Behaviour Therapy

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Behaviour Therapy Cognitive-Behaviour
TherapyAn Introduction for Psychiatric Registrars

• Frank McDonald
• Consultation-Liaison Psychologist
• www.fmcdonald.com
• The Townsville Hospital
• June 2002
• Web V.02.6.22

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Aims

• Introduce theoretical premises of Behaviour
  Therapy Cognitive-Behaviour Therapy
• Describe behavioural case formulations - how they
  flow from a complete Behavioural Analysis their
  value
• Describe a range of Behavioural CBT treatments
  - nuts bolts of some psychological techniques
• Provide supplementary material
• therapist pt written info material
• videos of strategies for mx of panic depression
  (not on Web version)
• self-help professional literature Web
  references
• Check transfer of learning - discussion of
  medical practice case vignettes in which
  knowledge of strategies from learning theory
  based therapy may be helpful

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BT CBT Overview Click action button to advance
to section

• Paradigmatic bases of CBT BT
• Distinguishing characteristics of CBT BT
• Suitable disorders and problems
• Behavioural analysis the etiological inquiry
• Survey of strategies for common conditions

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BT CBT Overview

• Examples of specific behavioural strategies
• Exposure therapy for anxiety disorders
• Behavioural responses to panic symptoms
• Activity scheduling for depression
• Behavioural management of chronic pain
• Behavioural marital counselling
• Token economies for children

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BT CBT Overview

• Examples of cognitive-behavioural strategies
• Anxiety
• Depression
• Pain
• Your comment on how CBT Behaviour Therapy may
  help with pt problems in some psychiatric
  practice scenarios
• References Resource materials
• Credits

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1. Theory And Paradigm Bases

• Both therapies derived from Learning Theory and
  share some premises -
• Pts problems are, at least in part,
• causally related to antecedent events,
• a result of reinforcing consequences,
• a result of dysfunctional thoughts or behavioural
  deficits.
• And a pts condition is, at least in part,
  treatable by specific cognitive or behavioural
  techniques
  
• 
  (Sperry et al., 1992)

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1. Theory And Paradigm Bases

• Both BT CBT aim to modify or eliminate
  maladaptive thoughts, feelings and behaviours
• However their paths to this same goal differ
  (i.e. different therapeutic targets and rx
  strategies)
• Reflects differing paradigmatic bases

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1. Theory And Paradigm Bases

• Behaviourists say change behaviour (/or
  environment) - changes in thoughts feelings
  follow
• Cognitivists say change thoughts, images, etc
  (cognitions) - changes in feelings behaviour
  follow

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1. Theory And Paradigm Bases

• Conditioning paradigm experiences action
• Two subclasses
• Classical conditioning
• Operant conditioning
• Cognitive-behavioural paradigm internal
  representation
• For further discussion examples see
  separate notes.
• Click here (Document links require a
  PDF reader.)

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2. Characteristics of CBT Behaviour Therapy

• What distinguishes Learning Theory based
  therapies?
• Psycho-educational format
• Systematic measurement
• Individually-tailored, structured treatment
• Home assignments
• Ultimate aim of self-management and self-control

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3. Some conditions suitable for BT CBT

• Anxiety disorders
• (PD /- A, OCD, GAD, PTSD, Social Specific
  Phobias)
• Depression
• Chronic pain
• Social skills deficits
• Marital/relationship problems
• Sexual problems
• Childrens behaviour problems
• Eating disorders
• Habit disorders (e.g. sleep disturbances,
  smoking)
• Abnormal grief reactions
• Anger problems

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4. Behavioural Analysis The Etiological Inquiry

• BT CBT not just a bunch of routinely applied
  procedures such as response prevention, exposure
  therapy, cognitive restructuring etc
• Good BT CBT rests on thorough Behavioural
  Analysis of how problem began why continues

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4. Behavioural Analysis The Etiological Inquiry

• Behavioural Analysis a search for all relevant
  antecedents (recent remote), concomitants
  consequences the before, during after
  contingencies
• More specifically, stimulus-response links both
  personal (cognitions, autonomic behavioural
  responses) environmental associated with
  problem. Guides therapy

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4. Behavioural Analysis The Etiological Inquiry

