ON BEHAVIOR THERAPY: A CRITIQUE*

IRVING BIEBER

New York Medical College,

New York, New York 10029

It is as therapy that psychoanalysis began and as such it has developed and

thrived; however, our professional commitment to psychoanalysis as treat­
ment and science does not close us off from an interest in other therapies that
purport to resolve psychopathology. We want to know what different thera­
pies do, how they do what they say they do and what can be learned that can
be useful, so that we may incorporate new and valuable contributions into
our discipline.
For me, psychoanalysis is defined more by its goals than its tactics and
techniques. A method which has as its goal the resolution of psychopathology
through a cognitive process of delineating and extinguishing irrational belief
systems, is psychoanalysis. Styles and techniques are adaptable and lend
themselves to meeting the needs of various patients in different ways and I
consider a therapist whose methods and formulations are identical for each
patient to be an assembly-line thinker, limited and inflexible. It is in this spirit
that I turned my attention to a serious appraisal of behavior therapy.
Behavior therapy is basically rooted in stimulus-response theory. Labora­
tory psychologists for many decades now have been attempting to free S-R
theory from an exclusive preoccupation with muscular contractions and
physical energies and to stretch the theory to accommodate higher mental
processes, behavioral, cultural, and societal phenomena, and especially since
World War II, diagnosis, psychopathology and therapy (Berger and Lambert,
1968). S-R theory has indeed been valuable heuristically, in our own field
notably to Abram Kardiner, who used it as a paradigm in investigating basic
personality in the various cultures he studied (Kardiner, 1939). In brief, he
viewed cultural institutions as the units of stimulae, and social behavior as the
elements of response through which he delineated basic personality.
There are now many mini systems within the framework of the stimulus-
response theory, as in theories of conflict such as approach-avoidance, frustra­
tion-aggression, threat-inhibition, and so forth. Within the framework of that
♦Presidential Address, Academy of Psychoanalysis; read April 30, 1972, Dallas, Texas.
+Address all reprints to the author.
39

J. Amer. Acad. Psychoanalysis, 1(1):39-52

©1973 by John Wiley & Sons, Inc.
40 / BIEBER

system called “behavior therapy” there has been a rapidly increasing diver­
sity, and despite the common interests and common ground of the therapists
themselves, there are many disagreements and schisms. So much so, that
because of the increasing variance in methods and formulations, behavior
therapy appears not to be the unitary theory it essentially is. The basic point
agreed upon, and which I think defines behavior therapy, is that neurotic and
psychiatric behavioral symptoms are maladaptive bad habits acquired through
somehow having learned them. The bad teacher (or situation) is the noxious
stimulus-the bad habit, the response. The somehow, which is that vast area
in between, has no place in their schema. Once established, habits lead an
autonomous existence and are no longer organically related to the processes
from which the habits have sprung. In sum, behavior therapy is directed to
changing and improving malfunctioning, maladaptive responses within a
stimulus-response arc. In order to effectuate these changes, various workers
have emphasized varying aspects of the theory and methodology.
Joseph Wolpe (1969) is one of the pioneers and authorities in behavior
therapy and the one most involved in clinical work. He is especially identified
with a method known as “systematic desensitzation,” a concept fundamen­
tally based upon an immunilogical paradigm. Systematic desensitization con­
sists of exposing a patient to increasing doses of the noxious stimulus, a
method that may be compared to the treatment of allergies, until desensitiza-
tion is effected. Thè éxperimental underpinnings of Wolpe’s technique rest on
his experiments with cats who were rendered neurotic by exposing them to
electric shocks in an experimental chamber. Treatment consisted of putting
the cat in a room similar enough to the experimental chamber to trigger an
anxiety response, but dissimilar enough to minimize the anxiety. The animal
was then given food in the new room. Presumably, the feeding extinguished
the anxiety through a mechanism Wolpe calls “ reciprocal inhibition,” that is,
the anxiety and feeding became mutually exclusive. Actually, the concept
and term, reciprocal inhibition, was introduced by Sherrington in the latter
part of the 19th century to describe the simultaneous inhibition of the flexor
muscles of the arm when the extensors are innervated.
• Encouraged by his experiments with cats, Wolpe began to use systematic
desensitization to treat phobias. Instead of using feeding for the reciprocal
inhibiting stimulus, he substituted a relaxation procedure, assuming that
complete relaxation is physiologically incompatible with an anxiety state. I
shall come back to this point shortly. Wolpe constructs a hierarchy of phobic
stimulae and the patient is then exposed to the least noxious stimulae to
produce the least anxiety. If a patient is being desensitized to a dog phobia,
the hierarchies may consist of two variables—distance from and size of the
animal. Wolpe might first introduce a puppy at the far end of a large room.
The patient experiences miniai anxiety and then is encouraged to relax. Not
 BEHAVIOR THERAPY / 41

