Behavioural Interventions in Cognitive Behaviour therapy: Farmer and Chapman

Behavioural Interventions in Cognitive Behaviour therapy

Chapter 1 Overview    5
Behavioural Interventions in CBT, Underlying assumptions, common features and indicators of effectiveness    5
Behavioural Interventions within CBT: Description and Application    6
Do behavioural interventions within CBT work    8
Putting Behavioural and cognitive therapies into their context    8
Basic Theories of learning    8
Summary    9
Chapter 2 Principles, goals and structure of initial assessment sessions    10
Core Features of behavioural assessments    10
Goals of Behavioural Assessments    10
Conducting initial assessments: clarifying the clients problems and identifying target behaviour    10
Presenting Problem or Complaint    10
Assessment of Response Classes on the basis of correlated or descriptive features    10
Identification of behavioural repertoire and skills deficit    11
Evaluating coping behaviours    11
Evaluating impairments in functioning    11
The Behavioural Interview    13
Functional Analysis: clarifying the context and purpose of behaviour    13
The Antecedents of Behaviour    13
The Consequences of Behaviour    14
Person variables and learning history within a functional analysis    14
Self-Monitoring    14
Direct Observation    14
Summary    14
Chapter 3 Behavioural case formulation    16
Tailoring assessments to the client’s needs, goals, and strengths    16
Narrowing down the clients problem areas    16
Broadly surveying possible problem areas    16
Transitioning from broad survey to focal assessments    17
Developing the case formulation    17
Assumptions associated with behavioural formulations    17
A General framework for the development of a case formulation    17
Summary    19
Chapter 4 Treatment planning    20
Initial steps in developing a collaborative plan for therapy    20
Reaching consensus on the goals for therapy    20
Prioritizing Problem Areas    21
Deciding which interventions to select    21
The role of functional analysis in the selection of interventions    21
Some General Intervention Guidelines    21
Establishing a motivation to change and securing a commitment for action    22
Potential obstacles to effective therapy    22
Summary    22
Chapter 5 Changing behaviours by changing the environment    23
Overview of Contingency Management procedures    23
Key terms and Concepts    23
Key Assumptions of Contingency Management    23
Steps in applying Contingency Management Interventions    23
Changing behaviours by altering antecedents    24
Removing or avoiding antecedents    24
Modifying antecedents    24
Introducing stimulus cues to alter the frequency of behaviour    24
Discrimination training    24
Arranging Establishing Operations to decrease behaviour    24
Altering consequences to influence behaviour    25
Issues in reinforcement contingencies    25
Behavioural interventions for developing, increasing or strengthening behaviour    26
Procedures for decreasing or weakening behaviour    26
Additional approaches for changing behaviour through Contingency Management and self-management strategies    27
Self-management strategies    27
Behavioural contracting    27
Habit reversal procedures    27
Token Systems    27
Summary    27
Chapter 6 Targeting the functional aspects of thoughts and thinking patterns    28
Thinking and thoughts from a behavioural perspective within CBT    28
Reducing worry, rumination, and obsessions    28
Altering functional aspects of thinking through behavioural experiments    29
Types of behavioural experiments within CBT    29
Procedures for conducting behaviour experiments    29
Hypothesized mechanisms of change associated with behavioural experiments    29
Promoting behavioural flexibility by altering functional aspects associated with ones thinking    30
An overview of rule governed behaviour    30
Therapeutic Interventions for altering Rigid Adherence to faulty, inaccurate or harmful rules    30
Establishing rules that bring behaviour in line with desirable distal outcomes    32
Summary    33
Chapter 7 Changing behaviour by building skills    34
Summary    36
Chapter 8 Activating behaviour, the example of depression    36
Central assumptions for behavioural activation    36
Behavioural activation approach to therapy for depression    36
Phase 1 Self-Monitor Activities and Moods and the association between the two    36
Phase 2: Using problem solving and behavioural experimentation to identify activities associated with positive moods    37
Phase 3: Blocking avoidance behaviour and facilitating approach behaviour    37
Phase 4 Decreasing vulnerability to future episodes of depression    38
Summary    38
Chapter 9 Exposure based interventions    39
Defining exposure therapy    39
Exposure to the stimulus    39
Prevention of Emotion consistent responses    40
When do therapists use exposure interventions    40
Unjustified emotional responses    40
Deciding whether to use exposure interventions    40
How do exposure interventions work? Mechanisms of change    40
Counterconditioning    41
Extinction or Habituation    41
Learning new responses    41
Modification of rules that influence avoidance behaviour    41
Emotional Processing    41
Applying exposure interventions    42
Choosing the appropriate type of exposure    42
Orienting the client to exposure    43
Assessing breadth and intensity    43
Deciding between graduated exposure and flooding    43
Deciding how to schedule exposure sessions    43
Guidelines for conducting exposure interventions    43
Give client control over exposure    44
Summary    44
Chapter 10 Acceptance and mindfulness based interventions    44
Defining Acceptance and mindfulness    44
Defining acceptance    45
Defining mindfulness    45
Acceptance and mindfulness versus change    45
When does a therapist use acceptance and mindfulness based interventions    45
Justified versus unjustified responses    45
Changeability versus Unchangeability    45
Effectiveness versus Ineffectiveness    45
Balancing acceptance and change based methods    46
Mechanisms of change in acceptance and mindfulness interventions    46
Mechanisms of change associated with both acceptance and mindfulness interventions    46
Mechanisms of change associated with mindfulness interventions    46
Applying acceptance interventions    46
Acceptance strategies for the client    46
Acceptance strategies for the therapist: conveying acceptance of the client    47
Applying mindfulness based strategies    48
Observing the current experience    48
Summary    48
Chapter 11 Bringing Therapy to a close and aftercare    49
Deciding when to end therapy    49
The process of ending therapy    49
Anticipating problems that may arise around termination    49
Orienting the client to the process of termination    49
Tapering the frequency of therapy sessions    49
Evaluating the clients commitment to building on therapeutic gains    50
Relapse prevention, therapy continuation, and maintenance    50
The continuation phase    50
Summary    51

Chapter 1 Overview

Beck: maladjusted cognitions cause neurosis, change cognition, change emotion and behaviour. Works at the level of NATs and schema.  To remove symptoms changes NAT, to have long term change, change schema. Some cognitivists emphasise a cognitively constructed environment over a physical one.

Behavioural theory doesn’t give cognitions a causal role but rather places the primary emphasis of the physical environment.  Behaviourists see cognitions and emotional responses as a form of behaviour and are subject to the same rules as physical behaviour.  Thus within CBT there is the cognitivists, the behaviourists and the synthesis between the two. With practitioners you are likely to see people with a stronger bent to one camp or the other.

Behavioural Interventions in CBT, Underlying assumptions, common features and indicators of effectiveness

Psychological and psychiatric responses have a defective model of psychopathology, i.e. there is normality and patients are not that!  Medical model sees people having abnormal physical processes causing distress, psychodynamic sees a psychic abnormality as causing the distress. In other words there is a clash between drives, it is unresolved, and repressed causing symptoms, the repression is the abnormality, which if the conflict can be resolved then the symptoms will go.

Cognitivists have an abnormality view of psychopathology, i.e. that there is normal then there is abnormal, and the latter is described in the DSM. In other words clients have a dysfunctional, or abnormal schema or NAT that is producing their distress.

Behaviourists don’t search for causes of distress, but rather is more concerned with what is done and the context in which it is done.  Behaviourists see normality as a socio-cultural construct.  Socio cultural becomes the context for behaviour that defines normality.

 From a behavioural perspective the determinants that produce normal or abnormal behaviour are the same, the difference between the two is a cultural context.

Behavioural Interventions within CBT: Description and Application

A Focus on behaviour and its context

Behaviourists are concerned solely with behaviour be it, covert, i.e. internal or overt i.e. external which happens within a context.

Some behaviourists solely concern themselves with 3 term contingency. This is a behaviour theory that has three aspects the occasion in which the behaviour occurs, the behaviour and its consequences. The occasion is the antecedents, then there’s the behaviour, then there’s the consequences.  This is generally the main framework that behaviourists use to create a hypothesis. ABC analysis!!

Antecedents are anything that stimulates behaviour that set the conditions for the behaviour to occur. So it can be the context for behaviour, and the various impacting causal mechanism that cause\enable behaviour.  How antecedents affect behaviour is a person’s learning history. So a person learns about the consequences of certain behaviour, learns what antecedents are associated with this, then the antecedents start causing the behaviour, within a range of automaticity.

Behaviours are anything a person does, this can be external, i.e. observable by another, or internal, i.e. observable by oneself, e.g. think, feel and physical sensations.

Consequences are the effect this behaviour has which in turn produce the antecedents for more behaviour.

A Focus on Why People Act the way they do

Functionalism is why people behave the way that they do. Behaviourism states that behaviour is a function of an environmental context.  To behaviourists behaviour that is functional is made more likely and non-functional the reverse, so behaviour that reinforces its reoccurrence is functional. Therefore behaviour is to some extent determined, but then you also have to believe then that reinforcement is determined.

Behaviour is passed through generations through culture, via the mechanisms of modelling, imitation, rule following etc., and those behaviours that are most beneficial tend to be kept.

Contextualism is how events and behaviour are organised together in a meaningful way, i.e. an event provides a context for behaviour such that there is a meaningful link that connects the event to the behaviour.

Common features among behavioural assessments and interventions

Behaviourists see the central determinant of distress as the context in which it happens. They see that you can alter the antecedents to alter behaviour. They see that you can also alter consequences which are implied to some extent with a context, i.e. I always reward myself when I score a goal, therefore scoring a goal is the antecedent to the consequence, but there is no necessity. So in some ways the consequence is a contextual issue.  Behaviourists also see skill as a central determinant in client’s distress, as they may not have learnt the skills to behave in a way that they want.  Antecedents it should be remembered can be internal or external.

Behaviourists see Motivation is not seen as an internal event but rather an environmental outcome and thus something that can be modified, for instance with establishing operations.

Behavioural Assessment

1.       Antecedents or problematic behaviour

a.       What are the situations in which the problem behaviour often occurs, are there common antecedents

b.      What are the internal antecedents to problem behaviour

c.       What environmental cues have been associated with problem behaviour

d.      Are there verbal rules that govern behaviour

e.      Are there establishing operations that increase the effect of a stimulus, e.g. going shopping hungry and then buying too much food.

2.       Consequences of problematic behaviour

a.       What are the short and long term consequences

3.       Clients learning history

a.       What factors have shaped the clients behaviour

b.      What did they learn in the past to associate their current behaviour with

4.       Clients behavioural repertoire

a.       Over behaviours

                                                               i.      What are they

                                                             ii.      Is there a skills deficit

                                                            iii.      Are they adaptive, i.e. do they get what they want

                                                           iv.      Are the y adaptable

                                                             v.      Are they avoidant

b.      Thoughts

                                                               i.      Do they confuse belief with fact

                                                             ii.      If they think something do they think it will happen, i.e. thought action fusion

                                                            iii.      Are they confused

                                                           iv.      Are they overly focussed on the past or future

c.       Emotions

                                                               i.      Do they excessively experience one type of emotion

                                                             ii.      Do they experience their emotions in appropriate contexts

                                                            iii.      Are they flat or expressive emotionally

d.      Physiology

                                                               i.      Are there strong links between emotions and physical behaviour, e.g. anxiety and flushing

                                                             ii.      Do they associate physical behaviour with cognitions, my beating heart means I’m going to have a panic attack and go mad

e.      Clients motivation for change

                                                               i.      Can the client articulate their goal in specific terms

                                                             ii.      Is their current behaviour consistent with their goal

                                                            iii.      Is the client aware and believe in the likely outcome of their current behaviour

The outcome of this assessment determines what type of interventions are used.  Even though people may have similar problem behaviour they are likely to have unique reasons why they do it, and how they can change it, and this is shown through a behavioural assessment.  For instance there are two different types of alcoholism, one is episodic, avoidant and anxiety related, and the other is continuous and associated with crime, the former has negative reinforcement the latter has positive.

