Ethical practice has been a priority among behavior therapists. Nonetheless, concerns continue to arise. Particularly in cases where, at least potentially, the application of a technique can inflict pain, or where clients are relatively powerless or are involuntarily the subject of treatment, areas of ethical concern still remain.
USE OF AVERSION PROCEDURES. The use of aversion procedures (the application of subjectively unpleasant stimulation contingent upon performance of an undesirable behavior) has been, and remains, a source of criticism of behavior therapists. Particularly when procedures such as low-level electric shocks are applied to clients who lack the ability to offer informed consent to the use of such procedures, behavior therapists face a dilemma in which the desirability of treatment outcome goals has to be weighed against the rights of the client. Even when aversion therapy seems to be the best, most rapid means of suppressing other, perhaps more injurious, behavior, such as self-destructive behaviors in clients suffering from pervasive developmental disorders, behavior therapists are ethically bound to attempt to reduce the target behavior through nonaversive means before considering an aversion procedure. Only when the target behavior has been conclusively shown to be impervious to other means should aversion therapy be used.
The use of aversion techniques with clients for whom rapid, permanent behavior change is not essential, or for whom there may be some question as to the desire or willingness to change, raises significant ethical concerns. The application of aversion procedures to clients in powerless positions, or where the goals of the agent of behavior change seem directly counter to those of the client, requires careful assessment of the interests of all involved parties, with extra weight perhaps being given to the client's right to be free from external influence over his or her behavior. Practices such as those reported to have occurred in the former Soviet Union, including the use of aversion procedures or drugs for the subjugation of prisoners and psychiatric patients, are clearly not in keeping with the ethical application of behavior therapy or any other form of therapy. When aversion procedures are used, clear guidelines need to be established. Review by an institutional ethics board in order to set up extensive safeguards of client rights has to precede treatment.
TOKEN ECONOMIES IN INSTITUTIONAL SETTINGS. Token economies are based on the notion that behavior can be changed by systematically rewarding desired behaviors contingent upon performance. Token economies set up a microeconomy in which desired behaviors are "rewarded" by contingent distribution of tokens, or "points," that can later be exchanged for rewards (often food or privileges). Early proponents of token economies in institutional settings frequently sought to enhance the effects of this process by withholding basic needs, which could be regained only by compliance with token-reinforced behavioral contingencies imposed by therapist fiat. This practice is now judged to be both legally and ethically unacceptable. Clients forced to reside in facilities where token economies are in effect are entitled to have basic needs for food, shelter, clothing, and social companionship met, regardless of ability to earn token reinforcers. As with the application of aversion procedures, the legitimate parameters of reinforcers need to be clearly spelled out, and the application of contingencies monitored, through continuing and independent peer review. It is the obligation of the therapist to develop effective reinforcers that are consistent with these values.
Token economies present another ethical and theoretical dilemma: the degree to which behavior changes effected through a token economy either will or should generalize to other settings in which the client may be placed in the future. Much research suggests that the sort of reinforcement contingencies that prevail in most token-economy programs do not characterize most naturally occurring reinforcers. When a client who has learned a new behavior under conditions of monitored and controlled reinforcement in a token economy moves to a setting in which different contingencies apply, there is substantial risk that the new behavior may disappear, leaving the client bereft of adequate, meaningful reinforcers.
The consequences for both the client and society of such a failure of generalization can be significant. For example, psychiatric patients who acquire workplace social skills in a consistent and regulated token-economy program and then enter a "real world" workplace where reinforcement is inconsistent may not be able to respond adequately to the new contingencies, and will therefore be unable to cope with the new setting, even though they functioned well under the token-economy conditions. This may lead to a financial inability to live independently, and even to homelessness and the need for welfare benefits that might not have been required had attention been paid to the generalization of token-economy-acquired skills to the outside world. This possibility makes it essential for behavior therapists to address the issues of generalization and maintenance of behavior change across various settings.
COMPUTER-ASSISTED AND ADMINISTERED THERAPY AND SELF-HELP BOOKS. Since the mid-1990s there has been an increasing interest among behavior and cognitive-behavior therapists in the development of computer-assisted and administered treatments, as well as in the dissemination of self-help books that detail, for the lay person, ways to cope with one's problems without the assistance of a therapist. This movement has been driven by the ready availability of computer technology and the Internet, and by a desire to bring the benefits of behavior therapy to people who might otherwise have limited access to therapists (such as those in remote rural areas).
The promulgation of treatments that involve minimal or no professional guidance, but rely instead upon the theories and techniques of behavior and cognitive-behavior therapies, as well as the claims made by these therapies in such a context, raises important ethical issues. Specifically, to what extent is a human therapist necessary to produce effective behavior change, and is it ethically responsible to promote these approaches in this way?
Many of these programs function by attempting to mimic the interaction between therapist and patient using decision tree programming that provide standardize computer responses to a variety of specific client input statements.
Researchers have also validated a number of computerassisted and administered treatments using "virtual reality" and computer-assisted interviewing to treat panic disorder (Newman, Kenardy, Herman, and Taylor), anger (Timmons, Oehlert, Sumerall, Timmons, et al.), acrophobia (Vincelli), and problem drinking (Hester and Delaney). To the extent that these treatments have been found to be as effective as their human-delivered counterparts, they pose no more ethical concerns than do other behavioral therapies. However, there is a danger that untested approaches and methods will be used, possibly to the detriment of patients, and it is incumbent upon all behavior therapists to insure that computer or Internet-based treatments are subjected to thorough research testing prior to full dissemination.
Similar issues adhere to the publication of self-help books. As with computer- and Internet-based applications, it is incumbent upon the authors of these books to insure that they have reasonable research evidence for their efficacy.
Authors and users of both computer-assisted and administered applications of behavior therapy and self-help books need to be attentive to possible misapplication of these techniques, particularly by persons whose problems may be more complex and difficult than such approaches can address. Clear disclaimers and cautions to potential users with respect to the limitations of these approaches are necessary to insure their ethical dissemination and use. On the positive side, these approaches are entirely consistent with the traditional emphasis in behavior therapy on active client participation in treatment.
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