To understand the theoretical basis of the particular style of treatment that Kirk Murphy experienced, it is critical to know what Behavioral Therapy is all about.
June 9th, 2011
There are as many schools of psychology as there are blind men around the proverbial elephant, and they each feel out the same issues from very different perspectives. Psychoanalysts take their cues from Sigmund Freud, who saw the human psyche as a bundle of reactions to early childhood experiences, some going all the way back to infancy. Cognitive therapists see the psyche as a mishmash of knowledge, beliefs and myths which form the basis of a person’s reactions to his circumstances. Social psychologists take that a step further and examine the effects of societal norms on individual decision-making. Psychiatrists see the mind as a product of an organ known as the brain, and incorporate medical training in their understanding of human nature.
All of these have one thing in common: in one form or fashion, they all examine at least some aspect of an individual’s interior life in order to understand that person’s motivation for feeling or behaving the way he does. By understanding and working with what is going on inside — by discovering why the patient feels or thinks the way he does — the therapist hopes to modify what happens outside — namely the patient’s behaviors and reactions to those around him.
But there is one school of psychology that stands out: behaviorism flips this inside-out model on its head. Behaviorism works from the outside in, by retraining the individual with a new set of behaviors to replace old behaviors that are considered inappropriate. In fact, when behaviorism is taken to its purest form, it isn’t much concerned with anyone’s interior life at all, let alone changing it.
Pavlov’s Dog and Albert’s Rat
It all began when Ivan Pavlov taught – or “conditioned,” in the parlance of behaviorism – his dog to salivate at the sound of a bell. He did this by ringing the bell before every mealtime, and soon whenever the dog heard the bell it started salivating and licking its chops. The bell’s ringing didn’t make the dog hungry — it didn’t change anything interiorly in the dog. Instead, the dog merely responded to the sound of the bell by salivating and licking his chops. The dog also salivated and licked his chops at the sound of a bell even if there was no food around.
That famous behavioral experiment was at the turn of the last century, and it wasn’t long before very young children replaced dogs as experimental subjects. In 1920, John Watson, considered the father of behaviorism, wrote about a set of experiments with 11-month-old “Little Albert,” who delighted in playing with a harmless fluffy white rat. To change Albert’s association with the rat, Watson made a loud noise behind Albert every time he reached for the rat. After only five trials, Albert not only became afraid whenever the white rat came near, he also developed a fear of any fuzzy white object — even the white fuzzy beard of a Santa Claus mask.1 B.F. Skinner, perhaps the most famous behaviorist of all, experimented further (sometimes on infants) and carried his results to their most radical conclusion. “Mental life and the world in which it is lived are inventions,” he wrote. “They have been invented on the analogy of external behavior occurring under external contingencies. Thinking is behavior. The mistake is in allocating the behavior to the mind.”2
As radical as that sounds, behaviorism did contribute one important improvement in the practice of psychology. Behaviorists relied exclusively on clearly observable and measurable behaviors in their work, which was in sharp contrast to psychoanalysts, who they dismissed as being obsessed with the babbling drivel of dreams, feelings, perceptions, hysterias and neuroses.3 Behaviorists saw their approach as being inherently more disciplined and scientific for one simple reason: behaviors are measurable; dreams are not. In advocating for a better-defined, more replicable and more science-based discipline into the world of psychology, behaviorists derided psychoanalysis, then the dominant force in psychology throughout the first three-quarters of the twentieth century, as being hopelessly unscientific and regarded psychoanalysts themselves as their foe and arch-nemesis. 4
Breaking Up A Homosexual Fixation
And to be certain, behaviorism did provide enormous benefits for many people that psychoanalysis had failed to help. But along the way, the new discipline quickly began to adopt some of the most abusive therapies known to psychology. At a meeting of the New York Branch of the American Psychological Association in 1934, New York University’s Louis William Max introduced a new device that he invented to safely administer a painful electric shock to his patients.5 Max’s first recorded use of this device was in “breaking up a homosexual fixation.” Despite “some backsliding,” he reported, “That terrible neurosis has lost its battle, not completely but 95% of the way.”6
From then on, behavioral therapists connected thousands of gay men to electrodes and their penises to measurement devices. One twitch of arousal while looking at gay porn would result in a powerful electric shock.7 Similar therapies were devised for cross-dressers and male-to-female transgender people (biological women, whether lesbian or transmen, were more likely to be spared the painful ordeal). In a less common method, patients were injected with a powerful emetic, and then allowed to look at all of the gay porn they could stomach — while the emetic retched their stomachs into violent spasms of vomiting and sometimes diarrhea.8 While some gay men could work up an aversion to gay sex that way, they rarely became straight. They just became very sick homosexuals.9
While psychoanalysis had been the dominant force in psychology through much of the 20th century, its influence was already waning by the 1970s just as behaviorism’s tide was cresting — and that change in direction just happens to coincide with George Rekers’s arrival on the scene. Rekers’s mentor, Ivar Lovaas, had been trained as a psychoanalyst, but he soon became among the most prominent practitioners of behavioral therapy after sharply criticizing his former discipline for its unscientific methods. Lovaas was interested in childhood autism (a condition for which there is no hope for interior change), and he saw that the principles of Applied Behavioral Analysis, or ABA, were uniquely suited for improving an autistic child’s functional abilities. While some of his methods have changed since the 1960s (he initially used electric shock to try to reduce self-injurious behaviors in autistic children, but he later abandoned the practice), many regard what has become known as the Lovaas Method a valuable tool for working with autistic children today.
