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Anorexia nervosa and Bulimia nervosa are two eating disorders that impact 0.5-1% and 1-4% of the population respectively (Beatriz Meyer, 2008). The recovery rate for both eating disorders is between 50-60% and the mortality rates for individuals diagnosed with these disorders is between 6-15% (Beatriz Meyer, 2008). The majority of the treatment literature centered on these diagnoses is outside the corpus of behavior analytic research. In fact, single-subject studies focusing on eating disorder intervention technology is lacking. As a result, practitioners within the field of behavior analysis must seek out interdisciplinary perspectives to inform their treatment design.
Another major challenge posed to even the most experienced behavior analyst is that diagnostic criteria for eating disorders often includes private events such as fear of gaining weight, anxiety, compulsive behaviors, and covert emission of targeted responses (The Diagnostic and Statistical Manual V, 2013). Currently there is little disseminated behavior analytic research that denotes specific methods for treating overt behaviors that are established upon covert variables. This means, the field of behavior analysis currently has very few empirically verified methods for effectively treating eating and related disorders.
Therefore, the purpose of this paper is to examine the ways in which an individual’s verbal and social community affects the development of private behavior. Then, a review of pertinent and seminal literature will seek to identify the relationship between covert and overt behaviors. Finally, with these components and relations pinpointed, this discussion will analyze and evaluate potential behavior analytic intervention methods for the treatment of eating and related disorders.
Historical Overview of Eating Disorders
The Role of Environment on Behavior
In his text, B.F. Skinner (1974) outlines the role of the environment in shaping an individual’s behavior. Specifically, Skinner identifies the relationship between the environment and the evolution of organisms. Skinner states that the evolution of species, in addition to the role of the environment throughout an organism’s lifespan, ultimately affects observable and private behaviors (Skinner, 1974). Skinner unpacks this concept further by introducing the concept of environmental control on an organism’s behavior. Simply, Skinner explains that our knowledge of the environmental impact on the evolution of organisms, combined with our observation of measurable variables within an individual’s present environment, facilitates prediction and control in the realm of human behavior (Skinner, 1974).
Although Skinner’s text and studies were published more than forty years ago, the effects of manipulating environmental variables for the purpose of predicting and controlling human behavior continue to be evaluated within both applied and clinical behavioral settings. Throughout the corpus of behavior analytic literature, responses such as self-injury, nonfunctional vocalizations, pica, aggression, elopement, and property destruction have been analyzed and treated by means of experimental analysis (Smith & Churchill, 2002; Travis & Sturmey, 2010; Mitteer, Romani, Greer, & Fisher, 2015; Stevenson, Ghezzi & Valenton, 2016; Ebanks & Fisher, 2003). Within these studies, researchers identify environmental determinants that maintain the target behavior (i.e. attention, escape/avoidance, access, and automatic reinforcement) and subsequently intervene by developing a treatment that allows the subject to contact reinforcement without engaging in the problem behavior.
The efficacy of the technology found within the aforementioned studies relate directly to Skinner’s statements regarding the environment and its impact on predicting and controlling human behavior. However, a noteworthy facet of these studies is that the behaviors under examination are considered overt. Meaning, the researchers were able to directly observe each subject emit the target behavior within the clinical setting. Currently, within the field of behavior analysis there are very few examples of experimental analysis and treatment of covert behaviors; responses such as anxiety and depression that are private and take place within the subjects’ skin (Skinner, 1974). Therefore, in order to examine the historical evolution and treatment of eating and anxiety-related disorders, one must turn to scholarship outside the field of behavior analysis. Thus, an analysis of the origin and past interventions takes on an interdisciplinary perspective.
A Behavior Analytic Lens for Examining Interdisciplinary Source Material
The social environment. Prior to examining the historical texts on this subject, it is critical to ensure the source materials are analyzed through a behavior analytic lens. B. F. Skinner (1974) states that after the “vocal musculature” of organisms evolved and verbal behavior came under operant control, it broadened the reach of an individual’s social environment (p. 98). Cooper, Heron, and Heward (2014) further explain that the function of the response was key; therefore, Skinner deemed that any response could be considered verbal despite its form (Cooper, Heron, and Heward, 2014). The reinforcing relationship between the speaker and the listener brings to the forefront the importance of an individual’s verbal community. The verbal community not only shapes the verbal repertoire of an organism, it also establishes the contingencies of reinforcement between speakers and listeners. Per Skinner’s statements regarding the impact of an individual’s social environment, as well as the reinforcing relationship between the speaker and the listener, one can utilize the principles of verbal behavior as a lens for analyzing and interpreting historical sources. Thus, in order to synthesize historical texts behavior analytically, one must identify the verbal and social community as well as the contingencies of reinforcement in place between the speaker and the listener.
Objective and measurable definitions. In addition to maintaining a behavior analytic viewpoint in regards to verbal and social contexts within historical sources, it is essential to have behavioral definitions so that one can synthesize the literature in a scientific and methodical way. Therefore, the following objective and measurable behavioral definitions will be utilized throughout this paper. Restrictive eating is defined as a decreased rate of food intake across settings and over time. Binge eating and purging is defined as an increased rate of food intake across settings. This includes large intakes of food in a single sitting. The behavioral event is often followed by forced vomiting, the use of laxatives or diuretics, and/or a long duration of exercise for the purpose of mitigating the effects of caloric intake. Body image expectation is defined as any instance in which the social environment and verbal community indicate preferences for body size, exercise routines, and/or food intake. Body image expectations can be found within literature, studies, and social media. Ritualistic behaviors are defined as high rates of repeated engagement in public and or private activities. Examples of ritualistic behaviors include engaging in high-magnitude, long-duration exercise routines (i.e. excessive exercise) that exclude specific behavioral skill-building criterion (i.e. training criterion set by an expert for a specified outcome such as competing in an athletic competition). With these objective and measurable definitions established, one is better able to analyze and compare eating and ritualistic behaviors within the context of ancient and modern societies; for the purpose of evaluating the chronological evolution of these targeted responses.
The Body and Mind within the Classical World
Many of our modern traditions herald back to the customs found within ancient Greek society. The foundation of modern democratic systems, structure of athletic competitions, adherence to particular matrimonial and familial rites, and the pursuit of academic scholarship are practices that reflect the beliefs, tenets, and customs of the classical world. Due to the influence of antiquity upon our modern society, an analysis of historical and primary source material can uncover ancient ideals and contingencies that still shape the values of our present verbal and social community. In this section, an examination of texts within the classical corpus will take place to determine the purpose of the body and mind throughout the evolution of our social environment.
The role of the body and mind in ancient Athens. Expectations regarding the purpose and use of the body and mind was clearly defined by the social environment in ancient Athens. The structure of this civilization was dependent upon men and women fulfilling obligations and duties prescribed to them by members of their social community. In regards to education, men began their scholarship at age seven, attending to their studies for the next ten years under the guide of a tutor (Renshaw, 2008). A young man’s education was divided into three domains: academic, musical, and physical education. The academic facet of a man’s education prepared them for their role in politics, farming, or business. In particular, an education in the physical realm was crucial for Athenian men.