General characteristics of behavioural intervention

1.       Empirical orientation

2.       Therapists client collaboration

a.       It’s a behavioural experiment!

3.       Active orientation

a.       Clients are actively encouraged to do something about their problems and not just talk

4.       An emphasis on context

a.       Behaviour always happens in context and is understood through that context

5.       Time limited and present focussed

6.       Problem and learning focussed

a.       Clients have problems, together you both learn about them and find solutions through experimentation

Do behavioural interventions within CBT work

In mild to moderate anxiety and depression cognitive and behavioural work equally well, but with major depressive disorders then behavioural is more effective.  Anxiety treatment has many effective behavioural interventions, exposure for instance.

Putting Behavioural and cognitive therapies into their context

Basic Theories of learning

The roots of CBT and behaviourist interventions are from the following concepts.

Firstly classical\respondent conditioning, which is where an environmental stimuli yield an innate response, e.g. knee jerk. The knee jerk is an unlearned unconditioned response to a stimuli. You can then pair a neutral object with a stimulus object to get the same response, this previously paired object becomes a conditioned stimuli, which will produce a conditional response.  Thus a loud bang can make you jump, you can then pair the loud bang with a rat, then every time you see the rat you will expect the bang and then jump.

Whilst a neutral object can be paired, there is also generalisation of the CS whereby similar stimuli can generate the CR. This is known as generalisation. Extinction is the process of repeatedly generating the CS without the UCR and then the CS becomes unpaired with the UCR

Thus to extend the original unconditioned stimulus then you can either use association or generalisation. To move the other way then you can de-associate the conditional stimuli with the unconditioned response then the association would be broken also known as extinction. Association and extinction are both functions of the level of reward associated with the behaviour, more reward more association less reward less association or extinction.

Secondly operant behaviour. This theory is that an operant is a unit of behaviour that operates on the environment producing consequences, so a can open operates on a can to produce an open can.  Operant behaviour is consequence based, Classical is antecedent. Operant behaviour says I am trying to get a certain consequence and behave because of that, classical says I have associated an outcome with a certain stimuli, which is based on an unconditioned stimuli. Operant behaviour explains reinforcement, whereas conditioning explains antecedents.

Behaviourism is therefore founded on the basis of the theories of conditioning which deals with antecedents and operant behaviour which focusses on consequences.

Summary

Behaviourists just focus on behaviour not causes per say. Behaviour happens in a context and is motivated by two aspects the antecedents and the consequences.  Through learning a person associates certain objects with certain actions and certain consequences, so when I come into the study I associate the desk with studying in a certain way. If I get rewards for studying at my desk then the desks association with studying becomes stronger.  Likewise I can also be motivated by consequences and this will be positive or negative reinforcement. Positive gives me something I value and negative takes away something that I don’t value, e.g. pain.

For a behaviourist the environment is the main determinant of action.  The environment is constructed out of antecedents and consequences. The antecedents have varying level of impact. Some stimuli are known as discriminating stimuli, where when I see the object I have associated with a certain reinforcement and I am more likely to perform a certain action. Thus seeing a kettle means I have associated the kettle with making tea, and tea gives me pleasure. There are also things\events that increase the effect that the distinguishing stimuli produces, known as establishing operations. Thus if I have worked hard and associated having a rest with a cup of tea, then this is going to increase my desire to have a cup of tea when seeing the kettle.  If every time I have a cup of tea I get pleasure out of it, then the association between kettle and pleasure gets stronger and this becomes more of an automatic relation, closer to a reflex which is known as stimulus control. Thus alcohol has stimulus control over a heavy drinker.

In some ways behaviourists appear to be determinists. When you work out the power of the association between antecedents and reinforcement you should be able to tell what a person will do. However the picture gets more difficult when you consider that the situation is the product of cognition, which is a functional of attentional bias, which is a function of our emotional state. What this also missed out is the sense of the calling of the world and wonder. The world is active and gives as things to be perceived, there can be a sense of wonder and exploration that is there, where instead of going on your previous learning you look to see what happens. In this case the antecedents don’t determine the behaviour.  Likewise reinforcement works by our valuations, which there seem to be a certain choice over. So again when you look at operant behaviour and indeed classical conditioning both depend on reinforcement to work. Reinforcement is a function of our values, which allows some choice in terms of which values are chosen.

Chapter 2 Principles, goals and structure of initial assessment sessions

Key principle is that behaviour is determined by its antecedents and its expected consequences.  Thus there is the aim to look for common antecedents in problem behaviour.

Core Features of behavioural assessments

Behavioural assessments are person centred as everyone is unique in their context , i.e. idiographic,  this is as opposed to variable centred approaches where assessment looks for key variables to enable classification e.g. with the DSM

Goals of Behavioural Assessments

Any understanding must be situation specific, and without labels or character definitions e.g. I do this because I am lazy

1.       Understand  both problem and target behaviour in terms of antecedents and consequences

2.       Understand  how much the problem impacts on a person’s life

3.       Understand  what maintains the problem

4.       Collaborate with the client to achieve

5.       On-going evaluation of effectiveness of treatment

Conducting initial assessments: clarifying the clients problems and identifying target behaviour

A case formulation is the hypothesis of what causes and what maintains a client’s problems.

Presenting Problem or Complaint

A client often presents vague problems. What you need to do is to get specific, how would you like to behave when the problem is fixed. Likewise you need to do a good ABC analysis to understand the problem.  When multiple problems are presented then a problem list should be produced and the most pressing problem, or the easiest to address are looked at first.

Assessment of Response Classes on the basis of correlated or descriptive features

When you assess then you get a description of all behaviour that a client exhibits around their target problem. You can classify these into response classes. However these response classes whilst useful to classify, don’t help when it comes to the unique person and how to deal with their problems. Response classes are useful for communication between professionals and for studies into disorders which look at efficacy, but they are not useful in terms of treatment.

Diagnostic assessments

Questionnaire, checklists and Rating Scale Assessments

Questionnaires generally compare one person against a group of people, but in behaviourism can be useful in terms of looking at the frequency and intensity of behaviour

Identification of behavioural repertoire and skills deficit

When you assess it is useful to see if the problem behaviours are caused through behavioural deficiency or behavioural excess.

Behavioural excess are maintained by reinforcement be it positive or negative.

Behavioural deficits can be lack of capacity or lack of ability to use the right behaviour at the right time, e.g. flexibility. Appropriate behaviours are not used as there has been appropriate reward in the past, i.e. do right behaviour don’t get rewarded

Evaluating coping behaviours

Coping behaviours are how someone responds to adversity. Many problems arise for clients as coping behaviours may work in the short term but provide long term problems, e.g. drinking

Coping skills

1.       Problem solving skills

a.       Feelings of helplessness can be due to a lack of problem solving skills

2.       Social skills

a.       These are needed to engages with the social environment which brings support, grounding, advice and direction

3.       Self-regulation skills

a.       This is to say relating to any internal response, so acting on anger, eating the doughnut etc., acting on crazy thought etc.

4.       Mindfulness skills

a.       Fostering full awareness in the moment, you need this to see what is going and best adapt yourself to your environment

b.      The opposite of mindfulness Is rumination, worry and dissociation

5.       Self-worth

a.       Many people come to and stay in therapy because of problems with self-worth and therefore need self-valuing skills. So when clients are highly reactive, or highly sensitive and impulsive may need to look at how they get their own sense of self, their own sense of self-worth.

Evaluating impairments in functioning

Evaluating the degree of functional impairment evaluates the severity of the person’s problem.  It also influences the choice of intervention and is also part of the DSM criterion of diagnosis and ensures that a more objective criterion is used as opposed to a mere subjective judgement.

Domains are

1.       Personal functioning

2.       Family and social relations

3.       Occupational functioning

Personal Functioning

Useful to compare with past performance, this can show whether the client has the skill at all.

Has problem?

·         Caused you any difficulties

·         Discomfort

·         Meant you can’t enjoy things you did

·         Stopped you taking care of yourself

·         Made for changes in sleep patterns

·         Made you feel out of control

Family and social relations

Families and social relations can provide support and protection against distress. It can be useful to find out for social problems if the problem is:

1.       Due to avoidance tendencies

2.       Through deficit in skills

3.       Though suppression of social behaviour by the environment, i.e. skills are practiced but then punished

4.       Low rate of reinforcement for social activity

Since the problem

·         Have you noticed any different relations with your family and friends

·         Have you been to anyone that you would go to see to get help with your problems

Occupational and School functioning

First signs of problems emerge in day to day living

Since the problem

·         Has this had any effect on work\school

Legal difficulties or proceedings

Reviewing any legal aspects, whether their problems has caused them any brushes with the law, then this can reveal psychological conditions that might otherwise not be present.

Health and Medical Status

Physical health is often correlated with mental well-being. Likewise some mental health problems can be manifested in physical health, e.g. alopecia, eczema etc. Likewise physical habits, e.g. caffeine use can increase mental health outcomes like anxieties

Current Situation and quality of life

Lifestyle can interfere with therapy, e.g. no money for therapy, no time, chaotic housing etc.

So by quality of life here it means

1.       Financial resources

2.       Housing situation

3.       Work\play balance

Suicide risk and other risk areas

Here evaluation should be around suicide and homicide, past and present, as well as levels of hallucination.

To assess these areas then you need to know frequency and intensity of thoughts\activities and the levels of desire to act on them.  Preparation and having the means to do them also indicates likelihood of doing them.

The Behavioural Interview

A behavioural interview looks to:

1.       Establish problem behaviour and patterns

2.       Establishing antecedents and maintaining factors

3.       Establish strengths and weaknesses, the former which can be used in solving the problem behaviour

To get this data then the therapist asks what, where, when, how and how often questions about behaviour.

Functional Analysis: clarifying the context and purpose of behaviour

Isolating the significant aspects of behaviour that cause a problem enables both a hypothesis to be created as well as interventions.

There are 4 aspects

1.       Antecedents

2.       Person variables

a.       Learning history

b.      Physiological makeup

3.       Behaviour

a.       Internal and external

4.       Consequences

a.       Immediate\delayed

b.      Punishment or reward

The Antecedents of Behaviour

Discriminative Stimuli

This is an event that provides information that punishment or reward will follow from an action, so the existence of people in a classroom can be discriminative stimuli that being disruptive in a classroom will get attention from peers, or a policeman can be a discriminative stimuli, that jumping a red light will mean points on your license.

Establishing Operations

These are motivators whose presence increases the impact of the discriminative stimuli, thus if you have not eaten before going to a supermarket, the displays of food are going to be stronger influencers in you buying food, so not eating is an establishing operation. Rules operate as establishing operations by having them they make the behaviour more likely in certain contexts, e.g., if believing that you must display your feelings, then when you are angry you are more motivated to shout. Rules give reinforcement when carried out there is a feeling that you have done what is right, in some way harking back to the time when the rule was laid down for you and the feeling that were felt at that time.

The Consequences of Behaviour

Behaviour is performed in our belief that a certain consequences will ensue.

Factors that increase or maintain behaviour

Positive and negative reinforcement is how behaviour is maintained.

