BulletPointsummary of Behavioral Interventions in Cognitive Behavior Therapy by Farmer and Chapman - 2nd editon

Bulletpoints Chapter 1

• Cognitive Behavior Therapy (CBT) is a widely used treatment approach for psychological conditions such as depression, anxiety disorders, personality disorders, substance abuse disorders, eating disorders and couple’s distress. CBT is a broad concept, which represents a variety of therapeutic approaches that highlight cognitive, behavioral, emotional, physiological and environmental factors in relation to psychological disorders. 
• In contrast, behavior theory and therapy avoid to ascribe mental concepts a causal role in behavior, instead they place emphasis on the physical environment. Thinking and emotional responding are examples of behavior, according to the behavioral perspective. 
• Behavior theorists and therapists do not search for internal causes of behavior. Although it is acknowledged that genetics might predispose individuals to react in certain ways, they are primarily concerned about what a person does and the context where the behavior occurs. Culture provides the context for referencing which behaviors are (ab)normal. Cultural norms and values can change over time (homosexuality was seen as a mental disorder until the 70s).
• The three-term contingency concept of Skinner represents the basic unit of analysis within some forms of behavioral therapy. It consists of three elements: (1) antecedents of behavior: stimuli and conditions that set the occasion for behavior to occur, (2) behavior: anything a person does (overt and covert), and (3) consequences that follow behavior.
• The following features are assessed an evaluated in the behavioral assessment: (1) antecedents of problematic behavior: internal or environmental cues, verbal rules, (2) consequences of problematic behavior: short-term, long-term, positive or negative reinforcing, (3) the client's learning history as it relates to current problematic behaviors, (4) current behavioral repertoire: emotions (appropriate responses, overly reactive), thoughts ((confused) evaluations of self, world and future), overt behaviors (skill deficits, coping and problem-solving skills) and physiological sensations or responses (associations with catastrophic outcomes), (5) motivation for change: behavior consistent with values and goals.
• In the late 1800s and early 1900s Ivan Pavlov and his colleagues studied reflexive and conditioning processes. Respondent or classical conditioning is that environmental stimuli yield a reflexive, innate (unlearned) response. For example, when a rubber hammer is struck right below the kneecap (unconditioned stimulus, UCS), a reflexive kneejerk response follows (in this case an unconditioned response, UCR). A neutral stimulus object or event will come to acquire certain stimulus properties over time when repeatedly paired or associated with the UCS. This neutral stimulus becomes a conditioned stimulus (CS). The CS will excite a response (conditioned response, CR) under some circumstances that seem quite similar to the UCR produced by the UCS.
• In the 1970s CBT became firmly established. Bandura came up with the social learning theory, later termed as the social cognitive theory. He elevated symbolic cognitive processes to determinants of behavior. Whether or not certain behavior will be demonstrated is influenced by the individual’s belief about his or her ability to perform the behavior. The 'cognitive revolution' was underway and clinicians and researchers sought to incorporate cognitive mediators of learning into their models of abnormal behavior. 
• These new cognitive behavior therapies focus on the context rather than the modification of the physical environment. The new generation of CBT deals with the range of human experience more broadly.

