Behavioural and Cognitive-Behavioural Therapies

Chapter VIII

Behavioural and Cognitive-Behavioural TherapiesBehaviour disorders are seen as developing through

the same laws of learning as any other behavioursTherapy methods should be guided by the results of

research on learningTherapy should be aimed at modifying overt,

maladaptive behaviours, as well as the cognitions, physical changes, and emotions that accompany overt behaviour. The covert aspects of clinical problems should be dealt with as directly as possible

Treatment should address client’s current problems by dealing with the contemporary environmental forces, learned habits, and cognitive factors that maintain them

There is a commitment to the experimental evaluation of treatment.

The Beginnings of Behavioural Therapy The term behaviour therapy appeared in a paper in

1953 Roots goes back to 1920, experimental neurosis

studies (the role of conditioning and learning in the development of anxiety)

John Watson and Rosalie Rayner’s study with Albert B. (associated loud noise with a domesticated white rat → rat alone elicited a strong emotional reaction → generalisation of the fear to other previously neural, furry objects)

Jones tried several techniques to reduce children’s fears:Peter - afraid of rabbitsSocial ImitationDirect conditioning

Theoretical FoundationsClassical Conditioning:When neutral stimulus (such as musical tone)

comes just before another stimulus (pin-prick) that automatically triggers a reflexive response (startle reaction). If the two stimuli are paired often enough, the startle reaction begins to occur in response to the previously neutral musical tone

Operant conditioning:When certain behaviours are strengthened or

weakened by the rewards or punishments that follow that behaviour

The adaptive and maladaptive response patterns we learn can be associated with some situations but not others

When two situations are similar enough that they elicit the same response, stimulus generalization has occurred. In another words, the person does not psychologically discriminate between the situations and instead responds to them as if they were the same

Observational or Vicarious Learning:Bobo Doll studies

Assessment in Behaviour TherapyIs intended to understand client’s problematic

behaviours, the environmental circumstances under which those behaviours occur, and the reinforcers and other consequences that maintain them

They perform functional analysis or a functional assessment

Table 8.1.

The Role of TherapistEmpathic and supportive in response to client’s

feelings of anxiety, shame, hopelessness, distress, or confusion

Client-therapist relationship merely provides the context in which specific techniques can operate to create change

Therapeutic benefits occur when clients make changes in their environment (reducing exposure to triggers), internal responses (learning relaxation to lower levels of arousal) and overt behaviours (practicing conversational skills)

The Goals of Behaviour TherapyIs to help the client modify maladaptive overt

behaviours as well as the cognitions, physical changes, and emotions that accompany those behaviours

Clinical ApplicationsProgressive Relaxation Technique The most common relaxation technique. Tensing and then releasing various groups of

muscles while focusing on the sensations of relaxation that follow

Sometimes breathing exercises are included as well

Systematic Desensitisation:

Graduated hierarchy of situations that the client finds increasingly anxiety provoking (EXERCISE)

Imaginal desensitisation → clients relaxes and imagines the easiest item on the hierarchy. If the client can imagine the scene without anxiety for 10 seconds, the therapist describe the next one. If not, the client signals the anxiety and stops visualising the scene. After regaining complete relaxation, the client again pictures the item

Virtual Reality ExposureDesensitization appears especially effective

when clients are exposed slowly and carefully to real (rather than imagined) items in their hierarchies

In vivo sensitisation:Clients use relaxation skills to stay calm while

actually confronting gradually more threatening versions of what they fear

Virtual Reality Exposure:Computer generated simulation of feared

environments

Exposure Techniques:Direct exposure to frightening stimuli but the

idea here is not to prevent anxiety, instead exposure to feared stimuli is arranged so that anxiety occurs and continues until it eventually disappears through the process of exposure

Flooding → clients might be asked to touch and remain in contact with items they afraid of

Exposure times must be long enough for anxiety to disappear

Exposure should not be terminated while the client is still anxious because the resulting anxiety reduction would reinforce avoidance behaviour

Exposure treatment are generally used for the treatment of OCD, agoraphobia, panic attacks

Response prevention:Clients are not allowed to perform the rituals

they normally use to reduce anxiety

Social Skills Training:Some psychological disorders may develop

partly because people lack the social skills necessary for participating in satisfying interpersonal relationship and for gaining other reinforcers

Depression, anxiety disorders, antisocial and delinquent behaviors, schizophrenia, and social withdrawal and isolation

Assertiveness trainingDesigned to teach clients how to express

themselves appropriately if they do not already have the skills to do so and to eliminate cognitive obstacles to clear self-expression

Assertion training has four components: 1. defining assertion and distinguishing it from

aggression and submissiveness 2. discussing the rights of the clients and others 3. identifying and eliminating cognitive obstacles 4. practicing assertive behavior (role playing or

role rehearsal)

Modelling:Based on observational learning of BanduraMore effective than learning through direct

reinforcement or punishmentUsed for social withdrawal, OCD,

unassertiveness, antisocial conduct, physical aggressiveness, and early infantile autism, and fears

