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PSY 245 CLINICAL PSYCHOLOGY II

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PSY 245 CLINICAL PSYCHOLOGY II Assoc. Prof. Dr. BAHAR BA TU Clinical Psychologist * * * * * * * * * * * * * * * * * * * * * * * * * * * YAPILAN B R ALI MADA BA ... – PowerPoint PPT presentation

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Title: PSY 245 CLINICAL PSYCHOLOGY II


1
PSY 245 CLINICAL PSYCHOLOGY II
  • Assoc. Prof. Dr. BAHAR BASTUG
  • Clinical Psychologist

2
Behavioral Theory and Therapy
3
  • This weeks focus is on behavioral theory and
    therapy.
  • We should all put our science caps on. ?

4
  • Behaviorism and its application, behavior therapy
    are linked to the science within academic
    psychology. Behaviorism and behavior therapy
    sprang from scientific efforts to describe,
    explain, predict and control observable animal
    and human behavior.

5
  • Behaviorism and psychoanalysis are opposite each
    other in some ways, and similar in some ways.
  • The biggest difference between behaviorism and
    psychoanalysis is
  • Psychoanalysis subjectively focuses on inner
    dynamic or mental concepts. Behaviorism
    objectively focuses on observable phenomena or
    materialistic concepts.

6
  • Psychoanalysis use techniques derived from
    clinical practice.
  • Behaviorism use techniques derived from
    scientific research.

7
  • Both approaches are highly deterministic,
    positivistic and mechanistic perspectives to
    understanding human.
  • Michael Mahoney referred to psychoanalysis and
    behaviorism as the yin and yang of determinism
    (1984).

8
  • They are often considered reactions to
    unscientific psychoanalytic approaches.

9
  • For the behaviorist, all behavior is LEARNED. The
    most complex human behaviors are explained,
    controlled, and modified through LEARNING
    PROCEDURES.

10
HISTORICAL CONTEXT
  • Three major historical stages in the contemporary
    behavioral approaches
  • Behaviorism as a scientific attempt
  • Behavior therapy
  • Cognitive behavior therapy (CBT)

11
HISTORICAL CONTEXT
  • Existential-humanistic psychology is called the
    third force. As a third force, existential-humanis
    tic psy is an alternative to psychoanalysis and
    behaviorism. Why does this behavior therapy
    chapter come after the existential- humanistic
    chapters?

12
  • Although behaviorism began gaining popularity in
    the early 1900s, behavior therapy was not
    identified until the 1950s. Applied behavior
    therapy came later.

13
Behaviorism
  • In the early 1900s, a new and different
    mechanistic view of humans, behaviorism, was in
    contrast to other perspectives. Most early 20th
    century psychologists were interested in human
    consciousness and free will, and used a procedure
    called introspection to identify the inner
    workings of the human mind.
  • Behaviorists excluded consciousness and
    introspection. They believed in determinism
    rather than free will.

14
John Watson (1878-1958)
15
  • Prior to Watson, William James, identified
    himself as a philosopher, claimed that psy is no
    science, only the hope of a science.

16
Father of behaviorism
  • Watson believed in psychological science. He was
    interested in experimental psy, the classical
    conditioning learning model as demonstrated by
    Pavlovs dogs.
  • For Watson, behaviorism was far beyond the hope
    of a science. He published behaviorist manifesto
    in 1913, and redefined psychology as a pure
    science.
  • Psy as a behaviorist views it is a purely
    objective branch of natural science.

17
  • He was elected to the presidency of the APA in
    1915, at the age of 35.

18
  • In opposition to Jamess free will, the purpose
    of Watsons behaviorism was the deterministic
    prediction and control of human behavior. Watson
    viewed humans and animals as indistinguishable.

19
  • Give me a dozen healthy infants, well-formed,
    and my own specified world to bring them up in
    and Ill guarantee to take any one at random and
    train him to become any type of specialist I
    might selectdoctor, lawyer, artist,
    merchant-chief and yes, even beggar-man and
    thief, regardless of his talents, tendencies,
    abilities, vocations, and race.

20
  • Watson had a strong interest in the application
    of behavioral scientific principles to human
    suffering. This may have been because he
    experienced a nervous breakdown as a young man
    and had not found psychoanalysis helpful.

