Cognitive and Behavior change Flashcards
Modeling
WHAT - Modeling is a learning process where one observes and imitates others behaviors, attitudes, or emotions. Can be observed directly (in person) or symbolically (video/image). The 4 steps of the model are attention, retention, reproduction, and motivation. This concept is closely associated with Albert Bandera’s social learning theory which emphasizes that individuals can learn not only through direct experience, but also through observing others
WHY - Modeling is important because it can be used as a powerful tool in promoting behavioral change and teaching social and problem solving skills
EX - A caregiver may teach a child to share a toy by actively displaying giving a toy to a peer while the child watches to model what it looks like for the child to replicate.
Acceptance and Commitment Therapy (ACT)
WHAT - A third generation behavioral therapy that helps clients with a range of mental health conditions that are stuck in avoidance and rigid thinking. The goal is to build psychological flexibility by learning to accept thoughts and feelings instead of avoiding or controlling them. This therapy is done through mindfulness and behavioral change skills to align with the clients personal values and beliefs
WHY - ACT is important to allow clients to accept things within or outside of their control and stay true to themselves and their values
EX- A social anxious client learns in ACT to use cognitive diffusion to accept feelings of discomfort and engages in meaningful connections instead of isolating for wellbeing
Ambivalence
WHAT - Occurs when an individual has conflicting feelings, attitudes, or beliefs about a situations. Central to motivational interviewing and emerges when a client is considering changing a behavior or maintaining it.
WHY - Ambivalence is important as it allows clients to weigh the pros and cons of a behavior without judgement therefore, once a decision is made for change can strengthen motivation and commitment
EX- A client is displaying ambivalence by wanting to quit smoking for better health, but also wanting to keep relying on smoking because it brings them stress relief
Anxiety and Fear Hierarchy
WHAT - Anxiety and Fear Hierarchy is a structured exposure process to reduce anxiety and fear in exposure therapies. The hierarchy is built collaboratively with therapist and client by the client ranking fear/anxiety inducing situations or objects from least distressing to most distressing using SUDs. Then the client is exposed to the least stress inducing situation on their list until the fear response is extinguished, then they move to the next situation on the list and so on. This is used in exposure therapies to treat OCD, phobias, among other anxiety related disorders.
WHY - The anxiety hierarchy is useful so clients can create a visual plan to have expectations and it makes it easier to monitor and track progress.
EX- A client comes in with a phobia of clowns. The therapist and the client create a fear hierarchy starting with imagining a clown being the lowest, and sitting next a clown in a room being the highest. The client imagines the clown until her anxiety is gone and then they tackle the next on the list and so on aiming to get to the highest.
Assets
WHAT - Skills, strengths and resources a client possesses that can be leveraged during therapy to enable resilience and enhance motivation. Assets are part of the ABCPA behavioral analysis model that represents what the client is already doing well
WHY- Assets are important as they help clients overcome challenges and achieve goals as they build self-confidence and self efficacy
EX- A client comes in with low self esteem but has a strong support system. The therapist might point this out and encourage the client to lean on them for positive reinforcement
Automatic thought
WHAT- Spontaneous, often negative thoughts, that seem plausible and are often in response to a stimulus or situation. Often involve irrational and distorted thinking tied into deeper core beliefs. These contribute to emotional responses such as anxiety and depression. The concept is central to cognitive-behavioral therapy (CBT), which aims to help individuals recognize and challenge these thoughts to improve their mental health.
WHY - Automatic thoughts can be maladaptive and persistent therefore it is important that these need to be challenged. In therapy, a therapist can help a client challenge these thoughts with more realistic alternatives. These cognitive distortions can be a maintaining factor in ones anxiety, depression, and overall wellbeing
EX- Someone in a social setting might think “they don’t like me” because someone didn’t smile back at them
Behavioral Activation Theory
WHAT - Therapeutic approach primarily to treat depression. It focuses on helping individuals reengage in meaningful and rewarding activities which can improve mood. Addresses low positive reinforcement, avoidance and isolation.
WHY - BAT is important because it allows a way for client to gradually improve their quality of life and decrease avoidance and isolation behaviors
EX - Sarah, a client with depression, she used to love to paint and would do it almost daily. The therapist may suggest that sarah begins drawing in a sketchbook after work each day. Sarah has implemented this for weeks and reports that she now looks forward to coming home from work knowing that she has a fun activity to look forward to.
