Chapter 1: Abstract

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, behavioural and environmental factors in relation to psychological disorders. The term CBT contains points of vies that can be contradictory or even incompatible.

There are at least 10 different schools. The cognitive perspectives differ in the degree to which they view the environment as a determinant of action, thinking and emotion.

The influential cognitive approach assumes that mood and behaviour are influenced by distorted and that dysfunctional thinking and inaccurate and biased forms of thinking are common to all psychological disorders. For each disorder there is a unique set of thought distortions and underlying beliefs (schemas). Therapeutic activities should promote realistic, accurate and balanced thinking. The modification of thinking will produce changes in mood and behaviour and establish lasting therapeutic change. Schemas are cognitive structures that can predispose persons to emotional and behavioural disorders and influence evaluation and interpretation of experiences.

Behavioral views on abnormality

Individuals who have psychological disorders or who display problematic behaviors are often considered as deviant or abnormal because of the dominant role of ‘deviant’ or ‘defect’ models of abnormality. Psychological disorders are often regarded as having maladaptive schemas and underlying diseases or biological processes are presumed to underlie psychological syndromes. The internal defect that the person has must be changed, removed or altered in some way to no longer be disordered.

Behavior theorists and therapists do not search for internal causes of behaviour. 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).

From a behavioral perspective normal and abnormal behaviour are shaped by the same determinants. They assume that there is nothing inherently defective or deviant about people who report emotional or behavioral problems.

Description and application

Some people have negative thoughts about terms as behavioral therapy. These reactions are the result of misunderstanding, such as the belief that behavioral therapy is an attempt to control someone’s actions.

Psychological disorders from a behavioral perspective are defined by behaviour, occurring both within the individual (covert behavior such as thoughts) and as actions that can be observed by others (overt behavior). The environment establishes the context of such behavior.

The three-term contingency concept of Skinner represents the basic unit of analysis within some forms of behavioral therapy. It consists of 3 elements:

1. Antecedents of behavior: stimuli and conditions

2. Behavior

3. Consequences that follow behavior

This framework is often used to develop hypotheses about behavior.

Engaging in certain behavior depends on the learning history of behavior under similar conditions and reinforcement. When behavior was successful in the past, it is more likely to occur in similar current and future environments. Functionalism is a term based on the evolution theory of Darwin. The physical structure of a species is determined by its associated function. Natural selection is selecting the most adaptive physical structures with functional properties that are associated with the enhancement of gene fitness. People are more likely to select functional behavior that produces reinforcing consequences.

Behavior varies and some units of behavior are selected because they are more successful than other units. Environmental determinism is the process of selection of variations in an individual’s behavior during his or her lifetime. Cultural norms are also selected. Norms that proved to be most beneficial or enhance fitness tend to be retained over time.

Contextual approaches in behavioral theories focus on how events and behaviour are organize and linked together in meaningful ways. Contextualism is about the context within behavior takes place, also called the contextual flow in which behavior occurs.

Therapies differ in underlying theories and presumed mechanisms of behavior change. Cognitive therapies, for example, focus on automatic thoughts, underlying assumptions and schemas. Every therapy targets on the most central determinant or cause of problematic behavior (understood by associated theory). Consequently the types of interventions vary between the different therapies.

Features among behavioral assessments

In the assessment of clients, behavior therapies focus on the behavioral repertoire to see if it is necessary to learn new alternatives and the context within which the problematic behavior occurs. They are looking for internal and external factors that maintain problematic behavior. The motivation to change is also important. Motivation is seen as a condition resulting from environmental events and is changeable by manipulations of the environment.

The following features are assessed an evaluated in the behavioral assessment:

• Antecedents of problematic behavior: internal or environmental cues, verbal rules.

• Consequences of problematic behavior: short-term, long-term, positive or negative reinforcing.

• Current behavioral repertoire: emotions, thoughts, overt or motor behaviors and physiological sensations.

• Emotions: appropriate responses, overly reactive.

• Thoughts: (confused) evaluations of self, world and future.

• Overt behavior: skill deficits, coping and problem-solving skills.

• Physiological sensations or responses: associations with catastrophic outcomes.

• Motivation for change: behavior consistent with values and goals.

Even though some people have similar problems, the factors that influence behavior vary across individuals.

General characteristics of behavioral interventions:

• Empirical orientation.

• Client and therapist work together to formulate problems and a plan for therapy.

• Active orientation: client is actively encouraged to work on his problem areas.

• Flexible approach with continuous evaluations and testing of the hypotheses.

• Emphasis on environment-behavior relations: describing the actions of clients, their thoughts, emotions and physical sensations within the context in which they occur.

• Focus on current situation rather than the past.

• Solutions to problematic behaviors are sought.

• Emphasis on change and acceptance.

Do behavioral interventions work?

The components of CBT that are associated with positive treatment effects vary in relation to which disorder is targeted in therapy. However, cognitive and behavioral elements within CBT are equally effective in the case of depression and anxiety disorders. Cognitive interventions do not necessarily add to the effectiveness of behavioral interventions. Behavioral interventions are most strongly associated with overall treatment effects for anxiety disorders and depression. Especially exposure techniques are associated with the most consistent reduction in anxiety (PTSD, many types of phobia).

History of behavior therapy and behavioral interventions in CBT

In the late 1800s and early 1900s Ivan Pavlov and his colleagues studied reflexive and conditioning processes. Classical conditioning is that environmental stimuli yield a reflexive, innate (unlearned) response. A neutral stimulus object or event will come to acquire certain stimulus properties over time when repeatedly paired or associated with the unconditional stimulus (UCS). This neutral stimulus becomes a conditional stimulus (CS). The CS will excite a response (conditional response, CR) under some circumstances that seem quite similar to the UCR produced by the UCS.

Generalization is the process of CRs who often occur in the presence of stimuli that are similar to the CS. When the CS is presented several times without the UCS the conditioned response disappears (Extinction).

Classical conditioning is most obvious in conditioned emotional responses (trauma related stimulus cues). The traumatic event is the UCS and it elicits different reflexive or unlearned responses (UCR) such as fear. Individuals with PTSD have strong emotional responses (CR) to events or objects (CS) that are similar to those that were present at the time of the traumatic event.

Thorndike’s theory, the law of effect, implies that the consequences of behavior influence the learning process and associated behaviors. Skinner refined this theory and came up with the operant theory of behavior. Operant means that behavior is selected and shaped over time by the consequences that such behavior produces. Effects of behavior directly influence future behavior. Human behavior is the result of phylogenetic processes (Darwin) and cultural selection processes.

The beginning of behavior therapy took place in the late 1950s. Wolpe published the first treatment procedure based on reciprocal inhibition. According to Wolpe anxiety and neurotic states could be reduced or eliminated by pairing the experience of anxiety with an inconsistent feeling such as relaxation.

Eysenck introduced the term behavior therapy and published a book with different treatment methods (for example desensitization and aversion therapy), based on the Pavlovian learning theory. Behavior modification is the change of behavior though learning principles.

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 (social efficacy).