21
Little Hans and Little Albert
  • In 1909, Freud reported an analysis of Little
    Hans (5-year-old) who was afraid of being bitten
    by a horse because of unresolved Oedipal issues
    and castration anxiety.
  • Freud explained that Little Hanss phobia was
    from castration anxiety.
  • Watson showed that Little Albert could develop a
    phobia from classical conditioning.

22
  • Watson sought to demonstrate that severe fears
    and phobias were caused not by psychoanalytic
    constructs but by classical conditioning of a
    fear response. In his famous experiments with
    11-month-old Little Albert, after only five
    trials in which Watson and his assistant Rosalie
    Raynor paired the presentation of a white rat to
    Albert with the striking of a metal bar. Albert
    developed a strong fear and aversion to white
    rats.

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  • His conditioned fear response generalized to a
    variety furry white objects, such as a dog,
    cotton wool and Santa Claus mask.

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Little Peter MARY COVER JONES
  • Jones showed that fear could be extinguished
    through counterconditioning and/or social
    imitation.

29
Little Peter
  • In 1924, Mary Cover Jones, who was student of
    Watson, conducted an investigation of the
    effectiveness of counter-conditioning or
    deconditioning with a 3-year-old boy named Little
    Peter. It was study that illustrated the
    potential of classical conditioning techniques in
    the treatment of psychological fears and phobias.

30
  • Prior to his involvement in the behavioral
    experiments, Little Peter exhibited fear in
    response to several furry objects, including
    rabbits, fur coats, and cotton balls. Jones
    proceeded to systematically decondition Little
    Peters fear reaction by pairing the gradual
    approach of a caged rabbit with Peters
    involvement in an enjoyable activityeating his
    favorite foods. In the end, Peters fear response
    was extinguished.

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32
Early behaviorists made many important
contributions to psychology
  • The discovery by Pavlov, Watson, and their
    colleagues that emotional responses could be
    involuntarily conditioned in animals and humans
    via classical conditioning procedures.
  • The discovery by Mary Cover Jones that fear
    responses could be deconditioned by either (1)
    replacing the fear response with a positive
    response or (2) social imitation.
  • The discovery by Thorndike and its later
    elaboration by Skinner that animal and human
    behaviors are powerfully shaped by their
    consequences.

33
Behavior Therapy
  • In the 1950s, three different groups in three
    different countries independently introduced the
    term behavior therapy to modern psy
  • 1. B. F. Skinner in the United States
  • 2. Joseph Wolpe, Arnold Lazarus, and Stanley
    Rachman in South Africa
  • 3. Hans Eysenck and the Maudsley Group in the
    United Kingdom

34
B. F. Skinner in the United States
  • Skinner box

35
Skinner (1904-1990)
  • His early work was an experimental project on
    operant conditioning with rats and pigeons in the
    1930s. He demonstrated the power of positive
    reinforcement, negative reinforcement,
    punishment, and stimulus control in the
    modification of animal behavior. Within the
    confines of Skinner box, he was able to teach
    pigeons to play ping-pong via operant
    conditioning procedures.

36
Skinner
  • In the 1940s, he began extending operant
    conditioning concepts to human social and
    clinical problems. His book Walden Two was a
    story of how operant conditioning procedures
    could be used to create an utopian society. His
    next book, Science and Human Behavior, was a
    critique of psychoanalytic concepts and a
    reformulation of psychotherapy in behavioral
    terms.
  • In 1953, Skinner and his colleagues first used
    behavior therapy referring to the application of
    operant conditioning procedures to modify the
    behavior of psychotic patients.

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Joseph Wolpe, Arnold Lazarus, and Stanley Rachman
in South Africa
  • Joseph Wolpe was interested in conditioning
    procedures as a means for resolving neurotic
    fear. He established the first nonpsychoanalytic,
    empirically validated behavior therapy technique.
    His book Psychotherapy by Reciprocal Inhibition
    outlined the therapeutic procedure now called
    systematic desensitization.
  • Wolpes approach is very similar to Joness
    counterconditioning principle wherein a
    conditioned negative emotional response is
    replaced with a conditioned positive emotional
    response.

40
  • Wolpes work attracted the attention of two South
    African psychologists, Arnold Lazarus and Stanley
    Rachman.
  • Conditioning procedures were used as a means for
    resolving neurotic fear.
  • A conditioned negative emotional response is
    replaced with a conditioned positive emotional
    response.

