408 pre-final material

Question 1

Zeitgeist and contextual considerations

Answer 1

• “spirit of the times”
• the dominant form of therapy has changed over time, dependent on culture
• what is the believed etiology of psychological problems?
• who is believed to be qualified to perform psychotherapy?
• can we use the scientific method to understand human behaviour?
• can we study psychotherapy using the scientific method?

Question 2

early treatment (prior to 19th century)

Answer 2

• removal from society = prisons where people were treated like prisoners
• the animal tradition like zoos

Question 3

19th century treatment

Answer 3

• moral treatment: giving people relaxing environments and allowing them to contribute to society
• big nice asylums with gardens and a ballroom for socializing, everyone given a job

Question 4

psychoanalysis

Answer 4

• the first formal outpatient psychotherapy (used to be only medication)
• Freud trained as a neurologist and established the first private psychotherapy practice
• hysteria and dream interpretation (case of Anna O. translated into English)

Question 5

Freud’s major contributions

Answer 5

• drive theory: everything comes down to sex instinct, avoiding death, facing mortality
• levels of consciousness: pre-conscious, conscious, unconscious
• personality structure: id, ego, superego
• psychosexual stages of development: oral, anal, phallic, latency, genital stage
• defense mechanisms: repression (preventing thoughts from consciousness), denial
• therapy techniques: dream analysis and free association didn’t stick around
• therapy processes: transference and counter-transference (client-therapist relationship)

Question 6

transference and counter-transference

Answer 6

• transference: client projecting feelings onto the therapist
• counter: therapist feeling some way about the client related to the behaviours the client is showing

Question 7

Stanley Hall

Answer 7

• established APA dedicated to research (science not practice)

Question 8

Lightner Witmer

Answer 8

• first to use the term clinical psychology and to develop a training clinic at a university

Question 9

psychological developments in 1900s

Answer 9

• intelligence testing
• personality testing
• WWII soldiers returning with shell shock syndrome, so academics became interested in practice, not just academics

Question 10

Eysenck’s critique of psychotherapy

Answer 10

• examine 19 studies for psychoanalytic or eclectic psychotherapy looking at neurotic patients for ‘recovery’ (defined by practitioner)
• 44% recovered from psychoanalytic
• 64% with eclectic
• 72% with general practitioner
• concluded that recovery was inversely correlated with amount of psychotherapy received
• 2/3 of patients recovered regardless of psychotherapy
• inspired controlled research studies of psychotherapy (this critique wasn’t based on random assignment or follow-up)
• inspired development of alternatives to psychoanalysis

Question 11

client-centered therapy

Answer 11

• Carl Rogers
• focused on the therapy process and the therapeutic relationship over the techniques
• success of therapy depends on the therapist (different from psychoanalysis where the therapist is a blank slate for the client to project onto)
• focus on person over problem, developing a relationship with the client
• three core therapist qualities: genuineness, empathy, unconditional positive regard
• mobilize self-actualizing tendency (people have the ability to get better)
• Rogers was the first to conduct research on psychotherapy process and outcomes

Question 12

three waves of behaviour therapy

Answer 12

• first: focus on observable behaviour and objective environment (learning and behaviour)
• second: focus on cognitive representations of the environment (your interpretation of the objective environment), emotions and behaviour not just reinforcement
• third: focus on how internal processes are functionally related to the objective environment (thoughts and emotions are normal outcomes of the world)

Question 13

origins of behaviour therapy

Answer 13

• british empiricism: knowledge comes from experience (a blank slate for experience)
• learning theory: we can shape people based on experience (Pavlov’s classical conditioning and Edward Thorndike’s Law of Effect)

Question 14

Behaviourism

Answer 14

• John Watson: Little Albert conditioning and generalization (father of behaviourism)

Question 15

Behaviour therapy

Answer 15

• Mary Cover Jones: de-conditioning a fear in Little Peter (precursor to treatment of phobias and anxiety)
• Mowrer & Mowrer: Bell and pad method for treating enuresis
• Skinner: applied operant conditioning to increase social behaviour in patients with psychosis
• Joseph Wolpe: systematic desensitization (based on classical conditioning) for fear and anxiety - first formal alternative treatment to psychoanalysis

Question 16

Cognitive therapy Bandura & Beck

Answer 16

• Albert Bandura: social learning theory (behaviour influenced by stimuli, reinforcement AND cognitive processes), learning through modelling not just reinforcement
• Aaron Beck: cognitive theory (people respond to cognitive representations of the environment that aren’t always right), biased information processing

Question 17

Cognitive therapy Mahoney & Ellis

Answer 17

• Mahoney mediational approach: need cognition for things to generalize beyond a single situation (goes from stimulus-response to stimulus-organism/interpretation-response)
• Ellis: rational emotive behaviour therapy (unsatisfied with psychoanalysis, so involved cognitions), beliefs as irrational so used persuasion to help patients see thinking errors and adopt more rational philosophies (ABCDE model, therapist has an active role), a clinician but not a researcher

Question 18

ABCDE model

Answer 18

Activating Event/Adversity (situation) = Belief about adversity (interpretation) = Consequences (emotions) = Disputations (therapy challenging beliefs) = Effective new beliefs to replace irrational ones

Question 19

Aaron Beck

Answer 19

• depression due to beliefs of inadequacy and being unlovable (generalized beliefs that people had trouble unlearning)
• beliefs as inaccurate but not irrational
• used empirical disconfirmation to test beliefs (helping people see inaccuracy for themselves, therapist is more passive)
• negative cognitive triad in schemas (negative beliefs about self, world, future)
• conducted RCTs on cognitive therapy vs. medication and showed that it was as effective as pharma, and maintained at follow-up
• developed treatment manuals for research and practice (disseminating)

Question 20

third wave behaviour therapy

Answer 20

• distinct from traditional CBT; emphasis on learning to accept emotions, cognitions, behaviours rather than trying to change them
• thoughts don’t correspond to objective reality, distance yourself instead of engaging with them (don’t need to act in accordance with them)
• focus on valued living instead of symptom reduction (change impairment from Sx)
• ACT, mindfulness-based CT, dialectical behaviour therapy

Question 21

CPA principles for psychotherapy

Answer 21

in ascending order of importance:
(1) respect for dignity of persons and peoples
(2) responsible caring
(3) integrity in relationships
(4) responsibility to society

Question 22

(1) respect for dignity of persons and peoples

Answer 22

• informed consent: understanding the nature of psychotherapy, limits of confidentiality, opportunity to ask questions
• privacy: collect minimal information necessary and keep all records secure
• confidentiality: do not share client information unless required by law

Question 23

(2) responsible caring

Answer 23

• competence and self-knowledge: practice within areas of competence or seek consultation, supervision, training, engage in self-care
• maximize benefit: provide best service possible according to research
• minimize harm: be aware of power differential in therapy, no sexual intimacy

Question 24

integrity in relationships

Answer 24

• accuracy/honesty: accurately represent your credentials and qualifications
• straightforwardness, openness: be clear about fees, policies, limits of confidentiality
• avoidance of conflict of interest: avoid anything that gets in the way of treating your client (avoid multiple relationships)

Question 25

responsibility to society

Answer 25

• respect for society: familiarize yourself with laws and regulations in your jurisdiction
• development of society: act to change aspects of the discipline that detract from beneficial societal change

Question 26

limits of confidentiality

Answer 26

• harm to self or someone else (risk of suicide or homicide) or harm/neglect of a vulnerable person (children, elderly, people with disabilities)
• assessment of degree of risk so clients can still disclose suicidal thoughts

Question 27

Tarasoff v. Board of Regents

Answer 27

• patient had a high likelihood of harming someone else, doctor notified the police
• police questioned the patient but determined no risk, patient later killed Tarasoff
• doctor found liable for the death; duty to warn AND protect (should have contacted Tarasoff to ensure their protection)

Question 28

confidentiality and treating adolescents

Answer 28

• disclosure increases when teens expect confidentiality BUT guardians hold rights to records by providing informed consent so can request info
• therapist should make rules and enforce them (everyone agrees)
• NSSI or suicidal thinking? unsafe sexual activity? drugs and alcohol? violence?
• considerations for disclosure: immediate and future harm (pattern of behaviour?), parental reaction and client-parent relationship, best interest of client and therapeutic relationship
• if disclosure is needed: involve the teen and how to handle it

Question 29

multiple relationships

Answer 29

• multiple roles with the same person or someone closely associated with the client
• not all multiple relationships are unethical, cannot always be avoided, but can create conflicts of interest
• clear violations: sexual relationship with current client
• guiding questions: is the multiple relationship necessary? is it exploitative? who does the multiple relationship benefit? could it damage the client or disrupt the therapeutic relationship?

