501- Principles of Cognitive and Behavioral Change Flashcards
Acceptance and commitment therapy
3rd generation behavioral therapy developed by Steven Hayes. Says that psychopathology comes from experiential avoidance and cognitive fusion. Paradoxically the process of avoiding yields more distress. The primary goal of ACT is to create psychological flexibility in clients. This is done through acceptance and mindfulness skills and commitment and behavior change skills. Six Therapeutic Components:* Be here now: Making contact with the present moment.* Defusion: Separating/detaching from private thoughts; holding on to thoughts lightly, not tightly.* Acceptance: Opening up and making room for all experiences, including so-called unpleasant ones* Self-as-context: The observing self determines context and is the entity through which awareness happens.* Values: The goals you desire and the activities/beliefs that matter to you.* Committed action: Doing what you need to do to move toward and live by your values. Clinical Example: A patient presents with symptoms of depression and chronic pain. The pain they live with is due to an autoimmune disorder with no cure. The depressive symptoms seem to stem from the patient’s inability to change her disorder and the pain that accompanies it. The therapist recommends ACT to help the patient shift her expectations about living pain free, to living as well as she can in accordance with her values while accepting her pain and disorder.
Ambivalence
A state of having mixed feelings about something including seeing reasons to changes and reasons not to. It involves both wanting and not wanting to change which is not compatible. It derives from cognitive dissonance theory and motivational interviewing helps resolve dissonance. It is important to know to help conceptualize a client’s behavior as a therapist.
Clinical examples:
Want to stop drinking but also want to continue to drink.
Anxiety/fear hierarchy
Used in exposure therapy, a fear hierarchy is a breakdown of a person’s feared stimuli into components, ordered in terms of how much subjective distress they produce (SUDs). The client is led through either imaginal or in vivo exposure to each item on the hierarchy, starting with the least distressing, until they are able to tolerate the discomfort. It is important because it is one of the key components in exposure therapy.
EXAMPLE: a soldier suffering from PTSD (Post Traumatic Stress Disorder) is now terrified by guns. Even a picture of a gun can elicit a fear response in the soldier. Handling a gun could cause a serious fear response. In this case, the soldier could choose looking at pictures of guns as the least intense fear for his anxiety hierarchy, and holding or shooting a gun could be the most intense fear for his anxiety hierarchy.
Assets
In ABCPA behavioral assessment/analysis model, assets are the skills or strengths an individual has that may prove useful during the therapeutic process. It is helpful for a counselor to be able to identify because it can be used to reach client success and goals. Clinical example: You have a client that is struggling with debilitating social anxiety. He comes in because he is worried about going off to college next year; he frequently skips class now and knows that this will become a problem. During the assessment you’ve uncovered the fact that he has a very strong commitment to learning. This is an asset of his that you plan on using to help overcome some of his class skipping behaviors.
Automatic thought
According to Beck’s Cognitive therapy, automatic thoughts are conditioned ideas that arise quickly and spontaneously in response to particular stimuli.* Can include cognitive distortions such as dichotomous thinking, personalization, emotional reasoning, etc.* Can be maladaptive and persistent - need to be challenged * In Beck’s cognitive therapy, pt and therapist monitor, identify, and categorize dysfunctional automatic thoughts; pt taught to consider automatic thoughts as hypotheses to be tested. * Downward arrow technique explores underlying assumptions and schemas related to automatic thoughts Clinical example: Your client is upset because Bob, the new co-worker, won’t talk to her. She states it is because she is worthless and no one likes her. As a therapist conducting Beck’s cognitive therapy , you would view this is an automatic thought riddled with absolute thinking and jumping to conclusions. Your next step might be utilizing the downward arrow technique to get at the deeper schema/core belief.
Behavior activation therapy
Developed by Lewinsohn, behavioral activation stems from a behavioral model of depression which conceptualized depression as a lack of positive reinforcement from a client’s avoidance behaviors. It involves clients scheduling particular activities that are positively reinforcing, such as seeing a friend or going for a walk, and that engaging in those behaviors may lead to positive psychological and emotional changes as well.* Occurs via: * Self-monitoring of activities and mood * Scheduling Activities * Mastery and pleasure ratings Clinical example: Tony has recently been feeling very low. He wakes up foggy and can’t seem to motivate himself to get his school work done or to attend to the tasks of daily living. He hasn’t seen his friends in weeks, but not for lack of trying on their part. He thinks resting will help clear the fatigue but the more he rests the worse he feels. His therapist recommends behavioral activation therapy and asks Tony to identify a few activities that bring him joy. He says fresh air and seeing friends. His therapist then asks him to take a morning walk a few times a week. At the end of the week, Tony reports that while it was difficult to schedule and even harder to go to his scheduled activities, he felt lighter and more hopeful afterward.
Behavioral parent training/therapy
A behavior therapy intervention involved in teaching procedures to parents effectively managing their children’s behaviors. The primary goals of behavioral parent training is to increase parents use of clear, direct and age appropriate instructions, consistent and direct reinforcemsnt for desirable behaviors, and consistent/ appropriate punishment for noncompliant and non desirable behaviors. Some skills taught and token economies and response cost. It has been applied to effective parent-child trainings.
