Behavior Therapy PDF

Behavior Therapy Elvira C. David, PhD., RPm., RGC., RPsy. Proponents B. F. SKINNER (1904–1990) championed radical behaviorism, which places primary emphasis on the effects of environment on behavior. ALBERT BANDURA (b. 1925) did pioneering work in the area of social modeling and demo...

Behavior Therapy Elvira C. David, PhD., RPm., RGC., RPsy. Proponents B. F. SKINNER (1904–1990) championed radical behaviorism, which places primary emphasis on the effects of environment on behavior. ALBERT BANDURA (b. 1925) did pioneering work in the area of social modeling and demonstrated that modeling is a powerful process that explains diverse forms of learning. Theoretical approach - Social Cognitive Theory ARNOLD A. L AZARUS (b. 1932) He is a pioneer in clinical behavior therapy and the developer of multimodal therapy, Behavior Therapy Focus on directly observable behavior, current determinants of behavior, learning experiences that promote change, tailoring treatment strategies to individual clients, and rigorous assessment and evaluation. Used to treat a wide range of psychological disorders with different client populations. Anxiety disorders, depression, posttraumatic stress disorder, substance abuse, eating and weight disorders, sexual problems, pain management, and hypertension Used in the fields of developmental disabilities, mental illness, education and special education, community psychology, clinical psychology, rehabilitation, business, self-management, sports psychology, health-related behaviors, medicine, and gerontology. Behavior Therapy vs. Cognitive Behavioral Therapy Four Areas of Development Classical conditioning Operant conditioning Social Learning Approach triadic reciprocal interaction among the environment, personal factors (beliefs, preferences, expectations, self- perceptions, and interpretations), and individual behavior Cognitive behavior therapy (CBT) represents the mainstream of contemporary behavior therapy and is a popular theoretical orientation among psychologists. Assumption: what people believe influences how they act and feel. Key Question “What treatment, by whom, is the most effective for this individual with that specific problem and under which set of circumstances?” The Therapeutic Process Therapeutic Goals The general goals of behavior therapy are to increase personal choice and to create new conditions for learning. The therapist assists clients in formulating specific measurable goals. Behavior therapists and clients are guided by a contract but can alter goals throughout the therapeutic process as needed. The Therapeutic Process Relationship Between Client and Therapist collaborative working relationship Lazarus (1993) emphasizes the need for therapeutic flexibility and versatility. Progressive Muscle Relaxation Components: 1. Clients are given a set of instructions that teaches them to relax. They assume a passive and relaxed position in a quiet environment while alternately contracting and relaxing muscles. * 2. Clients learn to mentally “let go,” perhaps by focusing on pleasant thoughts or images. 3. Clients are instructed to actually feel and experience the tension building up, to notice their muscles getting tighter and study this tension, and to hold and fully experience the tension. 4. It is useful for clients to experience the difference between a tense and a relaxed state. The client is then taught how to relax all the muscles while visualizing the various parts of the body, with emphasis on the facial muscles. * 5. Relaxation becomes a well-learned response, which can become a habitual pattern if practiced daily for about 25 minutes each day. Systematic Desensitization (Joseph Wolpe) Steps: 1. Teach deep relaxation Introduce relaxation response to replace adverse response 2. Develop a hierarchy identify situations that elicit a fear response from lowest to highest level of anxiety use specific statements to enable visualization 3. Systematic Desensitization proper Proceed through the hierarchy counterconditioning by introducing a relaxation response to a situation that previously elicited a fear response. Follow up and evaluate Therapeutic Techniques And Procedures In Vivo Exposure and Flooding Exposure therapies are designed to treat fears and other negative emotional responses by introducing clients, under carefully controlled conditions, to the situations that contributed to such problems. Exposure is a key process in treating a wide range of problems associated with fear and anxiety. Exposure therapy involves systematic confrontation with a feared stimulus, either through imagination or in vivo (live). Imaginal exposure can be used prior to implementing in vivo exposure when a client’s fears are so severe that the client is unable to participate in live exposure (Hazlett-Stevens & Craske, 2008). Therapeutic Techniques And Procedures In Vivo Exposure involves client exposure to the actual anxiety-evoking events rather than simply imagining these situations. Key Elements (Hazlett-Stevens & Craske, 2008) 1. Functional analysis of objects or situations a person avoids or fears. The therapist and the client generate a hierarchy of situations for the client to encounter in ascending order of difficulty. In vivo exposure involves repeated systematic exposure to fear items, beginning from the bottom of the hierarchy. 2. Clients engage in a brief, graduated series of exposures to feared events. As is the case with systematic desensitization, clients learn responses incompatible with anxiety, such as responses involving muscle relaxation. 