Question 30

telepsychology

Answer 30

• benefits: increased access, availability, flexibility, rural communities, access to specialist care
• benefits: convenience, satisfaction, increased demand, anonymity and privacy
• ethical concerns: privacy, confidentiality, security (how to secure disclosure, using encrypted tools)
• concerns: therapist competence for technology, therapeutic relationship, informed consent and emergency issues (verifying patient identity and location)
• concern: practicing across borders - therapist needs to be licensed where the client is located (PsyPact for practicing across state borders)

Question 31

recommendations for telepsychology

Answer 31

• comprehensive informed consent procedure
• know emergency care options in client’s area
• ensure clinical and technological competence
• verify client identity
• ensure client and presenting problem are appropriate for telepsychology (social anxiety or agoraphobia)

Question 32

methods to evaluate psychotherapy

Answer 32

• case studies
• naturalistic (how do your clients compare to before with a new form of psychotherapy)
• quasi-experiments (comparing outcomes from different forms of psychotherapy but no random assignment)
• randomized controlled trials (cause-and-effect experimental design) - main tool for efficacy and effectiveness

Question 33

RCT steps

Answer 33

(1) develop the protocol (2) choose a comparison to treatment of interest (3) select participants of interest which will generalize to the population (4) random assignment (5) administer Tx and assess fidelity (6) evaluate outcomes at end of treatment and follow-up

Question 34

RCT step 1

Answer 34

• what is the treatment?
• comes from a theoretical model about the maintenance of a psychological problem
• comes from basic psychological research, armchair theorizing, clinical observation
• treatment techniques: what to do in therapy to change problems
• how will the Tx be administered (needs to be standardized): treatment manual, training, supervision

Question 35

RCT step 2

Answer 35

• comparison Tx
• waitlist control (not very useful anymore since people know they’re not receiving Tx so not like placebo)
• supportive psychotherapy (controlling for interaction with therapist and common factors): doesn’t contain active ingredients so equivalent to placebo
• gold-standard Tx (CBT) to show that it’s at least equivalent, so provides another Tx option

Question 36

RCT step 3

Answer 36

• selecting participants
• balance concerns of internal validity (quality of experimental design and control of extraneous factors) vs. external validity (generalizability to other people and settings)
• want sample to be representative of the population (demographic factors: gender, ethnicity, comorbid diagnoses exclusion vs. inclusion)
• exclusion of comorbidity will improve internal validity but reduce external validity

Question 37

RCT step 4

Answer 37

• random assignment
• assess baseline characteristics
• random assignment minimizes preexisting differences between groups that could affect outcome
• single-blind: P doesn’t know what condition they’re in (may be possible if Ps don’t know much about psychotherapy)
• double-blind: neither P or experimenter knows what condition they’re in (impossible in psychotherapy trials)

Question 38

RCT step 5

Answer 38

• administer Tx
• fidelity checks: ongoing supervision, sessions are recorded and coded to check adherence to treatment
• some therapists are better than others (general interpersonal factors)
• therapist factors: strong therapists doing the Tx and non-skilled doing supportive psychotherapy (confound)

Question 39

RCT step 6

Answer 39

• evaluate Tx
• what is the outcome of interest: decrease in symptoms? not meeting criteria? increase in functioning (more meaningful than statistical significance)
• statistical significance will depend on both magnitude of effect and sample size (larger sample size = more statistical power)
• effect size: magnitude of difference independent of sample size
• therapist and site effects: random factors unrelated to Tx
• attrition: once people are assigned to groups, we account for them in our analyses

Question 40

effect size norms

Answer 40

• Cohen’s d (0.2 small, 0.5 medium, 0.8 large)
• usually we want people to move from being within 1SD of a clinical group to within 1SD of a non-clinical group

Question 41

RCT step 7

Answer 41

• follow-up: relapse or sleeper effect
• sleeper effect: during the Tx people don’t do well, but continue to get better after the treatment (continue practicing skills)
• psychological treatments are more enduring than medication: CBT maintains its improvements better than antidepressants
• CONSORT flow diagram: why people were excluded, how people were randomized, who followed-up, who dropped out

Question 42

meta-analysis

Answer 42

• pools effect size estimates about psychotherapy body of research
• considers sample size into account, weighting more heavily according to the quality of the study
• looks at moderators of efficacy that determine the strength or direction of a relationship

Question 43

Smith & Glass (1977)

Answer 43

• first meta-analysis of psychotherapy of 375 controlled studies
• typical therapy client did better than 75% of untreated clients (compared to Eysenck’s inverse correlation)
• combined effect size = 0.68
• effect sizes similar across treatments

Question 44

Chambless & Hollon criteria for well-established treatments

Answer 44

• at least two ‘good’ between-group design experiments that show that Tx is better to meds, psychotherapy placebo or other treatment OR equivalent to an established Tx OR
• a large series of single-case design experiments with good experimental design and comparison to another treatment AND
• must be conducted with treatment manuals
• characteristics of samples must be clearly defined
• effects must be demonstrated by at least two different investigators or teams

Question 45

probably efficacious treatment criteria

Answer 45

• two studies show Tx is better to waitlist control OR
• one or more experiments meeting criteria for well-established but have not been replicated by independent investigators OR
• a small series of single case design experiments

Question 46

Tolin et al. (2015) criteria

Answer 46

• criticism of Chambless: no consideration of what to do with many studies showing ‘no effect’ or a mixed effect
• focus on systematic reviews and meta-analyses + consider quality and risk of bias of individual studies and systematic review
• focus used to be on Sx reduction, now measure functional impairment and quality of life
• criticism of Chambless: no guidelines for how to choose an EST from the list
• so include information on the strength of treatment and evaluate clinical and statistical significance

Question 47

common factors

Answer 47

• factors characterizing psychotherapy in general: therapeutic alliance, empathy, expectation for improvement, therapist skills

Question 48

history of common factors

Answer 48

• Salu Rosenzweig Dodo bird verdict (all therapies are helpful)
• Jerome and Julia Frank: common factors model (therapist should clarify Sx, inspire hope, facilitate successes and mastery to re-moralize patient to make changes themselves)
• Wampold contextual model

Question 49

Wampold contextual model

Answer 49

• three pathways through which psychotherapy exerts effects
• initial therapeutic relationship (first impression): more clients drop out of therapy after the first session than at any other point
• first pathway: real relationship (genuineness and perception that you’re getting to know the person)
• second: expectations (idea that participation in therapy will aid coping which motivates action = expectations that they can get better)
• third: healthy patient actions (the actions will depend on the type of therapy, but any type of healthy action will be helpful)

Question 50

therapeutic alliance

Answer 50

• an aspect of common factors
• affective bond: do you like the person, respect them, feel good in their company
• agreement on end goals: how do we know when therapy is over, when is there sufficient improvement
• agreement on in-session tasks: what do we do in therapy
• measured with Working Alliance Inventory (can be done after every session to measure a drop or improvement)
• correlation between early therapeutic alliance and therapy outcome is medium

Question 51

empathy

Answer 51

• an aspect of common factors
• an individual can be affected by and share emotional state of another, assess reasons for that state and identify with others’ perspectives
• related constructs: positive regard, affirmation, congruence, genuineness
• when rated by clients, therapists, observers, empathy correlates with therapy outcome (strongest when rated by client)

Question 52

expectations

Answer 52

• an aspect of common factors
• explanation of patient disorder, rationale for treatment, participating in therapeutic actions
• basis for placebo effect: you think it will be helpful, so it will be
• relationship with outcome is small (but patients must understand the rationale to engage in helpful actions)

Question 53

therapist effects

Answer 53

• some therapists produce better outcomes, regardless of nature of patients and treatments delivered
• effects are small-medium in clinical trials (because the treatment delivery is highly controlled), but higher in naturalistic settings (not being supervised as much)

Question 54

facilitative interpersonal skills (FIS) with 8 skill domains

Answer 54

• verbal fluency, therapist’s emotional expression, persuasiveness, warm and positive regard, therapist’s hopefulness, empathy, alliance bond capacity, alliance-rupture-repair responsiveness (recognizing the problem, talk about it and repair it)
• thought to be pre-existing skills that predict client outcome
• self-report assessments are biased (using performance-based measure instead)

Question 55

Anderson et al. (2016)

