Behavior Therapy

Presenter Dr PAVAN KUMAR K Chair person Ms NEETHI NAROTH

PSYCHOTHERAPY

DEFINITION

The modern meaning, the treatment of disorders of the mind or personality by psychological or psychophysiological methods (Frederik van Eeden, 1892)

Wolberg in 1967 defined..

Treatment by psychological means of the problems of an emotional nature, in which a trained person deliberately establishes a professional relationship with the patient with the object of removing, modifying or retarding the existing disturbing symptoms, modifying disturbed patterns of behavior and promoting positive personality development and growth

Psychotherapies

employ language and communication and the relationship with a skilled therapist as their means of producing change. enhance self acceptance, empower the patient to make life changes and help patient to cope with enviroment more effectively

core components

Empathetic and non-judgemental stance towards the patient Awareness of the importance of the setting in which therapy takes place Use of the therapeutic relationship between the therapist as both diagnostic and therapeutic agent

Classification of Psychotherapies

according to how many persons are involved in the treatment an individual a group a couple a family therapy

Based on the content and methods

(karasu 1977) Dynamic psychotherapies (classical,

neo-Freudian psychoanalysis , psychoanalytically oriented psychotherapies)

Behavioral therapies (Wolpes systematic

desensitization, Skinners behavior modification therapy, Banduras social learning therapy)

Experiential or humanistic psychotherapies

(client centered, existential rational emotive therapies, transactional analysis)

Wolberg in 1967 classified

Supportive psychotherapy
Strengthening of existing defences, better mechanisms of maintaining control, adaptive equlibrium Guidance, Externalisation of interest, Reassurances, Pressure and coercion, persuation, emotional catharsis , suggestive hypnosis

Reductive psychotherapy
Efforts at readjustment ,goal modifications and living upto existing creative potentials Behavior therapy, conditioning therapy, directive therapy and family therapy

Reconstructive psychotherapy
Insight into unconcious conflicts Classical and neofreudian psychoanalysis, psychoanalytically oriented psychotherapy

BEHAVIOR THERAPY

Techniques based on learning theory used in order to extinguish maladaptive behaviors and substitute more adaptive ones

HISTORY

Ivan Pavlovs research Rise of behaviorism by Watson

The first figure in the United States directly linked with the development of behaviorism in the early 1900s was J. B. Watson

E.L. Thorndikes research on animal learning (rewarding and punishing) Joseph Wolpes systematic desensitization Eysencks description of BT as applied science Skinners operant conditioning paradigms Banduras social learning theories

1st century- Pliny the Elder - aversion therapy modify drinking behavior by putting spiders at the bottom of a drinker's glass. early 19th century - Alexander Maconochie - token economy prisoners awarded points for positive behaviors in a penal colony at Norfolk Island, Australia. In 1920, the classic case of Little Albert was published, demonstrating the application of classic conditioning principles to the acquisition or learning of fear.

Fourteen years later, another set of investigators demonstrated the use of a belland-pad technique for treating enuresis, or bed-wetting. In mid-1950s, Principles of operant conditioning by B. F. Skinner and his colleagues - applied to the treatment of psychiatric disorders.

During the 1970s, BT had another surge in growth with the addition of attention to cognitions and the development of cognitivebehavioral therapy (CBT). Based on Albert Bandura's social learning theory, People learn by observing the actions of others in their environments. emphasized the roles of thoughts, images, and expectations in the development of psychological or psychiatric disorders development of treatments that target these internal components of behavior more directly

BEHAVIOR THERAPY

Basic Assumptions

Overt behavior holds primacy Maladaptive behavior is learned in the same way as adaptive behavior Assessment and evaluation is key Treatment is active, directive and collaborative

Based on the principles and procedures of the scientific method Learning new behaviors is the core of the therapy Interventions tailored to fit individual needs Therapy deals with clients current problems and the factors influencing them Does not deal with historical determinants Behavior therapy does not provide insight Conclusions are made based on what is observed Treatment goals are stated in concrete and objective terms

Therapy is a collaboration between therapist and client Therapists treat symptoms rather than causes Therapy involves control and manipulation by the therapist Therapists use empirically supported techniques Therapists are ethical in their practice Therapists examine effectiveness of their procedures in terms of generalizability and durability of change Treatment is as brief as possible

Clients are expected to be active Clients have control and freedom Clients can monitor and manage their interventions Clients do something to bring about a change: engage in new behaviors Clients monitor their behavior outside of sessions, learn coping skills, role-playing Several behavioral techniques are often combined in a treatment package to increase efficacy of treatment

Aspects of Behavior Therapy

1. 2. 3.