3. Clients are encouraged eventually to experience their full fear response during exposure without engaging in avoidance. Between therapy sessions, clients carry out self-directed exposure exercises. Therapeutic Techniques And Procedures Flooding refers to either in vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of time. As is characteristic of all exposure therapies, even though the client experiences anxiety during the exposure, the feared consequences do not occur. In vivo flooding consists of intense and prolonged exposure to the actual anxiety-producing stimuli. Remaining exposed to feared stimuli for a prolonged period without engaging in any anxiety-reducing behaviors allows the anxiety to decrease on its own. Imaginal flooding is based on similar principles and follows the same procedures except the exposure occurs in the client’s imagination instead of in daily life. An advantage of using imaginal flooding over in vivo flooding is that there are no restrictions on the nature of the anxiety- arousing situations that can be treated. Both used as treatment for anxiety-related disorders, specific phobia, social phobia, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and agoraphobia. Therapeutic Techniques And Procedures Eye Movement Desensitization And Reprocessing (EMDR) is a form of exposure therapy that entails assessment and preparation, imaginal flooding, and cognitive restructuring in the treatment of individuals with traumatic memories. The treatment involves the use of rapid, rhythmic eye movements and other bilateral stimulation to treat clients who have experienced traumatic stress. Designed to assist clients in dealing with posttraumatic stress disorders, EMDR has been applied to a variety of populations including children, couples, sexual abuse victims, combat veterans, victims of crime, rape survivors, accident victims, and individuals dealing with anxiety, panic, depression, grief, addictions, and phobias. The treatment consists of three basic phases involving assessment and preparation, imaginal flooding, and cognitive restructuring. Therapeutic Techniques And Procedures Social Skills Training is a broad category that deals with an individual’s ability to interact effectively with others in various social situations; it is used to help clients develop and achieve skills in interpersonal competence. Social skills involve being able to communicate with others in a way that is both appropriate and effective. Individuals who experience psychosocial problems that are partly caused by interpersonal difficulties are good candidates for social skills training. Typically, social skills training involves various behavioral techniques such as psychoeducation, modeling, behavior rehearsal, and feedback. Social skills training is effective in treating psychosocial problems by increasing clients’ interpersonal skills. Therapeutic Techniques And Procedures Social Skills Training Segrin (2008) identifies these key elements of social skills training, which entail a collection of techniques: assessment, direct instruction and coaching, modeling, role-playing, and homework assignments. Clients learn information that they can apply to various interpersonal situations, and skills are modeled for them so they can actually see how skills can be used. A key step involves the necessity of clients putting into action the information they are acquiring. It is through role-playing that individuals actively practice desired behaviors that are observed. Segrin notes that by monitoring clients’ successes and failures therapists can fine-tune clients’ performances. The feedback and reinforcement clients receive assists them in conceptualizing and using a new set of social skills that enables them to communicate more effectively. A follow-up phase is critical for clients in establishing a range of effective behaviors that can be applied to many social situations. Therapeutic Techniques And Procedures Assertion Training Assertion training can be useful for those who: have difficulty expressing anger or irritation have difficulty saying no are overly polite and allow others to take advantage of them find it difficult to express affection and other positive responses, feel they do not have a right to express their thoughts, beliefs, and feelings have social phobias. The basic assumption underlying assertion training is that people have the right (but not the obligation) to express themselves. One goal of assertion training is to increase people’s behavioral repertoire so that they can make the choice of whether to behave assertively in certain situations.*  Therapeutic Techniques And Procedures Self-Management Programs and Self-Directed Behavior Self-management strategies include self-monitoring, self-reward, self- contracting, and stimulus control. The basic idea of self-management assessments and interventions is that change can be brought about by teaching people to use coping skills in problematic situations. * Basic Steps (Watson and Tharp, 2007): 1. Selecting goals. Goals should be established one at a time, and they should be measurable, attainable, positive, and significant for you. It is essential that expectations be realistic. 2. Translating goals into target behaviors. Identify behaviors targeted for change. Once targets for change are selected, anticipate obstacles and think of ways to negotiate them. 3. Self-monitoring. Deliberately and systematically observe your own behavior, and keep a behavioral diary, recording the behavior along with comments about the relevant antecedent cues and consequences. 