Behavior therapy
Type of psychotherapy that uses principles of learning & conditioning (classical and operant) to reduce maladaptive behaviors & to increase adaptive behaviors.* Originally based upon Pavolv’s theory of classical conditioning & focused on problem bxs that were directly observable - ignored cognitions* Present-focused & generally brief* Behavior therapy began developing as a reaction to psychoanalysis* focus is on the behavior itself and the contingencies & environmental factors that reinforce or maintain the behavior rather than exploring the underlying causes of the behavior* During the course of therapy, the client and the therapist work collaboratively.* Pavlov, Wolpe, Watson & Skinner all contributed to the early development of Behavior Therapy. Clinical example: John is a 12 year old client whose parents brought him to therapy because he has been acting out in school, yelling at his peers when he feels angry, and throwing things in the classroom. The therapist uses principles of behavior therapy in order to reduce these undesired maladaptive behaviors and to increase more adaptive behaviors.
Chaining
Chaining is an instructional procedure based on operant conditioning, used to teach a person to engage in a complex behavior that has multiple components.* Therapist conducts a task analysis that breaks down the chain into stimulus-response components. There are two types of chaining: forward and backward chaining* Forward chaining is to teach one bx at a time and chain the bxs together. In this way, each response cues the next, and the last response is reinforced. * Backward chaining is where the whole sequence is taught with coaching at each step and then then coaching is removed that way with reinforcement to follow the last step. It is frequently used for training behavioral sequences (or “chains”) that are beyond the current repertoire of the learner.
EXAMPLE: An autistic child learning to wash her hands independently. Therapist implements the chaining process: The therapist defines the target behavior: washing hands independently.
Classical/respondent conditioning
Developed by Ivan Pavlov; classical conditioning is a form of associative learning in which an unconditioned stimulus (US; that naturally and automatically produces a response) is repeatedly paired with a conditioned stimulus (CS; a previously neutral stimulus) in order to evoke an unconditioned response (UR; an unlearned natural response/reaction). Eventually, the US is removed and the CS comes to elicit the CR on its own.* Principles emphasized in Behavior Therapy* CR is stronger if CS precedes UCS by short vs long time* Phases of conditioning: acquisition, extinction, spontaneous recovery, reconditioning, and counterconditioning Clinical example: Pam comes to therapy complaining of phobia of the dark. She tells the therapist that, when she was little, she was sexually molested by her uncle, who would come to her room when it was completely dark. The therapist hypothesized that classical conditioning played an important role in the acquisition of her phobia: the molestation (US), which elicited fear (UR), came to be associated with the dark (CS), which then elicited the same response (CR).
Cognitive fusion
A principle of psychological inflexibility in Acceptance and Commitment Therapy (ACT), cognitive fusion involves over-identifying with one’s thoughts in a way that has a negative influence on action and awareness; cognitions cause a person to do, say, or focus on things that don’t build the life they want. Helping a client recognize cognitive fusion in themselves can help them detach from their thoughts and improve their psychological flexibility (one of the six core therapeutic processes, according to ACT). A goal of
Clinical example: A client presents with anxiety which seems to be related to her role as a mother. She reports having constant thoughts about how she is failing and her children will suffer the consequences. She describes a constant stream of thoughts about her performance as a mother and feelings of shame and depression following these thoughts. The therapist identifies that the client is demonstrating cognitive fusion, and asks her to step back and see her thoughts as just thoughts, not facts.
Cognitive restructuring
Therapeutic technique used in Beck’s cognitive therapy and REBT; teaches clients to identify and change distorted and maladaptive cognitions. Cognitive restructuring can help clients identify and understand the powerful link between thoughts, feelings, and behavior.* Based on the idea that the client has an excess of maladaptive thoughts* Helps client identify self-talk and thoughts* Client is encouraged to identify cognitive distortions that are maladaptive, challenge the validity of these distortions, and explore more adaptive alternatives* Crucial questions during cognitive restructuring * What is evidence for/against this belief? * What are alternative interpretations of this event? * What are the implications, if the belief is correct? EXAMPLE: A Grad student comes into therapy experiencing great anxiety about her comps exam in the fall. She reports having thoughts like, “I’m stupid and I can’t do this,” every time she sits down to study. The cognitive therapist points out these maladaptive cognitions and uses the cognitive restructuring to challenge their validity. She asks questions like “What evidence do you have for and against this belief?”
