Cognitive Psychology Chapter 9

Cognitive, Behavioral, and Acceptance-Based Psychotherapies

Overview

  • These therapies grew from learning theory, cognitive psychology, and acceptance approaches rooted in Eastern philosophies.
  • They are often combined in practice and have strong empirical support for their efficacy.

Behavior Therapy

  • Focuses on identifying and changing maladaptive behaviors.
  • Developed out of research on learning.
  • Techniques help clients change problematic behaviors and/or the environmental circumstances that support them.
  • It is not a single method but a collection of techniques:
    • Exposure therapies
    • Behavioral activation
    • Contingency management (reinforcement principles)
    • Relaxation training
    • Biofeedback
    • Assertiveness training
  • Used widely to treat both children and adults.
  • Employ learning principles such as positive reinforcement to increase helpful behaviors and decrease unhelpful ones.
Theoretical Foundations
  • Disorders are reflections of how learning principles have influenced behavior in particular situations.
  • Understanding comes from:
    • Classical conditioning
    • Operant conditioning
    • Observational learning
Classical Conditioning
  • A neutral stimulus (e.g., musical tone) precedes or signals another stimulus (e.g., pin-prick) that automatically triggers a reflexive response (e.g., startle reaction).
  • If paired often enough, the startle reaction occurs in response to the previously neutral musical tone.
  • Learned association develops gradually but can occur quickly (one-trial learning), leading to phobias.
Operant Conditioning
  • Behaviors are strengthened or weakened by rewards or punishments that follow them.
  • Avoidance behaviors are reinforced by the rewarding sense of relief and anxiety reduction that follows them.
  • Socially anxious person avoids parties for relief and anxiety reduction, leading to social avoidance.
  • Adaptive and maladaptive response patterns are associated with some situations but not others.
  • When two situations elicit the same response, stimulus generalization has occurred.
  • The person does not psychologically discriminate between the two situations and responds as if they were the same.
  • A child frightened by a large white dog may later react with fear to all large dogs, or all white dogs, or even to all dogs.
Observational Learning

  • People learn by watching how others behave and what happens to them as a result.

  • Bandura et al.'s (1963) "Bobo doll" studies demonstrated observational learning and vicarious conditioning.

  • Children who watched an adult model being rewarded after behaving aggressively toward an inflatable "Bobo" doll were themselves significantly more aggressive.

  • The link between viewing and acting aggressively is less clear-cut than early studies suggested (Mcleod, 2023), but learning from observing others' reactions still holds.

  • The continuum of behavior, from normal to abnormal, can be explained by the same set of learning processes.

  • Crucial to modify problematic behaviors and learn new and more adaptive alternatives is an evaluation of the environment to determine whether helpful contingencies are in place to motivate and reward adaptive behaviors.

  • The treatment process begins with an assessment of the problem to be solved.

  • Depressed people often find few activities rewarding and exhibit a pattern of withdrawal.

  • A therapist using behavioral activation techniques would encourage these clients to plan new activities that will provide more reinforcement.