Behavior therapy has its place (for example, in smoking cessation, alcohol and drug dependency, anxiety disorders, eating disorders, depression, and a host of other issues), but as is also true with the other schools of psychology, behavior therapy’s place isn’t everywhere. That’s why many mental health professionals avoid the tribalism of practicing only one kind of therapy at the expense of other useful techniques. But some therapists, when their favorite tool in their toolbox is a hammer, they have a tendency to see every problem as a nail. Lovaas possessed nearly unlimited faith in the ABA’s potential. “If I had gotten Hitler here at UCLA at the age of four or five,” he once said, “I could have raised him to be a nice person. A humanitarian.”10 When Lovaas saw the work Stoller, Green, and others were doing in the Gender Identity Clinic, he wondered if ABA might be useful in extinguishing gender variant behavior in children. And so with a grant from the National Institute of Mental Health for “Behavioral Treatment of Childhood Gender Problems” and a grad student kicking around for a project, the rest, unfortunately, is history.
That grad student was George Rekers, and his approach to treating four-year-old Kirk Murphy was a classic ABA technique known as “operant conditioning”: the use of consequences (i.e. punishment or the withdrawal of attention) to “extinguish” the occurrence of undesirable behavior. It must be emphasized that even though Lovaas was Rekers’s mentor, Rekers did not use electric shock aversion therapy with Kirk or with any other patient during his career. (I have found no evidence that electric shock therapy was used on any children at UCLA’s Gender Identity Clinic.) But Rekers’s brand of therapy was nonetheless both behavior-based and punishment-based. And Rekers’s single-minded focus on behavior only reflected behaviorism to its core: if you only focused on behavior, the rest would somehow manage to take care of itself. In 1991, Rekers summed it up this way:
The boy who is encouraged to act in a masculine way will develop a firm masculine identity.
The boy who develops a firm male identity will behave in a more masculine way.
Similarly, the girl who is encouraged to act in a feminine way will develop a firm female identity.
The girl who develops a firm female identity will behave in a more feminine way.11
Over 50 children with gender disturbances have been comprehensively treated by Rekers and his colleagues as well as Bates [another UCLA therapist] and his colleagues. Preliminary results after follow-up into adolescent years have indicated permanent changes in gender identity and overall psychological adjustment to the extent that gender identity can be measured by independent clinicians with interview and testing techniques. No other therapeutic intervention approach in childhood has been experimentally demonstrated to have this same effectiveness.
— Rekers, George A. “Gender identity problems.” Chapter 16 in Philip H. Bornstein & Alan E. Kazdin (eds.) Handbook of Clinical Behavior Therapy with Children (Homewood, IL: Dorsey Press): 658-699.
Rekers and Lovaas’s 1974 paper introducing “Kraig” to the therapeutic world catapulted Rekers to nearly instant renown among behavioral therapists working to change their clients’ sexual orientation or gender identity. Until then, nearly all behavior therapists had focused their efforts toward adults, but Rekers and Lovaas’s reported success with Kirk represented “the first experimental study on the subject of childhood cross-gender problems”12 (emphasis mine). Rekers quickly followed that with a second paper claiming similar success with “Carl,” an eight-year-old boy whom Rekers labeled a “pre-transsexual.”13 Before his referral to UCLA, “Carl” had been treated by a family therapist for eight months to no avail. Rekers used the same methods on “Carl” as he did on Kirk — the same playroom at UCLA, the same chips at home — but with one addition: because “Carl” was in school, Rekers enlisted his teachers in the behavior modification program as well. While Kirk was Rekers’s most famous case study, “Carl” would also become a much-discussed case study in his own right, especially among educators.14
In 1975, Rekers published another paper, this time detailing his success in the playroom only.15 For this paper, he presented data from Kirk’s files, and augmented it with data from four other young boys: “Jack” (5 years, 5 months), “Ken” (6 years, 5 months), “Wayne” (7 years), and “Larry” (8 years). In 1976, Rekers published another paper illustrating the kinds of play behavior that could serve as markers for “cross-gender identity.” Here he included data from these five boys and added another ten “feminoid boys.”16 By then the rate of referrals of gender-variant children to UCLA had skyrocketed, forcing the clinic to institute group therapy programs for the first time.17
When the Bough Breaks
Behaviorists however weren’t universally smitten with Rekers’s accomplishment. In 1977, the Journal of Applied Behavioral Analysis, one of the premiere journals dedicated to behavioral therapy (and the same journal that first published Rekers and Lovaas’s 1974 paper about Kirk), published two articles challenging Kirk’s treatment. In the first article,18 researchers from the University of Kansas mocked the idea that Kirk needed treatment because of how other people reacted to him. “Not every social pressure, not even every extensive social pressure, need be taken to define a deviancy that thereby needs treatment,” they wrote. They also questioned Rekers’s choices of “feminine” behaviors targeted for elimination: playing with dolls, playing with girls, walking with a “swishy” walk, recoiling from aggressive play. If Kirk actually had some of the more serious gender-neutral problems that Rekers wrote about — fears of getting hurt, avoiding his brother, declining to defend himself — they asked why those weren’t the targets of his therapy instead? They also questioned Rekers’s definition of appropriate play for young boys. “One might ask,” they added pointedly, “if aggression is representative of healthy play.”
