Counterconditioning is a therapeutic technique that replaces an undesired response or behavior with a more positive or desired response through principles of behavioral conditioning.
It is primarily based on the principles of classical conditioning (Pavlov, 1927).
Counterconditioning is often used in systematic desensitization in the treatment of phobias and anxiety, in aversion therapy to reduce maladaptive behaviors, and in applied behavioral analysis (ABA).
In systematic desensitization, the patient is conditioned (or trained) to exhibit a pleasant response to a stimulus that had previously evoked an unpleasant response.
In aversion therapy, the patient’s unwanted behavior is conditioned to be associated with an aversive experience.
In ABA, an unwanted behavior is replaced with a desirable behavior. It is often applied in educational settings to help children with autism or learning disabilities. The goal is to eliminate the undesirable behavior and replace it with a desirable behavior.
- Treating Fear of Spiders: A therapist starts by asking their patient to look at a black-and-white photo of a spider across the room while breathing deeply. After a while, the patient does not feel anxious when looking at the photo. Over the next several weeks, this process is repeated as the photo is gradually moved closer, replaced with a toy spider, and eventually a real (but small) spider placed in the patient’s hand.
- To Treat Nail-biting (Onychophagia): Neem oil has a very bitter taste. When applied to finger-nail polish it can deliver an unpleasant sensation when someone bites their nails. Neem oil is often used in aversion therapy to reduce nail-biting in patients.
- A Dog’s Fear of the Vet: A family’s dog is so fearful of the vet that it starts being aggressive and growling when entering the treatment room. So, the vet recommends just bringing the dog in a few times to the lobby and giving treats. Over time, they gradually move the treats closer to the room, then just outside the room’s door, then in the room, and eventually up on the table.
- In School: A behavior analyst works with a teacher to identify the disruptive behaviors of a child with a learning disability. They collaborate to produce an action plan to replace those actions. The teacher will utilize the principles of operant conditioning to ignore disruptive behaviors and reward replacement behaviors.
- In Treatment for Addiction: Antabuse is a prescription medication that induces nausea approximately 10 minutes after ingestion of an undesirable substance. The association between the substance and nausea decreases the likelihood of repeating the behavior.
- In Guided Imagery: A therapist narrates different relaxing scenes as the patient tries to visualize them in their mind. This takes place in a room with pleasant music playing in the background and aromas from essential oils filling the air. When the patient is relaxed, the therapist will present a mild version of an anxiety-provoking stimulus.
- Fear of Public Speaking: Weeks before delivering a speech to investors, the CFO starts practicing at home in front of his family. He then practices with colleagues, then strangers he hired to be a pretend audience. By the time of the big day, he feels relaxed enough to deliver the speech without tremendous failure.
- In a Psychiatric Hospital: A large, non-verbal male patient can become physically aggressive when wanting a snack. So, the on-site psychologist works with the staff to replace those aggressive actions with a constructive means to communicate his needs. When hungry, he holds up one of several picture cards that show the type of snack or beverage he wants.
- To Treat Nocturnal Enuresis: Bed-wetting is often treated by a system known as the “bell-and-pad.” When liquid is detected on the bed or child’s clothes, an alarm is activated. This can help the child become more aware of internal sensations that indicate a full-bladder and provides a positive reinforcer when they do.
- With VR Technology: A clinical psychologist uses VR equipment to help his clients see their fears while teaching them how to tense and relax their muscles at the same time. He starts by presenting only mildly anxiety-provoking scenes in the VR headset, and then gradually escalates the stimuli as the patient makes progress maintaining a relaxed state.
Counterconditioning vs. Extinction
There is a subtle distinction between counterconditioning and extinction. They both involve the elimination of a behavior, but they do so by different processes.
- Counterconditioning refers to conditioning a new behavioral response to a stimulus that replaces a previous response. The previous unwanted behavior is extinguished and replaced with a new, wanted response.
- Extinction refers to the eventual elimination of a behavioral response and does not involve replacing it with another response. It does not require a replacement action, behavior, or reaction.
Extinction occurs as a result of reinforcement no longer following a target behavior. If the target behavior is no longer rewarded, then the organism (animal or person) no longer has motivation to engage in the behavior. So, the target behavior becomes extinct.
