PSYC 501 - Principles of Cognitive & Behavioral Change

Question 1

ABA or Reversal Design

Answer 1

ABAB Design; a type of single-subject outcome research design in which a baseline is assessed (A), the treatment is introduced (B), then the treatment is removed (A), and reintroduced again (B). If the dependent variable changes with the introduction of the treatment and then changes back to baseline following the removal of treatment, this provides strong evidence of a treatment effect.

Limitations:

• Lack generalizability
• Only useful when behavior is maintained by external factors
• Withdrawal of tx may be unethical
• Learned skill(s) may not be able to be unlearned

Clinical Example: A psychologist is interested in testing the efficacy of a new behavioral treatment for ADHD and decides on a reversal design for their study. They measure an individual’s hyperactivity at baseline (pre-treatment), then introduce the treatment and assess hyperactivity again, then remove the treatment to see if hyperactivity returns to baseline. Some designs may then reintroduce the treatment again to assess behavior change again.

Question 2

Acceptance and Commitment Therapy (ACT)

Answer 2

Acceptance and Commitment Therapy is a third-generation behavior therapy developed by Stephen Hayes that focuses on increasing psychological flexibility by (1) decreasing cognitive fusion, (2) decreasing experiential avoidance, (3) increasing mindful contact with the present moment, and (4) clarifying the client’s goals and increasing behavior towards those goals. ACT and other 3rd wave therapies expanded the concept of psychological health by helping individuals see that pain and suffering are a part of all lives, and learning to live with pain is more adaptive than trying to eliminate it from our experience.

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.

Question 3

Anxiety/fear Hierarchy

Answer 3

A process or step in graduated/brief exposure therapies in which a person’s feared stimuli are broken down into components and ordered in terms of how much subjective distress they produce (SUDs). Then, typically a client will be exposed to each item starting with the one that induces the least amount of fear. Once they conquer that item or their distress is greatly reduced upon exposure, they move to the next item on their list.

Clinical example: A client presents with social anxiety disorder. He reports that his anxiety has become so intense, he has trouble leaving his house even for activities he used to enjoy. His therapist recommends graduated exposure therapy to help the client face his fears in a safe environment and develop coping skills to manage the physical symptoms accompanying his anxiety. They work together to create a fear hierarchy which includes steps like, getting ready to leave the house, walking out of the front door to get the mail, going for a walk in his neighborhood with the therapist, then alone, visiting a grocery store with the therapist and then alone. The patient conquers each step on his fear hierarchy.

Question 4

Assets

Answer 4

In ABCPA behavioral assessment model, assets are the skills or strengths an individual has that may prove useful during the therapeutic process. For example, if an individual is highly motivated to change, that is an asset they bring to therapy with them that could impact the success of therapy. Assets are critical factors for behavioral therapists to consider when designing a personalized intervention for a patient.

Clinical example: A patient seeks therapy for a fear of doctors and hospital settings following the severe illness and hospitalization of her young child. She has previously completed EMDR and exposure therapy for trauma and has experience with mindfulness and yoga, both of which are assets that a therapist may consider when designing and evaluating an intervention for her presenting problem.

Question 5

Automatic Thought

Answer 5

Part of Beck’s Cognitive therapy, automatic thoughts are one level of cognitive distortion that may be impacting the mental health of an individual and, therefore, are a target for treatment. Automatic thoughts are conditioned ideas that arise quickly and spontaneously in response to particular stimuli. For example, a person who is attending a party and feeling uncomfortable may have an automatic thought like, “no one here is interested in talking to me.” Automatic thoughts are informed by an individual’s assumptions and schema, deeper levels of beliefs.

Clinical example: A patient presents with symptoms of depression. She is currently failing all of her courses in college and was recently fired from her part-time job for showing up late. She cancels on her friends a lot, and they have all but stopped inviting her to planned activities. Her therapist gives her the assignment to notice and record the thoughts she has when attempting to complete classwork. She says, “what’s the point of doing this if I am just going to fail anyway” and “I’m not smart enough to be in college.” These automatic thoughts are distortions her therapist can challenge and may provide insight into her assumptions about the world and her core beliefs or schema.