Classical Conditioning Operant Conditioning Social Learning Approach

Behavior Therapy: The 3 Cs

Counterconditioning

Joseph Wolpe B.F. Skinner Donald Meichenbaum

Contingency Management

Cognitive-Behavior Modification

Classical Conditioning

Clinical Applications

Classical Conditioning
A neutral stimulus is repeatedly paired with a stimulus that naturally elicits a particular response. The result is that eventually the neutral stimulus alone elicits the response. e.g., Pavlovs dogs Pavlov demonstrated that, over time, repeated pairings of one stimulus (e.g., a bell ringing) with another (e.g., the presentation of food) could elicit a reliable response (e.g., a dog salivating).

Conditioning Paradigm Terminology

UCS- Unconditioned stimulus which naturally, without learning elicits. UCR- Unconditioned response-reflex CS- Conditioned stimulus-previously neutral stimulus that, through repeated paring with UCS, elicits a . CR- Conditioned response

Conditioning Paradigm
UCS------------------------------UCR Meat Salivation : : : : CS-------------------------------- CR Bell ringing Salivation

ACQUISITION The development of the association between the UR and the US producing the CR. Requires 3-15 pairings EXTINCTION The loss of association between the CR and the CS, occurs when CS is repeatedly not followed by the US. ( the dog learns that the bell no longer means food will follow).

GENERALISATION similar stimuli to the initial CS produce the response.(CR) (eg. to a buzzer as well as bell) HIGHER ORDER CONDITIONING demonstrate the CR to new stimuli by pairing them with the CS (pairing bell with a light stimulus,dog becomes conditioned to salivate to light)

SPONTANEOUS RECOVERY During extinction trials following a rest period the CR often briefly reappears. This behavior will extinguish rapidly if the UCS does not follow quickly HABITUATION The subject becomes accustomed to and less responsive to a stimulus after repeated exposure.

TECHNIQUES BASED ON CLASSICAL CONDITIONING CONCEPTS Systematic desensitization Invivo desensitization Exposure therapy Therapeutic-Graded Exposure Flooding

Systematic Desensitization

Developed by Joseph Wolpe Also known as reciprocal inhibition Based on counterconditioning or respondent conditioning Follows directly from the work of Pavlov Pair relaxation with CS

person overcomes maladaptive anxiety by approaching the feared situation gradually, in a psychophysiological state that inhibits anxiety. patients attain a state of complete relaxation and exposed to the stimulus that elicits the anxiety response. The negative reaction of anxiety is inhibited by the relaxed state, a process called reciprocal inhibition. The learned relaxation state and the anxiety-provoking scenes are systematically paired in treatment.

Indications Systematic desensitization works best in cases of a clearly identifiable anxietyprovoking stimulus. Phobias, obsessions, compulsions, and certain sexual disorders treated successfully with this technique.

Systematic Desensitization: Components

Relaxation training Anxiety hierarchy Desensitization proper

Relaxation training

Progressive muscle relaxation(Edmund Jacobson)

Patients relax major muscle groups in a fixed order, beginning with the small muscle groups of the feet and working cephalad or vice versa. yoga and Zen, Mental imagery is a relaxation method in which patients are instructed to imagine themselves in a place associated with pleasant relaxed memories. Relaxation produces physiological effects opposite to those of anxiety(adrenergic stress responses ): slow heart rate, increased peripheral blood flow, and neuromuscular stability.

Anxiety Hierarchy

creating a hierarchy list of 10 to 12 scenes about a feared situation Ordered from least to most anxiety provoking

Example: an acrophobic hierarchy may begin with a patient's imagining standing near a window on the second floor and end with being on the roof of a 20-story building, leaning on a guard rail and looking straight down.

