Systems of Psychotherapy: A Transtheoretical Analysis

1. Systems of Psychotherapy:A Transtheoretical Analysis Chapter 9. Behavior Therapies

2. A Sketch of Behavior Therapists • Behavior therapists vary in both theory and technique • Learning theory is core, but differences on what version (Pavlov's, Hull’s, Skinner’s, Mowrer’s, or other) • Treatment must be validated under controlled conditions

3. Major Characteristics • Abnormal behavior is acquired & maintained by same principles as normal behavior • Continuous assessment focuses on current determinants of behavior • Focus on thoughts, feelings, & actions • Treatment is specified, replicable, & tailored • Outcomes should generalize to real-life & be maintained over time

4. 3 Cs of Behavior Therapy Counterconditioning Contingency management Cognitive-behavior modification

5. 1. Counterconditioning • Also known as reciprocal inhibition • Learn the healthy opposite of problem behavior • Based on respondent conditioning • Follows directly from the work of Pavlov • Techniques include systematic desensitization, assertiveness training, & stimulus control

6. Sketch of Joseph Wolpe • 1915 – 1997 • Psychoanalytic in his early years • Used deep relaxation to inhibit anxiety • Reported success with 90% of clients • Major & controversial figure in establishment of behavior therapy

7. Theory of Psychopathology • Anxiety is a response of sympathetic nervous system to threatening stimulus • Anxiety causes most behavioral disorders • Anxiety can be conditioned to any stimuli • Thoughts associated with threatening stimuli can elicit anxiety

8. Conditioning • The more similar a stimuli is to original fear provoker, the more fear it produces • Constantly anxious clients have been conditioned to a omnipresent fear stimuli • Anxiety impairs other behaviors, leading to secondary symptoms • As disorder progresses, client’s complaint goes from anxiety to avoidant behaviors

9. Therapeutic Processes • Anxiety can be unlearned through counterconditioning • Countercondition the original conditioning (a learning process) • Do the opposite of problem & it will disappear (reciprocal inhibition)

10. Counterconditioning Techniques 1. Systematic desensitization: Relaxation inhibits anxiety response 2. Assertiveness training: Assertion inhibits passivity & aggression in relationships 3. Sexual arousal: Relaxation & arousal inhibit sexual anxiety 4. Stimulus control: Rearrange environment and triggers to combat old triggers

11. 2. Contingency Management • Known as behavior mod or behavior analysis • Human behavior is controlled by its consequences (operant conditioning) • Skinner the influential theorist • Reinforcements & punishments impact prob-abilities of maladaptive behavior & development of new responses • Assessment of behavior chain is foundation for modifying contingencies

12. Categories of Problems • Excess – excessive response (e.g., washing hands 30 times a day) • Deficits – lack of response (e.g., rarely interacting with people) • Inappropriateness –inappropriate response to situation (e.g., flashing others)

13. Therapeutic Processes • Environmental contingencies shape, maintain, & extinguish behavior • Behavior modification systematically controls contingencies to shape behavior • Change the contingencies & the behavior will change

14. 6 Steps of Effective Contingency Management • State problem in behavioral terms • Identify behavioral objectives • Take baseline measures • Conduct naturalistic observations • Modify existing contingencies • Monitor the results

15. Types of Contingency Management • Institutional control (e.g., token economies) • Self-control • Mutual control or contracting • Therapist control • Aversive control

16. 3. Cognitive-Behavior Modification • Behaviorism was established as radical alternative to existing mentalistic theories • Conditioning replaced cognition as critical determinant of human behavior • Cognition gradually reintroduced in tx • Most behavior therapists now incorporate cognitive techniques

17. Theory of Psychopathology • Maladaptive behaviors reflect a deficit, excess, or inappropriatenessin cognitive activity • Problems are characterized by: • Lack of coping response • Use of inappropriate cognitive responses (e.g., mislabeling) • Ineffective strategies for problem solving

18. Therapeutic Processes • Increase client awareness with information • Biofeedback: allows clients to become conscious of changes in biological function • Cognitive restructuring: if problem stems from mistaken labels and expectancies • Self-instructional training: Learn to decrease hurtful thoughts & increase helpful ones

19. Phases of CBM • Conceptualizing the problem • Educate the client & encourage problem solving • Trying on the conceptualization • Generate alternatives to the situation • Modifying cognitions & producing new behavior • Decision making & verification of alternative

20. Therapeutic Relationship • Its value and nature depends on behavioral method and clinician • Therapist establishes secure, trusting relationship as treatment precondition • Therapist modeling is crucial

21. Practicalities of Behavior Therapy • Large variation in practice • Typically conducted in individual format; group format used for cost efficiency • Time-efficient; clients seen less frequently & for shorter durations than other therapies • Therapy success is frequently monitored

22. Practicalities of Behavior Therapy (Cont.) • Interventions performed in the natural environment have benefits • Much of behavior treatment conducted by caseworkers, teachers & technicians • Technology used as part of treatment • Demonstrate competency in evidence-based practices (EBP)

23. Effectiveness of Behavior Therapy • More empirical research than any other system of psychotherapy • Consistently superior to no treatment & placebo • More effective than non-behavioral therapies for childhood disorders • Behavior marital therapy (BMT) produces significant changes maintained over time

24. Criticisms of Behavior Therapy • From a Psychoanalytic Perspective (misguided focus on symptom relief) • From a Humanistic Perspective (lack of concern for relationships and humanity) • From a Cultural Perspective (neglect of social causes, too individualistic) • From an Integrative Perspective (endless, mechanistic techniques without integration)

25. Future Directions • Continue to experiment & expand • Integration with cognitive therapy and third-wave therapies • Used in many health fields (e.g., pediatrics, cardiology, dentistry) • Increase in health psych (e.g., assist in illness recovery, coping with chronic disease) • Increase in technological interventions

26. Key Terms 3 Cs of behavior therapy ABAB (reversal) design anxiety hierarchies assertiveness training attribution/attributional styles autogenic training aversive conditioning baseline measures behavior analysis behavior chain (ABC sequence) behavior exchange theory behavior modification behavioral modification behavioral deficits behavioral excesses behavioral inappropriateness behavioral parent training behavioral marital therapy biofeedback classical (respondent) conditioning clinical representativeness cognitive-behavior modification (CBM) cognitive restructuring communication skills training contingency management contracting

27. Key Terms (cont.) counterconditioning covert sensitization discriminative stimuli evidence-based practice fading functional analysis generalization generalization gradient graduated homework assignments in vivo desensitization institutional control learned optimism maintenance modeling/observation learning multiple baseline design mutual control naturalistic observation neurobiofeedback operant conditioning operationalizing the target behavior problem solving (therapy) prompt publication bias punishment reciprocal inhibition refusal skills training

28. Key Terms (cont.) reinforcement relaxation training respondent conditioning response cost self-control self-instructional training self-statement modification sensate focus shaping small-n designs social skills training stimulus control stress inoculation symptom substitution/return systematic desensitization target behaviors token economy treatment-as-usual (TAU) urine alarm validation

29. Recommended Websites • Association for Behavior Analysis International: www.abainternational.org/ • Association for Behavioral and Cognitive Therapies: www.abct.org/home • Behavior Analysis: www.apadivisions.org/division-25/index.aspx • European Assoc for Behavioural and Cognitive Therapy www.eabct.eu/ • The Melissa Institute (Meichenbaum): www.melissainstitute.org/