Unit X: Treatment modalities

Cognitive Therapy and Behavioral Therapy

Introduction
Psychotherapy is the treatment of mental disorder by psychological rather than medical means
Psychotherapy can be defined (modified from Wolberg) as, the treatment by psychological means, of
the problems of an emotional nature, in which a therapist deliberately establishes a professional
relationship with the patient to,
1. Remove, modify or retard existing symptoms,
2. Mediate disturbed patterns of behaviour, and/or
3. Promote positive personality growth and development.

Psychotherapy can be conducted by either verbal or non-verbal means. There are several different
kinds of psychotherapies
Therapy/School Proponent(s)
1. Psychoanalysis Sigmund Freud
2. Analytical psychology Carl Gustav Jung
3. Behaviourism John Broadus Watson
4. Character analysis Wilhelm Reich
5. Classical conditioning Ivan Petrovich Pavlov
6. Client-centred psychotherapy Carl R Rogers.
7. Cognitive behaviour therapy Donald Meichenbaum
8. Cognitive therapy Aaron T Beck

Types of Psychotherapy

Dimensions Types
Depending on the number of patients taking Individual therapy
part Group therapy

Depending on the duration of treatment Long-term therapy

Short-term therapy

Depending upon the depth of exploration Supportive psychotherapy

Deep psychotherapy

Depending upon the amount of responsibility Directive therapy

given to the patient Non-directive therapy

Depending on the nature of the group Family therapy

Marital therapy
Group therapy
Therapy with children and adolescents

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 Cognitive therapy
We know that our thoughts (cognitions) affect our feelings. Cognitive therapy is based on making
cognitive changes, which, in turn, alters feelings.

Cognitive therapy is a short-term, structured therapy that uses active collaboration between patient
and therapist to achieve its therapeutic goals, which are oriented toward current problems and
resolutions.
Cognitive therapy is a psychotherapeutic approach based on the idea that behavior is secondary to
thinking.
It focuses on how patients feel about themselves and their world, make changes in current ways of
thinking and behavior. It also focuses on present thinking, behavior, and communication rather than
on past experiences and is oriented toward problem solving.
The main goal is to identify and alter cognitive distortions that maintain symptoms.
Duration: time-limited, usually 15-25 weeks, once weekly meetings.
12 to 16 weeks (Beck & Weishaar, 2011).
Sadock & Sadock (2007) suggested that if a client does not improve within 25 weeks of therapy, a
reevaluation of the diagnosis should be made.

A central feature of the cognitive theory of emotional disorders is its emphasis on the psychological
significance of people’s beliefs about themselves, their personal world (including the people in their
lives), and their future—the “cognitive triad”. When people experience excessive, maladaptive
emotional distress, it is linked to their problematic, stereotypic, biased interpretations pertinent to
this cognitive triad of self, world, and future. For example, clinically depressed patients may be
prone to believe that they are incapable and helpless and to view others as being judgmental and
critical and the future as being bleak and unrewarding. Similarly, patients with anxiety disorders may
be apt to see themselves as highly vulnerable, others as more capable, and the future as likely to be
characterized by personal disasters.

Historical Background
Cognitive therapy has its roots in the early 1960s research on depression conducted by Aaron Beck
(1963, 1964). Beck had been trained in the Freudian psychoanalytic view of depression as “anger
turned inward.” In his clinical research, he began to observe a common theme of negative cognitive
processing in the thoughts and dreams of his depressed clients (Beck & Weishaar, 2011). A number
of theorists have both taken from and expanded upon Beck’s original concept. The common theme is
the rejection of the passive listening of the psychoanalytic method in favor of active, direct dialogues
with clients (Beck & Weishaar, 2011). The work of contemporary behavioral therapists has also
influenced the evolution of cognitive therapy. Behavioral techniques such as expectancy of
reinforcement and modeling are used within the cognitive domain. Lazarus and Folkman (1984),
upon whose premise of personal appraisal and coping the conceptual format of this book is founded,
have also contributed a great deal to the cognitive approach to therapy. The model for cognitive
therapy is based on an individual’s cognition, or more specifically, an individual’s personal
cognitive appraisal of an event and the resulting emotions or behaviors. Personality—which
undoubtedly influences our cognitive appraisal of an event—is viewed as having been shaped by the
interaction between innate predisposition and environment (Beck, Freeman, & Davis, 2007).
Whereas some therapies may be directed toward improvement in coping strategies or adaptiveness
of behavioral response, cognitive therapy is aimed at modifying distorted cognitions about a
situation.

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Cognitive behavior therapy has been used to treat people suffering from a wide range of
disorders, including:
 Anxiety
 Phobias
 Depression
 Addictions/substance abuse
 Eating disorders
 Panic attacks
 Anger
 Personality problem
 Suicidal thoughts or attempts
 Sexual disorders
 Somatoform disorders

Goals of Cognitive Therapy

Beck and associates (1987) defined the goals of cognitive therapy in the following way:
The client will:
1. Monitor his or her negative, automatic thoughts.
2. Recognize the connections between cognition, affect, and behavior.
3. Examine the evidence for and against distorted automatic thoughts.
4. Substitute more realistic interpretations for these biased cognitions.
5. Learn to identify and alter the dysfunctional beliefs that predispose him or her to distort
experiences.

Principles of cognitive therapy

Principle 1. Cognitive therapy is based on an ever-evolving formulation of the client and his or
her problems in cognitive terms.
The therapist identifies the event that precipitated the distorted cognition. Current thinking patterns
that serve to maintain the problematic behaviors are reviewed. The therapist then hypothesizes about
certain developmental events and enduring patterns of cognitive appraisal that may have predisposed
the client to specific emotional and behavioral responses.

Principle 2. Cognitive therapy requires a sound therapeutic alliance.

A trusting relationship between therapist and client must exist for cognitive therapy to succeed. The
therapist must convey warmth, empathy, caring, and genuine positive regard. Development of a
working relationship between therapist and client is an individual process, and clients with various
disorders will require varying degrees of effort to achieve this therapeutic alliance.

Principle 3. Cognitive therapy emphasizes collaboration and active participation.

Teamwork between therapist and client is emphasized. They decide together what to work on during
each session, how often they should meet, and what homework assignments should be completed
between sessions.

Principle 4. Cognitive therapy is goal oriented and problem focused.

At the beginning of therapy, the client is encouraged to identify what he or she perceives to be the
problem or problems. With guidance from the therapist, goals are established as outcomes of
therapy. Assistance in problem solving is provided as required as the client comes to recognize and
correct distortions in thinking.

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Principle 5. Cognitive therapy initially emphasizes the present.
Resolution of distressing situations that are based in the present usually lead to symptom reduction.
It is therefore of more benefit to begin with current problems and delay shifting attention to the past
until
(1) the client expresses a desire to do so,
(2) the work on current problems produces little or no change, or
(3) the therapist decides it is important to determine how dysfunctional ideas affecting the client’s
current thinking originated.

Principle 6. Cognitive therapy is educative, aims to teach the client to be his or her own
therapist, and emphasizes relapse prevention.
From the beginning of therapy, the client is taught about the nature and course of his or her disorder,
about the cognitive model (i.e., how thoughts influence emotions and behavior), and about the
process of cognitive therapy. The client is taught how to set goals, plan behavioral change, and
intervene on his or her own behalf.

Principle 7. Cognitive therapy aims to be time limited.

Clients often are seen weekly for a couple of months, followed by a number of biweekly sessions,
then possibly a few monthly sessions. Some clients will want periodic “booster” sessions every few
months.

Principle 8. Cognitive therapy sessions are structured.

Each session has a set structure which includes:
 reviewing the client’s week,
 collaboratively setting the agenda for this session,
 reviewing the previous week’s session,
 reviewing the previous week’s homework,
 discussing this week’s agenda items,
 establishing homework for next week, and
 summarizing this week’s session.
This format focuses attention on what is important and maximizes the use of therapy time.

Principle 9. Cognitive therapy teaches clients to identify, evaluate, and respond to their
dysfunctional thoughts and beliefs.
Through gentle questioning and review of data, the therapist helps the client identify his or her
dysfunctional thinking, evaluate the validity of the thoughts, and devise a plan of action. This is done
by helping the client to examine evidence that supports or contradicts the accuracy of the thought,
rather than directly challenging or confronting the belief.

Principle 10. Cognitive therapy uses a variety of techniques to change thinking, mood, and
behavior.
Techniques from various therapies may be used within the cognitive framework. Emphasis in
treatment is guided by the client’s particular disorder and directed toward modification of the client’s
dysfunctional cognitions that are contributing to the maladaptive behavior associated with their
disorder.