Extinction in exposure therapy, for example, occurs when the client is presented with the anxiety-provoking stimulus without experiencing the aversive outcome. This entails a gradient process that begins with minimally anxiety-provoking versions on the stimulus and then progresses as the client’s negative reaction decreases. Note that no replacement behavior has been introduced, unlike in counterconditioning.
In this sense, extinction seems to be quite similar to extinction. The term extinction is often used as being part of the underlying theoretical framework from which exposure therapy is based (Abramowitz, 2013). That is, exposure therapy is based on the principles of extinction.
Fact File: Systematic Desentitization
Counterconditioning and extinction are fundamental concepts within systematic desensitization.
The earliest experiment on systematic desensitization in humans was the “Little Peter” study conducted by Jones (1924).
A three-year-old child named Peter was scared of a white rabbit, among other stimuli. At first, the rabbit was placed on the far side of the room from Peter as he consumed candy.
Over repeated sessions, the rabbit was gradually placed closer and closer as Peter consumed candy. Eventually, his fear of the rabbit dissipated and he even allowed the rabbit to nibble his fingers.
The “Litter Peter” experiment is considered a precursor to the development of systematic desensitization devised by Wolpe (1961).
Applications of Counterconditioning
1. In Treatment of Anxiety Disorders
Anxiety disorders refer to a group of psychological disorders that are characterized by intense and uncontrollable feelings of fear and anxiety. Anxiety disorders include: generalized anxiety, specific phobias, social phobias to objects or situation, depression, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD).
All of these disorders can be treated with techniques based on the principles of counterconditioning.
However, one difficulty encountered when examining the efficacy of a particular treatment for these disorders is that behavioral treatments that involve counterconditioning are often, in clinical settings, combined with other treatments such as cognitive behavioral therapy (CBT) (Ramnerö, 2012).
There are some exceptions. For example, Huntley et al. (2019) conducted a meta-analysis of 44 studies utilizing behavior therapies (BT) for the treatment of test anxiety. The authors concluded that there was “substantial evidence” to support its effectiveness.
However, there was considerable heterogeneity in the specific versions of BT, which included biofeedback, progressive muscle relaxation, relaxation therapy, and systematic desensitization, just to name a few.
Pascal et al. (2020) conducted a meta-analysis of eight studies that specifically examined if exposure-based treatments (EBT) affected disgust, which is considered an emotional component of some anxiety disorders.
The results revealed that EBT yielded a small effect, which was much lower than typical effect sizes targeting anxiety disorders or emotional distress, but still meaningful as it is a component of these disorders.
Ougrin (2011) concluded that there is no evidence that cognitive-based therapies or exposure-based therapies have different efficacy rates in treating PTSD and OCD, but strong evidence that cognitive therapy is superior in treating social phobia.
2. In Applied Behavior Analysis (ABA)
Applied behavior analysis (ABA) is a behavior modification strategy that utilizes the principles of counterconditioning to replace undesirable behavior with desirable behavior (Madden, 2012).
It is often implemented with students suffering from a learning disability such as autism, or with children that have typical learner profiles.
For instance, Riley et al. (2011) applied counterconditioning principles to increase the on-task behavior and off-task behavior of two students
with typical learner profiles, but difficulty staying focused.
Teacher provided praise increased “the on-task behaviors of both student participants” (p. 159).
Eikeseth (2009) concluded that ABA is well-established and effective in changing the behavior of autistic children under the age of six.
Warren et al. (2011), in a comprehensive review of research, concluded that ABA and similar therapies improved cognitive performance, language skills, and adaptive behavior.
However, the researchers noted that the strength of evidence is low. It is also possible that research which demonstrated treatment efficacy might be due to the improvement of a small subset of the sample in each study.
However, in a more promising analysis, Eldevik et al. (2010) stated: “Recent narrative and meta-analytic reviews suggest that EIBI (early intensive behavioral intervention) may meet criteria as a “well-established” intervention…effect sizes for Intelligence quotient (IQ) and adaptive behavior outcomes are in the medium to large range” (p. 17).