Factors that decrease or extinguish behaviours

There are two types of punishment positive and negative, positive adds pain, negative reduces pleasure.

Extinction also changes behaviour when reinforcement isn’t give to a behaviour that behaviour becomes more infrequent.

Additional Considerations associated with behaviour consequences

A reinforcer is anything which as a consequence to behaviour increases that behaviour over time. Therefore anything can become a reinforcer, so don’t judge a book by its cover.

Person variables and learning history within a functional analysis

These can be physical, genetic characteristics and a person’s learning history. Genetics and physiognomy seem determining in attitude, and not the space for behaviourism, however they can make environmental variables more significant, i.e. a discriminating stimuli, and making it easier that events come under stimulus control

Self-Monitoring

This can really help establish antecedents for actions and their consequences, likewise the act of self-observation will change the act itself.

Direct Observation

This is observation of the client’s action by another.

Summary

Okay the assessment within a behaviourist approach looks to understand:

1.       Presenting Problem

a.       Frequency, intensity and duration

b.      Impact on functioning

2.       Coping behaviours

a.       This can guide therapy in terms of what’s been tried before, and also what has been discarded which can produce useful information in terms of why an approach was stopped and what the pitfalls for therapy are

A case formulation is an understanding of the causes of a problem and what maintains it.

In behavioural terms then you need to understand

1.       Antecedents

a.       Discriminative stimuli

                                                               i.      Are there any factors present that will provide a sign that reinforcement can be achieved

b.      Establishing operations

                                                               i.      Are there any factors present that modulate the desire

c.       Do any of the antecedents have stimulus  control, if so what is the chain of action that leads up to it, as it could be broken

d.      What are the emotions,  cognitions and physical sensations prior to the action

2.       Consequences

a.       What are the positive\negative reinforcers

b.      What are the short term and long term consequences

3.       Behaviours

a.       What is the internal and external behaviours

4.       Person variables

a.       What is a person’s learning history that makes problematic behaviour likely

b.      Are there any physical\genetic factors to take account of

Ok so how are we going to do this and what’s the use of the above. Well in doing an ABC analysis a client can get a much better understanding of what they do and why. As soon as you start to see commonality of antecedents, i.e. commonality of situation then you can start to see how there is an association between behaviour and antecedents. Through highlighting the positive and negative reinforcers then this can again show how behaviour is rewarded.  It may well take some psychoeducation to show how ABC affects behaviour.  To be able to highlight discriminative stimuli then you need to have a clear understanding of reinforcement and for negative reinforcement you need to have a clear idea of antecedents as you may see negative reinforcement through an unpleasant emotion being reduced. Of course with full blown avoidance behaviour then this isn’t seen as the avoidance will avoid the perceived unpleasant event and emotion but after repetition of this then you lose consciousness of it.

Behavioural analysis then looks to understand a client’s problems in terms of ABC. It seeks to concretise their problems in terms of the effects it has in functioning in various domains, personal, social, occupational and legal. It seeks to understand the problem in terms of either excesses or deficiencies in skills. It also seeks to understand problems as situationally specific and not cross situational. Indeed it is the situation that provides the ABC analysis. The central idea to behavioural work is it is reinforcement that perpetuates behaviour, and antecedents that make it more likely. So if you can modify both antecedents and consequences then you should see behavioural change.  There is also the aspect of learning theory whereby a person learns to behave in a certain way, this might have had sense at one point in their life but now context have changed this learning needs to be changed. So in this instance it is to look at the outcomes of behaviours, the rules that underpin the learning and an analysis of it is functional or not.

Chapter 3 Behavioural case formulation

Case formulation emphasises operant and classical conditioning and the social learning principles that derive from such influences.

Tailoring assessments to the client’s needs, goals, and strengths

Protocol driven approaches say if client has x then use treatment y. This is useful when either the client presents with a single isolated problem, or there are a variety of recommended protocols and none exactly fits.  Behavioural assessment treats each client as unique and assesses on that basis.  This is because each client has a unique learning history and confronts unique situations.  The formulation and treatment plan also looks to build on a client’s strengths to ensure an effective treatment.  Protocol approaches are nomothetic , i.e. using general scientific laws. Behavioural formulation is ideographic, which means specific to the client.

Narrowing down the clients problem areas

Broadly surveying possible problem areas

The process from assessment to formulation to treatment, and the repeating of this process is a funnelling.

Phases of clinical assessment

1.       Broad survey of problem areas

a.       Questionnaires, problems are constructed in broad conceptual terms

2.       Description of the clients problem areas

a.       This uses diagnostic labels, functional response classes

3.       Identification of behaviour patterns to target in therapy

a.       Generate hypotheses concerning behavioural principles which maintain behaviour, i.e. reinforcement and design of interventions

4.       Implementation of an intervention and continuous evaluation of effectiveness

5.       Post treatment assessment of behaviour patterns

Problem areas will fall into one of the following

1.       Thinking problems

2.       Substance abuse

3.       Mood disturbance

4.       Anxiety

5.       Physical complaints

6.       Social functioning

7.       Personality problems

To understand the problem you need frequency, intensity and duration

Transitioning from broad survey to focal assessments

In the second phase of treatment there is an aim to get a definition of the client’s problem area, a diagnosis or some sort of classification.

In the third phase the aim is to identify the target behaviours and design the interventions for change.

Targets for intervention:

1.       Behavioural excess

2.       Behavioural deficit

3.       Difficulties in stimulus control, lack of boundaries

4.       Failures to display appropriate behaviours in relevant contexts, e.g. fails to carry out required tasks, although has the ability

5.       Excessively high or low standards, perfectionism or depression

6.       Problems in self-regulation, i.e. impulsive behaviour

Developing the case formulation

Assumptions associated with behavioural formulations

There are several assumptions in behavioural case formulation

1.       The primary analysis is the whole person interacting with their environment

2.       The reason why behaviour started is not the same as why it is maintained, and it is the maintenance that needs to be addressed.

3.       Problematic behaviour might indicate the lack of skills

4.       You can only change the present so this should be the focus

The context of action is the environment, the fabric within which behaviour occurs and is defined by prior learning, physiological make up and situational determinants.

Much behaviour is internal. A thought, emotion, or physiological change is an internal behaviour, whereas moving your body, speech is an external behaviour.  Thus thought, emotion, cognition are both a context and an action. The antecedent is the context, and the behaviour the action.

A General framework for the development of a case formulation

Behavioural formulation is across structural and functional lines. This means both the context in which the behaviour happens and the topographical features of this behaviour. So describe the situational antecedents and a description of the behaviour in both type and detail.

The validity of the formulation is

1.       Ability to account for areas on the problem list

2.       Ability to predict clinically relevant behaviour

3.       Clients reaction to the formulation

4.       Effectiveness of interventions based on the formulation

Steps in case formulation

1.       A problem list should contain the top ten problems, i.e. behaviour patterns

a.       Can be useful to monitor the non-targeted items on the list. To see their rise and fall

b.      A problem should be a short description, i.e. 2 words and a short behavioural description

c.       To monitor change you need to quantify in some way

d.      Are there common themes running through the problems

2.       Antecedents to problems that are the sufficient conditions

a.       So look to abstract those antecedents that when present will indicate the problem

3.       Hypothesised origins of problem s

4.       Working hypothesis, i.e. origination and maintenance

5.       Share with client

6.       Treatment plan

7.       Establishing a motivation for change and a commitment to action

8.       Isolate potential obstacles to therapy

The problem list

This should contain the unwanted behaviours and no more than 10 items and summarised in a few words. To monitor change some kind of count is useful to support each problem. It can be useful to look at the common themes that run through the list, and to classify, e.g. experiential avoidance.

Situational determinants of behaviour: Precipitants, Activating situations, and behavioural consequences

Precipitants and activating situations refer to antecedent conditions (discriminative stimuli, establishing operations, stimulus control) that set the situation for behaviour. Consequences are the events that follow from behaviour which influence the frequency, intensity and duration of future behaviours. It is shown that verbal rules, rule governed behaviour, is a stronger influence on behaviour that environmental determinants.

Performing a functional analysis, an ABC analysis is then done on the problem behaviour. Whilst the standard antecedent analysis looks at external antecedents, what are the internal antecedents. Behaviour can often be more influenced by cognitive rules, if I do x then y than environmental  contingencies. This is rule governed behaviour, the association is made between action and consequence. These rules have been learnt but may be now incorrect. Outcome expectations refer to the rules that can govern behaviour, if I try I will succeed\fail.  These will motivate or demotivate action.

Verbal rules can be broken down into self-efficacy rules, i.e. what you think you are capable of and also outcome expectations, if I try then I will succeed. Rules also provide for reinforcement, so acting according to a rule, becomes a reinforcer for behaviour.  In some ways rules provide a predicted antecedent in which if a behaviour occurs then a certain consequence will occur, thus in some ways  a rule is an ABC  determinant, a prediction and creator of the future.

Hypothesised origins

These can be a person’s learning history and genetic\physical make up. Learning history is made up of education, modelling, reinforcement, social and cultural practices. A behavioural origin is a learning origin as opposed to psychodynamic which is the experience of an event that made you the way that you are.

Questions that can be useful to gain the origin

1.       When did you first notice the origin

2.       What was happening in your life when it occurred

3.       Do you have ideas about how the problem came about

4.       How have people responded to you when the problem is present

5.       Can you recall a time when the problem helped you in some way

6.       Are there other people you know who have this problem

7.       What has been the lasting effect of this problem

It seems that the behavioural origin of problems, the learning history of the client will result in rules and core beliefs about self, the world, the future and the other.

Working Hypothesis

The aim in a working hypothesis is to have a formulation across the problem list. This is a slightly odd turn for me as the problem list of 10 would mean that you could spend quite a bit of time merely formulating.  What it aims to do is to explain the problematic behaviours that share functional similarities, so it is transdiagnostic.

Summary

A formulation looks to explain origin and maintaining factors of a client’s problem.  A behavioural formulation looks to stick very closely to behaviour both internal and external. An example of an internal antecedent would be a rule, which if I try then I will fail. In this instance this means that there is positive reinforcement with not failing.

The process of assessment is to start broad, get specific, and uniquely define the clients ABC. So you start off with generating a problem list and get one or two words to define the problem behaviour.

As soon as you have the problem list, then what you need to do is to establish:

1.       The origins

2.       The maintaining factors

3.       The intensity, severity of the problem

Whenever you look for origins then you need to look for a person’s learning history. So how come you have learnt to behave like this, were you told to, did you model someone, did you get rewards for doing it. Within the maintaining factors then you need to get clear on reinforcement, positive and negative. With antecedents then you need to ensure you get inner and outer antecedents and what has stimuli control, what the discriminating stimuli are and what the establishing operations are. So if there are people around and I cry and get sympathy then people are the discriminating stimuli. If I’m very tired and I cry then this might be the establishing operation, as I’m more motivated to cry when I’m tired.

Chapter 4 Treatment planning

Treatment planning involves two steps problem solving and decision making. In the former the problem is understood and agreed, in the latter the appropriate course of action is selected and implemented.

Initial steps in developing a collaborative plan for therapy

When deciding what the first problem to address is then it’s either the most significant, or the easiest. Client’s motivation should be taken into account and how much his social world will support him in his change.