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Basic Concepts
Wright and associates (2008) stated, “The general thrust of cognitive therapy is that emotional
responses are largely dependent upon cognitive appraisals of the significance of environmental cues”.
Basic concepts include automatic thoughts and schemas or core beliefs.

Automatic Thoughts
Automatic thoughts are those that occur rapidly in response to a situation and without rational
analysis. These thoughts are often negative and based on erroneous logic. Beck and associates (1987)
called these thoughts cognitive errors. Following are some examples of common cognitive errors:
Arbitrary Inference
In a type of thinking error known as arbitrary inference, the individual automatically comes to a
conclusion about an incident without the facts to support it, or even sometimes despite contradictory
evidence to support it.
e.g. Two months ago, Mrs. B. sent a wedding gift to the daughter of an old friend. She has not yet
received acknowledgment of the gift. Mrs. B. thinks, “They obviously think I have poor taste.”
Overgeneralization (Absolutistic Thinking)
Sweeping conclusions are overgeneralizations made based on one incident—a type of “all or nothing”
kind of thinking.
e.g. Frank submitted an article to a nursing journal and it was rejected. Frank thinks, “No journal will
ever be interested in anything I write.”
Dichotomous Thinking
An individual who is using dichotomous thinking views situations in terms of all-or-nothing, black-or-
white, or good-or-bad.
e.g. Frank submits an article to a nursing journal and the editor returns it and asks Frank to rewrite
parts of it. Frank thinks, “I’m a bad writer,” instead of recognizing that revision is a common part of
the publication process.
Selective Abstraction
A selective abstraction (sometimes referred to as a “mental filter”) is a conclusion that is based on only
a selected portion of the evidence. The selected portion is usually the negative evidence or what the
individual views as a failure, rather than any successes that have occurred.
e.g. Jackie just graduated from high school with a 3.98/4.00 grade point average. She won a
scholarship to the large state university near her home. She was active in sports and activities in high
school and well liked by all her peers. However, she is very depressed and dwells on the fact that she
did not earn a scholarship to a prestigious Ivy League college to which she had applied.
Magnification
Exaggerating the negative significance of an event is known as magnification.
e.g. Nancy hears that her colleague at work is having a cocktail party over the weekend and she is not
invited. Nancy thinks, “She doesn’t like me.”
Minimization
Undervaluing the positive significance of an event is called minimization.
e.g. Mrs. M. is feeling lonely. She telephones her granddaughter Amy, who lives in a nearby town,
and invites her to visit. Amy apologizes that she must go out of town on business and would not be
able to visit at that time. While Amy is out of town, she calls Mrs. M. twice, but Mrs. M. still feels
unloved by her granddaughter.
Catastrophic Thinking
Always thinking that the worst will occur without considering the possibility of more likely positive
outcomes is considered catastrophic thinking.
e.g. On Janet’s first day in her secretarial job, her boss asked her to write a letter to another firm and
put it on his desk for his signature. She did so and left for lunch. When she returned, the letter was on
her desk with a typographical error circled in red and a note from her boss to redo the letter. Janet
thinks, “This is it! I will surely be fired now!”
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 Personalization
With personalization, the person takes complete responsibility for situations without considering that
other circumstances may have contributed to the outcome.
e.g. Jack, who sells vacuum cleaners door-to-door, has just given a 2-hour demonstration to Mrs. W.
At the end of the demonstration, Mrs. W tells Jack that she appreciates his demonstration, but she
won’t be purchasing a vacuum cleaner from him. Jack thinks, “I’m a lousy salesman” (when in fact,
Mrs. W’s husband lost his job last week and they have no extra money to buy a new vacuum cleaner at
this time).
Schemas (Core Beliefs) Beck and Weishaar (2011) defined cognitive schemas as:
Structures that contain the individual’s fundamental beliefs and assumptions. Schemas develop early
in life from personal experience and identification with significant others. These concepts are
reinforced by further learning experiences and, in turn, influence the formation of beliefs, values, and
attitudes.
These schemas, or core beliefs, may be adaptive or maladaptive. They may be general or specific, and
they may be latent, becoming evident only when triggered by a specific stressful stimulus. Schemas
differ from automatic thoughts in that they are deeper cognitive structures that serve to screen
information from the environment. For this reason they are often more difficult to modify than
automatic thoughts. However, the same techniques are used at the schema level as at the level of
automatic thoughts. Schemas can be positive or negative, and generally fall into two broad categories:
those associated with helplessness and those associated with unloveability (Beck, 1995).

Schema category Maladaptive negative Adaptive positive

Helplessness N No matter what I do, I will fail. If I try and work very hard, I will
u succeed.
I must be perfect, if I make one
m mistake, I’ll lose everything. I I am not afraid of a challenge. If I
m make a mistake I will try again.

U Unloveability I’m stupid, no one would love me.I I am a loveable person.

I
I am nobody without a woman. People respect me for myself.

Techniques of Cognitive Therapy

The three major components of cognitive therapy are didactic or educational aspects, cognitive
techniques, and behavioral interventions (Sadock & Sadock, 2007; Wright, Thase, & Beck, 2008).

1. Didactic (Educational) Aspects

One of the basic principles of cognitive therapy is to prepare the client to eventually become his or
her own cognitive therapist. The therapist provides information to the client about what cognitive
therapy is, how it works, and the structure of the cognitive process. Explanation about expectations
of both client and therapist is provided. Reading assignments are given in order to reinforce learning.
Some therapists use audiotape or videotape sessions to teach clients about cognitive therapy. A full
explanation about the relationship between depression (or anxiety, or whatever maladaptive response
the client is experiencing) and distorted thinking patterns is an essential part of cognitive therapy.

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2. Cognitive Techniques
Strategies used in cognitive therapy include recognizing and modifying automatic thoughts
(cognitive errors) and recognizing and modifying schemas (core beliefs). Wright, Thase, and Beck
(2008) identify the following techniques commonly used in cognitive therapy.
Recognizing Automatic Thoughts and Schemas
a. Socratic Questioning
In Socratic questioning (also called guided discovery), the therapist questions the client about his or
her situation. With Socratic questioning, the client is asked to describe feelings associated with
specific situations. Questions are stated in a way that may stimulate in the client recognition of
possible dysfunctional thinking and produce dissonance about the validity of the thoughts.
b. Imagery and Role Play
When Socratic questioning does not produce the desired results, the therapist may choose to guide
the client through imagery exercises or role-play in an effort to elicit automatic thoughts. Through
guided imagery, the client is asked to “relive” the stressful situation by imagining the setting in
which it occurred. Where did it occur? Who was there? What happened just prior to the stressful
situation? What feelings did the client experience in association with the situation? Role-play is not
used as commonly as imagery. It is a technique that should be used only when the relationship
between client and therapist is exceptionally strong and there is little likelihood of maladaptive
transference occurring. With role-play, the therapist assumes the role of an individual within a
situation that produces a maladaptive response in the client. The situation is played out in an effort to
elicit recognition of automatic thinking on the part of the client.
c. Thought Recording
This technique, one of the most frequently used methods of recognizing automatic thoughts, is
taught to and discussed with the client in the therapy session. Thought recording is assigned as
homework for the client outside of therapy. In thought recording, the client is asked to keep a written
record of situations that occur and the automatic thoughts that are elicited by the situation. This is
called a “two-column” thought recording. Some therapists ask their clients to keep a “three-column”
recording, which includes a description of the emotional response also associated with the situation.

Modifying Automatic Thoughts and Schemas

a. Generating Alternatives
To help the client see a broader range of possibilities than had originally been considered, the
therapist guides the client in generating alternatives.
b. Examining the Evidence
With this technique, the client and therapist set forth the automatic thought as the hypothesis, and
they study the evidence both for and against the hypothesis.
c. Decatastrophizing
With the technique of decatastrophizing, the therapist assists the client to examine the validity of a
negative automatic thought. Even if some validity exists, the client is then encouraged to review
ways to cope adaptively, moving beyond the current crisis situation.
d. Reattribution
It is believed that depressed clients attribute life events in a negatively distorted manner; that is, they
have a tendency “to blame themselves for adverse life events and to believe that these negative
situations will last indefinitely” (Wright, Thase, & Beck, 2008, p. 1216). Through Socratic
questioning and testing of automatic thoughts, this technique is aimed at reversing the negative
attribution of depressed clients from internal and enduring to the more external and transient manner
of nondepressed individuals.
e. Daily Record of Dysfunctional Thoughts (DRDT)
The DRDT is a tool commonly used in cognitive therapy to help clients identify and modify
automatic thoughts. Two more columns are added to the threecolumn thought record presented
earlier. Clients are then asked to rate the intensity of the thoughts and emotions on a 0- to 100-
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percent scale. The fourth column of the DRDT asks the client to describe a more rational cognition
than the automatic thought identified in the second column and rate the intensity of the belief in the
rational thought. In the fifth column, the client records any changes that have occurred as a result of
modifying the automatic thought and the new rate of intensity associated with it. With this tool, the
client is able to modify automatic thoughts by identifying them and actually formulating a more
rational alternative.

f. Cognitive Rehearsal
This technique uses mental imagery to uncover potential automatic thoughts in advance of their
occurrence in a stressful situation. A discussion is held to identify ways to modify these
dysfunctional cognitions. The client is then given “homework” assignments to try these newly
learned methods in real situations.