41
  • Lazarus advocated the integration of
    laboratory-based scientific procedures into
    existing clinical and counseling practices. He
    used the term behavior therapy in a journal.
  • Rachman has influenced developing behavior
    therapy procedures. His contribution involved the
    application of aversive stimuli to treating
    neurotic behavior, including addictions.

42
Hans Eysenck and the Maudsley Group in the United
Kingdom
  • British psychiatrist Hans Eysenck used the term
    behaviour therapy to describe the application
    of modern learning theory to the understanding
    and treatment of behavioral and psychiatric
    problems.

43
  • Conclusion,
  • All these researchers lead to born behavioir
    therapy.

44
Cognitive Behavior Modification
  • Contemporary behavior therapy now includes
    cognitive variables. Most behavior therapists now
    work with cognition.
  • Many articles focus on thoughts, expectations,
    and emotions. Behavior therapy is no longer a
    process that focuses on external behavior.
  • Behavior therapy continues to develop.

45
THEORETICAL PRINCIPLES
  • Two primary principles characterize behaviorists
    and behavioral theory
  • Behavior therapists employ techniques based on
    modern learning theory.
  • Behavior therapists employ techniques derived
    from scientific research.

46
Theoretical Models
  • The four main models of learning form the
    theoretical foundation of behavior therapy.
  • Operant Conditioning Applied Behavior Analysis
  • Classical Conditioning Neobehavioristic,
    Mediational Stimulus-Response Model

47
Operant Conditioning Applied Behavior Analysis
  • B. F. Skinner
  • Applied behavior analysis is a clinical term
    referring to a behavioral approach based on
    operant conditioning principles.
  • The operant conditioning position is
    straightforward Behavior is a function of its
    consequences.
  • Operant conditioning is a stimulus-response
    theory.

48
Applied Behavior Analysis
  • Applied behavior analysis is a clinical term,
    based on Skinners operant conditioning
    principles. Behavior is a function of its
    consequences.
  • Operant refers to how behaviors operate on the
    environment, thereby producing specific
    consequences.

49
Applied Behavior Analysis
  • Operant conditioning is a stimulus-response (SR)
    theory. Applied behavior analysis focuses on
    observable behaviors. Therapy proceeds through
    the manipulation of environmental variables to
    produce behavior change.

50
Applied Behavior Analysis
  • The main procedures are reinforcement,
    punishment, extinction, and stimulus control.
    These procedures are used to manipulate the
    environmental contingencies (rewards and
    punishments). The goal is to increase adaptive
    behavior through reinforcement and stimulus
    control and to reduce maladaptive behavior
    through punishment and extinction.
  • Several behavior therapy techniques, such as
    assertiveness training, the token economy, and
    problem-solving training are derived from applied
    behavior analysis.

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Classical Conditioning Neobehavioristic,
Mediational Stimulus-Response Model
  • The neobehavioristic mediational SR model is
    based on classical conditioning principles. Its
    principles were developed and articulated by
    Pavlov, Watson, and Wolpe.
  • Classical conditioning is sometimes referred to
    as associational learning because it involves an
    association of one environmental stimulus with
    another.

54
Classical Conditioning Neobehavioristic,
Mediational Stimulus-Response Model
  • In Pavlovian terms, an unconditioned stimulus is
    one that naturally produces a specific
    physical-emotional response. The physical
    response elicited by an unconditioned stimulus is
    mediated through smooth muscle reflex arcs, so
    higher-order cognitive processes are not required
    in order for conditioning to occur.

55
Classical Conditioning Neobehavioristic,
Mediational Stimulus-Response Model
  • The experience of being struck from behind while
    waiting for a red light is the unconditioned
    stimulus. This stimulus automatically (or
    autonomically) produces a reflexive fear response
    (or unconditioned response). After only a single,
    powerful experience, the 34-year-old man suffers
    from a debilitating fear of impending death (a
    conditioned response) whenever he is exposed to
    the interior of an automobile (a conditioned
    stimulus).

56
Classical Conditioning Neobehavioristic,
Mediational Stimulus-Response Model
  • As Wolpe emphasizes, this scenario represents
    classical autonomic conditioning or learning
    because the man has no cognitive expectations or
    cognitive triggers that lead to his experience of
    fear when he is sitting inside an automobile.
    Because of the lack of cognitive processing
    involved in classical conditioning, when an
    individual experiences a purely classically
    conditioned fear response, often he or she will
    say something like, I dont know why it is, but
    Im just afraid of elevators.