Behavioral parent training/therapy
WHAT - Therapeutic approach that helps parents manage and improve their child’s behavior. Used typically in cases of oppositional defiant disorder, ADHD and general conduct disorder. The goal is to equip parents with effective strategies and techniques to promote positive behaviors and reduce problematic ones
WHY - PCIT is important because it can lead to parents appropriate responsiveness and is effective for family dynamics and building a secure and nurturing bond
EX - A mother uses consistent rules, praise for good behavior, and time outs for negative behavior as learned in PCIT to address tantrums and homework refusal
Behavioral Therapy
WHAT - Behavioral therapy was developed in response to psychoanalysis based on theorist Pavlov, Skinner, and Watson. The focus is to decrease maladaptive behaviors and increase adaptive ones using learning and conditioning theories. It is used for many disorders such as anxiety, depression, phobias, among others
WHY - Behavioral therapy can be essential for clients to become aware and provide insights into their behavioral patterns that are maintaining their poor mental health problems. They can use behavioral techniques to then learn and promote positive change
EX - A teacher reinforces positive behaviors in case by giving students who raise their hand a sticker instead of giving attention when they shout out to decrease the behavior of them calling out of turn.
Classical/Respondent conditioning
WHAT - Classical conditioning was developed by Ivan Pavlov and explains how automatic and reflexive responses are learned and unlearned through pairing. This is a type of association learning that occurs when a neutral stimulus is repeatedly paired with a stimulus that naturally produces a response, so eventually the neutral stimulus produces the same response.
WHY - Understanding classical conditioning can help clients identify and then modify maladaptive behaviors to then create healthier ones.
EX - Jane come to therapy following a mugging. It occurred when she was in a parking garage alone and the experience was traumatizing for her. As a result, she can not enter a parking garage without feeling intense fear or anxiety. The parking garage was once a neutral stimulus but now elicits fear by being paired with the mugging
Cognitive Fusion
WHAT - Core concept of ACT, cognitive fusion occurs when someone treats their thoughts as literal truths. The idea that thoughts are fused with identify and there is excessive weight given to internal dialog. Leads to negative self appraisals, rigid thinking, and worsening symptoms
WHY - Addressing cognitive fusion is essential in therapy to help clients create distance with their thoughts, reduce distress, improve self awareness, and enhance their ability to act in alignment according to their values and goals
EX - Dan is a therapy client that is having anxiety about his approaching finals. He said she hasn’t bothered studying much because he believes he is bad at memorizing and pretty much not good at school in general. The therapist might intervene and remind Dan that just because he believes these things about himself doesn’t mean they are true
Cognitive Restructuring
WHAT - A key CBT technique that identifies, challenges and changes maladaptive thoughts into adaptive ones. The therapist guides the client through examining evidence for and against beliefs, generating alternatives explanations, and adopting healthier and more realistic mindsets
WHY - Cognitive Restructuring is essential for disorders such as anxiety and depression where negative thinking underlies symptoms. It helps clients recognize and invalidate harmful thoughts which puts them in the position to take better control of their lives
EX - A student believes a friend “hates him” for choosing another seat in class instead of the one next to him. The therapist challenges this thought and explores with the client other reasons which helps the client look at a more realistic perspective
Cognitive Therapy
WHAT - Therapy approach coined by Beck and Ellis that focuses on how thoughts, beliefs, and attitudes contribute to psychological distress. The main idea of this therapy is that distorted and negative thinking patterns about self, others, and the world maintain maladaptive behavior and emotions. Many mental health issues, such as depression, anxiety, and PTSD, stem from distorted thinking (e.g., catastrophizing, black-and-white thinking) and cognitive therapy helps challenge and modify these thought
WHY - CT is important because it is an evidence based and effective treatment that provides clients with skills to challenge and modify negative thought patterns which leads to cognitive flexibility, emotional resiliency and lasting change.
EX - A client comes to therapy with anxiety about starting a new job. She claims her coworkers don’t like her because they laugh every time she walks by their desks, meaning they must be making fun of her. The therapist will identify this belief and work with the client to find evidence to disprove it and come up with more realistic alternatives.
Cue Exposure Therapy
WHAT - Specialized form of exposure with prevention therapy that targets cravings rather than fear. Involves presenting a client with a substance or food that is associated with their problematic behavior and having them prevent consumption in a controlled environment. The goal is to weaken the responsiveness to craving cues through extinction.