Question 6

Behavioral Activation Therapy

Answer 6

Behavioral activation is a type of behavioral therapy often used to treat symptoms of depression. Developed by Lewinsohn, behavioral activation stems from a behavioral model of depression which conceptualized depression as a lack of positive reinforcement. 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 lists seeing his friends, skiing, and reading. His therapist then asks him to schedule time to engage in each of these activities this 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.

Question 7

Behavior Therapy

Answer 7

Behavior Therapy is an umbrella term for types of therapeutic approaches that treat mental health disorders as maladaptive patterns of learned behavior. Originating in the 1950s largely in response to psychodynamic schools of thought, behavior therapy embraced empiricism and overt or observable behaviors as targets of study and therapy rather than unconscious processes. Behaviorists argued learning through processes like operant and respondent conditioning could relieve patients of psychological distress. Behavior therapy is present-focused rather than past-focused and action-oriented in that it requires clients to do something (other than just talk) about their problems.

Clinical example: Jake seeks therapy for help with some fears he has developed around walking alone at night. Six months earlier, he was jumped and robbed of his wallet and cell phone while walking home from his girlfriend’s house. Since then, he has had persistent thoughts about it happening again and often avoids walking at all especially at night. This is problematic for him as he does not have a car and there is no public transportation in his town. His therapist, who practices behavior therapy, recommends a brief course of exposure therapy. She explains that Jake learned to associate walking in the dark with the pain and terror of the attack and that by pairing that same antecedent with instances in which there was no attack would reduce Jake’s anxiety. In other words, he would learn to associate safety with walking. She explains that Jake’s avoidance of walking is actually strengthening his fear of walking at night via the principles of negative reinforcement.

Question 8

Chaining

Answer 8

Part of: Behavioral therapy/Skills Training

What: a technique used by behavioral therapists to teach complex behaviors that involves breaking the behavior down into specific steps, and reinforcing the learning of each step until the complex behavior is mastered. There are two types of chaining, forward chaining in which the complex behavior is broken into smaller, teachable components and then taught and reinforced in order. Backward chaining involves reinforcing the behavior sequence in reverse order. The therapist would help the client perform each task in the sequence except that last task and then would reinforce the last task upon completion by the client and work backward until the entire behavior was learned.

Clinical example: A therapist is working with a child with autism and wants to teach them to make their bed. The therapist decides to use chaining to help the client learn this new, complex skill. She breaks the behavior sequence into smaller steps, (1) smoothing the sheets, (2) arranging the blankets, and (3) fluffing the pillows. At first, when the child successfully smooths the sheets, she is rewarded with a candy until that step is mastered upon which she is only reinforced when she smooths the sheets and arranges the blankets. This process continues until the child learns the entire sequence.

Question 9

Classical/Respondent Conditioning

Answer 9

Respondent conditioning is an important process in the study and application of behavior therapy. It is a type of learning process that happens via association. Based on Ivan Pavlov’s work with dogs, respondent conditioning occurs when a previously neutral stimulus is paired with an unconditioned stimulus several times in order to create a conditioned response. In his seminal experiments, Pavlov paired the ringing of a bell (NS) with the presentation of food (UCS) and elicited a specific behavior - drooling in his subjects (UR). After repeated pairings, the mere presentation of the bell (CS) would elicit drooling behavior (CR). Understanding this process has led to a deeper understanding of how environmental conditions can elicit specific responses and have advanced how we treat certain psychological disorders.