4. Working out a plan for change. Devise an action program to bring about actual change. Various plans for the same goal can be designed, each of which can be effective. Some type of self- reinforcement system is necessary in this plan because reinforcement is the cornerstone of modern behavior therapy. Self-reinforcement is a temporary strategy used until the new behaviors have been implemented in everyday life. Take steps to ensure that the gains made will be maintained. Therapeutic Techniques And Procedures Multimodal Therapy: Clinical Behavior Therapy is a comprehensive, systematic, holistic approach to behavior therapy developed by Arnold Lazarus Multimodal therapy is grounded in social-cognitive theory and applies diverse behavioral techniques to a wide range of problems. This approach serves as a major link between some behavioral principles and the cognitive behavioral approach that has largely replaced traditional behavioral therapy. Multimodal therapy is an open system that encourages technical eclecticism in that it applies diverse behavioral techniques to a wide range of problems. Multimodal therapists borrow techniques from many other therapy systems.* Therapeutic flexibility and versatility, along with breadth over depth, are highly valued, and multimodal therapists are constantly adjusting their procedures to achieve the client’s goals. Therapists need to decide when and how to be challenging or supportive and how to adapt their relationship style to the needs of the client. Multimodal therapists tend to be very active during therapy sessions, functioning as trainers, educators, consultants, coaches, and role models.* Therapeutic Techniques And Procedures The BASIC I.D. The essence of Lazarus’s multimodal approach is the premise that the complex personality of human beings can be divided into seven major areas of functioning: B - behavior A - affective responses S – sensations I – images C – cognitions I - interpersonal relationships D - drugs, biological functions, nutrition, and exercise Multimodal therapy begins with a comprehensive assessment of the seven modalities of human functioning and the interaction among them. A complete assessment and treatment program must account for each modality of the BASIC I.D., which is the cognitive map linking each aspect of personality. Therapeutic Techniques And Procedures Mindfulness and Acceptance-Based Cognitive Behavior Therapy Newer facets of cognitive behavior therapy, labeled the “third wave” of behavior therapy, emphasize considerations that were considered off limits for behavior therapists until recently, including mindfulness, acceptance, the therapeutic relationship, spirituality, values, meditation, being in the present moment, and emotional expression Third-generation behavior therapies have been developed that center around five interrelated core themes: an expanded view of psychological health a broad view of acceptable outcomes in therapy Acceptance Mindfulness creating a life worth living Therapeutic Techniques And Procedures Mindfulness involves being aware of our experiencing in a receptive way and engaging in activity based on this nonjudgmental awareness (Robins & Rosenthal, 2011). In mindfulness practice, clients train themselves to intentionally focus on their present experience while at the same time achieving a distance from it. Mindfulness involves developing an attitude of curiosity and compassion to present experience.* Clients learn to focus on one thing at a time and to bring their attention back to the present moment when distractions arise. Therapeutic Techniques And Procedures Acceptance is a process involving receiving one’s present experience without judgment or preference, but with curiosity and kindness, and striving for full awareness of the present moment. Acceptance is not resigning oneself to life’s problems; rather, it is an active process of self-affirmation (Wilson, 2011). Acceptance is an alternative way of responding to our internal experience. By replacing judgment, criticism, and avoidance with acceptance, the likely result is increased adaptive functioning. Therapeutic Techniques And Procedures The four major approaches in the recent development of the behavioral tradition include 1. Dialectical Behavior Therapy (Linehan, 1993a, 1993b), which has become a recognized treatment for borderline personality disorder 2. Mindfulness-based Stress Reduction (Kabat-Zinn, 1990, 2003), which involves an 8- to 10-week group program applying mindfulness techniques to coping with stress and promoting physical and psychological health 3. Mindfulness-based Cognitive Therapy (Segal et al., 2002), which is aimed primarily at treating depression 4. Acceptance And Commitment Therapy (Hayes, Strosahl, & Houts, 2005; Hayes, Strosahl, & Wilson, 2011), which is based on encouraging clients to accept, rather than attempt to control or change, unpleasant sensations. Therapeutic Techniques And Procedures Dialectical Behavior Therapy (DBT) Formulated by Linehan, DBT is a promising blend of behavioral and psychoanalytic techniques for treating borderline personality disorders. Like analytic therapy, DBT emphasizes the importance of the psychotherapeutic relationship, validation of the client, the etiologic importance of the client having experienced an “invalidating environment” as a child, and confrontation of resistance. DBT treatment strategies include both acceptance- and change-oriented strategies. The treatment program is geared toward helping clients make changes in their behavior and environment, and at the same time communicating acceptance of their current state. Therapeutic Techniques And