57
Classical Conditioning Neobehavioristic,
Mediational Stimulus-Response Model
  • Classical conditioning principles include
  • stimulus generalization,
  • stimulus discrimination,
  • extinction,
  • counter-conditioning, and
  • spontaneous recovery.

58
  • Classical conditioning principles
  • Stimulus generalization the generalization of a
    conditioned fear response to new settings,
    situations, or objects.
  • In the case of Little Albert, stimulus
    generalization occurred when Albert experienced
    fear in response to stimuli similar in appearance
    to white rats (e.g., Santa Claus masks, cotton
    balls, etc.).
  • .

59
Classical conditioning principles
  • Stimulus discrimination occurs when a conditioned
    fear response is not elicited by a new or
    different stimulus.
  • In the case of Little Albert, stimulus
    discrimination occurred when Little Albert did
    not have a fear response when exposed to a fluffy
    white washrag.

60
  • Classical conditioning principles
  • Extinction the gradual elimination of a
    conditioned response. It occurs when a
    conditioned stimulus is repeatedly presented
    without a previously associated unconditioned
    stimulus.
  • If Watson had kept working with Little Albert and
    repeatedly exposed him to a white rat without a
    frightening sound of metal clanging, Little
    Albert would lose his conditioned response to
    rats.
  • Extinction is not the same as forgetting.

61
Classical conditioning principles
  • Counter-conditioning.New associative learning.
  • Mary Cover Joness work with Little Peter is an
    example of successful counter-conditioning or
    deconditioning. Counter-conditioning involves new
    associative learning. The subject learns that the
    conditioned stimulus brings with it a positive
    emotional experience.
  • When Jones repeatedly presented the white rat to
    Little Peter while he was eating some of his
    favorite foods, eventually the conditioned
    response (fear) was counter-conditioned.

62
Classical conditioning principles
  • Spontaneous recovery occurs when an old response
    suddenly returns after having been successfully
    extinguished or counterconditioned.
  • If, after successful counter-conditioning through
    systematic desensitization, Wolpes client
    suddenly begins having fear symptoms associated
    with the interior of automobiles, he has
    experienced spontaneous recovery.

63
Theory of Psychopathology
  • MALADAPTIVE BEHAVIOR IS LEARNED AND CAN ALWAYS BE
    EITHER UNLEARNED OR REPLACED BY NEW LEARNING.
  • PSYCHOPATHOLOGY MAY BE A FUNCTION OF INADEQUATE
    LEARNING OR SKILL DEFICITS.

64
Theory of Psychopathology
  • An underlying principle of assertiveness training
    is that individuals who exhibit too much passive
    or too much aggressive behavior simply have skill
    deficits they havent learned how to
    appropriately use assertive behavior in social
    situations. The purpose of assertiveness training
    is to teach clients assertiveness skills through
    modeling, coaching, behavior rehearsal, and
    reinforcement.

65
Theory of Psychopathology
  • Behaviorists systematically apply following
    scientific methods
  • Observe and assess client maladaptive behaviors.
  • Develop hypotheses about the cause,
  • Test behavioral hypotheses through the
    application of empirically justifiable
    interventions.
  • Observe and evaluate the results of their
    intervention.
  • Revise and continue testing new hypotheses as
    needed.

66
THE PRACTICE OF BEHAVIOR THERAPY
  • To practice behavior therapy requires that you
    take notes and think like a scientist. You are a
    teacher. Your job is to help clients unlearn old
    maladaptive behaviors and learn new, adaptive
    behaviors.

67
What Is Contemporary Behavior Therapy?
  • Nearly all cognitive therapies are used in
    conjunction with behavior therapies.
  • There are now several new-generation
    cognitive-behavioral therapies. These therapies
    include
  • Dialectical Behavior Therapy (DBT)
  • Acceptance and Commitment Therapy (ACT)
  • Eye Movement Desensitization Reprocessing (EMDR)

68
Assessment Issues and Procedures
  • Behavior therapists would be able to directly
    OBSERVE clients in their natural environment to
    obtain specific information about what happens
    before, during, and after adaptive and
    maladaptive behaviors occur.
  • The main goal of behavioral assessment is to
    determine the external (environmental or
    situational) stimuli and internal (physiological
    and cognitive) stimuli that directly precede and
    follow adaptive and maladaptive client behavioral
    responses. Both internal and external stimuli may
    be of interest.

