne generalized ro orher furry obiects,
bread range of responses will he observed. with rhe rnax- \ Vatson and Rayner hoped ro exringuish Alberr's reur b~~
irnal response beinz ar 01' near the rarzer.srimulus of 60 using condirioning techniques, but Albert's morher re-
bears per minute (Figure 19-1). This i; krrown as gener- moved him frorn che srudy before me experirnent could
alization, The secone! phenornenon, discrirninarion. is de- go any further,
signed ro prevent wasreful. inefficienr behavior. For ex- Ir becornes easy ro undersrand mar before children are
ample, if a dog is exposed ro several di ffere nr rates on rhe old enough ro comprehend why chev are poked, prodded.
merronorne bur is presenced with food after only one fre- and gerierullv manipula red against their will by physicians
quenC~· (e.g .. 60 be.us per minute), the dog will only sal- and nurses. rhey ofren cr:' ;H rhe sighr of O1n:·person in J
ivare in rhe pr!,:sence of rhe 60 bears per minute stirnulus, whire coar. They have learned ro associare cold instru-
that is, orily the 60 beats pcr minute stirnulus becomes a· menes, usrringenc srnells, hypcderrnic injecrions. and pain
conditioned stirnulus (Figure 19-3). These rwo phenorn- (US) wirh a whire coar (CS) and show a conditioned re-
ena ulso occur wirh operanr condirioning. sponse of fear in me presence of che previously neutral
The principies of condirioning are clearlv relevanr ro stirnulus (me white coar). .vlany pediarricians, pediarric
clinical medicine. Classical conditioning is especíally im- denrists, und rheir sraff do not wear whire coats so chil-
porunt in rhe acquisirion ofphysiological responses. par- dren will nor learn this association. Of course, me chil-
ricularly mnladaprive enes that can lead ro psychosomaric dren sol! leurn ro associare rhe sighr oí' rhe insrrumenrs
diseuse. In uddirion, mamo. srnooth rnuscles are caoable
. of and orner relured stirnuli with pain and muy sol! cry at
being conditioncd h~' me.ms of classical condirioning che sighr of thern but nor at che sighr of che health ca re
rechniq ues. professional.
Emociona! responses. especially fear, can be learried via Classical condirioning has been used in che rreatmenr
classical condirioning. The tirst and rnosr tamous e!em- of addicrions, especially alcoholisrn. In this context me
onsrrarion of rhis condirioning of fear was curried out by alcohol is rhe CS. which in rurn produces me l7R of u
\ Varson and Rayner in 1920. In rheir srudv, a 9-monrh- pleasurable physiological effecr, The stirnuli mar reliablv
old boy, "Lirtle Albert," was conditioned ro fear a white precede me alcohol's effects, me sighr and smell of me
beverage. becorne condit.ioned stirnuli. To eliminare mis

10
10r
8
.~ ..• 8~
'1 6 .~
~ 6
'O
:'4 ~
e
o2 ~
CoA
..
o
2
0L-~20~~3~0~-4~0--~570--6~0~~7~0--~870--~90~~100
Beats pe!' minute O
20 40 60 80 100
Beats per minute
FIGVRE 19-2
rypical generaliz:Jcion cur .••.
•.l" e for classical condirioning. :\"ore that me FIGVRE 19·3
subiecr responds ro scimuli rhar are differenr rrorn che original stirnulus, .\ rypical discriminacion cur ve for classical condicioning. ~ore mar me
bur che srrengrh of the resoonses diminishes :JSme scimuli become less animal responds only ce me conditioned srirnulus. because ir is me only
similar ro me origin:J1 scimulus. srirnulus OUt reliably predices me presenrarion oí tood.

Learning Theof)' and Human Behavior 273

.·,·~o~·
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 conditioning, a rechnique ealled countercondition.ing is key ro receive grain, me training procedure migh; be s s
used. Here, a noxious stirnulus (e.g. an elecrric shock) is follows, Initiallv me zrain would be made available \\'hen~
'paired wirh the alcohol. After several pairings che pain ever me vello\~' liO'hr was on, In me n ext scaze. zrain
and fear assoeiared with the.elecrric shock become asso- would be g¡\'en when me pigeon looked ar the yellm;~ key,
ciated with me alcohol. This rreaanent is ofren carried rhen when me pigeon approached me yellow kev, then
Out in a setting resembling a bar in an inparient ward of only when me pigeon put its beak on me yellow kev, and
a psychiatric hospital so mar the learning will generalize finally only when me pigeon pecked the yellow key. The
ro bars in the outside world once me patienc h2.S been r esulr of chis process, called shaping, is thar when me
discharved. light comes on, me pigeon sees rhe lighr, pecks the key.
..\hn~' human behavior patterns are a result of both and is reinforced bv grain, If me feeder is rurned off and '
c1assical conditioning and me second type oi learning, no grain is given, experimental extincrion is observed. As
which is discussed in the following section on instrumen- with classical conditioning, che learnirig re:lppear, in sub-
tJI condirioning. sequerit sessions (spcnraneous recoverv). and ir takes sev-
eral extinction sessions (Q observe rrue extinction. _-\5 wirh
INSTRVMENT AL (OPERANT) CONDITIONINCi cIassical conditionina. zeneralizarion ro other. similar
, stirnuli and discrimination berween stimuli are found with
Instrumental (operant) conditioning is a procedure in' instrumental conditioning.
whích me environrnent is arranged so mar reinforcernent Differences berween instrumental and classical condi-
or punishment is rnade conringent on a response, The rioning exist, In instrumental condirioning ;1 conringencv