Reaching consensus on the goals for therapy

It can be useful to agree up front to do homework when appropriate. To get focus on a vague problem then the following questions may be useful

1.       How will you know when you have solved this problem

2.       How will your life be different if you solve this problem

3.       What will you do differently when you solve this problem

Suggesting areas to address that the client does not acknowledge as problems

For problems not specified by the client, assess the impact on functioning these problems have.  To do this then you need to give a rationale for your choice of this problem

The overarching therapeutic goals of developing psychological flexibility, freedom and effectiveness

The general aim of therapy is to behave more effectively not to eliminate behaviours. Behaviourism aims to add new skills, new behaviours as opposed to removing them.

Behavioural therapists aim to build a behavioural repertoire, so give more options, more possibilities to the client.  So instead of eliminating depression or sadness, it means developing coping skills when you feel like that. Having coping skills tends to decrease the frequency and intensity of the emotional disturbance

Freedom is having options, choices in situation

So this is a big difference with CT approaches that seek to cognitively restructure to reduce emotion. Here new skills are taught such that when a situation arises that could cause a negative feeling then there are capacities the client has to deal with them.

Prioritizing Problem Areas

Priorities for therapy goals from a DBT perspective

1.       Stage 1

a.       Life or safety threatening

b.      Behaviour which interferes with therapy

c.       Quality of life affecting behaviours

2.       Stage 2

a.       Post traumatic stress responses

3.       Stage 3

a.       Behavioural skills to increase functionality

4.       Stage 4

a.       Values work to address any emptiness in life and acceptance of reality

With a person with multiple problems which do you target first?  Well those that are naturally reinforced by the environment would be a good choice, occur lower in the skill hierarchy.

Deciding which interventions to select

The role of functional analysis in the selection of interventions

On working through a chain of analysis and a detailed ABC, then you should see both the activating aspect of the situation and the reinforcement. On the basis of this you can disrupt the chain or look to get the reinforcement elsewhere.

Evaluating the functional similarity of different forms of problem behaviour

Seeing similar patterns of behaviour across different problems, can raise the problem that needed to be addressed, for instance experiential avoidance, how can you be with distressing emotions, or deal with them in a more functional fashion.

A Case formulation driven modular approach to intervention selection

In this instance there are CBT modules for how to deal with specific problems that are tailored to an individual’s needs. So for a given protocol there is a cherry picking process to tailor the treatment to the client.

Some General Intervention Guidelines

Interventions for behaviours that are reinforced by positive reinforcement

Seek environments that reinforce the behaviours you are looking for the client to adopt.

Interventions for clients who are depressed

See chapter 6

Interventions to increase effective behaviour

See chapter 7

Interventions to target unhelpful thinking patterns

Clients with a variety of psychological conditions often display overly rigid rule governance which incorrectly links behaviour to a consequence. This reduces flexibility. Chapter 6 is going to talk more about this. Chapter 9 looks at exposure therapies which are useful for people who use avoidance with anxiety. Acceptance and mindfulness is useful for clients who need to accept\validate their experiences and their environment.

Establishing a motivation to change and securing a commitment for action

If the motivation to be actively involved in therapy is low then the likelihood of positive outcomes is likely to be low. Motivational interviewing can help when motivation is low.

Motivational Interviewing

1.       Challenge client to give reasons to change

2.       Provide feedback about personal risk to client

3.       Teach the client problem solving skills

4.       Help client assess their strengths and weaknesses

5.       Provide advice

6.       Facilitate the clients sense of self advocacy

Motivational Interviewing is not a behavioural strategy per se but helps a client to understand be aware of the consequences of their action

Potential obstacles to effective therapy

Brainstorm with the client any possible obstacles to the therapeutic plan

Summary

Doing a functional analysis means getting:

1.       Antecedents

a.       Internal and external

2.       Person variables

a.       Learning history

3.       Behaviour

4.       Consequences

a.       Short term

b.      Long term

When you write out the problem list for a person, instead of saying I don’t want to be depressed any more what are the behavioural aspects of this you want to change.  When you work with a client then you do a problem list and you can see the types of behaviour that are exhibited. Use this understanding to shape how therapy will go, if someone is excessively avoidant, ask how it will be if things get difficult in therapy will you want to avoid

Chapter 5 Changing behaviours by changing the environment

Contingency management is the term for changing your environment to change behaviour. So the idea is to change the environment prior to antecedents of clinical interest or post consequence. So there’s the situation in which the problem happens, change it! There are two classes of Contingency Management, those that change the antecedents that influence behaviour, and the consequences that motivate it. Contingency Management is often used with children and severely impaired adults. With normal adults then Contingency Management is best used with people with behavioural excesses or behaviour maintained by primary reinforcers.

Overview of Contingency Management procedures

Key terms and Concepts

Behavioural contingency is the relationship between events that occasion a behaviour and the behaviour itself, i.e. the causal relationship between the events that occasion the behaviour and the outcomes of the behaviour.

Stimulus control alters the antecedents to behaviour

Discriminative stimuli are antecedents that signal the positive\negative reinforcement of behaviour

Establishing operations increase the magnitude of positive\negative consequences, i.e. are motivating.

When behaviour is learnt through conditioning it takes more of an automatic response, where behaviour is learnt through operant learning then it’s more voluntary. Discriminative stimuli have voluntary learning and is quickly extinguished.

Reinforcement, punishment and extinction are modulators on operant behaviour.

Stimulus control: a behaviour is under stimulus control when it occurs under a stimuluses’ presence and not under its absence.

Extinction removes the reinforcers for behaviour

Key Assumptions of Contingency Management

Primary assumption is that behaviour is a result of direct acting environmental antecedents and consequences. This is in contrast to rule governed behaviour, a rule an anorexic has of if I’m slim then people will like me is often not played out by the environment, they don’t get these pay offs.  Contingency management procedures are most effective when behaviour is governed by environmental pay offs and not when behaviour is governed primarily by rules.  Contingency management also assumes that the target behaviour is within the client’s repertoire.

Steps in applying Contingency Management Interventions

1.       Identifying  and operationalize target behaviour

2.       Psychoeducating the client to contingency management

3.       Being alert to occurrences of the target behaviour

Specifying and defining target behaviours and relevant contextual factors

To sell contingency management to the client then you need to say that rewards and punishments only work if they increase\decrease behaviours.  So they firstly must be contingent, and secondly must have the desired effect. Likewise people are not always aware of what their current reinforcers are, so these need to be made clear. Again people are influenced by reinforcers but are not motivated by them so a self-harmer may get more attention through harming themselves but are not self-harming in order to get this, i.e. volitionally but are influenced by it. This is useful as otherwise a client may feel shame or be resistant to see what the benefits there are to dysfunctional behaviour.

Changing behaviours by altering antecedents

Removing or avoiding antecedents

Cue removal is a common approach for substance misuse issues. However it doesn’t teach a client how to deal with the cues if they are there, but is a first step in being able to manage this.

Modifying antecedents

If friends insist that you drink when you’re out then talk to them before hand and say you’re trying to control your drinking and don’t want to drink too much. This modifies the antecedents as your friends will not ask you as forcefully to drink.

Introducing stimulus cues to alter the frequency of behaviour

A client can have coping cards or other mnemonic to remind them of alternative behaviour to their problematic behaviour. Likewise you can add cues to behaviour, if you are trying to run more, then lay your running clothes out in the morning.

Discrimination training

Stimulus generalisation makes a discriminative stimuli out of something that does not have a negative outcome, thus they are incorrectly reinforced. Discrimination training gets the client to notice what about the stimulus indicates it’s not a dangerous situation. The stimuli, can be physical events in the world, or emotional events. The aim here is to better describe the stimuli to understand that it will not result in the feared outcome.

Arranging Establishing Operations to decrease behaviour

Thus if you are trying to diet, drink a lot of water to fill yourself up which decreases your desire to eat. Satiation therapy also works in a similar way, where you over indulge in a behaviour you are trying to stop to get sick of it, smoke a packet of cigarettes, for example.

You can also use non-contingent reinforcement to counteract behaviour that is maintained by positive reinforcement. So if a suicidal patient gets attention for suicide attempts, then give them attention at random times and not associate attention with suicide but rather time.

Setting a contract can increase the establishing operations of the desired behaviour.

Altering consequences to influence behaviour

The ways to alter behaviour by consequences is to use reinforcement, extinction and punishment. Generally to get new behaviour then you do this by reinforcement, to extinguish old behaviour then use extinction and punishment. All of these consequences must be contingent on the behaviour in question.  You should also understand modulators of the behaviour

Steps with antecedents

1.       Establish which contingencies are under the clients control

2.       Establish ways to stop reinforcement of undesired behaviours

3.       Establish ways to reinforce new behaviour.

a.       If you continually do this you should be able to get stimulus control

4.       If they are discriminating stimulus and they are incorrect from stimulus generalisation then you can look to see what is it about this that event that makes them not dangerous, i.e. use description

5.       You can modify establishing operations to make the behaviour less likely

Steps with consequences

1.       Look to extinguish the reinforcement for existing behaviour

2.       Choose incompatible behaviour and reinforce that

a.       Immediately reinforce new behaviour

b.      Look to move from continuous to variable reinforcement            

Issues in reinforcement contingencies

·         Reinforcement is idiographic and varies client to client, and context to context!!

·         Reinforcement that happens quickly after the event has more impact than if it doesn’t.

·         Continual reinforcement for behaviour has more of an impact, and makes the behaviour more under stimulus control.

·         Start reinforcement on small items, then when they are automatic move it on to larger items, this is how you’d use shaping and reinforcement.

·         Variable ratio reinforcement is less likely to extinction.

·         So best way is to start with continuous reinforcement to initiate the task and then to move onto variable reinforcement.

·         Reinforcement can be too large and needs to be commensurate with the task.

·         Natural reinforcers are better than arbitrary. A natural reinforcers is in the same theme as the desired consequence of behaviour. So if you’re trying to run, reward yourself with some new running shoes.

·         Repeating reinforcers can satiate the client to this type of reinforcer and therefore need to be changed.

Determine which consequences are under the influence of the therapist

You can use reinforcement, extinction and punishment within the session to alter behaviour, although this would seem to threaten the therapeutic alliance and restrict the types of behaviour that are shown, so a client only does, or talks about things that get praise.

Prevent the reinforcement of dysfunctional or undesirable behaviours

Sometimes empathising with maladaptive behaviour can reinforce it.

Reinforce adaptive behaviours and progress

You can use direct reward e.g. money, or a token system to reward adaptive behaviour

Behavioural interventions for developing, increasing or strengthening behaviour

Shaping

This is most appropriate to learn a new skill. Reinforcement is given for each of the sub tasks achieved. This learns the skill, then you must maintain, so reinforcement is given for the number of times the task is successfully repeated. Behavioural rehearsal, imaginary or role play can also help with each step

Increasing reinforcement for desired behaviours that occur at a low rate

If avoidance happens, get the person back into a situation that used to give them pleasure. Likewise reinforce incompatible behaviours, or merely alternatives to target behaviour.

The matching law is that the level of intensity, frequency and duration of behaviour is matched by the level of reinforcement.

You can also use Premack here, where you have a low rate behaviour and you make it contingent on a high rate behaviour.

To get someone to change behaviour then the new behaviour has to have a greater reinforcer than the old, simple!

 

Procedures for decreasing or weakening behaviour

Extinction and differential reinforcement

First identify the reinforcers, then withhold them from the behaviour, this will extinguish the behaviour. DRO is differential reinforcement of other behaviour, this is reinforcement for not performing the maladaptive behaviour and DRA is the reinforcement for the adaptive alternative behaviour. With extinction when reinforcement is removed then there can be a sudden burst of activity to try to keep the reinforcement. This is known as extinction burst, and if you hold steady and don’t reinforce then the behaviour will diminish.