Cognitive therapy focuses on identifying the client’s idiosyncratic way of thinking and changing thought processes through rational examination. Automatic thoughts, processing biases, core beliefs and schemas are used to explain variations in emotion and behavior and central treatment targets.

A new generation of CBT represents a theoretical evolution with many new approaches such as acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT). The symbolic function of language is seen as an important factor. Feelings are closely tied to language, so language can provide emotional experiences without actual physical events or objects. Frequently pairing an emotional experience such as anxiety with a negative evaluation of that experience makes the two functionally equivalent.

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.

Chapter 2: Initial assessment sessions

The behavioral assessment approach focuses on the person, the clinically relevant behaviors and the environmental factors that influence and maintain those behaviors. This approach is based on theoretical principles. One of the goals is the identification of potentially changeable contextual factors associated with maintenance of problematic behavior. Therapists focus on the uniqueness of the individual and his or her context. In contrast to other approaches, behavioral assessments are idiographic (person centered).

The medical model approach evaluates the presence of behavioral and physiological signs of diseases. This approach is most used for psychiatric diagnoses. According to the DSM-4-TR disorder signs (markers) are defined by emotional experiences, certain behavior and idiosyncratic ways of thinking. A positive diagnosis is made when a person displays enough markers. Treatment focuses on the symptoms that define the diagnostic concept instead of the interaction between the individual and his environment.

There are 5 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. Development of a therapeutic intervention plan.

5. Evaluation of the effectiveness of the treatment.

Features that distinguish behavioral approaches from more traditional approaches:

• Analyzing the whole person in interaction with the environment (context).

• Each individual is unique, and therefore the treatments.

• Behavior is situation specific. External influences are important.

• Behavior itself is focus of therapy and construct labels are avoided.

• Client’s problems are defined in behavioral terms.

• Therapy focuses on the development of effective behavior and competencies.

The chances of dropping out of therapy are high in the first few sessions. It is important that the therapist provides realistic expectations about the therapy. Therapy is enhanced when the therapist shows genuineness, respect, warmth, acceptance, validation and empathy. Other important behaviors for therapists are appropriate demeanor (sympathetic and interested), facial expressions, eye contact, body posture that conveys interest and easily understood communication, which is free of technical language.

CBT is an action-oriented therapy, so the client should be active and share responsibility in carrying out the therapy.

The therapist’s theoretical orientation influences initial sessions and hypotheses about the causes and maintaining factors of the client’s problems, also called a case formulation. CBT is an active and directive approach. After a (non-directional) period of free speech the therapist needs to make several inquiries to clarify and assess the problem area. More serious and severe behaviors are addresses first.

Topographical classifications pay attention to the types of behavior that are frequently displayed. Note that these findings do not provide a (causal) explanation for the behavior or the influential factors that maintain the behavior.

Diagnostic assessments can be used to identify groups of persons who were similar on some dimension on the basis of symptom presentation. Numerous diagnostic interviews have been developed that assess single disorders, a group of related disorders or several distinct classes of psychiatric disorders. Just like the diagnostic categories, psychological constructs are often defined in terms of groupings of behaviors.

Questionnaire assessments are focused on the clients score referenced to those from a larger normative sample. Cut scores are used to indicate an extreme score. Someone familiar with the client, for example a parent of the child, often completes checklists and rating scales. They indicate the severity of behavioral problems and suggest specific behavioral targets.

Problematic behaviors can be categorized within two broad categories: behavioral excesses and behavioral deficits. When a person displays certain behaviors that are excessive in terms of frequency, intensity or duration we speak of behavioral excesses. The behaviors are associated with distress and impaired functioning. Excessive behaviors are maintained by positive and negative reinforcements, especially among persons who display strong avoidance and escape behavior.

When persons do not demonstrate adequate behavior in different contexts or do not display flexibility when circumstances are changing, we call it behavioral deficits.

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. Another possibility is that past environments did not shape or reinforce such behaviors.

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 problem-solving skills, social skills, mindfulness skills and self-regulation.

Evaluating the impairments in functioning is important because it indicates the severity of the client’s problem, the nature of impairment can be relevant for the emphasis therapy interventions and psychological disorders are partly defined by the presence of behavioral patterns associated with subjective distress or functional impairment.

Depending on the different areas of impairment, therapy might also be offered in multiple modalities. Because of risk and safety issues therapy might be prioritized to the potential of harm.

It is useful to compare a person’s current functioning with how well he or she had functioned in the past. This personal functioning evaluation suggests a level of impairment and it could clarify which skills are already present. Social relations can protect individuals against the development of psychological disorders and enhance health. The first signs of impairment can be seen in response to demands for day-to-day living in places such as school or work.

It can be useful to review a person’s legal history because it can reveal the presence of psychological conditions that were not visible at first sight. When someone has a history of substance abuse, bipolar disorder and antisocial behaviors it is more likely that there will be legal difficulties.

Physical health is associated with overall well-being. Some medical conditions can produce signs and symptoms that are similar to psychological disorders and conversely some psychological disorders increase the risk for health-related problems. Overall well-being can be influenced by quality of life factors and form a threat to ongoing therapy.

Indicators of risk such as thinking anomalies (hallucinations or delusions), suicidal or homicidal intentions, substance abuse and self-harm tendencies should be assessed. Reports of risk factors have priority over the regular treatment, because it is important to ensure the safety of clients and their environment. Exploring protective factors such as reasons for living is also important.

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. There are two types of antecedents that set the occasion for behavior: discriminative stimuli and establishing operations. Discriminative stimuli (S^D) provide information about the impact that reward and punishment will have on behavior. The S^D is associated with punishment or reinforcement because of the experiences in the past with this S^D. Disruptive behavior of children in school is more likely to occur when classmates reinforce this behavior, in this case the presence of classmates is the S^D.

Establishing operations (EO), also called motivational operations, set the occasion for certain behavior. Environmental events influence behavior by changing the reinforcing or punishing characteristics of the environmental events. Internal events such as thoughts and emotional states are common EOs. For people who often binge eat, negative thoughts about the self can be EOs for binge eating behavior.

EOs are rules which specify consequences or outcomes associated with behaving in certain ways. Behavior that is influenced by verbal rules is called rule-governed behavior. For example a person who is afraid of speaking in public can have a verbal rule such as: “If I speak in front of a public, I will be evaluated negatively” and because of this rule this person will avoid public speaking.

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. An example of negative reinforcement is relieve of anxiety provided by substance abuse. Both types of reinforcement maintain behavioral excesses.

To decrease the likelihood of behavior in future similar situations there are two types of punishment. When behavior results in the application of an aversive event and decreases the likelihood of the behavior in similar situations it is called positive punishment. Negative punishment occurs when behavior results in the removal of a reinforcing event that decreases the likelihood of the behavior in the future. A punishment is an operation that decreases behavior over time. Extinction is another type of process that results in a reduction of behavior. This occurs when behavior is frequently performed without being followed by reinforcing consequences.

Consequences of problematic behavior are short-term or immediate versus long-term or delayed. Short-term consequences maintain problematic behavior and long-term consequences make them problematic.