until the minimal stimulation fails to produce anxiety is the next stronger
stimulus introduced, that is, a larger puppy or at a closer distance. The de­
sensitization is continued until the patient is able to tolerate the close pres­
ence of a dog or perhaps handle the animal without anxiety. Originally used
to treat simple phobias, the technique has been extended to other sorts of
fears—patients are desensitized to social fears, fear of taking examinations,
and so forth.
Wolpe’s basic premise about neuroses is that they are persistent, unadap-
tive, learned habits of reaction. I believe that the basic fallacy in his thinking
is contained in his view that anxiety is almost universally a prominent
constituent of neurotic reactions, and since anxiety involves a primitive
(subcortical) level of neural organization, its unlearning can be procured only
through processes that involve this primitive level. “Neurotic anxiety cannot
be overcome purely by intellectualization-logical argument, rational
thought-except in the special cases where it stems entirely from misconcep­
tions.”
To put these ideas into a syllogism, they read: anxiety accompanies most
neurotic reactions; anxiety is mediated through a subcortical mechanism,
therefore anxiety cannot be removed by insight which is a cortical function
and therefore the major strategy must involve techniques to eliminate anxi­
ety.
Wolpe conceptualizes anxiety as the cause of neuroses instead of its
symptom. Anxiety is, in fact, a physiological response to a perception of
threat; it is an excitatory hypermobilization of basic physiological resources
preparatory to meeting a threat and it is manifested in such hypermobiliza­
tion events as tachycardia, tachypnea, rise in blood pressure, and so forth.
Relative to the situation, an anxiety response may or may not be abnormal. If
one comes face to face with a lion, one will normally experience anxiety.
Neurotic anxiety refers to an alarm response to a stimulus which, in reality, is
not threatening. If an individual with an insect phobia develops the same
degree of anxiety on meeting with a roach that he would with a lion, the
reaction is neurotic, not because the anxiety reaction itself is abnormal, but
because the perception of the roach has been distorted into a symbol of
danger. Anxiety is anxiety whether triggered by a realistic or illusory threat.
Neurotic anxiety is always based on misconceptions, not, as Wolpe claims, “in
special cases.” The therapeutic aim, therefore, must be to change or extin­
guish irrational ideas, not simply eliminate anxiety. In sexual impotence
where there is an inhibition of erectile potential, the impotence may occur in
the complete absence o f anxiety. The impotent individual fears engaging in
sexual intercourse; however, fear and anxiety are not identical. Fear is a
cognitive awareness of danger. One can be afraid to fly, be quite aware of the
fear, but develop anxiety only when faced with the experience itself. In
42 / BIEBER