Covert sensitization and other positive punishment procedures

Aversion therapy, i.e. using positive punishment is rarely used as it fosters resentment and at best angry compliance. However covert sensitisation is used where the client imagines engaging in their dysfunctional behaviour and then imagine an unpleasant outcome.

To do this:

1.       Identify problem behaviour and aversive outcome

2.       Get into state of deep relaxation

3.       Imagine the problem behaviour leading to the aversive outcome

4.       Imagine the problem behaviour stopping and the aversive outcome going

Response Cost

Most punishments that are used in CBT is the removal of pleasure. Examples of this are time outs, fines etc. You currently have, then it’s taken away.

Additional approaches for changing behaviour through Contingency Management and self-management strategies

There are four approaches:

1.       Self-management strategies

2.       Behavioural contracting

3.       Habit reversal procedures

4.       Token Systems

Self-management strategies

Self-management in this context means reinforcing incompatible behaviours, reinforcing alternative antecedents, breaking chains of behaviour etc. Self-management also means taking delayed gratification and adding immediate gratification to it.

Behavioural contracting

Contracting is agreeing a behavioural plan. This can have maximum and minimum targets, relation to reinforcement and punishment. Creating a plan can have an impact on behaviour sometimes it means behaviour isn’t done, sometimes it can be an establishing operation.  With plans though they can be set ups to failure, so again the likelihood of the plan being realistic and put into practice needs to be established.

Habit reversal procedures

Habits are often related to negative reinforcement.

Techniques

1.       Observer the habit, intensity, frequency duration

2.       Do an ABC analysis to find out situations when it does occur

3.       Do an incompatible behaviour as soon as the habit does occur

Token Systems

This is where you can get reinforcement for small acts and then combine them together to get a reinforcement that the client wants. It enables a direct relation between act and reinforcement, although the token is only a substitute and needs to be cashed in reasonably quickly or its value will diminish. There needs to be credibility in the economy of tokens, so they need to always be redeemable.

Summary

Contingency management is about changing the context, the environment of antecedents and consequences. It is most used with children or severely impaired adults but can be used well on people with substance abuse problems. It also works best when behaviour isn’t rule governed and is primarily determined by context.

The ways you can change target behaviour is using reinforcement, discriminative stimuli, establishing operations, extinction and punishment.

So to use contingency management first define the target behaviour and the replacement behaviour if there is one, operationalizing each. You need to know in detail about both such that you can modify behaviour so a good ABC analysis is essential here.

When you are clear on the current antecedents and consequences, then you should be able to see what the significant antecedents are and what the reinforcement is.

With the antecedents, then you can look to:

1.       Avoid them

2.       Associate them with aversive consequences

3.       Change them by using different behaviours which you reward

Chapter 6 Targeting the functional aspects of thoughts and thinking patterns

Thinking and thoughts from a behavioural perspective within CBT

Behaviourism distinguishes between the content of thought, e.g. what is thought and the function of thought, why someone thinks.  For instance worrying might be a form of avoidance. Cognitive therapy looks at the content of thinking, behaviourism looks at the function of thinking. Thinking as a behaviour aims to do something, get something, and has reinforcement for being performed.

Thoughts can be

1.       Discriminative stimulus

a.       I’m beginning to feel overwhelmed I better slow down my breathing

2.       An establishing operation

a.       If I can climb the next hill then I’ll almost be there

3.       Conditioned stimulus

a.       Imagining germs on a handle means a feeling of anxiety

4.       Reinforcing or punishing

a.       You did a really good job today

Reducing worry, rumination, and obsessions

Rumination is standardly an avoidance behaviour as it suppresses anxiety.  The difference between rumination and problem solving is the latter is goal and solution focussed, where with rumination there is a repetition of an event and looking at various standardly negative or vexing aspects but action isn’t taken.  Worrying standardly focuses on the past or a hypothetical future, thus there is a disconnection from the present. The behavioural question is why is the person disconnecting from the present.  Techniques to deal with rumination is exposure therapy and mindfulness.

Altering functional aspects of thinking through behavioural experiments

Thoughts, rules and beliefs are seen as hypothesis to be tested.

Types of behavioural experiments within CBT

1.       Hypothesis testing

a.       Test if x then y

2.       Discovery orientated

a.       Find out from people if they think x then y, or indeed maybe its x then z

Procedures for conducting behaviour experiments

Two types of intervention in vivo and simulated ones in session. The trick with experiments is to get the client to observe what happens, what the antecedents where what the behaviour was and what the outcome is. Doing this they learn by experience.

There are also observational experiments where the therapist performs an activity that would produce high anxiety in the client if they did it. Even watching can make a difference, but what is also useful is to observe the clients thoughts, feelings and bodily sensations.

Any experiment must

1.       Have a clear rationale for the client

2.       Clearly stated what is to be observed, i.e. ABC  and recorded

3.       Operationalize specific elements of the plan

4.       Discuss possible obstacles

5.       Assess the difficulty of the task with the clients abilities

6.       Record pre and post experiment thoughts and feelings and strength of belief\intensity

7.       The client being fully attentive to all aspects of the experiment, before during and after, paying attention to their standard modes of dysfunctional behaviour

8.       Creation of a new rule, generalising from the situation

Dependent of the strength of the belief\feeling to start off with there may need several repetitions of the experiment to make a change in belief.

Hypothesized mechanisms of change associated with behavioural experiments

Behavioural change is considered to be the mechanism for effecting cognitive change.  There is also a decentring aspect of behavioural experiments, where you see thoughts as beliefs not facts, and feelings as transient. Decentring is the act of taking some distance from thoughts and feelings and promotes flexibility.  It also gives a distinction between the observing self and the acting self, which for people with self-esteem issues which are in the observing self can provide some relief.

Promoting behavioural flexibility by altering functional aspects associated with ones thinking

Verbally represented rules are an antecedent to behaviour.

An overview of rule governed behaviour

How rules might influence behaviour

Rules can specify consequences, if I do x then y will happen. Rules are distilled experiences and if correct can make for effective behaviour, if they are wrong, then trouble ensues. Rules are establishing operations giving greater motivation to act in a certain way.  With long range consequences such as if I go to the gym every day I will be strong and happy then it is the rule that primarily governs behaviour and not the long range consequence which only influences it.  If you don’t follow your own rule then you can get anxious.  So sometimes rule following can be escape behaviour to avoid anxiety.

Individual differences in rule following

Rule behaviour is correlated with how often the rule has been reinforced.  Some people are more insistent on following the rule irrespective to how the rule is operating, its consequences, which results in overly inflexible behaviour.

Deficits in rule following can also be a problem. This can be due to overly strong stimulus control of antecedents, poor attentional skills, substance intoxication, emotional intoxication. Lack of concern with consequences.

Generally speaking overly rigid rule following is characteristic of internalising disorders and rule deficiency with externalising disorders.  Anxiety would follow with rigid rule following, behavioural excess with rule deficiency.

Assessment of rules that influence behaviour

First of all you need to observer what rules govern behaviour

Therapeutic Interventions for altering Rigid Adherence to faulty, inaccurate or harmful rules

There are some rules that are rigidly held but which don’t deliver the promised outcome, such as if I please people they will like me, or if I work really hard then I will succeed. Why these rules are held to is that they could have negative reinforcement to deal with anxiety of not being liked or failures, in TA terms they could be child scripts that have been learnt and held to as that’s the way that they learnt to deal with the world, and the script is still active.

There are two ways to deal with this:

1.       Strengthening the influence of immediate reinforcement contingencies on behaviour (see chapter 5)

2.       Weakening the influence of rigidly held rules

You can weaken rules by looking for any logical error in them. Common errors include

1.       Black and white thinking

2.       Personalisation

3.       Overgeneralisation

a.       You can usually spot these by the inclusion of words such as all, every, none every etc.

4.       Disqualifying the positive

5.       Should statements

a.       These contain judging statements about how one should act against often unrealistic standards, should statements are also contain in statements using must, ought and have to.

6.       Catastrophising

a.       This views small events in extremely negative terms

Steps to deal with rigid rules

The best way to deal with thinking errors to is examine the evidence from the client’s life and see if the rule is true. The second way to deal with it is to see what the effect of the rule is, if there is avoidance, passivity or anger, could it be that the rule is wrong rather than the world, or the clients behaviour.

Techniques

1.       Show what the effect of having such a rule is

2.       Block any maladaptive behaviour that results from the rule

3.       Engage in behaviour that is more problem solving in approach to the event that occasioned the rule

4.       Create behavioural experiments to test the rule

Perfectionism goes with black and white thinking. It is a common trait amongst people with depression, anorexia, and OCD.

Techniques for black and white thinking

1.       Does having high standards help you achieve them

2.       Behavioural experiments to test the effect of operating on lower standards. What is the effect of making mistakes, are you humiliated or ridiculed?

3.       Explore other ways of representing reality outside black and white. Are some people good at some things bad at others, how did the guy who split the atom do it, did he make mistakes in the process, is atomic energy good or bad, or both.

4.       Shift the focus of behaviour from the judgement of good and bad, to one of effectiveness

With paranoia then ask if there are any other explanations as to why someone behaved in the way that they did. Alternatively you can focus on the emotion that preceded the interpretation, as the paranoid thinking will be as a result of some emotion, maybe anger.

People who suffer from anxiety or depression tend to have rigid rules. If there is no evidence to fully support the rule, then look to generate a rule that reflects the evidence on hand.

External avoidance is passive avoidance or active escape.

Internal avoidance is rumination, disassociation or distraction.

OCD, self-harm and substance misuse can also be ways of avoiding certain feelings.

Acceptance and commitment therapy is a way to deal with avoidance.

Modelling and observation are also ways in which rigid rules can be loosened. Watch someone you respect and see how they behave and maybe even ask the rules that govern their behaviour. When a model is reinforced for their behaviour then there is a greater likelihood that imitation will happen by the client.

Establishing rules that bring behaviour in line with desirable distal outcomes

Distinguishing goals and values from a behavioural perspective

Distal outcomes are only a partial influence on behaviour, what is a stronger influence is the rule governing that outcome. That has anxiety if not followed, and a potential feel good of following a rule and doing the right thing.  Goals to be functional are ones that accord with ones values. You never attain your values, but rather you judge action according to them.  Goals and values may be out of sync, where you want to get high to feel good, but this doesn’t accord with your values of feeling sustainably good. It could be that your values, say being close to people creates anxiety, and thus you act with goals against your values, as acting with your values creates distress.

Goal setting and time management

Goals should be achievable within a reasonable time frame and have evidence that progress is being made towards them. Goals are easier to achieve when you are working towards something rather than away from something. Goals should have a reinforcement strategy in place for the various steps. Also involving others can increase the likelihood of the goal being achieved.  You must also detail obstacles up front so that when they are hit some coping strategies are in place.

Goal setting must also go with time management as you must have sufficient time and energy to achieve your goals.

To achieve distal goals may mean dealing with some immediate distress. One target then of therapy is to view the means as the end, see going down the gym as part of having a good body. So what is needed then is to act according to values as opposed to immediate outcome which may be aversive.

Values based intervention strategies

In ACT valuing is seen as manifest through action, to value is to act in a certain way.

Motivational interviewing is most related to substance misuse. What it does is to associate immediate action with distal goals, with a view to lessening immediate action and to bring it into line with values. In the first phase of MI then the goal is to get the client to link their current behaviour to the future outcome. In the second phase there is the move to produce the clients commitment to change. Various options are looked at and the most attractive selected. In the last phase a plan to put the selected option into action is made.