Cognitive therapy
Developed by Aaron Beck; focuses on cognitions as the origin of psychopathology.* Assumptions - link between cognitions and behavior, cognitive activity is potentially observable, it can be monitored, counted, altered.* Client is considered expert and collaborator* Two main components are BA and cognitive restructuring* Levels of cognitive distortions (triggered by event) * Automatic thoughts: spontaneous thoughts that appear plausible. Includes dichotomous reasoning, personalization, emotional reasoning etc. * Assumptions: abstract ideas that have generalized rules; often if-then statements * Schemas/Core beliefs: cognitive structures that organize and process info; deepest most ingrained level of cognitions e.g. negative cognitive triad (self, world, future)* Goals: * Correct faulty information processing * Modify beliefs maintaining maladaptive behaviors and emotions * Provide skills for adaptive thinking* Techniques include: downward arrow, psychoeducation* Focus: more on present vs. less on past, pathology and assets, objective data vs. projective tests, interventions and their evaluation. This is an important part of what is now known as cognitive-behavioral therapy. It has been shown to help clients with depression and anxiety.
EXAMPLE: A Grad student comes into therapy experiencing great anxiety about her comps exam in the fall. She reports having thoughts like, “I’m stupid, I can’t do this,” etc. when she sits down to study. The cognitive therapist points out these automatic thoughts and uses the downward arrow technique to begin exploring the client’s schemas and core beliefs so that they can work to change/correct them.
Cue exposure therapy
A specialized form of exposure therapy with response prevention, often used for substance-related disorders, OCD, and eating disorders.* Client is exposed to cue for eating/substance abuse/obsessive thoughts but is unable to eat, use drug, or engage in compulsions; goal is to decrease responsiveness to cues* Best when paired with coping strategies to enhance effectiveness of treatment. Based on Pavlov’s classical conditioning, specifically extinction * Initial sessions consist mostly of repeated cue exposure *
Later sessions consist of cue exposure with coping/social skills as alternative responses
Cues can be olfactory, visual, and auditoty. EXAMPLE: You’re treating a client that is struggling with alcohol use disorder. You are working with her to try and decrease her urges to drink when she’s out at a restaurant. She is extremely used to ordering drinks every time she goes out. You suggest cue exposure therapy and decide to go out to dinner with her at several restaurants without allowing her to order a drink. By preventing her from ordering drinks, you are helping break that association between going out to dinner and drinking
Decision-balance matrix
Technique used in motivational interviewing or other situations where there is ambivalence and often used in working with ambivalence in people who are engaged in behaviors that are harmful to their health i.e. problematic substance abuse, over eating* therapist asks the client to list the pros and cons of making a change or staying the same* Constructed in a decisional matrix consisting of four blocks: advantages of the status quo, disadvantages of the status quo, advantages of changing, disadvantages of changing* Informal measure of client’s readiness for change
Using a client’s decisional balance matrix can help that client to work through ambivalence. EXAMPLE: You’re working with a teenager that is using substances to a dangerous extent. You are considering a substance use disorder diagnosis; the client is extremely ambivalent, and still in denial. You explain to her that it can be good to think through all of the pros and cons of change. You work with her to fill out a decision balance matrix worksheet that assesses all of the costs and benefits. After completing the worksheet, you spend time discussing and exploring her answers to see if her ambivalence has been resolved. That is, is the client more or less ready to change?
Dialectical behavior therapy (DBT)
Dialectical Behavior Therapy is a third-generation behavior therapy that focuses on both validating and accepting a client’s experience and helping them develop strategies or problem-solving behaviors that lead to positive changes in their lives. The key concept is that every argument has an assertion or thesis and opposing position (antithesis) but resolution is reached to incorporate both. Developed by Marsha Linehan as a treatment for suicidality, self-harm, and BPD, DBT focuses on: (1) creating mindfulness by helping clients use their wise mind (the intersection of their rational and intuitive or emotional mind), (2) developing interpersonal effectiveness skills, (3) emotion-regulation skills, and (4) increasing distress tolerance. Often consists of weekly individual and weekly group therapy sessions has been successful in helping clients who are resistant to other forms of treatment, such as clients with Borderline Personality Disorder, create positive changes in their functioning and lives. Clinical example: Debbie enters therapy because she has BPD; her immediate problem is that she is frequently cutting her arms b/c of recent break up. The therapist uses DBT and validation/acceptance strategies. She tells her “Your emotions can be very upsetting, and it makes sense that you would want to alleviate them, which you do by cutting yourself. Perhaps you can learn other, less destructive ways to do that.” Saying this creates a space to use problem-solving strategies to help the client find more skillful ways of regulating her emotions.
Differential Reinforcement
DRO is a procedure or technique based on the principles of operant conditioning often used in Applied Behavior Analysis that can lower the frequency of a target problem behavior by reinforcing a desirable behavior as an alternative. The five types are the reinforcement of incompatible behaviors, competing behaviors, compatible behaviors, any other behavior, and low response rates. It is effective because the more the client engages in the alternative behavior, the less opportunity they have to engage in the undesirable behavior. Clinical example: Curtis, a 13-year-old boy with autism, has a problem with aggression (problem bx). After conducting a Functional Analysis, the therapist was able to confirm that the target behavior (aggression) was maintained by social reinforcement. A DRO schedule was created in which he received a reward (praise) every 3 minute interval in which no aggression occurred. There was no alternate bx required for praise, simply the absence of aggression.