probabiliry of that response then increases or decreases as' is established berween a srimulus siruation, a response,
a conseauence oi rhe behavior. Thus me essential fe arure. and a reinforcer: in CJaSSiC3! condirioning :1 conrinzencv
of ins~menrJl condirioninz is m~c an orzanisrn opcratcs is esrablished berween (\\'0 stimuli. In instrumental con-
on che e nvironrnenr ro 'prod-uc; a response that is iJ/57ru- dirioning a response must occur before ,1 r eward (~l rcin-
mm/a! in obraining sorne goaL \\"¡th rhisrype of condi- forcing stirnulus: is obtained: in classical condirioning the
tioning rhe subiecr's behavior determines the ourcorne. es occurs before and elicirs che response (t,g .. th e mear
Thor ndikc. in his earlv experiments, srudied me behavior powder is placed in che dogs mouth whether or nor the
oí hunzrv cars locked in a puzzle box. The cats were able dcg salivares). Thus in instrumental condirioning [he an-
ro escapt frorn the box b:' hirring a larch mar operied a imal emirs the required response, wher eas wirh classical '
door and allowed access ro food. \ Vhen placed in che box, condirioning the srimulus clirirs che response, Finallv, in-
the cars would 2( firsr rnove around vigorously. rnaking strumental condirioning involves gre~rer variabiliry of be-
!TIan!, responses, During r epeared trials, however. the cats huvior than does classical conditioninc. In instrumental
began ro learn rhe appropriare response of hirting the condirioning rhe subicct may be raced witl: <1 v.uierv (¡i'
larch, In chis exarnple of instrumental conditioning a re- response alternatives and musr come ro se leer th e ,1ppru,
sponse had ro occur before 2 reward, or ;1 reinrorcing pn3te response,
stirnulus, was obtained. This is differem frorn ciassical
conditioning in which the 'les occurs before me reS¡:lOnse,
Also, in classical condirioning ene es (fooci in me mourh) Types of Operant Conditioning
is presericed r~~;lrdless oí what rhe subject dces. \\"e can classify (\\'0 basic ~'pcs of opcra nr condirioninc
The f'~rson who is perhaps mosr closely associared b:' separarinz posirive and ne~;lri\'(: reinror ceme nr. Figur:::
with oper:1llt 'conditionin~ is the American psvchologisr 19--!- shows rhe relarionship berween th e narur e (Ji the
B, F, Skinner. :\ cornmonlv used device in instrumental reinforcing stimuli (posirive or negarive) arid the hehavior
conditioning is an enclosed charnber somerirnes called a involved wirh rhe presem3 rion or rernova 1of [he stirnulus.
Skinner box. e\. hungry or thir srv animal (one rnaintaincd Posirive reinforcemenr J't.:itr~ ro rhe pre senr.uion of :'
or JéSS ,;;::n lOO'J,¿, bodv \\'éizn, or deprived of wa rer for stimulus that increases the probabilirv of rhe response r:,;,:
severa! hours i is placed 'in rh~ box and 'is required re press preceded it. for insrance. the prescntution '.Ji gr::iJ: rcin-
,~ bar ro obtain food or water. Ini1:ialh' al1 animal. such ,15 torces rhe pigeon's peci..:ing:l :'e11o\\' };e:', ,'\nu¡:her l\l)e o:'
a r2r, mOl'es abour randomly and m<11:es a varie~' of re- posici\'e reinforcemenr is (J7I/J~\',\'ÍuJ.' rmiliiilg, in \':hich re-
sponses: g-radu<!ll:' che anim::!] learns ro press 1:he ba¡-, the inr'orcement is cO!1rinqenr on rhe omission or ,'D;ence o(
response rhar achie\'es 3 re\\'ard, and eliminares responses a response in a certain time period, For example, a chron-
rhar do nor lead [O'a re\\'ard, The follo\\'ing eX:lJTIol; usinz ic:JlI:' bao chilo may be re\\'arded for goqd beh'l\'ior dur-
" ?i~eOI~ 35 rhe experimem3! 5ubiecr sho\l; [he p~ocess o-f in~ a se, time period (omission o;" b,ld bel~2':ior\,
acqUlSItIOl:, :1\'egaove reinforcement ret'ers ro rhe remo\,;:¡l or' an
If a hungr\' oiqeon (mainrained ar 80% of irs normal a\'ersiye stimulus (something rhar causes pain or an.\.Íe~'},
free-feeding. bod:~ \\'cight) is pL:ced in:1I1 oper:lI1r chamber \l'hich in creases che probability of the response ch~t prt-
(Skinner bo:\) and required ro peck an ilIuminared :'ello\\- ceded ir. In cscape cOlldiriOllillg an ¡j\'ersi\'e srimulus is pres-

274 :\s5essmem of Patiems

j
 "

NATURE OF STIMULUS

Positive Negative

~
....., ,-

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o
z>
.::
e
~ ¡
I
I
Posinve
reinioreement
I f Behavior)
Punishment
i + Behavior)

:.:
o -:;
~ ,. .--:egarive
¡¡
g Punishrnent
reinioreement

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:.: ! r Behavior) (+ Behavior)

Fll,VRE 19-4
1:~;:1 r;, I¡~~::;
p~ ¡~:
:-.'.
;,.'1..";"; ~)' ••• ! ~i;,
'e rci n!'~-re;: :::t,.·n r. !:-:::·.E ¡';.":.= ~;.: i:1 :', };t.:~::~:::1~.
Jr.d puru-hrner.r.

.nr, ~::ld;:hc ~'..!¡.~:!_·(.·tíC~P()l1dS ro :::r:l1j!lJr~ rhc srimulus.

Fur e:X~1111p¡e:, in ~lhor room ;l pc:rson ll1~1~' mm on che air
·:'.Il1diri(l!1il1~-,ll rernove rhe uversive stimulus (hean. A
second kind or' condirioning involving' aversive stimuli is
known 3S iI:'r,!,!i/i/,t' condirioning. In ovoidunce condirioning
A 130y is Bearcn Because He 13roke a )ar Fruncí;(!) J!);~ de Coya
3 subjecr mukes ;l response in che ubsence of rhe srimulus
(circJ 11;00), Courtesy ef thc NJlíonJI Library oí Medicine,
ro prel'em rhe presenrarion of rhe srirnulus Ié,g .. purring Parcnts trcquently use punishrnent to control the 'áehevior of their
(Jt1 ~I heavy cour before g-oing ourside on :l cold duv).
cliildrcn, bu/ rcinlorccment is more eticctivc in the long run.
Punishment is the deliverv of an uversive stirnulus or
rhe rernoval (l¡' J posirive Orle :IS rhe consequence of ;l
response. Punishrnenr initiallv decreuses the response rh.ir
prec<:,'¡..:d ir. The d'¡g' ~p'll1kt:d tor illlll~,in~ on pcopie is
;ós likelv ro iump on rhC:I11in the rurure. However. there Or' ;;::\"(~r:1J
responses m.u!e ro che SJIll<! siru.uion. rhose which
.ire problerns wirh the use of punishrnenr because the use are accompunied or roliowed o,' suristncrion m che animal will.
of :1 painful stimulus l11a~- provoke counreraggression. orher rhings being cqual. be more tirrnlv connected with rhe
Punishrnenr is derined DI' the erfecr ir has on behavior. siruution. 50 01:1(. when ir recurs. thev wil] be: more likelv ro
For exarnpie. spankinz J child, which mighr be classiried recur: rhose which are uccompanied or close followed by dis-
al- :1 p3renr as punishmenr, mav nor lead ro J decrease in corntorr ro che animal will. other rhings being equal. have their
the behuvior because the child is receivinz artention, This conneccions with rhar siruurion weukened. 50 thar when ir recurs,
urtenrion m:1~' be a posirive reinrorcer for rhe child. Thus, they will be less likelv te occur. The greacer che satisraction or
rhe spanking will nor lead ro a decrease in the undesired
discornforr. me
g,e:lter the srrengrhening or weakening of me
bond,
behavior thar preceded ir. :\.150, if punishrnenr is used wirh
children. the child mal" hecome feurful and inhibited. This C311 be surnrnarized as follows: Rewards cend ro
Alrhough punishmenr mny reach people what rhey are increase the probabiliry of a response: punishments rend
doing "'rong, ,ir dces nor reach thern whar rhey should be ro decrease che probabiliry OL1 response, Thorndikes law
doing. The use of punishrnenr should be accornpanied by simply describes me dependency rhar exists berween be-
posirive reinforcement of more.,?~.'~ti'-e alternative be- havior and irs consequences, ,_ ....,.._.
haviors. ,-,;;-, The manner in which reinforcemem is delivered -af=-'-~'
fecrs the srrengrh of the behavior, and rhe panern of re- ,~,
inforcernenr and nonreinforcemenr is cailed a schedule
Reínforcernent and Schedules of Reinforcernent
of reinforcernerir. Schedules can be classified on me ba-
Reinforcemenr reters ro a srrengthening process whereby sis of the nurnber of responses required to produce a re-
me response probabiliry in rhe presence of J stirnulus is inforcemenr (ratio schedules) or on me basis of me
increased, This is pan of Thorndike's (1911) Law of Ef- elapsed time berween successive reinforcernenrs (interval
fecr, which stares: schedules).'