3. Behavioral Interventions
It is believed that in cognitive therapy, an interactive relationship exists between cognitions and
behavior; that is, that cognitions affect behavior and behavior influences cognitions. With this
concept in mind, a number of interventions are structured for the client to assist him or her to
identify and modify maladaptive cognitions and behaviors. The following procedures, which are
behavior oriented, are directed toward helping clients learn more adaptive behavioral strategies that
will in turn have a more positive effect on cognitions (Basco, McDonald, Merlock, & Rush, 2004;
Sadock & Sadock, 2007; Wright et al., 2008):

a. Activity Scheduling.
With this intervention, clients are asked to keep a daily log of their activities on an hourly basis and
rate each activity, for mastery and pleasure, on a zero-to-ten scale. The schedule is then shared with
the therapist and used to identify important areas needing concentration during therapy.
b. Graded Task Assignments.
This intervention is used with clients who are facing a situation that they perceive as overwhelming.
The task is broken down into subtasks that clients can complete one step at a time. Each subtask will
have a goal and a time interval attached to it. Successful completion of each subtask helps to
increase self-esteem and decrease feelings of helplessness.
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c. Behavioral Rehearsal.
Somewhat akin to, and often used in conjunction with, cognitive rehearsal, this technique uses role-
play to “rehearse” a modification of maladaptive behaviors that may be contributing to dysfunctional
cognitions.
d. Distraction.
When dysfunctional cognitions have been recognized, distraction can occur by engaging in activities
that redirect the client’s thinking and divert him or her from the intrusive thoughts or depressive
ruminations that are contributing to the maladaptive responses.
e.Miscellaneous Techniques.
Relaxation exercises, assertiveness training, role modeling, and social skills training are additional
types of behavioral interventions that are used in cognitive therapy to assist clients to modify
dysfunctional cognitions. Thought-stopping techniques may also be used to restructure dysfunctional
thinking patterns.

EFFICACY
Cognitive therapy can be used alone in the treatment of mild to moderate depressive disorders or in
conjunction with antidepressant medication for major depressive disorder. Studies have clearly
shown that cognitive therapy is effective and in some cases is superior or equal to medication alone.
It is one of the most useful psychotherapeutic interventions currently available for depressive
disorders, and it shows promise in the treatment of other disorders. Cognitive therapy has also been
studied as a way of increasing compliance with lithium (Eskalith) prescription by patients with
bipolar I disorder and as an adjunct in treating withdrawal from heroin.

Indications for cognitive therapy

1. Criteria that justify the administration of cognitive therapy alone:

Failure to respond to adequate trials of two antidepressants
partial response to adequate dosages of antidepressants
failure to respond or only a partial response to other psychotherapies
diagnosis of dysthymic disorder
variable mood reactive to environmental events
variable mood that correlates with negative cognitions
mild somatoform disorders (sleep, appetite, weight, libidinal)
adequate reality testing (i.e, no hallucinations or delusions), span of concentration and
memory function
inability to tolerate medication effects or evidence that excessive risk is associated with
pharmacotherapy

2. Features that suggest cognitive therapy alone is not indicated:

evidence of coexisting schizophrenia, dementia, substance related disorders, mental
retardation
patient has medical illness or is taking medications that is likely to cause depression
obvious memory impairment or poor reality testing (hallucinations, delusions)
h/o manic episode (bipolar I disorder)
h/o family member who responded to antidepressant
h/o family member with manic episode (bipolar I disorder)
absence of precipitating or exacerbating environmental stresses
little evidence of cognitive distortions
presence of severe somatoform disorders (e.g. pain disorder)

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3. 3. Indications for combined therapies (medications plus cognitive therapy):
partial or no response to trial of cognitive therapy alone
partial but incomplete response to adequate pharmacotherapy alone
poor compliance with medication regimen
historical evidence of chronic maladaptive functioning with depressive syndrome on
intermittent basis
presence of severe somatoform disorders & marked cognitive distortions (e.g
hopelessness)
impaired memory and concentration and marked psychomotor difficulty
major depressive disorder with suicidal danger
h/o first degree relative who responded to antidepressants
h/o manic episode in relative or parent

Process of cognitive therapy

CT involves 7 phases:
1. Provision of a cognitive rationale for depression and its remediation
2. Training in self-monitoring of mood and activities
3. Behavioral activation strategies
4. Training in the identification of automatic thoughts (which are defined as accessible
ruminations that often exist on a “back channel” of the stream-of-consciousness)
5. Evaluation of beliefs
6. Exploration of underlying assumptions (which are defined as higher-order beliefs
inferred from consistencies in individual’s thoughts, emotions and behavior
7. Preparation for termination and relapses.

The process of cognitive therapy entails both set of techniques and a particular style of interaction or
therapeutic relationship known as ‘collaborative empirisism’ (Beck et al. 1979a). The therapist
aims to create an atmosphere where resistance and competition between therapist and patient are
reduced by a collaborative, task-oriented alliance. The therapist blends empathy with an active and
problem-oriented focus. The main tool to maintain this focus is referred to as ‘Socratic questioning’
(Beck et al. 1979a), so-called in that it attempts to imitate a philosophical dialogue. Socrates used
questions rather than assertions to expose the illogical or inconsistent quality of another person’s
position. Patients are expected to develop questioning and curious attitude towards their condition,
extending to erecting hypothesis about links between thoughts and feelings and designing
experiments to test these. The therapist’s stance is prescriptive in so far as s/he makes certain
assumptions about the phenomena on which to focus and plays an active role in structuring sessions
and setting homework tasks. However, the role is not entirely directive since the therapist looks to
the patient to provide crucial information and to participate actively in gaining an understanding of
his problems.
Just as the therapist is expected to be active, so is the patient. He completes homework exercises
from the very first session in order to generalize skills acquired in therapy to everyday life.
Completion of the exercises is associated with better outcomes, an effect not solely due to
differences in motivation or the use of active coping strategies.
The structure of a typical session reflects this active, problem-focused style. It often begins with a
review of homework tasks, followed by the drawing up of an agenda in order of importance. Only a
limited number of issues can be covered during a single session. Many patients find it difficult to
focus on a distinct topic without straying into other ostensible relevant problems, but which may not
facilitate resolutions of the issue at hand. This is not surprising given that most patients experience
their situation as a complex tangle of intertwined facets; this contributes to a perception of being
‘stuck’ and unable to change self-defeating behaviors. A cardinal technique is to inculcate the idea of
dealing with one problem at a time, or even to divide it up into subtasks. Accordingly, an important
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skill for the therapist is to re-direct a patient to the task at hand, while empathetically confirming that
any related matters raised are pertinent but will be attended to at another time.
The therapist seeks to identify the salient cognitive and behavioral dimensions of the problem.
Specifically, s/he tries to differentiate between objective reality and the patient’s idiosyncratic
cognitive appraisal of events and related emotional reactions. Once these elements are clearly
delineated, therapist and patient attempt to identify one or two automatic thoughts inherent in the
emotional response. With target cognitions mapped out, a range of strategies are deployed to
evaluate their veracity and adaptiveness and to devise more realistic and useful alternatives. At the
end of the session the therapist reviews the material covered, seeks the patient’s feedback and sets
homework exercises to be completed before the next appointment.
Techniques relate to the aims of therapy: to elicit and test automatic thoughts; provide rational
alternatives; and identify and modify underlying dysfunctional schemata. Early on, when symptoms
reduction is the goal stressed, work focuses on automatic thoughts. It is important to work efficiently
to affect prompt symptomatic relief, especially in a condition like depression where motivation is a
key factor and the risk of suicide may loom. Therapy is thus more prescriptive, behaviorally focused
and structures in early sessions.
Behavioral techniques (called thus because they emphasize overt behavior, not because they fail to
target cognitive mechanisms) include scheduling activities, graded task assignments, behavioral and
cognitive rehearsal and diversion techniques. Exposure may also be used extensively, especially to
overcome anxiety. Scheduling involves recording what is done between 9am and 12 midnight, on an
hourly basis. Activities are rated for both mastery (i.e level of achievement for the patient to do an
activity) and pleasure, on 10-points scales. This is usually the first task for patients, especially those
with depression, since it helps both the therapist and patient to observe links between activities and
mood. It also helps to break down the patient’s perception of being in a consistently dysphoric mood,
whatever the circumstances. Once these links are established, scheduling is used to lift mood (or at
least to alleviate the worst periods), as well as to provide for a sense of achievement when difficult
tasks are attempted.
Graded task assignments help patients to achieve difficult goals ( e.g. challenging a superior at work)
by breaking down the required activity into more achievable subtasks. These assignments are a good
‘tonic’ for those who typically try to achieve everything at once, or procrastinate. They also help
patients unwilling to accept the limitations imposed by their clinical status (i.e. being severely
depressed). In cases where problems in concentration, low self-efficacy or skill deficit interfere with
task completion, behavioral and cognitive rehearsal is conducted during the session or as homework
in order to increase the capacity to overcome these obstacles. Rehearsal is particularly effective to
improve skills for managing anger or interpersonal conflict. Finally, diversion techniques, such as
physical activity, social contact and imagery are used to achieve temporary relief form dysphoric
emotions.
Techniques applied early in therapy also seek to identify and test automatic thoughts. The nature of
these is first explained, including their role in maintaining unwanted emotional states and problem
behaviors. One explicit way to identify these thoughts is to ask patient what goes through their mind
when they experience an unpleasant emotional state or face a difficult situation. Although some
recall and report these phenomena readily, a clear recollection may be biased by the post hoc nature
of the task. Various strategies are therefore deployed to examine the relationship between automatic
thoughts and problematic behavior and emotions as realistically as possible. For instance, a mood
change during the session is an ideal opportunity to inquire about accompanying thoughts (e.g. a
depressed patient who becomes upset while reflecting on a past rejection, or the anxious patient
apprehension about the consultation itself). Imagery also helps to recall the full emotional context of
a situation in more detail than is afforded by verbal account alone. The therapist must work with the
patient to paint as vivid a picture as possible, while the latter shares associated thoughts and feelings.
Role-playing can also provide a more vital set of cues in order to recall cognitive-emotive links.