Types of Hierarchies

Spatial-temporal- items on the hierarchy get physically closer or get closer in terms of time Thematic - Items on the hierarchy share a basic theme

Spatial-temporal hierarchy
A temporal hierarchy for a public speaking phobia: Someone asks you to give a speech in two months Writing the speech a month before Rehearsing the speech a week before The morning of the speech Reciting the speech while dressing Approaching the auditorium Walking up to the podium Giving the speech

A spatial hierarchy for a Cynophobia

Seeing a dog go by in a car Seeing a dog in a yard on a leash and behind a fence Dog poking nose through the fence Passing a leashed dog across the street Passing a leashed dog on same side of street

Thematic hierarchies public speaking phobia

Telling a joke to several friends Making an announcement to a group of coworkers Speaking at a meeting Speaking at company banquet Giving the main address at a stockholders convention

Desensitization Proper

Get client in a relaxed state Present first item on hierarchy to imagine in a very detailed and clear way If no anxiety is signaled, present item a second time. After two presentations without anxiety move to next item

If item raised anxiety

Return to relaxation. Present item again. If anxiety still occurs go back to earlier step or reconstruct hierarchy. Continue up the hierarchy until all items can be imagined without anxiety

Adjunctive Use of Drugs

Clinicians have used various drugs to hasten relaxation, ultrarapidly acting barbiturate sodium methohexital or diazepam is given intravenously in subanesthetic doses. Advantages preliminary training in relaxation can be shortened, almost all patients can relax adequately, treatment itself seems to proceed more rapidly than without the drugs.

In-Vivo Desensitization

Instead of imagining a situation, the client actually confronts gradually more anxiety producing stimuli

In-Vivo Desensitization

Instead of imagining a situation, the client actually confronts gradually more anxiety producing stimuli same principles as systematic desensitization (counterconditioning treatment).

In-Vivo Desensitization

Instead of imagining a situation, the client actually confronts gradually more anxiety producing stimuli same principles as systematic desensitization (counterconditioning ). basic difference is that Progressive Muscle Relaxation is not typically used with stimulus because complete muscle relaxation is not possible when the patient is using muscles in real-life situations

Exposure Therapy

Patients expose themselves to feared objects or situations Exposure can be real (invivo) or imagined (invitro)

Exposure Therapy: Necessary Factors

Long exposure Repeated exposure until fear dissipates Graduated exposure Attention to fear object Anxiety must be present

Therapeutic-Graded Exposure

similar to systematic desensitization, except that relaxation training is not involved and treatment is usually carried out in a real-life context. individual must be brought in contact with (i.e., be exposed to) the warning stimulus to learn firsthand that no dangerous consequences will ensue. Exposure is graded according to a hierarchy. Patients afraid of cats, for example, might progress from looking at a picture of a cat to holding one.

Flooding or therapeutic extinction

An exposure procedure that harnesses the extinction process and reduces Abandons the hierarchy similar to graded exposure in that it involves exposing the patient to the feared object in vivo; however, there is no hierarchy Person confronts most upsetting situation right away

Flooding ( implosion)

based on the premise that escaping from an anxietyprovoking experience reinforces the anxiety through conditioning. clinicians can extinguish the anxiety and prevent the conditioned avoidance behavior by not allowing patients to escape the situation.

FLOODING contd..

Clinicians encourage patients to confront feared situations directly, without a gradual buildup, as in systematic desensitization or graded exposure. No relaxation exercises are used, as in systematic desensitization. Patients experience fear, which gradually subsides after a time

FLOODING

specific phobias contraindicated when intense anxiety would be hazardous to a patient (heart disease or fragile psychological adaptation). In a variant, called imaginal flooding, the feared object or situation is confronted only in the imagination, not in real life Disadvantage of Sudden Intense Anxiety provoking

Exposure and response prevention

In most cases, flooding (exposure) is accompanied by response prevention (RP) For exposure to produce extinction, avoidance behaviors that reduce fear need to be prevented e.g., looking at the floor during a speech can serve to reduce social anxiety; during exposure, to incorporate RP, the patient would be asked to look directly at the audience and not at the floor. Over time, although the patient remains in the fearproducing situation, anxious emotional response will be reduced.

the treatment of choice for OCD. In ERP, patients are exposed to the feared stimuli and obsessions while rituals/obsessions that typically serve to reduce anxiety are prevented. ERP also is used for the treatment of eating disorders, RP is a part of almost all anxietyreduction treatment programs that use exposure.