69
Assessment Issues and Procedures
  • Functional Behavior Analysis (FBA) This
    assessment procedure is sometimes referred to as
    obtaining information about the clients
    behavioral ABCs
  • A The behaviors antecedents (everything that
    happens just BEFORE the maladaptive behavior is
    observed)
  • B The behavior operant definition by
    concrete terms
  • C The behaviors consequences (everything
    that happens just AFTER the maladaptive behavior
    occurs)

70
Assessment Issues and Procedures
  • Through direct observation, the behavior
    therapist gathers information.
  • But, direct behavioral observation is
    inefficient, for several reasons
  • 1. Most therapists cant afford the time required
    to observe clients in their natural settings.
  • 2. Many clients object to having their therapist
    come into their home or workplace to conduct a
    formal observation.

71
Assessment Issues and Procedures
  • 3. Even if the client agreed to have the
    therapist come perform an observation, the
    therapists presence influences the clients
    behavior.
  • Because behavior therapists usually cannot use
    direct behavioral observation, they employ a
    variety of less direct data collection procedures.

72
The Behavioral Interview
  • The clinical or behavioral interview is the most
    common assessment procedure. During interviews,
    behavior therapists directly observe client
    behavior, inquire about behavioral antecedents
    and consequences, and operationalize the targets
    of therapy. The operational definition or
    specific, measurable characteristics of client
    symptoms and goals are crucial behavioral
    assessment components.

73
  • Defining the clients problem(s) in behavioral
    terms is the first step in a behavioral
    assessment interview. Behavior therapists are not
    satisfied when clients describe themselves as
    depressed or anxious. Instead, behaviorists
    seek concrete, specific behavioral information.

74
The Clinical or Behavioral Interview
  • Despite many practical advantages of behavioral
    interviews, this assessment procedure also has
    several disadvantages
  • (1) low interrater reliability,
  • (2) lack of interviewer objectivity, and
  • (3) frequent inconsistency between behavior in a
    clinical interview and behavior outside therapy.
  • (4) false, subjective clients report.

75
The Clinical or Behavioral Interview
  • Behavior therapists compensate for the
    inconsistent and subjective nature of interviews
    through two strategies
  • They employ structured or diagnostic interviews
    such as the Structured Clinical Interview for the
    Diagnostic and Statistical Manual of Mental
    Disorders, fourth edition (SCID-DSM-IV).
  • They use additional assessment methods beyond
    interviewing procedures.

76
Self-Monitoring
  • Sometimes, to directly observe client behavior
    outside therapy is impractical. Clients are
    trained to monitor their own behavior. In CBT,
    clients frequently keep thought or emotion logs
    that include at least three components
  • disturbing emotional states,
  • the exact behavior engaged in at the time of the
    emotional state, and
  • thoughts that occurred when the emotions emerged.

77
  • Advantages of selfmonitoring is cheap, practical,
    and usually therapeutic.
  • Disadvantages of selfmonitoring is that the
    client can collect inadequate or inaccurate
    information, or resist collecting any
    information. Clients may not make accurate
    recordings of their behavior.

78
Standardized Questionnaires
  • Objective psychological measures include
    standardized administration and scoring.
    Behaviorists prefer instruments that have
    established reliability and validity.
  • These are often used to determine outcomes.

79
Operant Conditioning and Variants
  • In the tradition of Skinner and applied behavior
    analysis, the application of behaviorism to
    therapy is direct operant conditioning. Skinners
    emphasis is on environmental manipulation rather
    than processes of mind or cognition.

80
Contingency Management and Token Economies
  • Using operant conditioning requires an analysis
    of behavioral consequences in the clients
    physical and social environment. This process is
    contingency management. Its used more common in
    educational, family, institutional and drug
    treatment settings.

81
Contingency Management and Token Economies
  • An appropriate use of operant conditioning
    involves several systematic steps
  • 1. The parents need to operationalize the target
  • behaviors and identify behavioral objectives.
  • 2. The therapist helped the parents develop a
    system
  • for measuring the target behaviors. They were
    each
  • given a pencil and notebook to follow the
    frequency
  • of their teens behaviors.
  • 3. The parents were instructed on how to monitor
    and evaluate the effects of their new contingency
    schedule.

