PSY 245 CLINICAL PSYCHOLOGY II

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PSY 245CLINICAL PSYCHOLOGY II

• Assoc. Prof. Dr. BAHAR BASTUG
• Clinical Psychologist

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Behavioral Theory and Therapy
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• This weeks focus is on behavioral theory and
  therapy.
• We should all put our science caps on. ?

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• Behaviorism and its application, behavior therapy
  are linked to the science within academic
  psychology. Behaviorism and behavior therapy
  sprang from scientific efforts to describe,
  explain, predict and control observable animal
  and human behavior.

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• Behaviorism and psychoanalysis are opposite each
  other in some ways, and similar in some ways.
• The biggest difference between behaviorism and
  psychoanalysis is
• Psychoanalysis subjectively focuses on inner
  dynamic or mental concepts. Behaviorism
  objectively focuses on observable phenomena or
  materialistic concepts.

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• Psychoanalysis use techniques derived from
  clinical practice.
• Behaviorism use techniques derived from
  scientific research.

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• Both approaches are highly deterministic,
  positivistic and mechanistic perspectives to
  understanding human.
• Michael Mahoney referred to psychoanalysis and
  behaviorism as the yin and yang of determinism
  (1984).

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• They are often considered reactions to
  unscientific psychoanalytic approaches.

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• For the behaviorist, all behavior is LEARNED. The
  most complex human behaviors are explained,
  controlled, and modified through LEARNING
  PROCEDURES.

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HISTORICAL CONTEXT

• Three major historical stages in the contemporary
  behavioral approaches
• Behaviorism as a scientific attempt
• Behavior therapy
• Cognitive behavior therapy (CBT)

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HISTORICAL CONTEXT

• Existential-humanistic psychology is called the
  third force. As a third force, existential-humanis
  tic psy is an alternative to psychoanalysis and
  behaviorism. Why does this behavior therapy
  chapter come after the existential- humanistic
  chapters?

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• Although behaviorism began gaining popularity in
  the early 1900s, behavior therapy was not
  identified until the 1950s. Applied behavior
  therapy came later.

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Behaviorism

• In the early 1900s, a new and different
  mechanistic view of humans, behaviorism, was in
  contrast to other perspectives. Most early 20th
  century psychologists were interested in human
  consciousness and free will, and used a procedure
  called introspection to identify the inner
  workings of the human mind.
• Behaviorists excluded consciousness and
  introspection. They believed in determinism
  rather than free will.

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John Watson (1878-1958)
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• Prior to Watson, William James, identified
  himself as a philosopher, claimed that psy is no
  science, only the hope of a science.

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Father of behaviorism

• Watson believed in psychological science. He was
  interested in experimental psy, the classical
  conditioning learning model as demonstrated by
  Pavlovs dogs.
• For Watson, behaviorism was far beyond the hope
  of a science. He published behaviorist manifesto
  in 1913, and redefined psychology as a pure
  science.
• Psy as a behaviorist views it is a purely
  objective branch of natural science.

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• He was elected to the presidency of the APA in
  1915, at the age of 35.

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• In opposition to Jamess free will, the purpose
  of Watsons behaviorism was the deterministic
  prediction and control of human behavior. Watson
  viewed humans and animals as indistinguishable.

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• Give me a dozen healthy infants, well-formed,
  and my own specified world to bring them up in
  and Ill guarantee to take any one at random and
  train him to become any type of specialist I
  might selectdoctor, lawyer, artist,
  merchant-chief and yes, even beggar-man and
  thief, regardless of his talents, tendencies,
  abilities, vocations, and race.

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• Watson had a strong interest in the application
  of behavioral scientific principles to human
  suffering. This may have been because he
  experienced a nervous breakdown as a young man
  and had not found psychoanalysis helpful.

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Little Hans and Little Albert

• In 1909, Freud reported an analysis of Little
  Hans (5-year-old) who was afraid of being bitten
  by a horse because of unresolved Oedipal issues
  and castration anxiety.
• Freud explained that Little Hanss phobia was
  from castration anxiety.
• Watson showed that Little Albert could develop a
  phobia from classical conditioning.