Answer 55

• self-reported social skills and FIS performance task during first two weeks of graduate program
• clients (2 years later) reported on general Sx and functioning for each session
• higher FIS therapists had clients with better outcomes later on
• effect only present for shorter duration (less than 8 weeks)
• therapist FIS could contribute to sudden gains early on (getting better quicker then leaving therapy)
• if lower FIS therapists can form a strong relationship earlier in therapy and retains the client for longer, the effect goes away

Question 56

evidence for common over specific factors

Answer 56

• any therapy is better than no therapy
• therapies often do not differ when directly compared (and any differences usually reduce when controlling for investigator alliance)
• within a therapy, the therapist who adheres to the manual doesn’t outperform another therapist (null correlation between therapist fidelity and outcome)
• but agree that there need to be actions by the client to elicit change AND that some techniques are better for some conditions

Question 57

evidence for specific factors over common

Answer 57

• no controlled studies exist to demonstrate common factors are sufficient for causing therapeutic change (cannot study common factors experimentally)
• but most people agree that common factors are important and the therapeutic relationship is necessary (though not sufficient)

Question 58

meta-analyses for common factors

Answer 58

• 17 meta-analyses comparing forms of psychotherapy (mean effect size, d - .21 which lowers when controlling for investigator allegiance)
• meta-analysis of 198 studies comparing psychotherapies for depression (each intervention more effective than waitlist, but effect sizes similar for different interventions, except that interpersonal was better than supportive)
• CBT vs. other psychotherapies = CBT only better than psychodynamic only for depression and anxiety

Question 59

suggestions for the future in common vs. specific debate

Answer 59

• prioritize treatment process over treatment outcome research (how the therapy works rather than what works)
• evidence for efficacy from RCTs doesn’t mean that the treatment is valid or will be effective in all situations
• train people on therapeutic principles instead of very specific techniques (only do this if there is very strong support for those techniques)

Question 60

Wampold vs. Fonagy debate

Answer 60

• Fonagy: some therapies work, others don’t - try to figure out which ones work best according to patient needs
• Wampold: the therapies that are more helpful are ones that make patients take actions toward change, just empathy doesn’t work (difference between focused and unfocused unstructured therapy)
• psychodynamic therapy doesn’t work for EDs because just talking doesn’t tackle the focal problem (but CBT does)
• we keep developing new therapies, but patient outcomes don’t change (what changes the outcome is the therapist)

Question 61

conflict between research and therapy

Answer 61

• research is nomothetic (how well does a therapy work, on average, for a population of people)
• therapy is idiographic (conducted one-on-one with a person who may or may not be represented in research studies - lower SES, minorities)
• trying to generalize from nomothetic research to idiographic practice

Question 62

what is the difference between EST and EBP

Answer 62

• EBP is a comprehensive concept including but not limited to EST
• three legs of EBP: best scientific evidence from research + clinical expertise and experience + client perspective and input

Question 63

best available research evidence

Answer 63

• upper levels of the hierarchy minimize sources of error, only go down the levels if nothing else is available
• systematic reviews, meta-analyses (1)
• RCTs (2)
• cohort studies (3)
• case control studies (4)
• case series, case reports (5)
• editorials, expert opinion (6)
• research studies must move beyond best outcome and consider patient or Tx characteristics

Question 64

sources of evidence for EBP

Answer 64

• treatment efficacy: strength of evidence about causal relationships between intervention and disorder (RCTs - carefully designed studies prioritizing internal validity)
• treatment effectiveness or clinical utility: how well does the therapy work in real-world clinical settings (generalizability, feasibility, costs and benefits of intervention)
• basic psychological processes relevant to treatment (memory, attention, emotion, etc.; are these improving in the course of a treatment)

Question 65

patient or treatment characteristics to consider in EBP and research studies

Answer 65

• does a Tx work better for certain patients (patient diversity)
• mode of delivery of treatment (group therapy vs. individual), feasibility of delivery, treatment costs, therapeutic relationship (what role does it play in the treatment)

Question 66

clinical expertise

Answer 66

• competence attained by psychologists thought education, training, and experience that results in effective treatment
• need continuing education
• clinical case conceptualization, treatment planning and implementation, interpersonal expertise (FIS), self-reflection, knowledge and use of research literature, understanding the influence of diversity and culture on treatment, seeking consultation and resources if necessary
• cannot use research evidence for every decision, so make use of clinical judgment (though still grounded in research)

Question 67

patient characteristics, culture, preferences

Answer 67

• just because something works in a RCT doesn’t mean it works for your individual clients
• research can examine patient moderators of Tx effects (is something less helpful for a certain group)
• do treatments generalize to minority groups
• how do comorbid conditions affect effectiveness
• not everyone has the same etiology or maintenance mechanisms

Question 68

CPA report on EBP

Answer 68

• treatment planning comes from RCTs, treatment process research, basic psychological research
• use best available evidence (hierarchy) like replicated studies and studies that address threats to validity
• if no treatment research exists, use practice guidelines (expert consensus) – this is not in APA report
• monitor client reactions, Sx, functioning (see if they’re responding) & prepare to alter Tx based on this, discussion with client, and reconsideration of the evidence – this is not in APA report
• include treatment process research in the evidence

Question 69

treatment process research

Answer 69

research looking at therapeutic relationship, empathy, etc. (how does therapy produce its outcome)

Question 70

advantages of EBP

Answer 70

• improves quality and cost effectiveness of treatment
• enhances accountability (public knows which Tx is recommended so they hold the therapist accountable)

Question 71

criticisms of EBP

Answer 71

• treatment amenable to research is more likely to be included in the list of ESTs (CBT is shorter than psychodynamic, easier to train people, easier to study)
• inappropriately restricting access to certain treatments (insurance won’t pay for non-ESTs even if they might work)

Question 72

relationship between the theoretical base of a treatment and its outcome

Answer 72

• proposed mechanisms of change should be validated in basic research to be shown to be related to the techniques being used
• proposed mechanisms of change should be related to proposed mechanisms of disorder
• change in proposed mechanisms should relate to change in symptoms in treatment studies (changes in emotion regulation should be the mediator between the treatment and the symptoms of the disorder)

Question 73

unvalidated treatments

Answer 73

not sufficiently researched (not EST, but may still work)

Question 74

invalidated treatments

Answer 74

• shown not to work
• suggestion: make a list of invalidated treatments and make it available to the public

Question 75

case study EBP from lecture

Answer 75

• Leg 1: CBT is the only Tx with strong research support for PD and GAD (cognitive techniques for catastrophic thinking and the adaptive function of worry and behavioural techniques like interoceptive exposure and worry time)
• Leg 2: case conceptualization (externalizing statements, irritability, lack of trust, difficulty with mentalization, etc.)
• Leg 3: presented for help with anxiety (target of treatment because this is what the patient wants), personality and emotional characteristics may impact effectiveness, bad experiences with previous therapists
• treatment approach: focus on building therapeutic alliance, mood monitoring and thought restructuring, exposures, mentalization-based therapy eventually

Question 76

behaviour modification 4 types

Answer 76

• classical conditioning
• operant conditioning
• observational learning
• rational behaviourism

Question 77

classical conditioning

Answer 77

reflexive responses elicited by a new stimulus (phobias and anxiety)

Question 78

operant conditioning

Answer 78

• behaviour influences by consequences (reinforcement and punishment)
• Skinner and pigeons

Question 79

observational learning

Answer 79

• learning through observation of another’s behaviour without direct reinforcement or punishment
• Bandura and bobo dolls

Question 80

rational behaviourism

Answer 80

• learning and performance of responses that have not been directly trained
• organisms look for cause-and-effect relationships in their environment and learn from them
• imbedded in the organism to learn these things (like a baby knowing how to swim)

Question 81

reinforcement and punishment

Answer 81

• reinforcements INCREASE the likelihood of that behaviour occurring again
• punishments DECREASE that behaviour
• you can add or remove things from the environment
• something you think is punishment could be acting as reinforcement

Question 82

Jenny has no candy, she cleans her toys and receives candy - what is the behaviour and type of consequence?

Answer 82

• behaviour: cleaning up toys
• positive reinforcement

Question 83

Adena has access to toys, she hits her brother and her toys are removed - what is the behaviour and type of consequence?

Answer 83

• behaviour: hitting her brother
• consequence: negative punishment (behaviour decreases, toys are removed from her environment)

Question 84

Li is cold, she puts on a sweater, and she is no longer cold - what is the behaviour and type of consequence?

Answer 84

• behaviour: putting on a sweater
• consequence: negative reinforcement (removing the aversive state of coldness = behaviour increases)

Question 85

John has no pain in his hand, he touches a hot stove and has a painful hand - what is the behaviour and type of consequence?