WHY - CET allows a client progress to be easily tracked by both the therapist and client as they can witness responsiveness decrease to cues
EX- A client with binge eating disorder is going through cue exposure therapy. The client is exposed to a box of donuts and is tasked with preventing eating them when the therapist leaves the room for a brief amount of time. This is repeated over sessions until the cravings are reduced.
Decision-Balance Matrix
WHAT - Tool commonly used in motivational interviewing that is used to weigh the pros and cons of changing a behavior or maintaining it. The purpose is to clarify motivation and barriers to change to reduce ambivalence so the client can make an informed decision that aligns with their values
WHY - The DBM is essential to help clients weigh pros and cons without judgement and provides the clarity and organization for them so when a decision is made it is made with confidence and commitment to promote long lasting change
EX - A client unsure about quitting smoking completes the decision-balance matrix with their therapist. he fills out that a pro of quitting is better health, while a con is withdrawal symptoms. After continuing the client realizes that there are more pros than cons and is feeling more confident about quitting
Dialectical Behavior Therapy
WHAT - DBT is a third generation behavioral therapy that emphasizes a collaborative structured approach that works to combine validation and acceptance with problem solving and change. The 4 skills in DBT include mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance. Usually used to treat cases of suicidality, self harm, depression, and BPD
WHY - DBT emphasizes skill building as main strategy of treatment which is crucial for clients as it allows for long-term maintenance. Also, combining acceptance and change to foster resilience and improved coping
EX - A client is experiencing intense anger in a heated argument, instead of lashing out, they use a DBT skill that they learned in therapy to actively calm themselves by taking deep breaths to emotionally regulate
Differential reinforcement
WHAT - A behavioral modification technique that rewards desired behaviors while withholding reinforcement for unwanted behaviors. There are three types: DRO (other behavior) - reinforcing after an interval of no problem behavior, DRA (Alternative behavior) - reinforcing a problem alternative and not reinforcing the negative behavior, DRL (low interval) - reward when the behavior stays below threshold
WHY - These reinforcements are important to understand as they allow therapies and their clients to focus on a specific behavior to modify or shape it towards set goals
EX - James is a first grader who has been disrupting his classmates by loudly tapping his pencil. To decrease this behaviors, his teacher implements DRO by praising James for every hour he goes without tapping
Escape and Avoidance
WHAT - Escape is leaving a distressing situation. It is a reaction to an existing threat or discomfort. Avoidance is preventing distress by not encountering the aversive situation, it occurs before the event is experienced
WHY - Escape and avoidance are crucial to understand how people may react to aversive and discomforting events. They often serve to maintain anxiety disorders by never learning the threat may be less severe. Interferes with extinction because the event is never fully experienced
EX- A client coming into therapy for a fear of clowns might try to use escape or avoidance. Escape would be if the client was on the exposure level where they would be in the same room as the clown, but once the clown enters the room the client runs out. Avoidance wold be the client knowing their next exposure is being in the same room as the clown so they cancel the next session so they don’t have to have the distressing experience
Exposure therapy
WHAT - Therapy commonly used to help clients confront and reduce their fear and anxiety to object or situation. Confronts feared stimuli under safe conditions with the goal that repeated exposure reduces fear through habituation and extinction. Used to treat phobias, OCD, and other anxiety related disorders.
WHY - Exposure therapy can be crucial for clients to reaching longterm benefits as it teaches them confidence that they are able to endure the anxiety inducing/distressing situations without needing to rely on escape/avoidance behaviors
EX- A client with a fear of dogs is first shown pictures of dogs, then stands in the same room as a calm dog at a safe distance, and finally progresses to gently petting the dog, allowing anxiety to lessen over repeated exposures.
Exposure with response prevention
WHAT - Type of exposure where clients are confronted with feared stimulus and prevent any safety or avoidance behaviors. Anxiety is allowed to peak and subside showing the clients that feared outcomes are unlikely or tolerable. Targets OCD, phobias, and panic
WHY - Important to help clients reduce stress over multiple exposure and build self-confidence and resiliency that they can overcome their anxiety or fear
EX - A client with contamination fear touches a doorknob and then prevents themselves from washing their hand which is their safety behavior for their OCD diagnosis. They tolerate the anxiety until it subsides, learning that its safe without washing
Extinction
WHAT - Concept rooted in conditioning and behavioral therapies that refers to the process of reducing or eliminating a behavior by removing the reinforcer that is maintaining it.
