Chapter 15 Flashcards
Anxiety
- Specific phobias
- Social anxiety disorder
- Generalized anxiety disorder
- PTSD
- Panic disorder (with and without agoraphobia)
- Most effective treatment is Exposure Therapy
and Cognitive Behavioural Therapy
Exposure
Approaches
Used to change behaviours involving fear
and anxiety
* Imaginal or in vivo
* Graduated or intense
* Spaced out sessions or en masse
* One session or multiple sessions
Exposure
Techniques
Common element: client is exposed to
anxiety-eliciting stimuli without
experiencing the feared negative
consequences
Treatment includes:
Modification of the operant
escape and avoidance
behaviours
Modification of the
respondent behaviours (the
Conditioned Responses)
Avoidance
Diagram
2 parts: Escape + Avoidance
- Escape – removal of negative reinforcer
- Avoidance – prevention of further
negative reinforcers
Maintains the cycle
* HARD to extinguish because of
intermittent reinforcement
Exposure
Interventions
Systematic Desensitization
In Vivo Desensitization (Exposure)
Prolonged Exposure (PE) Therapy
Virtual Reality Exposure Therapy (VRET)
Eye Movement Desensitization Reprocessing (EMDR)
Exposure and Response Prevention (ERP)
Systematic
Desensitization
Techniques
* Imaginal exposure (generalizes to real life)
* Decrease phobic responses
* Using a graduated hierarchy of feared stimuli
* Relaxation Techniques
* Don’t focus on what US initially created the fear (UR), but on
what is maintaining the CRs now
Three steps:
* Relaxation Training
* Construction of anxiety hierarchies
* Pair the relaxation + phobic stimuli until phobic stimuli no
longer elicits anxious symptoms
In Vivo
Desensitization
(Exposure)
Similar to Systematic Desensitization → extinction of the
anxiety and avoidance response
* Except uses real-life situations (not just imagined)
- Remain in the presence of the feared stimulus for brief
periods of time → longer and longer time - Don’t need to worry about generalization because it’s already
happening in the real-life already - Phobia Treatment:
- Anxiety CRs are extinguished by repeated presentation of
the conditioned stimulus (CS) in the absence of the US. - The operant avoidance response also extinguishes
because of the removal of the negative reinforcement
contingency established previously.
Prolonged Exposure Therapy
- Rather than graduated exposure, this is at fullintensity for a prolonged approach (either
imagined or in vivo) - Flooding – sometimes even 1 session
- Prevent any escape or avoidance from the
feared stimulus - Absence of feared consequences
- Develop a tolerance for the anxiety
- Associate the feared stimulus with being safe
- Panic disorder – this is an essential aspect of
treatment - PTSD – equivocal (not enough RCTs)
Virtual Reality
Exposure Therapy
(VRET)
- Computer-generated exposure
environment - Visual, auditory, and olfactory
stimuli - Effective in PTSD * Augmented reality
– enhances
aspects of the “real
-world” - Good for specific phobias (e.g.,
spider) - Generalizable??
Eye movement
Desensitization
Reprocessing (EMDR)
- Imaginal exposure of a stressful/traumatic event (PTSD)
- Performing rapid eye movements back-and-forth
Controversial whether the eye moments add to the effectiveness, or if
the cognitive processing part is the key element.