Physical education comprised of wrestling, running, long jump, javelin, and combat training. This training took place in a gymnasium, which doubled as a meeting place for men to gather and engage in discourse (Renshaw, 2008). For the Greeks, there was a relationship between the body and the mind in regards to strength. The Greek philosopher, Plato, detailed this connection in his many works. In Protagoras, Plato states that Greek families “send their sons to a trainer, that having improved their bodies they may perform the orders of their minds, which are now in fit conditions, and that they may not be forced by bodily faults to play the coward in wars and other duties” (Plato, trans. 1967, 326b-c). Thus, Greek society required men to be physically and mentally suited for a life of a soldier, political entity, and as the head of the household. Therefore, a rigorous course of academic and physical training was essential.
Although there is much scholarship on the lives and education of men in ancient Athens, Renshaw (2008) notes that a true understanding of the female experience must be gathered primarily from original sources written by men. Therefore, one can infer that the role of a woman’s body and mind was dictated in society and outlined in the literature by a verbal community consisting mostly of men. From the beginning of their life, texts indicate that the birth of a baby girl was seen as a disappointment within classical Greek community (Renshaw, 2008). This is reflected in the practice of exposure within Greek communities. Exposure was the act of abandoning newborn children outside of the city proper. In regards to the treatment of newborn girls, sources indicate that baby girls were “more likely to be abandoned at birth than boys” (Renshaw, 2008, p. 150). If a baby girl was not abandoned, their inferiority was seen throughout their upbringing.
A woman’s environment was comprised of the domestic. Thus, women received no formal education. Instead, young girls remained at home and developed skills centered around working with textiles, cooking, and overseeing household finances. Domestic practices in ancient Athens further highlight the society’s viewpoint on the role and importance of a woman’s body and mind. Namely, it was not necessary for young girls to progress academically because their futures centered on marriage, child bearing, and managing their husband’s home. As a result, many Athenian women remained illiterate. In addition, the stages of a woman’s life did not include the military; thus, physical education was not required. This fact, as well as the Greek’s relationship with food and the body, was reflected in the allocation of portions at meal time. Specifically, women forfeited larger portions of food to their male family members (Renshaw, 2008). The connection between portion sizes and gender suggests that the social environment deemed women’s bodies less useful to the Greek public than their male counterparts.
The role of women within the public sphere was limited. Unlike the positions men held within political, academic, or military circles, women were mainly allowed to take part in religious rituals and festivals that took place outside the home (Renshaw, 2008). Although the public realm for women was small, Connelly (2007) notes that women’s role in religious rights, as priestesses and sacred office holders, “mirrored” their class, age, and sexual status (p. 28). Specifically, young girls of a certain status engaged in cult responsibilities as a means of contributing to their community and preparing for the domestic stages in their life (Connelly, 2007). These festivals honored Greek goddesses that held dominion over facets of an Athenian woman’s life. The rituals and celebrations took place to honor goddesses such as Artemis, Athena, and Aphrodite who were patrons of childbirth, sexuality, and textiles (Renshaw, 2008). Therefore, a woman’s body and mind were utilized for the purpose of praising, sacrificing, and serving deities that embodied a woman’s purpose in their social environment. In this way, these practices, as well as the academic and physical rituals engaged in by Athenian men, demonstrate how variables such as socio-economic status, gender specific expectations, religion, and government impact the shaping of behaviors surrounding physical development, food, and intellectual enrichment.
The role of the body and mind in ancient Sparta. Similar to Athenian society, young Spartan boys began their education at age seven. However, at this age, Spartan boys left their homes, lived in the city barracks, and began a course of study that centered upon the development of physical strength and intellectual compliance (Renshaw, 2008). In contrast to an Athenian philosophical education, Spartan boys only acquired academic skills that enabled them to communicate. In Plutarch’s Lives, the historian Plutarch specifically describes the Spartan education system. Plutarch states that the Spartan reformer, Lycurgus, dictated that reading and writing should give Spartan boys “just enough to serve their turn; [Lycurgus’] chief concern was to make them good subjects, and to teach them to endure pain and conquer in battle” (Plutarch, trans. 1859, 16.6). Thus, the purpose of the Spartan educational system was to cultivate unstoppable “killing machines for the state” (Renshaw, 2008, p. 240). Therefore, one can infer that Spartan men did not have possession of their own body and mind. Rather, the sole purpose of developing their body and intellect was to better serve their government and social community.
Spartan girls received an education and household treatment that was comparable to Spartan boys. In fact, by law, Spartan families were required to provide girls with the same care and allotment of food portions as their brothers (Renshaw, 2008). In regards to academics, Spartan girls remained at home and most likely learned how to read, write, and ultimately manage households (Renshaw, 2008). Despite their domestic education, sources indicate that Spartan girls also received a public education that promoted the development of strength and physical prowess. Although both men and women had strength building and endurance components to their education, unlike their male counterparts, women were not developing the physical skills necessary for military combat. Instead, the Spartan social environment and verbal community believed if a Spartan woman was physically robust and resilient, she would bear strong Spartan children.
In his work, Plutarch details and unpacks the values of the Spartan state further. Plutarch notes that Lycurgus ordered women to learn how to wrestle, run, and throw the javelin “to the end that the fruit they conceived might, in strong and healthy bodies, take firmer root and find better growth” (Plutarch, trans. 1859, 14.2). Although the women of Sparta lived seemingly less restricted lives than Athenian women, and despite a more formal education, Spartan women were not deemed individuals within their social environment. Rather, comparable to women throughout the ancient world, Spartan women adhered to the dictates of their social community by honing their physical body and their intellect only for the purpose of bearing strong offspring.
Cultural comparisons and context for future evaluations. An analysis of historical and literary texts within the classical corpus reveals the overall status of the body and mind within each classical society. Specifically, Spartans believed the strength of the body, rather than the agility and sharpness of the mind, determined the utility of men and women within their social environment. In contrast, Athenians deemed both physical and intellectual development in male citizens was necessary to produce politicians, landholders, and businessmen. In regards to Athenian women, the advancement of their intellect and the development of their body was limited to their private roles as wife and mother.
Examining the particular cultural variables that influenced what was valued by ancient verbal communities enables one to pinpoint similar contingencies and relations later in history, as well as the values held within modern societies. Specifically, the contemporary correlations between gender roles and food, as well as gender roles and the development of physical and intellectual competencies. With these contingencies and values identified, one possesses the context and tools necessary to begin assessing historical evidence surrounding food restriction and determine what variables possibly maintained these responses.
Early Historical Evidence of Restrictive Eating
In her text, Joan Jacobs Brumberg (2000) describes the role “food abstinence” played during the Middle Ages (p. 44). In particular, the historian notes that during the medieval period, abstinence from food consumption could be linked to an individual’s religious practices. The prevalence of spiritual fasting amongst followers of Catholicism became so commonplace that by the seventeenth and eighteenth centuries, physicians referred to restrictive eating as “inedia prodigiosa (a great starvation) and anorexia mirabilis (miraculously inspired loss of appetite)” (Jacobs Brumberg, 2000, p. 44). The behavior of restricting one’s food intake or refraining from food consumption altogether, directly reflects the values of the medieval, religious verbal community. Specifically, Brumberg (2000) states that individuals engaged in food restriction or religious fasting as a means of expressing spiritual “ideals” such as piety, spiritual perfection, and service to others (p. 47). In essence, the religious-verbal community established the contingency that if one abstained from food, one achieved spiritual perfection in the eyes of the Lord. Despite some decline of religious fasting towards the end of the medieval period, there is evidence that the practice of spiritually-inspired restriction continued on into the nineteenth century (Jacobs Brumberg, 2000).