Bulletpoints Chapter 2

• There are five general goals of behavioral assessment: (1) clarification of client’s problem and identification of associated behaviors, (2) evaluation of functional impairments, (3) identification of factors that maintain problematic behavior, (4) collaborative development of a formulation of the client's problems and development of a therapeutic intervention plan, and (5) evaluation of the effectiveness of the treatment.
• There are several features that distinguish behavioral approaches from more traditional approaches: (1) analyzing the whole person in interaction with the environment (context), (2) each individual is recognized as unique, and therefore also the treatments, (3) behavior is situation specific. External influences are important, (4) behavior itself is the focus of therapy and construct or diagnostic labels are avoided, (5) client’s problems are defined in behavioral terms, (6) therapy focuses on the development of effective behavior and competencies.
• Ideally, the therapist and client work together in developing and maintaining a context in which issues can be constructively addressed as they emerge. The therapist has to keep in mind that this relationship itself can facilitate behavior change.
• When persons do not demonstrate adequate behavior in different contexts or do not display flexibility when circumstances are changing, we call it behavioral deficits. There are generally two reasons for behavioral deficits. The first is that past environments failed to model, shape or reinforce the behaviors. Another is that absent behaviors have been learned and are part of someone repertoire, but they appear deficient because they have been negatively reinforced or have been extinguished.
• Coping behaviors are important to assess because they show how a person responds to adversity. Therapists focus on developing, strengthening and maintain alternative and adaptive coping skills such as: (1) problem-solving skills: assisting the client to find effective solutions to problems that arise, (2) social skills: requisite for developing and maintaining social relationships and for obtaining reinforcement from others, (3) mindfulness skills: several skills or abilities that foster a full awareness in the moment. Rumination, worry and dissociation are examples of behavior patterns that are antithetical to mindfulness, (4) self-regulation skills: skills for exercising self-control in areas as emotions, thoughts, impulses, attention and bodily sensations, (5) many clients have had the experience of growing up in an invalidating environment and struggle with issues of self-worth, value as a person and acceptance of themselves and their experiences. Acceptance, self-validation and tolerance skills are often helpful.
• Evaluating the impairments in functioning is important because of several reasons: (1) it indicates the severity of the client’s problem and helps determining a customized therapy; (2) the nature of impairment can be relevant for the emphasis therapy interventions; and (3) psychological disorders are partly defined by the presence of behavioral patterns associated with subjective distress or functional impairment.
• Behavioral interviews are used by the therapist to gather information about the development of a behavioral case formulation. The focus of such interviews is on the designation of the client's problem areas, an identification of specific behavioral patterns related to these areas, an exploration of possible precipitants and maintaining factors associated with these patterns, and an investigation into the possible commonalities across these areas.
• Functional analysis of behavior focuses on the conditions under which behaviors are most prevalent. There are four important components: antecedent stimuli, person variables, behavior and consequences.
• To maintain (problematic) behavior there are two types of reinforcement. Positive reinforcement refers to behavior resulting in the application of something and increases the likelihood of the behavior in future similar situations. Negative reinforcement occurs when behavior results in the removal of an aversive event and increases the likelihood of the behavior in future similar situations. Both types of reinforcement maintain behavioral excesses, or behaviors that occur with such frequency or intensity that they become problematic. An example of negative reinforcement is relieve of anxiety provided by substance abuse.
• Person variables, also called organismic variables, are biological characteristics and effects of past learning. Examples of biological characteristics are genetic predispositions and physical appearance. It is suggested that many psychological conditions such as schizophrenia have genetic influences. It can be useful to know the client’s family history. Learning history is the influence of lifetime environmental learning on behavior. Many forms of problematic behavior endure for years or decades. Knowledge of learning history might reveal the functional development of a person's problem areas, suggest variables that influence these problem behaviors, or imply additional problem areas not readily apparent but consistent with prototypical histories associated with certain forms of psychopathology.

