Behavioral & Cognitive Treatments

1. Behavioral & Cognitive Treatments

2. Behavior Therapy • Defined: "The attempt to alter human behavior and emotion in a beneficial manner according to the laws of modern learning theory." --Eysenck

3. Quick review of learning theories • Classical: CS paired with UCS ; CS eventually produces CR in absence of UCS • Watson & Rayner (1920): Little Albert • Pavlov's dogs

4. Operant • Positive (adding something) • Punishment (adding bad) • Reward (adding good) • Negative (removing something) • Punishment • Reward • Social learning theory (observational learning) • Bandura's BOBO doll experiments.

5. Behavioral therapists classify abnormal behavior as excesses or deficits • Excess: behavior occurs more strongly/frequently and causes problems for the person (e.g., aggression) • Deficit: behavior does not occur strongly/frequently enough and causes problems (e.g., social skills--often a problem in schizophrenia or social anxiety disorder)

6. 3 ways in which behavioral and other therapies differ: • behavior therapy is more directive • goals of behavioral therapy are more circumscribed (behavior change rather than reconstruction of personality) • behavior therapy has empirical underpinnings (intuitive, since behaviors and the laws that govern them are more readily observable than personality characteristics)

7. Behavioral therapy techniques based upon classical conditioning • Systematic desensitization (counterconditioning): pair feared object with relaxation (e.g., muscle relaxation) • example • Flooding: client exposed to feared object w/o being able to escape; eventually, response is diminished--client cannot maintain it

8. Implosive therapy: more psychodynamic than flooding; client exposed to feared object in addition to images based on psychodynamic conflicts • Aversive conditioning: a stimulus previously associated with an undesired behavior is paired with an aversive stimulus (often used for paraphilias)

9. Systematic desensitization, flooding, and implosive therapy are often used with anxiety disorders • Therapists (& clients) tend to prefer systematic desensitization because it does not generate as much distress and it is more practical

10. Behavioral therapy techniques based upon operant, or instrumental conditioning • Token economy: clients get tokens for good behavior; they can exchange them for desired things; most often used in group/institutional settings; parents do this with stickers

11. Shaping: systematic reinforcement of successive approximations to a desired behavior; often used to treat speech problems in autistic children • Stimulus control: identify event that triggers unwanted behavior; change that stimulus

12. Behavioral therapy techniques based upon social learning • Modeling: often used in assertiveness training Behavioral therapy is very often paired with cognitive therapy (CBT).

13. Rational-Emotive Therapy (RET) • Cognitive therapies are all based on the assumption that emotional disorders result from maladaptive thought patterns. The task of therapy, therefore, is to restructure these maladaptive cognitions. • The two most prominent forms of cognitive treatment are Ellis’s rational-emotive therapy (RET) and Beck’s cognitive therapy.

14. Brief history and rationale • Ellis’ rational emotive therapy (RET) was the first of the modern cognitive interventions to gain widespread clinical acceptance. • Ellis was trained psychodynamically but he became more interested in exploring clients’ cognitions and changing their irrational beliefs.

15. According to the principles of RET, emotional disorders are rooted in people’s irrational beliefs, which are distortions of objective reality. • Ellis listed 12 irrational core assumptions that could be at the root of most emotional disturbances. Some examples of these irrational ideas are: • It is absolutely necessary to be loved by everyone for everything you do. • It is easier to avoid life’s difficulties and responsibilities than to face them. • People have virtually no control over their emotions.

16. A-B-C model • In everyday situations, individuals do not always consciously or deliberately tell themselves these irrational assumptions. Rather, such assumptions appear to be automatic and pervasive because people repeat them so often that these assumptions become overlearned responses.

17. According to RET, it is not the experience itself but how the individual perceives that experience that causes anxiety and depression. This perceptive process is illustrated by Ellis’ A-B-C analysis of depression.

18. Ellis links the environmental or Activating event (A) to the emotional Consequences (C) by the intervening Belief (B) • Example: in the middle of a phone call, the connection is interrupted  person assumes she is not worth talking to  feels depressed.

19. Techniques • In RET, the therapist helps the client identify irrational ideas and replace them with more constructive, rational thoughts. • In doing so, the therapist must directly challenge the client’s irrational ideas and then model rational reinterpretations of disturbing events.

20. Together, the therapist and client work on cognitive rehearsals aimed at substituting rational self-statements for previously irrational interpretations. • Often, the therapist assigns behavioral tasks that are designed to develop rational reactions to replace the client’s formerly irrational assumptions.

21. Evaluation • The effectiveness of RET remains to be proven. Part of the difficulty in doing this lies in specifying the treatment’s procedural components; that is, RET has never been manualized. • It is difficult to empirically test non-manualized treatments due to the lack of reliability that can occur when different therapists interpret and apply a theory in different ways (for lack of a manual that details each step in the therapy).

22. In response to criticism of the conceptual and empirical bases of RET, Ellis has argued that his approach has been misinterpreted; however, RET has still not been manualized. • The data from studies using RET suggest that this type of therapy can be effective for some disorders like depression and anxiety, but the studies are few and some of the findings are not consistent across studies.

