Behavioral Treatment in Natural Environments

Description of the Strategy

The natural environment has long been an ally for behavior therapy in the production and facilitation of therapeutic change, especially in anxiety disorders and mood disorders. Although behavior therapy more commonly occurs in analog settings (e.g., in office, in hospital, day treatment), ultimately, therapy gains realized in such artificial settings have to be transported, or generalized, to the natural settings in which any given individual patient conducts his or her personal life. This eventuality and necessity have led to relying on natural-environment settings in cases where analog settings alone do not sufficiently produce the desired clinical outcome. This is especially relevant in cases when there are problems with generalizability, or transportability, to settings in which the patient later has to be able to apply the skill sets acquired during in-office treatment to their real-life circumstances.

It is not unusual to see problems of generalizability in treatment-refractory, chronic, and severe cases due to the role naturally occurring reinforcers and punishers play in the production and maintenance of clinical behavior sets. Indeed, it may be that the naturally occurring information present in the patient's environment, which maintains problems over time, cannot be adequately reproduced in an analog setting. Without access to the genuine, or actual, maintaining variables, it may be that results produced in an artificial setting are general enough that they lack sufficient specificity to adequately mimic what the patient later encounters when he or she returns to the natural cues that historically have produced and maintained the clinically relevant behavior set. This likely, in part at least, accounts for high rates of lapse and relapse realized by many anxietyand mood-disordered patients upon return to natural settings. That is, skill sets established in the analog setting fail to be relevant enough in natural environments to sufficiently translate across these different settings, thereby leading to a return to the genuine behaviors the natural settings support. This is often referred to as the centrally important issue of ecological relevance.

In fact, some clinical presentations often cannot be adequately treated without direct reliance on the natural environment or naturally occurring cues. For example, treatment of specific phobias often rely on presence of the phobic cues within an exposure paradigm. While some natural cues can readily be brought into an office setting (e.g., a dog), others are not as readily recreated artificially (e.g., heights). Even with a simple cue, such as an animal or an insect phobia, there are commonly more cues than the direct, single stimulus contributing to fear conditioning and avoidance learning. To reduce fear from exposure to a dog, it might have to be a specific dog (i.e., a surrogate is similar, but not sufficient), or it might have to be dogs generally but in a specific location (i.e., there is something specific to the setting that makes the dog, or dogs, especially threatening). Until adequate functional assessments can be conducted of the contributions natural settings might bring to a simple stimulus, it cannot be fully known whether using the stimulus alone in exposure will be sufficient.

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