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.

A group of behaviors that produce similar outcomes are called functional response classes. Phobic behavior, dissociation and substance abuse are different types of behavior with the same underlying function of avoidance. These behaviors have negative reinforcing short-term outcomes and harmful long-term outcomes.

Examples of other behavioral assessment methods are self-monitoring and direct observation. When target behaviors are clearly defined, client’s can collect data on behaviors of interest in naturalistic settings. Examples of self-monitoring are thought records, mood charts and diary cards. They can be helpful by defining the context and frequency of certain behavior and are effective in producing desirable behavioral changes.

Direct observation occurs when a person other than the client monitors the frequency of target behaviors, the contextual features or a combination of both. ABC recording is when the therapist observes the client in his natural environment. It refers to antecedents of behavior, target behaviors and the consequences of behavior.

Functional analytic psychotherapy is an interpersonally oriented behavior therapy based on the idea that the therapeutic environment is a social context that is in some way similar to the interpersonal situations the client participates in outside of therapy. The therapist can positively reinforce good behavior by expressions of warmth or support. Problematic behavior will be placed on an extinction schedule and the therapist can ignore problematic behavior from the client. The therapist is acting as a participant-observer. Role plays are also examples in which the therapist acts as participant-observer, providing feedback is important.

Before closing the initial interview the therapist should give the client the opportunity to come up with questions or any discomfort, summarize the main points of the session and anticipate the next steps in the process.

Chapter 3: Case formulation

A case formulation consists of the identification of the client’s problem areas and hypotheses about maintaining factors. The focus of behavioral case formulations is operant and classical conditioning and social learning principles.

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”). The EST approach focuses on symptom presentation and is protocol-driven. Behavioral assessments acknowledge the client as a unique individual and tend to be ongoing, iterative and adjustable. Treatment is most effective when the therapeutic interventions are adapted to the client’s problem areas.

Assessments are used to get more information about the severity of the problem, its frequency or its persistence. Phases of clinical assessment:

1. Examining the client’s problem areas

2. Description of the problem areas

3. Identification of behavior patterns

4. Intervention on target areas or behaviors

5. Evaluation the maintenance of therapy gains

In the first phases of assessment it can be useful to use general (nomothetic) principles that can serve as guides for formulating problems.

It can be difficult to identify behavior patterns because clients often display a combination of behaviors such as behavioral excesses, deficits, limited social skills and difficulty in stimulus control.

Behavioral case formulation assumptions:

• Behavior and context (environment) are analyzed as a whole. Learning history, physiological makeup and current situational antecedents and consequences of behavior define the context. The most important behaviors occur within the client, for example thoughts and bodily sensations.

• Behavioral interventions focus on current situational determinants of behavior. Therapists can promote new learning and environmental events can modify brain functions.

• The difference between the development and the maintenance of a disorder is another important assumption. Historical factors responsible for the development are not necessarily responsible for maintaining the disorder. Behavioral interventions have a here-and-now focus.

• Problematic behavior is often an indicator of the absence of alternative and more effective behaviors in the client’s behavioral repertoire. Teaching new behaviors (such as coping skills) and modify faulty thoughts or (verbal) rules can be helpful.

The case formulation approach within CBT involves the development of an in-depth and individualized formulation of the problem areas. The formulation involves the functional (contextual) and structural (topographical) features of behavior.

The initial formulation is continually evaluated and refined.

Validation of the case formulation:

• Is it able to account for the problem areas?

• Can it predict clinically relevant behavior in specific situations?

• Does the client support the formulation?

• Are the selected interventions effective?

Formulation elements based on Persons model of case formulation:

• The problem list: typically 5-8 items to address in therapy, not more than 10.

• Eliciting and activating situations: 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: personal variables such as relevant biological features and learning histories.

• Working hypothesis: an integrated and cohesive formulation of each problem area tied together (interrelations among the problem areas). Similar functional properties or relations.

• Sharing the formulation with the client: therapist’s understanding of the problem areas and agreement of the client.

• Treatment plan: goals, activities and interventions.

• Motivation for change and commitment for action: non-confrontational and empathic discussions between the therapist and client about the effects and consequences of problematic behavior.

• Therapy obstacles: one or two hypotheses about potential obstacles to avoid problems.

• Evaluating the effectiveness: measurable therapy goals.

Monitoring change in the problem areas can be done by frequency counts of the problem, problem intensity ratings or relevant self-report measurement.

For most people (verbal) rules have more influence on behavior than actual environmental contingencies. Behavior is rule-governed when verbal rules function as an antecedent of behavior. According to the social cognitive theory of Bandura, verbal rules can be similar to Self-efficacy expectations and outcome expectations. Self-efficacy expectations are beliefs about the ability to perform certain behavior. When self-efficacy is low, the likelihood of performing certain behavior is low, even when the expectations are inaccurate. Outcome expectations are beliefs that behavior will result in certain outcomes. Positive outcome expectations will increase the likelihood of performing certain behavior. Negative expectations function as disincentives. Verbal rules (primary assumptions) have significant influence on efficacy and outcome expectations, and therefore on behavior.

Diagnostic concepts are group or variable centered (nomothetic). As previously stated the behavioral assessments within CBT are idiographic, they focus on the individual’s uniqueness. Psychiatric diagnoses and psychological test should be used as a supplement to individualized case formulation, not as a substitute.

When exploring the problem formulation with the client the therapist should present it in an open and collaborative manner. It is useful to describe the expected etiology of the problem areas and its development over time. Maintaining factors should also be discussed. When using technical terms associated with CBT, the therapist should explain them by using examples. Disagreements about the formulation are often based on small details that can be easily clarified.

By distinguishing the client from the problem the client sees the therapy emphasizes on the problem. The client then realizes that the problem is understandable and that by working together with the therapist a solution can be found.

For better understanding the therapist can use diagrams that summarize the overall model. The diagram should focus on changeable factors as a result of therapy. To check if the client understands the problem, the therapist can ask him or her to explain it like he or she is talking to a friend.

It’s not always wise to share labels (diagnoses) with clients. For some clients it can be a relief to know the name of their problem, but for labels such as personality disorders are not always appropriate to share. A label isn’t always a diagnostic label, it can also refer to a collection of behaviors like chronic pain or intentional self-harm.

Chapter 4: A plan for therapy

The client and therapist collaboratively identify the problem areas and decide how the areas should be approached. The process of treatment planning and formulation is in some respects similar to problem solving and decision-making. We need alternative approaches to respond to problems and like decision-making processes we should use rules to select an alternative approach.

Characteristics of target behaviors, characteristics of the client, social-environmental factors, diagnosis, treatments history and characteristics of interventions (for example maintenance of treatment effects) are all factors that influence which interventions are optimal for a client.

Currently there is no method for integrating assessment data and developing an effective intervention. It is useful to ask a client if he or she had therapy in the past and how the problem areas were approached.

Guidelines to develop a collaborative plan for therapy that uses behavioral interventions within CBT:

• Reaching agreement on goals of therapy: central topics of therapy, duration and frequency of sessions and the use of follow up sessions.