impotence, anxiety may not develop simply because the inhibition precludes
sexual activity, the feared situation. As I mentioned, Wolpe assumes that
relaxation reciprocally inhibits anxiety or is incompatible with it. I have
observed individuals who were relaxed muscularly but had tachycardia and the
sweating typical of anxiety. Some showed these signs of anxiety while
presumably relaxed during hypnosis; others were in various other types of
situations. Wolpe has not reported the vital signs of his patients under
relaxation. By counting carotid pulse, for example, pulse rate is easily
determined, as is respiration and so forth. Without such data, the assumption
that relaxation reciprocally inhibits anxiety remains unsupported.
Classical psychoanalytic theory has also been in error in its view that
anxiety is a central focus around which psychological defenses are formed.
Most defenses become organized as a protection against anticipated'danger.
Thus, if an impotent man fears castration for having intercourse, the impo­
tence is not simply a defense against anxiety but against castration. Now, if
Wolpe had proposed that anxiety is a good way to test the intensity of
irrational fears, as in the case of phobias, that would be a different matter. If
a patient with a dog phobia no longer reacted with felt anxiety to handling a
dog, it would indicate that his irrational belief in the danger of all dogs had
been greatly modified or extinguished.
Actually, Wolpe actively involves cognitive functioning in his therapeutic
work. In some instances, he does not present patients with the threatening
stimulus; instead, he instructs them to imagine it again and again in appro­
priately desensitizing dosages. Obviously, imagination is a function of cortical
activity, as are responses to instructions to relax. He also attempts to
neutralize a patient’s anxiety by teaching him assertive attitudes and acts.
Surely, such attitudes and behaviors are cortically mediated, as are behavioral
rehearsals, a technique involving role play which he also uses. Originally, he
referred to this technique as “behavioral psychodrama,” but later thought
behavioral rehearsal a more suitable term. The therapist takes the role of a
person towards whom the patient has a neurotic anxiety reaction. The
patient is instructed to express formerly inhibited feelings with strong emo­
tion and in a firm, suitably modulated voice. The patient is made to repeat
each statement over and over, being constantly corrected until the utterance
is in every way satisfactory. “The aim of the rehearsal is, of course, to make it
possible for (the patient) to express himself with his real ‘adversary’ so that
the anxiety the latter evokes may be reciprocally inhibited and the motor
assertive habit established.”
Thus, Wolpe’s second major therapeutic technique is assertiveness training.
He maintains that phobias may be alleviated through self-assertion. Illustra­
tive is his report of a 32-year-old woman who developed a phobia of knives
when she was 26 years old while still in the hospital following the birth of a
 BEHAVIOR THERAPY / 43

son. She had the persistent fear that she might use a knife to injure her child.
All knives had to be removed from her home. Wolpe concluded that her fear
of knives was based on her inability to assert anger; why she was so angry
seemed beside the point, but she first had to learn to assert it before being
desensitized about her fear of knives. As a psychoanalyst, my assumption
would be that the patient had had a postpartum, depressive reaction with an
accompanying fear of injuring her child, a common symptom in postpartum
reactions. A frequently noted fear during the pregnancies of such women is
that something will be wrong with the child. Many normal women have such
a dread but it evaporates with the birth of a normal baby. The later
postpartum psychiatric syndrome may include the fear of injuring one’s child.
In my clinical experience with patients having a reaction like the one Wolpe
described, the psychodynamics almost invariably involve a masochistic need
to injure a highly valued object. The masochistically derived destructiveness is
a defense against unconscious expectations of hostility and predation from
the mother, a fear usually generalized to include other women. Wolpe’s
failure to associate the symptom with a postpartum reaction especially since
the symptom appeared so soon after the delivery, and his exclusion of the
psychodynamic processes inherent in postpartum reactions, led him to an
erroneous interpretation and, I think, inappropriate therapy.
On the other hand, Wolpe has described in detail a patient with a
traumatic neurosis following an auto accident. His personal dedication to her
therapy and the success he achieved with her are impressive. Once a traumatic
neurosis becomes chronically established, it is incredibly intractible to most
other types of therapy. But it is also clear that in this patient-the rapist
relationship, there were present those psychoanalytic variables that Wolpe
denies exist in his procedures. Marmor (1971) has pointed out that Wolpe’s
disclaimer against any psychoanalytic variables appearing in his work merely
reflects his failure to appreciate the complexity of variables involved in the
patient-therapist relationship. Says Marmor, “I cannot believe that anyone
who watches Wolpe’s own filmed demonstration of his technique would agree
that there are no elements of transference, insight, or suggestion in it. Indeed,
one could make as plausible a case for the overriding influence of suggestion
in his technique as for the influence of desensitization.”
If we turn the problem around and ask whether psychoanalysts, as part of
everyday practice, use behavioral techniques, I would say we do—at least I do.
For example, I have a patient who had never felt at ease in the presence of
others, never free and relaxed except when alone. He is now in a relationship
with a woman who is in love with him and completely accepts him. I have
worked out with him all those private behaviors he considers to be unaccept­
able and I have been encouraging him to express in her presence those
behaviors he is ashamed of. They are, of course, quite normal, including
singing which this mother actively discouraged despite his good voice. Until
44 / BIEBER