Especially effective when the models are similar to the client, have high status, and are rewarded for their actions

Presenting coping models who initially display fearfulness, then cope with and overcome it is one way

Aversion Therapy:Is a set of techniques in which painful or

unpleasant stimuli are used to decrease the probability of unwanted behaviours, such as drug abuse, alcoholism, overeating, smoking, and disturbing sexual practices

Following classical conditioning principles aversion methods pair stimuli that elicit problematic behaviour with a noxious stimulus

Following operant conditioning principles electric shock or some other aversive stimulus acts as a punisher. It is delivered after the client performs the problematic behaviour

There is a concern about whether the changes produced are extensive, durable, and generalizable enough to justify the unpleasantness of the treatment

It does not teach clients alternative behaviours that can replace their maladaptive ones

Contingency Management:Is a generic term for any operant technique

that modifies a behaviour by controlling its consequences

Refers to presenting or withdrawing reinforcer and aversive stimuli contingent upon the appearance of certain target behaviours

Used for autism, temper tantrums, learning difficulties, hyperactivity, retardation, aggression, phobias, sexual disorders, eating disorders, etc.

Shaping → also called successive approximation, it is a procedure for developing new behaviours by initially reinforcing any act that remotely resembles the desired behaviour

Time out → to reduce the frequency of unwanted behaviour we temporarily remove the person from the setting where that behaviour is being reinforced

Contingency contracting → formal, often written agreement between therapist and client spells out the consequences of certain client behaviours. Includes five components: 1. responsibilities of each of the parties 2. rewards for fulfilling the contract 3. a system for monitoring compliance with the contract 4. bonuses for unusual accomplishments, and penalties for failures

Response cost → is a punishment contingency that involves the loss of a reward or privilege following some undesirable behaviour

Token economies → include four elements: 1. target behaviours 2. token is identified as payment for

performing target behaviours 3. back-up reinforcers are established (goods

or services for which tokens may be exchanged)

4. rules of exchange governing (number of token for each target behaviour/the number of tokens to purchase goods)

Cognitive TherapyBy the 1970s, however, many behaviourally

oriented theorists had begun to stress the importance of cognitions and self-statements as mediators between environmental events and behaviours

They focused on how thoughts about the self can contribute to a number of psychological disorders

Cognitive mediationNormal and abnormal behaviour is triggered by

our cognitive interpretation of events, not by the events themselves

A cognitive model would suggest, then, that every event is followed by an appraisal – a cognitive response – that then shapes our emotional and behavioural responses to that event

Event

Cognition1

Cognition 2

Cognition 3

Emotion 1

Emotion 3

Response 2

Emotion 2

Response 1

Response 3

Schemas:

Our thoughts are guided by our schemas (also called schematas), the organized knowledge, structures that influence how we perceive, interpret and recall information

They serve as filters that influence how person perceive himself and his relations to the world

Thus, a depressed person who always unworthy is likely to interpret new information in ways consistent with that schema

The Role of Automatic Thoughts:Negative schema-driven thoughts can occur so

quickly that we are not consciously aware of having them, let alone by influenced by them

These non-conscious cognitions are not deeply buried, nor are they made inaccessible by defence mechanisms. Instead, cognitive therapists view our maladaptive cognitions as learned habits that near the surface and accessible by simple questioning and conversation

Negative attribution style: depressed people have a habitual way of explaining the causes of events, particularly negative events.

Table 8.5.

Beck’s Cognitive TherapyBased on the assumption that depression and

other emotions are determined by the way people think about their experiences

Depressive symptoms result from logical errors and distortions that clients make about the events in their lives

Clients also exaggerate the importance of trivial events in their lives

Depressed individuals show a characteristic pattern of negative perceptions and conclusions about a) themselves b) their world c) their future → Cognitive Triad

Rational Emotive Therapy:

Psychological problems result not from external stress but from the irrational ideas people hold, which lead them to insist that their wishes must be met in order for them to be happy

The therapists task is to attack these irrational, unrealistic, self-defeating beliefs and to instruct clients in more rational or logical thinking patterns that will not upset them

Therapists are active, challenging, demonstrative, and often abrasive (sharp)

Assessment in Cognitive TherapyDeveloping a detailed understanding of the

chronicity, intensity, and extent of the client’s automatic cognitive distortions

Rating scales, self-reports, and standardized instruments

The Role of the TherapistIn addition to support and trust, the alliance is

built on education about how maladaptive schemas, self defeating beliefs, negative attributional styles, and other important cognitive factors create and maintain psychological disorders

Collaborative empiricism

The Goals of Cognitive TherapyEducate the client about the role of

maladaptive thoughts in behaviour and experience

Help clients learn to recognize when they engage in those thoughts

Arm them with skills for challenging maladaptive thoughts and for replacing them with more accurate and adaptive ones

In short: Identify, Refute, and Replace

Clinical applications:PsychoeducationSocratic questioningRefuting and replacing maladaptive thoughtsThought recording and multicolumn records