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.

According to Bandura (social cognitive theories) freedom is having different behavioral options by what you have previously learned and experienced. CBT interventions try to increase the people’s freedom by learning them more skills, abilities and options for responding. Sometimes the client needs to learn that problem behaviors or dysfunctional ways of coping are inconsistent with the goals of the therapy.

• Prioritizing problem areas: high-risk behaviors, such as suicidal behaviors, have priority in therapy.

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 4 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.

• Deciding which interventions to select

Empirically supported theories (ESTs) are referenced to specific diagnostic concepts (protocol driven) and therefore most useful when clients have specific problems. ESTs are less suitable when clients have multiple problem areas, in tis case several approaches can be used (simultaneously). It is important that only relevant components of the EST protocol are treated, otherwise clients can get bored or drop out. When there is no EST for the client’s problem, the therapist has four options:

1. Do not treat the client

2. Refer to another therapist

3. Use a collection of ESTs

4. Use evidence-based cognitive and behavioral principles for developing a formulation.

Behavioral case formulation and planning of treatment are principle-driven approaches to select treatment interventions. Principle driven case formulation approaches are idiographic.

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.

Multiple problem behaviors often occur under similar circumstances and produce similar outcomes. These behaviors have a different form or expression but are often influenced by similar variables; they are called functional response classes. Awareness of the functional response classes can help determine the core processes that maintain the problem behaviors. The core processes can be treated by the same intervention strategies.

The second principle-driven (idiographic) approach that can be used to select interventions for therapy is the case-formulation-driven modular approach. This approach can be used as a strategy to develop an individualized and flexible treatment plan. Selection is based on pretreatment assessments, the client’s needs and therapy goals. Only the relevant components of different ESTs are used within this approach.

General behavioral interventions guidelines:

• Problem behaviors that are maintained by positive reinforcement can be addressed by interventions that focus on environmental change.

• Clients who are depressed or who experience low self-esteem have low outcome expectation. They need to learn that they are capable of performing behavior that will lead to positive outcomes.

• Through direct instructions, advice, modeling, behavioral rehearsal and skills training clients can develop and strengthen effective behavior.

• Clients with a variety of psychological conditions often display overly rigid rule governance, which reduces flexibility in responses. It can be helpful to discuss the accuracy of these rules. Interventions focus on the unhelpful thinking patterns and try to bring behavior more in line with the client’s goals and values.

• Exposure-based interventions are helpful for clients with excess negative emotions, particularly anxiety. Avoidance or conditioning processes often maintain anxiety and therefore need to be addressed in therapy. Acceptance and mindfulness interventions can be useful when the client is looking for acceptance for his or her experiences in the past or has difficulty with staying in the moment.

• Consider if it is appropriate to have a medical evaluation or medical examination (for example in the case of severe psychological disorders).

Dialectical behavior therapy has 4 primary treatment modalities:

1. Individual outpatient therapy that focuses on problem areas.

2. Skills training group (8-10 clients, taking place in stage 1).

3. Telephone consultations between the sessions.

4. Case consultation (supervision) meetings on a weekly basis.

For many clients it’s not necessary to include all these modalities. When behavior is more chronic and severe, more modalities are used in the therapy.

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 two primary areas the therapist often discusses with the client are the rationale of therapy and the rationale for between-session activities such as homework. The client’s acceptance of the treatment rationale is associated with more therapeutic benefits. It is useful to inform the client about the effectiveness of the therapy for persons with similar problems and that the therapy is widely tested. Sometimes clients doubt the therapy rationale. In that case it can be helpful to explain the difference between the development and the persistence of problems. Completing questionnaires and self-monitoring are examples of between-sessions activities carried out by the client. It is important to explain how the activities such as homework are tied to therapy goals.

A moderate degree of discomfort about one’s problems is associated with the motivation to try out new and different ways of responding as a way to decrease distress. An inverted “U” form can describe the relation between motivation for change and distress.

The strategy of motivational interviewing can be used to facilitate motivation. This is a non-confrontational and empathic approach to discuss the effects and consequences of problem behavior and explore the benefits of change. Identifying reasons for changing, feedback about risk or impairment, learning problem-solving strategies and identifying strengths and resources are examples of components of this approach. Sometimes a low motivation is associated with severe forms of psychological disorders, for example a severely depressed mood. Medical consultation should be considerate to evaluate the possible use of medications.

Motivation can also be enhanced by the use of treatment-contracts. When the therapy goals for therapy are set, a formal treatment contract can be developed which describes the responsibilities and expectations of the client and therapist.

According to Otto there are 3 benefits of a treatment-contract:

1. Contracts promote motivation for change.

2. A contract is a reminder of the therapy options, principles and treatment contingencies. The therapy contract can be used as a checklist of coping skills to use in stressful situations.

3. The contract is a framework for crisis resolution and often includes a suicide crisis plan and a checklist for family members (how to protect the client).

In the process of case formulation suggesting one or two potential obstacles can be useful. The therapist and client should explore potential obstacles and problems and brainstorm on how the obstacles can be avoided and in case they occur how the problems can be solved. The expected obstacles can be translated into therapeutic goals. Therapy goals should be measurable to see if the client is making any progress.

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’t 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).

According to Nelson and Hayes measures should accurately assess the targeted behaviors, measures should occur frequently and before treatment. the collected data should be graphed and regularly reviewed.

Case illustration

Background: Robert is a 24-year-old accountant with a long-standing fear of heights. Robert is seeking for therapy because he is avoids driving over a bridge and by doing so he had to delay the start of his new job.

At the age of 5 he fell from a patio-deck. Robert’s mother became overly protective after the incident and did not allow him to play outside without her supervision. She also tended to exhort caution frequently: “if you get too close, you’ll fall and break your neck!”. When Robert was 12 years old a friend fell and he saw a lot of blood gushing out of his head. He recalls this incident when he’s around high places.

Avoiding heights increased in time and loud, unexpected sounds cause him very strong physiological reactions. Robert had troubles making decisions without advise and expressing disapproval. Four years ago Robert received therapy for his fear of heights. He talked a lot about his past and his mother en the fear of heights didn’t change.

The therapist came up with the following formulation (problem list):

1. Exaggerated fear of heights.

2. Catastrophic thoughts related to being in high places.

3. Avoidance of high places.

4. Avoidance of travel when heights are involved.

5. Frequent reliance on others (for support and advice).

6. Strained marital relations related to height phobia.

Avoidance and escape behavior is reinforced behavior because it produces relief.

The fall from the patio-deck and the change of his mother’s behavior are seen as the hypothesized origins. Robert learned that by avoiding heights the uncomfortable emotions and physical sensations would disappear. This way of coping was effective in reducing anxiety, but he did not develop alternative responses.

According to the DSM-4 Robert met the criteria for Specific Phobia, Natural Environment Type (Acrophobia). Working hypothesis: Robert needs a therapy program that exposes him to high places but blocks escape and avoidance behavior. This should reduce the fear and uncomfortable physiological sensations and images he experiences. Skill training will also be useful.

