Pharmacotherapy and Behavior Therapy

Description of the Strategy

In general, pharmacotherapy involves the use of drugs to improve behavior, whereas behavior therapy involves the use of procedures based on principles of learning to achieve the same objective. Drugs that are intended to improve mood, cognitive status, or overt behavior are termed psychotropic drugs. Since the 1950s, when the first generally effective antipsychotic drug, chlorpromazine (Thorazine), was introduced, psychotropic drugs have played a major role in treating adults with a wide range of behavior disorders. Dozens of different psychotropic drugs currently are available, and millions of prescriptions are written for them. With few exceptions, pharmacotherapy is under the control of psychiatrists and other physicians.

Not surprisingly, therefore, discussions of pharmacotherapy often are couched in terms of a medical model, in which a patient's signs and symptoms are assumed to be indications of an underlying disease that involves a neurochemical aberration. A deficiency in serotonergic activity, for example, is widely assumed to be responsible for the signs and symptoms of depression. Effective psychotropic drugs are assumed to alter the neurochemical processes responsible for the disease, which, in turn, leads to improvements in [Page 431]behavior. For example, effective antidepressant drugs increase serotonergic activity. They also improve mood and overt behavior in most people diagnosed with depression.

Since the 1960s, behavior therapy has been widely and successfully used to treat many different behavior disorders. Behavior therapy comprises many different therapeutic techniques. Although most contemporary behavior therapists acknowledge the role of neurochemical events in controlling behavior, they typically do not emphasize events at this level of analysis. Instead, they concentrate on how learning contributes to the genesis and maintenance of behavior disorders and how procedures based on principles of operant and classical conditioning can be used to treat them. For example, a real or perceived decrease in the quantity or quality of reinforcement that a person receives can lead to the signs and symptoms of depression. Interventions that enable patients to increase reinforcement and to avoid negative and erroneous evaluative statements are effective in treating most people with depression.

Interestingly, there is growing evidence that effective behavior therapies produce changes in brain activity comparable to those produced by effective psychotropic drugs. Behavior therapists do not, however, index therapeutic gains in terms of changes in central nervous system activity, but rather in terms of overt behavior, which is important in its own right and as an index of affect and cognitive status. Physicians also use behavior change to index clinical effectiveness, and the general approaches used by physicians and behavior therapists to treat behavior disorders are similar. With both therapeutic modalities, treatment is most likely to be effective when:

• 1.
  The treatment is appropriate for the patient and behavior problem of concern. The results of wellcontrolled studies provide the best rationale for matching patients to treatments.
• 2.
  The treatment is individually tailored to the patient and administered consistently in the intended fashion. Failure of patients to be exposed consistently to intended interventions is a serious issue with respect to both pharmacotherapy, where it is known as medication noncompliance, and behavior therapy, where it is known as inadequate treatment integrity.
• 3.
  The treatment is evaluated carefully. Treatment evaluation requires clear specification of goals, collection of accurate data directly relevant to those goals, and data-based decisions concerning the costs and benefits of treatment.
• 4.
  The treatment is altered until success is attained. If outcome data indicate that the initially selected intervention is not producing the desired effects, the treatment should be altered and reevaluated. Changes in treatment may involve altering some aspect of the initial intervention (e.g., adjusting drug dosage or the frequency of therapy sessions), moving to an alternative intervention (e.g., substituting a tricyclic antidepressant for a serotonin-specific reuptake inhibitor in treating a patient with depression, substituting response cost for time-out in treating a physically assaultive patient with severe mental retardation), or adding a treatment component (e.g., prescribing an antidepressant medication to a patient with depression being treated with cognitive behavior therapy, or vice versa).
• 5.
  The treatment is integrated with other kinds of interventions to best serve the needs of the patient. Many adults who are candidates for treatment with a psychotropic drug or behavior therapy have problems in several areas of their lives. Such individuals often benefit from the services of a number of professionals (e.g., a psychologist, psychiatrist, social worker, and religious leader), as well as from the support provided by family and friends. Steps taken to ensure open communication and collaborative problem solving among all of these individuals go far in optimizing benefits for the patient, who, of course, participates in the process.

Research Basis

Pharmacotherapy and behavior therapy encompass so many specific treatments and are used to treat so many behavior disorders that it is impossible to review the relevant research in a brief document. In general, there is abundant evidence of the effectiveness of each treatment strategy. For instance, there is compelling evidence that most patients suffering from obsessivecompulsive disorder or depression will derive benefit from either pharmacological or behavioral treatment, if well designed and executed. There also is some, although often less compelling, evidence of the value of the two in combination. Although there are many noteworthy exceptions, the majority of published clinical studies of psychotropic drugs have utilized betweensubjects experimental designs and statistical analysis of data. Measures of behavior often are indirect, involving [Page 432]rating scales or global clinical impressions. Most of the research evaluating behavior therapy, in contrast, has involved within-subject experimental designs, visual data analysis, and direct measures of behavior. Neither strategy is superior in a general sense, but they do differ in the kind of information that they provide and in the difficulties they pose for researchers. Randomizedgroups designs with double-blinds and placebo controls, for example, are the “gold standard” for research in clinical psychopharmacology. It may, however, be difficult to obtain access to enough participants to allow for the use of such designs, especially when protected populations, such as people with mental retardation, are of interest. For this and other reasons, several scientists have suggested that the small-N research methods widely used by behavior therapists may be invaluable in certain areas of clinical psychopharmacology and should be more widely used.

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