Clinical Psychology

Spring 2015Kyle Stephenson

Overview – Day 9•Behavioral theories•Behavior therapies

▫Systematic desensitization▫Contingency management▫Exposure therapy

•Cognitive behavioral therapies▫Rational Emotive Therapy▫Beck’s Cognitive Therapy▫Dialectical Behavior Therapy

•Strengths & weaknesses•Efficacy

Origins of the Behavioral Approach•Origins:

▫Scientific approach to human behavior▫Learning theory▫Classical conditioning▫Operant conditioning

Overview – Day 9•Behavioral theories•Behavior therapies

▫Systematic desensitization▫Contingency management▫Exposure therapy

•Cognitive behavioral therapies▫Rational Emotive Therapy▫Beck’s Cognitive Therapy▫Dialectical Behavior Therapy

•Strengths & weaknesses•Efficacy

Systematic Desensitization▫Assessment and briefing patient▫Relaxation training

Muscle tensing then release Possible use of hypnosis Breathing exercises

▫Development of anxiety hierarchy

Difficulties identified Ordered by anxiety level Low to moderate to extreme Relaxation practiced at each level of hierarchy

Systematic Desensitization•Rationale

▫Counterconditioning: the substitution of relaxation for anxiety

▫Extinction of behaviors: when the patient repeatedly visualizes

anxiety-generating situations but without ensuing bad experiences, the anxiety responses are eventually extinguished

▫Habituation▫Positive reinforcement

•Changing behavior by manipulating consequences▫Common with children and adolescents

•Examples▫Shaping/ successive approximation:

attempts at a desired behavior are rewarded until it is achieved

▫Time out: removal of patient from environment in which unwanted behavior is reinforced

▫Token economy: provision of symbolic reinforcer that can be exchanged for specific rewards later

Contingency Management

Exposure Therapy•Emotional-processing theory (Foa & Kozak, 1986)

▫Fear structures Schemas regarding threat Likelihood or severity of threat is

overestimated Threat perceptions are maintained through

avoidance behaviors▫How to disconfirm fear structures?

Exposure, why? Habituation

▫(Makes sense, but may not actually be mechanism) New learning

•nice overview

Exposure Therapy

•Client placed into anxiety causing situation▫Testing threat perceptions and allowing for

creation of new schemas •Message from scientist-practitioners•Examples

▫Exposure treatment for Panic Disorder▫Exposure and response prevention for OCD▫Prolonged Exposure for PTSD

Sample Hierarchy: OCD

• Touch top of shoes• Touch door near

knob• Touch doorknob• Touch public

bathroom flusher• Touch bottom of

shoes• Touch street• Touch inside of trash

can• Touch porta-potty

under lid

• SUDS: 45

• SUDS: 70

• SUDS: 100

AVOID!

Relief!

Short-term relief, long-term anxiety maintenance

Message: The situation or sensations really are dangerous, intolerable

Avoidance behavior prevents new learning

An

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ty/F

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Time

Avoidance

AVOID! Message: The situation or sensations are not as dangerous as they feel; they are tolerable

Short-term distress, long-term anxiety reductionA

nxie

ty/F

ear

Time

Exposure

Exposure Therapy•Ingredients of effective exposure therapy

▫Long duration of exposures For within-session habituation

▫Repetition to extinction of anxiety For between-session habituation

▫Graduated process To build confidence in clients

▫Active attention to feared stimuli To counteract avoidance

▫Exposure must provoke anxiety To activate fear structure

Overview – Day 9•Behavioral theories•Behavior therapies

▫Systematic desensitization▫Contingency management▫Exposure therapy

•Cognitive behavioral therapies▫Rational Emotive Therapy▫Beck’s Cognitive Therapy▫Dialectical Behavior Therapy

•Strengths & weaknesses•Efficacy

Cognitive-Behavioral Therapy

•Cognitive-Behavioral Therapy (CBT)▫Combine behavioral treatments with

attention to cognitions (thoughts)▫Goals expanded from focusing just on

observable behavior▫Now, also attempted to modify content of

thoughts, or at least the person’s relationship to his/her thoughts

Cognitive-Behavioral Therapy

•Rational restructuring▫Relabeling of situations, more realistically▫Modification of the internal “self-talk”▫Rational Emotive Therapy (RET)

Activating events (A) Beliefs/thoughts (B) Consequences (C) Therapist as a teacher; correct “illogical”

thinking•example

Cognitive Model

Cognitive-Behavioral Therapy•Beck’s Cognitive Therapy for Depression

▫Utilizes cognitive & behavioral methodology

▫Modify dysfunctional patterns of thinking▫Wide array of techniques including

Increase pleasurable activities Identify and challenge maladaptive,

automatic thoughts Search for more accurate and/or helpful ways

of thinking or coping

Identification and Challenging of Distorted Thoughts•Class activity

Overview – Day 9•Behavioral theories•Behavior therapies

▫Systematic desensitization▫Contingency management▫Exposure therapy

•Cognitive behavioral therapies▫Rational Emotive Therapy▫Beck’s Cognitive Therapy▫Dialectical Behavior Therapy

•Strengths & weaknesses•Efficacy

Cognitive-Behavioral Therapy

•Strengths▫Efficacy▫Efficiency▫Evidence based▫No evidence for symptom substitution▫Breadth of application▫Scientist Practitioner / Clinical Scientist

model

Cognitive-Behavioral Therapy

•Limitations▫Dehumanizing?▫What about growth and existential

meaning?▫Manipulation & control▫Do these effects generalize to real-world

clients? I think the biggest issue – who does it work

for and when?▫Lack of a unifying theory?

(Your book says this, but I disagree somewhat)

Overview – Day 9•Behavioral theories•Behavior therapies

▫Systematic desensitization▫Contingency management▫Exposure therapy

•Cognitive behavioral therapies▫Rational Emotive Therapy▫Beck’s Cognitive Therapy▫Dialectical Behavior Therapy

•Strengths & weaknesses•Efficacy

Does CBT work?

•Yes

Efficacy

•Hundreds of studies have suggested that CBT is consistently better than no treatment and slightly more effective than many other types of therapy, especially for anxiety disorders and depression.

•Managed care providers (insurance companies, VA) have begun to specify that they only want CBT to be done and won’t support some other treatments.

Take-Home• CBT is the most popular and (maybe) most

effective method of treatment practiced by therapists.

• Most modern treatments include both behavioral and cognitive interventions aimed at changing behaviors, thought content, and people’s relationship with their experiences.

• There are many different CBT interventions for a very wide variety of psychological problems, some of which have been tested more than others.