Chapter 7 - Behavior Therapy (Updated 2/23/06)

Chapter 7 - Behavior Therapy (Updated 2/23/06)
Current Psychotherapies
Chapter 7
Behavior Therapy
G. Terrence Wilson
Instructor: Jeff Garrett Ph.D


Four Major Figures that have Influenced Behavior Therapy
Ivan Pavlov (1849-1936)
B.F. Skinner (1904-1990)
Joseph Wolpe (1915-1997)
Alert Bandura

The first figure in the United States directly linked with the development of behaviorism in the early 1900s was J. B. Watson
In its early stages, behavior therapy was most closely linked with modern learning theory
Wolpe made important contributions to behavioral therapy e.g., systematic desensitization
Eysenck - One of the only behavior theorists to use a trait theory of personality was Eysenck
Albert Bandura is usually associated with the development of the social cognitive theory


Basic Concepts
Behavior Therapy (often termed CBT) integrates behavioral techniques derived from principles of learning and cognitive restructuring techniques based on cognitive theories.


Basic Characteristics of all BT
Practical: Symptoms seen as problems in living – empirically derived
Requires client collaboration
Acknowledges underlying precursors of symptoms, but focuses on present
Sees behavior (normal and abnormal) as learned
Treatment driven by functional analysis of behavior


Continuum of BT (Power Point slide in lecture)


Basic Concepts
Applied Behavior Analysis
Extension of Skinner’s radical behaviorism; Cognition is ignored
Focus is on overt behavior
To alter behavior one attempts to alter the relationship between behavior and consequences
(When a behavioral therapist focuses only on altering the antecedents and consequences associated with a behavior. The approach is the therapist utilizing is applied behavior analysis)


Basic Concepts
Neobehavioristic Mediational
Stimulus-Response (S-R) Model
Recognizes that covert processes may mediate the stimulus response relationship
Cognition is believed to follow the same principles of learning as behavior
Imagery is often utilized


Basic Concepts
Social-Cognitive Theory
Initially espoused by Albert Bandura
Recognizes the interconnection between stimulus, reinforcement and cognition
Sees the critical role of vicarious learning, cognitions, self regulations and expectations
Person is seen as the agent for change; Self efficacy seen as a critical variable
(The social-cognitive theory suggests that one of the best ways to predict a person's future behavior is to assess associated stimuli, reinforcers and cognitions)
(According to social learning theory, a person would be predicted to act consistently across situations if similar behavior leads to similar consequences)


Comparison of BT with Other Systems (Power Point slide in lecture)


In contrast to psychoanalysts, behavior therapists are more directive


Comparison of BT with Other Systems
Little Hans - In the classic case of Little Hans, Freud attributed the phobia of horses to castration anxiety whereas a behavior therapist would see it as classically conditioned response
Comparison of BT with Other Systems


Other Key Contrasts
Can include family systems when appropriate
Empirical studies generally show it to be more effective than verbal therapies
Treatment of choice for phobias, OCD, sexual dysfunction and many childhood disorders
Treatment outcome studies comparing other forms of psychotherapy with behavior therapy have shown behavior therapy is likely more effective than psychoanalytic approaches


Ways BT Meets the Needs of Children and Adolescents
Practical, here and now, experimental emphasis
Techniques can be adapted to meet developmental level
Action oriented which matches the fact that children learn by doing
Incorporates rewards which helps engage the child or adolescent


History
Ivan Pavlov’s research
Rise of behaviorism by Watson
E.L. Thorndike’s research on animal learning (rewarding and punishing)
Joseph Wolpe’s systematic desensitization (Systematic desensitization primarily involves incrementally exposing a client to anxiety producing stimuli)
Eysenck’s description of BT as applied science
Skinner’s operant conditioning paradigms
Bandura’s social learning theories


Four Aspects of Behavior Therapy
Classical Conditioning
Operant Conditioning
Social Learning Approach
Cognitive Behavior Therapy


1. Classical Conditioning
A neutral stimulus is repeated paired with a stimulus that naturally elicits a particular response. The result is that eventually the neutral stimulus alone elicits the response.
e.g., Pavlov’s dogs


2. Operant Conditioning
*B.F. Skinner is associated with this behavioral approach (i.e., Operant Conditioning)
*Skinner's view of controlling behavior is based on the principles of Operant Conditioning
Focuses on actions that operate on the environment to produce consequences
If the environmental change brought about by the behavior is reinforcing, the chances are strengthened that the behavior will occur again. If the environmental changes produce no reinforcement, the chances are lessened that the behavior will recur
e.g., *positive and negative reinforcement, punishment, and extinction techniques.


3. Social Learning Approach
Behavior is influenced by triadic reciprocal interaction among …
- environment
- personal factors (beliefs, preferences, etc)
- individual behavior


Capable of self-directed behavior change
Self-efficacy refers to the individual’s belief that they can change.


