Behavior Therapy

Behavior Therapy PSYC E-2488 Lecture #9 11/26/07

Introduction and Historical Background • 1. Not a unified approach, but a collection of 150+ strategies (Bellak & Hersen, 1985) • 2. Includes: exposure-based therapies for anxiety disorders, relaxation training, biofeedback, reinforcement-based treatments, assertiveness training, sensate focus for sexual dysfunction, “bell and pad conditioning” for bed wetting, etc. • 3. Modern therapies integrate other components from other therapies, e.g., cognitive and relationship factors can be introduced • 4. Controversy over whether standardized or individualized approach is better • 5. Place and length of therapy session may vary • 6. In Vivo Exposure>systematic desensitization techniques • 7. Cognitive + behavioral techniques frequently used together

Historical Background • 1. Started to blossom in the 50s and 60s with the work of A.Lazarus, Hans Eysenck, Joseph Wolpe, Cyril Franks, S. Rachman, G.Terence Wilson • 2. Stage set by: Increased popularity of learning theory based explanations of clinical phenomena, e.g., Mowrer’s (1939) 2-Factor Model of Phobias (fear classically conditioned by trauma and later maintained by operant conditioning – reinforced be avoiding fear stimulaus); and, Eysenck criticizing psychoanalysis

The Concept of Personality • The concept of personality is based on trait theory and the idea that people have characteristic ways of thinking, feeling and behaving • Behavior theorists emphasize role of context/situation in determining an individual’s behavior • Apparent conflict between two schools of thought is based on misunderstandings - Approaches are compatible (individual behavior is both intrinsic and context specific which is consistent with behavioral emphasis on knowing the typical behavior of an organism and its learning history) - Biological constraints on people ,e.g., genetics, temperament * Personality to a behaviorist is behavior consistent across a range of situations * Behaviorists differ with respect to the role of cognitions in behavior, but acknowledge the impact of genetics.

Psychological Health and Pathology • Behavior is judged within its context and for its consequences; and, therefore is not inherently healthy or not healthy • Seen as excessive or deficient (adaptive/maladaptive) within their cultural context (DSM) and whether it causes distress, disability, or risk to the individual • Adaptive/maladaptive behavior is caused by learning.

The Process of Clinical Assessment • 1. Conceptual Issues in Behavioral Assessment: - Purposes (understanding the individual’s problem, planning treatment, and measuring change) - Functional Assessment (Stimulus, Organism, Response, Consequence) - Differences in extent to which idiographic vs. standardized assessment is used - Thorough assessment and outcome measurement is key • 2. Assessment Strategies Used in Behavior Therapy - Direct Behavioral Observation - Monitoring Forms and Behavioral Diaries - Clinical Interviews - Self-Report Scales - Psychophysiological Assessment, e.g., heart rate, EMG, etc.

Principles of Behavioral Treatment • 1. Evidence based • 2. Focused on changing variables thought to be maintaining a problem • 3. Problem-oriented • 4. Client provided with a behavioral model of explanation • 5. Action oriented • 6. Flexible format • 7. Traditional approach is idiographic • 8. Recent approaches involve standardized treatment packages • Differences may be small in practice

The Practice of Therapy • 1. Psychoeducation • 2. Exposure-based treatments, e.g., exposure to feared objects and situations results in reduction of fear. - Exposure Modalities: a. In Vivo Exposure: i.e., OCD pt. touches the contaminating object. b. Imaginal Exposure: - not as powerful as exposure, but may be used with thoughts, images, memories; and, if unable/unwilling to do In Vivo. i.e., OCD, PTSD c. Interoceptive Exposure: exposure to feared sensations, e.i., panic – racing heart, dizziness may be treated by hyperventilation, spinning, jumping jacks, etc. d. Vitual Reality: VA and video helmet combat exposure for PTSD

The Practice of Therapy – con’d. e. Guidelines for Effective Exposure: - Predictable and under client’s control; - Longer > shorter exposures; - Should be intense enough to trigger fear, but not overwhelming; - Sessions closely spaced; - Vary across practices to improve long-term outcome; - Conduct them in multiple contexts; - Distraction may interfere with the process so have clients attend closely; f. Exposure Hierarchies: Construct such hierarchies with client for guidance of sessions and outcome measurement;