Clinical example: Jane seeks therapy for help managing stress and anxiety. She has an intense job and has trouble unwinding or destressing at home. She says she thinks about work all the time and is unable to escape the intense feelings of having to get more and more done. Her therapist asks a few questions about her time spent away from work and realizes that Jane always carries her work with her via her cell phone. Jane’s colleagues and clients are able to reach her 24/7 via email, text, or IM. The therapist recommends that Jane turn off the notifications of her email, text, and IM explaining that the tones and buzz they elicit may have become associated with feelings of stress and overwork and thoughts about needing to respond immediately and essentially work constantly. The tone of her notifications, a previously neutral stimulus, has come to elicit conditioned responses of anxiety and thoughts about work. Jane reports that turning off the notifications allowed her to take a break from work and return rested after the weekends. She feels a decrease in her symptoms of stress and anxiety.

Question 10

Cognitive Fusion

Answer 10

A principle of psychological inflexibility in Acceptance and Commitment Therapy (ACT), a third wave behavioral therapy that shifts therapeutic approaches from changing or shifting cognitive distortions to accepting thoughts as just thoughts. Cognitive fusion involves over-identifying or believing in one’s thoughts. In other words, “fusing” one’s thoughts with one’s identity. Recognizing cognitive fusion in a client can lead to strategies that help them detach from their thoughts and, potentially, improve their psychological functioning.

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.

Question 11

Cognitive Restructuring

Answer 11

A process or therapeutic technique most often used by cognitive behavioral therapists in which errors in thinking or cognitive distortions are identified, the events that elicit them and their emotional and behavioral consequences are identified, and certain strategies are used to challenge them and replace them with more adaptive ways of thinking. Based on the idea that clients have an EXCESS of maladaptive thoughts. Cognitive restructuring can help clients identify and understand the powerful link between thoughts, feelings, and behavior.

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?

Clinical Example: A client presents with anxiety surrounding work. He was recently promoted and, as part of his new role, he manages a small team of people and regularly presents his team’s progress to his managers. The meetings he is required to lead as part of his new role create an immense sense of fear. He finds himself constantly rescheduling them or dreading them so badly he can’t get his other work done. He says he worries that his employees will find him incompetent and that his managers will ridicule his performance. His therapist recommends cognitive restructuring to help manage these erroneous thought patterns in hopes of reducing his fear and anxiety surrounding meetings at work.

Question 12

Cognitive Therapy

Answer 12

A type of therapy developed by Aaron Beck in the 1960s that is based on the premise that cognition, or the way one interprets one’s experiences in the world, directly impacts an individual’s feelings, behavior, and overall functioning. Cognitive therapists believe that cognitions are potentially observable and targeting errors in thinking or cognitive distortions can lead to positive therapeutic change. They aim to correct faulty information processing, modify maladaptive beliefs or cognitive distortions, and provide skills for more adaptive thinking.

Clinical Example: A client presents with anxiety surrounding work. He was recently promoted and, as part of his new role, he manages a small team of people and regularly presents his team’s progress to his managers. The meetings he is required to lead as part of his new role create an immense sense of fear. He finds himself constantly rescheduling them or dreading them so badly he can’t get his other work done. He says he worries that his employees will find him incompetent and that his managers will ridicule his performance. He undergoes a short course of cognitive therapy in which his therapist helps him identify that his thoughts of being ridiculed or being found incompetent could be contributing to his fear and anxiety and his constant rescheduling. She helps him create a thought record in which the client can start to identify his thoughts, understand how they impact his feelings and behaviors, and identify more adaptive thoughts such as, “I would not have been promoted to this role if I was not qualified” and “Even if I don’t perform my best one week, that does not mean I am failing.”

Question 13

Conditioned and Unconditioned Responses

Answer 13

Part of: In Respondent or Classical Conditioning

Who: Pavlov

What: CR and UCR are terms used to describe physiological or behavioral responses to stimuli; an unconditioned response (UCR) is the regular and measurable response to an unconditioned stimulus. A conditioned response (CR) happens as the result of a continuous pairing of a CS and an UCS. It is always the same as the UCR. Understanding both UCR and CRs can help therapists identify environmental stimuli that may be producing maladaptive or unpleasant responses in their clients.