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The ‘downward arrow’ technique (Burns 1980) is a method to explore the relationship between
conscious cognitions and dysfunctional assumptions. The therapist repeatedly asks ‘ so what if that
is true, what does that mean ?” (with appropriate variations in phrasing) to thoughts a patient
associates with a dysphoric state. This is particularly pertinent when automatic thoughts are not as
potent as the emotional response engendered by them. Insight into basic fear, such as loneliness,
failure, subordination or being overwhelmed by one’s own emotions, often ensues. The technique
also enables hypothesis development about dysfunctional schemata that underlie vulnerability.
Another strategy commonly utilized to assess negative automatic thoughts is self-monitoring such
the daily record of dysfunctional thoughts. Patients are required to recognize unpleasant emotions by
recording their occurrence, the situation or thought that trigerred them and associated automatic
thoughts. Patients complete this record sheet during or as close to actual experience as they are able
in the hope that the quality of information gained will be superior when recorded in vivo rather than
when recalled during a session. The next step is to test the accuracy and adaptiveness of negative
thoughts. Much time is devoted to this and to developing rational alternatives. Socratic questioning
is used to probe thoughts related to problematic emotions and behavior. These questions are:
What is the evidence to support the thought ?
Are there any alternative interpretations ?
Am I totally to blame for this negative event and can I do anything about it ?
What if my interpretation is true? How will I manage then? (Thase and Beck 1993).
These questions aim to establish to what degree particular thoughts or skill deficit, how the patient
can best cope with a ‘worst-case scenario’.
The final step in dealing with negative automatic thoughts is to develop rational alternatives. The
therapist leads a problem-solving exercise to test current thoughts and alternatives by posing the
above questions. The daily record of dysfunctional thoughts is used extensively at this point, first
during and then between sessions at times of distress. The record asks the patient to consider realistic
alternatives to specific negative automatic thoughts and to re-rate their emotional state and level of
belief in the original thoughts. The therapist guides this process initially in the anticipation that the
patient will eventually apply the procedure in the ‘heat of the moment’. When facing an emotionally
demanding situation she first records her thoughts in vivo and then collaboratively works on
developing alternatives during a session. A phase follows in which the patient is encouraged to
become progressively more independent at this task, until she is able to apply it during the most
difficult episodes between sessions.
On occasion, evolution of realistic cognitions prompts further negative automatic thoughts which
ironically make it seem that realistic thoughts are emotionally aversive. For instance, a patient
responding to the thought: ‘because a person only spoke to me briefly, he must be angry with me’
with a realistic response ‘If he were really angry with me he probably would have expressed it more
obviously’ may be reminded of previous occasions when people expressed anger towards him and of
his perceived inability to cope with this experience. These second-order automatic thoughts are dealt
with directly to ensure they do not hinder therapy. With progress the patient is encouraged to
‘internalize’ these new skills by relying less on recording techniques, such as the daily record of
dysfunctional thoughts and more on mental self-monitoring.
During therapy, consistent themes in the negative automatic thoughts that a patient experiences in a
number of circumstances usually emerge. These themes are indicative of dysfunctional assumptions
underlying these phenomena. All the above procedures are relevant to detect these. Autobiographical
techniques are also applied to examine the evolution of these assumptions. This process may begin
from as early as the first few sessions to a later point after a measure of symptomatic control has
been achieved. Techniques used to bring about change in basic attitudes resemble those used with
automatic thoughts in that they employ a logical, philosophical and empirical examination.
However, the process is slower, involving more exploration and reflection than modifying thoughts.
Conducting ‘behavioral experiments’ in which a patient acts in accordance with an alternative to a
customary dysfunctional assumption provide experiential as well as logical evidence that he need not
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 be bound by these maladaptive beliefs. For instance, in a patient living by the rule: ‘if I disagree with
someone, even in the smallest way, he will reject me,’ an experiment in which he voices polite
disagreement with others in order to find that this is not necessarily followed by rejection, may
provide crucial evidence for an alternative viewpoint.

BEHAVIOR THERAPY
The term behavior in behavior therapy refers to a person’s observable actions and responses. It
involves changing the behavior of patients to reduce dysfunction and to improve quality of life.
Behavior therapy includes a methodology, referred to as behavior analysis, for the strategic selection
of behaviors to change, and a technology to bring about behavior change, such as modifying
antecedents or consequences or giving instructions.
Behavior therapy has not only influenced mental health care, but, under the rubric of behavioral
medicine, it has also made inroads into other medical specialties.
A form of psychotherapy, the goal of which is to modify maladaptive behavior patterns by
reinforcing more adaptive behaviors.
It is form of treatment for problems in which a trained person deliberately establishes a professional
relationship with the patient, with the objective of removing or modifying existing symptoms and
promoting positive personality, growth and development.
Behavior therapy represents clinical applications of the principles developed in learning theory.
Behavioral psychology, or behaviorism, arose in the early 20th century in reaction to the method of
introspection that dominated psychology at the time. John B. Watson, the father of behaviorism, had
initially studied animal psychology. This background made it a small conceptual leap to argue that
psychology should concern itself only with publicly observable phenomena (i.e., overt behavior).
According to behavioristic thinking, because mental content is not publicly observable, it cannot be
subjected to rigorous scientific inquiry. Consequently, behaviorists developed a focus on overt
behaviors and their environmental influences. Today, different behavioral schools continue to share
a focus on verifiable behavior. Behavioral views differ from cognitive views in holding that
physical, rather than mental, events control behavior. According to behaviorism, mental phenomena
or speculations about them are of little or no scientific interest. The principles of behavior therapy as
we know it today are based on the early studies of classical conditioning by Pavlov (1927) and
operant conditioning by Skinner (1938).