Goals for the treatment plan: eliminate fear of heights, reduce intensity of physiological sensations and unpleasant images, eliminate avoidance and escape, support alternative coping methods and participate in places which are previously avoided. Interventions: self-monitoring, mindfulness training, breathing retraining, exposure and response prevention.

Chapter 5: Changing the environment

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. For individuals with normal cognitive functioning, CMS can be used for behavioral excesses or deviations maintained by primary reinforces (for example drugs, alcohol and sexual promiscuity).

Behavioral contingency is the causal relation between events in which behavior occurs, behavior itself and the consequences of the behavior. It is a central concept associated with CMS. We speak of behavioral contingency only if the behavior specified in the relation is performed.

Stimulus control works by altering the antecedents to behavior. The two general classes of antecedents are discriminative stimuli (SD) and establishing operations (EO). Discriminative stimuli are events that signal the likelihood of punishment or reinforcement and a SD in operant conditioning is different from a conditional stimulus (CS) in classical conditioning. In classical conditioning the individual ‘s responses are automatically, SDs only influence whether or not an individual will respond in a particular manner.

Assumptions of contingency management:

1. Contingency management is most effective when direct-acting environmental antecedents influence the target behavior instead of (verbal) rules.

2. CMS can only increase behavior that is already part of the individual’s behavioral repertoire.

Applying contingency management interventions:

1. Specify and operationalize target behaviors. Target behaviors are those to be altered and should be directly observable and be recorded or monitored. It is also important to specify the contextual factors that are associated with the target behaviors.

2. Orienting the client to contingency management. Clients need to understand that reinforcement, punishment and extinction are defined by their effect on behavior. Only when pleasurable activities increase the likelihood of behavior over time we can call them reinforces. Also when a client cuts his arm to punish himself, it’s not automatically a ‘punisher’. Behavior can be performed with the intention to receive reinforcement from the environment, but most of the time clients are unaware of all the factors that influence their behavior.

3. Clinicians should be alert to the occurrence of target behaviors within and outside the sessions. This can be done by self-monitoring and observational methods and is useful in assessment and treatment.

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.

Another strategy is modifying the antecedents; this involves changing the cues that are strongly associated with the problematic behavior. An example of this strategy is asking drug-using peers to stop offering drugs in the client’s presence.

To increase the likelihood of desired behavior or reduce problematic behavior it can be helpful to rearrange cues in the client’s environment. These cues can be notes to remind the client to perform the desirable behavior or a coping card, which is a list with new behaviors to use in times of crisis. This strategy is especially effective for clients who are motivated to change, but forgetful or busy.

To teach an individual in which situations certain behavior is appropriate, the therapist can use discrimination therapy. During this therapy they can learn that a given stimulus situation (S^D) will provide reinforcers for desirable behaviors. Other stimulus situations (S) are associated with the unavailability of reinforcement. This will lead to ignorance of the irrelevant cues and an increase in attention to relevant cues. Discrimination therapy is especially useful when clients have problems that result from inappropriate stimulus generalization. Neutral stimuli that are similar to the SD are prone to stimulus generalization and then become signs for threat to the client. Individuals who suffer from PTSD show a generalization of trauma related cues.

Some people have problems with discriminating emotional states as a result of mislabeling emotional experiences. Teaching a client how to accurately label emotional experiencing is called self-labeling training.

Establishing operations (EO) can be used to reduce problematic behavior. Using methadone to decrease the use of heroin is an example of it. Methadone blocks the positive reinforcing effects of heroin.

(Over)Satiation therapy involves an excessive amount of reinforcers to make them less desirable or less effective in influencing behavior. An example of satiation is masturbatory satiation, which can be used for pedophiles. The goal of the therapy is reducing sexual arousal to inappropriate stimuli such as children. Because of prolonged masturbation the sensations are no longer pleasurable and the inappropriate sexual stimuli will lose their stimulating qualities.

Non-contingent delivery of events, actions or objects that usually reinforce problematic behavior, can help to reduce the behaviors in addition to a larger treatment program. The reinforcers are no longer associated with the problematic behavior; this especially works for social reinforcement. For chronically suicidal individuals it can be helpful when the therapist uses the strategy of a random support call that is a non-contingent delivery of attention and support. Forms of self-harm and attention from the environment become less associated. By already providing the client with the reinforcer, from an EO perspective, there is less need to perform the problematic behavior.

Behavioral contracts can be used to specify the client’s goals, the steps to achieve the goals and the consequences of acting toward or away from the goals. The contract is a sign of commitment and therefore can function as an EO that increases the likelihood of behavior that is specified in the contract.

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.

3. Determine how to reinforce desirable behaviors.

What is seen as reinforcement varies per person, this makes reinforcement idiographic. The timing of reinforcement influences the effectiveness of increasing behavior. Immediate reinforcement is more effective than delayed reinforcement.

The scheduling of reinforcement influences the degree to which reinforcement increases future behavior. There are many types of reinforcement schedules.

• Continuous schedule: providing reinforcement every time a client performs a particular behavior. When this schedule is made less frequent, behavior is vulnerable to extinction.

• Variable ratio schedule: providing reinforcement following a varying number of responses. For example providing reinforcement to an anorexia patient after eating 3 healthy meals and at other times after 5 or 6 healthy meals. This schedule is associated with the most resistance to extinction.

To learn a new behavior it is best to reinforce new behavior continuously and then thin reinforcement to a variable ratio schedule. By doing so “extinction-resistance” behavior can be produced.

How reinforcements influences behavior is also influenced by the characteristics of the reinforcer. When available, natural reinforcers are more preferable than using arbitrary reinforcers because they have an inherent connection with the behavior of interest. The therapist should provide the client with natural responses. Arbitrary reinforcers do not occur in the client’s natural environment.

On page 22 there is a list of behaviors the therapist can use to reinforce, extinguish or punish the client’s behavior. It is critical to avoid reinforcement of dysfunctional or undesirable behavior, especially for patients with suicidal behaviors.

There are two key ways to the use of contingency management strategies:

1. Use consequences within the therapeutic relation.

2. Set up (in)formal reinforcement, extinction or punishment systems.

Providing reinforcing responses is more likely to influence the in-session behavior than behavior that occurs outside of sessions.

When a behavior that is not currently in the person’s repertoire need to be established, shaping is the most appropriate intervention. Shaping is about reinforcing successful approximations to a final response. Every time it takes a closer approximation to the desired response for the client to get the reinforcement. Shaping processes are often informally carried out and use behavioral rehearsal (role playing). The 4 components of behavioral rehearsal:

1. Willingness of the client to learn new behavior

2. Identification of situations in which deficit responses cause distress

3. Participation in role plays

4. Performing rehearsed behaviors in natural environments

Desired behaviors can occur at a low rate when reinforcers are not available in the client’s natural environment, which can result in extinction. It can be useful for the client to reenter situations that he or she avoided but that were associated with reinforcement or scheduling pleasant events. Substance abusers can have a restricted range of reinforcers, that is why they need to participate in alternative pleasant activities and learn that behaviors that are unrelated to the substance can be reinforcing.