Inhibiting problematic behaviours through rule generation and adherence

Some people are stimulus driven and short term reinforcement at long term cost. These people are impulsive, erratic, and pleasure seeking. To move from this short termist approach can be to identify client’s values, get them to explain how they see value, then get them to operate on. One technique in this space is acting as if, i.e. acting consistently with their value. Acting in line with how one would like to be, acting as if, one is the person one wants to be.

In GAD when you do a thought record is the emotional intensity is higher than the belief in the thought it shows that the belief doesn’t fully create the anxiety

Summary

Behaviourism looks at the function of thought, what purpose does it serve? Some thinking is problem solving, some is an intellectual investigation, some is ruminating, some operates on rules.

Thinking can function as:

1.       A discriminative stimuli

a.       I think I’m tired, I should go to bed

2.       An establishing operation

a.       I will fail will make behaviour less likely

3.       An avoidance

a.       GAD

4.       A reinforcer

a.       You did great today

5.       A conditioned stimulus

a.       There are germs on that handle

How do you find out how this operates with a client? So you are thinking about x, how does this affect you, what was happening before? What would you do if you didn’t think this.  Doing an ABC will see if anxiety is reduced,  if some behaviour is reinforced. Likewise you can introduce the notion of reinforcement that behaviour is performed for some reason, there are influences that are beneficial that is why the behaviour is repeated, what do you think they might be.  Thinking about this in this way looks to get the purpose of thought which can be useful.

With rumination this is an avoidance behaviour. Trick here is to get the positives of rumination and then to do behavioural experiments around them. Do they help you prepare for problems, do they solve problems. You must do and ABC to find out what was happening before they started worrying, and what happened afterwards to see what the outcome was. Also doing multiple ABC’s then provides some commonality that can again see what the antecedents are, so someone is bored, or anxious then they ruminate.

Most human behaviour is rule governed. Rules are condensed wisdom that make behaviour more effective and are passed down through generations and they link antecedents with consequences in the most part.  Some people don’t use rules very much and they are erratic, impulsive and pleasure seeking.  Some people follow rules rigidly, so they perform them even if they don’t get the expected consequences. The reason for this may be that not following a rule produces anxiety, which then lessens through carrying it out and the rule is under stimulus control

To work with people who have rigid rules then you can ask where’s the evidence, you can seek to use logic to challenge the rules and if that doesn’t work you can ask if following the rule helps them to get their desires\outcomes.

If people don’t follow rules then what you can do is to find out about their values, what is important to them and try to get them to act as if they are the person that they want to be, the question then is how. You can get them to say what are values, do you hold in them, how do you know that you act in accordance with them, are values only made manifest through action, right well act on them, and forego immediate gratification for the sake of your values. Modelling and observation are also ways of acting according to values so long as you choose a good role model.

The behavioural experiments that are done to challenge the method of thinking are highly efficacious, so if you have a rule, then check for evidence and act on the basis of the new rule.  Thoughts are derivative from action.  When you think excessively you take yourself away from the present.

Chapter 7 Changing behaviour by building skills

Skills training is to address skills deficits. Some clients don’t have the skills and need to be taught them, some clients have the skills but have difficulty in using them at the appropriate time. The aim of skills training is to promote effectiveness and flexibility. Skills training can also involve increasing rule governed behaviour when x then new skill y.

Behavioural constraints

The environment may be constraining action. Behaviour may be suppressed through rule governed behaviour, e.g. what’s the point in trying, so here we can work with that, examine the evidence, see he effect of the rule, try a behavioural experiment. Behaviour may be suppressed through the reaction of another, or by antecedents creating establishing operations, or an antecedent under stimulus control producing behaviour incompatible with the desired skill.

With new behaviours then it is important to operationalize them, break them down into small and specific contextual detail. Often then observation of the situation and of oneself is key to any new skill as its contextual application is as important as the skill itself.

Class of behaviour:

1.       Coping behaviours

2.       Social skills

3.       Emotional regulation behaviours

Skills training can be learnt by social imitation, i.e. modelling peers

Progressive relaxation and diaphragmatic breathing are key to reducing panic.

It’s not enough to psychoeducate skills rather people need to be trained in these skills

People who don’t use skills can be understood in two groups those who don’t know how and those who do but don’t. Kinda difficult in describing someone as having the capacity but not doing something. Often a skill is used contextually and it is the context that needs to be understood. Again saying someone has the capacity to do so something adds nothing more to a sentence than saying they have done it.

Skills are composed of

1.       Skills=behaviour

a.       The subset of skills making up the class

2.       Performance=display of behaviour

a.       The display of those skills

3.       Effectiveness=use of behaviour to achieve goals\values

a.       The use of those skills at the right time to aid toward successful outcome

4.       Flexibility

a.       Adapts use of skills to context

Advantages of skills training in a group:

1.       Focus on problem

2.       Learning interactions with peers

3.       Peer learning

4.       Modelling

5.       Cost effective

Advantages of skills in training by therapist

1.       Ability to adapt skill to client

Self-Instructional training

SIT has 5 steps

1.       Cognitive modelling

a.       Model performs a task client says what is happening

2.       Cognitive participant modelling

a.       Client performs the skill and model talks about what is happening

3.       Overt self-instruction

a.       Client performs skill and talks about what is happening

Disclosure regarding skill use

1.       Former clients discuss how they use their skills

Studies indicate that modelling is best used for overcoming challenges or difficulties, rather than for modelling mastery or expertise

Chaining is breaking down a task into subunits

Shaping is chaining plus reinforcement as every link in the chain is achieved

Homework types

1.       Discrete, do x 3 times

2.       Self-monitoring

3.       Skills practice

4.       Conditional homework, if you are feeling panicky then do diaphragmatic breathing

Summary

To increase your level of skills training to be used with clients then read the DBT book on borderline personality.

Chapter 8 Activating behaviour, the example of depression

Central assumptions for behavioural activation

The main assumption is that the maintenance of depression lies in the environment and in the outcomes of the actions of a person. If a person has low levels of pleasure their happiness levels are low. If a person has low levels of mastery then their feelings are of low confidence, efficacy and self-esteem. When someone has low levels of happiness and self-esteem then they feel depressed, this also then leads them to explaining their behaviour in terms of there is something wrong with me.  Low levels of activity that lead to pleasure or mastery happen because there is not positive reinforcement for these actions or because there is positive reinforcement for incompatible behaviours. Depression can also happen as there can be contextual change that leads to a decreasing levels of pleasure and mastery so stressors including job loss, divorce etc. Being consumed in terms of time and emotion can lead to more pleasant activities being reduced, these other activities can also be seen in very negative light and produce unpleasant feelings.

Behavioural activation approach to therapy for depression

Phase 1 Self-Monitor Activities and Moods and the association between the two

Observation here is the relation between behaviour, context and mood.  This can be done cognitively through finding out what situations promote certain moods, good and bad.  What can also be done is to an activity diary to see what the relation between behaviours and moods are, and if there is anything significant about time of day or context. Observing can do a number of things, firstly it decenters the client and allows them to observe what happens and to see the observing self is not the same as the depressed self. Secondly it slows down activity and so a greater number of choices become available. Thirdly it produces the observer affect, so that when you watch yourself do something it changes how you do it. Fourthly it can challenge clients understanding of themselves, to see that they are not depressed all the time and rather they feel better and worse at certain times of the day, in this manner it loosens the label and encourages a greater description.  This observation should link activity with mood and behaviour.

Phase 2: Using problem solving and behavioural experimentation to identify activities associated with positive moods

On the basis of a relation between contextual activities, mood and behaviour, then comes the way to select new behaviours to replace the old and to see what impact can be made. Thus targeting patterns of depression, maybe the first in the link of a downward spiral would be a good place to start. To find new behaviours, firstly catalogue existing ones, then catalogue previous ones, then brainstorm, then ask what someone you looked up to would do.  Then it’s a case of trying these behaviours and seeing the impact. Of course things aren’t going to change overnight if this is a deep seated depression, so the idea is to observe, change behaviour, observe, change behaviour and see how it has an impact on mood, you should be able to increase feelings of pleasure, and through sustained activity then have an impact on mood.

Phase 3: Blocking avoidance behaviour and facilitating approach behaviour

Avoidance behaviour is when you do one thing to avoid doing something more important. Now this can be something obvious and pressing, for instance you need to do your tax return and you play cards to avoid doing it. Then there is also behaviour where you avoid doing something about your problems, so if you are bored, you watch some TV and still remain bored and unsatisfied.

Countering mood dependent behaviour

People avoid certain situations through their mood, but actually sometimes doing these things can lift the mood, so firstly go to the party and take your anxiety with you, or act as if you aren’t anxious, both of these things will take you to the party.  Clients can learn that it is possible to act independently of your mood, there is your mood and there is your behaviour and that through behaving differently different emotions will appear and the mood can change.

The acronyms are avoidant behaviour are TRAP, TRAC and action.

1.       Trigger

2.       Response

3.       Avoidance Pattern

1.       Trigger

2.       Response

3.       Alternative choice

1.       Assess behaviour and mood

2.       Choose alternative behaviours

3.       Try the alternative behaviour

4.       Integrate alternative behaviour into a routine

5.       Observe the outcome of behaviour

6.       Never give up, repeat, repeat, repeat.

Phase 4 Decreasing vulnerability to future episodes of depression

Relapse is high with people with depression.  Using the principles of behavioural activation in other areas of life can help, so do a diary see the mood and emotion that is created, look for patterns and alternative behaviours.  Likewise learning about the short term gains of avoidant behaviour and the long term costs can help relapse. Relapse prevention can be aided by getting the client to identify clearly triggers in their life that can cause depression.  Once identified they either need to be managed or avoided. For the former then thinking about the things they can do for themselves to prevent an onset of depression. Regular positive routines and habits can also reinforce positive behaviour.

Summary

The theory here is that depression relates to the environment and the outcomes of the client’s actions. As they act then they don’t receive feelings of pleasure and mastery. As this happens so the mood slumps and there is unhappiness and low feelings of self-esteem, on the basis of this distress emotional state, then the idea comes that it’s my fault, then comes the feelings of blame and thoughts that nothing can be achieved. The low levels of pleasurable activity can come from lack of reinforcement for pleasurable activities, so there may be unpleasant feelings involved in them, anxiety and the like. Alternatively they could have learnt inactivity by modelling, or indeed by punishment of these activities before.  In some ways you don’t really need to speculate, where we are is where we are, and there will be the originating factors and then the maintaining factors.

So how to do behavioural activation!!

Client walks in and says he depressed. You say well let’s have a look at this, what I need you to do is to observe yourself over a day and track what you do, what your mood is like and what your emotion is. Doing this will give us a better understanding of your moods, emotions and their relation to behaviour. As there is much thought that says there is a strong relation between the two so let’s see with yourself.  In the act of observing we will also get a deeper understanding of your depression, when is it worse, is it triggered by certain things, does it happen at certain times of the day, are there any patterns any depressive spirals, where one thing leads to another.  The act of observing can also give you some distance from your feelings and give you more options in terms of being able to do something about them.  When the observation is over then you can look to see what patterns there are and if there is any obvious behaviour that creates a depressive outcome. On the basis of that knowledge you can look for alternative behaviours.  These alternative behaviours then can come from the activity diary, or can come from previous behaviours or via brainstorming of possibilities.  The next stage then is to put these behaviours into practice, repeatedly to see the outcome of doing them. If the client doesn’t do them and repeats old patterns then you can work through finding out what was going on for them.  What is also useful when you review the diary is to see if there were things that the client would have preferred to be doing, was putting off, or alternatively there were problems to be solved, i.e. feeling bored that weren’t adequately dealt with. In this instance then you can introduce avoidance behaviour where the client is getting a short term gain in the reduction of the unpleasant feeling, or avoiding a potential feeling but at a long term cost. Here the acronyms to remember are TRAP, TRAC and ACTION.