23. Video of Ellis with Gloria

24. Beck’s Cognitive-Behavioral Therapy (CBT) • Brief history • Developed by Aaron Beck, who also came from a psychodynamic background. In contrast to the Freudian notion that basic drives control the individual and his intellect, Beck believes that this relationship operates in the opposite direction; that is, that, to some extent, our intellect influences our drives. Beck originally developed his theory for the treatment of depressed individuals.

25. The core principle of Beck’s cognitive therapy is that holding negative assumptions leads to having negative moods, which, in turn, increases the probability of more negative thinking in what becomes a vicious cycle. • Beck argues that people who fall into this pattern become victims of their own illogical self-judgments.

26. Rationale • Beck argues that depressed individuals feel as they do because their thinking is biased toward negative interpretations. • Throughout the person’s life, these interpretations build on one another and become schemas (recall that a schema is a body of knowledge that an individual has stored in memory).

27. According to Beck, the negative distortions and schemas maintain the cognitive triad: a negative views of the self, the world, and the future. • We’ll look at some of the principal cognitive biases of the depressed individual.

28. Arbitrary inference refers to the process of drawing a specific conclusion in the absence of evidence to support the conclusion or when the evidence is contrary to the conclusion (example: person down the street does not wave  does not want to talk to me, she must hate me).

29. Selective abstraction consists of focusing on a detail taken out of context, ignoring other more salient features of the situation and conceptualizing the whole experience on the basis of this fragment (example: did poorly on a difficult question in exam-- even if did well on the rest of exam  I am stupid).

30. Overgeneralization refers to the pattern of drawing a general rule or conclusion on the basis of one or more isolated incidents and applying the concept across the board to related and unrelated situations (previous example: I am stupid in all of my classes, I’ll never amount to anything).

31. Magnification and minimization are reflected in errors in evaluating the significance or magnitude of an event that are so gross as to constitute a distortion (example: normally do reading, but forget to do reading for class one day  I am going to fail the class because I did not read for today).

32. Personalization refers to the client’s tendency to relate external events to himself when there is no basis for making such a connection (example: encounter religious zealot on the Pentacrest yelling “you must repent for all of your sins”  assume that it is aimed at you because you are such an awful person).

33. Absolutistic, dichotomous thinking (a.k.a., all or nothing) is manifested in the tendency to place all experiences in one of two opposite categories; for example, flawless or defective, saint or sinner, etc. • Often, in describing himself, the client selects the extreme negative categorization (example: like to play basketball but cannot enjoy it unless you make every shot—distorted cognition: cannot play unless I do it perfectly).

34. Strategies • A variety of cognitive and behavioral strategies are utilized in cognitive therapy to combat the cognitive distortions and biases. • Cognitive techniques are aimed at delineating and testing the client's specific misconceptions and maladaptive assumptions.

35. highly specific learning experiences designed to teach the client: 1) to monitor his negative, automatic thoughts 2) to recognize the connections between cognition, affect, and behavior 3) to examine the evidence for and against his distorted automatic thoughts 4) to substitute more reality-oriented interpretations for these biased cognitions 5) to learn to identify and alter the dysfunctional beliefs which predispose him to distort his experiences

36. In addition, to help clients challenge their dysfunctional assumptions, therapists raise number of questions. For example, in the case of a client who felt he was a total failure, Beck would ask some of the following questions: • How do you define failure? What are your standards? • Have there been degrees of failure: that is, were some failures more total than others? • If some experiences were only partial failures, did they also represent partial successes? • Were there some areas in your life (friends, family, schoolwork, recreation) in which you did not fail? • Even if you did fail in specific areas, does it follow that you cannot improve and become more successful? • Do failures in reaching a goal make you a failure as a person?

37. Another strategy used by cognitive therapists is to require clients to do homework assignments. • For example, clients might be required to identify and challenge the dysfunctional cognitions associated with their problems using dysfunctional thought records

38. The explicit use of behavioral methods is a fundamental feature of cognitive therapy. Clients do behavioral tasks to help correct dysfunctional cognitions and disprove maladaptive expectations.

39. Instead of arguing with clients about whether their cognitions are valid or helpful, therapists collaborate with them in devising specific tasks that will help them assess this for themselves. • For example, Beck recommends that clients treat their beliefs as hypotheses and test them using their own behaviors as experiments to examine the accuracy of those beliefs.

40. Evaluation • A major advantage of Beck’s cognitive therapy is that it is clearly defined. Because it is adequately implemented and differs procedurally from alternative methods, cognitive therapy has consequently lent itself to research on treatment outcome. Beck’s cognitive therapy has been shown effective in controlled outcome research.

41. It has been tested extensively in the treatment of depression and consistently produced positive results. • Evidence has shown that cognitive treatment is also effective in treating anxiety disorders (e.g., panic disorder) and eating disorders (i.e., bulimia and anorexia). • However, the reasons for its success in treating these disorders remains to be fully established. That is, the causal link has not been established.