Procedures Dialectical Behavior Therapy (DBT) To help with emotional regulation problems, DBT teaches clients to recognize and accept the existence of simultaneous, opposing forces. By acknowledging this fundamental dialectic relationship—such as not wanting to engage in a certain behavior, yet knowing they have to engage in the behavior if they want to achieve a desired goal—clients can learn to integrate the opposing notions of acceptance and change, and the therapist can teach clients how to regulate their emotions and behaviors. Mindfulness procedures are taught and practiced to develop an attitude of acceptance. DBT employs behavioral and cognitive behavioral techniques, including a form of exposure therapy in which the client learns to tolerate painful emotions without enacting self- destructive behaviors. DBT integrates its cognitive behaviorism not only with analytic concepts but also with the mindfulness training of “Eastern psychological and spiritual practices (primarily Zen practice)”. * Therapeutic Techniques And Procedures Dialectical Behavior Therapy (DBT)* Skills are taught in four modules: 1. Mindfulness is a fundamental skill in DBT and is considered the basis for other skills taught. Mindfulness helps clients to embrace and tolerate the intense emotions they experience when facing distressing situations. 2. Interpersonal effectiveness involves learning to ask for what one needs and learning to cope with interpersonal conflict. This skill entails increasing the chances that a client’s goals will be met, while at the same time not damaging the relationship. 3. Emotion regulation includes identifying emotions, identifying obstacles to changing emotions, reducing vulnerability, and increasing positive emotions. Clients learn the benefits of regulating emotions such as anger, depression, and anxiety. 4. Distress tolerance is aimed at helping individuals to calmly recognizing emotions associated with negative situations without becoming overwhelmed by these situations. Clients learn how to tolerate pain or discomfort skillfully. Therapeutic Techniques And Procedures Mindfulness-based Stress Reduction (MBSR) The essence of MBSR consists of the notion that much of our distress and suffering results from continually wanting things to be different from how they actually are. MBSR aims to assist people in learning how to live more fully in the present rather than ruminating about the past or being overly concerned about the future. It does not actively teach cognitive modification techniques, nor does it label certain cognitions as “dysfunctional,” because this is not consistent with the nonjudgmental attitude one strives to cultivate in mindfulness practice. Therapeutic Techniques And Procedures Mindfulness-based Stress Reduction (MBSR) The approach adopted in the MBSR program is to develop the capacity for sustained directed attention through formal meditation practice. The skills taught include sitting meditation and mindful yoga, which are aimed at cultivating mindfulness. The program includes a body scan meditation, which helps clients to observe all the sensations in their body. Clients are encouraged to bring mindfulness into all of their daily activities, including standing, walking, and eating. Therapeutic Techniques And Procedures Mindfulness-based Cognitive Therapy (MBCT) This program is a comprehensive integration of the principles and skills of mindfulness applied to the treatment of depression. MBCT is an 8-week group treatment program adapted from Kabat-Zinn’s (1990) mindfulness-based stress reduction program, and it includes components of cognitive behavior therapy. MBCT represents an integration of techniques from MBSR and teaching cognitive behavioral interventions to clients. The primary aim is to change clients’ awareness of and relation to their negative thoughts. Participants are taught how to respond in skillful and intentional ways to their automatic negative thought patterns. Therapeutic Techniques And Procedures Fesco, Flynn, Mennin, and Haigh (2011) describe the essence of the seven sessions in the MBCT program: 1. Therapy begins by identifying negative automatic thinking of people experiencing depression and by introducing some basic mindfulness practices. 2. Participants learn about the reactions they have to life experiences and learn more about mindfulness practices. 3. Third session is devoted to teaching breathing techniques and focused attention on their present experiencing. 4. Emphasis is on learning to experience the moment without becoming attached to outcomes as a way to prevent relapse. 5. Participants are taught how to accept their experiencing without holding on. 6. Participants are taught to describe thoughts as “merely thoughts;” clients learn that they do not have to act on their thoughts. They can tell themselves, “I am not my thoughts” and “Thoughts are not facts.” 