Interoceptive exposure

Patients do things that will induce feared physical sensations(e.g., breathing through straw, hyperventilating) The goal is to change patients misinterpretation of uncomfortable physical sensations as signs of imminent catastrophe Used in the treatment of panic disorder

Operant or Instrumental Conditioning

Operant or Instrumental Conditioning (B.F. Skinner)

Developed by Thorndike and Skinner Basic principle if a response to a stimulus produces positive consequences for the individual it will tend to be repeated,while if it is followed by negative consequences it will tend not to be repeated A response is emitted, perhaps randomly at first, and this results in consequences. Hence, the probability of the responses future occurrence is changed.

The ABC Model Three things necessary for Operant Conditioning (i.e. behavior change) 1) Antecedent 2) Behavior 3) Consequence

 Operant Conditioning

1) Reinforcement Positive Reinforcer Negative Reinforcer

2) Punishment Positive punishment Negative punishment

Operant Conditioning

Increases Behavior Present Stimulus Remove Stimulus Positive Reinforcement Negative Reinforcement

Decreases Behavior Positive Punishment Negative Punishment

Intermittent (or partial) Reinforcement

Not every response is reinforced Yields a stronger response ultimately Fixed ratio schedule

Delivers reinforcement after a fixed number of responses and produces high response rate Example: Commission Work Yields the highest rates of response and greatest resistance to extinction. Example: Gambling

Variable ratio schedule

Fixed interval schedule

Reinforces the next response which occurs after a fixed period of time elapses. Example: Scheduled exams
Delivers reinforcement after unpredictable time periods Example: Pop Quizzes

Variable interval schedules

Schedule Effect ______________________________________________ Fixed Ratio (Relatively fast rate of response) ______________________________________________ Fixed Interval (Response rate drops to almost zero after reward; Picks up rapidly before next reward) _______________________________________________ Variable Interval (Slow steady response) _______________________________________________ Variable Ratio (Constant high rate of response; May be difficult to break)

Operant Conditioning Techniques

1. Functional Assessment

Understanding the behavior in terms of the function it serves Identify the A, B and C Implement functional treatments

Contingency contracts formal written agreement Shaping the process in which complex terminal behaviors are reinforced in approximate successive stages

Techniques based on operant conditioning concepts Behavior modification Token Economy Aversion therapy

Contingency Management

defined as the general application of operant principles (e.g., reinforcement, punishment) in the process of behavior change.

Child management training

The most empirically established form of contingency management is child management training (CMT), a structured program that teaches basic disciplinary skills to parents in group settings Include : how to attend to a desirable behavior to increase its frequency and ignore undesirable behaviors to decrease their frequency ; how to use time outs and response costs.

used successfully with a range of behavioral problems, including oppositional and disruptive behavior, aggression, eating disorders, and homework completion.

Time out

Time out is punishment by the removal of positive reinforcement. When applying time out, the therapist must consider the duration of the timeout interval, the location where time out occurs, and what behavior the child is required to exhibit before time out.

Behavior modification

Based on operant conditioning Behavior may be shaped towards the desired final modification through the rewarding of small ,achievable intermediate steps Utilized in behavioral disturbance in children and patients with learning difficulty

Token Economy

Token Economy

Tokens: poker chips, coins, tickets, stars, points, checkmarks, etc. that function as money Exchanged for back-up reinforcers Token economy: reinforcement system based on token

behavioral response is followed by a generally rewarding event, such as food, avoidance of pain, or praise, tends to be strengthened and to occur more frequently than before the reward. In inpatient hospital wards, patients with mental disorder receive a reward for performing a desired behavior, such as tokens that they can use to purchase luxury items or certain privileges.