Assessment in Behavior Therapy
  • Gather detailed information about a client's problematic behaviors, the environmental circumstances, and the reinforcers that maintain the behaviors.
  • Typically does not employ projective personality tests and only sometimes uses diagnostic labels.
  • Behavior therapists perform a functional analysis, also known as a functional assessment (SORC).
    • Stimulus
    • Organism (person)
    • Response
    • Consequence
  • The "ABC" approach identifies Antecedents (triggers), Behavior, and Consequences.
  • Short-term and long-term consequences are considered separately.
  • Structured interviews and objectively scored, quantitative assessment methods are used.
  • Measures establish the precise nature of a client's problems and provide an empirical baseline level of maladaptive behavior.
  • Diagnostic labeling is generally not the focus of behavioral assessment.
  • Treatment can proceed without exploring early childhood experiences, unconscious processes, or inner conflicts.
  • It is enough to know how a maladaptive behavior disorder is being maintained and how it can be changed.
Role of the Therapist
  • Recognize the importance of a good therapeutic relationship, with empathy and support.
  • See it as the supportive context in which specific techniques can operate to create change, instead of the relationship itself creating change.
  • Therapeutic benefits occur when clients make changes in their environments, internal responses, and overt behaviors.
  • Focus actively and directly on these factors in therapy.
  • Play an educational role, explaining the theory behind what they do so the client can understand.
  • Hope that the client will become a collaborator in a systematic analysis of behavior and its consequences.
Clinical Applications
Exposure Techniques
  • Facing and interacting with frightening stimuli.
  • Help clients discover that the terrible outcomes they fear do not occur and that they can remain in a feared situation even when they are anxious.
  • Designed to provoke anxiety in a way that helps clients gain a greater sense of mastery.
  • Anxiety declines through habituation: clients get used to the situations that once terrified them and are no longer as fearful.
  • The process of habituation occurs in part as peak physiological arousal declines over time and the conditioned stimulus is no longer reliably associated with the conditioned fear response.
  • Process called extinction (Abramowitz et al., 2019)(Abramowitz \ et \ al., \ 2019).
  • The success of exposure techniques is based less on the extent to which anxiety declines and more on the client's willingness to tolerate rather than avoid anxiety, and thus increase self-efficacy.
  • Effectiveness depends on expectancy violation: discovering that the negative outcomes clients expected do not appear.
  • Violation of their negative expectancy allows them to develop new and less threatening expectations (Pittig et al., 2023)(Pittig \ et \ al., \ 2023).
  • The old admonition to "face your fears" has a strong basis in science.
Forms of Exposure
  • Varies depending on the problems being addressed, especially in the case of anxiety disorders.
  • A person with social anxiety disorder may need to return to the party situations that they've been avoiding.
  • A person who fears driving across bridges may have to practice doing so.
  • A person with obsessive-compulsive disorder (OCD) may need to repeatedly leave his house without double-checking that he remembered to lock the door.
Early Approaches: Systematic Desensitization
  • Emphasis in modern exposure therapies on helping clients learn to tolerate anxiety and not avoid anxious feelings because research suggests that they are more effective than earlier versions whose aim was to eliminate anxiety altogether (Craske et al., 2008)(Craske \ et \ al., \ 2008).
  • Systematic desensitization was developed in the 1950s by Joseph Wolpe.
  • Wolpe reasoned that if conditioned anxiety could inhibit eating, perhaps eating might inhibit conditioned anxiety through the principle of reciprocal inhibition.
  • Wolpe taught clients to use progressive relaxation training (PRT) to create a mental and physical state that is incompatible with anxiety.
  • His clients worked with Wolpe to create a graduated list, or hierarchy, of increasingly anxiety-provoking situations.
  • Desensitization began by having the client achieve deep relaxation and then imagine the least threatening situation on the anxiety hierarchy.
  • If anxiety occurred, the imaginal exposure was paused until the client regained relaxation.
  • This pairing of the imagined feared event and relaxation was repeated until the feared situation no longer created distress, at which point the client would imagine the next item in the hierarchy.
Progressive Relaxation Training (PRT)
  • Often also called progressive muscle relaxation, or PMR, PRT involves tensing and then releasing many different muscle groups, one at a time, while focusing on the sensations of relaxation that follow (Hazlett−Stevens&Bernstein, 2022)(Hazlett-Stevens \& Bernstein, \ 2022).
Modern Exposure Treatments
  • In flooding, clients are asked from the outset to do the things that frighten them the most.
  • Most forms of exposure therapy today involve methods that are more like the gradual ones seen in desensitization.
  • The use of in vivo exposure means that the client actually enters the feared situation.
  • Gradual exposure can also be imaginal, meaning that the client either imagines increasingly frightening stimuli, or is exposed to them using virtual reality technology (Miloff et al., 2019)(Miloff \ et \ al., \ 2019).
  • In vivo exposures are the most common and generally preferred options, but imaginal or virtual reality exposures are especially useful when it is difficult or impractical to put clients in certain situations $$(Andersen \ et \ al., \ 2023; \ Rib\'e-Vi\'nes \ et \ al., \ 2024; \ Schr\