Bulletpoints Chapter 3

• Empirically supported therapies (ESTs) target single disorders such as OCD or panic disorder. Especially the cognitive, behavioral or cognitive behavioral therapies are identified as efficacious. Because of the success of ESTs, the practice of therapy has become more protocol-driven (“if the client has diagnosis x, then use treatment y”). These therapies are successful for clients whose needs are consistent with the therapeutic objectives of the treatment protocol.
• During the early phases of assessment, it may be useful to clarify what aspects of the client's behavior are problematic. Also, the degree of impairment or distress associated with problematic behavior is useful to know for gauging the severity of the problem area.
• During the first phases, it is often useful to consider the relevance of general principles of behavior as well as general scientific and clinical knowledge about the behavior patterns displayed by the client. These general, or nomothetic, principles can guide the case formulation.
• A case formulation consists of the identification of a set of problem areas and the generation of hypotheses about factors associated with their development and maintenance. Behavioral case formulation approaches emphasize operant and classical conditioning principles and social learning principles.
• Persons model of case formulation is based on the following formulation elements: (1) a problem list, (2) precipitants and activating situations, (3) hypothesized origins, (4) the working hypothesis, (5) sharing and exploring the formulation with the client, (6) the treatment plan, (7) establishing a motivation for change and action, (8) potential obstacles to effective therapy, and (9) procedures for evaluating the effectiveness of therapy.
• Situational determinants of behavior are antecedents that set the occasion for problem behavior and the consequences of behavior. The events that follow behavior influence the frequency, intensity and duration of future behavior. Functional analyses can be useful by developing hypotheses about the functions of problematic behavior.
• Hypothesized origins are personal variables such as relevant biological features and learning histories. Biological features include temperament, genetic predisposition and other physiological characteristics that might have some relevance. Aspects of the learning history are modeling experiences, social and cultural values or practices, or a history of reinforcement for engagement in the problematic behaviors.
• The working hypothesis is an integrated and cohesive formulation of each problem area tied together (interrelations among the problem areas). It seeks to explain the function of problematic behavior and to specify the forms of problematic behavior that share similar functions. Assessment of the degree of distress or impairment associated with the problems is important because this may provide implications for appropriate treatment setting and treatment modalities. Treatment settings refer to whether the client would best benefit from: outpatient sessions or inpatient sessions or other forms of institutional care. Treatment modalities are exemplified by individual therapies, group or milieu therapies, biological interventions or a combination.
• The therapist has the following tasks related to communicating the formulation to the client: (1) presenting the formulation in an open and collaborative manner, (2) distinguishing the client from the problem, (3) using effective communication strategies, and (4) dealing effectively with the issues of diagnosis.
• CBT is an active approach that focuses on current behaviors and problem areas. Therapists should focus on the development of effective behaviors instead of eliminate problematic behaviors. By doing this, the therapist provides the client with more behavioral options and greater flexibility for responding.
• There is agreement about the need for priority regarding high-risk behaviors, such as suicidal behaviors. Linehan came up with the dialectical behavior therapy (DBT) in which she outlined a schema for prioritizing behaviors to attend to during therapy sessions. Linehand describes four stages: (1) Potential life-threatening behaviors have the highest priority such as abusive actions, suicidal behavior and non-suicidal self-injury. When the targets of stage 1 have been properly addressed the therapy should focus on the targets of stage 2. (2) Therapy-interfering behaviors (from client or therapist) or posttraumatic stress responses. In this stage the client can work on acceptance, lessening self-blame and stigmatization that is associated with trauma and abuse. Reducing emotional suffering and dealing with grief can also be targets in this stage. (3) Quality of life interfering behaviors, for example substance abuse, unprotected sexual behavior and criminal activities. This stage focuses on the more ordinary problems in life. (4) Behavioral skills to increase. Skill training often takes place within a separate skills training group. Integrating the skills in daily life is an aspect of individual therapy sessions. Many persons experience some sort of emptiness, in this stage they can work on the acceptance of reality and experiencing joy and freedom.
• A clinical functional analysis (principle driven) can identify links between antecedent events and problem behaviors. The client and therapist identify these links and look for alternative responses that might produce more desirable outcomes. This approach provides a cost-benefit analysis of specific problem behaviors in terms of consequences and the extent to which such outcomes are consistent with long-term goals. Good interventions take the client skills and abilities into account, this can help the client succeed in situations that are different from those in which the problem emerges.
• Clients differ in their reactions to therapist’s suggestions for treatment. To increase the client’s hope and optimism about therapy the therapist should provide a credible rationale. The three primary areas the therapist often discusses with the client are the rationale of therapy, appropriate therapy modalities and the rationale for between-session activities such as homework.
• Evaluating the effectiveness of therapy can be done by the A-B or A-B-C assessment framework. The “A” is the baseline phase in which frequency, intensity and duration of behavior is monitored. Intervention takes place in phase “B” and phase “C” represents a period of time after the active phase of therapy. Causal conclusions can not be made but when there is a desirable change between “A” and “B” it may have been influenced by the therapy. The framework only provides a correlational relation. Repeated assessments provide information about the effectiveness of the therapy (in the future).

