Monday, June 04, 2012

The Perfected Self - Skinner's Unlikely Comeback

Over at The Atlantic, David H. Freedman writes about the return of B.F. Skinner, the godfather of behavioral psychology. Back in the 1930s, Skinner, a Harvard psychologist, developed his theory of “operant conditioning,” which helped to dethrone the reign of Freudian psychoanalysis by the 1950s and 1960s, when interest in behavior modification techniques soared in the United States.

Although the emerging cognitive science movement dismissed behavioral analysis, some of his techniques (modifying thoughts instead of behaviors) have been integrated into more contemporary models such as cognitive behavior therapy (CBT) and rational emotive behavioral therapy (REBT). His behavior modification model is still widely used in a variety of learning situations

The current resurgence in interest in Skinner's behavioral analysis arose in the 1980s and 1990s as a result of some excellent results working with autism. The studies established that "behavior analysis, unlike any other treatment, was effective in helping children with autism communicate, learn, and refrain from violent behavior, to the extent that some patients shed their diagnosis."

Since then, researchers have sought new challenges for which to apply behavioral analysis, and with the obesity rate soaring past 1 in 3, they found a target behavior on which to work.

The Perfected Self

B. F. Skinner’s notorious theory of behavior modification was denounced by critics 50 years ago as a fascist, manipulative vehicle for government control. But Skinner’s ideas are making an unlikely comeback today, powered by smartphone apps that are transforming us into thinner, richer, all-around-better versions of ourselves. The only thing we have to give up? Free will.

By David H. Freedman

Frederik Broden 

My younger brother Dan gradually put on weight over a decade, reaching 230 pounds two years ago, at the age of 50. Given his 5-foot-6 frame, that put him 45 pounds above the U.S. National Institutes of Health’s threshold of obesity. Accompanying this dubious milestone were a diagnosis of type 2 diabetes and multiple indicators of creeping heart disease, all of which left him on a regimen of drugs aimed at lowering his newly significant risks of becoming seriously ill and of dying at an unnecessarily early age.

He’d be in good company: a 2007 study by The Journal of the American Medical Association found that each year, 160,000 Americans die early for reasons related to obesity, accounting for more than one in 20 deaths. The costs are not just bodily. Other studies have found that a person 70 or more pounds overweight racks up extra lifetime medical costs of as much as $30,000, a figure that varies with race and gender. And we seem to be just warming up: cardiologists who have looked at current childhood obesity rates and other health indicators predict a steep rise in heart disease over the next few decades, while a report from the Organization for Economic Cooperation and Development projected that two-thirds of the populations of some industrialized nations will be obese within 10 years.
Dan had always been a gregarious, confident, life-of-the-party sort of guy, but as his weight went up, he seemed to be winding down. Then, on a family visit to Washington, D.C., early last year, he and I dropped in on the National Gallery of Art, where 10 minutes of walking left him so sore in one leg that I had to find him a wheelchair. That evening, I decided to say the obvious: He was fast heading to incapacity and an early grave. He had a family to think of. He needed to get into some sort of weight-loss program. “Got any suggestions?” he retorted. As it happened, I did.

Today, my brother weighs 165 pounds—what he weighed at age 23—and his doctor has taken him off all his medications. He has his vigor back, and a brisk three-mile walk is a breeze for him.
Sorry if this sounds like a commercial for a miracle weight-loss program. But in fact my brother did it with plain old diet and exercise, by counting calories and walking. He had no surgery, took no supplements or pills, ate no unusual foods, had no dietary restrictions, embarked on no extreme exercise regimen. He will need to work his whole life to keep the weight off, but he shows every sign of being on the right track. He has changed his eating and exercise habits, and insists he enjoys the new ones more than the old.

In short, Dan seems a lot like many of the people in the National Weight-Control Registry, the research database of those who, despite the popular wisdom that avoiding weight regain is a Herculean task, have kept off a minimum of 30 pounds for at least a year. Most of us know someone who lost weight years ago and has kept it off, and we all see celebrities who claim to have slimmed down for good using plain old diet and exercise, from Bill Clinton to Drew Carey to Jennifer Hudson. But we keep hearing that the vast majority of us—98 percent is a figure that gets thrown about—can’t expect to do the same.

Alcoholics don’t seem to face such dismal prospects, thanks to Alcoholics Anonymous and similar multistep programs, which are widely regarded as effective treatments. With obesity, we’re apparently at a loss for a clear answer. Fads like the Atkins diet slowly fade in popularity after dieters watch the weight return. We’re left with the impression that the techniques needed to permanently lose weight don’t exist, or apply to only a tiny percentage of the population, who must be freaks of willpower or the beneficiaries of exotic genes. Scientists and journalists have lined up in recent years to pronounce the diet-and-exercise regimen a nearly lost cause—a view argued in no fewer than three cover stories and another major article in The New York Times Magazine over the past 10 years, and in a cover story in this magazine two years ago.