According to Hernstein’s matching law the intensity, frequency and time that an individual spends performing particular behavior is directly proportional to the reinforcement value of the behavior.

To increase low-rate behaviors the high-frequency behaviors should be contingent on performance of the low-frequency behaviors (Premacking).

Extinction and punishment can be used to decrease the frequency of problematic behavior. Eliminate reinforcers that maintain the problematic behaviors, consider how to respond when target behavior does not occur and establish an alternative.

• 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.

• 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 can be used when the alternative behavior is not currently in the client’s repertoire and when these behaviors are reinforced consistent with long-term goals and inconsistent with drug use they can facilitate drug abstinence among dependent individuals.

Sometimes the undesirable target behavior temporarily increases in frequency after positive reinforcement is withdrawn. This side effect of extinction procedures is called an extinction burst. When the reinforcers continue to be withheld the side effect will gradually decline.

Covert sensitization is used to reduce behavioral excesses (5-10 times per session) and is based on positive punishment principles. The client needs to imagine participating in the target behavior and the co-occurrence of some type of aversive event. Key steps:

• Identify behavior, context and reinforcing consequences.

• Inducing a state of relaxation.

• Imagination of participating in the target behavior.

• Imagination of experiencing aversive consequences.

• Imagine these consequences worsening.

• Aversive consequences peak when target behavior is first covertly enacted.

• Imagination of escaping the situation.

• Feelings of relief

Olfactory aversion is also based on positive punishment principles and can reduce sexually deviant behaviors.

Responses cost interventions are based on negative punishment principles, which involve removing a rewarding event to weaken targeted behavior (speeding ticket, time out, donation jar).

• Strategies to modify behavior through contingency of self-management procedures: Self-management strategies (delay of gratification): reducing the influence of immediate reinforcers on behavior. This is shown when a person performs a behavior to influence the occurrence of another behavior. Self-control is defined as “choice of a larger but more delayed outcome over a smaller but less delayed outcome”. Impulsivity (immediate gratification) is the opposite of self-control, whereby preference is given to small immediate rewards.

• Behavioral contracting is a method to formalize agreements between the client and therapist. Four central functions:

• • Formalization of behavioral goals

  • Provide an accessible reference that serves as a reminder of the goals and a means for measuring progression.

  • Specification of responsibilities.

  • Public statement suggesting commitment to the goals.

• 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 3 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:

• Awareness training: focuses on the ability to detect and discriminate cases of the habit behavior when it occurs.

• 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.

• Token systems (token economies): when behaviors are consistent with the identified personal goals, people receive conditional positive reinforcers such as points or vouchers. This method is often used when other approaches are ineffectual or unavailable. Token systems activate and initially support new behaviors but are not effective in long-term maintenance of behavior.

Chapter 8: Activating behavior

The behavioral activation interventions for treating depressive disorders are refined in the past years. Approximately 17% of the general population experiences a major depressive disorder at some point in life.

Jacobsen identified a treatment element to make individuals more behaviorally active. Helping them with depression in approaching and accessing positive reinforcers (natural antidepressant functions) while avoiding unpleasant situations. Avoidance coping strategies such as rumination and social isolation are seen as obstacles to behavioral activation and need to be blocked.

According to the functional analytic account of depression (Fester) there is a causal link between depression and environmental factors. Passive responding, avoidance, escape, withdrawal in development and maintenance of depression are highlighted in this model.

The behavioral theory of depression (Lewinsohn) states that a low rate of response contingent positive reinforcement (RCPR) results in low rates of behavior and therefore reduced opportunities to receive positive reinforcement. This extinction process results in depressive symptoms. Participation in pleasant activities can be measured by the Pleasant Events Schedule.

According to behavioral activation depression is caused by problematic life events and not by dysfunctions within the individual.

In contrast to Lewinsohn, who states that certain events or activities are intrinsically pleasant and reinforcing for all individuals, the behavioral activation approach assumes that events are only reinforcing when they clearly influence behavior.

Behavioral activation is probably the most important ingredient of CBT for depression and is responsible for the therapeutic change. There is also evidence for the effectiveness of behavioral activation for reducing depression among hospitalized inpatients (in comparison with standard treatments).

Dimidjian found no difference between antidepressant medication, behavioral activation and CBT in treating depression among adults.

The behavioral activation theory of depression assumes that factors that contribute to the development and maintenance of depression are situated in the environment (not the person) and are related to the outcomes of the individual’s behavior. Depression is seen as an experience resulting from the interaction between the environment and the individual, that is why this theory focuses on contextual change (when risk situations increase). Goal of the therapy is to increase activity, counteract avoidance behavior and increase access to positive reinforcers. Thinking patterns are also important, their content is less important. The duration of behavioral activation therapy is 16 to 24 weeks.

The therapist encourages the client to engage in activities that are reinforcing and helps to develop life routines that function to maintain behavior consistent with their long-term goals.

3. The first phase of behavioral activation therapy (self-monitor activities and moods) focuses on what one does in certain situations because it is difficult to change personality or genetic endowments. 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 (drinking alcohol worsens the problems).

4. The second phase 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 (problem solving part of phase 2).

5. The third phase 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. After identifying a TRAP the client need to get back on TRAC: Trigger, Response and Alternative Coping. The client should accept emotional reactions and work towards his or her goals. 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. One strategy to overcome avoidance patterns is graded task assignments, which means taking small significant steps toward a goal. Subjective units of distress (SUDS) can help the client to rate the level of distress for avoided areas on a scale from no stress (0) – most distress ever experienced (100). Countering mood-dependent behaviors can be used to block avoidance and learn that people can behave independently of acute moods. For some individuals it can be helpful to act ‘as if’ there is nothing that blocks them.

6. The fourth phase focuses on reducing the risk of relapse. Clients are encouraged to apply the behavioral activation principles to other aspects of their lives (skill generalization). Reducing the risk of relapse (vulnerability to depressed mood) can help overcome past traumas en accept and value oneself. A maintaining factor of depression is disruption of regular routines, therefore it is important to establish regular routines and keep the client in regular contact with events that maintain behavior.

Chapter 9: Interventions based on exposure

The most clients seek therapy for emotional problems, for example difficulties with managing anger. Especially when these emotional problems are associated with maladaptive avoidance behaviors it can be useful to use exposure therapy.

Within CBT, exposure therapy helped people with a variety of clinical problems, particularly those with fear and anxiety, but also other problems like anger control problems, eating disorders and substance dependence.

Especially for the treatment of anxiety, exposure based interventions are the most powerful behavioral interventions. The exposure component of a treatment is often just as effective as the entire treatment package. Studies have found that prolonged exposure for PTSD is just as effective as more complex treatments.

The panic control therapy (Barlow) has two types of exposure therapy: interoceptive exposure and in vivo exposure. Interventions based on exposure have success rates of 80-100% in reducing the frequency of panic attacks.

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.

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.