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• Watson sought to demonstrate that severe fears
  and phobias were caused not by psychoanalytic
  constructs but by classical conditioning of a
  fear response. In his famous experiments with
  11-month-old Little Albert, after only five
  trials in which Watson and his assistant Rosalie
  Raynor paired the presentation of a white rat to
  Albert with the striking of a metal bar. Albert
  developed a strong fear and aversion to white
  rats.

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• His conditioned fear response generalized to a
  variety furry white objects, such as a dog,
  cotton wool and Santa Claus mask.

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Little Peter MARY COVER JONES

• Jones showed that fear could be extinguished
  through counterconditioning and/or social
  imitation.

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Little Peter

• In 1924, Mary Cover Jones, who was student of
  Watson, conducted an investigation of the
  effectiveness of counter-conditioning or
  deconditioning with a 3-year-old boy named Little
  Peter. It was study that illustrated the
  potential of classical conditioning techniques in
  the treatment of psychological fears and phobias.

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• Prior to his involvement in the behavioral
  experiments, Little Peter exhibited fear in
  response to several furry objects, including
  rabbits, fur coats, and cotton balls. Jones
  proceeded to systematically decondition Little
  Peters fear reaction by pairing the gradual
  approach of a caged rabbit with Peters
  involvement in an enjoyable activityeating his
  favorite foods. In the end, Peters fear response
  was extinguished.

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Early behaviorists made many important
contributions to psychology

• The discovery by Pavlov, Watson, and their
  colleagues that emotional responses could be
  involuntarily conditioned in animals and humans
  via classical conditioning procedures.
• The discovery by Mary Cover Jones that fear
  responses could be deconditioned by either (1)
  replacing the fear response with a positive
  response or (2) social imitation.
• The discovery by Thorndike and its later
  elaboration by Skinner that animal and human
  behaviors are powerfully shaped by their
  consequences.

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Behavior Therapy

• In the 1950s, three different groups in three
  different countries independently introduced the
  term behavior therapy to modern psy
• 1. B. F. Skinner in the United States
• 2. Joseph Wolpe, Arnold Lazarus, and Stanley
  Rachman in South Africa
• 3. Hans Eysenck and the Maudsley Group in the
  United Kingdom

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B. F. Skinner in the United States

• Skinner box

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Skinner (1904-1990)

• His early work was an experimental project on
  operant conditioning with rats and pigeons in the
  1930s. He demonstrated the power of positive
  reinforcement, negative reinforcement,
  punishment, and stimulus control in the
  modification of animal behavior. Within the
  confines of Skinner box, he was able to teach
  pigeons to play ping-pong via operant
  conditioning procedures.

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Skinner

• In the 1940s, he began extending operant
  conditioning concepts to human social and
  clinical problems. His book Walden Two was a
  story of how operant conditioning procedures
  could be used to create an utopian society. His
  next book, Science and Human Behavior, was a
  critique of psychoanalytic concepts and a
  reformulation of psychotherapy in behavioral
  terms.
• In 1953, Skinner and his colleagues first used
  behavior therapy referring to the application of
  operant conditioning procedures to modify the
  behavior of psychotic patients.

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Joseph Wolpe, Arnold Lazarus, and Stanley Rachman
in South Africa

• Joseph Wolpe was interested in conditioning
  procedures as a means for resolving neurotic
  fear. He established the first nonpsychoanalytic,
  empirically validated behavior therapy technique.
  His book Psychotherapy by Reciprocal Inhibition
  outlined the therapeutic procedure now called
  systematic desensitization.
• Wolpes approach is very similar to Joness
  counterconditioning principle wherein a
  conditioned negative emotional response is
  replaced with a conditioned positive emotional
  response.

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• Wolpes work attracted the attention of two South
  African psychologists, Arnold Lazarus and Stanley
  Rachman.
• Conditioning procedures were used as a means for
  resolving neurotic fear.
• A conditioned negative emotional response is
  replaced with a conditioned positive emotional
  response.

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• Lazarus advocated the integration of
  laboratory-based scientific procedures into
  existing clinical and counseling practices. He
  used the term behavior therapy in a journal.
• Rachman has influenced developing behavior
  therapy procedures. His contribution involved the
  application of aversive stimuli to treating
  neurotic behavior, including addictions.