All of which is odd, because weight-loss experts have been in fairly strong agreement for some time that a particular type of diet-and-exercise program can produce modest, long-term weight loss for most people. But this program tends to be based in clinics operated by relatively high-priced professionals, and requires a significant time commitment from participants—it would be as if the only way to get treated for alcoholism were to check into the Betty Ford Center. The problem is not that we don’t know of a weight-control approach that works; it’s that what works has historically been expensive and inconvenient.

But now that’s changing. Consider my brother, who has never been to a weight-loss clinic. His program has taken place entirely in his home, at his office, and when he’s out at restaurants or visiting friends and family—and it happens at his convenience, or even automatically, literally without his doing more than lifting a finger.

Early studies of a fast-expanding pool of electronic weight-loss aids suggest that, by allowing people like Dan to construct their own regimen on their phone and computer, these tools could be a key to reversing the obesity epidemic. Applied across the health-care spectrum—to improve senior care, fix sleep problems, and cure addiction, for example—these affordable, accessible tools could radically change the way we conceive of and administer health care, potentially saving the system billions of dollars in the process.

And the basic formula underlying Dan’s weight loss reaches well beyond health. Behavioral technology allows users to gradually and permanently alter all kinds of behavior, from reducing their energy use to controlling their spending. Now, with the help of our iPhones and a few Facebook friends, we can train ourselves to lead healthier, safer, eco-friendlier, more financially secure, and more productive lives.

Ironically, this high-tech behavioral revolution is rooted in the work of a mid-century psychologist once maligned as morally bankrupt, even fascist. But the rise of social media has reoriented our societal paranoias, and more and more people are incorporating his theories into their daily lives. As a result, psychology’s most misunderstood visionary may finally get his due.

In 1965, when Julie Vargas was a student in a graduate psychology class, her professor introduced the topic of B. F. Skinner, the Harvard psychologist who, in the late 1930s, had developed a theory of “operant conditioning.” After the professor explained the evidently distasteful, outmoded process that became more popularly known as behavior modification, Vargas’s classmates began discussing the common knowledge that Skinner had used the harsh techniques on his daughter, leaving her mentally disturbed and institutionalized. Vargas raised her hand and stated that Skinner in fact had had two daughters, and that both were living perfectly normal lives. “I didn’t see any need to embarrass them by mentioning that I was one of those daughters,” she says.

Vargas is a retired education professor who today runs the B. F. Skinner Foundation out of a one-room office in Cambridge, Massachusetts, a block away from Harvard Yard. The foundation’s purpose is largely archival, and Vargas spends three days a week poring over boxes and shelves full of lab notes, correspondence, and publications by her father, who died in 1990. A prim but engaging woman, Vargas can’t seem to help seething a bit about how her father’s work was perceived. She showed me a letter written in 1975 by the then wildly popular and influential pediatrician Benjamin Spock, who had been asked to comment on Skinner’s work for a documentary. “I’m embarrassed to say I haven’t read any of his work,” Spock wrote, “but I know that it’s fascist and manipulative, and therefore I can’t approve of it.” 

Skinner’s reputation has hardly improved with time. I shared with Vargas a recent Philadelphia Inquirer article by a science reporter who passed along this assessment of “that famed rat researcher B. F. Skinner” and the behaviorists who followed him: “[They] thought homosexuality was a mental illness that could be cured, usually by giving electric shocks and other painful stimuli to try to create an aversion to homosexual thoughts.” 

Vargas could only shake her head. Skinner employed punishment in one early experiment—through a device that delivered a light rap to a rat’s paw—and was so disturbed that he never used it again, arguing passionately and publicly throughout the rest of his life against the use of punishment in school, at home, and in the workplace. And he never had anything to do with trying to change sexual orientation, or any other aspect of identity. Skinner sought to shape only consciously chosen, directly observable behavior, and only with rewards; the entirely un-Skinnerian therapy to which the reporter was alluding is a form of “classical,” or “Pavlovian,” conditioning that trains a subject to reflexively associate a pleasant stimulation with an unpleasant one. The field Skinner founded, known as “behavior analysis,” has overwhelmingly hewed to the example he set in these regards. (And, for the record, “that famed rat researcher” worked, except in his earliest experiments, almost exclusively with pigeons.) 