Answer 85

• behaviour: touching a hot stove
• consequence: positive punishment

Question 86

escape conditioning

Answer 86

• negative reinforcement
• immediate response-contingent removal of aversive condition that increases the frequency of future behaviour
• starting to feel anxiety in a situation = leave that situation to remove the fear = more likely to leave again in the future
• important starting point in anxiety (no opportunity to learn that anxiety will decrease naturally)

Question 87

avoidance conditioning

Answer 87

• negative reinforcement
• immediate, response-contingent prevention of aversive condition that increases frequency of future behaviour
• not even putting yourself in the situation that causes your anxiety
• the second step in anxiety after escape conditioning

Question 88

extinction

Answer 88

• stop reinforcing the behaviour to hopefully reduce the pairing and behaviour will decrease over time

Question 89

differential reinforcement

Answer 89

• reinforce some behaviours and not others, or reinforce behaviours under some conditions but not others

Question 90

schedules of reinforcement

Answer 90

• fixed vs. variable: time-based (on a fixed schedule or random?)
• ratio vs. interval: after a certain number of times the event has to happen

Question 91

shaping

Answer 91

• reinforcement of successive approximations of a final response
• used when the organism doesn’t have the desired response in their repertoire so you reinforce partial responses

Question 92

chaining

Answer 92

• create a series of behaviours from distinct behaviours
• each individual behaviour is in the individual’s repertoire, you have to teach them to put them together

Question 93

discrimination

Answer 93

• different responses under different stimulus conditions
• we behave differently with our friends vs. work

Question 94

generalization

Answer 94

• stimulus generalization: having the same response to different stimuli
• response generalization: having different responses to the same stimulus

Question 95

ABCs of behaviour

Answer 95

• antecedent: stimuli, settings, context that occur before and influence behaviour
• behaviour: things the individual does or doesn’t do
• consequences: events that follow behaviours and may or may not influence future behaviour (make note of everything that follows)

Question 96

functional behaviour analysis

Answer 96

• application of scientific approach to human behaviour
• what behaviour do you want to change? specific operational definition (objective and observable, clarity, completeness
• assess behaviour at baseline (frequency, duration, latency, intensity)
• determine functions of behaviour (what is its purpose? what are the maintaining contingencies)
• use this info to develop an intervention

Question 97

steps of FBA

Answer 97

• collect information (define behaviour, assess baseline, determine consequences - the ABCs)
• generate hypotheses about the functions
• test the hypotheses to isolate each individual function
• devise an intervention

Question 98

assessing ABC relations

Answer 98

• indirect assessments: self-report, interview (person, parent, school)
• direct assessment: naturalistic or analog

Question 99

Peter took his sister’s cake and threw it on the floor while everyone was singing happy birthday to her, so his parents took him aside and yelled at him - what are the ABCs and function and maintaining contingencies?

Answer 99

• behaviour: picking up the cake and throwing it on the floor
• antecedent: parents singing happy birthday to the sister (sister getting more attention)
• consequence: parents yelled at Peter
• function: behaviour shifted attention from his sister to him
• maintaining contingencies: likely to increase this behaviour in the future to get attention from parents again

Question 100

Ellis reading main takeaways

Answer 100

• history of cognition in psychotherapy comes from self-help
• early philosophers = cognitive therapists (self-help)
• before Freud, psychotherapy was cognitive, but Freud was interested in emotion
• self-concept is a definition that people can change
• rational-emotive therapy: philosophy + behavioural therapy + cognitive debating to change philosophy/attitude
• evidence for RET comes from success in sex therapy

Question 101

Stoll telepyschology reading

Answer 101

• ethics in favour: increased access, availability, flexibility (rural areas, limited mobility), convenience, satisfaction, economic advantages, anonymity and privacy
• ethics against: privacy, confidentiality, security, therapist competence and training, communication issues (missing non-verbal cues, emails lack warmth), research gaps (long-term outcomes?), emergency issues, cross-border practice guidelines

Question 102

Wonderlich BN reading takeways for research methods

Answer 102

• RCT for testing integrative cognitive-affecting therapy (maintenance areas like self-directed behaviour, interpersonal problems, self-discrepancy and evaluative standards)
• comparison group: enhanced CBT (gold standard)
• outcomes: bulimic symptoms, severity, co-occurring conditions, measures of maintenance mechanisms
• included sub-clinical presentations since they tend to resemble people with diagnosed BN (generalizing to population)
• therapist adherence monitored throughout, clinicians trained in both types and administered both types
• within-group improvement at end of treatment and follow-up, but no between-group differences (ICAT equivalent to CBT-E so alternative Tx option)

Question 103

Wampold common factors reading

Answer 103

• contextual model 3 pathways which depend on the initial therapeutic relationship
• therapeutic alliance: therapist contribution is more important than patient contribution
• empathy can have a threat to validity (easier to be empathetic to a collaborative client than an aggressive one)
• cultural adaptation of EBP has a medium effect size

Question 104

Anderson FIS reading

Answer 104

• therapist FIS improves alliance and outcome
• prospective study pointing to a causal relationship
• greater effect for shorter therapy durations (less than 8 sessions)
• rapid improvement due to nonspecific and therapist factors (implicates common factors)
• nonexistant effect for longer durations (more than 16 sessions): maybe due to client dropout and since harder-to-treat patients tend to stay for longer and may not benefit from high-FIS or any other intervention
• unclear whether therapist FIS could change over time
• clients not randomly assigned

Question 105

Dozois EBP reading

Answer 105

• APA list of ESTs based on Chambless criteria didn’t narrow the gap between research and clinical practice
• EBP isn’t narrowly focused on evidence, just incorporates evidence
• first consider studies that have addressed threats to validity (internal and external) and are replicated

Question 106

FBA reading

Answer 106

• identifying relations between antecedents, behaviour, consequences AND developing interventions (behaviour’s function within its environment)
• maintaining contingency: factors that lead to maintenance of the behaviour
• frequent functions: social attention, escape or avoidance, automatic reinforcement (like sensations), tangible reinforcement
• indirect assessment (interviews and questionnaires are convenient, easy, but fallible)
• direct observation: naturalistic (informal and unstructured or rigorous) or lab analog (antecedents and consequences are manipulated)

Question 107

what are the core features of CBT

Answer 107

• structured
• short-term (6-8 sessions can lead to symptom improvement, but will depend on disorder and presentation)
• present-oriented (as opposed to the past)
• empirical (both nomothetic and idiographic)
• directed toward modifying dysfunctional thinking
• based on cognitive case conceptualization/formulation for individual clients
• designed to produce cognitive change

Question 108

cognitive model

Answer 108

• situation = thought (interpretation) = emotion (result of the thought) = behaviour (result of the emotion)
• can also include a physiological reaction (instead of an emotion)
• different thoughts in responses to situations will incur different emotions, so different behaviours
• this is the process of identifying automatic thoughts: what are people thinking when they notice a change in their emotions or behaviours (people are better at noticing these more obvious shifts)

Question 109

intermediate beliefs & core beliefs & automatic thoughts

Answer 109

• core belief: basic organizing principle about how we experience ourselves in the world
• leads to intermediate beliefs: rules, attitudes, assumptions about how the world works, how it should work, how we should behave
• lead to automatic thoughts

Question 110

principles of CBT (14)

Answer 110

1. based on cognitive conceptualizations
2. requires a good therapeutic alliance
3. continually monitors client progress
4. culturally-adapted and tailored to the individual
5. emphasizes the positive
6. emphasizes collaboration and active participation
7. aspirational, values-based, goal-oriented
8. initially emphasizes the present
9. aims to be educating
10. aims to be time-limited
11. consists of structured sessions
12. teaches patients to identify, evaluate, and respond to dysfunctional beliefs
13. includes action plans (therapy homework)
14. uses a variety of techniques to change thinking, mood, and behaviour

Question 111

what does it mean that CBT is “culturally adapted and tailors treatment to the individual”

Answer 111

• there is a general approach in treatment manuals (broad philosophy and treatment technique suggestions), but needs to be adapted for the individual
• CBT tends to be ‘brainy’ and cognitive which may not work for everyone (using different examples instead of emphasizing the scientific approach and examples)

Question 112

what does it mean that CBT “emphasizes the positive”

Answer 112

• people have negative filters on, so you have trouble seeing anything positive in your life or you’re misinterpreting positive things as negative
• the therapist needs to bring attention to the positive

Question 113

what does it mean that CBT “emphasizes collaboration and active participation”