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Hans Eysenck and the Maudsley Group in the United
Kingdom

• British psychiatrist Hans Eysenck used the term
  behaviour therapy to describe the application
  of modern learning theory to the understanding
  and treatment of behavioral and psychiatric
  problems.

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• Conclusion,
• All these researchers lead to born behavioir
  therapy.

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Cognitive Behavior Modification

• Contemporary behavior therapy now includes
  cognitive variables. Most behavior therapists now
  work with cognition.
• Many articles focus on thoughts, expectations,
  and emotions. Behavior therapy is no longer a
  process that focuses on external behavior.
• Behavior therapy continues to develop.

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THEORETICAL PRINCIPLES

• Two primary principles characterize behaviorists
  and behavioral theory
• Behavior therapists employ techniques based on
  modern learning theory.
• Behavior therapists employ techniques derived
  from scientific research.

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Theoretical Models

• The four main models of learning form the
  theoretical foundation of behavior therapy.
• Operant Conditioning Applied Behavior Analysis
• Classical Conditioning Neobehavioristic,
  Mediational Stimulus-Response Model

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Operant Conditioning Applied Behavior Analysis

• B. F. Skinner
• Applied behavior analysis is a clinical term
  referring to a behavioral approach based on
  operant conditioning principles.
• The operant conditioning position is
  straightforward Behavior is a function of its
  consequences.
• Operant conditioning is a stimulus-response
  theory.

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Applied Behavior Analysis

• Applied behavior analysis is a clinical term,
  based on Skinners operant conditioning
  principles. Behavior is a function of its
  consequences.
• Operant refers to how behaviors operate on the
  environment, thereby producing specific
  consequences.

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Applied Behavior Analysis

• Operant conditioning is a stimulus-response (SR)
  theory. Applied behavior analysis focuses on
  observable behaviors. Therapy proceeds through
  the manipulation of environmental variables to
  produce behavior change.

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Applied Behavior Analysis

• The main procedures are reinforcement,
  punishment, extinction, and stimulus control.
  These procedures are used to manipulate the
  environmental contingencies (rewards and
  punishments). The goal is to increase adaptive
  behavior through reinforcement and stimulus
  control and to reduce maladaptive behavior
  through punishment and extinction.
• Several behavior therapy techniques, such as
  assertiveness training, the token economy, and
  problem-solving training are derived from applied
  behavior analysis.

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Classical Conditioning Neobehavioristic,
Mediational Stimulus-Response Model

• The neobehavioristic mediational SR model is
  based on classical conditioning principles. Its
  principles were developed and articulated by
  Pavlov, Watson, and Wolpe.
• Classical conditioning is sometimes referred to
  as associational learning because it involves an
  association of one environmental stimulus with
  another.

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Classical Conditioning Neobehavioristic,
Mediational Stimulus-Response Model

• In Pavlovian terms, an unconditioned stimulus is
  one that naturally produces a specific
  physical-emotional response. The physical
  response elicited by an unconditioned stimulus is
  mediated through smooth muscle reflex arcs, so
  higher-order cognitive processes are not required
  in order for conditioning to occur.

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Classical Conditioning Neobehavioristic,
Mediational Stimulus-Response Model

• The experience of being struck from behind while
  waiting for a red light is the unconditioned
  stimulus. This stimulus automatically (or
  autonomically) produces a reflexive fear response
  (or unconditioned response). After only a single,
  powerful experience, the 34-year-old man suffers
  from a debilitating fear of impending death (a
  conditioned response) whenever he is exposed to
  the interior of an automobile (a conditioned
  stimulus).

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Classical Conditioning Neobehavioristic,
Mediational Stimulus-Response Model

• As Wolpe emphasizes, this scenario represents
  classical autonomic conditioning or learning
  because the man has no cognitive expectations or
  cognitive triggers that lead to his experience of
  fear when he is sitting inside an automobile.
  Because of the lack of cognitive processing
  involved in classical conditioning, when an
  individual experiences a purely classically
  conditioned fear response, often he or she will
  say something like, I dont know why it is, but
  Im just afraid of elevators.

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Classical Conditioning Neobehavioristic,
Mediational Stimulus-Response Model

• Classical conditioning principles include
• stimulus generalization,
• stimulus discrimination,
• extinction,
• counter-conditioning, and
• spontaneous recovery.

