Psychotherapy Exam 2

Behavioral Background

Based in learning theory

• Behavior in response to environmental stimuli

• Ivan Pavlov & J.B. Watson (earliest behavioral psychologists)

  • classical conditioning (automatic associations that we learn between stimuli)

• B.F. Skinner

  • operant conditioning (reinforcemnt & punishment processes)

• Albert Bandura (bobo doll experience)

  • modeling (learn behaviors by observing others)

Classsical Conditioning

Learning acquired through paired associations between an UCS & a CS to produce a CR

Starts w/a neutral stimulus

• Process in which a neutral stimulus acquires capacity to produce response that originally came from a diff stimulus

Before conditioning events just a neutral stimulus, produces no response

• After conditioning events is a conditioned stimulus, produces a conditioned response

Ex: Post-traumatic stress response after a car accident

• Unconditioned Stimulus: loud noise

• Unconditioned Response: startle response

• Conditioned Stimulus: traffic noises

• Conditioned Response: startle response

Behavioral Theory

Generalization

Spreading of a learned association to a new stimulus or situation

• to similar stimuli

• often time stimuli thats inappropriate or doesn’t warrent the reaction its producing

Behavioral Theory

Operant Conditioning

“Target Behavior”

More intentional, not an automatic association

• Reinforcement: Increases a behavior

• Punishment: Decreases a behavior

• Positive: Adding a stimulus

• Negative: Removing a stimulus

  • Pos reinforcement: if client attends session, receives praise

  • Neg reinforcement: if client does deep breathing, anxiety symptoms stop

  • Pos punishment: if client makes sexual advances, receives a warning

  • Neg punishment: if client becomes aggressive, therapy session stops

Behavioral Theory

Modeling

Learning behavior from observing others

• Observer sees a specific behavior performed by a role model & repeats that behavior

• Developed & maintained via reinforcement (pos or neg)

Ex: Intergenerational Abuse (relevent for how psychopathology developed; strong familial link) (big enviornmental component)

• Aggressive behavior modeled by parents

• Survivors of abuse learn aggressive behaviors are a way to obtain needs or wants

Behavioral Sources of Psychopathology

Aligned w/DSM diagnoses

• Applied to most types of psychopathology

• bc developed to target specfic diagnosis/psychopathology

Learning a problematic behavior

• Adaptive vs. Unadaptive behaviors

  • Adaptive: promote well being

  • Unadaptive: determental to our well being

    • Context dependent

      • behaviors interact w/environment youre in)

    • Developed from learning history through classical conditioning, operant conditioning, or modeling

    • Inappropriate stimulus generalization

Factors that predispose, trigger, strengthen, or maintain a problematic behavior

Behavioral Focus of Therapy

Assessing & understanding target behaviors (adaptive & unadaptive)

Changing learning around target behaviors

• break up classically asscoiated stimuli

• use operant conditioning to increase or decrease a target behavior

Approach

• Directive (therapist leading the show)

• Goal-focused (come up w/really specific goals of what want to accomplish)

• Skills-based (to apply in day to day life)

• Therapeutic relationship de-emphasized (but not unimportant)

  • not as central

Manualized treatment options

• Standardized approach

• Session-by-session guides

Brief, usually less than 20 sessions

Behavioral Therapy Techniques

1st wave

Psychoeducation on target behaviors & therapy

• education on psychology; educating client on their specifc probs

Exposure

• Developing new learning to replace feared associations (Inhibitory learning)

Functional analysis

• Understanding target behavior & factors controlling it

Behavioral Activation

• Increasing pos reinforcement through rewarding activities

Exposure

Exposure for anxiety provoking situations

Graduated

• Anxiety hierarchy

Types:

• Imaginal

• In-vivo

• Interoceptive

Subjective units of Distress (SUDs)

Repeated exposure leads to inhibitory learning

To be effective exposures should:

• Be within client’s control/predictable (but less over time)

• Be long enough in duration for learning to occur

• Provoke high, but manageable anxiety

• Be repeated w/no long gaps

• Occur in multiple contexts

• Have client focus on feared stimuli

  • Safety behaviors-Ways to avoid feared stimulus

  • Distractions

  • Comfort objects or “safety signals”