It can also help treat conditions and disorders such as:

 Depression
 Anxiety
 Panic disorder
 eating disorders.
 post-traumatic stress disorder (PTSD)
 bipolar disorder.
 ADHD.
 phobias, including social phobias.
 obsessive compulsive disorder (OCD)
 self-harm.
 substance abuse.
Behavior therapy involves identifying maladaptive behaviors and seeking to correct these by
applying the principles of learning derived form the following theries:
 Classical conditioning model by Ivon Pavlov (1936)
 Operant conditioning model by BF Skinner (1953)

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Classical Conditioning
Generally, behavior therapy reduces the occurrence of problematic behaviors. Behavioral therapy is
very effective when used with a current problem that is relevant to the client’s life (Zeidan et al.,
2011). It focuses on behavioral learning processes, including classical conditioning . The principles
of classical conditioning are as follows:
■ People learn to associate a particular feeling state with a particular circumstance that then
becomes a conditioned stimulus for the feeling.
■ Over time, the association between the circumstance and the feeling is strengthened through
repetition and rehearsal.
The therapist’s goal in behavior therapy is to decrease or eliminate the association of a particular
circumstance (the conditioned stimulus) with a particular feeling.

Operant Conditioning
Operant conditioning is another behavioral learning process and is based on the following concepts:
■ People are positively reinforced for certain behaviors.
■ People learn to seek further positive reinforcement (an environmental event that rewards, and
thus increases the probability of, a behavioral response) by increasing that behavior.
■ Positive reinforcement results from either obtaining something desirable or avoiding something
unpleasant.
The therapist’s goal in operant conditioning is to help the individual increase positive reinforcement
through more adaptive and effective behavior. The effort to change health-related behavior can be
facilitated with a behavioral contract. An effective behavioral contract must be tailored for the
individual, and a comprehensive behavioral assessment is necessary to design such a contract and
form practical, measurable, and feasible objectives and goals.

Techniques for Modifying Client Behavior

1. Shaping: In shaping the behavior of another, reinforcements are given for increasingly closer
approximations to the desired response. For example, in eliciting speech from an autistic child, the
teacher may first reward the child for (a) watching the teacher’s lips, then (b) for making any sound
in imitation of the teacher, then (c) for forming sounds similar to the word uttered by the teacher.
Shaping has been shown to be an effective way of modifying behavior for tasks that a child has not
mastered on command or are not in the child’s repertoire (Souders, DePaul, Freeman, & Levy,
2002). Behavior shaping has been used to treat selective, or elective, mutism, a condition
manifested by an otherwise normal child's refusal to speak in school.

2. Modeling: Modeling refers to the learning of new behaviors by imitating the behavior in others.
Role models are individuals who have qualities or skills that a person admires and wishes to imitate
(Howard, 2000). Modeling occurs in various ways. Children imitate the behavior patterns of their
parents, teachers, fri alike model many of their behaviors after individuals observed on television
and in movies. Unfortunately, modeling can result in maladaptive behaviors, as well as adaptive
ones. In the practice setting clients may imitate the behaviors of practitioners who are charged with
their care. This can occur naturally in the therapeutic community environment. It can also occur in a
therapy session in which the client watches a model demonstrate appropriate behaviors in a role-play
of the client’s problem. The client is then instructed to imitate the model’s behaviors in a similar
role-play and is positively reinforced for appropriate imitation.
Behavior modeling is used effectively to treat people with a variety of mental health concerns, from
anxiety disorders to post-traumatic stress disorder, attention deficit disorder to eating disorders and
phobias.

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3. Premack Principle This technique, named for its originator, states that a frequently occurring
response (R1) can serve as a positive reinforcement for a response (R2) that occurs less frequently
(Premack, 1959). This is accomplished by allowing R1 to occur only after R2 has been performed.
For example, 13-year-old Jennie has been neglecting her homework for the past few weeks. She
spends a lot of time on the telephone talking to her friends. Applying the Premack principle, being
allowed to talk on the telephone to her friends could serve as a positive reinforcement for completing
her homework.

4. Extinction Extinction is the gradual decrease in frequency or disappearance of a response when the
positive reinforcement is withheld. A classic example of this technique is its use with children who
have temper tantrums. The tantrum behaviors continue as long as the parent gives attention to them but
decrease and often disappear when the parent simply walks away from the child and ignores the
behavior. It is used in negative behaviors such as guilt tripping, temper tantrums, manipulation,
gossiping, jealousy, poor listening, bad manners.

5. Contingency Contracting In contingency contracting, a contract is drawn up among all parties

involved. The behavior change that is desired is stated explicitly in writing. The contract specifies
the behavior change desired and the reinforcers to be given for performing the desired behaviors.
The negative consequences or punishers that will be rendered for not fulfilling the terms of the
contract are also delineated. The contract is specific about how reinforcers and punishment will be
presented; however, flexibility is important so that renegotiations can occur if necessary. It is used in
eating disorders, aggression, marital problems.

6. Token Economy Token economy is a type of contingency contracting (although there may or
may not be a written and signed contract involved) in which the reinforcers for desired behaviors are
presented in the form of tokens. Essential to this type of technique is the prior determination of items
and situations of significance to the client that can be employed as reinforcements. With this therapy,
tokens are awarded when desired behaviors are performed and may be exchanged for designated
privileges. For example, a client may be able to “buy” a snack or cigarettes for 2 tokens, a trip to the
coffee shop or library for 5 tokens, or even a trip outside the hospital (if that is a realistic possibility)
for another designated number of tokens. The tokens themselves provide immediate positive
feedback, and clients should be allowed to make the decision of whether to spend the token as soon
as it is presented or to accumulate tokens that may be exchanged later for a more desirable reward. It
is used in alcoholics, prisoners, OCD, ADHD clients.

7. Time-Out Time-out is an aversive stimulus or punishment during which the client is removed
from the environment (5-10mins) where the unacceptable behavior is being exhibited. The client is
usually isolated so that reinforcement from the attention of others is absent. It is used in patients with
Aggressive or abusive behavior (shouting, personal insults gossip, insulting, discrimination, bully).

8. Reciprocal Inhibition Also called counter-conditioning, reciprocal inhibition decreases or

eliminates a behavior by introducing a more adaptive behavior, but one that is incompatible with the
unacceptable behavior (Wolpe, 1958). An example is the introduction of relaxation exercises to an
individual who is phobic. Relaxation is practiced in the presence of anxiety so that in time the
individual is able to manage the anxiety in the presence of the phobic stimulus by engaging in
relaxation exercises. Relaxation and anxiety are incompatible behaviors. It is used in patients with
anxiety and phobias.

9. Overt Sensitization Overt sensitization is a type of aversion therapy that produces unpleasant
consequences for undesirable behavior. For example, disulfiram (Antabuse) is a drug that is given to
individuals who wish to stop drinking alcohol. If an individual consumes alcohol while on Antabuse
15
therapy, symptoms of severe nausea and vomiting, dyspnea, palpitations, and headache will occur.
Instead of the euphoric feeling normally experienced from the alcohol (the positive reinforcement
for drinking), the individual receives a severe punishment that is intended to extinguish the
unacceptable behavior (drinking alcohol). It is used in patient with overeating, alcohol and drug
abuse, and smoking.

10. Covert Sensitization Covert sensitization relies on the individual’s imagination to produce
unpleasant symptoms rather than on medication. The technique is under the client’s control and can
be used whenever and wherever it is required. The individual learns, through mental imagery, to
visualize nauseating scenes and even to induce a mild feeling of nausea. This mental image is
visualized when the individual is about to succumb to an attractive but undesirable behavior. It is
most effective when paired with relaxation exercises that are performed instead of the undesirable
behavior. The primary advantage of covert sensitization is that the individual does not have to
perform the undesired behaviors but simply imagines them. It is used in patient with eating
disorders, alcohol abuse, drug addictions, sex addiction, self-injury, and suicide attempts.