While ABA has demonstrated value, critics within the autism community argue that ABA has an underlying perspective that is non-accepting of their true personalities (Solomon, 2008).
Educators should not be trying to make autistic children “normal.” Instead, educators and society in general should accept the harmless traits of autistic individuals.
Counterconditioning is a technique utilized in behavior modification and treatment of psychological disorders.
It is primarily based on the principles of classical conditioning. This approach involves trying to replace one behavior with its opposite. For instance, replacing drinking with not drinking, or replacing feelings of anxiety with a relaxed state.
In a clinical setting, treatments based on counterconditioning principles are often implemented in conjunction with other strategies, such as CBT. This can make a direct analysis of treatment efficacy complicated and inconclusive.
In ABA, research has been promising and demonstrated the effectiveness of replacing unwanted socially undesirable behaviors with more constructive behavior that can improve educational outcomes.
Abramowitz, J. S. (2013). The practice of exposure therapy: Relevance of cognitive-behavioral theory and extinction theory. Behavior therapy, 44(4), 548-558.
Eikeseth, S. (2009). Outcome of comprehensive psycho-educational interventions for young children with autism. Research in Developmental Disabilities, 30(1), 158-178.
Eldevik, S., Jahr, E., Eikeseth, S., Hastings, R. P., & Hughes, C. J. (2010). Cognitive and adaptive behavior outcomes of behavioral intervention for young children with intellectual disability. Behavior Modification, 34(1), 16-34.
Huntley, C. D., Young, B., Temple, J., Longworth, M., Smith, C. T., Jha, V., & Fisher, P. L. (2019). The efficacy of interventions for test-anxious university students: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 63, 36-50.
Keller, N. E., Hennings, A. C., & Dunsmoor, J. E. (2020). Behavioral and neural processes in counterconditioning: Past and future directions. Behaviour Research and Therapy, 125, 103532.
Lattal, K. M., & Lattal, K. A. (2012). Facets of Pavlovian and operant extinction. Behavioural Processes, 90(1), 1-8.
Madden, G. J. (2012). APA Handbook of Behavior Analysis (APA Handbooks in Psychology).
Newall, C., Watson, T., Grant, K. A., & Richardson, R. (2017). The relative effectiveness of extinction and counter-conditioning in diminishing children’s fear. Behaviour Research and Therapy, 95, 42-49.
Ougrin, D. (2011). Efficacy of exposure versus cognitive therapy in anxiety disorders: systematic review and meta-analysis. BMC Psychiatry, 11(1), 1-13.
Pascal, S. A., Rodina, I. R., & Nedelcea, C. (2020). A meta-analysis on the efficacy of exposure-based treatment in anxiety disorders: implications for disgust. Journal of Evidence-Based Psychotherapies, 20(2), 31-49.
Pavlov, I.P. (1927). Conditioned reflexes. London: Oxford University Press.
Ramnerö, J. (2012). Exposure Therapy for Anxiety Disorders: Is There Room for Cognitive Interventions? Exposure Therapy: Rethinking the Model-Refining the Method, 275-297.
Riley, J. L., McKevitt, B. C., Shriver, M. D., & Allen, K. D. (2011). Increasing on-task behavior using teacher attention delivered on a fixed-time schedule. Journal of Behavioral Education, 20(3), 149-162.
Skinner, B. F. (1938). The behavior of organisms: An experimental analysis. New York and London: Appleton-Century Company.
Skinner, B. F. (1963). Operant behavior. American Psychologist, 18(8), 503–515.
Solomon, A. (2008). The autism rights movement. New York Magazine, 25, 2008.
Warren, Z., McPheeters, M. L., Sathe, N., Foss-Feig, J. H., Glasser, A., & Veenstra-VanderWeele, J. (2011). A systematic review of early intensive intervention for autism spectrum disorders. Pediatrics, 127(5), e1303-e1311.
Wolpe, J. (1961). The systematic desensitization treatment of neuroses. The Journal of Nervous and Mental disease, 132, 189-203.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press. Wolpe, J. (1964). Behavior therapy in complex neurotic states. The British Journal of Psychiatry, 110(464), 28-34.