  • Coupled w/“response prevention”

Functional Analysis

S-O-R-C Model

• Stimulus: antecedent aka what comes before target behavior

  • bad living conditions

    • move apartments

• Organism: variables unique to individual that will inform the behavior

  • poor emotional regulation

    • self-regulation skills

• Response: the behavior of interest

  • eating cat food

    • relaxation exercise (alternative behaviors: replace the unadaptive behaviors)

• Consequence: punishment or reinforcement resulting from the behavior

  • falling asleep easily

    • feeling rested

Classical Conditioning Fear

aquire anxiety over time

things elicit anxious response that they didn'tt have before

• ex: fear of spiders

  • Pain from being bitten (body’s automatically gonna do)

  • Panic behaviors: response to pain

  • Seeing spider: now has conditioned property to it

  • Panic behavior: after seeing spider bc of previous learning

  • Spider transformed from neurtal stimulus to CS which now ellicit CR, panic behavior

Behavioral Activation

Addresses Depressive Disorders through improving mood & anhedonia

• (lack of pleasure when experiencing something typically reinforcing to you)

Focused on pos reinforcement

• Increasing reward & pleasure

Primary components:

• Activity monitoring & scheduling (focus on social activities)

• Increasing mastery & pleasure experiences

  • contribute to long-term goals

• Decreasing avoidance behaviors

• Goal setting

• Role playing / social skills training

  • deal w/cons of social withdrawal

Treatment Mechanisms

Change in reinforcement contingencies

• Reinforcement of more adaptive, varied alternative behaviors

• Increased behavioral repertoire for increase flexibility in how ppl respond to situations

Inhibitory learning

• Cognitive changes

  • New beliefs that feared situations aren’t dangerous

Increased tolerance of neg emotions

Cognitive-Behavioral Background

Behavioral treatments less successful for specific cases

• Evolution from 1st-wave behaviorism

  • Thoughts influence emotions & behavior

Multicomponent approach

• Behavioral: Understanding & changing learned behavior

+

• Cognitive: Understanding and changing thoghts

  • Neg interpretations about oneself, world, & future

Cognitive-Behavioral Theory

Thoughts produce emotional & behavioral responses

• reaction to & thoughts about what youre experiencing

• goal = change how clients think bc should have an effect on both their emotions & their behaviors

ABC Model:

• interpretation of an event leads to the subsequent emotional response & behaviors

  • Not event itself

Cognitions

Cognitions

Automatic thoughts

• Surface level thoughts

• Quick, fleeting, possibly unconscious

  • ex: I messed up my assignment

Schemas

• Deeper beliefs that provide a cognitive framework for how a person understands & organizes the world

• Development of biases, assumptions

  • new info framed to fit these schemas

  • ex: confirmation bias

    • ex: failure bias, perceiving everything I do as a failure

Core beliefs

• Deepest level, hard to detect

  • Downward arrow + Cognitive Restructuring

• Lasting, globally held ideas

  • ex: I am worthless

Cognitive Behavioral Theory Sources of Psychopathology

Development of dysfunctional thoughts that are:

• Overly general/broad

  • no one loves me

• Extreme

  • worse case possible

• Rigid/Inflexiblie

  • really ingrained

• Irrational

  • Assumed true, regardless of available evidence

Dysfunctional thoughts developed earlier in life

• Ingrained over time

• Thoughts that lead to difficulties w/emotions, well-being, & functioning

Cognitive Behavioral Focus of Therapy

Bringing awareness to the role of thoughts on emotions & behaviors

Modifying dysfunctional thinking (change way approaching thoughts)

Approach

• Directive

• Goal-focused

• Skills-based

• Evidence-based practice

• Therapeutic relationship de-emphasized (but not unimportant)

Manualized treatment options

• Standardized approach

• Session-by-session guides

Brief, usually less than 20 sessions

Cognitive Behavioral Therapeutic Techniques

Functional analysis: The Cognitive Edition (ABC Model)

Thought monitoring

Downward arrow

• dig deeper into schemas & core beliefs

Labelling cognitive dysfunctions

Cognitive restructuring

Thought records

• Exercise to tie the above techniques together

Downward Arrow

Bring some attention to automatic thoughts, want to understand broad schemas & core beliefs person has about themselves