Spock and the Inquirer reporter are typical of Skinner’s critics in their ignorance of his work, yet Skinner’s theory was at its core so simple that it sounds purely commonsensical today: all organisms tend to do what the world around them rewards them for doing. When an organism is in some way prompted to perform a certain behavior, and that behavior is “reinforced”—with a pat on the back, nourishment, comfort, money—the organism is more likely to repeat the behavior. As anyone who has ever taught a dog to sit or a child to say “please” knows, if the cycle of behavior and reinforcement is repeated enough times, the behavior becomes habitual, though it might occasionally need a booster shot of reinforcement. 

Skinner himself worked mostly with animals, famously training pigeons to guide missiles by pecking on a video screen placed inside the nose cone. But his followers went on to demonstrate in thousands of human studies that gentle, punishment-free behavior-modification techniques could improve learning, modify destructive habits, and generally help people lead healthier, more satisfying, more productive lives. 

Behaviorism exploded in prominence in the 1950s and ’60s, both in academic circles and in the public consciousness. But many academics, not to mention the world’s growing supply of psychotherapists, had already staked their careers on the sort of probing of thoughts and emotions that behaviorism tends to downplay. The attacks began in the late 1950s. Noam Chomsky, then a rising star at MIT, and other thinkers in the soon-to-be-dominant field of cognitive science acknowledged that behavior modification worked on animals but claimed it did not work on people—that we’re too smart for that sort of thing. Then, seizing on Skinner’s loudly proclaimed conviction that communities should actively shape human behavior to promote social justice and harmony, they argued that if behavior modification were to work on humans, it would be a morally repugnant and even fascist method of forcing people to toe an official line. 

In 1971, Stanley Kubrick’s seminal film A Clockwork Orange echoed this fear by centering on a government’s attempt to reduce criminal behavior via methods amounting to a brutal caricature of behavior modification: the “debilitating and will-sapping techniques of conditioning” that presaged “the full apparatus of totalitarianism,” as one character puts it. (The movie actually depicts Pavlovian, not Skinnerian, conditioning—a distinction lost on the public.) That same year, Time put Skinner on its cover, headlining its profile “Skinner’s Utopia: Panacea, or Path to Hell?” The overheated charges stuck. By the mid-1970s, the behavior-analysis field had essentially gone underground, its remaining practitioners having moved from prominent universities to relatively obscure ones. 

Vargas took me to Harvard to see one of the few signs that her father was once the luminary of its psychology department, or indeed that he was ever there: an odd, cluttered display of circuit boards, random machinery, and a photo of Skinner, placed next to a self-service cafĂ© in the basement of the psychology building, a curiosity to be contemplated over a cappuccino. 

Skinner remains a staple of Psych 101 at most colleges, but typically only for a brief, often sneering mention, as if behaviorism was a strange, ugly fad. “He became a whipping boy for cognitive scientists,” says Dean Keith Simonton, a psychologist at the University of California at Davis, who has studied how his field views Skinner. “Psychology students were taught that his techniques didn’t work, that it was a bad direction for psychology to go in, and that he was a bad person, though he wasn’t. He just got kind of a bad rap.” It was a rap that the public bought wholesale, notes Christopher Bryan, a psychologist at UC San Diego. “There was a notion that there’s something icky about psychological techniques intended to manipulate people,” he says. 

It made little difference that holdout behaviorists continued to accumulate evidence that Skinner’s techniques helped tame all sorts of otherwise confounding behavioral problems, including nail-biting, narcotics addiction, child abuse, and, yes, criminal recidivism (no Clockwork Orange–style punishment involved). But the most stunning example was autism: studies in the late 1980s and early ’90s established that behavior analysis, unlike any other treatment, was effective in helping children with autism communicate, learn, and refrain from violent behavior, to the extent that some patients shed their diagnosis. The success with autism pumped money into the field of behavior analysis, leading many of its researchers to look for other big challenges. And by the beginning of the 21st century, there was widespread concern about an obesity epidemic. 

That Skinner’s theory could be successfully applied to obesity was no surprise. Decades earlier, when no one spoke of an obesity problem, Skinner had been writing about diet and exercise as an example of how behavior could be modified. In a 1957 paper in American Scientist, he cited a Harvard University study in which rats were conditioned to eat when they weren’t hungry, causing what Skinner called “behavioral obesity.” His followers did not have to reach far for the converse, speculating that an organism might be induced to willingly reduce food intake, were it rewarded for doing so. 

They were eventually proved right by Weight Watchers, which launched its “behavior modification plan” in the mid-1970s. The program’s close adherence to Skinner’s basic principles has consistently garnered some of the best long-term weight-loss results of any mass-market program. The key characteristic of Weight Watchers and other Skinnerian weight-loss programs is the support and encouragement they provide to help participants stick with them. (Much the same is true of AA, which is strikingly similar to a behavior-modification program.) Weight Watchers and the other programs do not claim to magically burn fat, or make appetite disappear, or blast abs. They aim to gradually establish healthful eating and moderate exercise as comfortable, rewarding routines of daily life rather than punishing battles of willpower and deprivation. 