Advantages of Tokens

Maintain behavior at a high level Bridge delay between response and reinforcement Less subject to satiation Easily administered Permits administration of a single reinforcer

Token Economy: Achievement Place

Residents earned redeemable tokens Receipt of tokens contingent on good behavior Undesirable behavior punished through response costs ie the removal or withdrawal of a reinforcer/reward following inappropriate or problem behavior (e.g., fining a child for swearing)

Disadvantages of Token Economies

Requires that goals be concrete and specific Can lead to dependency if weaning not done Requires a great deal of structure and organization by the administrator Can be costly if tangible reinforcers used May prevent or distract administrator from learning more appropriate strategies for controlling behavior May be easily abused Requires much time and attention

Aversion Therapy

Conditioned stimulus is paired with a stimulus that elicits a negative response

AVERSION THERAPY

When a noxious stimulus (punishment) is presented immediately after a specific behavioral response theoretically, the response is eventually inhibited and extinguished. aversive conditioning stimuli: Chemical aversion, administered via the olfactory or gustatory systems Electrical aversion (sometimes called faradic aversion), and Verbal aversion (also known as covert sensitization).

Many types of noxious stimuli are used: electric shocks, substances that induce vomiting, corporal punishment, and social disapproval Aversion therapy has been used for alcohol abuse, paraphilias, and other behaviors with impulsive or compulsive qualities , used in some cultures in the treatment of opioid addicts

AVERSION RELIEF

Punishment procedure in which aversive stimulus is presented concurrently with negative stimulus or response, Both are simultaneously terminated contingent upon the presentation of positive stimulus or response Commonly used in the treatment of sexual deviations or ego dystonic homosexuality

Covert Sensitization

Pairing of object or situation with an aversive scene that is imagined

SATIATION

A mild aversive technique that uses an excess amount of reinforcement to make the undesired reinforcer lose its effectiveness. Given in such quantities the subject not only tires of the reinforcer but also becomes repelled by it. Smoking, eating, and acting-out behaviors A major problem is that if satiation does not occur the behavior becomes entrenched

Behavioral Activation

From a behavioral perspective, depression is at least partially maintained by a lack of positive reinforcement. Severely depressed mood leads to behavioral withdrawal, which in turn results in a loss of reinforcement from pleasurable events or activities Initial behavioral interventions for depression focused on increasing access to pleasant and therefore reinforcing events through the daily scheduling of pleasant activities

Behavioral Activation Treatment for Depression

BATD Lejeuz and his colleagues Matching law. states that behaviors are allocated to various alternatives on the proportion of reinforcers obtained from the various alternatives.

depression persists because depressed behavior is highly reinforced than nondepressed behavior BATD increases the individual's exposure to the positive outcome of healthy behavior, and reduce depressed behavior Recent data suggest that behavioral activation leads to greater improvement than CBT in depressive symptoms for patients with major depression, with equivalent outcomes to antidepressant

Eye Movement Desensitization and Reprocessing

Saccadic eye movements are rapid oscillations of the eyes that occur when a person tracks an object that is moved back and forth across the line of vision. A few studies have demonstrated that inducing saccades while a person is imagining or thinking about an anxiety-producing event can yield a positive thought or image that results in decreased anxiety. used in posttraumatic stress disorders and phobias

Social Learning Approach

Gives prominence to the reciprocal interactions between an individuals behavior and the environment

Observational Learning

Bandura ,a leading social learning theorist of the 1960s and 1970s emphasized observational learning. Observational learning occurs through vicarious reinforcement (being influenced by seeing somebody else get reinforced), modeling (learning by watching another person perform a behavior), and behavior rehearsal (acting out a behavior to learn it and refine it as a skill).

Social Learning Techniques

Modeling: learning by observing others

Serves two purposes: 1. Person can learn new behavior 2. Behavior that is inhibited becomes less frequent Participant Modeling

Vicarious Learning

observing other peoples behaviors being rewarded or punished leads to reinforcement of those behaviors in an observer

Behavioral Rehearsal

COVERT MODELING imaginal practice of a desired behavior and is essentially role-playing in the imagination( ie covert). ROLE-PLAYING the rehearsing of speech and actions while pretending to be in a particular situation or in a set of circumstances

Observational Learning as Therapy

Participant Modeling

patients learn a new behavior by imitation, primarily by observation, without having to perform the behavior until they feel ready has been used successfully with agoraphobia by having a therapist accompany a patient into the feared situation

Exposure to Stimuli Presented in Virtual Reality

Advances in computer technology have made it possible to present environmental cues in virtual reality for exposure treatment acrophobia, fear of flying, and claustrophobia.