1. Identify activating event

2. Ask what event means about themselves, others, or world

3. Ask same question until a maladaptive belief is revealed

4. Review types of cognitive dysfunctions

Links automatic thoughts to schemas & core beliefs

Types of Cognitive Dysfunctions

All-or-nothing thinking

Overgeneralization

Mental filter

Jumping to conclusions

Mind reading

Catastrophizing

Emotional reasoning

“Should” & “must” statements

Examples of Dysfunctional Thoughts

Major depressive disorder:

• tendency to see oneself as a failure, the future as hopeless, & to focus on neg aspects of situations

Generalized anxiety disorder:

• tendency to overestimate the probability & severity of a crisis (e.g., losing a job)

OCD:

• overestimates of threat & responsibility, beliefs that intrusive thoughts are highly significant & need to be controlled, & the intolerance of uncertainty & imperfection

Panic disorder:

• idea that experiencing anxiety is dangerous or harmful (e.g., when my heart beats fast, I worry I’m having a heart attack)

Illness anxiety disorder:

• beliefs that one is medically ill (despite a lack of evidence) & that any pain or discomfort is a sign of a serious medical problem

Cognitive Restructuring

Evaluating negative automatic thoughts or core beliefs

• “Hot thoughts”

  • enduce a particular heightened emotion or lead to a maladaptive behavior

• Considering evidence that both supports & dosen’t support the automatic thought

Exploring more helpful adaptive explanations

• Developing alternative thoughts

Ex:

• fails test —> “I’m worthless” —> depression (maladaptive)

• fails test —> “1 test doesn’t define my ability” —> more hopeful (restructuring)

CBT Thought Record

Take all technique and package them together to help client

• activating event

• connect to emotions they were experiencing (consequence); how strongly felt

• identify automatic thoughts

• cognitive restructuring of thoughts

  • identify what evidence supports those thoughts (evidence for & against)

  • develop a new belief, alternative thoughts (more balanced, more complex)

• new consequence now (new emotions and feelings) reassess

Presenting problem:

• Behavioral components

• Cognitive components

Panic attacks:

• Interoceptive exposure

• Challenge catastrophic thinking

Depression:

• Behavioral activation

• Increase awareness of failure schemas

Bulimia:

• Self-monitoring, response prevention

• Develop adaptive body-related thoughts

Treatment Mechanisms

Change in maladaptive thoughts

• Increased rationality

• Increased awareness of thoughts

• Challenging dysfunctional thoughts

Reduction in unadaptive behaviors + Increase in adaptive behaviors

Acceptance-Based Background

3rd-wave Behavioral Therapies

• Acceptance Based Approaches

Acceptance & Commitment Therapy (ACT)

Mindfulness-based cognitive therapy (MBCT)

• Intensive mindfulness practice + recognizing depressive thoughts (rumination) + Behavioral activation

Dialectical Behavior Therapy (DBT)

What is “acceptance-based”?

• Suffering is universal & unavoidable (inhertantly part of human experience)

• We can take steps so we don’t amplify suffering (can’t avoid)

Negative thoughts & emotions are NOT the prob

How we respond to them IS the prob

• Reduced focus on changing distressing thoughts & emotions

• Increased focus on accepting distressing thoughts & emotions

Acceptance-Based Theory

Philosophy: based in functional-contextualism

• Understanding the function a psychological processes (e.g., thoughts, emotions, behaviors) serves from the person’s learning history context (historical) & current context (situational)

  • What function does it serve?

  • What maintains it?

  • How can we influence it?

What is the function of alcohol use? Depends on:

• Past relationship w/alcohol (historical context)

• Current relationship w/alcohol (situational context)

• Can we change this relationship w/alcohol in therapy?