Clinical Example: A child presents with a debilitating fear of dogs. The parents report that their neighbors have a dog who regularly chases and nips at their child and that she has since become afraid of all dogs. The therapist explains that the child has learned to fear dogs because of their neighbor’s nipping. She learned to associate the pain (UCR) of being nipped with the sight of the dog and now reacts fearfully (CR) to all dogs.

Question 14

Conditioned and Unconditioned Stimuli

Answer 14

In Respondent or Classical Conditioning, CS and UCS are terms used to describe stimuli that are paired to produce physiological or behavioral responses to stimuli. An unconditioned stimulus is a stimulus, which at the onset of an experiment, evokes a measurable and regular response such as a loud noise, pupil dilation, or salivation. A conditioned stimulus is a stimulus that is neutral at the onset of an experiment. After repeated pairing with an UCS, individuals will learn to associate the CS with the UCS and the CS alone will elicit a response.

Clinical Example: A child presents with a debilitating fear of dogs. The parents report that their neighbors have a dog who regularly chases and nips at their child and that she has since become afraid of all dogs. The therapist explains that the child has learned to fear dogs because of their neighbor’s nipping. Seeing a dog, a previously neutral stimulus, after repeated pairing with the pain of being nipped, has been associated with pain and fear. Now the sight of the dog (CS) with the pain of being nipped (UCS).

Question 15

Cue Exposure Therapy

Answer 15

Cue therapy is a type of exposure therapy with response prevention that generally treats problem behaviors like substance use or disordered eating. In cue therapy, clients and therapists first identify specific environmental cues that provoke problem behaviors or cravings, and then clients are exposed to these cues in a systematic and safe way while preventing them from their typical problem behaviors (using or disordered eating). Working with the principles of respondent conditioning, cue therapy aims to break the association between the environmental cues and problem behaviors associated. Clients learn they can manage the cues without their typical responses.

Clinical example: A client approaches a therapist for help with curtailing his frequent drinking. The client says his drinking has increased as his professional and family life has become more demanding. He often goes for a beer with colleagues after a hectic day at work and often continues to drink after arriving home to what feels like more work (helping kids with homework, cleaning, etc). The drinks feel like a reward for the stress. His therapist recommends he develop a list of all the things that trigger or cue his drinking. The client lists feeling stretched thin at work, having to lead meetings, the noise, and the clutter that seem to accompany arriving home each night after work. The client then selects one cue to work with at a time, exposes himself to the trigger, and then does not drink when he usually would. He works with the therapist to develop strategies to help manage the discomfort of stressful situations and engages in those behaviors instead of drinking. Over time, the client learns he does not have to drink in response to each cue and is successfully able to modify his problematic drinking behavior.

Question 16

Decision-Balance Matrix

Answer 16

Part of: Motivational Interviewing

What: a tool used to help clients who feel ambivalent about behavior change, in which clients lay out the advantages and disadvantages both for continuing with their current behavior patterns (status quo) and for behavior change. Motivational Interviewing is a technique that assumes behavior change is lasting only if an individual is motivated to change, and therapists help clients uncover their readiness to change by identifying their beliefs surrounding both changing and not changing. Knowing the reasons behind the behavior is key to eliciting a person’s own reasons for change rather than providing reasons.

Clinical Example: A client who is disturbed by his own excessive drinking seeks a therapist to help him change the behavior. He knows it’s causing problems in his life, but continues to drink nearly every day. His therapist begins by asking the client to create a decision-balance matrix to help uncover his reasons for drinking and not drinking. In doing so, the therapist can help the client understand his motivations for continuing to drink and the client can better understand if they are ready to change their behavior.

Question 17

Dialectical Behavior Therapy (DBT)

Answer 17

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. 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. It 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: A client seeks therapy after her second suicide attempt. She has seen therapists since she was 13, but has never felt as if therapy helped her manage her intense emotional reactions. She reports a preoccupation with being abandoned, likely stemming from her childhood in which her mother left the family. She has trouble maintaining relationships with her friends and family. Her therapist recommends DBT, which may help the client develop her interpersonal, emotion-regulation skills, develop tolerance to personal distress, and develop mindfulness to understand that her emotions are ever-changing and fleeting, and hopefully break the behavioral patterns associated with the emotions.