The specifics may sound familiar: set modest goals (to encourage sustainable progress and frequent reinforcement); rigorously track food intake and weight (precise measurement is key to changing behavior, especially when it comes to eating, since a few bites a day can make the difference between weight loss and weight gain); obtain counseling or coaching (to diagnose what environmental factors are prompting or rewarding certain behaviors); turn to fellow participants for support (little is more reinforcing than encouragement from peers, who can also help with problem-solving); transition to less-calorie-dense foods (to avoid the powerful, immediate reinforcement provided by rich foods); and move your body more often, any way you like (to burn calories in a nonpunishing way). 

Study after study proves the effectiveness of this rough Skinnerian formula, which is the basis of the great majority of well-regarded weight-loss programs. “Willpower doesn’t work,” says Jean Harvey-Berino, a University of Vermont behavioral scientist who researches weight-loss methods. “What works heavily relies on Skinner—shaping behavior over time by giving feedback, and setting up environments where people aren’t stimulated to eat the wrong foods.” As the evidence continues to pile up, it’s getting harder to find weight-loss researchers who disagree, says Jennifer Shapiro, a psychologist specializing in weight loss and the scientific director at Santech, a San Diego health-technology firm. “More and more studies demonstrate the effectiveness of behavioral approaches based on Skinnerian reinforcement.” 

Not that Skinner ever gets much credit. The experts who run successful behavioral weight-loss programs, including Weight Watchers, seem at best vaguely aware of these techniques’ Skinnerian roots, or choose to downplay them. Instead, they frame their programs in the more fashionable terms of behavioral economics or social-cognitive theory, or offer the nontheoretical argument that they just plain work. But this would have been fine with Skinner, says Vargas. “He used to say that the ultimate worth of a science is in how much good it can do in the world.” 

So widely accepted is the long-term effectiveness of Skinnerian weight-loss programs that most well-regarded bariatric-surgery clinics require patients to follow such a program before surgery, in order to prove their ability to avoid regaining much or even most of the weight after—as more than one-fourth of bariatric patients eventually do, according to some studies. Even clinical programs for rapid weight loss rely on Skinner’s tenets. The 25-year-old Weight Management Program at the Miriam Hospital—one of Brown University’s teaching hospitals in Providence, Rhode Island, and the home of the National Weight-Control Registry—is a highly regarded program in which many of the patients are more than 200 pounds overweight. Typically, patients are started out on an Optifast diet, a physician-mediated program that replaces some or all meals with liquids and food bars in order to “give patients some distance from food,” as one psychologist there puts it. But the Miriam program’s goal is for its patients to gradually build healthy eating habits with ordinary food, and to add in daily walks. The program reports that about one-third of its patients keep all the weight off for two or more years. And that figure, which is some 16 times the success rate implied by the “98 percent gain it all back” statistic we keep hearing, turns out to be fairly typical of leading clinical weight-loss programs. 

But despite their relative success, Skinnerian weight-loss programs have not become the default treatment for obesity the way AA has for alcoholism. One reason, of course, is that most would-be weight-losers can’t afford these programs (insurance usually won’t cover them) or don’t have the time, patience, or motivation to commit to one. At up to $3,500, the six-month Miriam outpatient program is a relatively good deal, especially compared with Canyon Ranch, which offers a well-regarded residential program for about $1,200 a day. 

“We know how to get people to eat healthier and exercise,” says Steven Blair, an exercise and epidemiology researcher at the University of South Carolina. “The question is how to roll out the needed behavioral strategies to 50 million unfit adults in the U.S. Even if there were enough trained counselors to work with that many people, which there aren’t, the cost issues would be overwhelming.” 

And there’s another limitation. These programs work by sticking participants in a “Skinner box”—which was, literally, a closed glass box in which Skinner trained his animals; figuratively, it’s an environment that can be tightly controlled and in which behavior can be rigorously tracked, so as to ensure the dominance of the prompts and reinforcements that lead to a desired change. When a patient is “in the box”—that is, actively participating in a formal program—results are reliably good. The bigger challenge comes when people leave the program to plunge back into an environment rife with caloric temptation. 

Most programs try to provide remote monitoring and support, but inevitably, many patients let these looser ties dissolve, and then they gain back weight. That’s why these programs tend to report long-term success rates of only about 30 percent. This is a much bigger problem for mass-market programs like Weight Watchers, which don’t charge enough to offer individual coaching or frequent, intimate group meetings. Effective as it is for a highly affordable program, Weight Watchers places its clients in a Skinner box of gossamer walls. 

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