Trigger

Response

Avoidant Behaviour

Trigger

Response

Alternative Choice

Assess whether behaviour is avoidant

Choose an alternative behaviour

Try the alternative behaviour

Integrate the alternative behaviour in a routine

Observe the outcome of the alternative behaviour

Never give up but repeat the behaviour

 To embed what is learnt then he needs to repeat the behavioural activation as often as possible until it gets second nature, also he needs to repeat the principle of experimentation and problem solving to other areas. Then finally he needs to look at what possible triggers he has to depression and how to manage or avoid these in the future.

Chapter 9 Exposure based interventions

Defining exposure therapy

The key elements are

1.       Expose client to stimuli

2.       Prevent a behavioural response that is consistent with the emotional response, e.g. avoidance behaviour

Exposure to the stimulus

Exposure is going to expose the client to the feared stimuli until that emotional response extinguishes.

Prevention of Emotion consistent responses

The standard response to the feared stimuli, is anxiety and aversion, but the aim here is to feel anxious and to stay still with the feared object, in other words to prevent a behavioural response that is inconsistent with the emotional response produced.  If anxiety then stay, if euphoria then leave. In this way the emotion is faced full on without a coping response, so the anxiety is there, so are you and so is the spider. What happens is in time the emotion will subside. So the inconsistent behaviours also apply well to making a presentation where you might be riven with anxiety but yet still act in a confident way.

When do therapists use exposure interventions

Unjustified emotional responses

This is slightly difficult, if the emotion is unjustified then exposure therapy can be a reasonable choice as what the client is doing is effectively challenging their emotional response. So if a person is scared of spiders then they sit with them for a while, get anxious and don’t run away and then their anxiety drops.  If a person is afraid of being heckled when they speak, and this does happen then their fear is justified. So this is entirely subjective and depends on what the client says.

Unjustified emotional responses are described as maladaptive, this means doesn’t suit a purpose, are intense, inflexible, resistant to change and serve no useful purpose.

The only thing that I would notice is that we can’t stay long with the feeling of fear, if we do we overcome that fear and get acclimatised to whatever we are facing. Thus in war people overcome their fear to face and perform horrendous acts, would this be a good outcome of exposure therapy?

Deciding whether to use exposure interventions

The best way to do this is to ask the client think if these fears are justified, and to work through them with him to get to the clear articulation of what frightens him, if there is reasonable certainty that it is unjustified then exposure is possible.  It seems natural that the therapist will also ascertain if they think their fears are justified, so caution needs to be used here, they could be afraid of their teacher as they have abused them.

How do exposure interventions work? Mechanisms of change

Three key aspects

1.       Expose

2.       Prevent behavioural response consistent with emotional response

3.       Emotion dissipates as there is no negative outcome from exposure.

So the possible answers are:

1.       Counterconditioning

a.       We condition a new response

2.       Extinction

a.       We extinguish stimulus generalisation

3.       Learning new response

a.       We have another response available and stimulus control is weakened

4.       Modification of rules

a.       Rules are challenged through seeing there are no negative outcomes

5.       Emotional Processing Theory

a.       Emotions hold a memory structure together, high buildings+anxiety=danger if you continually experience high buildings without anxiety then the link to danger will be weakened

Counterconditioning

When the standard response to seeing a spider is anxiety then you substitute relaxation. So one way to do exposure therapy is to have a graded set of anxiety provoking events, get a client relaxed and then move up the hierarchy.  In this approach the first thing to do is to learn to relax, once you have done this then the next step is to relax and expose

Extinction or Habituation

Classical conditioning shows how we develop fears, and operant conditioning shows how we maintain fears.  So in classical conditioning we have stimulus generalisation between something that created our fear and something that didn’t that becomes associated with it. The maintenance of it is through operant conditioning, so being in the presence of the feared stimuli produces anxiety through its stimulus generalisation, to reduce this and get negative reinforcement then this stimulus is avoided. Therefore you cannot see that in fact there has been stimulus generalisation and that there is nothing to be afraid of.  What exposure therapy does is to extinguish the avoidance response as you can see that you don’t need to do it to get the reward of diminishing painful feelings, as if you just stay with it then these feelings will reduce. Exposure therapy also attaches the classical conditioning response as being exposed to the feared stimuli without the feared result shows that the stimulus generalisation was false.

Learning new responses

Thus when confronted with spiders we look for a response which is incompatible with our emotional response, which is aversive, so maybe we get interested in spiders about how they behave, their biology etc. Thus we have a new response and the response from the stimuli is weakened.

Modification of rules that influence avoidance behaviour

There is a rule in operation often with people’s feared responses, so a spider will bite me is the rule that is believed, so if you stay in the presence of a spider and they don’t bite you then you are forced to modify your belief.

Emotional Processing

There’s a theory out there that emotion links together experiences to form the depth of belief in the relation between an antecedent and a consequence.  So spider is related to danger by a cognitive structure that relates memories of spiders with memories of fear or anxiety and through reconditioning these experiences so that the relation is broken then spider=avoidance=fear will be broken. This is a bit of a weak explanation but think there are cognitive structures that link antecedents and consequences through a set of memories that are emotionally loaded. If you can create a new set of memories that contradict these memories then it weakens the relationship of these ideas and weakens the structure.

Applying exposure interventions

Stages to doing exposure interventions

1.       Choose the type of exposure appropriate to a client

2.       Orient a client to exposure, i.e. psychoeducate

3.       Teach relaxation or incompatible response

4.       Decide between exposure and flooding

5.       Apply and learn, repeat until SUDs reduce

Choosing the appropriate type of exposure

There are 6 types:

1.       Imaginal

2.       In vivo

3.       Interoceptive

a.       For instance staring into a mirror for depersonalisation fears.

4.       Opposite action

5.       Cue

a.       This can be used within drug exposure therapy where being around gear without using is the behaviour to be changed

6.       Informal

Imaginal Exposure

Useful as precursor to in vivo exposure, to make sure the exposure works. Also useful where situation can’t easily be recreated. Also useful is what is feared is a mental object, e.g. memory of a trauma.

In vivo Exposure

Best to do but if the therapist is there to this is a skew on the actual in life experiment which must be done without the therapist.

Informal Exposure

This means exposing the client to their feared stimuli during sessions, so if a client feels shame when they talk about their sexual practices then you can engage them in behaviour that prevents the shame taking place such as making eye contact.

Interoceptive Exposure

These are useful to people who are afraid of interoceptive experiences, such as overly beating heart, dizziness and the fear that they will go mad on the basis of this. Some clients are emotion phobic and so exposure would be to elicit a certain emotion. Sometimes the emotion and the cognition may be too powerful for the client to bear, in this case then get the client to focus on their bodily sensations only which will reduce the impact of the cognitions.

Opposite action

This allows other emotions, shame, anger etc. to come under exposure therapy and not just fear and anxiety. So if you feel shame talking about your sex life, find out more people to talk to this about.

Cue exposure

Primarily used with substance abuse problems but can be used with eating disorders.

Orienting the client to exposure

Teaching a client about exposure is to connect the repetition of the exposure to stimuli with nothing bad happening, and also the natural extinction of fear and anxiety.

Assessing breadth and intensity

The breadth of response is how many different situations does the client experience it in, and the intensity is how high on the SUDS scale are they. The reason for knowing breadth is that the best exposure will either get out what is common in all these situations or to expose to each of them individually. Intensity must be known so that if flooding is use the most intense feeling is used, or if not then a graduation in suds will be required, i.e. start off at the easiest one first.

Deciding between graduated exposure and flooding

Research suggests that flooding gives no adverse effects and has a better long term effects, it is also quicker than a graduated exposure technique. If flooding is used then a longer recovery time is needed.  You also need to establish if a client can manage to sit with the emotions and not use their coping behaviours.

Deciding how to schedule exposure sessions

There is massed and spaced formats, so massed is for a long period of time, and spaced is over regular intervals.

Guidelines for conducting exposure interventions

1.       Nonreinforced Exposure

2.       Prevent emotion consistent behaviours

3.       Habituate client

4.       Client takes control over exposure

Conduct non-reinforced exposure

So you are exposed and your feared consequence doesn’t materialise.

Prevent emotion-consistent responses

You need to know what the emotional response is standardly and what inconsistent behaviour and consistent behaviour is with this to get this part right.

Monitor Subjective units of distress (SUDS) rating

It is vital to know that the suds level has reduced to know that you can either move up a graduated task or that the flooding task is being successful.

Continue exposure until the clients emotional response has habituated

You shouldn’t consider that you have habituation until SUDS have dropped at least 50%

Give client control over exposure

If the client has knowledge that they can stop the experiment at any time then they are more likely to get engaged with this.

Summary

Exposure therapy premises on the notion that people have unjustified responses to stimuli. This happened because there was stimulus generalisation to start it then negative reinforcement to continue it. Exposure therapy works by breaking the classical conditioning of the stimulus generalisation by showing that the feared outcome doesn’t materialise. Likewise the negative reinforcement is weakened by showing that there are other ways to response to the distressing feeling of anxiety.

So the way to use exposure therapy is:

1.       Decide if response is unjustified

2.       Decide if response is maintained by existing behaviour

3.       Establish breadth and intensity of this

4.       Decide on type of exposure

a.       Imaginal

b.      In vivo

c.       Opposite action

d.      Interoceptive

5.       Then decide on method

a.       Flooding

b.      Graduation

6.       Understand clients emotional and behavioural response

7.       Then decide on a behaviour that is incompatible with their emotion

8.       Explain rationale with client, give them control over the work, then expose

Troubleshooting

1.       Habituation does seem a strong effect but then you can habituate to things that you don’t want to

a.       Investigate their problem behaviour in some depth to find out if it is justified or desired

2.       Client can’t manage any aspects of the task and reverts to their standard behaviour

a.       Make the steps smaller

b.      Increase the skill in the incompatible behaviour, so if relaxation, ensure that they can get deep relaxation before doing this

Chapter 10 Acceptance and mindfulness based interventions

Defining Acceptance and mindfulness

Mindfulness is a subset of acceptance, First you accept that they your experiences are there, and  then what they are. So mindfulness is description of the present moment and acceptance is attention. However on the other side, mindfulness is description of the present which is a precursor to accepting what is there.

Defining acceptance

Acceptance is allowing something to be as it is, or was.

 This means helping the client:

1.       Stop trying to change

2.       Experience the event without protest or reaction

Defining mindfulness

Experiencing what is right here, right now in the present.

Mindfulness is:

1.       Observe the current experience, thoughts, feelings, smells etc.

2.       Describe the current experience, without using labels

3.       Immerse yourself in the current experience

Acceptance and mindfulness versus change

Whilst it may seem that acceptance and mindfulness prevent change actually they are a change in engagement with change and that through not trying to change, or control a situation your relationship with it will change and derivatively your outcome.

When does a therapist use acceptance and mindfulness based interventions

So you have action based interventions on one side, i.e. exposure therapy, behavioural activation and acceptance based interventions on the other. How do you choose which to use? Key factors are@

1.       Justified vs Unjustified response

2.       Changeability vs unchangeability

3.       Effective vs. ineffective

Justified versus unjustified responses

If a client’s response is unjustified then you need to use some kind of restructuring. If the response is justified then acceptance is needed for the situation. If the response is unjustified, then they need to accept the response and modify their reaction.