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• Classical conditioning principles
• Stimulus generalization the generalization of a
  conditioned fear response to new settings,
  situations, or objects.
• In the case of Little Albert, stimulus
  generalization occurred when Albert experienced
  fear in response to stimuli similar in appearance
  to white rats (e.g., Santa Claus masks, cotton
  balls, etc.).
• .

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Classical conditioning principles

• Stimulus discrimination occurs when a conditioned
  fear response is not elicited by a new or
  different stimulus.
• In the case of Little Albert, stimulus
  discrimination occurred when Little Albert did
  not have a fear response when exposed to a fluffy
  white washrag.

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• Classical conditioning principles
• Extinction the gradual elimination of a
  conditioned response. It occurs when a
  conditioned stimulus is repeatedly presented
  without a previously associated unconditioned
  stimulus.
• If Watson had kept working with Little Albert and
  repeatedly exposed him to a white rat without a
  frightening sound of metal clanging, Little
  Albert would lose his conditioned response to
  rats.
• Extinction is not the same as forgetting.

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Classical conditioning principles

• Counter-conditioning.New associative learning.
• Mary Cover Joness work with Little Peter is an
  example of successful counter-conditioning or
  deconditioning. Counter-conditioning involves new
  associative learning. The subject learns that the
  conditioned stimulus brings with it a positive
  emotional experience.
• When Jones repeatedly presented the white rat to
  Little Peter while he was eating some of his
  favorite foods, eventually the conditioned
  response (fear) was counter-conditioned.

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Classical conditioning principles

• Spontaneous recovery occurs when an old response
  suddenly returns after having been successfully
  extinguished or counterconditioned.
• If, after successful counter-conditioning through
  systematic desensitization, Wolpes client
  suddenly begins having fear symptoms associated
  with the interior of automobiles, he has
  experienced spontaneous recovery.

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Theory of Psychopathology

• MALADAPTIVE BEHAVIOR IS LEARNED AND CAN ALWAYS BE
  EITHER UNLEARNED OR REPLACED BY NEW LEARNING.
• PSYCHOPATHOLOGY MAY BE A FUNCTION OF INADEQUATE
  LEARNING OR SKILL DEFICITS.

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Theory of Psychopathology

• An underlying principle of assertiveness training
  is that individuals who exhibit too much passive
  or too much aggressive behavior simply have skill
  deficits they havent learned how to
  appropriately use assertive behavior in social
  situations. The purpose of assertiveness training
  is to teach clients assertiveness skills through
  modeling, coaching, behavior rehearsal, and
  reinforcement.

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Theory of Psychopathology

• Behaviorists systematically apply following
  scientific methods
• Observe and assess client maladaptive behaviors.
• Develop hypotheses about the cause,
• Test behavioral hypotheses through the
  application of empirically justifiable
  interventions.
• Observe and evaluate the results of their
  intervention.
• Revise and continue testing new hypotheses as
  needed.

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THE PRACTICE OF BEHAVIOR THERAPY

• To practice behavior therapy requires that you
  take notes and think like a scientist. You are a
  teacher. Your job is to help clients unlearn old
  maladaptive behaviors and learn new, adaptive
  behaviors.

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What Is Contemporary Behavior Therapy?

• Nearly all cognitive therapies are used in
  conjunction with behavior therapies.
• There are now several new-generation
  cognitive-behavioral therapies. These therapies
  include
• Dialectical Behavior Therapy (DBT)
• Acceptance and Commitment Therapy (ACT)
• Eye Movement Desensitization Reprocessing (EMDR)

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Assessment Issues and Procedures

• Behavior therapists would be able to directly
  OBSERVE clients in their natural environment to
  obtain specific information about what happens
  before, during, and after adaptive and
  maladaptive behaviors occur.
• The main goal of behavioral assessment is to
  determine the external (environmental or
  situational) stimuli and internal (physiological
  and cognitive) stimuli that directly precede and
  follow adaptive and maladaptive client behavioral
  responses. Both internal and external stimuli may
  be of interest.