* Other treatments:
* Cognitive Processing Therapy (CPT) - https://www.apa.org/ptsdguideline/treatments/cognitive-processing-therapy
* Trauma-Focused CBT -
Exposure and Response
Prevention (ERP)
Often used in OCD
* Obsessions – repetitive, unwanted
thoughts or images
* Compulsions – repetitive, excessive overt
acts or responses that have negative
consequences for them or others
- Two components:
- In vivo exposure
- Strict response prevention
- Efficacy rates high (75-85%), but high dropout
rates (20-30%) - Similar outcomes to medication alone
- Helpful if you can involve social support
Habit
Reversal
Training
From Chapter 4:
1. Awareness Training – detect pre-urge signs
2. Competing Response Training
* Blocks the behaviour over the duration of
time (fixed/variable)
3. Motivational and Social Support
* Behavioural Reward System,
Parent/Peer/Teacher praise
Comprehensive behavioural intervention for tics (CBIT)
Dr. Ali Mattu
Aversion Therapy
- Used to treat behavioural excesses
- Aversive stimulus is presented with the stimulus to
prevent the undesired response - Enhances escape/avoidance behaviours through
negative reinforcement - Not used frequently, ethical concerns, complex
intervention - Requires extra supervision and monitoring, explicitly
discourages in the College of Psychologists of Ontario
(CPO). - More emphasis on the use of positive reinforcement
currently
Cognitive Behavioural
Therapies
(CBT)
- Rational Emotive Behaviour
Therapy (REBT) - Cognitive Behavioural
Therapy (CBT) - Family-Based Cognitive
Behavioural Therapy (CBFT) - Panic Control Treatment
(PCT) - Behavioural Activation
Therapy
Cognitive biases
*Most powerful, hardest to change,
and most likely to be in our moment-to-moment awareness
Perceptions
selective attention
attributions
expectancies
assumptions
standards
Cognitive
Distortions
arbitrary inference
selective abstractions
overgeneralization
magnification/minimization
personalization
dichotomous thinking
labeling/mislabeling
tunnel vision
biased explanations
mind reading
Rational Emotive Behaviour
Therapy (REBT)
Albert Ellis (1961): Rational-Emotive Therapy (RET)
* Problems (anxiety, depression, anger, guilt) occur when individuals:
* Hold irrational or dysfunctional beliefs
* Make negative evaluations and interpretations of self or others because of these beliefs
* Negative cognitive processes (irrational thought patterns) → strong negative emotions (distress)
→behave in negative ways toward self or others
- Irrational beliefs:
- Identify
- Challenge
- Change these irrational beliefs by use of rational argument → “rational beliefs”
- Added “behaviour” to the name to emphasize changing overt behaviour through behavioural
assignments/homework (*key component)
Cognitive Therapy (CT) Principles
Changing thought processes
is a key part (“reframing”
and “change talk”)
* Expectancies
* Beliefs
* Attributions
Cognitions represent an
underlying belief system in
the individual
* Learn to evaluate and
modify problematic or
dysfunctional cognitions by
looking for evidence (not
just rational arguments)
* Learn to communicate and
problem-solve
CBT – uses both the
cognitive and behavioural
interventions
* Adds in the use of
homework assignments to
collect data
* Clients and therapists work
collaboratively
* Need more work in diverse
populations
Cognitive
Restructuring
thought diary
Additional CBT
Techniques, thought stopping
- Covert technique used to decrease
frequency of recurring negative or selfdefeating thoughts - Interrupt the undesired thoughts →
redirect the client’s attention to coping
thoughts that are incompatible with the
undesired thoughts - Positive self-statements
Additional CBT
Techniques
* Self-Instruction Training (SelfTalk)
- Cognitive modeling
- Cognitive behavioural rehearsal
- Shift from overt external
instructions (therapist) → covert,
self-instructions through fading
techniques
Motivational
Interviewing
(Miller & Rollnick, 1991)
A patient-centered, therapeutic style that
incorporates:
Patient-provider relationship:
* collaborative, empathetic & non-judgmental
* quiet and eliciting responses from provider
Self-efficacy:
* Change is internally, not externally, motivated
* Maintains patient’s autonomy
Creating and resolving discrepancies/ambivalence:
* Between current behavior and future goals
Advice giving:
* In a non-confrontational style
Transtheoretical Model (TTM)
(Prochaska & DiClemente, 1982)
“Readiness to Change”
- Precontemplation – not yet considering change
- Contemplation – evaluating reasons for and against change
- Preparation – planning for change
- Action – making the identified change
- Maintenance – working to sustain changes
General Tenets of the Spirit of MI
Three Communication Styles
1. Directing (Advice only)
2. Guiding (Listen & encourage ideas)
3. Following (Empathetic listening only)
→ Guiding is thought to provide the best outcomes. The overuse
of the directing style is part of well-intentioned efforts, but is not
as effective. Following is too passive.