82
Contingency Management and Token Economies
  • Operant conditioning principles have been applied
    to educational and institutional settings.
    Following Skinners work aimed at modifying the
    behavior of psychotic patients, operant
    conditioning within institutions has come to be
    known as a TOKEN ECONOMY.
  • Within token economy systems, individuals are
    givencoins or symbolic rewards for positive or
    desirable behaviors. These tokens are used like
    money, to obtain goods or privileges.

83
Contingency Management and Token Economies
  • Token economies have been criticized as forcible
    and as not having lasting effects that generalize
    to the world outside the institution. After the
    desirable behavior patterns are well established,
    the behavioral contingencies would be slowly
    decreased. This procedure is referred to as
    fading and is designed to maximize the likelihood
    of generalization of learning from one setting to
    another. The desired outcome occurs when the
    subject internalizes the contingency system.

84
Contingency Management and Token Economies
  • Positive reinforcement faces some criticism.
  • Thorndike, Skinner concluded that punishment led
    to behavioral supression, but it wasnt effective
    for controlling behavior.
  • Then, Solomon claimed that punishment could
    generate new, learned behavior.

85
Contingency Management and Token Economies
  • Now, it is accepted that punishment is a powerful
    behavior modifier, but it has disadvantage.
  • In the attachment and trauma literature,
    excessive punishment leads to trauma bonding.
  • There is a debate on using punishment as a
    learning tool.

86
Contingency Management and Token Economies
  • The direct application of punishment, or aversive
    conditioning, is used to reduce undesirable and
    maladaptive behavior. It has been applied with
    some success to smoking cessation, repetitive
    self-injurious behavior, alcohol abuse or
    dependency, and sexual deviation.

87
Behavioral Activation (BA)
  • For Skinner, depr was caused by an interruption
    of healthy behavioral activities.
  • Depressed individuals engage in fewer pleasant
    activities and obtain less positive reinforcement
    than others. So, if they change their behavior,
    they may improve or recover.

88
Behavioral Activation (BA)
  • BA was previously referred to as activity
    scheduling and used as a component of various
    cognitive and behavioral treatments for
    depression.
  • Recent research suggests BA may be as good as the
    whole CBT package for depressive disorders.

89
Relaxation Training
  • Edmund Jacobson was the first scientist to write
    about relaxation training as a treatment
    procedure. Progressive muscle relaxation (PMR)
    was initially based on the assumption that
    muscular tension is an underlying cause of a
    variety of mental and emotional problems.

90
Relaxation Training
  • PMR is an evidence-based treatment.
  • But PMR can make some clients more anxious.

91
Systematic Desensitization and Other
Exposure-Based Treatments
  • Joseph Wolpe introduced systematic
    desensitization as a technique.
  • Systematic desensitization Jones
    deconditioning approach Jacobsons PMR
    procedure.
  • To be relaxed is the direct physiological
    opposite of being excited or disturbed.
    (Jacobson, 1978, p. viii)

92
Systematic Desensitization and Other
Exposure-Based Treatments
  • After clients are trained in PMR techniques, they
    build a fear hierarchy in collaboration with the
    therapist. Systematic desensitization usually
    proceeds in the following way
  • 1.The client identifies a range of various
    fear-inducing situations or objects.

93
  • Systematic Desensitization and Other
    Exposure-Based Treatments
  • 2. Using a measuring system referred to as
    subjective units of distress, the client, with
    the support of the therapist, rates each
    fear-inducing situation or object on a scale from
    0 to 100 (0 no distress 100 total distress).
  • 3. Early in the session the client engages in
    PMR.
  • 4. While deeply relaxed, the client is exposed,
    in vivo or through imagery, to the least feared
    item in the fear hierarchy.

94
Systematic Desensitization and Other
Exposure-Based Treatments
  • 5. The client is exposed to each feared item,
    gradually progressing to the most feared item in
    the hierarchy.
  • 6. If the client experiences anxiety at any point
    during the imaginal or in vivo exposure process,
    the client reengages in PMR until relaxation
    overcomes anxiety.
  • 7.Treatment continues systematically until the
    client achieves relaxation competence while
    simultaneously being exposed to the entire range
    of fear hierarchy.

95
Imaginal or In Vivo Exposure and Desensitization
  • Systematic desensitization is an exposure
    treatment. In the exposure treatments, clients
    are treated by exposure to the thing they want to
    avoid the stimulus that evokes intense fear,
    anxiety, or painful emotions.