Learning Theorv and Human Behavior 275

 ~-. . -; -._

. ~-
There are twO kinds of ratio schedules: che number of ..._ forcernears, che response rate begins tO accelerate rapidly
responses required may be fixed (fixed ratio, or FR), or (e.g., the cramming by srudenrs on che day before a quizi,
ir rnav be variable (variable ratio, or VR). In an FR.-lO \ Vith me Vl schedule there is no scalloping and tliis
schedule, for exarnple, che subject is reinforced afrer every schedule produces a slow, constant, and sready rate of
··10Tesponses. With ·a·VR=lO·sch·edule; reinforcement is responding. Ir is clear that che relarionship ü-i·corítingency
obrained on an average of every tenth response, bur the berween me response and che reinforcemenr is a powerful
number of responses required to obtain reinforcemenr on deterrninant of behavior.
anv ~iven trial varies randornlv. These ratio schedu!es re-
suÍr in very high rares of responding, with che VR sched-
ule inducing a steadier rate and being more resistant to Biofeedback
extincrion. The worker who receives SI for every rwo Biofeedback, an extensión of operanr coridirioning , is a
irerns he or she produces illustrates a fixed ratio schedule; method of reaching patients voluntary control over their
che slot machines ar Las Veg-as illustrare a \""R schedule. muscular and visceral responses ro stress so that they can
The slor machines are usually ser tO pay off on a relarivelv recognize and reduce body rension, Essentially chis train-
high VR schedule; chis results in che garnblers ernirring o. iI1g provides che individual with cominuous. accurate in-
high rate of responding. forrnation about sorne particular rype of physiologica! ac-
Interval schedules reward responses afrer a period of 0\1t'".
time has elapsed sin ce che last reinforcement. Reinforce- The mosr cornmoniv used instrurnents in biofeedback
rnent ma:; be prograrnmed afrer a fixed time period be- ar e devices tO monitor che electrical acriviry of muscles or
rween successive reinforcers (fixed interval, or FI) or che ro monitor finger temperarure (orher devices can be used
time berween successive reinforcers rnav be variable ro monitor brain rhythms, hearr rate, or blood pressure).
around a mean (variable inrerval, or VI). Exarnples of The goal of muscle biofeedback is to decrease muscle ten-
mese schedules inelude an instructor who gives a quiz sion.iwhereas the goal of ttmperarure biofeedback is to
every .:'Ilonda~· (FI-7 days) and a fisherman who catches incr ease fing er remperarure by dilaring che underlying
six trout over 2 12-hour period (\'1-:: hours) (che catches blood vessels. ... . ... .... .
being randomly disrributed during che 12 hours), AJ- Thre e fundamental principies are involved in che use
rhough ir rnay be diffieult ro conceive of 2 quiz as 3 re- of biofeedback. First, the physiological activirv to he mod-
inforcer, che pattern of study rime bv che srudenrs follows ified must be detectable and measurable. Second, ther e
mar of behaviors maintained on an Fl schedule. Figure rnust be continuous flo\\" of inforrnation back to rhe sub-
19-) shows rypical parterns of resporiding for each of ject. Finallv, che subjecr muse be rnorivared ro learn. Bio-
mese ratio and inrerval schedules, The FI performance is feedback is not an autornntic process: success r equires
characrerized bv a characrerisric scallop. There is a p8USt. rime and pracrice.
and a period of no responding is observed arrer me last An illustration ofhiofeedback is elcctromyozraphic re-
reinforcement, but as the availabiliry of the next rCIl1- cordinz of [he activirv of che frontalis muscle of rhc fore-
hcad .. .l. tone C1J1 be ~sed ro si~il<ll the 1::\·.::1 of acriviry in
this muscle. \\nen the muscle is cense. the tone is nigh
in pirch: as rhe individual relnxes che muscle. me pirch ni
che tone simulraneouslv decrcases. The tone varie s di-
variable
ratio recrlv wirh muscle activiry. and the subiect receives \'ir-
ruallv irnmediate feedback about muscular rension. T;l::
sarue feedback technique can be applied ro an~' measur-
able physiological activirv.
Fixed
interval The similariry of biofeedbuck tO operant conditioning
is apparem. The individual cmirs ~1responsc-s-muscle re-
laxation-e-and is inuuediatel: .: reinforceci b~' rhe churice in
ronc.
Biofeedback is a rapidlv expanding aren oí" bchavior
rherapy. lt is used in che tr eatmenr of anxiery disorders
and stress-relared disorders such as muscle tcnsion head-
··40 60 80 . elches. migraine headaches. nnd hyperrerision. However.
Time (minutes) this is not a passive therapv. The patienr has ro be moti-
vared and rnusr uridersrand thar the learriintr process takes
FI~VRE '9·) ", ======:=:::=::========================== time and practice .. -\hhough inicial rraining usually takes
Typical response p:lC!CrJ1;[or each o;' the tour majo, schedule- (Ji re-
inforcernent. As che gr2ph shows. each schedule produces a disrincrive
place in an office setring with relatively expensive equip-
o
pa"ern. The has rnarks indicare the noint at which rhc reinforcer "·0; mene. the ultimare goal is for rhe individual ro use the
deiivered. . training in his or her everyday life.

276 Assessment of Patients

-,/' .
.,l.:
,

.- qu~n~~- children, and subjects who have had classroom Reciprocal inhibition techniques have also beeh ·c~u.;
. behavior problems. pled with hypnosis. These methods seem particularly use-
fu! in the treatrnent of specific phobias the parienr is
5ystematic Desensitization highly motivated tO change.

Systemacic desensicizacion is a technique used ro trear pa-

tients who experience anxiery in specific siruations. The Emotive lmagery
technique is based on the principie of reciproca] inhi-
Emorive imagery is a variation of systernatic desensitiza-
bition and the assumption that a person cannot be relaxed rion that has been used rnainly in the treatment of chil-
and tense at the sarne time. The patienr is raughr basic
dren's phobias. With this procedure the phobic scimulus
relaxation techniques before actual therapy sessions. The is gradually presented in the context of an enjoyable fan-
therapy is based on the idea that profound muscle relax- ras)' created in the form of an exciting srory involving me
acion leads tO parasyrnpathetic dominance in the auto- child and his or her heroic figure or figures. Emotive irn-
nornic nervous system, which is used as a cornoetinz re- agery was used successfully ro trear children with a phobia
sponse incompatible with anxiery (associa'red ~ith tO dental injecrions. The dentist induced the irnagery in
sympathecic dorninance in the auronornic nervous sys- his or her dental treatrnent room before the administra-
rern). Before actual therapy sessions the patienr and the tion of che local anesthetic and the iniection. However,
therapist have construcred a hierarchical list of iterns that ernorive irnagery does require a good imagiriation and
produce the patient's anxiery. The leasr anxiery-provok- considerable skill on the pan of the health professional.
ing itern is lisred first, and the last itern is the siruacion in
which the parient is most uncomforrable. The patient
then bezins his or her relaxarion routine and tries ro re- In Vivo Desensitization
main relaxed while the therapisr enlarges on each irern, In \;\'0 desensitization is a technique similar ro sysremaric
bezinninz wirh those least likelv ro produce anxiery. A desensitization, which uses relaxation rechniques ro assist
nurnber of sessions are required before the parient can patients with phobias and specific anxiery disorders. In che
retain a relaxed stare when his or her rnost agiraring fan- in vivo desensitizarion technique the inrroduction of a re-
tasies are evoked. The followinz illustra tes a hierarchv sponse incompatible with anxiery inhibits or diminishes
that rnizhr be used with a patient who is afraid of fly'ing anxiery. The patient is first raught muscular relaxation,
(Luria, 1982, p. 195): after which the patient and therapisr construcr a graded
Imagine a rov airolane. hierarchv of anxierv-orovokinz siruations. In this rech-
Imagine 2 picrure of a real airplane. nique, h~wever. th~ parierit acruallv works through each
Imagine drivinz tO an airporr. siruation. For a person who has afear of snakes, the fol-
Ima~int beinz at me airport with 2 real airplane. lowing hierarchy might be used.
Im3;;;ne srandinz nexr ro rhe real airplane.
Ill13.~lle geccing -into che airplane. Imagine lookinz at 3 snake.
Irnazine sirtinz down in a sear 011 rhe airplane. Look ar picrure of a snake.
3.