• Analysis therapy lie in the context of a
  supportive relationship
• Despite apparent technical nature of BT CBT,
  research says warm therapists get significantly
  better results than cold therapists. Even in
  more mechanical treatments like graded exposure
  therapy for phobias

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4. Behavioural Analysis The Etiological Inquiry

• Irrespective of paradigm, behavioural analysis a
  sine qua non of learning theory based therapies
• Hypotheses formulated about precise variables
  controlling problem so as to suggest treatment.
  Reduces chances of trial error therapy
• Hypotheses tested by outcomes reformulated if
  unsupported, loop-fashion, until success

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4. Behavioural Analysis The Etiological Inquiry

• Treatment targets are specified in strict
  operational, measurable terms not vague
  language like less anxious a hallmark of
  behaviour therapies
• Treatment target options change causes, change
  responses, change both or environment
• Changing environment often produces quickest,
  most efficient improvement in feelings

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4. Behavioural Analysis The Etiological Inquiry

• Treatment is basically hypothesis testing of
  testable constructs
• Click on links for Behavioural Analysis notes
  for expansion and for example matrix to guide
  assessment

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5. Survey of BT CBT Techniques for Common
Conditions

• Anxiety
• Breathing retraining
• Relaxation training
• Graded exposure therapy
• Flooding (rarely used)
• Response prevention (extinction)
• Cognitive restructuring strategies
• Structured problem solving

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5. Survey of BT CBT Techniques for Common
Conditions

• Anxiety (contd)
• Meditation
• Assertiveness Training / Social Skills Training
• Stimulus control
• Eye Movement Desensitisation Reprocessing
• Thought stopping
• To see how anxiety disorders are treated using
  psychological strategies on a disorder by
  disorder basis click here

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5. Survey of BT CBT Techniques for Common
Conditions

• Depression
• Cognitive Therapy for ways of thinking common to
  depression (e.g. 3 Ps permanent, pervasive
  personal)
• Activity scheduling gradually increasing
  pleasurable and achievement events
• Structured Problem Solving
• Social skills training/Assertiveness training to
  increase social rewards
• Consider involving family/partner in therapy

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5. Survey of BT CBT Techniques for Common
Conditions

• Habit Disorders/Addictive behaviours (e.g.
  Primary Insomnia, smoking)
• Stimulus control
• Relaxation/ imagery/ autosuggestion
• Environmental changes
• Self-reward
• Self-monitoring
• Aversion therapy
• Saturation (extinction)

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5. Survey of BT CBT Techniques for Common
Conditions

• Social Skills Deficits
• Behaviour modelling
• Covert modelling
• Behaviour rehearsal
• Role playing
• Assertiveness Training
• Social Skills Training (e.g. conversational
  skills)
• Communication Skills Training (e.g. listening,
  negotiation, conflict resolution)

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5. Survey of BT CBT Techniques for Common
Conditions

• Chronic Pain
• Goal setting
• Self-monitoring
• Pacing
• Graded physical conditioning
• Relaxation for any tension component
• Emotion defusing strategies (for frustration,
  anxiety etc)

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5. Survey of BT CBT Techniques for Common
Conditions

• Chronic Pain (contd)
• Autosuggestion/self-hypnosis
• Structured problem solving
• Distraction (more suited to acute pain)
• Meditation
• Assertiveness Training (e.g. making/refusing
  requests given physical limitations)
• Depression management strategies

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5. Survey of BT CBT Techniques for Common
Conditions

• Relationship Difficulties
• Communication Skills training
• Basic Listening, validating,
  levelling
• Intermediate Assertiveness training
• Advanced Negotiation skills (win/win)
• Conflict resolution
  skills
• Reciprocity counselling (quid pro quo agreements)
• Miscellaneous
• Token economies
• Behavioural exchange contracts

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6. Behavioural Strategies

• A. Exposure therapy for anxiety (used in OCD,
  PTSD, PDA, Specific and Social Phobia)
• Exposure to anxiety in graded fashion. Identify
  specific goals and break them into smaller,
  manageable steps

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6. Behavioural Strategies

• Learn to master situations that cause mild, then
  gradually greater, anxiety. Teach test a
  relaxation strategy before to reduce
  distress/panic during exposure
• Aim is to achieve relative relaxation before next
  step