recently, the patient had been unable to spend a complete night with his
sweetheart. Of late, he has been able to spend weekends with her and feel
comfortable. The psychoanalytic process was never even slightly disturbed by
direct efforts to modify certain of the patient’s anxiety ridden behaviors.
For many years, B. F. Skinner had been deeply immersed in his well-
known black box in which he and his followers had been conditioning and
unconditioning experimental animals. Now he has moved to the more formid­
able arena of philosophy and social engineering, but the name of the game is
still operant conditioning. It is the keystone of his larger concept involving
man and society and which he refers to as behavioral technology.
As to what, in brief, operant conditioning is about: An operant is a
behavior that can be controlled by its environmental consequences, that is to
say, it is a behavior whose fate is determined by the effects it produces. Thus,
if a behavior evokes positive responses, i.e., attention, affection or rewards, it
becomes positively reinforced and the probability of its repetition is greatly
increased. The reward and other positive responses are termed “positive
reinforcers.” If the behavior results in the removal of a noxious stimulus such
as disapproval, then the operant behavior is also reinforced; this is called
“negative reinforcement.” Hence, behavior may be reinforced by either of
two sets of contingencies-positive reinforcement or negative reinforcement.
A stimulus that follows a behavior and weakens the immediately preceding
response is a “punishing stimulus.” An “aversive stimulus” is an example of a
punishment stimulus. When behaviors that had been reinforced or diminished
by punishment no longer are subjected to reinforcement or punishment, the
effects of these contingencies then tend to disappear, a process termed
“extinction.” Several basic environmental manipulations can be applied to
the development, maintenance, or êhange of operant behavior: reinforcement
contingencies (positive and negative), punishment contingencies, and extinc­
tion.
As a conceptual model, operant conditioning may be quite logically applied
to some of the processes and procedures of psychoanalysis. Patient produc­
tions can be categorized as the stimulae and the analyst’s responses (silence,
gesture, or verbalization) as the contingencies. The analyst may reinforce a
production by interpreting it, thus indicating a positive reception, or the
production may be discouraged by silence, the silence possibly interpreted by
the patient as disapproval, a punishment contingency. To elucidate further, if
a patient brings a dream or produces associative material he believes to be
unacceptable, i.e., masturbation or incestuous feelings, and the analyst
remains silent, the silence may be reacted to as a punishment stimulus. The
material would then tend to disappear rapidly from future productions. I
have noted that if a patient depicts incestuous behavior in the manifest
 BEHAVIOR THERAPY / 45