Look at a live snake through a window,

Ima~ne che take-off of me airplane. Ir is a perfect cake-off
Look at a live snake in an aquarium.
and che weather is perfect.
Toueh the side of che aquariurn.
Imasine che rake-off of che airplane. Ir is nighrtime and vou
Toueh rhe snake in the aquarium.
e:l~mOt see verv well.
Toueh che snake whíle sorneone else holds it.
Irnazine takinz ~fi in a rainsrorrn. It is a perfect cake-off
Hold me snake.
Ima;'ine takinz off and ridinz in a biz srorrn, with thunder,
li;hminf:. a -Iot of rurbule,;ee and burnpiness. As the parient progressively masters the inicial anxierv
Ima~ne la~ding on 3 clear day, 3 perfect Ianding ..
scenes (bv rnainraininz relaxation). he or she moves on ro
Imag.ine ianding in a rainstorrn with 3. lot of wind and
more diB;cult beha\-i~r21 rasks and finallv progresse~ al!
bumpiness,
rhe \'.':1\' rhrouzh che anxierv hierarchv. Once the patie nt
\\"hile rhe rherapist is ralking about increasingly dis- can successfullv enzase in' rhe hierarchy's terminal be-
rurbing aspects of riding' in an airplane, me parient with havior, he or she ha~ been desensirized ro me anxiery sir-
the fear of fivinz is simultaneouslv doinz something tO uaoon.
relax, such a~ fccusing on breathing and relaxing bodv
pam. \,,'ith this technique the parienr only imagines the
siruations and rhey are not practiced in vivo: however. Flooding
considerable evidence suzzesrs that maximal benetits are Another type of desensitizarion is flooding. a procedure
obtained whcn progress inthe physician's office using irn- in which a person is bombarded with the stimuli he or
agery is coupled with actual exposure in rhe natural en- she rnost finds uncornfortable, under the assumption thar ¡,
vironrnent. "me first 5 minutes are the hardest." Unforrunarelv, this
i!
278 Assessrnenr of Patiems I
!
I
1.
,;,'"
,MODELlNCi of syrnproms, leading rhe parient ro elaborare more and
more on mese symproms while ignoring orhers thar are
'_\ Iodeling is rhe lasr of the three rnajor types of learning. just as significanr, The physician should conceptualize
le is prirnarily observarionai learning and is imporrant in disease derection as a psychological process. Reinforce-
human learning, especiully with children. Ir is vicarious in mene affecrs pain threshold, me dis, :iminacion of stirnuli,
narure, und modeled behavior is Jearned wirhout rein- and me reporring of s)'mproms,
forcemenr or punishrnenr. In one srudv children were
shown an adule model acting aggressi\-ely toward a
Behavior Modification
"Bobo" doll (a plastic inflatable clown rhar righcs irself
creer being knocked over) and found rhar children who Basic oper:mc rechniques are frequently used in mental
had been warching chis aggression were more likelv ro acr hospital sertings. For example, Ayllon (1963) applied
:¡ggressively rhan children who had not watched me' adule. chese principies with a schizophrenic wornan who insisred
.\'lodeling is a cornplex process and can involve many on wearing severa! lavers of clorhing (dresses, shawls,
procederes. However, by observing a rnodel, a person can sheets, towels) weighing about 11 kg. Avllon modified her
grasp an eririre parrern of responding, as well as compo- behavior using food as rhe reinforcer. He told che patient
nene parts, In addition. afrer observation che observer C:1n that ro enter che hospital dining room, she would huve ro
askche mode! questions and receive feedback, The model be wei ghed and rnusr weigh less rhan a speciried targec
can 'also facilitare new-behaviors by prirning mese behav- weighr. At tirst she had ro reduce che weighr b~- abour 1
iors. That is. che behavior of me model may increase the kg. thar is. she had ro shed approxirnarely l kg of clorhing.
likelihood of similar behavior on the pare of che observer, After she rner chis requiremenr, stricter crireria were irn-
,\ Iodeling rechniques have be en used exrensively in che posed for subsequem meals. The parient did miss a few
rrearrnent of phobic disorders. The effectiveriess of mcd- rneals during the process. bur afrer u fe\\' months she was
eiing has bee n srudied in overcorning excessive Jemal wearinz onlv lA kg of clorhinz. This condirioninz trea t-
feurs. The subjecrs we re 15 girls (+-8 years old) who had mene obviouslv did not cure che schizophrenia. b;t ir did
pr eviouslv dernonsrrated phobic behavior abour rienral atfecr her relationship wirh her farnilv and other parients
trearment. In che rnodel -condicion, each subject was beca use more people wer e willing ro inreracr with her
seared behind a one-way viewing screen in me presence afeer she sropped looking so bizarre.
of a dental srudenr who inforrried rhe child mar she was
to observe a parierit undergoing dental rrearrnent. The
Token Econorníes
model was an 8-year-oIJ girl who was rehearsed in che
appropriare responses, '\\nen cornpared with adequare _,\ posirive reinforcer increuses che frequency or anv be-
controls. me behavior of che subjecrs in the group that havior ir follows. This principie has been widelv used in
viewed che rnodel was rured as more adaprive and marure esrablishing new behaviors in adults und children who
bv che deritisr and his ussisranr. During subsequenc rrear- lack selt-care and social ski lis, Food is .m obvious and
rnent chese children never needed any direcr supporr ro powerrul primary reinforcer: however. for ethicai reasons
control rheir fears of che denrisr. ir is dirficulr ro use tood direcrlv as a re inrorcer. To avoid
.\Iodeling has also been used successfully ro crear med- chis problern psychologists have used token e coriomies.
ical phobías in children and adules. .vlodeling transrnits A token econornv is J svstern in which desired behaviors
inforrnation, helps to reduce anxierv, and develops coping are reinrorced wirh tokens t e.g. plastic poker chips) that
skills in behavior-chariging programs, can be saved in a bank account and rraded for certain
privilezes. For exarnple, in sorne psychiarric hospirals, pa-
CLlNICAL APPLlCATIONS OF LfARNINCi tienes who dress thernselves. rnake their own beds, clean
PRINCIPLES their roorns, and socialize earn tokens mar can be spenr
that evening ro warch a movie.
Physician-Patient Interactions
This rechniqué. requires careful observarion of a pa-
Phvsicians are porenr sources of remtorcernent for pa- tients behayior ~by'che ward sraff, and boch me patierit
rients, and physician beha\-ior rremendousl;' inl1uences and che staff need ro be aware of which behaviors will be
che beha'lor of patiems, Ph~-sician-paciem imeraccions reinforced and ,vhich wilI nor. Because reinforcemem is
affecr me reliabilitl' of me informaoon given b~- me pa- mose effeccive when presemed as quickly as possibJe after
ciem, me paúenc's compliance. and me crearmem, Phy- me desired behav;or. it is mosr praccical ro give me paciem
sicians have to be aware of me reinforcing propercies of sorne form of roken, :\. token economy serup can make a
\\'ords such as "good" and ""es," of facial e:\:pressions, and ward easier to manage: mOre imporram, ir can assist a
of omer nonverbal oehaliors, This is especiaU~' true dur-' paciem in learning behaviors mar will help at1:er he or she
ing- me incernew beca use instrumental condiciorung- can leaves che hospical.
m;rkedly modify me verbal behav"ior of me paciem~ For Token economy programs have be en e;..:'tended to
example, a physician mal' inadven:encly reinforce one ser omer groups, including che mentally retarded, delin-