WHY - Important for many therapy treatments that want to target unwanted behaviors to understand that extinction can occur y removing the reinforcers
EX - A student keeps interrupting in class because it is being reinforced by the teacher’s attention. Once the teacher starts ignoring the student when they interrupt, the student stops interrupting because they are no longer getting attention therefore the behavior has become extinct
Functional/Behavioral analysis
WHAT - Primary assessment method in behavioral therapy used to understand the purpose or function of a particular behavior. The goal is to clarify the behavior in context and take into account individual variables to get a holistic understanding. Examines the Antecedents, Behaviors, Consequences, Personal variables, and Assets of the client
WHY - Behavioral analysis helps to identify the causes and functions behind a behavior, which is crucial for developing the most effective interventions
EX -A parent comes in looking for help managing their child’s tantrums. Using behavior analysis we find that the Antecedent: A child became upset when asked to clean up toys, Behavior: The child cried and refused to pick up the toys, Consequence: Parents gave in and cleaned up the toys themselves.
Generalization and Discrimination
WHAT - Responses that occur in classical conditioning. Generalization occurs when a conditioned response that is learned in one context is then applied to similar situations/stimuli. Discrimination refers to the ability to distinguish between different stimuli and respond to appropriately to each specifically.
WHY - Important to understand because the two terms can explain why a client fear responses can spread or remain specific
EX - Generalization would be if a child fears all white animals after having a negative interaction with a white rabbit. Discrimination would be the child only fearing the white rabbit but not a white dog
In vivo vs imaginal exposure
WHAT - Both are exposure methods used in behavioral therapy that aim to reduce anxiety responses. In vivo is real life exposure where the client is coming in to therapy and directly coming into contact with their feared situation/stimuli. Imaginal exposure is through metal imagery without physical contact.
WHY - Having these two types of exposure therapies is important because it allows room to chose what is best suited for the client. Imaginal exposure is useful for situations where direct exposure is not safe or impractical
EX - A client with a fear of dogs could complete in vivo exposure by coming into a therapy session and being placed in a room with a dog under safe conditions. On the other hand, an example of imaginal exposure would be a client who is afraid of flying would have to imagine the situations
Learned Helplessness
WHAT - Occurs when exposed to repeated uncontrollable negative events leads one to feelings of apathy, depression, passivity, sense of powerlessness, and feeling like their actions don’t make a difference. Strongly linked with depression and other pathology and is a concept considered in often CBT. Therapy aims to restore a sense of control to the client to encourage proactive behavior.
WHY - LH helps to explain why people may give up/not take action in trying to help themselves and explain why people may seem complacent in situations that seem unfavorable/harmful
EX - Jenny is a therapy client who expressed that she wants to stop smoking but has given up trying. She said she has tried a couple methods in the past (cold turkey, tapering cigs a day, nicotine patches), but all have ended in her relapsing. She said she now believes it is impossible for her to stop smoking and sees no point in trying again
Learning Performance Distinction
WHAT - Learning is an internal process that is the acquisition of knowledge and skills. Performance is an external process that demonstrates what has been learned.
WHY - It is important to know that poor performance does not equal lack of learning, but possibly a lack of motivation or reinforcement that is hindering the learned knowledge/skill to be performed. Addressing both skill acquisition and conditions for performance is essential for creating effective interventions
EX -Sam, is the manager of a retail store who is frustrated with her employees. She trains all new hires on how to fold however, there has been an ongoing problem of items not being folded correctly. The therapist says that while the employees may know how to fold, they see no point in spending extra time doing it, since they know they won’t get any praise or reward, and therefore they lack any motivation to perform to the best of their abilities
Mindfulness
WHAT - Core element in any third generation therapies. It is the nonjudgmental attention to ones inner experience. Not necessarily about relaxation, but brings up present thoughts and encourages observation and acceptance of ones thoughts and feelings without labeling them good or bad.