Miraculous maids and assessment of restrictive eating. During the early modern period, European doctors, clergymen, and nobility began to investigate the behavior of women who lived for a prolonged period of time despite high magnitudes of restrictive eating. These young women came to be known throughout their communities as “miraculous maids” because their lives were sustained and nourished not by food, but by the miraculous grace of God (Jacobs Brumberg, 2000). Humility, piety, and holiness were the values attributed to women’s fasting behaviors during this period. However, some individuals that comprised the religious and medical-verbal community believed these miraculous maids to be influenced by Satan. Thus, leaders in the religious and medical field set out to assess the eating behaviors of the women (Jacobs Brumberg, 2000).
The French physician Jacob Viverius and the English philosopher Thomas Hobbes were two prominent individuals that assessed the behaviors of two miraculous maids. Viverius analyzed the case of Jane Balan, a young girl who was reported to have not eaten in three years (Jacobs Brumberg, 2000). Viverius assessed Balan’s anatomy and sought to discover whether or not the young girl urinated and defecated. After intense observation, Viverius determined that the lack of food consumption and the “absence of excrement” proved Balan’s behaviors were maintained by spiritual grace (Jacobs Brumberg, 2000, p. 51). In contrast, after observing and analyzing the emaciated anatomy of a young English woman, as well as seeking out the presence of “food waste,” Hobbes described the young girl as ill and not sustained by the spiritual realm (Jacobs Brumberg, 2000, p.51). Although the investigations of Viverius, Hobbes, and their contemporaries were devoid of procedures founded on the scientific method, these initial assessments set the precedent for future behavioral and medical research (Jacobs Brumberg, 2000). In addition, these early investigations, coupled with the behaviors emitted by the miraculous maids, wholly reflect the values and cultural standards shared by individuals living in the early modern period and beyond.
The Impact of Ancient and Medieval Texts
Due to technological and social advancement, individuals within our modern society have the ability to choose what and how much food to consume, as well as the frequency, magnitude and duration of physical exercise. However, the variables presented within these ancient and modern texts continue to impact and shape the values of our social, medical, and therapeutic-verbal communities. Therefore, the inclusion of these texts within this present discussion is pertinent because it establishes the necessity for examining the history of reinforcement or punishment of specific behaviors within a given society. With these components identified, one is able to determine how ancient and medieval histories of reinforcement and punishment continue to impact modern day eating and exercising behaviors, as well as the theories that form the foundation of behavior analytic treatment.
The Theoretical Foundation for Cultural Evolution
The Organism and the Environment
The theoretical relevance for examining the cultural and religious practices of ancient and medieval civilizations is found within Skinner’s work, “Selection by Consequences” (Skinner, 1981). Within his text, Skinner describes the relationship between individuals (organisms) and their environment, and how this correlation ultimately shapes new behaviors. Specifically, Skinner (1981) states that what society now considers behavior initially “evolved as a set of functions furthering the interchange between organism and environment” (p. 501). Skinner unpacks this statement further by explaining that within the organism-environment relation, the environment enacts certain limiting controls that ultimately shape or extinguish behaviors (Skinner, 1981). Therefore, when an individual emits a response, environmental variables dictate whether or not the behavior will be emitted in the future. Simply, environmental variables can increase (reinforce) or decrease (punish behavior). The relationship between the organism and environment, as well as the described controlling variables, form the basic tenets of operant conditioning.
Operant Conditioning and the Verbal Community
During operant conditioning, responses are strengthened (reinforced) or weakened (punished) by environmental variables that immediately follow the emission of the behavior. Understanding operant conditioning is vital to an examination of societal customs surrounding food and the body, as well as comprehending the role of the verbal community. Skinner’s work illustrates the powerful association between the verbal-social community and shaping new behaviors. In particular, Skinner (1981) states that through imitation, an organism can come into contact with novel contingencies of reinforcement that ultimately shape or maintain behaviors. Meaning, when an individual imitates the novel behavior of another member of his or her social community, the individual may access new contingencies and reinforcement, ultimately cultivating and preserving new behavioral skills.
Although Skinner states that novel behaviors are shaped by consequences on an individual level, when the response contributes to the survival, problem solving, or success of the verbal-social community, cultural evolution occurs (Skinner, 1981). Therefore, specific behavioral practices endure and impact the evolution of civilizations by means of powerful reinforcing consequences. This means that customs centered upon food and the body can be “transmitted” through the generations, and individual behaviors related to these practices will continue to access reinforcement from the evolving verbal-social environment (Skinner, 1981, p. 502). As a result, behaviors such as restrictive eating, binging and purging, and over-exercising will continue to transcend ancient and medieval societies and access reinforcement from our modern verbal and social community.
The Relationship Between Private Events and Human Behavior
Conceptualizing the principle of operant conditioning, as well as the role of the verbal community, is vital when observing and assessing overt behavior. The behavior analytic corpus is primarily comprised of research that evaluates treatment technologies focused upon utilizing operant conditioning to decrease or increase observable, overt behaviors. In regards to private events, unobservable internal experiences such as thoughts and feelings, behavior analysts have acknowledged their existence, but have not considered these internal states as controlling variables that can evoke behaviors. However, some analysts are expanding the scope of behavior analytic research to include studies centered upon developing empirical methods for studying private events and determining their role in evoking behavioral responses (Friman, Hayes, & Wilson, 1998). In order to discern the potential role internal events play in affecting overt behavioral responses, one must examine the difference between contingency-shaped and rule-governed behavior.
Contingency-shaped vs. rule-governed behavior. Operant conditioning forms the theoretical foundation of contingency-shaped behavior. Specifically, if a behavior is shaped by environmental contingencies, the response will be evoked by antecedent stimuli and strengthened or weakened by consequences immediately following the response. For example, an individual consumes a high quantity of chocolate in one sitting and then experiences a stomach ache. As a result, that individual does not consume the same quantity of candy in the future. The behavior of the individual is “under the control of consequences” (i.e. a stomach ache) that followed consuming a large quantity of sweets (Snyder, Lambert, & Twohig, 2011, p. 4). In contrast, a child is warned by a member of her verbal-social community not to consume too much candy in one sitting because she may become sick. The young girl then refrains from consuming a high quantity of food. In this example, the child’s behavior of consuming a conservative amount of sweets is not impacted and controlled by consequences in her environment; rather, the behavior is “under the control of a verbal rule specifying the contingency” between the response and the consequence (Snyder et al., 2011, p. 4). When a verbal rule controls the behavior instead of environmental contingencies, the behavior is considered rule-governed.
Rule-governed behaviors do access reinforcement. In fact, Snyder et al. (2011) states that the behavior of rule following can be maintained by reinforcement by the social-verbal community. In addition, rule-governed behavior can contact punishers within the verbal community. This concept is crucial for the larger discussion regarding the means in which private experiences may affect behavior, specifically when considering the role of “self-rules” (Snyder et al., 2011, p. 5).