Three core skills
1. Asking (to understand the problems)
2. Listening (actively)
3. Informing (to convey knowledge)
Cognitive
Behavioural
Family
Therapy
(CBFT)
Multiple forces occurring in a family – open systems approach
* Cognitive
* Behavioral
* Emotional
* Expressed emotion: the degree to which family members
exhibit criticism, hostility, overinvolvement
Interpersonal transactions
* Communication tools & PSST (to increase family functioning)
* Double-bind hypothesis (refuted in causing mental health
disorders, but still acts as a stressor on the family)
Contextual factors (extended family, cultural)
Explore all systems operating on each person
* Multidirectional and reciprocal influences
Panic Control Treatment (PCT)
Psychoeducation
* The causes of anxiety and panic
(fight-and-flight)
Cognitive restructuring
* Overestimating the danger of a
panic attack
* Catastrophizing the
consequences of a panic attack
In vivo exposure
* Settings or situations
Interoceptive exposure
(recreate physical
sensations of a panic attack)
* Dizziness, heart racing, shortness
of breath
Breathing retraining (to
prevent hyperventilation)
* Biofeedback tools used
Relapse prevention
* Develop coping strategies to
manage setbacks and “worst
case” scenarios
Interoceptive
Exposure
Worksheet
feel sensation record
Behavioural
Activation
Therapy
Major Depression:
* Increasing activities that are pleasurable or demonstrate
accomplishment
* Receive more positive reinforcement form the
environment
* Reduce escape and avoidance behaviours that maintain
depressive symptoms
Components:
* Daily activity monitoring
* Mood ratings
* Assessment of pleasure and mastery activities
* Social Skills training
* Behavioural Assignments
*often used in conjunction with other CBT treatment techniques
Three “Waves” of Behavior Change
First Generation (1950s)
* Classical Conditioning and Operant Conditioning
Second Generation
* Negative thoughts, images, feelings and beliefs → undesired/maladaptive behaviors
* Cognitive Behavioural Therapy (CBT) – learn to modify these cognitions constructively
* Most evidence base for effectiveness in many psychosocial problems
Third Generation (1990s)
* Accept negative cognitions AND pursue your valued goals
* Be present-oriented, nonjudgmental awareness of bodily states
* Psychological flexibility – bigger range of coping strategies
* Built on the 1st and 2nd generation waves
* Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT), and
Mindfulness-based therapies
Third Generation Behaviour Change Approaches
Mindfulness-Based Interventions
* Mindfulness-based stress
reduction (MBSR)
* Mindfulness-based cognitive
therapy (MBCT)
* Acceptance and Commitment
Therapy (ACT)
* Dialectical Behaviour Therapy (DBT)
Mindfulness
- Buddhist form of meditation
- Develop a purposeful, present-oriented, nonjudgmental
awareness of one’s bodily states (see, hear, taste, smell,
touch, think, feel): - Thoughts
- Emotions
- Sensations
- Perceptions
Regulate your focus of attention to the ever-changing internal and external stimuli - Minimizes the fight-and-flight response
- Openness, curiosity, and acceptance
Central Tenet of Mindfulness
- Thoughts do not cause distress
- The way in which you react to the thoughts cause distress
- Thoughts are not resisted, but acknowledged and released
- You do not have to believe all your thoughts
- Defuse yourself from your thoughts (decentering/distancing)
- Thoughts ≠ reality
Goal is psychological flexibility
* Greater range of coping skills to respond to cognitive processes
that contribute to emotional distress or problem behavior
Mindfulnessbased Stress
Reduction
(MBSR)
Goal: to cope with stress, pain, and illness
* Mindfulness meditation
* Yoga
* Body awareness/scanning
* Daily homework
* Outcomes: similar to CBT, but better than
supportive care and nutrition education programs
Mindfulness Apps:
* Eternal Sunshine
* Stop, Breathe, and Think for Kids
MindfulnessBased