Answer 113

• collective empiricism: teamwork in trying to figure out the problem and how to help

Question 114

what does it mean that CBT is “aspirational, values-based, goal-oriented”

Answer 114

• values: ongoing important aspects of your life
• goals: concrete, there are moments when the goals are accomplished

Question 115

what does it mean that CBT “initially emphasizes the present”

Answer 115

• here-and-now focus: the things that contribute to psychopathology aren’t necessarily the things that maintain it (the etiology isn’t the same as the maintenance)
• getting people out of a vicious cycle requires focusing on maintenance factors
• with time (and only if necessary), we can explore the past to understand patterns of beliefs and how they arose
• for some clients, changing thinking patterns on a daily basis will be sufficient, but for others it might be important to move to the past eventually

Question 116

what does it mean that CBT “aims to be educating”

Answer 116

• educate client on cognitive model and techniques (why we think this works, what does changing your thought incur)
• teaching clients to evaluate their own dysfunctional thoughts (the therapist can’t do all the work, the clients needs to do it so it can generalize)
• teaching the client to “be their own therapist” and give them the necessary tools

Question 117

what does it mean that CBT “consists of structured sessions”

Answer 117

• maximize efficiency and effectiveness
• start with a mood rating: how was your week
• agenda (client and therapist both bring items to the agenda)
• feedback and wrap-up: what did the client take from the session, what do they want to be done differently (an essential part of therapy so that the client has agency in their own treatment)

Question 118

what does it mean that CBT “teaches patients to identify, evaluate, and respond to dysfunctional beliefs”

Answer 118

• guided discovery: leading the client to the answer by asking them questions so that they get there on their own
• behavioural experiments: testing beliefs by doing something in real life to challenge the beliefs

Question 119

what does it mean that CBT “involves action plans”

Answer 119

• what the client is doing in between sessions to get benefits (one session per week is not going to do anything)
• client needs to build new patterns and habits
• anything we want clients to remember should be written down

Question 120

what does it mean that CBT “uses a variety of techniques to change thinking, mood, and behaviour”

Answer 120

• not only cognitive strategies
• can pull from other treatment approaches (mindfulness, behavioural)

Question 121

deconstruct the Lucy example in what the therapist was doing

Answer 121

• following the cognitive model
• focusing on a particular situation (not going to a lecture) so that the person can reconstruct the experience
• then going through thoughts (typically “I” statements that will be negative in a depressed person)
• then going through emotions (one-word, which can be difficult to grasp for clients)
• physiology (what you feel in your body)
• behaviours (what ends up happening because of thoughts and emotions)
• then how do you feel afterward: helps clients notice that their behaviours aren’t helpful

Question 122

what is the main focus of a CBT assessment?

Answer 122

• assessing the current problem (what brought you in right now, what pushed you to start therapy)
• ask clients to detail a recent occasion when problem symptoms were experienced (what happened before, during, after)
• break the presenting problem into four internal systems (cognitions, emotions, behaviour, physiology) and the environment (larger context)
• the present is a relevant source of information (how is the problem being maintained?)

Question 123

what are triggers and modifying factors

Answer 123

• antecedents, part of a CBT assessment
• triggers: what factors make the problem more or less likely to occur (can be external in the environment or internal)
• modifiers: contextual factors that impact how severe the problem is when it occurs

Question 124

what are consequences and how are they helpful in an assessment

Answer 124

• what has happened as a result of current problems
• when the problem does occur, what are the emotions, behaviour, physiology, relationship changes that are the consequences
• consequences give insight into maintaining processes (the function)
• all our behaviours serve a function, we should find some way to serve that function in a different way
• the past is not relevant to why the person is struggling right now

Question 125

what are maintaining processes

Answer 125

• vicious cycles that keep the problem going (this is where we intervene)
• different disorders have different common maintaining processes (but assessments must still be individualized)
• binge eating can be positive reinforcement or negative reinforcement depending on the episode and/or the person
• escape/avoidance (reducing aversive anxiety)
• reduction in activity (depression = withdrawal = lack of reward = more withdrawal)
• short-term reward (pleasurable experiences with maladaptive long-term consequences)

Question 126

what is past history and problem development in CBT assessment

Answer 126

• vulnerability factors: things that set the stage for a problem to develop, but are neither necessary nor sufficient (the diathesis like family history of a disorder, will not be expressed without a stressor)
• precipitants: events or situations that provoke onset of symptoms (more immediate stressors and life events, can be traumatic or normal events, even positive), activating a pre-existing vulnerability belief
• modifiers: changes to life circumstances that affect the severity of a problem (someone who is generally anxious has just experienced something that increased the severity of their anxiety, so they cam to therapy)

Question 127

cognitive model/conceptualization

Answer 127

• we always start at the level of automatic thoughts (most accessible and easiest to change because they’re situational)
• basic model: situation = thought = emotion = behaviour
• simple thought record: when you notice a change in emotion, try to identify what you’re thinking in that moment (used in cognitive restructuring and in assessment)

Question 128

expanded cognitive model

Answer 128

• includes core beliefs (enduring cognitive phenomena that are deeply rooted and difficult to access)
• people focus selectively on information that confirms core beliefs and disregard information that doesn’t (in CBT we try to consider the entire situation, not just confirmatory information)

Question 129

core beliefs

Answer 129

• global (apply to everything), rigid (difficult to change), overgeneralized
• fall into 3 categories:
  1. incompetence (achievement-related and internal): I’m stupid, I’m a failure
  2. unlovable (interpersonal): I’m bound to be rejected
  3. worthless (especially in people with suicidal ideation): I’m bad, I don’t deserve anything good

Question 130

intermediate beliefs

Answer 130

• between automatic thoughts and core beliefs
• attitudes: applies to everyone and all situations (not an I statement)
• rules: often includes “I” and “should”
• assumptions: often an If…Then statement
• also falls into 3 categories: helpless (incompetence core belief), unlovable, worthless
• the assumption is the easiest to work with because of implied causality (try to transform rules or attitudes into assumptions to be able to work with them)

Question 131

downward arrow technique

Answer 131

• technique for identifying intermediate and core beliefs
• people do thought records, find patterns in automatic thoughts
• ask clients about the meaning of automatic thoughts that likely come from core beliefs (if the thought is true, what does it mean?)

Question 132

what is a CBT conceptualization and what is it used for

Answer 132

• road map to therapy
• develop a treatment plan based on conceptualization
• there are different conceptualizations based on different disorders that get personalized based on the person
• a series of hypotheses about the client that are refined based on incoming data (developed in initial sessions but will change)
• always present the conceptualization to the client to see if it rings true (share a diagnosis if you have enough information, get feedback from the client, often presented using diagrams with arrows to depict maintenance processes)

Question 133

questions to answer when creating a case conceptualization

Answer 133

• how did the person develop this disorder
• what were significant life events, experiences related to this vulnerability
• what are the person’s basic beliefs about themselves, the world, and others (cognitive triad, rules, attitudes, assumptions)
• what are the person’s attitudes, rules, and assumptions?
• what strategies has the patient used to cope with beliefs (typically maladaptive)
• what automatic thoughts, images, and behaviours maintain the disorder
• how did beliefs interact with life events to make the person vulnerable to disorder?
• what is happening in their life right now and what are the patient’s perceptions about that? (one of the most important questions)
• diagram to present automatic thoughts (using examples provided by the client) including life history, core beliefs, intermediate beliefs, coping strategies, critical incidents
• emotions, thoughts, behaviours are not linear, everything affects everything

Question 134

how do we identify automatic thoughts

Answer 134

• they come in verbal, visual or both forms (for most people they’re verbal)
• often embedded within a broader statement or phrased as a question (try to re-phrase as a simple statement)
• basic question: what was going through my mind just then? in response to changes in emotions, mind/body, urge to engage in a dysfunctional way

Question 135

types of automatic thoughts

Answer 135

• distorted: occurring despite evidence to the contrary
• thought is accurate but conclusion is distorted
• thought is accurate, but not helpful

Question 136

evaluating automatic thoughts

Answer 136

• reviewing evidence for and against the thought
• worst case, best case, most realistic case
• advantages and disadvantages of having the thought
• distance self from thought
• problem-solving
• always assess the outcome of the automatic thought evaluation process (how much did it change mood, physiology, etc. after evaluating it)

Question 137

reviewing evidence for and against the thought

Answer 137

• what supports the thought (what is the reason this thought has occurred?) and evidence that doesn’t support the thought
• be as objective as possible (not just hearsay or feelings) and don’t dismiss the supportive evidence
• then come to a more balanced thought
• most people with depression think in a negative way, so thoughts are distorted
• used for distorted thoughts