Leaming Theory and Human Beha,ior 277

A ••• , __ • _.'
 Programs lo Address Specífic Problems
. sink or swim approaeh may preclude any further contact
with the srirnuli. One explanation for traumatic neuroses Smoking. Cigarerre smoking is che leading prevenrable
(e.g., when a person refuses to ride in or drive an auto- cause of death in che Unired States. Each vear more than
mobile after a ear wreck and beco mes anxious at even rhe 360,000 people die as a result of tobacco-relarej] deaths
thoughr of driving) is that the individual has become so including cancer (129,000), coronan' hearr diseas~
overwhelrned by unmanageable anxiery that he or she (170,000), or chronic obstructive lung disease (62,000) as
eontinues to link the original stimulus with che presenc documenred by Deparrmenr of Healrh and Human Serv-
anxiery and cherefore cannot funetion adequarely. ices reports.
Ir is possible ro understand and treat nicotine addiction
using rhe principies oE learning theory ·and, specifically,
Biofeedback Applicalions
operant conditioning. Behavioral therapists attempting to
Traditionally ir was believed that che autonornic nervous treat patients addicted ro nicotine first examine che .-\.Bes
systern, which concrols visceral responses, eould not be of smoking, that is, che ,-lntecedems, Behavior, and Con-
eonditioned. However, work on c1assieal eonditioning in sequences. Figure 19-6 illustrates chis relationship. ,-\.5 we .
the Soviet 1:nion, showed char a large nurnber of visceral can see, che antecedents are either of inrernal or externa!
responses can be classically conditioned, for exarnple, sal- origino The behavior is che smoking of che cigarerre. and
ivation, intestinal conrractions, uterine eonaactions, tern- che consequences can be either posirive or negative.
perarure changes, and vasomotor responses. The goal of smoking cessarion programs is ro develop
Wirh che advent of biofeedback cechniques, sorne \'01- straregies ro disrupt chis ,-\.BC chain. For example, the
unrary control over autonornic responses has been shown srnoker who desires ro quir might alter. elle antecedents of
ro be possible. These observarions are of particular inter- smoking by giving up coffee or learning ro manage stress-
ese el) psychosomaric medicine beca use, in me psycho- fui siruations more effecrively; che bebnuior irseif couid be
physiological disorders (e.g., essential hypertension, pep- altered by employing other incompatible behaviors (e.g.,
tic ulcer. and asrhma), ir is frequenrly auronornic activirv exercising, eating fruit, or chewing ice) or by deciding ro
that is dysfuncrional. Consequeruly, there has been greac .smoke in only one room; and che consequences of smoking
inreresr in whether biofeedbaek craining of auronornic ac- cou!d be modified by che individual's providing personal
tiviry mighr be useful in che rrearment of psychosomatie rewards for successful avoidance of smoking (e.g., wacch-
illnesses. ing celevision only on nights when no smoking has oc-
Biofeedbaek rechniques have be en used ro help people curred) or by punishing himself or herself for smoking
lower blood pressure, increase peripheral body tempera- (e.g., with rapid smoking rechniques). Cigarerte smoking
rure (useful for patients with migraine heudaches or Ra~;- is a series of linked behaviors, al! of which can be dis-
nauds disease), and reduce muscle rension (it is widely rupred by the adoprion of competing behaviors. Elirni-
used with tensión headaches), The rechnique has also nation of che various antecedenrs can help, as can various
be en applied ro che treatrnent of rernporornandibular modifications of che behavior itself The individual can
joim pain, bruxisrn, and related stress disorders. infiuence che consequences of behavior by serring various
Taub and Ernurian (1976) trained subjecrs to alter- goals and rewarding himself or herself when they are
narely increase and decrease che cemperarure of che index achieved or punishing hirnself or herself if che goals are
tinger of one hand, using che brighmess of a lighr as a not achieved. Ways in which physicians can help pariencs
feedback signal ro indicare chariges in ternperarure. Their quit smoking are discussed more fully in Chaprer 11.
subjects progressively learned ro produce increasingly Obesiry. Obesiry is a major public health problem of
larger ehanges and che advanced stages of rraining could che entire Western world. The terrn obese refers ro che fae
produce quite specific changes. Sorne. individuals could conrent or adipose tissues of me body .. Alrhough far stor-
increase or deerease rernperarure by as rnuch as 6° or -;' age is an efficient methcd of holding energy in reserve
F. Suhiecrs tested after sevéral rnonths of not receiving for times whert food may be in shorr supply, for rnost
reedback rraining rerained chis control. people toda:' chis is not necessary. Too much body far is
One particular applicarion of temperarure biofeedbaek associated with severa! health risks and che social conse-
has been in che rrearmenr of rnigraine headaches .. -\1- quences of decreased physícal artractiveness. Tbe Surgeon
though che exacr mechanisrns causing migraine pain are General's Repon on Nutrition and Healtb (Deparrmenr of
not kn own , ir is beliéved to be associaced with che re- Health and Human Services, 1988) was a result of che
bound vasodilarion in che cerebral arreries followinz an recognition rhar che rnost prevalem nutritional problems
inicial vasoconsrriction. This theorv has led ro che use of in América are caused by overconsurnprion and irnbal-
volunrary, biofeedback-assisted hand warming as a trear- ances in dietary intake. By me mid-1970s ir had becorne
ment for migraine headaches. The reason for chis treat- clear that many of che leading causes of death in che
rnent's suceess is now known; it may reflecr a specific ef- Unired Stares were linked ar least in part ro me con-
fecr or result from simple relaxation, sumption of diets toO high in fat, calories, salt, and aleo-

Leaming Theory and Human Behavior 279

 r, .'
. .:.:4' ....:..... . .. " -;.;~
.....
_ ..: ..
.~._.:<':'~";
..:'''._.

l. Self-rnonitoring
.. LI -_A_N_TI
__ C_E_D_ENT5
· ~-1. 2.
3:-
Stimulus control
Response control
Externa I
4. Conringency management
Intemal
Self-monitoring, Self-moniroring is a 1:echnique used
Craving 1ime
Driving
in rnany behaviora! programs. Patients are required to
Bored
1ired Watehing monitor their earinz behavior and record me time at
Stressed television which they ate, wharthey ate, how rnuch was eaten, where
Angry Drinking
coffee
thev are, and (often) their thouzhts and feelinzs at thar
Talking on tim'e. These data allow che dete;runation of m'e anrece-
telephone denr and consequent events, which are focused on in later
therapy sessions. During che pericd of self-rnoniroring,

J bodv weizhr is also recorded on a rezular basis.