content of a dream and the analyst does not direct himself to it, the
production may not again appear that explicitly. I categorically instruct
students to be alert to material they think the patient regards as highly
unacceptable. Whenever it surfaces, it must be handled in that session. Some
students consistently reinforce certain types of productions by interpreting
selected productions, yet extinguish others by disregarding or actively intro­
ducing another theme each time the verboten subjects come up; or they may
subtly convey a negative attitude through restlessness or some other sublimi­
nal communication.
With certain obsessional patients I employ techniques that could also be
described as operant conditioning. As the analysis proceeds, most obsessive
patients can begin to recognize their obsessions as diversionary symptoms. I
encourage them to search for the real fears being concealed by their obses­
sions and I teach them to approach the obsessional content as one would the
manifest content of a dream; however, when a patient obsessively and
repetitively produces the same unproductive material, I deliberately do not
respond. This deliberate lack of response may be viewed, I suppose, as
negative reinforcement; it is calculated to stimulate the patient to produce
material to which I will respond. Obsessive patients often attempt to engage
the therapist in sterile dialogues about their intellectualized rationalizations;
the more experienced analyst usually avoids these defensive quagmires by a
judicious silence.
In the last decade, Skinnerian principles have been adopted in treating
male homosexuality; aversive conditioning as a technique proceeds as follows:
A homosexual subject is shown slides depicting erotic homosexual situations
which the subject himself has chosen as particularly arousing cues. He views
the scene for a given period, say 8 seconds, and is then given a rather painful
electric shock through electrodes attached to his arms. The patient can
prevent the shock if he presses a switch that turns off the homoerotic slide
before the 8-second period is up. In the next stage of treatment, the subject
cannot guarantee shock avoidance simply by switching off the slide, since
shock may occur at any point during the viewing. Shock can be avoided only
by immediately replacing the slide by a heteroerotic one. This technique
purportedly extinguishes homosexuality and institutes heterosexuality.
The idea that the extinction of homosexuality automatically establishes
heterosexuality is neither theoretically sound nor is it supported by clinical
evidence. It may I» compared with the spurious notion of a fixed energy
system, as exemplified by the libido theory which proposes that if sexual
energy does not flow into homosexual channels, it will, of necessity, flow
into heterosexual channels. This same idea is reflected in the supposition that
if a patient stops masturbating, he will more likely have intercourse. From
psychoanalytic experience, we find that only when a homosexual patient
46 / BIEBER

resolves his fears about heterosexuality can he make a heterosexual adapta­

tion. An enforced termination of homosexuality merely establishes an asexual
adaptation.
The results reported for the treatment of homosexuality by aversive
therapy are indeed extraordinary. Feldman and McCulloch (1967) claim a
50% rate of reversal to heterosexuality within 5 to 28 sessions of aversive
therapy with 8 to 10 booster sessions the following year. Marmor (1971)
suggests that electric shock is so painful, that only those homosexuals very
strongly motivated to change would undergo this treatment and that given
such intense motivation for change, any procedure could be successful. The
long-term homosexuality study by Bieber et al. (1962) established a positive
correlation between a patient’s expressed wish to change his sexual adapta­
tion and achieved change with psychoanalytic therapy.
Operant conditioning techniques have been used in the treatment of
psychotics in psychiatric institutions (Sherman and Baer, 1969) in attempts
to promote more desirable behaviors and extinguish undesirable behaviors.
The method involves establishing a token economy on the wards; that is,
tokens having the value of privileges are given as rewards for those behaviors
to be reinforced, while deliberate inattention is directed to those behaviors
the staff and therapists wish to extinguish. As far as I can determine, the
token economies have met with limited success. What success has been noted
is restricted to behavior in the hospital and is not generalized to the patient’s
post hospital behavior.
As a theoretical model, operant conditioning is but one way one might
systematically order analytic data in order to sharpen an understanding of
ongoing processes and thus be more effective therapeutically. It is one thing,
however, to view operant conditioifing as a useful model; it is quite another
to elevate it to a system of psychology. As a psychological system, it excludes
the cognitive and affective processes that are as inextricably part of human
psychology as mass and energy are part of physics. Feelings, thoughts and
emotions make up the intricate tapestries of interpersonal relations that mark
us as human. Bypassing these variables can only result in a dehumanized,
anomic, sterile pursuit where a behavioral sequence becomes a machine-like
mechanism to be manipulated technologically, and where motivational and
interactional processes, now reduced to useless sentimentality, become
assigned to limbo. Skinner’s proposal that operant conditioning be the basis
for planning the future of mankind has the Chaplinesque quality of a
super-dictator building molds into which people are to be cast, yet the
dictator is quite ignorant about the material he is casting into the
molds.
H. J. Eysenck is also a pioneer of behavior therapy and one of its leading
theorists and methodologists. He has had a profound influence, particularly
 BEHAVIOR THERAPY / 47