Psychological Flexibility Model

Healthy mental functioning requires psychological flexibility

• Being able to adapt & cope even during suffering

Psychological inflexibility = more mental probs in the future

Psychological flexibility characterized by 3 response styles:

1. Centered response style

   • be present in the current moment

2. Open response style

   • opening self up to new experiences; willing to learn, willing to be uncomfortable (acceptance of discomfort)

3. Engaged response style

   • knowing whats important to you, what you value; living life in way/behaving thats in line with/whats important to you

Acceptance & Commitment Therapy

Alternative to typical CBT approaches

• not asking you to change anything about your thoughts'; just accept whats happening

• accept discomfort

A-C-T:

• Accept you reactions & be present

• Choose a valued direction

• Take action

6 “principles” of ACT known as the “hexaflex”

Six Core Principles of ACT

1. Acceptance

2. Defusion

3. Contact w/the present moment

4. Self-as-context

5. Values

6. Committed Action

Acceptance-Based Sources of Psychopathology

Responding to suffering w/psychological inflexability

• Emotional dysregulation

  • heightened emotions or difficulties managing emotions

• Decentering

  • being unable to attend to the present moment

• Experiental avoidance

  • avoiding painful thoughts or emotions

• Value/Action Misalignment

  • not recognizing what’s important or acting in line w/what’s important

Acceptance-Based Focus of Therapy

Increasing psychological flexibility through developing more centered, open, & engaged behavioral responding

Approach

• Experiential

  • learning by doing

• Context-focused

• Teaching a set of principles & associated skills that are flexibly applied

Focused on transdiagnostic evidence-based processes

• Span across a bunch of diff types of psychopathology

• Treating symptoms rather than the diagnosis

• E.g., emotion regulation

• Reduced emphasis on DSM diagnoses

Variable, but usually less than a year

Acceptance-Based Therapeutic techniques

Mindfulness

Metaphors

Values Work

Many, many, more…

Mindfulness

Also called centering or grounding

It is:

• Being non-judgmentally present & aware in current moment

It is not:

• A relaxation exercise

• Taking action to change your current situation

5 senses exercise

• 5 things you can see

• 4 things you can feel

• 3 things you can hear

• 2 things you can smell

• 1 thing you can taste

Metaphors

Clinicians use these to help clients conceptualize the ACT mode

Leaves on a stream

• use a metaphor, think about thoughts as leaves that are passing slowly infront of them

• allows them to slow down & take a lot of notice of the thoughts that are going through their mind

Values Bulls Eye

1. Identifying your values

2. Locating how fully youre living your values

3. Identifying obstacles

4. Values action plan

Acceptance-Based Treatment Mechanisms

Increasing psychological flexibility through developing changes in behavioral responses:

• Centered response

  • Increased contact w/the present moment

  • Recognizing self-as-context

• Open Response

  • Becoming more defused from thoughts/emotions

  • Greater acceptance

• Engaged response

  • Identifying values

  • Engaging in committed action

Dialectical Background

Dialectical Behavior Therapy (DBT) developed to treat:

• High risk forms of psychopathology

• Chronic suicidality

• Borderline Personality Disorder (BPD)

  • Difficulties related to:

    • Emotional dysregulation

      • Mood instability

      • Intense emotional reactivity (sensitivity to emotions)

    • Impulsive + Destructive behavior

      • E.g., substance use, risky sex, binge eating, self-harm, suicidality

    • Stress-induced paranoia + dissociation

    • Fear of abandonment

      • Relationship instability

    • Unstable sense of self

DBT more broadly applied to other types of severe emotion dysregulation

• Specifically designed for BPD though

Dialectical Philosophy

“Dialectic”

• Integrating & resolving two seemingly opposing ideas

  • Trying to find more of a middle ground; gray area instead of black & white thinking

• Ongoing synthesis between alternative & even contradictory positions

  • I accept who I am & I need to change

  • They are flawed & They are valued

Radical acceptance

• Notice & accept whatever discomfort experiencing

  • BPD marked by extreme avoidance

• Fully acknowledging & embracing whatever comes up “all the way”

  • Accepting reality (both past & present) w/out trying to change or control it

• Embracing slow change during high risk

  • Slow process; gonna come w/a lot of hurt & not doing a lot of these avoidance strategies

  • Accept elevated suffering thats gonna occur as move slow toward that change

• “Dancing” w/whatever comes up in session

  • Anger & hostility will come up; can work w/that frustration

Dialectical Focus of Therapy

Very intensive (6 months minimum)