Self-rules. Self-generated rules are established when a person repeats a rule to him or herself that was previously stated by social-verbal community, but never comes in contact with the contingency itself. For example, a young girl has never experienced a stomach ache induced by overeating but repeats to herself, “Do not eat too much candy or you will have a stomach ache” (Snyder et al., 2011). However, an individual may also “derive” a self-generated rule as a result of a history of coming in contact with an aversive contingency, and then tacting the verbal-community’s warning (Snyder et al., 2011, p. 5).
Understanding the impact of rule-governed behavior on other overt behaviors is essential to understanding the origin of restrictive eating, over-eating, and excessive exercising, because these behaviors can be strengthened or weakened without ever contacting environmental contingencies. For example, if a young man generates the rule that gaining weight will cause his peers on the hockey team to judge and humiliate him, he may avoid consuming high-calorie foods. As a result, the behavior of refraining from eating certain foods may be negatively reinforced because he is avoiding aversive social interactions. Although the young man may not be directly contacting reinforcing or punishing contingencies, the self-rule he established is acting as a stimulus that is impacting his overt eating and exercising behaviors (Snyder et al., 2011). Behavior analysis has developed a theory that acts as a vehicle for analyzing and discussing the relationship between private events and overt behavior. Relational frame theory provides behavior analysts with the language and tools for describing, conceptualizing, and treating “maladaptive self-generated rules” (Snyder et al., 2011, p. 5).
Relational Frame Theory
Although there are several important components to understanding relational frame theory and its impact on the study of private behavior, an unpacking of these elements goes beyond the scope of this paper. Therefore, a basic overview of key components will be discussed here. The primary precept of this theory is that relationships are “derived among stimuli, and stimuli are responded to” based upon those relations (Snyder et al., 2011, p. 5; Torneke, 2010). This principle is called derived relational responding and it is the overall process of “relating stimuli according to an arbitrary contextual cue” that is not founded on any physical characteristics of the stimuli; these relations are derived because they are untrained (Snyder et al., 2011, p. 5-6; Blackledge, 2003; Torneke, 2010). Another tenet of this theory is relational framing, the “patterns of derived relational responding that share the properties of mutual entailment, combinatorial entailment, and the transformation of stimulus functions” (Snyder et al., 2011, p. 6). An examination of the components of transformation of stimulus functions will be the primary focus of the paper.
Transformation of stimulus functions. In essence, a transformation of stimulus function has taken place when “the function of one stimulus is transformed” as a result of its relation to other stimuli (Snyder et al., 2011, p. 6; Torneke, 2010). Meaning, stimuli have the potential of developing reinforcing or punishing functions through relational frames (Snyder et al., 2011, p. 4). In regards to verbal, rule-governed behavior, this means that the function of specific stimuli can change based upon describing verbal relationships without coming into contact with reinforcing or punishing contingencies (Snyder et al., 2011). Using the scenario presented in the prior example, suppose when the athlete was a young boy, he observed his parents eating a brownie and requested to eat one too. However, his father did not want to give him access to this sweet, so he tells him that if he eats a brownie, he will gain weight. As an alternative, the boy’s father states that eating carrots are healthier. The young boy has never consumed either food, but the “comparative and coordinative relations” identified between the brownie and the carrots “transformed the previously neutral stimulus functions” of the brownie and the carrots (Blackledge, 2003, p. 427). As a result, the carrot becomes a better, healthier food and the brownie is now considered unhealthy and has the potential to cause an undesired result.
This particular component of relational frame theory is important to the discussion of private events and disordered eating because it enables behavior analysts to identify the covert stimuli and the contingencies that may be influencing overt behaviors. In regards to treatment, behavior analysts can ascertain the “variables that influence relational framing and its properties” and then control these elements to “disrupt” rule-governed behavior (Snyder et al., 2011, p. 6). In fact, the tenets found within relational frame theory have informed the development of Acceptance and Commitment Therapy, which will be discussed later within this paper.
Applying a Behavior Analytic Framework to the Treatment of Eating Disorders
A Behavior Analytic Approach to Eating Disorder Assessment and Treatment
Although there is an expanse of research surrounding feeding disorders within the behavior analytic corpus, there are very few recent studies on treating eating disorders by means of a behavior analytic approach. Therefore, this section offers a framework for evaluating interdisciplinary research for the purpose of developing a behavior analytic intervention model for assessing and treating eating disorders. More specifically, the literature review is divided into sections that reflect the main components of a functional behavior assessment. First, historical and cultural data are evaluated to determine the significance of eating disorders within a contemporary verbal-social community. Then, literature surrounding private events and their contribution to eating disorder diagnoses are examined. Finally, texts centered on private events and their relationship to behavioral functions are evaluated and compared to previous research. In regards to treatment methods, behavior analytic and non-behavior analytic treatment procedures are presented and considered for efficacy and compliance to ethical codes later in this paper.
Cultural Significance in the Evolution and Diagnoses of Eating Disorders
In their review of literature surrounding culture and eating disorder development, Miller and Pumariega (2001) examine the effect of westernization on the eating behaviors of various social-verbal communities. As a result of their examination of medical, anthropological, and sociological research, they conclude that the “idealization” of a slim body type has been shaped within Western culture and is a possible contributing factor to the development of eating disorders within certain populations (p. 94). In addition, this idealization may affect or be the result of certain values placed upon activity choices and patterns, the significance and role of food consumption, and “dieting behaviors” of adolescents (Miller & Pumariega, 2001, p. 94).
Dell’Osso et al. (2016) also considers the impact of the ever-changing standards for an ideal body type dictated by members of Western communities. Specifically, Dell’Osso et al. (2016) notes the transformation of the epitomized body shape, at one time curvaceous now “progressively thinner,” is a result of a globalized society, as well as the evolving criteria for personal fitness set by the health industry (p. 1654). Both Dell’Osso et al. (2016) and Miller and Pumariega (2001) state that variables such as immigration, the media, cultural and religious attitudes toward food, socio-economic status, and private events, such as the fear of gaining weight, may be impacted by Westernization and influence the development of disordered eating behaviors. Meaning, assimilation to Western standards and principles may directly affect and establish social contingencies that shape food consumption and exercise behaviors.
Despite the lack of single-subject research and the heavy reliance on statistical analysis and socio-anthropological theories, the work of Dell’Osso et al. (2016) and Miller and Pumariega (2001) are relevant to the present discussion of eating disorder assessment. In particular, the data and commentary found within these reviews reflect the environment-organism relation described by Skinner (1981). Specifically, their assertions that Westernization of certain populations and customs have led to the reshaping of food practices and private events regarding weight gain and body perception. From a behavior analytic perspective, the statements and statistical data found within the reviews indicate that strong reinforcing or punishing environmental contingencies ultimately maintain eating and exercising behaviors regardless of race, religion, gender, and sexual orientation.
The authors’ review of pertinent literature is also valuable to a behavior analytic eating disorder assessment because it once again brings to the forefront the role of the verbal-social community and its influence on rule-governed behavior. For example, say an adolescent, who identifies as male, transfers to the United States in order to attend college. After arriving to the States and commencing his coursework, he begins learning about popular culture by means of connecting with peers and consuming various forms of American media. Soon, he notices that the majority of men represented on television wear clothes that display muscular hypertrophy, and that his peers often make social media posts about their strength and body building routines. In addition, when he dines with his group of friends, he notices that they all consume high-protein and low-carb meals. Soon, this university student begins to adopt similar exercise and diet practices. As a result, his peers begin to praise him for his physique and his dedication to meal-planning. This student continues to engage in long physical training sessions, is invited to more social gatherings, and receives more body and eating specific social reinforcement from his broadening circle of friends.