11.Systematic Desensitization Systematic desensitization is a technique for assisting individuals to

overcome their fear of a phobic stimulus.
In systematic desensitization, patients attain a state of complete relaxation and are then exposed to
the stimulus that elicits the anxiety response. The negative reaction of anxiety is inhibited by the
relaxed state, a process called reciprocal inhibition. Rather than using actual situations or objects that
elicit fear, patients and therapists prepare a graded list or hierarchy of anxiety provoking scenes
associated with a patient’s fears. The learned relaxation state and the anxiety-provoking scenes are
systematically paired in treatment.
Thus, systematic desensitization consists of three steps: relaxation training, hierarchy construction,
and desensitization of the stimulus.
Relaxation Training Relaxation produces physiological effects opposite to those of anxiety: slow
heart rate, increased peripheral blood flow, and neuromuscular stability. A variety of relaxation
methods have been developed. Some, such as yoga and Zen, have been known for centuries. Most
methods use so-called progressive relaxation, developed by the psychiatrist Edmund Jacobson.
Patients relax major muscle groups in a fixed order, beginning with the small muscle groups of the
feet and working cephalad or vice versa. Some clinicians use hypnosis to facilitate relaxation or use
tape-recorded exercise to allow patients to practice relaxation on their own. Mental imagery is a
relaxation method in which patients are instructed to imagine themselves in a place associated with
pleasant, relaxed memories. Such images allow patients to enter a relaxed state or experience (as
Herbert Benson termed it) the relaxation response. The physiological changes that take place during
relaxation are the opposite of those induced by the adrenergic stress responses that are part of many
emotions. Muscle tension, respiration rate, heart rate, blood pressure, and skin conductance decrease.
Finger temperature and blood flow to the finger usually increase. Relaxation increases respiratory
heart rate variability, an index of parasympathetic tone.
Hierarchy Construction When constructing a hierarchy, clinicians determine all the conditions that
elicit anxiety, and then patients create a hierarchy list of 10 to 12 scenes in order of increasing
anxiety. For example, an acrophobic hierarchy may begin with a patient’s imagining standing near a
window on the second floor and end with being on the roof of a 20-story building, leaning on a
guard rail and looking straight down.

16
 Desensitization of the Stimulus In the final step, called desensitization, patients proceed
systematically through the list from the least to the most anxiety-provoking scene while in a deeply
relaxed state. The rate at which patients progress through the list is determined by their responses to
the stimuli. When patients can vividly imagine the most anxiety-provoking scene of the hierarchy
with equanimity, they experience little anxiety in the corresponding real-life situation.
An example of a hierarchy of events associated with a fear of elevators may be as follows:
1. Discuss riding an elevator with the therapist.
Look at a picture of an elevator.
3. Walk into the lobby of a building and see the elevators.
4. Push the button for the elevator.
5. Walk into an elevator with a trusted person; disembark before the doors close.
6. Walk into an elevator with a trusted person; allow doors to close; then open the doors and walk out.
7. Ride one floor with a trusted person, then walk back down the stairs.
8. Ride one floor with a trusted person and ride the elevator back down.
9. Ride the elevator alone.

Indications. Systematic desensitization works best in cases of a clearly identifiable anxiety-

provoking stimulus. Phobias, obsessions, compulsions, and certain sexual disorders have been
treated successfully with this technique.

12. Flooding This technique, sometimes called implosive therapy, is also used to desensitize
individuals to phobic stimuli. It differs from systematic desensitization in that, instead of working up
a hierarchy of anxiety-producing stimuli, the individual is “flooded” with a continuous presentation
(through mental imagery) of the phobic stimulus until it no longer elicits anxiety. Flooding is
believed to produce results faster than systematic desensitization; however, some therapists report
more lasting behavioral changes with systematic desensitization. Some questions have also been
raised in terms of the psychological discomfort that this therapy produces for the client. Flooding is
contraindicated with clients for whom intense anxiety would be hazardous (e.g., individuals with
heart disease or fragile psychological adaptation) (Sadock & Sadock, 2007). It is used to treat phobia
and anxiety disorders including post-traumatic stress disorder

THERAPEUTIC-GRADED EXPOSURE
Therapeutic-graded exposure is similar to systematic desensitization, except that relaxation training is
not involved and treatment is usually carried out in a real-life context. This means that the individual
must be brought in contact with (i.e., be exposed to) the warning stimulus to learn firsthand that no
dangerous consequences will ensue. Exposure is graded according to a hierarchy. Patients afraid of
cats, for example, might progress from looking at a picture of a cat to holding one. It is used in
anxiety-related disorders, including phobias, obsessive-compulsive disorder, social anxiety disorder
and post-traumatic stress disorder or PTSD.

EXPOSURE TO STIMULI PRESENTED IN VIRTUAL REALITY

Advances in computer technology have made it possible to present environmental cues in virtual
reality for exposure treatment. Beneficial effects have been reported with virtual reality exposure of
patients with height phobia, fear of flying, spider phobia, and claustrophobia. Much experimental
work is being done in the field. One model uses an avatar of the patient walking through a crowded
supermarket filled with other avatars (including one of the therapists) as a way of conquering
agoraphobia. It is used in fears such as public speaking and claustrophobia.

ASSERTIVENESS TRAINING
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Assertiveness is defined as assertive behavior that enables a person to act in his or her own best
interest, to stand up for herself or himself without undue anxiety, to express honest feelings
comfortably, and to exercise personal rights without denying the rights of others. Two types of
situations frequently call for assertive behaviors:
(1) setting limits on pushy friends or relatives and
(2) commercial situations, such as countering a sales pitch or being persistent when returning
defective merchandise.
Early assertiveness training programs tended to define specific behaviors as assertive or
nonassertive. For example, individuals were encouraged to assert themselves if somebody got in
front of them in a supermarket checkout line. Increasing attention is now given to context, that is,
what would be assertive behavior in this situation depends on circumstances. It is used in cases with
depression, social anxiety, and problems resulting from unexpressed anger, improve
interpersonal skills and sense of self-respect.

SOCIAL SKILLS TRAINING

Patients with social phobia often have not acquired social skills. In fact, their social defensive
behaviors (e.g., avoiding eye contact, making brief statements, and minimizing self-disclosure)
increase the probability of the rejection that they fear.
Social skills training (SST) is a type of behavioral therapy used to improve social skills in people
with mental disorders or developmental disabilities. SST may be used by teachers, therapists, or
other professionals to help those with anxiety disorders, mood disorders,
personality disorders and other diagnoses
Smooth social functioning is central to most human activity, and social skills problems exist in many
psychiatrically ill patients. Social skills training is based on the belief that skills are learned and
therefore can be taught to those who do not have them. The principles of skill acquisition include the
following:
• Guidance
• Demonstration
• Practice
• Feedback
These principles must be included in implementing an effective social skills training program, which
is often a component of recovery support . Guidance and demonstration are usually used early in the
treatment, followed by practice and feedback. Treatment typically follows four stages:
1. Describing the new behavior to be learned
2. Learning the new behavior through the use of guidance and demonstration
3. Practicing the new behavior with feedback
4. Transferring the new behavior to the natural environment
The types of behaviors that are often taught in these programs include asking questions, giving
compliments, making positive changes, maintaining eye contact, asking others for specific behavior
changes, speaking in a clear tone of voice, and avoiding fidgeting and self-criticism. This treatment
strategy is most often used with patients who lack social skills, assertiveness (assertiveness training),
or impulse control (anger management), as well as with patients who exhibit antisocial behavior.
It is used in anxiety disorders, mood disorders, personality disorders.

AVERSION THERAPY
When a noxious stimulus (punishment) is presented immediately after a specific behavioral
response, theoretically, the response is eventually inhibited and extinguished. Many types of noxious
stimuli are used: electric shocks, substances that induce vomiting, corporal punishment, and social
disapproval. The negative stimulus is paired with the behavior, which is thereby suppressed. The
unwanted behavior may disappear after a series of such sequences. Aversion therapy has been used
for alcohol abuse, paraphilias, and other behaviors with impulsive or compulsive qualities, but this
18
therapy is controversial for many reasons. For example, punishment does not always lead to the
expected decreased response and can sometimes be positively reinforcing. Aversion therapy has
been used with good effect in some cultures in the treatment of opioid addicts.

EYE MOVEMENT DESENSITIZATION AND REPROCESSING

Saccadic eye movements are rapid oscillations of the eyes that occur when a person tracks an object
that is moved back and forth across the line of vision. A few studies have demonstrated that inducing
saccades while a person is imagining or thinking about an anxiety-producing event can yield a
positive thought or image that results in decreased anxiety. Eye movement desensitization and
reprocessing has been used in posttraumatic stress disorders and phobias.

POSITIVE REINFORCEMENT
When a behavioral response is followed by a generally rewarding event, such as food, avoidance of
pain, or praise, it tends to be strengthened and to occur more frequently than before the reward. This
principle has been applied in a variety of situations. On inpatient hospital wards, patients with
mental disorders receive a reward for performing a desired behavior, such as tokens that they can use
to purchase luxury items or certain privileges. The process, known as token economy, has
successfully altered behavior.

Rational Emotive Behavioral Therapy

Rational emotive therapy (RET) was originated by Albert Ellis in 1975 and emphasizes cognitive
causes of emotional problems along with the importance of taking personal responsibility for
maintaining health-damaging thought habits and irrational beliefs (Ellis, 2011). An irrational belief
is a belief that lacks reason and sound judgment. It is a short-term form of psychotherapy that help
one identify self-defeating thoughts and feelings, challenge the rationality of those feelings, and
replace them with healthier, more productive beliefs. Healthy emotional consequences occur when
rational thinking drives adequate functional behaviors.
It is used in ADHD, aggression, fear, anxiety disorder.