WHY - Consistent practice cultivates a balanced, gentle, curious, and compassionate perspective toward oneself that can enhance cognitive flexibility and break rumination cycles
EX -Rachel comes to therapy for anxiety. The therapist is walking Rachel through mindfulness exercises and tells her to try breathing exercises, tries to ‘scan’ her body for any sensations, and teaches her how to observe her thoughts as mental events that she can chose how to respond to, rather than being controlled by them
Motivational interviewing
WHAT - Client centered collaborative therapy approach designed to enhance motivation for change. Utilizes tools like the decisional balance matrix to reduce ambivalence and figure out the discrepancy between goals and behaviors to encourage positive behavior change
WHY - MI emphasizes client autonomy and respects a clients values and goals. It is effective in facilitating behavior change by helping clients explore their own reasons for change and take ownership of the change process
EX - A client weighs pros (social enjoyment) and cons (guilt, health risks) of drinking, aligning choice with long-term goals
Operant conditioning
WHAT - Learning process where behavior is either strengthened or weakened by its consequences. Behaviors followed by desirable outcomes increase, while behaviors followed by undesirable outcomes decrease. Done through reinforcements and punishments
WHY - It helps to conceptualize many mental health conditions that are thought to be maintained by positive and negative reinforcement.Understanding the process of operant conditioning is essential to creating effective interventions.
EX - A therapist is doing behavioral therapy with a child with Autism. The therapist is trying to get the child to practice sharing a toy. Each time the child shares his toy, the therapist praises him. The praise serves as positive reinforcement and will increase the frequency/likelihood of the behavior occurring
Negative reinforcement
WHAT - A principle of Skinner’s operant conditioning that refers to the process of strengthening a behavior by removing an aversive stimuli after the behavior occurs
WHY - Negative reinforcement is a large part of what maintains fears, anxieties, and phobias. Understanding how escape and avoidance behaviors are negatively reinforcing an unhelpful behavior is important to creating an effective intervention
EX - Maria has OCD. Each time she begins to have obsessive thoughts regarding contamination, she washes her hands. Washing her hands removes the aversive stimulus of obsessive thoughts, making it more likely she will wash her hands again/more often
Positive Reinforcement
WHAT - A principle of Skinner’s operant conditioning that refers to increasing the likelihood or frequency of a behavior with the addition of a desired stimulus.
WHY - Important in understanding how behaviors are shaped and maintained
EX - A therapist is doing behavioral therapy with a child with Autism The therapist is trying to get the child to practice sharing a toy. Each time the child shares his toy, the therapist praises him. The praise serves as positive reinforcement and will increase the frequency/likelihood of the behavior occurring
Punishment
WHAT - Concept in Skinner’s operant conditioning that refers to delivering an immediate consequence to a behavior to reduce its frequency. Positive punishment adds an aversive stimulus, negative punishment removes a reinforcing stimulus, and vicarious punishment is observing someone being punished which discourages the behavior. Effectiveness depends on immediacy, consistency, individual differences, and magnitude.
WHY - Important in therapy to address maladaptive behaviors with punishments ethically and is important in shaping behaviors
EX - A parent spanking a child for throwing a tantrum is positive punishment, adding an aversive stimulus after the behavior to reduce its frequency
Self-monitoring
WHAT - CBT technique that involves tracking and recording ones own thoughts, behaviors, and moods. Populations that benefit from self-monitoring include those with obsessive-compulsive disorder (OCD), eating disorders, and impulse-control issues
WHY - Self monitoring is essential to promoting self-awareness and identifying patterns, triggers, and progress. Encourages ownership of behaviors and supports more personalized change options
EX - A client is using self-monitoring techniques by making a log of daily activities and tracking how they are feeling throughout the day.
Reciprocal determinism
WHAT - Reciprocal determinism, a concept from Albert Bandura’s social learning theory, suggests that an individual’s behavior, personal factors (thoughts, emotions, beliefs), and environment all influence each other in a continuous feedback loop. In therapy, this means that clients are not just shaped by their environment but also actively influence it through their behaviors and thoughts
WHY- Reciprocal determinism is important to address with clients in therapy to promote self-awareness and allow them to realize they have agency in shaping their environment and break negative cycles
EX- A client struggles with social anxiety and avoids social situations, reinforcing feelings of loneliness and negative self-perception
Schema
WHAT- Deeply held cognitive framework that shapes how individuals interpret themselves, others and the world. Often developed in childhood, it is the deepest and most ingrained level of cognition that influences assumptions and automatic thoughts. These endure despite the reality of the situation and can maintain psychopathology.