Stimu¡us control. Modificarion of me environmental
cues that elicit or rnaintain earing is called stirnulus con-
rrol. Examples of stimulus control strategies indude con-
fininz earinz tO one room, eatinz onlv at certain times,
associatine; ~o other acrivities ,\'ir:h eati~e- (e.z., not watch-
ing televisiori while eating), havirig only ;pp;opriate foods
available (e.g., shopping from a lisr that does nor inelude
junk food), clearing food away irnmediately after eating,
and srorinz food out of sizhr.
Response control. Learning to control the act of eatinz
BEHAVIOR
is also an irnportant pan of behavioral programs used ro
Smoking a cigarette belp people with obesiry. Because ir takes at least 20 min-

•
utes for satierv tO occur, fast eaters rnav inzesr an excessive
number of caiories before feeling me ph~';iological effects
of sariery. Patients are raughr ro eat more slowly bv laying
dO\\11 their urensils berween bires, counring che nurnber
. CONSEQUENCES
of chews, chewing slowly and rhoroughly, and sropping
for a period during me meal. Through chis slowing down
Rewarding Punishing patients m2~' begin to feel full when thev have caten less
Less eraving Nausea than rhey previously ate ar meals.
No: bored Dizziness Contingency nian agent en t. Conringencv man:lg-cmenr
Less tired Yellow teerh
refers tO the sysrernatic application of r eward and punish-
Stronger seh-irnage Cardiovascular
Social aceep:anee disease ment as a consequence of me patient's eating behavior.
Cancer Contingencv conrracts are frequentlv used ro build :3
Lung disease
cornmitment ro treatrnenr. In mis siruation the parient
FIQlffiE 19,6
provides a monetarv deposit, of which all or a portien is
5::j()kjng is ;! simple beh;n·jor \\";Ul. cornplex anrecedents anri cense- rerurned to che patient ar me end of the rreatrnenr pro-
q~enc.:cs. gramo For exarnple, a patienr may agree in a wrirren con-
traer ro lose 10 lb (4.5 kg) in a 5-week programo The"
rherapist collecrs an agreed on arnount. such as S50, frorn
me paticnt. At me end of the 5 weeks rhe parienr receives
55 for each pound lose. The balance of mcney not re-
I,Ol. and too ¡'.I\\' in ñ:);:;r ;¡nd orher healthv . dietar,'. fac.ors. rurncd is mailed, b~' thc rherapisr. ro ;1i1()rg~lI1iz;~ti();1 :h.:
Fi- ..e of che 10 leading causes of dcarh (coronary heart patient dislikes intenselv, This procedure is succcssrul in
disease. certain r:--pesof cáncer. strokes, diabetes mellirus, reducing artririon frorn che treatment programo
and atherosclerosis) nave been associated with dietar)" ex- Contingency maI12gemenr can also be applied ro
cesses and imbalances. changes in earing responses. Ir has been shown rhat pa-
F rorn the perspective of learning principies. obesiry . tienes who earn poinrs ior appropriare changes in behav-
rnay be viewed as che conseque nce of me rnaladaptive be- ior (e.g., record keeping, counring chews. or pausing dur-
navior of overearing. As with smoking cessation, mis mal- ing me rneal) learn LO modify their eating parterns. These
adaptive behavior C3n also be described in terms of the earned points can be used for tangible rewards. just as in
:\BCs. A rypical treatrnent program for overeating !D- me previously discussed token econorny procedure.
eludes me follo« ing behavioral principles. Dierary resrricrion alone has mer with only modest

280 Assessment of Patients

;..'.,.; ·f'· ,..... . _.::
........
,'. . .~.
,
. , , ;success. Trearment should also inelude establishing a reg-
ular exercise program, which increases me basal mera-
bolic rateo Weighr reducrion is not a short-terrn problem;
ir requires a long-rerm program and severa! life-sryle
changes,
Anxiery, Anxiery is <1 common symprom frequencly en-
countered by physicians. Ir is often found either alone or
in conjunction with other medical symptoms and can be
treated as an example of rnaladaprive learning. Wing
(l9í7) suggesred that ir is possible to explain me origin
of anxiery by one or al! of me three major learning me-
ories. For example, a patient felt anxiery whenever visiting
a particular part of town. A careful history revealed that
che parient had had severa! unpleasanr experiences in mar'
area, The unpleasanr experiences can be rhoughr of an
uncondirioned scimuli. The neizhborhood could be
thoughr of as che condicioned stirnulus. Thus a previously
neutral stirnulus is paired wirh an anxie ry-provoking stirn-
ulus causing che neutral scimulus ro attain anxiery-induc-
ing properries. This exarnple illusrrares che relarionship
berween c1assical condi rioning and anxiery.
A second possible explanarion offered bv \Ving is based
on operant conditioning and che facc that feeliñg anxious
·and behaving in an anxious manner usual!y occur ro-
gemer. An anxious person may nave been reinforced ac-
cidenrally by a parent or another person by receiving
more artention, symparhy, or even gifts whenever he or
she behaved in an anxious manner. (This operant condi-
tioning explanarion is based on the principIe that rein-
forced behavior rends ro occur more frequently in che
furure.) In chis case, anxiery is reinforced and rherefore
occurs more frequenrly.
A final possibiliry is based on che modeling theorv. The
anxious individual mal:. have had a verv. anxious father.
This individual imitares che father and develops anxiery
similar ro che fathers.
One further learning theory explanarion of anxiery
adopts a [\I.o·o-sragemodel, suggesring thar che inirial anx-
iery may resulr from c1assical condirioning bur mar, later,
operam condirioning plays a role. Dental phobia is an
exarnple. After an inirial traurnstic experience in which
che trauma is associared wirh me dental office (classical
condirioning), che person avoids furure visirs ro che den-
rist. This subsequem escape-avoidance behavior is nega-
rively reinforced by che reduction in anxiery (operanr con-
dicion..ing).
Obviously, these are nor me only possible explanarions
for anxie ry, There ar.e.also neurochem..ical, culrural, or
severa] psychodynamic explanarions. However. me aboye
three are learn..ing rheory posrulates and as such should be
considered in conjunction with other explanarions when
examíning a parient's hisrory of me illness,
These explanations of me origin of anxiery can dictare
me rnethods chosen ro ameliorare its effects on che pa-
ciento Severa! of the mechods given earlier have be en used
in che treaanent of anxiery, specifically, biofeedback, sys-
. ...
t~maric dese~sicization, and flooding. The basic assump-
non underlymg mese treatments is that a person cannot
be anxious and relaxed at che same rime. Therefore, after
learnir J to idencify an.x.iety-provoking events and how ro
respond to thern with incompacible behaviors (i.e., relax-
ation), me person can reduce the anxiery response, An-
rianxiery agents, such as che benzodiazepines, are sorne-
rimes used as a short-terrn intervention while these new
behaviors are being learned.
The physician's theoretical beliefs abour rhe cause of
anxiery may influence treatment, For example, if me phv-
sician acceprs a c1assical condicioning model of anxierv,
treatrnenrs such as sysrernatic desensitization are appro-
priare; in facr, mese techniques have been highly effective
in che rreatment of a variery of phobias. A physician wich
a more operanr view of learning is more likely ro look ca
me patienr's environment ro determine what rewards are
rnaintaining che patient's anxiery and ro decide how ro
strucrure trearment so that avoidance and wirhdrawal are
no longer allowed ro re in force che anxiery response thar
occurs when che parient is around the stimuli he or she
fears .. -\ person cornmirted ro the social lenrning theorv
rnay look for significant persons in me parienr's life who
have modeled rnaladaptive anxiery for che parient. A phy-
sician with a srricr neurochemical orientation may rejecr
alrnost all learning rheories and explain anxiery in terrns
of poorly understood biochernical changes. However, iust
as a single model is seldom adequate ro explain rhe phe-
nomenon of anxiery cornplerely, one approach ro rreat-
mene is seldom ernployed in isolation, and trearrnenr rnosr
ofren combines a combinar..ion of medicarion, psycho-
rherapy, and behavior cherapy that perrnits frequem and
prolonged exposure ro che stirnuli thar have previouslv
rriggered anxiery,
SVMMARY
This chaprer reviews che rhree main theories of learn..ing:
classical condirioning, instrumental conditioning, and
rnodeling. All have applications tO che trearrnenr of pa-
tienes. It has been shown that cerrain fears and phobias
can be acquired via c1assical conditioning. These fears can
be rreated by a variery of techniques, including modeling
and sysrematic desensitization. Fears and other inappro-
priate behaviors can be maintained by reinforcemenr,
such as through me avoidance of me feared evento By use
of che techniques of biofeedback and relaxation rraining,
many of rhese medical disorders can be successfully
rreared.
The principies of learning are irnportant in che rnan-
agement of life-sryle problems such as excessive smoking,
obesiry, and alcohol abuse. The health risks associared
with mese excesses are irnmense and can be markedly re-
duced by me use of me principies of learning ro rnodify
me parient's life-sryle.
Virtually al! forrns of psychotherapy can be concep-
Learning Theory and Human Behavior 281