Changeability versus Unchangeability

For unchangeable problems then acceptance is the way to go, but how do you tell the difference between the two.  ON one hand you can say that the past is an unchangeable event but then it’s how you perceive the past that creates it.

Effectiveness versus Ineffectiveness

If a standard approach to a problem is ineffective then change that approach, so if you are trying to change something and failing then maybe accept it instead.  Acceptance and mindfulness are at the opposite end of escape and avoidance behaviours, and so could well be an antidote for them

Balancing acceptance and change based methods

Some people need acceptance and some people need change, but how do you tell the difference and how do also see the signs in sessions when one approach isn’t working and another one is appropriate.

Mechanisms of change in acceptance and mindfulness interventions

Mechanisms of change associated with both acceptance and mindfulness interventions

Increasing the client’s repertoire of responses to aversive experiences and situations

So if you accept anxiety then you are stopping your avoidance behaviour then if there are no negative outcomes then you have just reduced stimulus generalisation and countered negative reinforcement, so acceptance and mindfulness are to some extent exposure tools.

Mechanisms of change associated with mindfulness interventions

Increasing contact with a broader array of stimulus properties

When you are mindful, then you find more properties of stimulus and events and indeed find out more of your responses to them, so it expands your behavioural repertoire.  Mindfulness can get to see the spider as not just big and hairy but graceful, or your partner not just as irritating but as thoughtful. Mindfulness takes the biggest impact of a situation and puts it to one side so the rest of the situation can be made apparent.

Positive and negative reinforcement

Being able to accept what is happening then leads to a decrease in escape behaviours, and increase in frustration tolerance.

Applying acceptance interventions

Acceptance strategies for the client

1.       Let go of the struggle

2.       Defusing language and cognition

3.       Willingness

4.       Radical acceptance

5.       Acceptance in dyadic interactions

Let go of the struggle

One way to get a client to accept is not avoid or escape. To sell this in you have to ask how their strategies have worked to date, if trying to avoid or change hasn’t worked then try acceptance

Defusing language and cognition

You can look to weaken the power of rationality through a couple of mechanisms.

1.       Repeat a troublesome word until its meaning defuses

a.       Words are arbitrary and have no intrinsic power

2.       Use paradox: Don’t do what I tell you

Willingness and wilfulness

Pain and suffering. Pain is produced by events, people and the like, suffering is when we can’t accept that pain but avoid it. Suffering leads to more pain.

What would it be like if you accepted your pain?

Would you be willing to both have your pain and go about your daily life?

Could you objectify your pain and imagine bringing it with you when you leave the house.

Radical acceptance

Accept all your experience as how it is without trying to change it. So for an unwanted memory then state the unaccepted experience in a neutral voice again and again, allow the memory to enter the mind without trying to modify it, get the client to write down all the things about the experience that they don’t want to accept.

Acceptance in dyadic interactions

Well here are some random relationship skills

1.       Express the softer emotion

a.        from I’m angry that you are playing golf, I’m sad that you are going as I will miss you. One is an accusation

2.       Unified detachment

a.       So treat the relationship as a problem to be solved, and you are the manager

3.       Tolerance building

a.       Practice a behaviour that irritates in a safe place to build up tolerance to it

4.       Self-care

a.       Help clients get their needs met outside of the relationship to take off the pressure within the relationship

Acceptance strategies for the therapist: conveying acceptance of the client

Validation in CBT

Conveys to the client that some experience is correct\real\true etc.

This can be done by

·         Expressing an interest

·         Reflecting

·         Stating the unsaid

·         Validating in view of learning history

o   This can normalise in terms of given what you’ve been through this makes absolute sense

·         Validating in current terms

o   normalising

Applying mindfulness based strategies

Observing the current experience

Whilst an outcome of mindfulness is relaxation it is not the goal, mindfulness seeks to get a greater awareness of the current moment and conceivably has the impact of making yourself an observer in your own life.

·         Observe thoughts

o   Leaves on a stream

·         Observe breath

·         Observe physical sensations

o   Body scan

·         Observe urges

o   Notice desire without doing anything

·         Observe sights and sounds

o   Allow a full range of experiences currently people only focus on one major modality

Summary

Mindfulness and acceptance. Well acceptance is not trying to change something and mindfulness is a greater awareness of the present.

If a client can’t come to terms with something that can’t be changed then acceptance is needed. If a client is tied up with one response then mindfulness can be used as it can increase the range of possibilities in a moment. If avoidance and escape behaviours are used then mindfulness can be used.

So all well and good but how do you do it?

1.       Express the rationale for you choice of it.

a.       Sometimes the desire to change something tries to ignore the pain and this then causes suffering.

b.      Sometimes there are more choice out to you than you realise

c.       Sometimes sitting with the pain you will see that it is not justified\goes away\etc.

d.      Finding out where you are is important before changing direction. So a really good understanding of the present will help you choose what’s next

2.       Explain techniques and perform

a.       Cognitions

                                                               i.      Let thoughts go like leaves

b.      Emotions

                                                               i.      Name them

                                                             ii.      Experience them

                                                            iii.      Allow them

c.       Physical

                                                               i.      Do a body scan

d.      Sensation

                                                               i.      Find out what sensations you notice

                                                             ii.      See if any of your other senses are missing, add them into the mix

e.      Breathing

                                                               i.      Use your breath to meditate to allow the above to go on

I guess these techniques are quite useful for homework.

Chapter 11 Bringing Therapy to a close and aftercare

Therapy is about helping people break free from their unhelpful patterns and behaviours and to act closer to their values

The end of therapy should be a collaborative decision and should include the procedures that will ensure that the gains of therapy are maintained, consolidated and any relapse is dealt with.

Therapy should also be terminated by the therapist if there is no progress or indeed therapy is detrimental to the client.

Deciding when to end therapy

If the client has reached treatment goals or no discernible progress is being made or if condition has worsened.

The process of ending therapy

Anticipating problems that may arise around termination

Some clients might avoid termination by developing new  symptoms.

Are there any rules that the client is using to understand the termination, were these learnt in childhood then reapplied in therapy

Orienting the client to the process of termination

Tapering the frequency of therapy sessions

Tapering can be used as an experiment to find out if there have been gains from therapy and if situations previously difficult can be managed.

Evaluating the outcomes of therapy

Considering what has been learned in therapy

What has been learnt and how can it be applied. Clients can think that the therapist or the therapy made a difference it is also important to show how it was them who did it rather than the therapist. So what has been learnt, what has changed, what do you still want to work on can be a useful list.

Troubleshooting future problems that might arise

Can be useful to play through a scenario which is likely to arise against the new skills that they have learnt.

Evaluating the clients commitment to building on therapeutic gains

Relapse prevention, therapy continuation, and maintenance

Distinguishing lapse from relapse

Lapse is a partial return to the problematic behaviour, a night on the booze for instance, a relapse is the full return of the problematic behaviour, so drinking all day.

Relapse prevention involves a plan to avoid lapse or relapse and a plan to get back on to the straight and narrow should it happen. It’s the interpretation of a lapse that can lead to a relapse. If you view a lapse as because of an internal problem, e.g. character, illness et c you are more likely to go to a relapse than if you attribute it to external factors. Identify high risk situation for lapse and relapse and work out an escape hatch routine. Abstinence violation rules are huge in stopping a lapse go into a relapse, what do you think if you eat one piece of cake, hell I’ve blown it that’s it may as well eat the whole cake. A life is balanced when should=wants. Developing beneficial routines can stave off lapses.

Anticipating high risk situations

To prevent relapses it can be useful to anticipate high risk situations and work out how they could be responded to

Developing new behaviour patterns

New skills to deal with high risk situations can be very useful, so how to refuse a drink for instance.

Establishing sustained patterns of behaviour

A sustainable lifestyle is where the shoulds and the wants are equal, a stressed life is more likely to return to previous problems.  If you develop a lifestyle with more benign routines in them, then this is consistent with a coping framework from distress.

If you can work out what the establishing operations are for any problematic behaviour then if you work out a lifestyle to ensure that you have no establishing operations then futural distress is unlikely.

If you have a routine then if you have a break with it then you can look at the resultant mood, so you can conceivably get to understand your moods better.

The continuation phase

Teaching the client to be his own therapist

So when a problem comes up, ask what do you think would be the best way to approach this, what have you previously learnt from our work that could usefully be applied

Generalisation of skills usage

Ask the client how they can reapply their skills to new areas.

Summary

So behaviourism says client distress is caused by their interaction with the environment. The environment impacts on them in terms of the influences of antecedents and the influence of consequences.  

First of all do a detail functional analysis to get clear on the antecedents, behaviours and consequences.  Look commonalities with the antecedents and look to isolate the consequences.

What you will find in the act of observation then you will decentre the impact of these antecedents and you will start to get more control and choice.  You will also find that you behave differently when you are watched to when you are not.  You will also find out more about yourself so if you say that I am always depressed then you might find that you’re not and it varies with different times of the day

If you can see 10 factors that influence behaviours then break them down into

1.       Stimulus control

2.       Establishing operations

3.       Discriminative stimuli

Then target either the ones that have most impact or the ones that you are confident you can do something about.  If you have something under stimulus control, look for the chain of action that ends up with it and look to break it earlier. For Establishing operations look to alter these to an incompatible response. For the discriminative stimuli, look again to satisfy your needs to reduce their impact.

When you want to replace the old behaviour with a new one, which is simpler than merely stopping, use your list of reinforcement from above and look to apply this to the new behaviour. It’s easier to get in if you shape it, such that each sub task is achievable.

If one of the antecedents is a rule, then , then you can do behavioural experiments to test the validity of that rule. You can also ask what is the effect of the rule and does holding that rule make the desired outcome more likely. Change the way of thinking from rule governed to outcome governed.

Finding out the relation of behaviour to emotion can be very useful in the case of working with people with depression as low activity levels are very common in such cases. Keeping an activity diary can show the relation of certain activities with certain outcomes, it can also relate mood with emotion, so that my mood is low when I have low levels of pleasure. It can also show depression spirals, where the consequence of one action becomes the antecedent to another and it is on a downwards spiral.

When there is clarity about the link between mood and emotion and the link between activity and emotion, then you can start looking to use alternatives to improve the picture. It will only be through repetition of this activity that you will start to see effects.

Exposure based interventions can reduce anxiety. It is common that anxiety and phobia problems are started through stimulus generalisation and maintained through negative reinforcement.

This being the case then a graded exposure can challenge the stimulus generalisation and also reduce the negative reinforcement, as it shows that you can get this reinforcement quite naturally and that avoidance will maintain the fear through not challenging the base problem.

What you need to do with exposure tasks is

1.       Establish the feared event in terms of breadth and intensity

2.       Structure either a graded exposure task or flooding task that takes all the gleaned information into account

3.       Establish what behaviour is incompatible with the emotional response and teach or practice that

4.       Work with the client either

a.       Imaginally

b.      In vivo

c.       Interoceptively

d.      Informally

e.      Cues

5.       Work until the suds level decreases by 50%

If a client has a reasonable response to a reasonable event and is still suffering with it, or their desire for change and control over their situation is causing problems, then a mindful or acceptance approach can be appropriate. Here there is a two pronged attack, be mindful so describe without prejudice the current perception as it is experienced. Then accept what is without trying to change it or modify it.  Whilst it is paradoxical change can be effected through trying not to change as this is a different way of interacting with the environment, it is also a very strong cure for avoidant behaviour.