WHY – Identifying schemas allows a therapist to understand a client’s outlook on many aspects of their life. It is essential to identify and restructure negative schemas into more adaptive thinking as it can be influencing and maintaining psychopathology. Can be an essential aspect in case conceptualization to identify the core belief that can be targeted with treatment
EX - A therapist has uncovered a client has a core belief that they’re unlovable. The therapist explains how this core belief is likely playing a part in her difficulty with maintaining relationships, poor self-esteem, and shame
Self-efficacy
WHAT - Self-efficacy refers to a person’s belief in their ability to successfully perform tasks, overcome challenges, and achieve their goals. In therapy, fostering self-efficacy helps clients feel more capable of managing their emotions, behaviors, and life circumstances. The concept, introduced by Albert Bandura, is a key component of cognitive-behavioral therapy (CBT) and other therapeutic approaches.
WHY - Strengthening self-efficacy is important and is the goal of several treatments because high SE builds confidence, promotes resilience, and enhances motivation which upholds long-lasting well-being
EX - A client struggling with social anxiety avoids speaking in group settings due to fear of judgment. By guiding the client to recall past successes and set small, achievable goals, the therapist helps build their self-efficacy, reinforcing the belief that they can improve their social confidence
Shaping
WHAT - Operant conditioning technique used to acquire a new behavior by dividing the behavior into smaller steps and reinforcing each approximation to the end goal. Encourages progress made toward final target behavior.
WHY - Shaping is important as it teaches new and complex behaviors by aiding in building a clients self-efficacy and confidence for each step
EX - Omar is a 12-year-old therapy client who has trouble making friends with kids his age. The therapist tries shaping to teach Omar new social skills, with the ultimate goal of initiating a conversation with a classmate. Instead of having Omar try to talk to a peer right away, shaping and reinforcement are used. First, Omar is rewarded for smiling at a peer. Then, saying hi, and later asking a simple question, such as “What game are you playing?” Once Omar has mastered these skills, he can try to initiate a longer conversation
Skills training
WHAT - Skills training is used in behavioral therapy such as CBT if the client is believed to have deficiencies in any knowledge, proficiency, discrimination, or motivation. Aims to improve social skills, assertiveness, problem solving, and coping using modeling, behavioral rehearsal, role-playing, coaching, feedback, and homework
WHY- Can help increase independence and self-efficacy, as well as help clients manage their symptoms to consequently improve quality of life
EX - Omar is a 12-year-old therapy client who has trouble making friends with kids his age. The therapist recommends social skills training– focused on asking appropriate questions, maintaining eye contact, and acting in a warm and friendly manner. The therapist begins modeling the skills for Omar. Omar then role-plays these skills with the therapist
Systematic desensitization
WHAT - A first generation exposure therapy by Joseph Wolpe. A gradual and imaginal exposure therapy that consists of relaxation techniques and anxiety hierarchy. Process includes the client successively imagining more anxiety-arousing situations while engaging in a behavior that competes with anxiety– using counter conditioning
WHY - Foundational for treating phobias and anxiety using a structured, gradual method to reduce fear
EX - Mia comes to treatment due to her phobia of spiders. The therapist teaches and practices with Minnah competing responses, and then they create a fear hierarchy. Minnah engages in relaxation while imagining the lowest item on the hierarchy for 10-15 seconds. Once she can do this several times with no anxiety, the therapist instructs her to move to the next item on the hierarchy
Token Economy
WHAT - Used in behavioral therapy, a tool using tokens to modify behavior. Learners earn tokens for desirable behaviors and lose tokens for undesirable ones. Tokens can be exchanged for things that are reinforcing to the learners such as treats. The four key elements are defined target behaviors and token values, list of backup reinforcers, type of token (e.g., points, stars), clear rules for earning, losing, and redeeming tokens
WHY - TEs can be essential for behavior modification because they are convenient (can work in multiple settings), organized, and fair. They provide instruction as to what is a desired behavior, rather than only punishing undesirable ones.
EX - An ABA therapist is conducting a social skills group for children ages 9-12. The therapist is trying to increase hand-raising and decrease interruption. Each time they raise their hand to answer a question, they get a sticker. If they blurt out an answer, they lose a sticker. Once a child has 5 stickers they can leave the room and go have a break in the playroom.