Behavior activation
It is an effective approach for treating depression. It seeks to help people understand environmental
sources of their depression and to target behaviors that might maintain or worsen the depression.
It aims to help patients engage more often in enjoyable activities and develop or enhance problem-
solving skills.
It targets inertia and avoidance, working from the “outside-in,” by scheduling activities and using
graded task assignments to allow the patient to slowly begin to increase their chance of having
activity positively reinforced.
Patients are asked to create a hierarchy of reinforcing activities. These are then rank-ordered by
difficulty. Patients track their own goals along with clinicians who reinforce success in moving
through the hierarchy of activities. It is used in patients with depression, obsessive- compulsive
disorder, body dysmorphic disorder, and hoarding.

Response prevention
Response prevention means refraining from compulsions, avoidance, or escape behaviors.
Guiding ind. through imagining a situation at lowest level of distress initially & developing &
rehearse adaptive responses to distress establishes a new pattern. Clinet will face fears and let
obsessive thoughts occur without ‘putting them right’ or ‘neutralising’ them with compulsions.

RESULTS
Behavior therapy has been used successfully for a variety of disorders and can be easily taught It
requires less time than other therapies and is less expensive to administer. Although useful for
19
circumscribed behavioral symptoms, the method cannot be used to treat global areas of dysfunction
(e.g., neurotic conflicts, personality disorders). Controversy continues between behaviorists and
psychoanalysts, which is epitomized by Eysenck’s statement: “Learning theory regards neurotic
symptoms as simply learned habits; there is no neurosis underlying the symptoms, but merely the
symptom itself. Get rid of the symptom and you have eliminated the neurosis.” Analytically oriented
theorists have criticized behavior therapy by noting that simple symptom removal can lead to
symptom substitution: When symptoms are not viewed as consequences of inner conflicts and the
core cause of the symptoms is not addressed or altered, the result is the production of new
symptoms. Whether this occurs remains open to question, however.

BEHAVIORAL MEDICINE

Behavioral medicine uses the concepts and methods described above to treat a variety of physical
diseases. Emphasis is placed on the role of stress and its influence on the body, particularly on the
endocrine system. Attempts to relieve stress are made with the expectation that either the disease
state will lessen or the patient’s ability to tolerate the disease state will strengthen. One study
measured the effects of a behavioral medicine program on symptoms of acquired immunodeficiency
syndrome (AIDS). The treatment group received training in biofeedback, guided imagery, and
hypnosis. Results included significant decreases in fever, fatigue, pain, headache, nausea, and
insomnia and increased vigor and hardiness. Another study of immunological and psychological
outcomes of a stress reduction program was conducted with patients with malignant melanoma.
Results included significant increases in large granular lymphocytes (defined as CD57 with Leu-7)
and natural killer (NK) cells (defined as CD16 with Leu-II and CD56 with NKHI), along with
indications of increased NK cytotoxic activity. Also noted were significantly lower levels of
psychological distress and higher levels of positive coping methods in comparison with patients who
were not part of the group. Many other applications of behavior therapy are used in medical care. In
general, most patients feel they benefit from such interventions, especially in their ability to cope
with chronic illness.

Process of behavioral therapy

1. Identify the problem: investigating problem and it’s history. Also, identifying the baseline
of the problem such as the frequency, duration and severity of the problem.There are a
number of techniques used to assess and identify the problem of a client. This involves
investigating what the problem is and its history. Techniques include: Interviews, reports and
ratings, observations, physiological methods, negotiate goals.
2. Behavioral techniques: involves identifying and developing strategies that will assist in the
change process. Techniques in behavioural therapies apply the learning principles to change
maladaptive behaviours. The techniques do not focus on clients achieving insights into their
behaviour, rather the focus is just on changing the behavior.
3. Implement the Plan: involves the plan that has been developed being implemented for the
process of change to occur
4. Assess progress: the progress pf the plan is assessed and the plan is evaluated. The plan is
revised for any areas of need and successes are reinforced. Reinforcing success helps to keep
the client motivated and ensures more success.
5. Continue the process: the process is continued by ensuring plans are continued and that
plans include preventing relapse of problems.

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Exposure treatment: It is effective in 2/3rd of agoraphobic patients (Mathews et al. 1981) and about
80% of these with obsessive-compulsive disorders (Foa and Goldstein 1987; Marks et al. 1975). It is
also highly effective for specific and social phobias (Marks 1981).
Despite its efficacy for a wide range of psychiatric conditions, there is often concern about using
exposure outside of specialist centre. This arises from erroneous views about its applicability,
success rate and time commitment. In fact, behavioral psychology is a remarkable cost-effective and
efficient treatment and easily applied in general practice and hospital settings. Although training is
required, this can be achieved by reading textbooks dealing with technique and obtaining supervision
from and experienced therapist.
The most effective exposure method has been shown to be prolonged rather than short duration, real
rather fantasy and regularly practiced as self-exposure homework tasks. There were three golden
rules for exposure treatment:
Anxiety is unpleasant but does no harm: ‘I will not die, go mad or lose control’.
Anxiety does eventually diminish: ‘it cannot continue indefinitely if I face up to the situation’.
Practice makes perfect: ‘the more I repeat a particular exposure exercise the easier it becomes’.
Concern about exposure treatment has been that it requires considerable professional input to
accompany a patient into fear-provoking situations. Fortunately, self-exposure instruction can be all
that is required for the treatment of many patients with phobic and obsessive-compulsive disorders.
The efficacy of self-exposure has led to the development of self-help manuals. However, few
patients can complete a treatment programme successfully without some professional assistance. A
professional needs to guide the patient, help to device targets, monitor progress, offer encouragement
and advice in the face of any difficulties.

Self-imposed response prevention

Although exposure is the cornerstone of treatment for obsessive-compulsive disorder, it is not
sufficient to overcome the problem as rituals serve to lessen anxiety and prevent habituation
occurring. Although compulsions or rituals initially reduce anxiety, they only reduce it minimally
and transiently. The limited efficacy of the rituals leads to them being repeated many times. Overall,
they serve, therefore, to prolong anxiety and do not allow the anxiety to diminish naturally.
It is thus necessary to ask the patient not to perform rituals. This can be achieved by educating the
patient about their effect. Exposure tasks should be graded commencing with those which cause
anxiety but at a level which is tolerable without ritualizing. Even with highly motivated patients,
slips will occur and they will find themselves performing the rituals occasionally. It is therefore
advisable to tell them that this is to be expected but will not interfere with therapy as long as they
repeat the exposure task immediately.
An identical approach is taken with the patient seeking reassurance, which also interferes with
habituation by causing temporary relief from anxiety. It is necessary to educate relatives, friends or
professionals who are offering the reassurance so that they respond appropriately. Since relatives
have difficulty withholding reassurance it is useful to role-play situations where this is requested and
suggest they reply ‘Dr X has asked me not to answer questions like that’.

Audio-taped habituation treatment for obsessive ruminations

It involves finding out the complete sequence of thoughts in a rumination. It is then found that some
of these thoughts cause anxiety and are obsessional in type whereas others are anxiety-reducing or
covert rituals. The patient is then asked to record the anxiogenic thoughts on to an audio-tape
without the anxiety-reducing words and phrases. A continuous loop tape, as in answering machines,
is utilized as this saves the patient having to record the same thoughts repeatedly. The patient is then
asked to play the tape back to himself several times a day. The tape is thus an exposure exercise and
must be listened to until anxiety is consistently reduced by at least half. As with all exposure
methods all exposure methods it must be performed regularly until the ruminations cease to be a
problem.
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 Reduction of undesirable behavior
Exposure is useful in overcoming anxiety in most forms of anxiety disorder. However, maladaptive
behavior may develop in response to stimuli unrelated to fear and in these cases alternative strategies
are needed. The therapist has several options depending on the problem:
 Eliminating the behavior using avesive stimuli (only indicated if the behavior is life-
threatening or constitutes a major public nuisance, e.g. convert sensitization);
 Modifying the stimulus leading to the response (e.g. orgasmic reconditioning);
 Modifying the response to the stimulus (e.g. stimulus control techniques);
 Replacing the problem behavior with alternative adaptive responses (e.g. habit reversal);
 Reducing the desirability of the problem behavior (e.g. mass practice; response cost).
These five categories are not mutually exclusive and a therapist who treis to eliminate a particular
behavior without helping the patient to develop alternative strategies will fail at the task.