The example signifies the ways in which one’s verbal-social community, as well as reinforcing environmental contingencies, can establish and maintain eating behaviors. Prior to moving to the United States, the student had never made contact with the particular contingencies present within his university and social-media environment. In addition, no one directly stated that adapting certain lifting and eating behaviors would result in contact with reinforcing social praise. Despite the lack of contacting these specific contingencies, the student cultivated private self-rules as an effect of interacting with stimuli within his verbal-social community.
This example reflects the suggestions put forth by Dell’Osso et al. (2016) and Miller and Pumariega (2001) in that the university student developed private self-rules that mirror the standards for the male physique set by a Western culture. Thus, the student’s behaviors surrounding food consumption and training were ultimately shaped by contacting novel environmental stimuli characteristic of a more Western culture. Although the work of Dell’Osso et al. (2016) and Miller and Pumariega (2001) do not adhere to behavior analytic research criteria, the data and the conclusions presented in these articles reflect and support the theoretical foundation of verbal behavior. Therefore, these interdisciplinary works are crucial to shaping eating disorder assessment and treatment procedures.
An Empirical Evaluation of Private Responses and Their Relation to Overt Behavior
As discussed in a previous section, the behavior analytic corpus is limited in regards to published empirical research on the role of private events and their affect on overt human behavior. However, in response to the breadth of psychological research on internal states, namely fear, anxiety, and depression, some researchers have conducted single-subject research and reviewed relevant literature to broaden the behavior analytic community’s understanding of the relationship between private and public responses. One study in particular demonstrates the difficulties that accompany the examination of private events and their relation to overt behaviors.
In their two-phase study, Taylor and O’Reilly (1997) analyzed the effect of overt and covert self-instructions on the successful completion of tasks in a grocery store. In addition, the researchers evaluated the relationship between trained self-rules employed as external directives and accurate overt behavioral responding. Overall, the results of the study demonstrated that overt and covert self-rules may control non-verbal responding (Taylor & O’Reilly, 1997). Furthermore, visual inspection of the data reveal that when the researchers implemented the pre-taught, self-instructions as external directives, the participants emitted correct task completion responses. This ultimately suggests that both private and public “self-verbalizations acquired a regulatory function” within the research setting (Taylor & O’Reilly, 1997, p. 54). Meaning, both overt and covert self-rules, as well as self-instructions employed as directives, affected behavioral responding. Therefore, this study indicates there may be a functional relationship between private self-rules and non-verbal behavioral responding (Taylor & O’Reilly, 1997).
Although the authors note several limitations within their research, specifically in regards to the lack of self-instruction data collected during the one phase of the study, the combined results of both phases are crucial to the present discussion. First, the authors detail the ways in which components of this study reflect the principles of contingency-shaped and rule-governed behavior. In particular, the authors put forth in their discussion that behavioral responses emitted in baseline as well as in self-instruction blocking phases were “automatic and therefore relatively free from rule-governing effects” (Taylor & O’Reilly, 1997, p. 56). Therefore, these responses can be considered contingency shaped. Additionally, the authors state that responses that occurred in the absence of overt self-instruction can be considered rule-governed responses (Taylor & O’Reilly, 1997). Finally, the authors state their findings expand upon previous research that demonstrated task-related self-talk “impairs” contingency-shaped responses but does not impact rule-governed behavior (Taylor & O’Reilly, 1997, p. 56).
The results of this study, as well as the discussion of the authors’ findings, are valuable to our analysis of the relationship between private responding and overt behavior. Specifically, they are valuable in regards to the ways this study provides empirical evidence that suggests a functional relationship between self-rules (i.e. rule-governed behavior) and overt behavioral responding. These findings are essential to the process of designing a behavior analytic model for eating disorder assessment and treatment because, as indicated by Dell’Osso et al. (2016) and Miller and Pumariega (2001), internal states, such as fear and anxiety, are often reflected in eating disorder diagnostic criteria. Therefore, with the empirical evidence of a functional relationship between private behavior and the occurrence of overt responding provided by this study, one is able to infer that private behavior may be a variable when analyzing responses through the lens of the four-term contingency.
The Function of Private Events
In their separate reviews of the literature surrounding private events, Anderson, Hawkins, Freeman, and Scotti (2000) and Friman, Hayes, and Wilson (1998), both acknowledge the difficulties of classifying private experiences behavior analytically. In regards to categorizing anxiety, Friman et al. (1998) note that “categories are not empirical events,” meaning “they cannot be observed directly” (p. 138). However, the authors state that despite some challenges in regards to its “essential composition,” behavior analysts can study the conditions that elicit an anxiety response (Friman et al., 1998, p. 138). Likewise, in their review, Anderson et al. (2000) suggest behavior analysts examine the relationship between private and overt behaviors and their “stimulus properties” (p. 5). Although each literature review differs in its approach to unpacking private events, collectively, the authors seek to determine scientific procedures and theories that enable analysts to identify how private responses factor into environment-behavior relations.
The question posed by the authors of each review is how to include private behaviors in an analysis of the relationship between the environment and overt responding (Anderson et al., 2000; Friman et al., 1998). Anderson et al. (2000) suggest several means of determining the role of private events in regards to four-term contingency. First, the authors state that private events can be considered “stimuli,” viewed as “causal events” such as “discriminative or motivative antecedents” (Anderson et al., 2000, p. 5). Within the confines of the four-term contingency, private events would be considered discriminative stimuli that set the occasion for or evoke an overt behavioral response. The authors note this could occur through direct training, (as exemplified in the technology described by Taylor and O’Reilly (1997)) or through derived relational responding (Anderson et al., 2001). In addition, Anderson et al. (2000) state that private responses could be deemed stimuli that are “functionally related to the occurrence of overt behavior” (p.6). Harkening back to rule-governed behavior, private events act as “contingency-specifying stimuli (CSS), also called rules,” that affect the function of other stimuli” (Anderson et al., 2000 p. 7). This hypothesis was also empirically supported in the work of Taylor and O’Reilly (1997).
Although the works of Anderson et al. (200) and Friman et al. (1998) do not include their own direct empirical support for their theories, their reviews are critical to our present discussion because they provide a framework for which behavior analysts can determine the role of private events in the prediction and control of eating behaviors. In terms of environment-behavior relations, labeling private events as discriminative stimuli enable behavior analysts to evaluate whether or not disordered eating increases (access reinforcement) in the presence of the private response. Likewise, if a behavior analyst views private events as contingency-specifying stimuli, through stimulus equivalence and stimulus generalization (i.e. via derived relational responding), private and overt responses can be considered a part of the same “relational class;” thus impacting behavioral function (Friman et al., 1998, p. 142). This means, behavior analysts can include private events as a variable within environment-behavior relations and therefore develop function-based interventions that treat eating disorders.