The Practice of Therapy – con’d. • 3. Response Prevention: Prevent response designed to decrease fear until urge to perform them has subsided, e.g., ritual prevention. - a variation on exposure techniques like those used in OCD. * 4. Operant Strategies: Based on behavioral principle that behavior is functional and evolves in response to favorable (+ reinforcement) or or undesirable consequences (punishment). a. Can reward or remove negative consequences; b. Disciminative stimuli are those cues in the environment that indicate if behavior is likely to be reinforced or punished. c. Applied Behavior Analysis incorporates the principle into comprehensive individualized programs – - Carefully assess what is maintaining behavior and what can be done to increase desired behaviors and decrease undesired behaviors by eliminating reinforcers or shaping behavior incrementally. Use Drug Addiction as an example. - Extinction (withdraw reinforcement); negative punishment (response cost); Time Out; Positive Punishment or Response Contingent Aversive Stimulation (can have negative consequences). - Stimulus Control (e.g., where sleep, eat, smoke, etc.) - Self-control or Self-management procedures;

The Practice of Therapy - con’d. • 5. Social Skills Training: Teaching individuals skills which will positively impact their interpersonal relationships which are negatively impacted by their problems and disorders. - Can range from assertiveness to eye-contact to refraining from interrupting. - Taught by modeling, psycho-education, behavioral rehearsal/role play, and feedback. - See how standardized and packaged to treat clients with schizophrenic illness. * 6. Modeling: Bandura’s work * 7. Problem-Solving Training * 8. Relaxation-based Treatments (PRT - Jacobson, Wolpe) - Exposure>relaxation for anxiety d/o, but incorporating the technique to reduce muscle tension may be helpful. - Biofeedback *9. Acceptance and Mindfulness-Based Treatment Strategies - Explain history and range, as well as contra-indications and side-effects - Technique vs. character change.

The Practice of Therapy – con’d. • Examples of Behavioral Protocols for Particular Conditions: • 1. Panic Control Treatment for Panic D/O and Agoraphobia (PCT): - Developed in mid-late 80s by David Barlow and includes a variety of components: a. Psycho-education, breathing retraining, cognitive therapy, interoceptive exposure, and in vivo exposure. b. 10-12 sessions; Initial sessions are psychoeducational and teach that (1) anxiety and fear are normal; (2) Pas are time-limited; (3) Panic symptoms have survial function; (3) States can be conceptualized as being made up of 3 components (physical symptoms, anxious behaviors, anxious cognitions); - Next stage is Breathing Retraining (diaphraghmatic to reduce symptoms) – research on PCT package suggests that it is not necessary; - Next stage is Cognitive Therapy, e.g., examining beliefs, disputing, etc. - Next is Interoceptive Exposure - Research shows the package to be among the most effective treatments for anxiety disorders.

The Practice of Therapy – con’d. • 2. Depression (Behavioral Activation) - Based on Ferster’s (1973) radical behavioral model of depression focusing on factors that cause and maintain inertia and withdrawal that take on secondary reinforcing characteristics, but ultimately disrupt routines - Establish a therapeutic relationship and present the model of depression; - Complete a functional analysis looking at triggers, responses, avoidant behaviors and disruptions in routine. - Clients taught how to functionally analize their own behavior • 3. Bipolar Disorder (Miklowitz): - Psychopharmacological intervention; - Adjunctive Interventions based on Diathesis-Stress Model: a.) Stressful life events, disruptions in routines, and family stress (high EE – over-involvement and criticism) impact a bio-genetic vulnerability. b.) FFT – Family Focused Therapy: Weekly for 3 months, biweekly for 3 months and then monthly for final three months: Clients enter pharmacotherapy; establish relationship of therapist with client and family; educate family and patient in the model (learn symptoms, course, etiology, ID stress, interventions); enhance communication skills that match idiographic needs of the family; and learn problem solving skills.

The Therapeutic Relationship and the Stance of the Therapist • 1. Initially Therapist and Relationship were thought to be less important than the techniques, but that has changed. • New evidence suggest that therapeutic relationship and characteristics of the therapist are predictive of positive outcomes.

Curative Factors or Mechanisms of Change • 1. Changes in Environmental Contingencies • 2. Emotional Processing • 3. Cognitive Models • Biological Changes

Treatment Applicability and Ethical Conciderations • 1. Applicability of Behavioral Treatments • 2. Ethical Issues

Behavior Therapy