Bulletpoints Chapter 4

• By changing aspects of the environment, people can change their behavior. Contingency management strategies (CMS) refer to a group of behavioral interventions to alter environmental conditions that are antecedents or consequences of behavior. The CMS are mostly used to modify behavior of children, individuals with developmental disabilities or severe psychological disorders.
• Stimulus control works by altering the antecedents to behavior. The two general classes of antecedents are discriminative stimuli (S^D) and establishing operations (EO). Discriminative stimuli are events that signal the likelihood of punishment or reinforcement based on learning experiences in the past. EOs alter the reinforcing or punishing properties of consequences.
• The assumptions of contingency management are: (1) contingency management is most effective when direct-acting environmental antecedents influence the target behavior instead of (verbal) rules, and (2) CMS can only increase behavior that is already part of the individual’s behavioral repertoire.
• Cue elimination is an approach of removing, eliminating or avoiding cues that occasion target behaviors that need to be altered in therapy. This approach can be used to reduce problematic behavior that is occasioned by specific environmental cues. For example removing all stimuli that are associated with drug use. Burning bridges is cutting of contact with the people associated with drug use.
• There are three essential steps to alter consequences to influence behavior: (1) determine which contingencies are under control of the therapist and client, (2) determine how problematic behaviors can be punished or prevented, and (3) determine how to reinforce desirable behaviors.
• The scheduling of reinforcement influences the degree to which reinforcement increases future behavior. There are many types of reinforcement schedules: (1) continuous schedule: providing reinforcement every time a client performs a particular behavior. It is most useful at learning a client a new behavior. When this schedule is made less frequent, behavior is vulnerable to extinction, and (2) variable ratio schedule: providing reinforcement following a varying number of responses. This schedule is associated with the most resistance to extinction.
• There are two key ways for the use of contingency management strategies: (1) use consequences within the therapeutic relation, and (2) set up (in)formal reinforcement, extinction or punishment systems.
• Shaping processes are often informally carried out and use behavioral rehearsal (role playing). The four components of behavioral rehearsal are: (1) willingness of the client to learn new behavior, (2) identification of situations in which deficit responses cause distress or impairment, (3) participation in role plays, and (4) performing rehearsed behaviors in natural environments.
• Differential reinforcement of other behavior (DRO): when the target behavior does not occur within a specified interval. The client and therapist determine the duration of the interval. The ideal reinforcer is at least as effective as the reinforcers that maintained the target behavior. 
• Differential reinforcement of alternative behavior (DRA): when the client displays an alternative behavior that is functionally similar to the target behavior but different in form. The main goal is to replace problematic target behaviors with more adaptive behaviors that produce similar outcomes. Shaping or other CMPs can be used when the alternative behavior is not currently in the client’s repertoire. Ideally, natural reinforces for the target behavior are accessible through the alternative behavior.
• Habit Reversal Procedures: habits are often maintained by negative reinforcement processes that are connected to anxiety or tension reduction or to automatic reinforcing processes associated with self-stimulation. There are three categories of habit behaviors: nervous habits such as nail biting and skin picking, motor or vocal tics and stuttering. Two features obtain positive treatment effects: (1) awareness training: focuses on the ability to detect and discriminate cases of the habit behavior when it occurs, and (2) competing response training: when the client is aware of the habit behavior this training focuses on immediately stopping the target behavior and perform an alternative behavior.