4. Cognitive Behavior Therapy
*Is now established as a part of mainstream behavior therapy.
Emphasizes cognitive processes and private events (such as client’s self-talk) as mediators of behavior change


View of Human Nature
Current view does not rest on a deterministic assumption that humans are a mere product of their sociocultural conditioning.
Current view – the person is the producer and the product of his or her environment


View of Human Nature
Increase individual freedom and increase people’s skills
Action-oriented approach
Stimulus events are mediated by cognitive processes
The role of responsibility for one’s behavior

Basic Characteristics and Assumptions
1. Based on the principles and procedures of the scientific method.
2. Deals with current problems and factors influencing them
3. Active behavior change (not mere talk-therapy)
4. Teaching clients skills to use in everyday life (outside of therapy).
5. Focus is on assessing behavior directly, identifying the problem, and evaluating change.
6. Emphasizes self-management strategies.
7. Treatment individually tailored to specific problems
8. Collaborative partnership
9. Practical applications to daily life in order to decrease maladaptive behaviors
10. Develop cultural—specific procedures and obtain clients’ cooperation.


Personality
Behaviorists generally reject theories of personality but do incorporate ideas such as Mischel's person variables.
Behaviorists view abnormal behavior as problems of living
Behaviorists generally see behavior as situation specific and reject trait theories of personality


Eysenck’s classification (mild impact)
Introversion vs. extroversion
Neuroticism vs. emotional stability


Mischel’s person variables
Competency to construct behaviors
Expectancies
Self-regulatory systems and plans
Categorization of events and people
Subjective values.


Basic Principles of Learning
Learning - A relatively permanent change in behavior, not due to fatigue, drugs, or maturation
Basic Principles of Learning


Classical Conditioning - Pavlov’s study: Food is presented to the dog and the dog salivates. No learning involved. A neutral stimulus is presented to the dog (a tone). The dog does not salivate.

UCS ----------------------------------UCR
Unconditional Stimulus Unconditional Response
(sight of food) (salivation)


CS ------------------------------------CR
Conditioned Stimulus Conditioned Response
(tone) (salivation)


Classical conditioning is now viewed as the pairing of conditioned stimuli with unconditioned stimuli and the process of learning correlational or contingent relationships are present

A positive reinforcer should affect behavior by generally strengthening it
Avoidance of an event that produces anxiety is negatively reinforcing
The occurrence of a behavior in a situation other than where it was acquired is known as generalization
The acquisition of new knowledge and behavior by observing other people and events is called vicarious learning

A variable ratio schedule of reinforcement yields the highest rate of response and the greatest resistance to extinction


If a cell phone is taken away from a teenager in order to get her to clean her room, the parents would be using negative reinforcement


In order to help a patient quit smoking, a therapist asks the patient to record what they were doing before smoking and how they feel afterwards. This is an example of using a self-monitoring technique


The form of behavior therapy which evaluates and treats only overt behavior is termed applied behavior analysis


Token Economy is a BT technique which backup reinforcers are given for completion of target behaviors


Ayllon and Azrin studied token economies with hospitalized schizophrenic patients and found earned tokens directly increased desired behavior


Personality
The UCS and CS are repeatedly paired together until the UCR is elicited by the CS. In other words, the CS elicits the same behavior which is now termed CR. If Stimulus Generalization occurs the dog might respond to related stimuli with the same or similar response. If Stimulus Discrimination occurs the dog might not respond.


Personality
Extinction - After learning has occurred, removing the UCS ultimately results in a decreased probability that the CR will be made. This is because the dog learns that the bell no longer means food will follow.


Spontaneous Recovery - After a time delay, if the stimulus is represented the CR will reoccur. This behavior will extinguish rapidly if the UCS does not follow quickly.

Operant or Instrumental Conditioning (B.F. Skinner)
A response is emitted, perhaps randomly at first, and this results in consequences. Hence, the probability of the response’s future occurrence is changed.


Continuous Reinforcement - Every response is followed by reinforcement, resulting in fast learning (acquisition) but also resulting in fast extinction


Personality
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


Fixed interval schedule
Reinforces the next response which occurs after a fixed period of time elapses.
Example: Scheduled exams


Variable interval schedules
Delivers reinforcement after unpredictable time periods
Example: Pop Quizzes


Variable ratio schedule
Yields the highest rates of response and greatest resistance to extinction.
Example: Gambling
Personality
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)


Personality
Secondary Reinforcement
A symbol or a token gains reinforcement value due to its association with a real reinforcer (e.g., dollar bill).
Personality
Vicarious Learning (Modeling)
Learning which occurs through observation
Vicarious learning is particularly relevant to children, but applies to all ages.
By observing a model one grasps entire behaviors as well as component parts
Vicarious learning may remain dormant until a situation warrants expression of the learned behavior
A belief in one's ability to successfully complete a behavior is referred to as self efficacy
A behavior therapist would not typically ask – what? When? Where? (but not why?)