For clients who experience unwanted, dysfunctional or unjustified emotional responses, exposure is most appropriate. Prior to exposure interventions a solid behavioral assessment is important to determine whether the emotional experience is adaptive or maladaptive. When a fear is realistic or justified the client should not be exposed to it because it can strengthen the emotional response. Maladaptive emotional responses are excessively intense, associated with problematic responses such as avoidance and resistance to modification. Foa and Kozak refer to this phenomenon as pathological fear. Exposure interventions are most useful when the client performs maladaptive behavior and the responses are unjustified and maladaptive. Most interventions are used for different types of anxiety, but other emotional experiences can also be treated.

Not experiencing the negative consequences, preventing the maladaptive emotional responses and repeatedly exposing the client to the emotion-eliciting stimuli works. There are hypothesized mechanisms that try to explain the therapeutic change effect of exposure:

• Counterconditioning: replacing a maladaptive response with an adaptive alternative response such as relaxation. When the client is in a relaxed mood and anxiety-eliciting stimuli are progressively presented it is called systematic desensitization. Manifestations of anxiety should function as cues for replacement behaviors that are associated with relaxation.

• Extinction / habituation: according to the two-factor theory of Mowrer classical conditioning is the process of developing a specific fear and operant conditioning the process of maintaining this fear. Avoidance needs to be blocked for a successful process of weakening the associations that are learned through classical conditioning (response prevention). Prolonged exposure can lead to extinction. It is also important that the client stays in the feared situation until the fear declines.

• Learning new responses to the CS that used to elicit the undesired emotional response. Exposure therapy is not about eliminating the old, but learning new ways to respond. It is important to know which contexts and events provoke the undesirable responses.

• Modification of rules: exposure interventions can result in more accurate rules about the relation between antecedents, behavior and consequences (“If I think about the trauma, I will likely feel discomfort but will not be harmed or threatened”). The client learns that the current rules are inconsistent with the exposure results and needs to modify his or her rules.

• Emotional processing: Foa and Kozak came up with the emotional processing theory (EPT) which 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). Cognitive processing therapy helps clients with fear related to PTSD and is based on EPT. Just like the other mechanisms of change, EPT focuses on identifying fear related stimuli and preventing avoidance.

Exposure involves the following procedures:

• Choosing the right type of exposure in the most effective manner. Commonly used types of exposure interventions are imaginal exposure, in vivo exposure, informal exposure, interoceptive exposure, opposite action and cue exposure.

• Orienting the client to exposure: the therapist needs to make clear to the client what involves exposure and why the client should undertake it. A clear orientation can be given by providing information about the choice of the type of exposure, describing how this type of exposure works and outlining specific tasks involved in exposure.

• Estimate factors that may inform the development of exposure scenarios

• Select an effective format, frequency and schedule of interventions

• Conducting non-reinforced exposure

• Prevent development of emotion-consistent behaviors

• Monitoring emotional responses

• Continue exposure until emotional responses diminish

• Providing the client with control over the exposure

Imaginal exposure is exposing the client to provoking stimuli in his or her imagination. This type of exposure is used when it is difficult or impossible to expose the client to relevant stimuli in real life, when flexibility of the client’s imagination is useful or as a precursor for in vivo exposure. Imaginal exposure focuses on reducing the fear of the memory of a traumatic event. After reducing the fear of the memory it is possible to progress to in vivo exposure.

In vivo exposure is exposing the client to provoking stimuli in real life, can take place in a variety of settings and is often used when clients have a variety of other disorders.

Informal exposure is exposing the client to stimuli that provoke emotional responses in an ad hoc manner during therapy. The therapist should explain to the client how and under what circumstances informal exposure works. The therapist can clarify whether or not avoidance is occurring when the client for example tries to avoid discussions about emotional material. If the client confirms the avoiding behavior, the therapist should encourage the client to describe the avoided experience in detail.

Interoceptive exposure is exposing the client to specific bodily sensations and is often used for treating panic disorders. A client who is afraid of experiencing dizziness can be asked to spin in circles. Paying attention to an emotional response and all of its accompanying experiences can be overwhelming for a client, therefore it can be helpful to focus on bodily sensations of the emotion and direct attention away from other experiences (like thoughts of distressing emotions).

Opposite action and reversing emotion-linked action tendencies: a more recent form of exposure involves acting in a way that is opposite to the urge (avoiding / escaping) that accompanies a particular emotion. The difference between opposite action exposure and other exposures is that opposite action can be used for any unjustified emotion (sadness, shame, anger, envy).

The 5 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

5. Engage in the opposite action (repeatedly)

During step 5 it is important that client pays attention to his or her environment and the consequences of the opposite action.

Cue exposure is specifically used for clients with substance use problems and in some cases of bulimia nervosa. The therapist presents substance cues to the client during this type of exposure but blocks the client in consuming the substance. By doing so the therapist weakens the association between the drug and the associated reinforcement. Cue exposure is an approach based on extinction and results in conditional emotional and physiological responses like cravings and urges to use. Cue exposure should be used as a component of a larger treatment package.

An assessment of the breadth of stimuli and intensity of the emotional response is another important step for therapists that carry out exposure-based interventions. The therapist should find out in which situations the unjustified emotions occur, because all key stimulus elements that elicit fear need to be captured in the exposure. The SUDS scale can be used to determine the intensity and therapists take SUDS rating every 5 to 10 minutes.

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 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. 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.

The 4 procedural points of conducting exposure:

1. Conduct non-reinforced exposure: exposure occurs in the absence of feared consequences. It is important for the client to experience consequences that are inconsistent with the maladaptive expectations and that do not justify the emotion.

2. Prevent behavior that is consistent with emotion: the emotional responses need to diminish in intensity while the client is exposed to the feared stimuli. By doing so, the situation becomes associated with a lower level of fear or emotion. Behaviors that are consistent with the emotion, for example avoidance or escape, must be blocked and prevented. Otherwise they will keep the fear alive.

3. Continue exposure until the emotional response has habituated and the SUDS rating have dropped. Exposure must not stop until the ratings are approximately 50% lower.

4. Allow the client some control over the exposure: the therapist needs to inform the client that he or she may stop the exposure at any time. However it is important to remain exposed to the stimulus and block behaviors that are consistent with the undesired emotion.

Chapter 10: Acceptance and mindfulness

Behavioral and cognitive interventions help clients to change behavior, thinking and environments. CBT interventions help them to accept various aspects of themselves, their life experiences, emotions and the world. Behavioral therapies often include acceptance or mindfulness in their titles. According to Hayes’ acceptance and commitment therapy (ACT) these types of treatments fit within a evolutionary period, also called the third generation.

Mindfulness is being aware of the present moment. Mindfulness interventions can be seen as a part of acceptance interventions. It is for example difficult for a client to be mindful of anxiety sensations without accepting their presence. On the other hand, acceptance can be seen as a subset of mindfulness, because mindfulness is necessary for acceptance.

Acceptance means willingly allowing a current of past experience to be exactly as it is or was. The therapist should help the client to stop the struggle to change behaviors, experiences and environments. The client needs to allow experiences to occur without protest or reaction.