Question 138

worse case, best case, most realistic case

Answer 138

• what is the worst thing that could happen? If it did happen, how would I cope?
• used for people with GAD who catastrophize and worry about the future
• for some people, even something with a small likelihood of happening may be worth worrying about

Question 139

advantages and disadvantages of having the thought

Answer 139

• what are the effects of believing vs. not believing the thought? how do you behave in response to the thought
• if the thought is accurate, we can’t evaluate evidence, but the thought is not helpful
• come up with a different way of thinking about it

Question 140

distance self from thought

Answer 140

• what would you tell a friend or family member in this situation
• used for accurate thoughts and for distorted thoughts
• easier to be compassionate toward others

Question 141

problem-solving method of evaluating automatic thoughts

Answer 141

• what can you do in this situation? what could you do differently next time?
• if the thought is accurate, there’s no getting out of the situation right now, but can change next time

Question 142

CBT thought record

Answer 142

• situation (what, who, when, where)
• emotion or feeling (one-word answers) rated 0-100
• negative automatic thought (what images, thoughts were going through your mind)
• evidence supporting and not supporting the thought (completely true all the time? what would you tell a friend? experiences that contradict the thought?)
• alternative thought
• re-rate emotion or feeling

Question 143

cognitive distortions

Answer 143

• unhelpful thinking styles that are very common and normal
• patterns in our automatic thoughts; ways that we generally think that create the automatic thoughts
• with a selection of automatic thoughts, we start to work with cognitive distortions (this will generalize)

Question 144

all-or-nothing

Answer 144

• black or white, only seeing extremes
• try to get people to see things in the middle
• in thought restructuring, evidence for and against, then come to a more balanced thought
• identify the extremes (worst case, best case), explore the steps in between

Question 145

mental filter

Answer 145

• seeing only the evidence that fits with how you think about yourself
• try to be more like a scientist and pay attention to all instances of an event and note both good and bad (get a more representative sample of information)

Question 146

behavioural experiments

Answer 146

• planned experiential activities undertaken to test validity of patient’s beliefs and construct more adaptive beliefs
• like exposure, but has a different purpose (exposure designed to provoke anxiety and learn that it decreases, experiments are about developing realistic beliefs)
• hypothesis testing (how will the person react in this situation) vs. discovery (gathering information)
• active (speaking to someone) vs. observational (watching people interact)
• can also be spontaneous

Question 147

what are some guidelines for successful behavioural experiments

Answer 147

• clients should push themselves, but also avoid setbacks (don’t do too much too fast)
• set it up so that the client learns something either way (if the experiment doesn’t go as planned)
• prepare for challenges ahead of time, set the client up for success
• client needs to be fully engaged rather than going through the motions (so they can’t make excuses after the experiment)
• monitor thoughts/feelings throughout
• be flexible and respond to the unexpected
• always debrief after the experiment: what actually happened? did this fit with predictions? what did you learn? what could you do differently next time?

Question 148

making decisions CBT technique

Answer 148

• advantages and disadvantages analysis
• weigh the advantages of both options and rate their importance from 1-10 (not every pro and con is of equal importance)

Question 149

refocusing CBT technique

Answer 149

• when evaluating automatic thoughts isn’t desirable or feasible (in the middle of an exam)
• label the automatic thought, then deliberately refocus attention on the task at hand (let it go, now I’m doing this)

Question 150

graded task assignments CBT technique

Answer 150

• if you have a really big task that is overwhelming
• break goal down into smaller pieces, focus on one step at a time
• success encourages further action

Question 151

pie technique CBT technique

Answer 151

• useful for setting goals or determining relative responsibility
• for EDs: how people evaluate themselves where weight/shape takes up a lot of the pie (try to allocate less space to it over time)

Question 152

self-comparisons and credit lists CBT techniques

Answer 152

• are you comparing yourself to you at your best or your worst (not always fair to compare yourself to your best, choose a more appropriate comparison point)
• give yourself credit when it’s due (take time to realize you’ve accomplished something)

Question 153

historical aspects of exposure for anxiety

Answer 153

• systematic desensitization developed after Joseph Wolpe was dissatisfied with psychoanalytic treatment for PTSD
• pairing things that were distressing with food, and the fear response was extinguished
• reciprocal inhibition: the experience of fear is incompatible with the experience of pleasure
• pair exposure with relaxation techniques
• Wolpe developed Subjective Units of Distress Scale (SUDS)

Question 154

model of exposure

Answer 154

• based on how fear develops
• neutral stimulus evokes fear response
• avoidance/safety behaviour maintains fear (lack of learning that the stimulus is neutral)
• trauma = generalizing from one specific instance
• benign stimuli associated with the event begin to evoke fear response
• exposure therapy designed to undo conditioning processes (teaching clients to approach rather than avoid)
• exposure may be paired with relaxation techniques and/or prevention of compulsions or safety behaviours (developing corrective information about the feared stimulus)

Question 155

exposure mechanisms of change

Answer 155

• habituation: over time, physical sensations associated with fear naturally reduce (cannot maintain arousal over time)
• extinction: feared stimulus is no longer paired with escape or avoidance, may be paired with relaxation (a new association is learned)
• learning corrective information (inhibitory learning): over repeated trials, clients learn that feared outcome doesn’t happen (change in cognitive expectations)
• increased self-efficacy: even if fear response isn’t completely extinguished, client learns that they can handle fear

Question 156

graded exposure

Answer 156

• type of exposure
• slowly exposed to increasingly difficult stimuli
• building a hierarchy and start at the bottom so that it’s not too overwhelming

Question 157

systematic desensitization

Answer 157

• type of exposure
• graded exposure with added relaxation techniques (incompatible states)
• not everyone like relaxation techniques

Question 158

prolonged exposure

Answer 158

• type of exposure
• designed to treat PTSD
• repeated revisiting of traumatic event; client recounts experience in great detail
• re-processing details surrounding the event
• exposures to situations or objects or individuals that are reminders of the traumatic event, but that do not pose a threat
• facilitates emotional processing of event (all emotions, but a complex constellation of feelings in PTSD)

Question 159

one-session exposure

Answer 159

• type of exposure
• extended, up to 3hrs
• includes instruction, modelling, exposure, cognitive challenge
• shown to be efficacious in adults, some evidence for kids
• need to be set up for many types of exposures because you need to move up the hierarchy within one session

Question 160

modes of delivery

Answer 160

• in vivo
• imaginal
• virtual reality
• interoceptive
• modelling (adjunct)

Question 161

in vivo exposure

Answer 161

• mode of delivery
• exposure to actual feared stimulus, or some approximation
• can require some creativity

Question 162

imaginal exposure

Answer 162

• mode of delivery
• client imagines feared stimulus when it isn’t feasible to do in vivo exposure
• frequently used for PTSD (cannot recreate the event), GAD (fearing future possibilities), phobias of uncommon stimuli
• not all clients will be able to engage in this (need good visualization skills)

Question 163

virtual reality

Answer 163

• mode of delivery
• when in vivo isn’t feasible
• good alternative to imaginal for clients who have difficulty visualizing
• becoming more accessible, not widely used yet

Question 164

interoceptive exposure

Answer 164

• mode of delivery
• exposure to physical sensations
• especially for panic disorder or clients who find physical anxiety symptoms to be unacceptable
• fear of fear: catastrophizing physiological anxiety
• clients learn that symptoms are not dangerous
• turning in an office chair, breathing through a straw, running in place

Question 165

modelling exposure

Answer 165

• mode of delivery
• not a primary intervention, but used as an adjunct
• can help ease clients into exposure
• shows clients that the feared outcome is unlikely or impossible
• we shouldn’t ask the client to do anything what we wouldn’t do (getting a sense of their experience)
• going past the reasonable experiences that we’re likely to experience in daily life to make sure generalization sticks
• model the type of response you want the client to show

Question 166

early sessions in typical course of therapy EX/RP for Caroline

Answer 166

• assessment of symptoms and interference (multiple obsessions and compulsions interfering with daily life as time-consuming and interpersonal avoidance)
• psychoeducation: describe nature of OCD, explain how compulsions maintain anxiety
• provide a rationale for exposure: extinction
  (stop feeding obsessions with compulsions), explain that improvement will take time (initial worsening), describe empirical findings
• introduce symptom monitoring and SUDS (shows patterns of anxiety; triggers, thoughts, distress, responses)
• construct fear hierarchy based on symptom monitoring and SUDS (start with items with SUDS<30 and end with over-and-beyond items)
• plan exposure exercises, prevention of rituals (for each obsession and compulsion)
• build rapport (client needs to trust the therapist)