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Assessment Issues and Procedures

• Functional Behavior Analysis (FBA) This
  assessment procedure is sometimes referred to as
  obtaining information about the clients
  behavioral ABCs
• A The behaviors antecedents (everything that
  happens just BEFORE the maladaptive behavior is
  observed)
• B The behavior operant definition by
  concrete terms
• C The behaviors consequences (everything
  that happens just AFTER the maladaptive behavior
  occurs)

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Assessment Issues and Procedures

• Through direct observation, the behavior
  therapist gathers information.
• But, direct behavioral observation is
  inefficient, for several reasons
• 1. Most therapists cant afford the time required
  to observe clients in their natural settings.
• 2. Many clients object to having their therapist
  come into their home or workplace to conduct a
  formal observation.

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Assessment Issues and Procedures

• 3. Even if the client agreed to have the
  therapist come perform an observation, the
  therapists presence influences the clients
  behavior.
• Because behavior therapists usually cannot use
  direct behavioral observation, they employ a
  variety of less direct data collection procedures.

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The Behavioral Interview

• The clinical or behavioral interview is the most
  common assessment procedure. During interviews,
  behavior therapists directly observe client
  behavior, inquire about behavioral antecedents
  and consequences, and operationalize the targets
  of therapy. The operational definition or
  specific, measurable characteristics of client
  symptoms and goals are crucial behavioral
  assessment components.

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• Defining the clients problem(s) in behavioral
  terms is the first step in a behavioral
  assessment interview. Behavior therapists are not
  satisfied when clients describe themselves as
  depressed or anxious. Instead, behaviorists
  seek concrete, specific behavioral information.

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The Clinical or Behavioral Interview

• Despite many practical advantages of behavioral
  interviews, this assessment procedure also has
  several disadvantages
• (1) low interrater reliability,
• (2) lack of interviewer objectivity, and
• (3) frequent inconsistency between behavior in a
  clinical interview and behavior outside therapy.
• (4) false, subjective clients report.

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The Clinical or Behavioral Interview

• Behavior therapists compensate for the
  inconsistent and subjective nature of interviews
  through two strategies
• They employ structured or diagnostic interviews
  such as the Structured Clinical Interview for the
  Diagnostic and Statistical Manual of Mental
  Disorders, fourth edition (SCID-DSM-IV).
• They use additional assessment methods beyond
  interviewing procedures.

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Self-Monitoring

• Sometimes, to directly observe client behavior
  outside therapy is impractical. Clients are
  trained to monitor their own behavior. In CBT,
  clients frequently keep thought or emotion logs
  that include at least three components
• disturbing emotional states,
• the exact behavior engaged in at the time of the
  emotional state, and
• thoughts that occurred when the emotions emerged.

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• Advantages of selfmonitoring is cheap, practical,
  and usually therapeutic.
• Disadvantages of selfmonitoring is that the
  client can collect inadequate or inaccurate
  information, or resist collecting any
  information. Clients may not make accurate
  recordings of their behavior.

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Standardized Questionnaires

• Objective psychological measures include
  standardized administration and scoring.
  Behaviorists prefer instruments that have
  established reliability and validity.
• These are often used to determine outcomes.

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Operant Conditioning and Variants

• In the tradition of Skinner and applied behavior
  analysis, the application of behaviorism to
  therapy is direct operant conditioning. Skinners
  emphasis is on environmental manipulation rather
  than processes of mind or cognition.

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Contingency Management and Token Economies

• Using operant conditioning requires an analysis
  of behavioral consequences in the clients
  physical and social environment. This process is
  contingency management. Its used more common in
  educational, family, institutional and drug
  treatment settings.

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Contingency Management and Token Economies

• An appropriate use of operant conditioning
  involves several systematic steps
• 1. The parents need to operationalize the target
• behaviors and identify behavioral objectives.
• 2. The therapist helped the parents develop a
  system
• for measuring the target behaviors. They were
  each
• given a pencil and notebook to follow the
  frequency
• of their teens behaviors.
• 3. The parents were instructed on how to monitor
  and evaluate the effects of their new contingency
  schedule.