.rualized' as being part of melearning process, for exarnple,
an individual lea m in tia new attirudes about himself or her-
0. •• '. • •
self and others (modifying his or her self-concept), chang-
inz his or her ernotional
_" _.:J ._. __ ... _ .. _.' _
reacrions . via assertive behavior
_.
.. when fearful, or learning relaxarion techniques to reduce
stress, The acquisition of new appropriare and effective
behavior also involves me principies of learning. Learning
and condicioning can play irnportant roles in medicine,
not only in me treatmenr of disorders but also in the pre-
venrion of diseases.
CASE STVDY
Fir st Visit
Mrs, i\l, is a 30-year-old, married wornan seen ter a gen-
eral physical examination. She was found ro be in good
physical health. 5he expressed concern about her smoking
and asked abour joining a smoking cessation programo As
a pan of me follow-up interview, she stared mar she cur-
rently smoked approxirnately t\.VOpacks of cigarertes per
day. 5he had a hisrory of smoking regularly ove r me past
·15 vears. She said that she was zertinz worried about her
smoking and its effects on her -healr:h and would "reallv
like tO Stop." She asked her physician if he had an~' sug-
.. gesoons.
tI'7J!It can .vou. do ro heIp )'0117' patienti 'Is belpÍllg ber to
quit-e-once )'011 've told ber to quit-e-really pm-r of vourjob? Do
)'011[eel c07l1perCllt ro belp ber Y01l1'JelJ, or does addicticn ro
nicotine require rejerra! to a psvcbologist 0]' psvcbiatrist?
Decerrnination of me Patient's Reasons for Smoking
Cessation. The physician reviewed me patierits reasons
for wishing 1:0 stop smoking. Mrs. 1\1. W2S concerned
about che healrh of her children who wer e exposed ro her
second-riand smoke, her own "srnokers cough." and her
added risk because she was raking oral birth cO:1ITolpills.
The phvsician concluded thar rhe parient appeared to be
motivated to stop smoking, had arrived at mis decisión by
herself. and had gcod reasoris for wanring ro stop smok-
Ing.
Are (be paricuts [ears rcnlistici Has sbe dalle (/ reasonablc
job o/ c,((imaúllg bcr ¡-¡JI.: o/ morbidity 171ldmortalitv as a C07/-
sequencc of be]' smoking? Are tbere t11l_1' otber risl: _(acto]'_<
tbe
client /;0,< not brougbt up? D' bcr couccrn about he¡' cbildrcn's
risl: [ror» passivc smoke justificd:
Developme nt of a Prograrn for Sropping Smoking,
The physician explained to rhe patient thar ir W¿5 irnpor-
tanr thar thev work rogerher ro develop a plan ro help her
$WP smoking and thar one of me most imponam pieces
of information \\'as a daily smoking record. ;\11'5, ;\1. was
asked ro keep a record of each cigaretre she smoked. She
\I'as 2sked te>nore rhe time, location, moti\'aoon. and the
actil'ir'\' in which she was en~?~ed el'en' time she smoked
a ciga~ette, The physician -ga-\'e her ~ree daij~' record
sheets and told her to fill mem in for me nexr 3 davs so
me\' couJd discuss rhe records at rheir nexr meetinQ'. (The
dat~ to be collected will gi\'e the c1inician a record of me
282 :\ssessment of Patients
...
antecedents of her smoking behavior). He then asked ¡,;er
if she could foresee anyproblerns in her attempt to' srvp :: .•..•.
smoking, The patient said mar she had heard mar mere
may be sorne uncornfortable withdrawal symprorns and
. weighe gain was Iikely aft~r quirting. She srared that her
husband did not smoke and that he would be '\'ery sup-
porrive of her decision. The physician assured her mar
me withdrawal symptOms could be minimiz.ed and thar
thev would discuss ways ro avoid any major weighr g;1in,
An appoinrmenr was scheduled for 1 week from chis ap-
poinrment.
Are the patient's C01/Ce171,Cabout -¡;;eight gai7/jusr~fied? Hot:
í:!ill .1'011 counscl bcr about tbc relarii:e risl:s of .<111okil/g a1/{I
obesity]
Second Visít
The parient rerurned for me second visir and brought her
three daily record sheers with her. .
Analysis of the Patient's Daily Smoking Records, A
review of mese records showéd mar approxirnarelv 60%
of Mrs. :\1.'5 smoking was in response tO iob stress. She
said mar she felt a lor of pressure in ha wor k arid thar
she was smoking ro help her relax, She also consurned
several cups of co ffee each dav while she \\'2S at work, This
may ha ve contribured ro her nervousness on me jobo Ir
was an office policy that she had ro go outside oí' her
building to smoke. The second most consisrent place for
her ro srnoke was in her car. and she srnoked at leasr one
cigarerte everv time she was in her car. She also smoked
ccnsisrently but \\'im less regulariry whe n she waeched
televisión in her den.
Can ,1'011 II-,C infomrorion about tbesc "discrirninati ic srim-
uli" to belp ."0111' patient quit SlIlOi.:illg?
Development of a Plan for a Smoking Cessarion Pro-
gram, Based on me data discussed earlier. tne physician
suggesred me following srrategies ro disrupr her smoking
p;lttern. Firsr, ar work when she felr stresse d. rarher than
smcke a cizarerte. sne shoulcJ leave hcr desk 3n¿ f'C> ror ~j
walk either inside or outside of me buildinc, He also suc-
gested mar she purchase a caffeine-fr ee di~r sort drink or
get a glass of water and sip on this wheri she rerurried ro
her desk rather than drinking coffee, He explained thar
bv reducing her caffeine inrake she would decr eas e her
nervousness. Second. ro reduce her urf!~ ro smoke in her
car, the uhvsician 5U2"Q't:s'(.:'d thar 5-11r: j<.)~.~ he:" .::iq~~rt:~lt'~
in the tr~nk o;' the c;:¡-r~
rcrnove the ciuar er:c. iié'¡jt~r
, - trorn
rhe car, and haye 3 pack oi sugar-f!'ee g-'.!il1 in me C2í t(\
che\\' on insread. Third, rhe physician s\]g~ested thar she
snould leave rhe cigarettes in me trunk oE her ear so thar
when ,she felr rhe desire ro smoke she had r<1 >Ir) tO the
f!ar3f!e ,md s:noke ir rnere. The n!l':sici:;" wlc'.\lrs. ,\1.
~ar -he knew ir \\'ould be \'ery ciitriculr tú her to Stop
smoking immediately, and he suggested rhar she do t\\'o
things: ser 3n imrnediate goal of smoking nO( more than
one cigarecte per hour for an inicial maximum of 1~ clg-
____ ; •• ,,<f" ••
.,
• ''1,
'c.. ~rettes per day and set a date within the next rnonth for
, qulttmg.
As a reward for saving rnoney by reducing her cigarette
consurnption, the physician suggested that she put the
money she had saved in ajar. She should plan ro purchase
sornething for herself when she had saved a certain surn
of rnoney, such as a cornpact disc or SOI11t:perfume.
The physician also suggesred thur a brief course in re-
laxation rraining would provide .\lrs . .\1. wirh un alter-
native means of handling- rhe stresses of her jobo He g;a\'e
her a brief overview of the procedure and a ser of rwo ;elf-
instrucrional audio relaxarion tapes. The parient \\'3S ulso
told ro record every cigarerre she smoked in rhe next week
on rhe daily record sheers provided .. Afrer answering' a tew
of rhe patient's questions. ;1 follow-up appoinrment wns
scheduled ter 1 week frorn this appoinrrnenr.
Has tbe pbvsician bandied tbe case competently so far? Ú
tbere allyrbillg else be could bace done ro belp bis patient in
ber ~tj07LS ro Jtop .~7J/oh71g?
Third Visi!
The patient rerurned as scheduled and said rhar she had
, Telephone
almost cornplerelv eliminare d smoking at horne but \\";IS
srill smoking approxirnarelv six cigarerres per dav at work
and severa] in her car. The c1inician cold her thar she had
done very well and asked her about using methods orher
[han smoking ro handle her stress. She said rhar [he re-
laxation tapes were helptul but rhat she iust could nor guíe.
The clinician reviewed her dailv smoking records arid
noted rhat mar.~' of [he cigurerres hud been smoked in
response ro work stress. He decided thar [he patienr re-
quired more rraining in relaxation and stress m,1I1<lge-
mene, He discussed chis with her .ind g3\'e her a srep-by-
step oudine of anxiery reduction rechniques., \ \ 'hen the
physician asked the parienr ubour her conrinued smoking
......- . vÓ:
. _ .. r. •. -__ ". _)~ n. ••. .. .
,¡
J
in her car, she adrnitred she had nor placed her cizarerres
in the trunk of her car but had kepr thern in he; purse.
The patienr agreed ro place the cigarertes in che rrunk of
her car rhereafrer.
"\Vhen asked abour setting ;1 date on which ro stop
smoking, che parienr said that ir was her birthdav in 1-:
days and char W;JS her rurget dure for quirting. Sh~ nore d
rhat ;1S uf chis time she hud hud no rnujor wichdrawol
symprorns und no noriceable weighr g¡lin. The clinician
said that wirh rhis gradual tapering off uf her smoking,
she should not experience anv physical wirhdrawal 5\111P-
torns bur rhur she would cO~(in~le ro crave tObacc~ f~r
sorne time. \\'ith respect ro the weighr g3in. he ;~ges(ed
that she (ry ro gr;:¡du;ll1~' incrense her daily exercise re gi-
men DV usinz [he sruirs at work und DI' rakinv a shorr -;\';:dl-:
whene"'er 5he felr rhe ,urge [() sl11ok~. ·He ;1150,sugg::srea
chal she eat or drink low-calorie toods such as dier drinks.
suzar-free zurn. and fruir when she felr the urze rosrnoke
insreud of higher-c:;¡forie toods such as C¡lnd~:-;l~d PO(;l[()
chips. He usked her ro cull hirn 3 01' -+ dJ~'S utter ;1<:: ¡;jrget
dure for sropping smoking,
Conversation
Th''; patienr callee! back ~ days afrer her rarget duce ;:0 :i~I:'
tha [ she had still nor cornplerelv stoppedsrnóking fiii"é had
reduced her daily consurn priori ro no more [ha" rive ci::r-
arerres per dJY, ;111smoked durirur wor]; hours: :lile S;Ú(!
rhur she would continue using' (he reluxarion rechniqucs
and rhat she \\'<15feeiing verv good about her ?L'og-rcss,
The clinical .isked her ro call hack in abour 1 monrh,
Tbis patient Ú (OmÍll/ú7lg ro stnol:r. f n,,/( isbcr :,rr;",!."I.'(j,,'i.";
Sbottld medicntinn b«:e bccu ttscd a.\· da IIJ¡~'/!I¡I¡""" ;-,··-..'.?¡/IICi/:.;
Do _ro/{ tbiul: tbc pIJYÚ(ÚI7I bns been gfiiiw¿ .tccuratc JIi,I _;-;'ljiil
tbe p.uieut? ¡_.. tbcre f/l/_l'rbiug jurtber tbe pbysicinu (di.' Jo ro
bCI:o i_.ú p.tricnr?
Learning Theory and Human Behavior 283
 , .•..~~.•. -
. ----.- ....•. _--....;__ -~
. '_ .•' .,:'.'>~,.-', . ~.~ ;'
.. .,...._--_ ...~