96
Imaginal or In Vivo Exposure and Desensitization
  • There are three ways in which clients are exposed
    to their fears during systematic desensitization
  • 1. Exposure to fears can be accomplished through
    mental imagery. Computer simulation (virtual
    reality) has been used in therapists office.
  • 2. In vivo exposure to feared stimuli. In vivo
    exposure involves direct exposure to real-life
    situations.

97
  • 3. computer simulation (virtual reality) has been
    used as a means of exposing clients to feared
    stimuli.
  • Psychoeducation and a good therapeutic alliance
    are essential for exposure.

98
Massed (Intensive) or Spaced (Graduated) Exposure
Sessions
  • Is desensitization more effective when clients
    are exposed to feared stimuli during a single
    prolonged session or when they are slowly exposed
    to feared stimuli during a series of shorter
    sessions?
  • Either approach can be used effectively.

99
Virtual Reality Exposure (VRE)
  • a procedure wherein clients are immersed in a
    real-time computer-generated computer
    environment. It has been empirically evaluated as
    an alternative to imaginal or in vivo exposure in
    cases of acrophobia (fear of heights), flight
    phobia, and spider phobia.
  • VRE has been empirically validated.

100
Interoceptive Exposure
  • It is similar to other exposure techniques but
    focuses on internal anxiety signals or triggers.
  • Research on Panic Disorder has showed that some
    clients who experience intense fear are
    responding less to situational stimuli and more
    to internal physical sensations.

101
Interoceptive Exposure
  • Panic-prone individuals are sensitive to internal
    physical cues (e.g., increased heart rate,
    increased respiration). They interpret those
    sensations as signs of physical illness, death,
    or loss of consciousness.
  • Although specific cognitive techniques have been
    developed to treat clients tendencies to
    catastrophically overinterpret bodily sensations,
    interoceptive exposure has been developed to help
    clients learn, through exposure and practice, to
    deal more effectively with the physical aspects
    of intense anxiety or panic.

102
Interoceptive Exposure
  • Six introceptive exposures that trigger anxiety
  • Hyperventilation
  • Breath holding
  • Breathing through a straw
  • Spinning in circles
  • Shaking head
  • Chest breathing

103
Interoceptive Exposure
  • Before interoceptive exposure, the client receive
    education about body sensations, learn relaxation
    techniques, and learn cognitive restructuring
    skills. Through repeated successful exposure, the
    client becomes desensitized to feared physical
    cues.

104
Response Prevention and Ritual Prevention
  • According to Mowrer, when a client avoids a
    feared or distressing situation or stimulus, the
    maladaptive avoidance behavior is negatively
    reinforced.
  • For example, clients with Bulimia Nervosa who
    purge after eating specific forbidden foods are
    relieving themselves from the anxiety and
    discomfort they experience upon ingesting the
    foods. Purging behavior is negatively reinforced.
  • Similarly, when a phobic client escapes from a
    phobic object or situation, or when a client with
    OCD engages in a repeated washing or checking
    behavior, negative reinforcement of maladaptive
    behavior occurs.

105
Response Prevention and Ritual Prevention
  • With the therapists assistance, the client with
    bulimia is prevented from vomiting after
    ingesting a forbidden cookie, the agoraphobic
    client is prevented from fleeing a public place
    when anxiety begins to mount, and the client with
    OCD is prevented from washing hands following
    exposure to a contaminated object.

106
Participant Modeling
  • Social learning principles have been evaluated
    for anxiety treatment.
  • For example, individuals with airplane or flight
    phobias dont find it helpful when they watch
    other passengers getting on a plane without
    experiencing distress. In fact, such observations
    can produce increased hopelessness. There is too
    large a gap in emotional state and skills between
    the model and the observer, so vicarious learning
    does not occur.

107
Participant Modeling
  • Behavior therapists provide models of successful
    coping.
  • Group therapy provides an excellent opportunity
    for participant modeling and vicarious learning.

108
Skills Training
  • Skills training techniques are based on skill
    deficit models of psychopathology. Many clients
    have not acquired the necessary skills for
    functioning.
  • Behavior therapists evaluate their clients
    functional skills during the assessment phase of
    therapy and then use specific skills training
    strategies to treatment the clients skill
    deficits.

109
  • Traditional skills training targets include
    assertiveness and other social behavior as well
    as problem solving.