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Contingency Management and Token Economies

• Operant conditioning principles have been applied
  to educational and institutional settings.
  Following Skinners work aimed at modifying the
  behavior of psychotic patients, operant
  conditioning within institutions has come to be
  known as a TOKEN ECONOMY.
• Within token economy systems, individuals are
  givencoins or symbolic rewards for positive or
  desirable behaviors. These tokens are used like
  money, to obtain goods or privileges.

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Contingency Management and Token Economies

• Token economies have been criticized as forcible
  and as not having lasting effects that generalize
  to the world outside the institution. After the
  desirable behavior patterns are well established,
  the behavioral contingencies would be slowly
  decreased. This procedure is referred to as
  fading and is designed to maximize the likelihood
  of generalization of learning from one setting to
  another. The desired outcome occurs when the
  subject internalizes the contingency system.

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Contingency Management and Token Economies

• Positive reinforcement faces some criticism.
• Thorndike, Skinner concluded that punishment led
  to behavioral supression, but it wasnt effective
  for controlling behavior.
• Then, Solomon claimed that punishment could
  generate new, learned behavior.

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Contingency Management and Token Economies

• Now, it is accepted that punishment is a powerful
  behavior modifier, but it has disadvantage.
• In the attachment and trauma literature,
  excessive punishment leads to trauma bonding.
• There is a debate on using punishment as a
  learning tool.

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Contingency Management and Token Economies

• The direct application of punishment, or aversive
  conditioning, is used to reduce undesirable and
  maladaptive behavior. It has been applied with
  some success to smoking cessation, repetitive
  self-injurious behavior, alcohol abuse or
  dependency, and sexual deviation.

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Behavioral Activation (BA)

• For Skinner, depr was caused by an interruption
  of healthy behavioral activities.
• Depressed individuals engage in fewer pleasant
  activities and obtain less positive reinforcement
  than others. So, if they change their behavior,
  they may improve or recover.

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Behavioral Activation (BA)

• BA was previously referred to as activity
  scheduling and used as a component of various
  cognitive and behavioral treatments for
  depression.
• Recent research suggests BA may be as good as the
  whole CBT package for depressive disorders.

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Relaxation Training

• Edmund Jacobson was the first scientist to write
  about relaxation training as a treatment
  procedure. Progressive muscle relaxation (PMR)
  was initially based on the assumption that
  muscular tension is an underlying cause of a
  variety of mental and emotional problems.

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Relaxation Training

• PMR is an evidence-based treatment.
• But PMR can make some clients more anxious.

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Systematic Desensitization and Other
Exposure-Based Treatments

• Joseph Wolpe introduced systematic
  desensitization as a technique.
• Systematic desensitization Jones
  deconditioning approach Jacobsons PMR
  procedure.
• To be relaxed is the direct physiological
  opposite of being excited or disturbed.
  (Jacobson, 1978, p. viii)

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Systematic Desensitization and Other
Exposure-Based Treatments

• After clients are trained in PMR techniques, they
  build a fear hierarchy in collaboration with the
  therapist. Systematic desensitization usually
  proceeds in the following way
• 1.The client identifies a range of various
  fear-inducing situations or objects.

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• Systematic Desensitization and Other
  Exposure-Based Treatments
• 2. Using a measuring system referred to as
  subjective units of distress, the client, with
  the support of the therapist, rates each
  fear-inducing situation or object on a scale from
  0 to 100 (0 no distress 100 total distress).
• 3. Early in the session the client engages in
  PMR.
• 4. While deeply relaxed, the client is exposed,
  in vivo or through imagery, to the least feared
  item in the fear hierarchy.

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Systematic Desensitization and Other
Exposure-Based Treatments

• 5. The client is exposed to each feared item,
  gradually progressing to the most feared item in
  the hierarchy.
• 6. If the client experiences anxiety at any point
  during the imaginal or in vivo exposure process,
  the client reengages in PMR until relaxation
  overcomes anxiety.
• 7.Treatment continues systematically until the
  client achieves relaxation competence while
  simultaneously being exposed to the entire range
  of fear hierarchy.

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Imaginal or In Vivo Exposure and Desensitization

• Systematic desensitization is an exposure
  treatment. In the exposure treatments, clients
  are treated by exposure to the thing they want to
  avoid the stimulus that evokes intense fear,
  anxiety, or painful emotions.