Key components of standard behaviors of mindfulness:

• Observing current emotional reactions, bodily sensations, thoughts and other experiences of the present moment.

• Describing the facts of the experience without using labels or judgments.

• Participating in the present experience.

• Approaching each experience as a unique and new one (beginners mind).

Acceptance and mindfulness interventions focus on changing the relationship with and the reactions to the experiences, not the experiences themselves. Mindfulness is necessary for exposure, because the client needs to be aware of relevant aspects and aversive situations for exposure to work. To get rid of negative emotions the client need to accept the current emotional pain.

Traditional CBT and interventions based on mindfulness and acceptance differ in the target of change. Traditional CBT focuses on changing the content of thinking, forms of behavior or aspects from the environment while acceptance and mindfulness based interventions focus on changing the client’s approach to thoughts, feelings, behaviors and the environment. When the client is not accepting that problems exist, it is impossible for CBT to make some changes.

The Freudian psychoanalysis made clear that it is important to allow repressed unconscious conflicts into consciousness, gestalt therapies emphasized the importance of openness and awareness of experiences and humanistic therapies the acceptance of the client by the therapist.

Jon Kabat-Zinn developed a treatment on the basis of his research of mindful practice on chronic pain and stress. Mindfulness-based stress reduction (MBSR) can effectively treat psychological difficulties, especially chronic pain and anxiety disorders.

There are many treatments that use mindfulness and acceptance based interventions. Acceptance and commitment therapy helps clients to accept their experiences, move forward in life and its use has been successful to different clinical problems. Integrative behavioral couple therapy (IBCT) helps partners to accept each other’s differences. The mindfulness-based cognitive therapy (MBCT) prevents relapse in depression.

There are 3 key principles for deciding whether or not to use acceptance and mindfulness interventions or interventions that focus on change.

1. Justified vs. unjustified experiences and responses. A justified response is a realistic fear and therefore warranted by the current situation. The therapist should accept the response as it occurs and help the client to change the situation that causes the response. An unjustified response, one that is not warranted by the current situation, should be modified.

2. Changeability vs. unchangeability. When problems are not readily changeable (unchangeable) it is effective to use acceptance interventions. Efforts to change them are likely to produce increased difficulties. Acceptance-based strategies are useful for clients who have lost relationships, jobs or experienced other significant losses, trauma or abuse.

3. Effectiveness vs. ineffectiveness of responses to emotions, thoughts, situations or historical events. Effective responses bring a client closer to achieving his or her goals or valued behavior. Avoiding behavior can be effective in the short term but has negative long-term effects and can increase suffering (creative hopelessness).

Clients often seek therapy to change unwanted emotional responding and distressing thinking patterns. Justified emotions and thoughts are not easily changed; it is more effective to accept the fact that they occur in the present moment. Another option is to change the situation in which the emotional responses or distressing thoughts occur. When an emotion or thought is unjustified it is not useful to change the situation or solve a problem, because there is no problem to solve. For example, a client who worries about overweight while he does not have it. In this case the therapist should focus on changing the emotional response or unwanted thoughts. Accepting the occurrence of the thoughts but not having to act on them is another useful strategy to deal with unjustified emotions or thoughts.

Validating the client’s justified responses and behaviors can be helpful to convey acceptance of the client.

Acceptance-oriented strategies are helpful for clients who seek therapy to deal with distressing events from the past. Acceptance is the best way to deal with them, because the events cannot be changed.

Mechanisms of change that are similar across acceptance and mindfulness interventions are increasing the client’s repertoire of responses and classical and operant extinction. The client needs to stop avoiding and escaping particular experiences, and by doing so the client learns to use alternative and more adaptive responses and accept previously avoided experiences to happen. Eventually acceptance can result in habituation by weakening the link between the conditioned stimulus and the unconditioned stimulus.

Mechanisms of change that are more specific to mindfulness interventions are increasing contact with stimulus properties, positive and negative reinforcement and neurobiological changes (particularly in the dopaminergic system). Mindfulness pays attention to the experience of the present moment and the properties of stimulus. Avoidance of the stimulus prevents the client from weakening the aversive response to the stimulus.

It is the therapist’s task to apply the most effective acceptance-based strategy in the most efficient manner, given the idiosyncrasies of the individual and the context of the session. There are two broad categories of acceptance-based interventions:

1. Acceptance strategies for the client: letting go of the struggle for control, defusing language and cognition, radical acceptance, willingness and acceptance in dyadic interactions (for example imagining what it would be like to accept and experience pain).

2. The therapist conveying acceptance of the client:

Two examples of cognitive defusion interventions:

1. Repeating a troublesome word or phrase until the meaning of the word disappears. Only the auditory stimulus properties of the word remain.

2. Using paradox to enhance acceptance.

Radical acceptance is an acceptance strategy that helps the client to completely accept the experience of the moment without the struggle to change or resist it. Asking the client to write out all the details of the experience is one way to do this.

During treatment for couples the therapist can ask the partner to express the softer side of their emotional experiences when communicating emotions or asking for a change in partner behavior, this is called empathetic joining. When the partner is expressing softer emotions it will elicit empathy and acceptance of the other partner.

Another acceptance strategy that can be used is unified detachment, in which partner approach the relationship as an “it” that they are both working collaboratively to solve.

Building tolerance for unwanted partner behavior is also a way to promote acceptance. The therapist asks one of the partners to behave in a certain way that will provoke the aversive reaction of the partner (non-reinforced exposure to the problem behavior). A way to increase tolerance is to get some of the needs met outside of the relationship (self-care).

Validation is a strategy to convey acceptance of the client and involves the therapist confirming the client’s experiences as authentic, true or correct. Validation is also a helpful strategy to model self-acceptance for the client. Validation is needed when the client is in extreme emotional or physical pain, when the client is not making progress or just needs to be heard and understood. Different ways to convey validation or acceptance of the client:

• Expressing interest (verbally and nonverbally).

• Accurately reflecting the client’s emotions, behaviors, thoughts and other experiences.

• Stating the unsaid (mind reading) involves validating by naming thoughts, emotions or experiences that the client has not mentioned.

• Communicating that the client’s response is valid given his or her learning history, medical problems, characteristics or psychological difficulties.

• Communicating that the client’s response is exactly what would be expected given the current situation. The client’s response is seen as reasonable, wise and normative.

Mindfulness is often used to cope with chronic pain or stress (mindfulness-based stress reduction). This intervention involves the client observing and attending to current physical sensations; they can step back and watch the experience of the present moment. Observing is not changing the current experience but noticing the experience by noticing physical sensations such as sights, smells and sounds.

Observing can be a way of calming the mind, this is a bonus function of observing.

Observing is noticing without judgment, a behavioral act of accepting experiences, emotions, thoughts and life in general. Observing exercises are observing thinking, breathing, physical sensations, urges, sights, smells, tastes, sounds and tactile sensations.

For the effectiveness of the therapy the therapist should pay close attention to what the client is saying, how he or she is saying it, (non)verbal cues and the influence of the therapist’s responses on behavior. The therapist and the client should pay attention to what is happening in the present moment.