The second article by a therapist from New South Wales challenged Rekers on what it was that Rekers was trying to prevent.19 As Rekers himself admitted, no one could predict whether Kirk would be transsexual, a cross-dresser, or homosexual. Homosexuality was no longer considered a mental illness. Even though transvestism and (beginning in 1980) transsexualism were, it still wasn’t clear that Kirk’s condition was enough to guarantee the emergence of anything even remotely approaching a pathology as an adult. Instead, the critic argued, Kirk was being treated because of how others reacted to him, and not because he suffered from an objective pathology. “Where ‘pathology’ is associated with sexual deviance,” he wrote, “much of it, if not all, can be regarded as a function of social attitudes to sexual behavior. As attitudes change, it becomes increasingly presumptuous to guess about the type of adult life a child with cross-gender behavior will lead.”
The objections raised by those two papers reflected several broad trends emerging among ABA practitioners in the late 1970s. The first mirrors psychology’s general movement away from regarding homosexuality as a mental illness. In fact, it can be argued that controversy over behaviorism’s excesses served as an important catalyst for the move. When Neil McConaghy, a famous behavioral therapist and avid proponent of electric shock averson therapy, finished reading a paper on his treatment for homosexuality at a 1970 American Psychiatric Association convention in San Francisco, gay activists stormed the podium with shouts of “vicious,” “torture,” and “Where did you take your residency, Auschwitz?”20 In 1972, activists interrupted a New York meeting of the Association for the Advancement of Behavior Therapy (AABT) during a presentation by another aversion therapy advocate.21 Those expressions of outrage opened the doors to serious discussions within both the APA and AABT, and those discussions finally led to the APA’s de-listing of homosexuality in 1973. AABT’s president followed suit in 1974 by telling his membership that providing treatment to clients seeking to change their sexual orientation was morally wrong.22 That statement was controversial and not well received, particularly among the great number of practitioners whose main focus was in precisely that arena. After all, aversion therapy was by far the favorite method for treating homosexuality among behavioral therapists.23 But within a few years, most of the grumbling ended and therapists began questioning their own previously rigid opinions of what it meant to be a man or a woman.
The second trend had to do with the general public’s reaction against the punitive therapies practiced by many behavioral therapists. Tales of torturous treatments provoked public disgust in magazines, documentaries and, most notably, in the popular 1976 film A Clockwork Orange, which fed a growing suspicion that behaviorism could become a tool for totalitarian control.24 Behaviorism’s plummeting esteem served as a wake-up call, prompting the movement to reconsider its reliance on punishment as a form of therapy. Negative reinforcements weren’t entirely eradicated, but by the 1980’s accounts of electric shock therapy began dying out in the professional literature25 along with many other forms of aversion therapy. Many behavioral therapists also began to incorporate cognitive therapy into their toolbox,26 opening the way for them to go beyond inducing superficial behavioral changes by also influencing interior improvements in their clients’ emotional distress (if not their sexual orientation).