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Imaginal or In Vivo Exposure and Desensitization

• There are three ways in which clients are exposed
  to their fears during systematic desensitization
• 1. Exposure to fears can be accomplished through
  mental imagery. Computer simulation (virtual
  reality) has been used in therapists office.
• 2. In vivo exposure to feared stimuli. In vivo
  exposure involves direct exposure to real-life
  situations.

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• 3. computer simulation (virtual reality) has been
  used as a means of exposing clients to feared
  stimuli.
• Psychoeducation and a good therapeutic alliance
  are essential for exposure.

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Massed (Intensive) or Spaced (Graduated) Exposure
Sessions

• Is desensitization more effective when clients
  are exposed to feared stimuli during a single
  prolonged session or when they are slowly exposed
  to feared stimuli during a series of shorter
  sessions?
• Either approach can be used effectively.

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Virtual Reality Exposure (VRE)

• a procedure wherein clients are immersed in a
  real-time computer-generated computer
  environment. It has been empirically evaluated as
  an alternative to imaginal or in vivo exposure in
  cases of acrophobia (fear of heights), flight
  phobia, and spider phobia.
• VRE has been empirically validated.

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Interoceptive Exposure

• It is similar to other exposure techniques but
  focuses on internal anxiety signals or triggers.
• Research on Panic Disorder has showed that some
  clients who experience intense fear are
  responding less to situational stimuli and more
  to internal physical sensations.

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Interoceptive Exposure

• Panic-prone individuals are sensitive to internal
  physical cues (e.g., increased heart rate,
  increased respiration). They interpret those
  sensations as signs of physical illness, death,
  or loss of consciousness.
• Although specific cognitive techniques have been
  developed to treat clients tendencies to
  catastrophically overinterpret bodily sensations,
  interoceptive exposure has been developed to help
  clients learn, through exposure and practice, to
  deal more effectively with the physical aspects
  of intense anxiety or panic.

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Interoceptive Exposure

• Six introceptive exposures that trigger anxiety
• Hyperventilation
• Breath holding
• Breathing through a straw
• Spinning in circles
• Shaking head
• Chest breathing

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Interoceptive Exposure

• Before interoceptive exposure, the client receive
  education about body sensations, learn relaxation
  techniques, and learn cognitive restructuring
  skills. Through repeated successful exposure, the
  client becomes desensitized to feared physical
  cues.

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Response Prevention and Ritual Prevention

• According to Mowrer, when a client avoids a
  feared or distressing situation or stimulus, the
  maladaptive avoidance behavior is negatively
  reinforced.
• For example, clients with Bulimia Nervosa who
  purge after eating specific forbidden foods are
  relieving themselves from the anxiety and
  discomfort they experience upon ingesting the
  foods. Purging behavior is negatively reinforced.
• Similarly, when a phobic client escapes from a
  phobic object or situation, or when a client with
  OCD engages in a repeated washing or checking
  behavior, negative reinforcement of maladaptive
  behavior occurs.

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Response Prevention and Ritual Prevention

• With the therapists assistance, the client with
  bulimia is prevented from vomiting after
  ingesting a forbidden cookie, the agoraphobic
  client is prevented from fleeing a public place
  when anxiety begins to mount, and the client with
  OCD is prevented from washing hands following
  exposure to a contaminated object.

106
Participant Modeling

• Social learning principles have been evaluated
  for anxiety treatment.
• For example, individuals with airplane or flight
  phobias dont find it helpful when they watch
  other passengers getting on a plane without
  experiencing distress. In fact, such observations
  can produce increased hopelessness. There is too
  large a gap in emotional state and skills between
  the model and the observer, so vicarious learning
  does not occur.

107
Participant Modeling

• Behavior therapists provide models of successful
  coping.
• Group therapy provides an excellent opportunity
  for participant modeling and vicarious learning.

108
Skills Training

• Skills training techniques are based on skill
  deficit models of psychopathology. Many clients
  have not acquired the necessary skills for
  functioning.
• Behavior therapists evaluate their clients
  functional skills during the assessment phase of
  therapy and then use specific skills training
  strategies to treatment the clients skill
  deficits.

109

• Traditional skills training targets include
  assertiveness and other social behavior as well
  as problem solving.