"::7 •
••. • f~
. 'SUGGESTED READINGS Taub E, Emurian C: Feedback-aíded sdf-reguJarion.of skm remper a -.,.. ..~
Avílon T: Inrensive rreatrnenr oé psychoric behavior by srimulus sana- rures with a single feedback locus: 2. Acquisirion and reversal training:r .::
. cio~'and food reinforcernenr, BebaeRes Tbn- ¡:53-61, ¡963. Bi~rwlbacJ:SdfR,gull:147-151, 1976. '. \:-
'This classic amele dernonstrates me applicarion of instrumental con- This amele provides a good descriprion oí me procedures used in
áirioning cechniqueson me modificarion of me behavior-ofa -schiz- . bicfeedback.rraininz ..
ophrenic. ',-'ing G: Learninz theorv and me behavioral rnodel of mental illness.
Lurie H]: Praaical m.an.!Jgmlmr nf rmotional problems in medicine. i'-~ew In - Simmons RC, Pard'es H (eds). Understanding human bebauior in
York. 19S~, Raven. bealtb and ilJ1WS. Baltimore. 197í, Williams & Wilkins.
This book has 5<:\'<T2l excellenr chaprers 011. tOe applicarion of behav- This chaprer discusses che possible sources oi anxiery behsvior frorn
ioral rechniques ro che trearment of various psychological problcrns. me various learning theory perspeccves .

. - .._ ~. .:~:!;
284 Assessment of Parients