Team approach

• Group of therapists & supervisors working together

Includes 4 components:

1. Group sessions for skills training

   • Core Mindfulness skills

   • Distress Tolerance skills

   • Emotion Regulation skills

   • Interpersonal Effectiveness

2. Individual sessions

   • Addressing life threatening/ therapy interfering behaviors

   • Focus on applying skills training on specific probs

3. Between-session coaching

   • Handling crises & advice on applying skills

4. Therapist consultation

   • Therapists meet as a team to:

     • Ensure treatment is being applied consistently

     • Manage burnout

     • Support therapists experiencing difficulties in their cases

Dialectical Therapeutic Techniques

Core mindfulness

• Present-focused, nonjudgmental awareness to help individuals observe, describe, & participate their experiences

• Ex skill: wise mind

Distress tolerance

• Crisis survival strategies & acceptance skills to manage intense emotions w/out making things worse

  • Radical acceptace

• Ex skill: TIPP

Emotion regulation

• Understanding & adjusting emotions through identifying feelings & reducing intense emotional reactions

• Ex skill: Opposite action

Interpersonal effectiveness

• Skills for assertiveness, maintaining relationships, & self-respect

• Ex skill: GIVE

Core Mindfulness

Wise Mind Skill

The “minds” are our ways of thinking & influences how we make decisions

• Different kinds of minds we have

• Based in logic or facts

  • Reasonable mind

• Based in feelings

  • Emotion mind (rash, impulsive, based on what feeling at that time)

Focusing on 1 over the other prevents effective judgement

• Need to have both of these minds on board

Be mindful when making choices

• Gather facts

  • Activating reasonable mind

• Identify & attend to emotions

  • What are emotions trying to tell them

• Consider values/goals

  • Is decision inline with/goals & values

• Integrate the reasonable mind & emotion mind

  • To try to come to wise mind decision

Distress Tolerance

TIPP or TIP Skill

• Crisis prevention for moments of intense emotions

  • When in crisis get into fight or flight mode

  • Help try to bring ppl out of fight or flight mode

    • Temp regulation; intense exercise; paced breathing; paried muscle relaxation

• Reduces extreme distress by providing concrete coping skills

Emotion Regulation

Opposite Action

• Reducing intense emotional responses by:

  1. Identifying the feeling

  2. Identifying the common behavior associated w/the feeling

     • How normally reacts to experience

  3. Behaving in the opposite way to change the feeling

Interpersonal Effectiveness Skills

Learning how to effectively communicate in relationships
Includes clear & assertive communication

GIVE

• Gentle: Be nice & respectful. Avoid attacks, threats, & manipulation. Express anger & pain directly through words. Stay in the discussion even if it’s painful. Avoid eye rolling.

• Interested: Listen to other points of views. Appear interested in the other person. Maintain eye contact & don’t interrupt.

• Validate: Show you understand the other person’s feelings & thoughts. See the world from the other person’s point of view & say or act on what you see like “I realize this is hard for you.”

• Easy Manner: Use a little humor, smile. Be political. Leave your attitude at the door.

Dialectical Stages of Therapy

1. Build a life worth living

   • Decrease life-threatening behaviors

   • Decrease therapy-interfering behaviors

     • Not showing up, not engaging, etc

   • Decrease quality-of-life-interfering behaviors

   • Increase behavioral skills

2. Decrease misery & increase emotional experiences (good & bad)

   • Emotional exposure & Acceptance techniques

   • Learn how to tolerate all kinds of emotions; happen in safe environment

3. Attain ordinary happiness

   • Skills in life domains like work, relationships

   • Improve relationships so day to day have more meaingful experiences w/others

4. Increase joy

   • Mindfulness

   • Increase positive emotions

Unconditioned Stimulus

Event that automatically produces a response

Unconditioned Response

Behaviors automatically produced from the event

Conditioned Stimulus

Event that becomes paired w/the UCS

Conditioned Response

Behavior produced by the CS

Subjective Units of Distress

Assessment used during exposures to track anxiety

• Effective exposures should provoke high anxiety that decreases during exposure

• Reflects new (inhibatory) learning

  • UCS ≠ CS

ABC Model

The interpretation of an event leads to the subsequent emotional response & behaviors