Question 167

middle sessions typical course of EX/RP for Caroline

Answer 167

• in-session exposure (therapist-guided, prevention of compulsions) with SUDS ratings throughout
• do no move up the hierarchy until the client can complete with little anxiety and without compulsions
• homework: out-of-session exposures (generalization and self-efficacy), continue symptom monitoring
• keys to success: manageable, refrain from compulsions, master one step before moving on, repeated over time
• modify the hierarchy as needed (according to changes in Sx, new behaviours, reactions to exposures)
• assess overall symptoms to track progress (severity over time)

Question 168

cognitive restructuring typical course of EX/RP for Caroline

Answer 168

• EXRP is very behavioural, but there is an added benefit of cognition
• can help clients engage in therapy more readily (more appealing, subjectively safe, to clients)
• introducing cognitions too early in therapy can result in clients using this cognitive restructuring to neutralize anxiety during exposure

Question 169

late sessions in typical course of EXRP for Caroline

Answer 169

• generalization and maintenance
• may not have time to go through every obsession or compulsion in therapy, so client needs to continue on their own
• have client develop additional hierarchies and response prevention strategies
• relapse prevention: predict challenges, problem-solve, normal to have slip-ups (doesn’t mean that progress is undone), what can you deal with on your own and when do you re-contact the therapist

Question 170

advantages of exposure therapy

Answer 170

• highly efficacious for various problems
• often superior to pharmacological treatment
• relatively brief (under 15 sessions) and can be done many times per week

Question 171

disadvantages of exposure therapy

Answer 171

• high dropout and refusal rate (aversive for clients)
• therapists find it aversive (pushing someone to do something they don’t want to do)
• several barriers: noncompliance, subtle avoidance, family involvement (maintaining symptoms and reinforcing rituals), comorbidities

Question 172

what are some main cognitive distortions

Answer 172

• all-or-nothing
• mental filter
• jumping to conclusions (making an unjustified inference)
• mind reading
• overgeneralizing (going from one instance to everything)
• personalization (it’s my fault)
• emotional reasoning (the strength of the feeling = the truth)
• labelling
• disqualifying the positive
• should and must statements
• magnification and minimization (similar to overgeneralization)

Question 173

behavioural model of depression

Answer 173

• originated from behavioural models of depression (behaviour therapy)
• depression associated with a particular behaviour-environment relationship that evolves over time (maintains depression)
• reciprocal relationship between actions and behaviour and the environment is occurs in + the responses from the environment (usually people)
• if-then contingencies; what are the consequences of the behaviour (we don’t care about the behaviour itself)
• Ferster model
• Lewinsohn model

Question 174

Ferster model of depression

Answer 174

• decreased rates of response-contingent reinforcement = turning inward, doing nothin, escape and avoidance
• not getting reinforcement from your environment = withdraw from environment = negative reinforcement of depression

Question 175

Lewinsohn model of depression

Answer 175

• social avoidance core to depression
• people not engaging in social relationships = not getting reinforcement from social life

Question 176

behavioural activation model

Answer 176

• behavioural responses reduce our ability to experience positive reward from the environment
• depression characterized by high negative affect, but also a lack of positive affect (lack of reward) which leads to withdrawal and lack of engagement
• treatment focuses on activation and processes that inhibit activation (like escape and avoidance and ruminative thinking)
• breaking the cycle; depressed = withdrawal = no reinforcement = more depression

Question 177

BA treatment rationale

Answer 177

• events in your life and how you respond influence how you feel (but we’re not focused on thoughts, just behaviour)
• lives that provide too many problems and not enough reward can lead to depression (too much negative, not enough positive = depression)
• people pull away from the world when life is less rewarding
• withdrawal = depression = difficulty solving problems
• treatment isn’t just ‘doing more’ but figuring out what activities are most helpful (personalized)

Question 178

BA form of treatment

Answer 178

• daily monitoring forms (pleasure and mastery)
• use monitoring forms to look for contingencies maintaining behaviour
• use activity monitoring to design intervention
• activity scheduling
• ACTION
• engagement strategies

Question 179

daily monitoring forms BA

Answer 179

• reporting what you do throughout the day + planning your days
• rating two aspects of reward (mastery and pleasure) for all activities
• see how activities are associated with different ratings to find contingencies
• positive reinforcement from family/friends can be a contingency (accommodating)
• negative reinforcement through escape and avoidance of painful feelings

Question 180

how to design a BA intervention

Answer 180

• use activity monitoring
• what would you be doing if you weren’t depressed? (what would you enjoy doing is not useful because happiness is often a foreign concept)
• look at relationships between specific activities or life contexts or problems and ratings of mastery and pleasure (expected or in the past)
• trying to distinguish between pleasure and mastery for the client
• explain how avoidance and withdrawal and rumination contribute to depression via negative reinforcement
• increase activities that have the potential to bring pleasure and mastery (and decrease activities related to avoidance and withdrawal)

Question 181

how to do activity scheduling in BA

Answer 181

• help clients maximize success (don’t over-schedule or aim for big events)
• public commitment: telling people the plan, doing activities with others (added benefit of social interaction, more reward) = holding you accountable
• structure the environment (putting workout clothes next to the door)
• arbitrary reinforcers (any type of reinforcer is helpful at this point, but it’s most effective if the reinforcers are naturally in the environment/activity you’re doing)
• aversive contingencies (like punishment, not ideal, but sometimes necessary)
• record context and consequences of activation (what environments promote activation vs. ones that dissuade from action = ratings of mastery and pleasure)
• gather information about incomplete homework to understand barriers and avoidance patterns

Question 182

ACTION

Answer 182

• targeting avoidance of tasks, emotions, interpersonal conflicts, etc.
• Assess whether the behaviour is approach or avoidance (foster approach, minimize avoidance)
• Choose to continue the behaviour (even if it’s making you feel worse), or choose a new behaviour
• Try the chosen behaviour
• Integrate a new behaviour into your routine (give it a fair chance)
• Observe the results (monitor the effects through ratings of mastery and pleasure–how long do they last?)
• Never give up! Change requires repeated efforts and attempts

Question 183

engagement strategies

Answer 183

• when people are doing the approach behaviours, they have to be fully engaged (not going through motions)
• rumination prevents people from engaging with their activities and environments
• unlike in cognitive therapy, we don’t care about the content of rumination (not trying to change the thoughts), but we care about function
• if the client isn’t experiencing pleasure, explore level of engagement in the activity
• draw attention to experience to ensure that people are benefitting

Question 184

rumination

Answer 184

• purpose could be to keep yourself detached from a stressful environment
• can be negatively reinforced (removing the engagement to avoid negative feelings)
• not able to experience positive affect if ruminating

Question 185

Dimidjian perinatal study

Answer 185

• pragmatic effectiveness RCT conducted at four sites (done in the context of existing treatment in clinics)
• randomized to BA or TAU
• BA: 10 sessions provided in-clinic, phone, in-home, delivered by health care professionals naive to BA (not an efficacy trial)
• primary outcomes: change in symptoms and remission rates based on Patient Health Questionnaire
• secondary outcomes: anxiety, stress, treatment satisfaction
• tested whether changes in early activation and environmental reward would mediate association between treatment condition and improvement in symptoms
• found more symptom reduction in BA vs. TAU at all follow-up points (small-to-moderate effect size)
• 56% remission in BA vs. 30% in TAU
• BA reduced anxiety and stress
• support for mediation model)
• conclusion: BA is a scalable intervention consistent with patient preferences to improve depression symptoms during pregnancy

Question 186

scalable

Answer 186

• can reach many people because it’s brief and simple and can be administered easily
• doesn’t require ltos of training

Question 187

evidence for BA

Answer 187

• Dimidjian (2006): among moderate-to-severe depression, BA was superior to cognitive therapy and equivalent or superior to meds (severe depression = unable to engage in cognitive effort, something simpler might be more effective in the beginning to relieve brain fog)
• Ekers meta-analysis: BA superior to control and antidepressants
• Richard et al: BA delivered by junior mental health workers was not inferior to CBT delivered by psychological therapists (scalability; BA can be taught and used widely, but CBT too complex)