But in 1977, none of those reforms had reached Rekers, and he gave no quarter in his rebuttal to his critics. He held firm to his choice of gender norms while denying that they were rigid. He also defended the rationale for treating Kirk, saying it didn’t matter that he couldn’t tell whether Kirk would be gay or transgender. Regardless of what the APA said, it was all still deviance:
It is clearly deviant for a boy to state repeatedly that he can bear children and to wear maternity clothes compulsively. It is pathological for a person to state that his genitals are not rightfully his property, thereby requesting that they be surgically altered. A boy’s request for a penectomy (typical of many cross-gender identified boys) is not legally an elective surgical procedure, as is the cosmetic removal of a wart. If a parent requests that the boy’s compulsive transvestic behavior be eliminated, it is appropriate for the psychologist to cooperate with that objective. If a parent asks a psychologist to help prevent the possibility of homosexual development, this is an ethically and professionally proper goal for the psychologist.27
While Rekers remained controversial, his reported successes inspired others to include behavior therapy techniques when treating their young charges. One case was particularly enlightening. Earlier that same year as Rekers’s defense, two Australian clinicians reported that they had incorporated elements of Rekers’s techniques for six-year-old “Greg.” In particular, they used a points system of reward and punishment at home that was very similar to Rekers’s red chip/blue chips.28 After eighteen months, they reported that “Greg is aware of the unacceptability of his feminine behavior and is able to deny expression of this at school, in therapy and with his parents.” But there was a caveat, which goes to the heart of behavior therapy’s Achilles heal: behavior therapy only targeted superficial external behaviors, and not the underlying personality. “The evidence that the underlying psychopathology persists,” they continued, “indicates the need for continuing with the programme and especially with Greg’s individual therapy.” In other words, “Greg” learned to hide his effeminate behavior when he wanted to, but deep down nothing really had changed. The blind men around the elephant were still groping and bluffing.
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Callahan, Edward J. Leitenberg, Harold. “Aversion therapy for sexual deviation: Contingent shock and covert sensitization.” Journal of Abnormal Psychology 81, no. 1 (February 1973): 60-73
Hale, Valerie E.; Strassberg, Donald S. “The role of anxiety on sexual arousal.” Archives of Sexual Behavior 19, no. 6 (December 1990): 569-581.
McConaghy, Nathaniel; Armstrong, Michael S.; Blaszczynski, Alex. “Controlled comparison of aversive therapy and covert sensitization in compulsive homosexuality.” Behaviour Research and Therapy 19, no. 5 (1981): 425-434.
Tanner, Barry A. “Avoidance training with and without booster sessions to modify homosexual behavior in males.” Behavior Therapy 6, no. 5 (October 1975): 649-653.
Acosta, Frank X. “Etiology and treatment of homosexuality: A review.” Archives of Sexual Behavior 4, no. 1 (February 1975): 9-29.
9. My thanks go to my good friend Dr. Jack Drescher, who came up with that observation during an overview of the history of ex-gay therapy at a 2009 Anti-Heterosexism Conference in Ft. Lauderdale, FL.
11. Rekers, George A. “Rearing masculine boys and feminine girls.” Chapter 17 in John Piper and Wayne Gridem (eds.) Recovering Biblical Manhood and Womanhood: A Response to Evangelical Feminism (Wheaton, IL: Crossway Books, 1991): 294-311.
17. Bates, John E.; Skilbeck, William M.; Smith, Katherine V.R.; Bentler, Peter M. “Intervention with families of gender-disturbed boys.” American Journal of Orthopsychiatry 45, no. 1 (January 1975): 150-157.
18. Nordyke, Nancy S.; Baer, Donald M.; Etzel, Barbara C.; LeBlanc, Judith M. “Implications of the stereotyping and modification of sex role.” Journal of Applied Behavior Analysis 10, no. 3 (Fall 1977): 553-557.
20. As recounted in McConaghy, Nathaniel; Armstrong, Michael S.; Blaszczynski, Alex. “Controlled comparison of aversive therapy and covert sensitization in compulsive homosexuality.” Behaviour Research and Therapy 19, no. 5 (1981): 425-434. It was Australian researcher Nathaniel McConaghy’s presentation of a paper that would be published a year later which prompted the disruption by those who McConaghy dismissed as “militant gay activists.”
See also Bayer, Ronald. Homosexuality and American Psychiatry: The Politics of Diagnosis (1987 ed.)(Princeton, NJ: Princeton University Press, 1987): 102.
The paper which caused the ruckus was: McConaghy, Nathaniel. “Aversive therapy of homosexuality: Measures of efficacy.” American Journal of Psychiatry 127, no. 9 (March 1971): 1221-1224.
25. One of the last papers describing the use of electric shock therapy to “cure” homosexuality appeared in 1981. McConaghy and his colleagues acknowledged “ethical objections to the use of behavior therapy in homosexuality,” but dismissed them and went on to present 10 cases in which men underwent electric shock aversion therapy for “compulsive homosexual urges.” However, based on past findings, McConaghy and colleagues concluded that “aversive therapy did not reorient homosexuals, it allowed them to control aspects of behavior they had previously experienced as beyond their control.”
McConaghy, Nathaniel; Armstrong, Michael S.; Blaszczynski, Alex. “Controlled comparison of aversive therapy and covert sensitization in compulsive homosexuality.” Behaviour Research and Therapy 19, no. 5 (1981): 425-434.