Application of covert sensitization in the treatment of sexual deviancy

There are very few indications for aversion therapy. It is infrequently used due to ethical
considerations. However, antisocial sexual behavior resulting in threat to others requires effective
action. Rapid treatment to suppress deviant sexual urges based on aversion principles may be
justified.
The form of aversion generally used is convert sensitization. This involves asking the patient, almost
always male, to describe two or three aversive scenes and to rate their degree of aversiveness. An
aversive scene may be related to the deviant behavior (e.g being attacked by fellow prisoners
following conviction) or, if no aversive scene connected with the behavior is forthcoming, can be
unrelated (e.g. falling into a vat of vomit). Scripts are then written describing arousing and aversive
scenes. The patient is asked to relax and to imagine in detail and arousing scene. Before the patient
ends the imagined scene the therapist asks him to change to an aversive scene which is also
described. This procedure is repeated five or six times per session. The patient is then instructed to
read through the scripts in a similar manner at home. Alternatively, the scripts can be audio-taped
and played back at home. It is important to check frequently the anxiety level caused by the aversive
scene as habituation can occur, reducing its aversion value. It is useful to change aversive scripts
frequently to prevent habituation. As therapy progresses the aversive scene is introduced
progressively earlier in the arousing scene until anxiety results as soon as the patient thinks about his
deviant fantasy.
The treatment can succeed but clearly requires high motivation. Even in such cases, an effective plan
must incorporate elements to increase general personal functioning including sexual.

Application of orgasmic reconditioning in the treatment of sexual deviance

If a patient has sexual preferences which worries him and his partner but is not inherently dangerous,
then less radical treatment is used. In orgasmic reconditioning, originally described by Marquis
(1970), the patient is asked to masturbate regularly to his troublesome deviant fantasies but at the
point of orgasmic inevitability, to switch to the desired, ‘non-deviant’ fantasy. As treatment
progresses, the non-deviant stimulus is introduced progressively earlier in the arousal process until
masturbation is achieved without a deviant fantasy. Following this, sexual or social skills training is
usually needed to ensure that the arousal to non-deviant stimuli persists.
When dealing with distressing sexual urges it is important to set realistic goals. It is not possible and
many would argue not desirable, to change the orientation of an exclusively homosexual person. In
this case, counseling to help accept the sexual preference may be indicated. Similarly, if a
homosexual paedophile is referred for treatment, it is unrealistic to set the goal of adult heterosexual
contact. Adult homosexual orientation is more likely to be achievable.

Application of stimulus control techniques in the treatment of obesity

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 Obesity is widespread in the western world and has been resistant to medical, psychodynamic and
early behavioral approaches. The development of behavioral treatment in the 1960s proved more
successful. The programme consists of 4 elements:
 Description of the behavior to be controlled. Patients are asked to keep daily dairies
of amount of food ingested, time and circumstances of eating.
 Modification and control of the discriminatory stimuli governing eating. Patients are
asked to limit their eating to one room, to use distinctive table settings and to make eating a ‘pure’
experience unaccompanied by other activities like reading or watching television.
 Development of techniques to control the act of eating such as counting each
mouthful of food and replacing utensils after each mouthful and leaving some food on the plate at
the end of a meal.
 Prompt reinforcement of behaviors which delay or control eating.
Although this treatment usually results in weight loss, many patients regain it following the
termination. Booster sessions, often run by therapists and available at the person’s worksite, have
been recommended to prevent such relapse.

Treatment of troublesome habits using habit reversal

Problem behavior may take the form of bad habits learned in response to a range of stimuli. Azrin
and Nunn (1973) pioneered the treatment of habit reversal for a number of habits including tics, nail
biting and neurodermatitis. This treatment has four components;
 Awareness training: habits may be performed repeatedly without the patient realizing it.
The first step in treatment is to promote awareness by discussing the habit and its trigger factors and
by asking the patient to record its frequency.
 Competing response training: this involves finding an activity incompatible with the habit
and encouraging the patient to perform this whenever the urge to practise the habit occurs. For e.g. a
young woman with facial tics, started the tic by furrowing her forehead and then progressed to
grimacing with her whole face and bending her neck. Firm pressure lifting her eyebrows aborted the
tic.
 Habit control motivation: It is important that the patient be encouraged to think about the
negative results of the habit and to focus on the improved quality of life resulting form overcoming
it.
 Generalization training: this involves incorporating the competing response into everyday
life in a way which is unobtrusive. For e.g. the woman with facial tics worked at a desk for much of
the day. She found she could control the tics by resting her forehead on to her hand and pushing her
eyebrows upwards. This manoeuvre was not noticeable to colleagues as she appeared to be resting
her head and thinking. She started to wear a hairband which also helped to remind herself not to
contract the muscle of her forehead.

Mass practice
It entails the patient repeating an activity until it becomes boringly repetitive. For e.g. a man who
repeatedly cleared his throat found he was being ridiculed by colleagues. He was instructed to clear
his throat continually for 30mins 3 times a day in private but not to engage in the habit at other
times. After a week of the exercises, he was unable to clear his throat for the period required and no
longer did it at other times.

Response cost
Response cost based on operant principles, involves having the patient perform a penalty which
either consumes time or effort or which is unpleasant whenever target behaviors are performed.
Examples include asking the patient to donate a set sum of money to her least favorite charity
whenever she used a swear word or requiring a child to mop the entire floor following an episode of
urinary incontinence.
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 Applying operant techniques to chronic problems
In the case of long-standing behavioral problems, such as in some institutionalized schizophrenic
patients, treatment based on operant conditioning has been used. This has been described as applying
‘sticks and carrots’ but careful analysis is needed before its application since one person’s ‘carrot’
may be another person’s ‘stick’. Premack (1959) addresses this aspect by observing that high-
frequency preferred activity can be used to reinforce lower-frequency, non-preferred activity. If a
child, for instance, spends most of his time playing with toy soldiers, this preferred activity of
helping to wash-up.
The demand for treatment aimed at reducing undesirable behavior and increasing socially acceptable
forms has increased since the 1980s with the closure of psychiatric hospitals and the move towards
community care.
Positive reinforcement is the most appropriate and commonly applied type of reinforcement.
Negative reinforcement (or punishment) is hardly ever used and only in dangerous or life-
threatening situations (due to ethical considerations). Examples of reinforces are listed below:
Reinforcers which increase specified activities-
(A) positive reinforcers
social approval (e.g. nurse’s approval of a patient’s improved self-care).
Higher frequency preferred activities
Feedback reinforcement (e.g. constructive comments in a social skills group).
Food reinforcers
Tokens: awarded for certain activities which can be ‘spent’ on a number of other reinforcers.
(B) Negative reinforcers: this entails removal of an aversive event
after a specific response is obtained (aversive relief) but it has little place in contemporary treatment.
It may be used covertly however in the management of deviant sexual behavior.
Reinforcers which reduce specified activities-
 Punishment – refers to applying an aversive stimulus in response to certain behaviors; it
should have no role in therapy
 Response cost
- penalty involving time and effort in response to certain behaviors.
- A positive reinforcers is removed if certain non-desired activities are indulged in,
for example, time out (removal of the person from a reinforcing environment for some minutes).

Social skills competence checklist of therapist-trainer behaviors

a. actively helps the patient set and elicit specific interpersonal goals
b. promotes favorable expectations, a therapeutic orientation, and
motivation before role playing begins
c. assists the patient in building possible scenes in term of “What
emotions or communication?” “Who is the interpersonal target?” “Where and when?”
d. structures the role playing by setting the scene and assigning roles
to the patient and surrogates
e. engages the patient in behavioral rehearsal – getting the patient to
role play with others
f. uses self or other group members in modeling appropriate
alternatives for the patient
g. prompts and sues the patient during the role playing
h. uses an active style of training through coaching, shadowing, being
physically out of a seat, and closely monitoring and supporting the patient
i. gives the patient positive feedback for specific verbal and
nonverbal behavioral skills

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j. identifies the patient’s specific verbal and nonverbal behavioral
deficits or excesses and suggest constructive alternatives
k. ignore or suppresses inappropriate and interfering behavior
l. shapes behavioral improvement in small, attainable increments
m. solicits form the patient or suggest and alternative behavior for a
problem situation that can be uses and practiced during the behavioral rehearsal or role playing
n. evaluates deficits in social perception and problem solving and
remedies them
o. gives specific stainable and functional homework assignments.

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