on English psychology and psychiatry, an influence that has directed it away

from psychoanalysis, though more recently, psychoanalysis seems to be
gaining some ground again.
In his first large study in 1944, Eysenck assembled a patient population of
700 neurotics and scored them for 39 items covering social history, person­
ality, and symptom manifestations. Using a statistical technique, factor analy­
sis, he constituted two bipolar continuua. He called one the
“neurotic-normality continuum” ; the other, the “ introvert-extravert con­
tinuum.” The. variables distributed on the neurotic-normality continuum
were: 1. badly organized personality; 2. dependency; 3. pre-illness abnor­
malities; 4. lack of energy; 5. poor muscular tone and 6. lack of group
membership. With these six variables, Eysenck attempted to tap the enor­
mous range of psychopathology, from the parameters of individual psychol­
ogy, through somatics and psychosomatics, to social psychology. For all its
pretense at methodological rigor, the study has the oddity of being at one and
the same time oversimplistic yet vague, complicated and reductionist. The
item “badly organized personality,” for example, is a poorly conceived and
very imprecise way of tagging psychopathology which is an enormously
complex entity.
On the second continuum, he equated introversion with a condition he
named “dysthymia” and extraversión with hysteria. At the introversion end
were subjects who showed anxiety, dependency, obsessive tendencies, irrita­
bility, headaches, tremor, and somatic anxiety. The hysteria pole included
those who showed conversion symptoms, sexual anomolies, and hysterical
attitudes. Eysenck then selected a nonpatient population—nonpatient, there­
fore considered normal-used the same 39 items and the same factors and
found he could distribute a normal group along two polarities: neurotic-
normal and introvert-extrovert. This meant that some normals could have high
neurotic scores yet not be neurotic; or they could have high introvert or
extravert scores, indicating they had the symptoms yet were not neurotic.
According to Eysenck, since his sample was made up of a population of
normals, by definition they could not be neurotic despite their high neurotic
scores and symptoms. He interpreted their high scores to mean that if the
normals with a high D score became neurotic, they would become dysthymic;
if they had high hysteria scores, they would become hysterics.
Eysenck also hypothesized that neurosis was constitutionally determined
and based on multiple neurotic genes. These genes accounted for different
types of neuroses though there might be a general overlapping to account for
mixed neuroses. He allowed that the constitutional factors articulated with
environmental stresses. To explain the genotypic and phenotypic differences
in various personality types, he formulated a fanciful neurophysiological
theory based upon what he called “reactive inhibition.” Reactive inhibition
48 / BIEBER