Bulletpoints Chapter 8

• Approximately 17% of the general population experiences a major depressive disorder (MDD) at some point in life. According to the DSM-5, at least depressed mood or loss of interest and pleasure (anhedonia) should be present for a diagnosis. In therapy the focus is on two processes that underlie these symptoms: avoidance coping and reduced responsiveness to reward incentives.
• The 'active ingredients' of CBT for depression might primarily be related to the behavioral activation component. Jacobson and colleagues found that the cognitive elements did not add to the effectiveness of the therapy, but that the behavioral components were sufficient. So, behavioral activation could be used as an effective stand-alone treatment approach for depression.
• Behavioral activation aims to increase activity, counteract avoidance behavior and increase access to positive reinforcers.
• The first component of behavioral activation therapy focuses on what one does in certain situations because it is difficult to change personality or genetic endowments. It is easier to change one's activities that influence how one thinks and feels. The therapist and client examine positive and negative life events. Self-monitoring is important to identify behavioral patterns that are linked to the depressed mood and can reveal depression loops.
• The second component of behavioral activation therapy focuses on identifying activities associated with variations in mood. More enjoyable alternative activities should be found to replace the activities that are associated with depressed mood. In this problem solving part, the first step is brainstorming around alternative activities, the second evaluating if the activity is likely to be associated with positive moods and if it is possible or desirable. Activities may then be selected and tested.
• The third component focuses on replacing avoidance and escape coping strategies with approach strategies. Avoidance results in immediate desirable effects but also blocks the individual in solving his or her problems in the long-term. Avoidance patterns can be conceptualized by TRAP: Trigger, Response, and Avoidance Pattern. It is important to examine if the behavior is adaptive or maladaptive.
• ACTION is the overall process of identifying and overcoming avoidance coping and refers to Assess behavior and mood, Choose alternative behaviors, Try alternative behaviors, Integrate alternative behaviors, Observe the outcome and Never give up.
• The fourth component focuses on reducing the risk of relapse. Clients are encouraged to apply the behavioral activation principles to other aspects of their lives (skill generalization). When therapy is almost completed, clients consider what they have learned about themselves.

Bulletpoints Chapter 9

• The two key components of exposure-based interventions in CBT are: (1) exposure to stimuli that provoke emotional responses in the absence of negative consequences. Exposing the client to feared stimuli or stimuli that elicit emotional responses, and (2) preventing behavioral responses that are consistent with the emotional response that is provoked by the stimuli. This is often avoidance or escape. The client is asked to engage in action tendencies that are inconsistent with the emotional response. Exposure is repeated until the emotional response no longer occurs. In this way exposure is a method to reduce the likelihood and intensity of emotional responses to specific situations.
• The strongest evidence for the use of exposure is for the treatment of OCD. For panic disorder, social anxiety disorder and GAD, exposure should be a component in a larger CBT package. PE alone has been proved efficient in the treatment of PTSD.
• The emotional processing theory (EPT) states that fear is represented as a memory structure that involves stimuli, responses and cognitive ‘meaning’ elements (labeling a stimulus or situation as dangerous). According to EPT, exposure should involve the presentation of relevant stimulus elements, activation of the memory structure and the incorporation of information that is incongruous with the fear structure. The link between the stimulus and the avoidance or escape response weakens because they are no longer necessary to reduce fear (habituation).
• The first step in exposure therapy is the performance of a behavioral and functional analysis. This starts with specifying problem areas and problematic behaviors, followed by developing a functional understanding of the behaviors. Based on this, therapists decide whether exposure might be an effective component of therapy.
• There are five commonly used types of exposure interventions: (1) imaginal exposure, (2) in vivo exposure, (3) informal exposure, (4) interoceptive exposure, and (5) cue exposure.
• The five steps for performing opposite action are: (1) identify and label the emotional experience, (2) determine if the experience is justified, (3) determine the associated action urge, (4) determine the opposite action, and (5) engage in the opposite action (repeatedly).
• Several advantages of virtual reality are the possibility to create controlled environment for exposure, without having to leave the office, this may otherwise not be possible without extensive and time-consuming in vivo exposure. Virtual reality exposure therapy (VRET) has large effect sizes as compared with nontreatment. For PTSD, findings have been promising. There are however important limitations and more research is needed on this topic.
• The therapist’s next step is to decide if he is going to apply a graduated or flooding exposure. Graduated exposure involves a hierarchy from items that are relatively low in subjective units of distress (SUDS) to items that score the highest in SUDS. Therapy starts with the relatively low items and progressively items that are higher on the hierarchy. Flooding exposure therapies start with the feared item with the highest SUDS score, need longer sessions and have better long-term effects than graduated exposures. It should be considered together with the client which form is used. The therapist should decide if exposure is set up in massed format (3-4 hours per day over 5-6 weeks) or spaced format (30-120 minutes during once-per-week sessions). Massed and spaced exposures have similar effects.