110
Assertiveness and Other Social Behavior
  • Wolpe and Lazarus defined assertiveness as a
    learned behavior. Individuals are evaluated as
    having one of three possible social behavior
    styles passive, aggressive, or assertive.
  • Passive individuals behave in submissive ways
    they say yes when they want to say no.
  • Aggressive individuals dominate others.
  • Assertive individual speaks up, expresses
    feelings.

111
Assertiveness and Other Social Behavior
112
Assertiveness and Other Social Behavior
  • The most common social behaviors targeted in
    assertiveness training are
  • introducing oneself to strangers,
  • giving and receiving compliments,
  • saying no to requests from others,
  • making requests of others,
  • speaking up or voicing an opinion, and
  • maintaining social conversations.

113
  • Assertive behavior is taught through the
    following strategies
  • Instruction Clients are instructed in
    assertive eye contact, body posture, voice tone
    verbal delivery.
  • Feedback The therapist or group members give
    clients feedback regarding how their efforts at
    assertive behavior come across to others.
  • Behavior rehearsal or role playing Clients are
    given opportunities to practice specific
    assertive behaviors, such as asking for help or
    expressing disagreement without becoming angry or
    aggressive.

114
  • Coaching Therapists whisper feedback and
    instructions in the clients ear as a role-play
    or practice scenario progresses.
  • Modeling The therapist or group members
    demonstrate appropriate assertive behavior for
    specific situations.
  • Social reinforcement The therapist or group
    members offer positive feedback and support for
    assertive behavior.
  • Relaxation training It is needed to reduce
    anxiety in social situations.

115
  • Assertiveness training for individuals with
    specific social anxiety and social skills
    deficits are used. Social Phobiaa condition
    characterized by an excessive, irrational fear of
    being scrutinized and evaluated by othersis
    treated with a combination of relaxation and
    social skills training that includes almost all
    the components of traditional assertion training
    and graduated or massed exposure to challenging
    social situations and interactions.

116
Problem Solving Therapy (PST)
  • It is a behavioral treatment with cognitive
    dimensions.
  • For rationale of PST, effective problem solving
    is a mediator that helps clients manage stresful
    life events. It focuses on
  • Problem orientation This involves teaching
    clients to have a positive attitude toward
    problems. Problems are opportunity, are solvable.
    Believing in own ability to solve problems and
    recognizing that effective problem solving
    requires time and effort.

117
Problem Solving Therapy (PST)
  • Problem-solving style Clients are taught a
    rational problem-solving style
  • 1. Define the problem.
  • 2. Identify the goal.
  • 3. Generate options.
  • 4. Choose the best solution.
  • 5. Evaluate the outcome

118
  • Discerning the differences between cognitive and
    behavioral therapies is difficult. Most behavior
    therapists use cognitive treatment and most
    cognitive therapists use behavioral treatments.
  • Cognitive-behavioral therapy.

119
  • One characteristic of behavior therapy is the
    generation of a clear and concrete problem list.
    Items in the problem list are defined in
    behavioral terms and measurable.

120
  • Each behavior therapy session includes four
    parts
  • 1.check-in and homework review
  • 2. psychoeducation about the patients disorder
    and behavior therapy
  • 3. in-session behavioral or cognitive tasks
  • 4. new homework assignments.

121
Cultural and Gender Considerations
  • Some research indicates behavioral treatments are
    effective with minority clients however, Craske
    (2010) admits that generally cognitive and
    behavioral therapies are not yet proven
    multiculturally efficacious.
  • Behavior therapists need to make multicultural
    adjustments in their practices.

122
Evidence-Based Status
  • Behavioral and cognitive therapies are far and
    away the largest producers and consumers of
    therapy outcomes research.
  • The most recent APA Division 12 list of ESTs
    includes 60 different treatment protocols, most
    of which are behavioral or cognitive-behavioral.

123
  • Token economies and contingency managementgtgt
  • Behavioral activationgtgtdepr
  • Progressive muscle relaxationgtgt
  • Exposureresponse preventiongtgtanx dissorders
  • Problem solving therapygtgtdepr.

124
Concluding Comments
  • Behavior therapy deserves credit for
    demonstrating that particular approaches are
    effectivebased on a quantitative
    scientific-medical model.

125
  • If it cant be empirically validated, then its
    not behavior therapy.
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