Functional Behavior Assessment
By using components of a functional behavior assessment as the framework for reviewing and synthesizing pertinent literature, an informal task analysis has been created to guide practitioners as they design a treatment for disordered eating and excessive exercising. First, behavior analysts should identify any cultural or historical variables that may have contributed to the evolution of the client’s social-verbal environment. Then, practitioners can determine whether or not clients are making contact with contingencies that are effectively shaping these target responses. Next, depending on the presence of self-rules and other private internal responses, behavior analysts can assess whether private stimuli are evoking overt responses or should be considered as variables within the whole of the client’s environment. With motivational operations, discriminative stimuli, and potential environmental consequences identified, a practicing behavior analyst can design a technology for treating disordered eating and excessive exercising that is individualized and effective. In the next section, potential behavior analytic treatment methods will be analyzed and evaluated by means of the Professional and Ethical Compliance Code for Behavior Analysts.
Ethical Considerations for Behavior Analytic Treatment Methods
When designing behavior analytic technologies for the treatment of eating disorders and excessive exercising, practitioners must ensure their interventions reflect and are in compliance with the Professional and Ethical Compliance Code for Behavior Analysts (PECC) (Behavior Analyst Certification Board, 2014). In this section, potential treatment methods will be introduced and tested against the tenets of the PECC. Due to the interdisciplinary nature of eating disorder treatment, the behavior analytic intervention principles and methods selected for review will also be examined through the lens of the Ethical Principles of Psychologists and Code of Conduct (EPPCC) (American Psychological Association, 2017). Finally, some of the treatments presented in this section were utilized prior to the establishment of the Behavior Analyst Certification Board. However, these methods will still be analyzed and held to the same ethical standards as the more modern treatment methods presented later in this discussion.
1.01 Reliance on Scientific Knowledge
Comparable to our discussion on private events, there are very few published empirical studies on eating disorder treatment within behavior analytic literature. The majority of the studies surrounding this topic are antiquated and found within the corpus of behavior modification research. As a result, there is some evidence of behavior analytic methodologies being utilized to treat individuals with eating disorders; however, these procedures are limited in regards to data driven efficacy and sound ethical practices. Eckert, Goldberg, Halmi, Casper, and Davis (1979) describe the difficulties of treating anorexia and related disorders. Eckert et al. (1979) state:
Evaluation of behavior therapy in anorexia nervosa is complicated by several factors. There is virtually no controlled study evaluating its therapeutic effectiveness. Often, medications are used concurrently with behavior therapy so that it is impossible to see which treatment is the effective one. Diagnostic criteria are often not carefully specified, resulting in the inclusion of patients suffering primarily from phobias, hysteria, or schizophrenia in the treatment studies. (p. 55)
In the section of the authors’ work, the researchers describe the presence of several confounding variables that they believe may limit a practitioner’s ability to determine the effectiveness of behavior therapy. Namely, the presence of medication and co-morbidity. However, PECC standard 1.01 establishes the necessity to evaluate the key historical, environmental, and medical variables prior to designing and implementing treatment. Thus, in order to be in compliance with the PECC standard 1.01 practitioners must document these variables and analyze their relevance by means of scientific procedures. Meaning, behavior analysts are responsible for determining empirical methods that not only treat the target behavior, but are also analytic and conceptionally systematic (Baer, Wolf, & Risley, 1968). Therefore, despite a multitude of variables that may pose a challenge when designing treatment, practitioners must plan and implement treatment methods that are founded on behavior analytic principles.
2.05 Rights and Prerogatives of Clients and 4.02 Involving Clients in the Planning and Consent
The role of the client within behavior-change procedures is crucial and is also outlined within the PECC. Standards 2.05 and 4.02 describe the specific rights of our clients. Especially in regards to their entitlement to detailed explanations of their legal prerogatives and their right to participate in, and consent to potential intervention components. In the past, patients diagnosed with eating disorders had many of their rights restricted in the initial stages of their treatment. Shmidt and Duncan (1974) and Eckert et al. (1979) both describe on-boarding in-patient procedures that included the removal of privileges such as receiving visits from relatives, access to the telephone, monetary funds, and personal clothing items. In addition, Blinder, Freeman, and Stunkard (1970) describe limiting a client’s access to physical activity until he or she gained a sufficient amount of weight. Although some may argue that denying clients privileges (at the commencement of treatment) are antecedent measures, the literature indicates informed consent and client involvement in treatment planning were absent from these studies. Therefore, these on-boarding protocols do not reflect ethical practices and should not be considered for behavior analytic therapy.
In addition to violating the PECC, proceeding with treatment without informed consent violates the EPPCC. Specifically, tenets 3.10 and 10.01 describe the client’s right to informed consent using language and/or methods that are comprehensible to the individual (American Psychological Association, 2017). Further, these standards indicate that therapists must describe the “developing nature of the treatment, the potential risks involved, and alternative treatments that may be available, and the voluntary nature of their participation” (American Psychological Association, 2017, p. 14). By ensuring the client has a comprehensive understanding of treatment components and their potential risk factors, therapists guarantee clients are legally and physically protected. In addition, both behavior and non-behavior analytic therapists must engage in acts of justice and “accord dignity” to their clients (Bailey & Burch, 2016). This means, regardless of diagnosis, behaviors, or skill level, therapists must establish appropriate rapports with their clients that are founded on ethical standards and trust. In doing so, behavior practitioners uphold their professional codes and ensure procedures reflect the dimension of “applied” treatment and research practices (Baer et al., 1968, p. 92).
2.09 Treatment/Intervention Efficacy and 4.03 Individualized Behavior-Change Programs
In her review of the literature, Ellen Haller (1992) puts forth that researchers and medical professionals have found:
The prognosis for persons with eating disorders is extremely variable. Some patients with anorexia may improve without treatment; for others, however, the course can be long and pernicious. After, treatment, 50% of patients with anorexia nervosa may continue having persistent psychological impairment, and after achieving remission through successful inpatient treatment, about 50% may relapse within a year. (659).
These findings, although based upon medical and not behavior analytic research, indicate the necessity of effective and generalizable treatment for individuals with eating disorders. One way to guarantee efficacy of eating disorder treatment is to evaluate intervention components by means of the dimensions of behavior analysis. Meaning, behavior analysts must identify and analyze environmental variables that may be maintaining the target responses and utilize behavior analytic principles to inform treatment planning (Baer et al., 1968, p. 92).
In their seminal article, Ayllon and Michael (1959) describe the specific technology and staff training procedures they utilized to decrease food refusal in two patients. In their work, the researchers describe two clients whose restrictive eating was maintained by a “combination of escape and avoidance,” and the focal point of behavioral treatment procedure relied upon “food spilling as the aversive stimulus” (Allyon & Michael, 1959, p. 330). During the study, the researchers trained the nursing staff to continue spoon-feeding the clients, but to do so in a way that would ultimately create a mess. Then in order to escape the aversive mess, the patients would begin to feed themselves. Social praise was only delivered contingent upon the patients feeding themselves (Allyon & Michael, 1959). The researchers indicated that once the patients began to independently feed themselves, the behavior would access natural reinforcement by coming under the “control of environmental variables which maintain this behavior in most people, such as convenience, social stimulation at mealtime, etc.” (Allyon & Michael, 1959, p. 330).