Therapeutic Goals
General goals: Increase personal choice and create new conditions for learning
To eliminate maladaptive behaviors and learn more adaptive behaviors
Client and therapist collaboratively decide the concrete, measurable, and objective treatment goals


Therapist’s function and Role
*Be active and directive
*Be a consultant
* Be a problem solver
Conduct a thorough functional assessment, formulate initial treatment goals, use strategies for behavior change, evaluate the success of the change, and conduct a follow-up assessment
Role modeling (observing others’ behavior)


Client’s Experience in Therapy
To be taught concrete skills
To be motivated to change
To enlarge the options for adaptive behaviors
To continue implementing new behaviors


Relationship Between Therapist and Client
*A good working relationship a necessary, but not sufficient, condition for behavior change to occur.
Common factors (warm, empathy, acceptance et al.) are necessary but not sufficient for behavior change to occur.
Believes the progress is due to specific behavioral techniques instead of therapeutic relationship


Therapeutic techniques and procedures
Operant conditioning techniques
Positive reinforcement (e.g., praise, money)
Negative reinforcement (e.g., alarm)
Extinction (e.g., tantrum = no attention)
Positive punishment (e.g., reprimanding)
Negative punishment (e.g., deducting money)


Therapeutic techniques and procedures
The functional assessment model
Gather data about the antecedents and consequences of problematic behaviors
Use indirect methods (questionnaires) and direct methods (observation)
Develop hypothesis
Devise functional treatments
Use negative punishment procedures only after functional approaches have been tried.
Develop strategies to maintain behavior changes.


Therapeutic techniques and procedures
Relaxation training---to cope with stress
progressive muscular relaxation
Soft and pleasant voice
Create relaxing imagery through visualization
Relax various parts of the body


Therapeutic techniques and procedures
*Systematic Desensitization – aimed at anxiety and avoidance reactions
*Systematic desensitization typically includes the use of relaxation procedures such as progressive muscular relaxation
Anxiety hierarchy
Desensitization – from visualizations to real life exposures. The client moves up the hierarchy from least to greatest anxiety arousing scene (then REPEATED EXPOSURE)


Therapeutic techniques and procedures
*Modeling – a model who is similar to the observer with respect to age, sex, race, and attitudes is more likely to be imitated than a model who is unlike the observer
*Modeling methods have been used in treating people with snake phobias and in teaching new behaviors to socially disturbed children


Therapeutic techniques and procedures
Exposure therapies
In Vivo Desensitization (in real life situations)
Brief and graduated exposure to an actual fear situation or event
*In Vivo Flooding
*Prolonged & intensive in vivo or imaginal exposure to highly anxiety-evoking stimuli without the opportunity to avoid them


Therapeutic techniques and procedures
*Eye Movement Desensitization and Reprocessing (EMDR)
*EMDR is used to help clients restructure their cognitions or to reprocess information.
An exposure-based therapy that involves imaginal flooding, cognitive restructuring, and the use of rhythmic eye movements and other bilateral stimulation to treat traumatic stress disorders and fearful memories of clients


Therapeutic techniques and procedures
Assertion Training – Good for people who have …
Difficulty expressing anger
Difficulty saying "No"
Overly polite
Difficulty expressing affection
Social phobias


Therapeutic techniques and procedures
*Self-management strategies
1. Selecting goals – measurable
2. Targeting behaviors
3. Self-monitoring – client observes their own behavior
4. Working out the plan – maintain gains
5. Evaluate – ongoing


Psychotherapy
Identify goals for change
Operationalize the behavior/thoughts separate traits from behaviors
Distinguish overt from covert behaviors
Obtain a baseline
Complete a functional analysis
Establish target behaviors to change: Behaviors to increase and to decrease
Behaviors should be small, discrete, and chosen based on severity, immediacy, centrality, and potential for success.
Develop a behavioral contract with goals and rewards
Problem solve about possible obstacles; periodically reevaluate
In behavioral therapy the goals are primarily set by the client


Psychotherapy
Assessment
Direct behavioral observation (Assessment technique)
Behavioral therapists view assessment as a continuous process throughout therapy
Treatment
A manual based treatment approach refers to treatment that provides a set of techniques to be implemented in a sequential fashion
Empirically supported, manual based treatments are consistent with actuarial approaches (actuarial refers to statisticians who compute insurance risks and premiums)


Psychotherapy
Techniques (Non-relaxation based)
Role Play
Physiological monitoring
Self monitoring
Behavioral Observation
Guided imagery
Cognitive restructuring (discussed in ch8)
Assertiveness training
Social skills training
Self control techniques
Systematic desensitization
To treat a client with a phobia, a therapist helps the patient develop a hierarchy of anxiety producing situations and then helps the patient face those situations.


Psychotherapy
Behavioral therapists most readily incorporate concepts consistent with the theory of Beck
Psychotherapy


Application
Anxiety disorders
Phobias, Panic Disorders, OCD
Sexual Disorders
Depression
Marital problems
Behavioral Medicine
Childhood Disorders
Behavioral Problems (ADHD, ODD)
Eating Disorders


Outcome Studies
Behaviorists recommend that treatment outcome be assessed through multiple, objective and subjective measures
Research has shown that behavior therapy is highly effective with the eating disorder of bulimia nervosa and may also be effective with the eating disorder termed binge eating disorder
Studies assessing the treatment efficacy of cognitive-behavioral therapy (CBT) and imipramine for panic disorder suggested CBT effects were maintained long term.