110
Assertiveness and Other Social Behavior

• Wolpe and Lazarus defined assertiveness as a
  learned behavior. Individuals are evaluated as
  having one of three possible social behavior
  styles passive, aggressive, or assertive.
• Passive individuals behave in submissive ways
  they say yes when they want to say no.
• Aggressive individuals dominate others.
• Assertive individual speaks up, expresses
  feelings.

111
Assertiveness and Other Social Behavior
112
Assertiveness and Other Social Behavior

• The most common social behaviors targeted in
  assertiveness training are
• introducing oneself to strangers,
• giving and receiving compliments,
• saying no to requests from others,
• making requests of others,
• speaking up or voicing an opinion, and
• maintaining social conversations.

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• Assertive behavior is taught through the
  following strategies
• Instruction Clients are instructed in
  assertive eye contact, body posture, voice tone
  verbal delivery.
• Feedback The therapist or group members give
  clients feedback regarding how their efforts at
  assertive behavior come across to others.
• Behavior rehearsal or role playing Clients are
  given opportunities to practice specific
  assertive behaviors, such as asking for help or
  expressing disagreement without becoming angry or
  aggressive.

114

• Coaching Therapists whisper feedback and
  instructions in the clients ear as a role-play
  or practice scenario progresses.
• Modeling The therapist or group members
  demonstrate appropriate assertive behavior for
  specific situations.
• Social reinforcement The therapist or group
  members offer positive feedback and support for
  assertive behavior.
• Relaxation training It is needed to reduce
  anxiety in social situations.

115

• Assertiveness training for individuals with
  specific social anxiety and social skills
  deficits are used. Social Phobiaa condition
  characterized by an excessive, irrational fear of
  being scrutinized and evaluated by othersis
  treated with a combination of relaxation and
  social skills training that includes almost all
  the components of traditional assertion training
  and graduated or massed exposure to challenging
  social situations and interactions.

116
Problem Solving Therapy (PST)

• It is a behavioral treatment with cognitive
  dimensions.
• For rationale of PST, effective problem solving
  is a mediator that helps clients manage stresful
  life events. It focuses on
• Problem orientation This involves teaching
  clients to have a positive attitude toward
  problems. Problems are opportunity, are solvable.
  Believing in own ability to solve problems and
  recognizing that effective problem solving
  requires time and effort.

117
Problem Solving Therapy (PST)

• Problem-solving style Clients are taught a
  rational problem-solving style
• 1. Define the problem.
• 2. Identify the goal.
• 3. Generate options.
• 4. Choose the best solution.
• 5. Evaluate the outcome

118

• Discerning the differences between cognitive and
  behavioral therapies is difficult. Most behavior
  therapists use cognitive treatment and most
  cognitive therapists use behavioral treatments.
• Cognitive-behavioral therapy.

119

• One characteristic of behavior therapy is the
  generation of a clear and concrete problem list.
  Items in the problem list are defined in
  behavioral terms and measurable.

120

• Each behavior therapy session includes four
  parts
• 1.check-in and homework review
• 2. psychoeducation about the patients disorder
  and behavior therapy
• 3. in-session behavioral or cognitive tasks
• 4. new homework assignments.

121
Cultural and Gender Considerations

• Some research indicates behavioral treatments are
  effective with minority clients however, Craske
  (2010) admits that generally cognitive and
  behavioral therapies are not yet proven
  multiculturally efficacious.
• Behavior therapists need to make multicultural
  adjustments in their practices.

122
Evidence-Based Status

• Behavioral and cognitive therapies are far and
  away the largest producers and consumers of
  therapy outcomes research.
• The most recent APA Division 12 list of ESTs
  includes 60 different treatment protocols, most
  of which are behavioral or cognitive-behavioral.

123

• Token economies and contingency managementgtgt
• Behavioral activationgtgtdepr
• Progressive muscle relaxationgtgt
• Exposureresponse preventiongtgtanx dissorders
• Problem solving therapygtgtdepr.

124
Concluding Comments

• Behavior therapy deserves credit for
  demonstrating that particular approaches are
  effectivebased on a quantitative
  scientific-medical model.

125

• If it cant be empirically validated, then its
  not behavior therapy.