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6. Behavioural Strategies

• Principle best way to overcome fear is to face
  it, but in ways research says are more likely to
  succeed
• Emphasise habituation to anxiety in each exposure
  session. Biggest trap is to flee a step at height
  of fear (re-forges association of situation
  fear)
• Confront fears regularly and frequently
• See Exposure Therapy notes Click here for
  pt notes Click here for therapist notes

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6. Behavioural Strategies

• Example of graded exposure hierarchy for
  Agoraphobia or Social Phobia
• Goal To travel alone by bus to the city and back
  
• 1. Travelling one stop, quiet time of day
  (anxiety level 4/10)
• 2. Travelling two stops, quiet time of day
• 3. Travelling two stops, rush hour (anxiety level
  6/10)
• 4. Travelling five stops, quiet time of day
• 5. Travelling five stops, rush hour (anxiety
  level 8/10)
• 6. Travelling all the way, quiet time of day
• 7. Travelling all the way, rush hour (anxiety
  level 10/10)

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6. Behavioural Strategies

• Some pts with Social Phobia may need assistance
  with developing social skills
• Click here for Conversational Skills
  materialClick here for pt introduction to
  Assertiveness Training Click here for list of
  Assertiveness TechniquesClick here for Conflict
  Resolution strategies
• Model role play to aid generalisation (role
  play practice the core element of any social
  skill development)

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6. Behavioural Strategies

• B. Teaching behavioural responses to early
  symptoms of panic
• After education about panic, pts breathing is
  re-trained
• Slow, steady breathing is central to controlling
  panic. Regular daily practice set up
• Strategies applied at earliest symptom in
  self-monitoring framework
• Prof. Gavin Andrews on hyperventilation control.
  See References to purchase CD-ROM video via
  CRUfAD Web address
• See pt guide Panic Attacks! Click here

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6. Behavioural Strategies

• Videos below (Andrews Hunt, 1998) on mx of
  panic in General Practice, demonstrate a learning
  theory framework psychological research on the
  issue
• Patient presentation
• Assessing antecedents and consequences
• Psycho-educational phase
• Breathing retraining discussion homework
  assignment
• Behaviour rehearsal real-world generalisation
• Videos not available on Web. See References for
  purchase details of complete clinical skills
  program on CD-ROM available via CRUfAD Web
  address in References

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6. Behavioural Strategies

• C. Behavioural management of depression
• Main psychological approaches
• Cognitive Therapy (see CBT section)
• Structured problem solving (see CBT section)
• Activity Scheduling
• Ask pt about recent frequency of activities that
  gave sense of pleasure or achievement either or
  both often unusually low in depressed pts
• Encourage achievable, gradual increases each day.
  
• See list of suggested Pleasant Activities
• Click here

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6. Behavioural Strategies

• D. Behavioural management of Chronic Pain
• Set specific adjustment goals. For suggestions on
  goal planning click here. Blank goal sheet -
  click here
• Increase behaviours associated with adjustment to
  chronic pain. For guidelines click here and for
  more comprehensive guidelines on targets rxs
  click here
• Baseline activity levels via pain diary. Raise or
  lower these according to principles of pacing.
  Click links for initial pain diary cover and
  follow-up diary cover and blanks for each day
  evening of the baseline periods

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6. Behavioural Strategies

• Build stamina with appropriate exercise.
  Behaviourists start exercise below current
  capacities to avoid association with pain before
  habits established
• Click links for movement guidelines movement
  diary

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6. Behavioural Strategies

• E. Behavioural Marital Counselling
• Reciprocity Counselling focuses on couples
  forming quid pro quo agreements about highly
  specific desirable changes by partner
• Reciprocal agreements prevent either partner
  feeling any unfairness about change
• Click links for guidelines home monitoring
  sheets

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6. Behavioural Strategies

• F. Token Economy
• Mainly for children young adolescents
• Makes a game of home discipline. Reduces
  emotionality of parents. Adds objectivity to
  task. Reciprocal control in that child can manage
  parent. Gets around imbalance of power problem in
  some behavioural programs
• Fade to more natural contingencies as habits
  established
• See example
• Can be adapted to closed institutional settings
  i.e. where access to privileges outside closed
  system difficultSee example

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7. Cognitive-Behavioural Strategies