• Not the event itself

A = activating event (relevant aspects of the situation)

• situations & stimuli associated with/distress

  • ex: date checking phone during dinner

B = beliefs (thoughts & perceptions about “A”)

• thoughts/cognitions that interpret the activating event

  • ex: “I’m being boring”

C = consequences (emotional & behavioral responses to the beliefs)

• is the result of the beliefs not the activating event

  • ex: anxiety, leaving to go to bathroom

All-or-Nothing Thinking

Seeing things in either “black or white” categories

• ex: “If I don’t get an A in the course, I might as well get an F”

• ex: “Either youre w/me or youre against me”

Overgeneralization

Seeing a single negative event as a never-ending pattern

• ex: “No one ever wants to be with me”

• ex: “I can never do anything right”

Mental Filter

Exclusively focusing on a negative aspect(s) of a situation

• ex: “I ruined the whole presentation bc I couldn’t answer 1 audience member’s question”

• ex: “My date went really well, but the awkward hug at the end ruined it.”

Jumping to Conclusions

Making neg interpretations w/out adequate evidence

• ex: “My doctor wants me to have another test, so there must be something seriously wrong with me”

• ex: “My partner is home late, they must have gotten into a car accident”

Mind Reading

Assuming you know what others are thinking w/out adequate evidence

• ex: “She didn’t text me back immediately, so she must be upset with me.”

• ex: “She didn’t laugh at my joke, she must think I suck.”

Catastrophizing

Attributing or anticipating extremely awful consequences to events

• ex: “If I get anxious & stumble over my words, my boss will fire me; then I’ll be unemployed forever”

• ex: “My car is making a weird noise, it will take all of my savings to fix it.”

Emotional Reasoning

Assuming that negative emotions necessarily reflect the situational reality

• ex: “I’m feeling depressed; therefore, I must be seriously flawed.”

• ex: “I feel so panicked I can’t handle the pressure of college.”

Should and Must Statements

Endorsing rigid yet arbitrary rules

• ex: “I must receive praise when I make an effort”

• ex: “I must study 10 hours a day to be successful.”

Steps of Cognitive Restructuring

1. Identify the “Hot Thought”

   • neg automatic thoughts or core belief that are difficult for the client

2. Consider evidence that suports the thought

3. Consider evidence that doesn’t support the thought

4. Explore more helpful adaptive explanations

   • developing akternative thoughts that includes both sides of the evidence

Functional-Contextualism

Philosophy for acceptance-based approaches

• To understand a client’s experiences we must understand:

  • What theyre experiencing:

    • unadaptive behavior

    • unadaptive thoughts

    • difficult emotions

  • The function that psychological processes serves….

    • why does the client experience it?

  • …in the historical context….

    • why did it develop?

  • …& in the current context.

    • why is the client still experiencing it?

Acceptance

Making room for unpleasant thoughts & feelings; allowing them to come & go w/out struggling w/them or giving them too much attention/power

• ex: noticing physical anxiety symptoms occur& pass in the body

• ex: allowing the feelings of anger when interacting with/supervisor

Defusion

Learning to perceive thoughts & feelings as bits of language, words, & pictures, rather than taking them as facts

• ex: labelling a series of worries as a “story” instead of a likely outcome

• ex: looking for Mr. Anxiety when noticing anxious thoughts

Contact with the Present Moment

Bringing full awareness to the here & now; focusing on, & engaging fully in whatever one is doing

• ex: paying attention in a stressful situation & not engaging in distractions

• ex: using mindful breathing when feeling sad about the past

Self-As-Context

Understanding that thoughts & feelings aren’t the essence of who we are; theyre just aspects of us that change constantly

• ex: visualizing anxiety as a small section of yourself & viewing it as an outside observer

• ex: watching panic symptoms in the body as a curious, outside observer

Values

Clarifying whats most important, significant, & meaningful in our lives

• ex: identifying charity as an important aspect in your life

• ex: recognizing freedom as an important aspect of one’s life

Committed Action

Setting goals, guided by values, & taking action to achieve them

• ex: engaging in volunteer work to match your value of charity

• ex: getting involved in local politics to encourage freedom