Although the BACB was not established at this time, the intervention and staff training reflected PECC standards because the authors utilized behavior analytic methods, and executed the procedures in a way that promoted client independence (Allyon & Michael, 1959). Results suggest that as the staff implemented the treatment with fidelity, the rate of meals consumed by means of self-feeding increased, as well as the clients’ weights. This is one of the first examples found within the literature of function-based behavior analytic protocols treating restrictive eating behaviors. Notably, Allyon and Michael (1959) indicate that one of the clients did “relapse;” however, within five days the client began engaging in the alternative self-feeding behavior. This anecdote is crucial to the present discussion because it implies that when interventions are designed with behavior analytic principles behavior-change will occur. Further, this study demonstrates the importance of upholding an underlying behavior analytic principle, the client’s right to effective and individualized treatment. As previously discussed, analysts can achieve this mission by implementing appropriate on-boarding records review procedures. In addition, behavior analysts can ensure they are implementing effective treatment by individualizing reinforcement procedures that promote independence through self-monitoring and the shaping of alternative responses.
Reinforcement. In their review of the literature, Lappalainen and Tuomisto (2005) discuss the challenges of reinforcement and schedules of reinforcement when treating individuals with eating disorders. The authors state that when working on decreasing restrictive eating or binge-purging responses, analysts may confront complex schedules of reinforcement that prevent clients from engaging in alternative behaviors (Lappalainen & Tuomisto, 2005). For example, the authors put forth that despite being in a state of food deprivation, alternative reinforcers such as exercising or purging can still “compete with the reinforcing value of food” (Lappalainen & Tuomisto, 2005, p.173). Thus, an analyst may have to evaluate and increase the value alternative reinforcers (i.e. preferred or novel activities) that are strong enough to “decrease the value of food and eating” (Lappalainen & Tuomisto, 2005). Simply, the authors suggest putting more emphasis on targeting and reinforcing alternative responses that in turn could affect the client’s eating behaviors. In order to effectively determine which alternative behaviors and activities should access reinforcement, practitioners can integrate self-monitoring and values-guided practices within their individualized treatment protocols.
Self-monitoring and values-driven treatment. Incorporating components of Acceptance Commitment Therapy (ACT) into eating disorder treatment protocols is one means of establishing values-driven, self-monitoring intervention procedures. Derived from the behavior analytic concepts discussed in previous section of this paper, ACT was founded on the principles of radical behaviorism, verbal behavior, relational frames theory, and the importance of acknowledging private events within the four-term contingency (Cullen, 2008; Zettle, 2005; Hayes & Shenk, 2004). The overall objective of ACT is to accept the discomfort of internal states while still engaging in meaningful, values-guided actions (Harris, 2006). There are six essential components and processes that create the framework for this treatment method: acceptance, cognitive defusion, present moment awareness, understanding self as context, determining values, and taking committed action (Cullen, 2008; Harris, 2006; Hayes & Wilson, 1994).
During the acceptance phase the client identifies private events (i.e. anxiety, anger, sadness, hopelessness etc.) that may evoke avoidance responses such as restrictive eating, binge-purging events, or excessive exercising. Next, the client engages in cognitive defusion, by tacting private events as simply emotions, “thoughts, images, memories, and other cognitions,” without emitting avoidance responses (Harris, 2006, p. 7). Then, the client engages in present moment awareness by tacting private experiences as he or she “notices” them, while still emitting an alternative or other behavioral response such as eating a meal, adhering to specified exercise duration criteria, or engaging an activity other than purging. During understanding self as context component, the client begins to develop the skill of discriminating between “the person he or she calls “I,” and the problem behavior the client wants to eliminate” (Hayes & Wilson, 1994, p. 294). This means the individual can make the distinction between “I am anxious about eating with my family” and “I am having the feeling or thought that I am anxious about eating with my family.” In the last two phases of ACT, determining values and taking committed action, the client defines alternative behaviors and values that are meaningful to him or her, and then emits the alternative, values-guided behavior.
Integrating the six core ACT processes into eating disorder and excessive exercising treatment procedures promotes intervention efficacy and individualized programming. Namely because ACT relies heavily upon identifying meaningful alternative activities and cultivating self-monitoring skills. Specifically, ACT acknowledges that while clients with similar behaviors may experience comparable feelings or states such as anxiety, depression, shame, or sadness, the manner in which these private events present themselves is wholly unique to the individual client. This means, the client becomes an integral part of identifying and determining whether or not their private events ultimately play a part in evoking the targeted responses (i.e. private events as discriminative stimuli) or are simply one variable in the environment-behavior relation (i.e. private events as motivating operations). Then, together with the client, the behavior analyst can determine and define alternative behaviors that align with the client’s goals or values.
These alternative responses (i.e. eating at a restaurant with peers, shopping at a grocery store, exercising to a specified criterion etc.) will access immediate, highly preferred (i.e. quality) and powerful reinforcement that is strong enough to impact future behavior (Schramm, 2006). Finally, by integrating ACT principles into treatment procedures that involve self-monitoring, the behavior analyst inevitably increases individualization of treatment and client independence. In addition, behavior analysts will adhere to the PECC and the EPPCC as they help clients discriminate between which responses they can control (i.e. value-driven alternative behaviors) and which responses (i.e. private events) they must acknowledge, but not attempt to avoid by emitting the target behavior (Beatriz Meyer, 2008; Hayes & Wilson, 1994). In this way, behavior analysts ensure the acquisition of alternative behavioral skills and treatment efficacy.
4.07 Environmental Conditions that Interfere with Implementation and 4.09 Least Restrictive Procedures
The final PECC standards 4.07 and 4.09 go hand-in-hand with EPPCC tenet 3.04 (Avoiding Harm), and are pertinent to eating disorder treatment protocols. When designing effective behavior analytic treatment for eating disorders behavior analysts are charged with the responsibility to utilize resources and methods that are reinforcing and supported by the environment. As previously mentioned, past intervention procedures for disordered eating and excessive exercise included withholding access to physical activity and forcing food consumption by means of a feeding tube (Blinder et al., 1970; Schmidt & Duncan, 1974). Without oversite from medical professionals, these two protocols can be considered punishing, and in regards to the feeding tube, a mechanical restraint (Bailey & Burch, 2016).
Instead of limiting a client’s ability to choose or denying access reinforcement, behavior analysts must make treatment decisions that promote alternative behavior acquisition within a safe and humane therapeutic environment (Van Houten et al., 1988). This can be accomplished by ensuring clients are a part of the treatment planning, identifying quality reinforcement, and by selecting alternative behavior skills that impact and reshape the manner in which the client interacts with his or her environment. One means of achieving least restrictive and environmentally supported treatment procedures is to utilize coping skills identified within the framework of ACT.
While delving into the breadth of ACT metaphors and experiential exercises goes beyond the scope of this paper, it is through a trusting client-practitioner relationship that these technologies can be utilized and evaluated for efficacy. For our purposes, employing verbal behavior principles such as tacting private events (i.e. shame), and then embedding these tacts into distancing phrases (i.e. “ I am having the thought that my action was shameful”) creates “separation,” so that engaging in values-based alternative responses becomes more reinforcing than emitting the target behavior (Hayes & Wilson, 1994; Harris, 2013). Although this is only one of many examples of ACT exercises, this technique represents the ways in which practitioners can employ ACT methods to support clients as they make value-driven alternative choices.
In addition to using ACT techniques, behavior analysts can also implement antecedent procedures that can potentially reshapes the manner in which clients engage with their environment and/or emit targeted responses. For example, instead of denying access to exercise, practitioners can model and teach more appropriate ways to engage in the target response. In their article, Moore and Quintero (2019) state that engagement in rigorous, “high-intensity” exercise programs have increased in popularity (p.50). However, in order to access the health benefits that are associated with weightlifting, clients must learn how to properly engage with and lift the barbell. Thus, the authors implemented a successful forward chaining procedure to teach novice lifters to safely and effectively complete the Olympic lifts. (Moore & Quintero, 2019).