supposedly takes place whenever an S-R event has occurred; it is similar to

what we know as a “refractory phase.” Eysenck theorized that in the
extravert, there is a genetically determined, strong, rapidly occurring and
slowly dissipating reactive inhibition that tends to predispose the individual
to resistance to learning and conditioning. Those who are not easily taught
are said to become psychopaths. In the introverts or dysthymics, reactive
inhibition is purported to be weak, slowly occurring, and rapidly dissipated;
such people are easily taught and conditioned. They develop symptoms such
as anxiety and they internalize their problems. The dichotomy is a familiar
one: acting out versus internalization. As Eysenck developed his theories,
they became more elaborate, anfractuous, abstruse, and continue to be
unrelated to any type of clinical data that I can identify.
Karlen (1971) has reported a verbatim interview with Eysenck. The
following excerpt speaks for itself:
Karlen: “I asked Eysenck about the people who volunteer for behavior
therapy. He said,
Eysenck: “We can only treat people who are truly dissatisfied with their
state. The one who says he is happy but is in jail or in psychotherapy, is not
for us. We only take the ones who really want to change.”
Karlen: “Who diagnoses the people as homosexual and on what grounds?”
Eysenck: “You will have to talk to my assistants about that. They deal with
the people. They can tell you better than I.”
Karlen: “Do you treat any of the patients?”
Eysenck: “I am just a theoretician. My assistants are the ones you should
talk to about things like that.”
Karlen: “Then you have never treated people at all?”
Eysenck: “I am just interested in the theory of learning. See Feldman, my
assistant. I do theory, not therapy.”
Karlen then returned to probing the subject of homosexuality.
Eysenck: “But you know there’s something wrong with so many of these
people anyway.”
Karlen: “How so?”
Eysenck: “I mean, they’re poor or ugly or something, inferior in some way.
So what choice do they have?”
The most recent technique to be claimed by the behavior therapists is the
treatment of sexual inadequacy. The work of Masters and Johnson (1970) is
too well known to warrant a description. There is no question that they and
others who have replicated their work, with or without modification, are able
to obtain positive results in secondary impotence and frigidity in relatively
short 'periods. The Masters and Johnson techniques are easily learned and
applied; these procedures include establishing a more intimate and sexually
accommodating attitude between patient and spouse. It also seems clear that
 BEHAVIOR THERAPY / 49

the support and permissiveness of a respected authority figure of either sex

helps in the resolution of sexual anxieties. Masters and Johnson refer to their
work as psychotherapy, not behavior therapy. “The basic means of treating
the sexually distraught marital relationship is, of course, to re-establish
communication. . .attaining skill at physical stimulation is of minor moment
compared to the comprehension that this is but another more effective means
of marital unit communication.”
One might well ask why the behavior therapists have included Masters and
Johnson’s work under the rubric of behavior therapy. Is it because they take
a directive, instructive approach in treating sexual inadequacy? If so, why are
their methods considered behavioral while conventional supportive, directive
therapy is not? Does the fact that Masters and Johnson engage the patient in
direct behavioral experience classify their methods as behavior therapy?
Analytic group therapy also engages the patient in direct experience.
The behaviorists consistently attack psychoanalysts on the ground that we
are concerned only with insight and that we are not concerned with changes
in behavior (as though insight and behavior change are mutually exclusive)
and that we seem to be unaware that changes in behavior can, in themselves,
be therapeutic. Their criticisms are, of course, erroneous. Bandura (1969)
puts forward the distortion that many of our contemporary theories of
psychopathology employ a quasi medical model, fashioned from an amalgam
of disease and immunology concepts; our theories, he states, have in common
the belief that deviant behavior is a function of inimical inner forces. He
interprets psychoanalysis as a process in which attention is generally focused,
not on the problem itself, “but on the presumably influential internal agents
that must be exorcized by catharsis, abreaction, and acquisition of insight
through an extended process.”
The entire process o f working through is an integrated, essential part of
psychoanalytic therapy; it is based on the recognition that insight must be
translated into behavioral change in the daily workshop of living, and that
behavioral changes reaffirm and consolidate the insights that are operant in
extinguishing irrational beliefs. We are quite aware that changes in belief
come about through verbal and nonverbal experiences alike. Franz Alexan­
der’s concept of the corrective emotional experience describes a corrective
cognitive experience though it may consist of nonverbal interactions with the
analyst. Group therapy, too, may be viewed as a workshop where patients
may actively test their attitudes and behavior and that of others through role
play and other interactive parameters. In fact, some patients appear to require
acting out their irrational beliefs before they can establish conviction that their
neurotic beliefs and life styles are destructive. The more active psychoanalysts
incorporate into their methods those techniques necessary to extinguish
irrationalities and establish realistic beliefs with conviction. Such techniques
50 / BIEBER