• A. Cognitive Therapy for Anxiety
• Explain cognitive restructuring to pts who
  potentially can think about their thinking -
  role of specific thoughts, thinking styles core
  beliefs. Supplement with info sheets /
  recommended reading Click here for samples
• Teach strategies
• Diary disputation / self-challenge of troublesome
  cognitions. Better than therapist persuasion,
  direct argument. Variation on role reversal
  strategy espoused by social psychologists for
  modifying attitudes. Model examples first using
  thinking out loud

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7. Cognitive-Behavioural Strategies

• Click here for disputing tips, example blank
  Daily Stress Tension Log.
• Cards with anti-worry statements /
  self-directions referred to regularly (principle
  of overlearning). Click here for example -
  Coping with Worrying Thoughts and other
  Managing Worry strategies
• Reframing (alternative perspective taking).
  Examples
• How would a reasonable person view same
  situation?
• Relate emotional reaction to point on a
  Catastrophe Scale. Click here for pt info sheet

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7. Cognitive-Behavioural Strategies

• Thought stopping. Click here for description. Use
  with other Managing Worry strategies
• Powerful, brief coping self-statements pt
  believes to be true. Rapid, abbreviated form of
  earlier, more complex disputation e.g. Feelings
  are not facts! Shit happens! Shouldhood is
  shithood! Im musterbating again! I am a
  fallible human being who can therefore make
  mistakes, some of them, big ones!
• Click here for pt info sheet

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7. Cognitive-Behavioural Strategies

• Meditation (conditions switching off what if?
  thinking in GAD, futurising type problems)
• Start with a one minute meditation exercise.
  Model out loud own multisensory awarenesses,
  moment to moment, free from any positive or
  negative judgments / adjectival speech
• Pt tries same for similar period out loud
  initially gradually increases time during
  repeated home assignments e.g. eventually long
  enough for hypnogogic phase of sleep to start

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7. Cognitive-Behavioural Strategies

• Guided Imagery. Used for relaxation, enhancing
  performance or imaginal confronting of avoided
  stimuli, obsessional cues, trauma recollections -
  often in graded exposure fashion e.g. sees self
  extending travel radii from home
• Can be intensified in hypnotic state or with
  associated cues e.g. vehicle crashes or aircraft
  sound effects recordings. Search Web for these

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7. Cognitive-Behavioural Strategies

• In confrontive applications, cognitive somatic
  counter-conditioning imperative before pt leaves
  session. Otherwise in vitro exposure resensitises
  rather than desensitises
• See Sleeping Better pt notes for example of
  relaxing Guided Imagery technique (Counting Down
  to Sleep)

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7. Cognitive-Behavioural Strategies

• Distraction (GAD, acute pain etc not when
  extinction needed e.g. specific phobias, P.D.A.,
  PTSD)
• Rational emotive imagery. Maultsbys technique -
  pts simply instructed to push themselves to
  feel better over a minute or so then articulate
  how they did it. (Usually with more rational
  thinking that provides starting point for further
  practice)

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7. Cognitive-Behavioural Strategies

• Structured problem solving (common skill deficit
  in worriers). Applied common sense. New variation
  on old Think, judge, act rule of conduct. Again
  see Managing Worry pt info sheets pp. 5-6
• See Video examples (Andrews Hunt, 1998) of
  structured problem solving with anxious pts on
  CD-ROM available via CRUfAD Web address in
  References

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7. Cognitive-Behavioural Strategies

• B. Cognitive Therapy for Depression
• As for CBT for anxiety, explain cognitive
  restructuring for depression to pt. Role of
  specific thoughts, thinking styles core
  beliefs.
• Perhaps start with examples of common thinking
  styles seen in those more prone to depression
  e.g. Seligmans 3Ps of adversity permanent,
  personal pervasive as they apply to the
  cognitive triad of depression future, self
  the world

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7. Cognitive-Behavioural Strategies

• Supplement with info sheets / recommended
  reading.
• Click here for pt. info sheet on Elliss ABC
  model. Probably easiest of cognitive therapies
  for pts to understand. Info sheet focus
  understanding modifying specific thoughts
  associated with depression
• Visit Albert Ellis Institute for more on Elliss
  Rational Emotive Behaviour Therapy
• Work thru structured program material with pt.
  Keep demands low at first because of problems
  with concentration, lethargy etc.