Cognitive
Therapy
(MBCT)
Goal: to reduce symptoms of depression
* Combines mindfulness-based stress reduction and
components of CBT
* Increase awareness of negative thoughts and
emotions
* Recognize the role of these thoughts in
maintaining the depressive symptoms
* Stay in the here-and-now to decrease
rumination about negative thoughts
- Outcomes: Better than treatment as usual, and as
effective as antidepressant medication treatment, helps
with relapse prevention - May be able to extend to Bipolar Disorder, panic
disorder, and medical conditions
Acceptance and
Commitment
Therapy (ACT)
Goal: to help individuals accept
their thoughts, sensations, and
feelings without attempting to
change or suppress them
* Decrease experiential avoidance
– avoidance of negative thoughts,
emotions, and physical
sensations
DNA-V Model
- Discoverer
- Noticer
- Advisor
- Values
Central
Tenant of
ACT
Functional contextualism (FC) – how cognitions and overt
behaviours function in specific contexts
* A thought, memory, feeling, or behaviour is only
problematic/pathological/dysfunctional depending on
the context in which you experience them
* Less impactful on one’s life if a painful cognition is
processed using cognitive defusion and acceptance
* Focus is living a value-drive life, and ensuring
behaviours are congruent
- Outcomes: similar to CBT, better than treatment as usual, useful in anxiety, depression, addiction, and somatic health
problems
Dialectical Behaviour
Therapy (DBT)
Marsha Linehan – developed for those who have Borderline Personality
Disorder and chronic suicidality
- Goal: to address emotional dysregulation, impulsivity, chronic suicidal
ideation, and self-harming behaviours by replacing/disrupting these
behaviours with more effective coping strategies. - Through both individual and group therapy:
- Behaviour Change Principles (contingency management, exposure)
- CBT (cognitive restructuring and problem-solving)
- Mindfulness practices to regulate emotions (distress tolerance,
reality acceptance)
Central Tenant of DBT
- Need to develop a more dialectical worldview – synthesis of polar extremes
- Replace rigid, dichotomous thinking (all-or-nothing), with a more balanced
perspective - Need to be accepting of client as who they are and validating them, while also
motivating them for change - Outcomes: In addition to BPD and suicidal behaviours (including in adolescents),
also effective in treatment of eating disorders, substance use, and PTSD
Summary of Techniques Used in
CBT, DBT, and ACT
graph
Choosing Interventions
Evidence-based practice
Using the best evidence to guide delivery of services
Ethical Guidelines:
Practitioners should select evidence-based
interventions
Training institutions and licensing boards should
differentiate evidence-based treatments from
those who lack such support
Future Trends
Common Elements
Transdiagnostic perspective – commonly occurring practice
elements (e.g., modeling) that help with suffering and
distress regardless of one’s specific diagnosis
Common Factors
* Therapist-specific – warmth, empathy, relationship
* Client-specific – psychological-mindedness, stress reactivity
* Interaction of the two
Studies show that the some
of the biggest variability in
outcomes is due to:
* quality therapist > specific treatment > placebo treatment
Future Trends in technology
Inside the “black box”
* fMRI – detect changes in neuronal
connections
* Connectome – structural and functional
connections in the brain
* Future research may be able to show the
connection between connectome and
psychological functioning (and whether
interventions can impact them!)
Technology/Telemedicine
* Smartphones, FitBits, Sensors
* Teams, Zoom and other client-therapist
computer platforms
* Socially assistive robots
Efficacy vs.
effectiveness
gap
*Transfer of
knowledge from
research to practice
is lagging
*Need more
interaction between
researchers,
practitioners, and
consumers