may include supportive and directive therapies, drug therapy when necessary,
even assertiveness training and behavioral rehearsal in the sense that the
therapist may correct a patient’s faulty judgment about a life situation
through delineating potential pitfalls. Insight raises the probability that a
belief altered in one situation will generalize to other situations; at the same
time, there is an increased probability that under stress, the patient will not
relapse.
Methods such as assertiveness training and behavioral rehearsal are actually
outside the stimulus-response model, as are cognitive restructuring, relation­
ship therapy and other behaviorist techniques easily recognizable as psycho­
analytic or psychoanalytically oriented therapy. A group of deviationists,
typified by Lazarus (1971), use these therapeutic variables in their work.
They have all but left the stimulus-response model, yet they call themselves
behavioral therapists and, o f course, they are hostile to psychoanalysis. Yet,
the deviationists seem to be entering the arena of the more conventional
insight therapies through a back door. They appear to believe that what they
are doing is not analytically oriented treatment, but I would bet that strict
behaviorists think so. Lazarus (1971) assails psychoanalysis but he also
attacks the use o f the stimulus-response model. He has stated that in recent
years his enthusiasm for desensitization procedures diminshed for two main
reasons: first, he finds that results have often failed to justify the effort
involved; second, behavioral rehearsal and direct instruction in rational and
assertive behavior are much more rapid and effective. “Carefully controlled
studies of desensitization by Gelder et al. (1967) and Marts et al. (1968) have
shown that desensitization contains several elements in common with conven­
tional psychotherapy and hypnosis and is not a clearly superior technique
even for phobic states, especially in tdrms of data revealing the nondurability
of change.” This is quite an admission. About psychoanalysis, Lazarus has
this to say: “The main factor which gave rise to the proliferation of more and
more techniques since Freud abandoned hypnosis (a grave error!) and intro­
duced free association, was the general discontent with methods that aim
only to promote insight or self knowledge.”
From its earliest history, psychoanalysis opted for more than symptom
removal. As it developed, psychoanalytic therapy became progressively longer
in duration. Psychoanalysis is oriented to a maximum reparative achievement
and to reaching the maximum potential for the individual in his functioning
and happiness. Ours is a humanistic therapy based on the importance of the
individual. This is not to minimize the significance of removing symptoms.
A physician who is called in to treat a patient suffering from pneumonia
and who successfully treats her for this condition but does not examine
the patient totally, might miss a small breast neoplasm which, one year
later, would be inoperable. In behavioral treatment, the therapist “contracts”
 BEHAVIOR THERAPY / 51

to treat an isolated symptom; in psychoanalysis, the thrust is to resolve as

much of existing psychopathology in total personality as is posable—a critical
difference between the two methods.
A sociopsychiatric paradox exists today. As a result of the immense
contribution psychoanalysis has made to psychiatry, everyone now is aware
of the widespread prevalence of psychiatric illness and o f the urgent need for
extensive therapeutic intervention. With governmental agencies looking toward
limited budgets for health expenditures on the one hand, and their being put
under pressure to supply broad psychiatric coverage on the other, they are
necessarily directed to rapid solutions. Understandably, people are attracted
to get-cured-quick therapies but, in general, only the more unrealistic sacrifice
reason to wish fulfillment and seriously pursue the short-cut route. Psycho­
analysis has been accused o f being an antisocial and an unrealistic method
because of its emphasis on the importance of the individual. Behavior therapy
has made rapid gains because of its claims of a quick cure. The get-cured-
quick type of climate has tended to produce a therapeutic polarization:
quality therapy, which is psychoanalysis at the one end-and, on the other,
the poor man’s therapy, which can be almost anything else.
As I stated at the outset, we psychoanalysts welcome innovations that
promise to facilitate treatment, and behavior therapy has developed ways of
treating discrete sequences of pathological behaviors, i.e., symptoms. Stimu­
lus-response learning theory may be of value to some of us as a way of
ordering our observations or planning therapeutic strategies. Some of the
behaviorist practices are easy to incorporate into existing psychoanalytic
theory and practice. This sort of influence, however, has only to do with
technique and is conceptually quite peripheral to dynamic psychiatry. Psy­
choanalysis is not likely to be significantly altered by the techniques of
behavior therapy.

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