Question 188

transdiagnostic formulation

Answer 188

• treatment for all EDs, not one specific one (CBT-E is the newest version that takes a transdiagnostic approach)
• many ED features present across diagnoses (weight/shape concerns, binge eating, purging, dietary restriction)
• most patients migrate across diagnoses over time (AN binge-purge = weight gain = BN, then purging stops = BED)
• over-evaluation of shape and weight is a central maintenance factor of all EDs
• precise form of applied treatment is individualized (level of intensity specific to weight status; BMI>17.5 is 20 sessions over 20 weeks, BMI<17.5 is 40 sessions over 40 weeks)

Question 189

CBT-E added components

Answer 189

• to make it enhanced, added modules that can be used to address symptoms external to core ED
• these modules should sustain remission over time instead of just targeting ED features
• perfectionism (globally, not just applied to eating behaviour), low self-esteem (generalized sense of failure and worthlessness), major interpersonal problem (often accompanied by emotional regulation problems)

Question 190

what is the “starting well” aspect of CBT-E

Answer 190

• start with self-monitoring, weekly weighing, regular eating
• engage the patient in treatment and change, increase motivation and commitment to treatment (AN w/o binge eating = low motivation to change (don’t want to gain weight), BED may have greater motivation)
• talking about pros and cons of changing or maintaining status quo
• collaboratively create a personalized formulation (symptoms)
• psychoeducation about treatment and EDs (consequences of EDs, of purging for dental health or cardiac complications)

Question 191

standard transdiagnostic formulation

Answer 191

• ED is a vicious cycles maintained by interactions among thoughts, behaviours, and beliefs
• over-evaluation of control over eating, shape, or weight (core maintenance factor)
• then engaging in strict dieting or other compensatory behaviours
• then one of two paths: either binge eating (because you’re hungry) OR features of under-eating and/or low weight (both of which act as reinforcers for over-evaluation of weight/shape)
• start with the behaviours at the bottom, the work your way to the more cognitive maintaining factors

Question 192

self-monitoring CBT-E

Answer 192

• better understanding processes maintaining ED (informs the formulation)
• continued throughout Tx
• get an accurate record of patient’s food intake (retrospective is unreliable)
• highlights key behaviours, feelings, thoughts, contexts in which they occur
• use these as examples for sessions
• allows therapeutic work between sessions
• increase patient self-awareness (an intervention for binge eating: writing everything down is so aversive that it decreases frequency or intensity)
• encourage self-monitoring in real time
• record time, food consumed, place, type of food (snack, binge, purge, meal), exercise, circumstances (thoughts, feelings)

Question 193

weekly weighing

Answer 193

• establish right at the beginning of treatment
• patients fall into 2 groups: either completely avoiding getting on a scale OR obsessively weighing themselves
• showing patients that weight will fluctuate throughout the day, in a week (misinterpreting inconsequential fluctuations is likely to result in weight control behaviours, no matter whether weight is up or down)
• procedure: no weighing at home, only in-session once a week (jointly; not hiding information)
• joint plotting of weight graph: we should see stable weight (CBT isn’t a weight loss program); by replacing binge eating and purging with regular eating, the end result is not weight gain

Question 194

regular eating in CBT-E

Answer 194

• introduced at the beginning of treatment and continues throughout
• prescribed pattern of regular eating
• 3 meals and 2-3 planned snacks per day
• no more than 3-4 hours between meals (hunger can be a trigger for binge eating)
• people don’t have a good sense of their hunger and fullness cues, so this is based on time and is very mechanical
• eating takes precedence over other activities
• initial emphasis on when people eat (later examine what they eat)
• we use their definition of a meal (no matter if it’s more of a snack or only low-cal)
• urge to eat between meals/snacks = problem-solve, use incompatible behaviours, surf the urge (wait long enough = craving dissipates)
• very effective to solve binge eating

Question 195

compensatory behaviour in CBT-E

Answer 195

• vomiting: education about ineffectiveness (only rids self of 30-50% of calories, so doesn’t eliminate binge episode), review consequences of vomiting (dental health, electrolyte imbalance), delay (feel an urge = what happens if you delay the behaviour?)
• laxatives and diuretics: ineffective at preventing calorie absorption, throw away supplies or plan a schedule of withdrawal
• if regular eating is effective at reducing binge eating, then the reduction in compensatory behaviours reduce naturally (purging disorder as an exception)

Question 196

addressing over-evaluation of shape and weight in CBT-E

Answer 196

• develop new domains for self-evaluation (identify and try interests and activities, use pie chart technique)
• decrease importance of shape and weight (body checking and avoidance, feeling fat)

Question 197

how to address shape checking

Answer 197

• either focused on shape with comparisons OR avoidance of shape (not looking in the mirror, baggy clothing)
• identify forms of shape checking (self-monitor to increase awareness of the behaviour)
• think before you look in the mirror: what am I trying to find out? can I find this out? Is there a risk that I will get unhelpful information?

Question 198

how to address body avoidance

Answer 198

• identify forms of avoidance and encourage exposure
• controlled mirror exposure

Question 199

how to address body comparison to others

Answer 199

• reduce frequency by bringing it into people’s awareness
• behavioural experiments: compare to every 5th woman you pass (illustrating sample bias by comparing in a more systematic way)
• we tend to compare ourselves to the extremes: upward (attractive and thin) or downward (at least I don’t look like them)

Question 200

how to address ‘feeling fat’

Answer 200

• feelings fluctuate over time, but actual weight is more stable
• your actual weight isn’t the main contributor to feeling fat
• identify triggers (monitor) and address them
• psychoeducation
• “What else am I feeling right now?” fat is not a feeling, there’s an underlying emotion
• feeling fat can lead to dieting or binge eating or purging as a way to cope

Question 201

dietary restraint vs. restriction

Answer 201

• restraint: attempted under-eating and food rules (cognitive aspect; doesn’t mean that someone is successful, could have many lapses)
• restriction: actual under-eating (behavioural aspect; leads to weight loss or promotes binge eating), almost everyone will restrict at some point (this is a maintenance mechanism)

Question 202

how to address dietary restraint and restriction

Answer 202

• restricting: regular eating
• restraint: dealt with later in treatment, decrease avoidance of certain foods using systematic exposure (of fear foods, foods people binge eat, food rules)
• foods people binge become ‘forbidden’ until the person has lost control over their eating (they would be less appealing if they were integrated into regular eating)
• create a food hierarchy: gradual exposure to feared foods using systematic exposure (in-session or in a natural environment), incorporate other fears (eating at night, eating in public)
• goal: decrease patient fear of loss of control, modify distorted assumptions
• plan ahead: identify food, when, where, etc.

Question 203

how to address residual binge eating

Answer 203

• regular eating should stop most binge eating (and subsequent compensatory behaviours)
• may not work for everyone, there may be lapses or residual
• residual binge eating may arise from: breaking a dietary rule, being disinhibited (drinking alcohol), under-eating (not adhering to the plan), adverse event or mood (relief from negative affect)
• binge analysis: identifying triggers that lead to residual binge eating

Question 204

evidence for CBT-E

Answer 204

• meta-analysis of 7 trials (3 with BN sample, 4 with transdiagnostic) = CBT-E performed better than IPT, psychoanalytic, no treatment, CBT-E equivalent to integrative cognitive affective therapy (broad (enhanced version) and focused (targeting only ED) were equivalent)
• remission rates were very variable (22-67%) due to differences in sample and variability in operationalization of clinically significant change
• Tatham et al. CBT-T

Question 205

Tatham et al.

Answer 205

• cohort comparison (not random) between patients treated with CBT-E vs. CBT-T (for non-underweight, non-severe patients)
• CBT-T shorter (10 sessions instead of 20), more scalable
• differences in treatment: focus on early parts of treatment protocol (more behavioural than cognitive components), delivered by assistant psychologists (BA degree), more exposure exercises (mirror exposure, coming from recent research that anxiety is an important component)
• change in ED symptoms and clinical impairment was similar in CBT-E and CBT-T (large decreases during Tx with gains maintained at 6-month follow-up)
• limitation: lack of random assignment, screened out for severity
• implications: cost efficiency, saving time = less waitlists (saving intensive Tx for those who are more severe), especially important because Tx for EDs is most effective if done early

Question 206

main components of BA

Answer 206

1. psychoeducation: explaining the rationale, present the treatment model (maintenance cycle)
2. daily activity monitoring form: socialize the client with what the Tx will entail AND gather information to guide Tx
3. look for contingencies maintaining behaviour (pleasure and mastery ratings-activities)
4. use activity monitoring to design intervention (adding activities back into routine, fake it till you make it)
5. work with clients to schedule activities
6. ACTION
7. help client engagement strategies (ruminating, worrying, cognitive interference)