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7. Cognitive-Behavioural Strategies

• Pt material on raising activity levels
  modifying depressive cognitions from Oxford
  University Psychology Dept click here (Melanie
  Fennell in Hawton et al., 1989)
• Structured problem solving for depression
• Click here for single sheet description of
  technique. Present sheet to pt in session to aid
  application

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7. Cognitive-Behavioural Strategies

• C. Cognitive Therapy for Chronic Pain
• Click here to see list of common thoughts
  associated feelings that can worsen pain
• Click here to see some suggested disputations of
  thoughts that can worsen pain

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7. Cognitive-Behavioural Strategies

• Cognitive therapy for self-defeating thoughts
  relies on usual strategies such as diarying
  disputation
• Hypnotherapy (perhaps the oldest cognitive
  therapy) seen by many pts as useful. A daily ½
  hour self-hypnosis session can provide a welcome
  break from constancy of pain
• Click here for list that includes other
  cognitive ( behavioural) pain mx strategies
• Click here for more details on cognitive
  treatment, targets, strategies their rationales
  (go to page 6 for cognitive treatments etc)

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8. Psychiatric Practice Scenarios How Can
Behaviour Therapy CBT Help?

• 1. As a psychiatric registrar you see many
  patients whose primary complaint is that they are
  "unable to sleep." Discuss the most common
  reasons for this presentation. How would you
  evaluate such a problem and how might you treat
  it using learning theory principles? (exclude
  therapist modelling as per pic)

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8. How Can Behaviour Therapy CBT Help?

• 2. Ms A is a 45 year old woman who presents at
  mid-morning to Emergency Dept. complaining of
  nausea and anxiety. She had been unable to sleep
  the previous night because she had run out of her
  usual sleeping tablets (Temazepam). She has been
  taking up to 4 tablets (10mg) nightly for several
  months as her insomnia had worsened. She had
  increased the dose herself as her doctor had
  refused to do so and she had resorted to visiting
  more than one doctor. She admits to being
  somewhat anxious and depressed in mood at times
  and to having difficulty concentrating on her
  work. She denies taking any other drugs.

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8. How Can Behaviour Therapy CBT Help?

• 3. Describe and discuss the various treatments
  that are currently used in the treatment of Panic
  Disorder with Agoraphobia.

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8. How Can Behaviour Therapy CBT Help?

• 4. You are treating a 45 year old man with
  chronic low back pain. He is requiring
  increasingly frequent pethidine injections and
  appears depressed and tearful. He says he can no
  longer cope with the pain. How do you approach
  this problem?

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8. How Can Behaviour Therapy CBT Help?

• 5. A rather shy and introverted Engineering
  Student attends your outpatient clinic and tells
  you that he can't present his assignments in
  front of his seminar group. How can you as his
  psychiatric registrar help him?

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9. Reference Material

• Andrews, G. and Hunt, C. (1998) Counselling and
  Management Skills in Clinical Practice. (CD-ROM)
  Clinical Unit for Research of Anxiety Disorders
  (Web link next page for purchase), UNSW
  Psychiatry St. Vincents Hospital, Sydney, NSW,
  Australia
• Hawton, K., Salkovskis,P. et al.(1989) Cognitive
  Behaviour Therapy for Psychiatric Problems A
  Practical Guide. Oxford University Press.
• Sperry, L. et al. (1992) Chapter 4 Behavioral
  Formulations in Psychiatric Case Formulations.
  American Psychiatric Press, Washington
• Treatment Protocol Project (1997) Management of
  Mental Disorders.
• WHO Collaborating Centre for Mental Health
  and Substance Abuse, Darlinghurst, NSW, Australia
  2010

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9. Reference Material

• Clinical Research Unit for Anxiety Disorders
  (CRUfAD) WebsiteA UNSW site with excellent
  anxiety resources for pts and professionals. Free
  treatment manuals, CBT teaching resources,
  assessment protocols, self-test, CD-ROM, videos,
  links etc http//www.crufad.com/homepage.htm
• MoodGym Excellent self-paced web program for
  behavioural CBT of depression (mainly) and
  anxiety. Downloadable relaxation instructions and
  music http//moodgym.anu.edu.au/