7. Participants learn how to take care of themselves, to prepare for relapse, and to generalize their mindfulness practices to daily life. Therapeutic Techniques And Procedures Acceptance And Commitment Therapy (ACT) involves fully accepting present experience and mindfully letting go of obstacles. In this approach “acceptance is not merely tolerance— rather it is the active nonjudgmental embracing of experience in the here and now”. Acceptance is a stance or posture from which to conduct therapy and from which a client can conduct life that provides an alternative to contemporary forms of cognitive behavioral therapy (Eifert & Forsyth, 2005). In ACT there is little emphasis on changing the content of a client’s thoughts. Instead, the emphasis is on acceptance (nonjudgmental awareness) of cognitions. Therapeutic Techniques And Procedures Acceptance And Commitment Therapy (ACT) The goal is for individuals to become aware of and examine their thoughts. Clients learn how to change their relationship to their thoughts. They learn how to accept and distance themselves from the thoughts and feelings they may have been trying to deny. Hayes has found that confronting maladaptive cognitions actually strengthens rather than reduces these cognitions. The goal of ACT is to allow for increased psychological flexibility. Values are a basic part of the therapeutic process, and ACT practitioners might ask clients, “What do you want your life to stand for?” Therapy involves assisting clients to choose values they want to live by, designing specific goals, and taking steps to achieve their goals. Therapeutic Techniques And Procedures In addition to acceptance, commitment to action is essential. Commitment involves making mindful decisions about what is important in life and what the person is willing to do to live a valued and meaningful life (Wilson, 2011). ACT makes use of concrete homework and behavioral exercises as a way to create larger patterns of effective action that will help clients live by their values (Hayes, 2004).* ACT is an effective form of therapy that continues to influence the practice of behavior therapy. ACT emphasizes common processes across clinical disorders, which makes it easier to learn basic treatment skills. Practitioners can then implement basic principles in diverse and creative ways. ACT has been effective for treatment of a variety of disorders, including for substance abuse, depression, anxiety, phobias, posttraumatic stress disorder, and panic disorder (Eifert & Forsyth, 2005). Application to Group Counseling Group-based behavioral approaches emphasize teaching clients self-management skills and a range of new coping behaviors, as well as how to restructure their thoughts. Distinguishing characteristic of behavioral practitioners is their systematic adherence to specification and measurement. The specific unique characteristics of behavioral group therapy include 1. conducting a behavioral assessment 2. precisely spelling out collaborative treatment goals 3. formulating a specific treatment procedure appropriate to a particular problem 4. objectively evaluating the outcomes of therapy. Behavior therapists tend to utilize short-term, time-limited interventions aimed at efficiently and effectively solving problems and assisting members in developing new skills. Behavioral group leaders assume the role of teacher and encourage members to learn and practice skills in the group that they can apply to everyday living. Application to Group Counseling There are many different types of groups with a behavioral twist, or groups that blend both behavioral and cognitive methods for specific populations. Structured groups, with a psychoeducational focus, are especially popular in various settings today. At least five general approaches can be applied to the practice of behavioral groups: 1. social skills training groups 2. psychoeducational groups with specific themes 3. stress management groups 4. multimodal group therapy 5. mindfulness and acceptance-based behavior therapy in groups Behavior Therapy From A Multicultural Perspective Strengths From a Diversity Perspective Behavioral counseling does not generally place emphasis on experiencing catharsis. Rather, it stresses changing specific behaviors and developing problem-solving skills. 8 Behavior therapy focuses on environmental conditions that contribute to a client’s problems. Social and political influences can play a significant role in the lives of people of color through discriminatory practices and economic problems, and the behavioral approach takes into consideration the social and cultural dimensions of the client’s life. In designing a change program for clients from diverse backgrounds, effective behavioral practitioners conduct a functional analysis of the problem situation. This assessment includes the cultural context in which the problem behavior occurs Behavior Therapy From A Multicultural Perspective Shortcomings From a Diversity Perspective Although behavior therapy is sensitive to differences among clients in a broad sense, behavior therapists need to become more responsive to specific issues pertaining to all forms of diversity. Because race, gender, ethnicity, and sexual orientation are critical variables that influence the process and outcome of therapy, it is essential that behavior therapists pay careful attention to these factors and address social justice issues as they arise in a client’s therapy. Contributions of Behavior Therapy Behavior therapy challenges us to reconsider our global approach to counseling. An advantage behavior therapists have is the wide variety of specific behavioral techniques at their disposal. A major contribution of behavior therapy is its emphasis on research into and assessment of treatment outcomes. It is up to practitioners to demonstrate that therapy is working. Evidence-based therapies (EBT) are a hallmark of both behavior therapy and cognitive behavior therapy. A strength of the behavioral approaches is the emphasis on ethical accountability. Limitations and Criticisms of Behavior Therapy Behavior therapy may change behaviors, but it does not change feelings. Behavior therapy does not provide insight. Behavior therapy treats symptoms rather than causes. Behavior therapy involves control and social influence by the therapist.