Social Skills Training.

SST usually includes a focus on verbal and nonverbal behaviors (eye contact, speech latency) to learn how to interact with others more effectively Possession of the basic skills for conversation is essential to master social interactions and overcome maladaptive anxiety Five techniques are used for social skills training: (1) instruction in the skill, (2) modeling of the skill , (3) behavioral rehearsal (4) corrective feedback, and (5) positive reinforcement behavioral rehearsal is the critical element

two broad components:

Social environment awareness (social perception) involves teaching the nuances of when, where, and why to initiate and terminate interpersonal interactions. Interpersonal skill enhancement includes teaching verbal and nonverbal mechanics of successful social encounters
(e.g., initiating, maintaining, and ending conversations; establishing and maintaining friendships; and being assertive).

It may also include more complicated skills, such as anger management skills, heterosocial skills, job-seeking skills, and public speaking skills. used effectively with adults and children with different psychological disorders and, in some cases, in individuals with medical conditions associated with interpersonal and environmental stress

Anxiety management training (stress Inoculation training)

Anxiety is a normal response to stress The goal of SIT is to teach patients to understand dynamics of stress and to enhance their intrapersonal and interpersonal skills for managing stress Include breathing and relaxation training , structured problem solving, guided selfdialogue , assertiveness training , behavioral rehearsal(covert modeling and role-playing).

stress Inoculation training

In PTSD, medical patients undergoing painful procedures, high stress-jobs, athletes

Assertiveness Training

enables a person to act in his or her own best interest, to stand up for herself or himself without undue anxiety, to express honest feelings comfortably, and to exercise personal rights without denying the rights of others. Two situations frequently call for assertive behaviors: (1) setting limits on pushy friends or relatives and (2) commercial situations, such as countering a sales pitch or being persistent when returning defective merchandise.

Habit Reversal Training

designed to reduce repetitive behaviors (habits) such as hair pulling, stuttering, nail biting, and tics Habits become associated with various situations and cues through the process of classical conditioning. They also are reinforced operantly because they serve to reduce stress

Done using a combination of procedures, including awareness training, habit control motivation, competing response training, relaxation training, and reinforcement. Competing response training is the core of HRT. This process involves identifying a motoric behavior that is incompatible with the habit and inconspicuous to others. Fist clenching is a commonly used. Patients learn to engage in these competing behaviors to break the conditioned stimulushabit cycle

Biofeedback

Biofeedback involves the recording and display of small changes in the physiological levels of the feedback parameter. Patients are instructed to change the levels of the parameter, using the feedback from the display as a guide. based on the idea that the autonomic nervous system can come under voluntary control through operant conditioning. (Neal Miller )

instruments are the electromyogram (EMG),; the electroencephalogram (EEG) the galvanic skin response (GSR) gauge, and the thermistor, which measures skin temperature (which drops during tension because of peripheral vasoconstriction). For example, a person can learn to raise the temperature of his or her hands to reduce the frequency of migraines, palpitations, or angina pectoris.

Biofeedback can be used by itself or in combination with relaxation. urinary incontinence to regain control over the pelvic musculature. rehabilitation of neurological disorders.

Strengths

Strong empirical tradition and evidence Specific problems are identified and attacked Forces client to be explicit about goals Can be used with a variety of populations

CONTRIBUTIONS
CONTRIBUTIONS Wide variety of techniques available Therapy stresses doing Techniques have been extended to more areas of human functioning than any other therapeutic approach Emphasis on research into and assessment of treatment outcomes

Weaknesses

Does not address broader human problems Does not integrate past Therapists can manipulate Difficult with certain groups May not emphasize the role of feelings enough

Application

Anxiety disorders Sexual Disorders Marital problems Childhood Disorders / behavioral syndromes Eating Disorders

THANK YOU

references

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