Although this article may not directly relate to individuals with disordered eating or excessive exercising behaviors, the goal of the research study was to apply behavior analytic principles in fitness-oriented environments. Therefore, one can infer that behavior analysts have the ability to utilize the technology and empirical evidence presented in the work of Moore and Quintero (2019) to design teaching protocols that enable their clients to safely and appropriately access gym environments. In doing so, practitioners facilitate healthy, value-based choice making and promote safe and alternative ways to access reinforcement. Finally, by enriching the client’s environment with proper training protocols, behavior analysts can effectively implement reinforcement procedures that impact the motivating operations affecting the targeted response. This is exemplified in the following scenario.
Suppose an adolescent client with restrictive eating and excessive exercising target behaviors identifies exercising for health and strength as two of her values. However, despite meeting with her barbell coach and learning about training related “stress, recovery, and adaptation,” she tacts private events surrounding food consumption and short training durations (Rippetoe, 2013). Partnering with the barbell coach, the behavior analyst supports the client as she utilizes defusion techniques, encourages the client to make contact with her values, and helps her to choose the alternative behavior response despite her private events. After weeks, the client’s body weight is still not increasing. As a result, the behavior analyst decides to re-focus the intervention on the alternative behavior activity of training. The analyst invites the client to be a part of the treatment planning process. The behavior analyst, barbell coach, and the client agree that the center of the treatment protocol will be to increase the client’s ability to accurately and safely complete the three major barbell lifts. They also agree that the client will keep a journal and indicated on a scale the magnitude of her private events. The new treatment procedure is implemented and after a month the client’s body weight has increased to a healthy criterion, the magnitude of her private events have decreased, and the client’s ability to safely train has also increased. Notably, the client no longer trains every day to excess, instead she utilizes rest days to sleep, eat, and try other novel activities. As a result, the client’s weight is maintained and she is able to access other environments and reinforcement that is typical for individuals her age (i.e. social gatherings with peers).
This scenario depicts the ways in which behavior analysts can partner with their clients to integrate activities that enrich treatment and encourage values-driven choices. It also demonstrates the ways in which analysts can design antecedent procedures (i.e. a safe barbell training protocol) that affects the target behavior. In addition, this scenario reveals the manner in which intervention choices can ultimately lead to clients accessing natural forms of reinforcement (i.e. eating, sleeping, social gatherings, eating at restaurants etc.) without directly programming these contingencies. In fact, the very nature of the barbell training antecedent procedure establishes a differential reinforcement component because the client gains access to technique-focused social praise (i.e. from the coach and analyst), automatic reinforcement in the form of living her values, and tangibles such as food (i.e. heavy training creates a deprivation of food and water) contingent upon her adhering to the program. Finally, this scenario also reveals the importance of developing relationships with professionals in related fields when designing treatment programs for individuals with eating disorders. Developing relationships with stakeholders and other professionals on the treatment team is crucial for client success. In the next section, the Missouri Leader Standards (Department of Elementary and Secondary Education, 2012) will be analyzed through the lens of Van Houten et al. (1988) work and then utilized to create organizational and interdisciplinary supports for behavior analysts specializing in eating disorder treatment.
Future Directions
Identifying and classifying the specific private events that may evoke restrictive eating, binge-purging, or ritualistic exercise behaviors in clients is a challenge (Anderson et al., 2000; Friman et al., 1998). Further, isolating the specific environmental variables that may be maintaining these target behaviors also pose a challenge to the experienced behavior analysts. Especially in regards to pinpointing the exact social or cultural contingencies that have historically punished or reinforced our clients’ targeted responses, or shaped their private verbal behavior (i.e. self-rules) (Dell’Osso et al., 2016; Miller and Pumariega, 2001). However, after thoroughly reviewing the literature, it is evident that our field already has the tools necessary to ensure clients with eating and related disorders have access to safe and enriched therapeutic environments, as well as the most effective behavior analytic treatment (Van Houten et al., 1988). By conducting observations, implementing assessments, and designing technology that is reflective of scientific and behavior analytic principles, practitioners have the ability to support clients as they engage in values-guided, alternative behaviors (Baer et al., 1968; Hayes & Wilson, 1994).
Despite possessing the technology to affect behavior change, there are several avenues within private and covert behavioral research that needs further examination. First, several authors note the impact a client’s immediate family may have on shaping and maintaining disordered eating behaviors (Haller, 1992; Blinder et al., 1970). Although delving into the exact way family systems influence eating behaviors goes beyond the scope of this research, future analysis is warranted to determine the manner in which immediate family members potentially contribute to a client’s overall history of reinforcement or punishment.
Second, as discussed in the ethical considerations section, selecting alternative skills and activities to focus treatment upon may be more beneficial then solely programming technology to decrease target responses (Lappalainen & Tuomisto, 2005). However, behavior analysts must select measurement procedures for both the target and alternative response that are meaningful. In the past, increased body weight signified effective and successful treatment (Blinder et al., 1970). Nevertheless, using body weight as the sole form of measurement does not provide a comprehensive picture of client’s path to recovery. Instead, practitioners treating individuals with eating disorders should additionally choose measurement procedures that accurately depict the acquisition of alternative skills.
For example, behavior analysts could record the total duration of a client’s pre-treatment and during treatment exercise routine. Comparing this data would provide a means of determining whether or not the client is adhering to treatment criterion and making value-guided choices. Further, practitioners could train clients and other members of the treatment team to collect frequency/rate data to determine how many times per day the client tacts private events surrounding the target or alternative response. Additionally, analyst could measure the latency of utilizing ACT coping exercises after the client tacts private events. Although some may argue that self-reporting is not an accurate form of measurement, having a precise method of determining an effective measurement system allows practitioners to correctly account for specific environmental variables impacting treatment (Le Blanc, Raetz, Sellers, & Carr, 2016). Effective forms of measurement, in regards to both the target and alternative response, is crucial to creating successful and conceptually systematic treatment technologies.
Finally, future researchers should focus on conducting more single-subject studies that demonstrate effective or non-effective eating disorder treatment methodologies. One of the greatest weaknesses in this present discussion is that the majority of the reviewed literature came from researchers in non-behavior analytic fields. Although an interdisciplinary model may be warranted for the treatment of eating disorders, it is crucial that behavior analysts disseminate technology that may enable other analysts to intervene on these challenging behaviors.
Concluding Remarks
The purpose of this research was to examine the ways in which our verbal-social community impacts the shaping of private events. In addition, this review of pertinent literature sought to determine the relationship between private experiences and overt behaviors. With these elements and relationships identified, this research strove to present and evaluate potential behavior analytic strategies for the treatment of eating and related disorders. Despite some areas where future research is necessary, the findings and intervention methods presented in this paper represent scientifically sound, behavior analytic approaches to treating challenging covert and overt eating behaviors. With this preliminary evidence, behavior analysts have the means of selecting effective and individualized treatment methods to begin reducing these life-threatening behaviors and supporting clients as they cultivate the skills necessary to live a meaningful and rich life.
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