Question 18

Differential reinforcement of other behavior (DRO)

Answer 18

Part of: Behavioral therapy/operant condition

What: DRO is a procedure or technique often used in Applied Behavior Analysis that can lower the frequency of a target problem behavior. When using DRO, no alternative behavior is identified, an individual is reinforced only when NOT performing the target behavior for some interval of time. DRO reinforces the absence of non-performance of an identified problem behavior. The procedure works by removing the external reinforcement associated with a behavior, thus decreasing the likelihood that the behavior will be performed.

Clinical example: A family seeks treatment to get help with their child who is having trouble with behavior at home and at school. One behavior that is particularly problematic is the child will often leave his seat during lunch and dinnertime. The therapist recommends DRO and instructs the parents to set a timer for ten minutes. If the child does not leave his seat during this time, he is rewarded with television time following dinner. If he does leave his seat, the parents are requested to ignore him until he returns, and reset the timer.

Question 19

Discriminative Stimulus

Answer 19

Part of: Operant conditioning

Who: B.F. Skinner

Where: Behavior Therapy

What: a cue that is present when a specific behavior is reinforced. Often used in discrimination training, a discriminative stimulus increases the probability of a particular behavior because it has been successfully reinforced or conditioned to do so. In other words, the cue has been part of a process of differential reinforcement.

Why: Having the ability to help clients discriminate between particular stimuli is a critical learning process that can help individuals shape more adaptive behaviors through reinforcement.

Clinical example: A therapist is helping a child with autism develop more adaptive social skills. She helps the child first identify cues and discriminate between social cues that require a response. The therapist waves to the child. If the child waves back or says, “hi”, the therapist reinforces that behavior with praise. If the child looks away or does not wave, her behavior is not reinforced. The therapist also demonstrates that a wave is not required if a person does not make eye contact or wave to her. Throughout this process, the child learns that waving is a discriminative stimulus and waving or saying hello in return is an adaptive response.

Question 20

Efficacy Expectations

Answer 20

Part of: Social Learning Theory/Cognitive-Behavioral Psychology

Who: Albert Bandura

What: a belief that an individual can successfully execute a behavior and achieve a specific outcome or goal. There are two types of expectancies: Outcome: the belief that a behavior will produce a particular outcome [independent of SE] and Self- Efficacy: belief that one can perform a given behavior successfully or master a situation

Why: The knowledge that our efficacy expectations directly impact our behavioral choices is powerful for therapists. In some cases, an individual may have the ability to achieve a particular behavioral goal, but a belief that they are incapable. Changing the belief efficacy expectation could then lead to therapeutic behavioral change.

Clinical example: A client presents with a desire to quit gambling. She has identified a support program and is highly motivated to change. However, she has been unable to curb her gambling behavior for more than a week. After questioning, the therapist discovers that the client has a belief or efficacy expectation that she is not strong-willed enough to give up the behavior and works to help the client see this cognitive distortion. They work on developing the belief that she has the will AND the ability to change.

Question 21

Empirically-supported therapy/tx (EST)

Answer 21

Part of: a movement to ensure clients were getting the best treatment available; prior to the 1990s, there were no specific guidelines for what treatments to use for what disorders

Who: Div 12 of the American Psychological Association

Where: ESTs must meet specific APA criteria and be manualized in order to be considered ESTs.

What: psychological interventions that have been proven to be efficacious for one or more disorders through rigorous research. ESTs are therapies that have demonstrated: (criteria for EST)

• (a) superiority to placebo in two or more methodologically rigorous controlled studies, or
• (b) equivalence to a well-established treatment in several rigorous and independent controlled studies, or
• (c) efficacy in a large series of single-case controlled designs (>9)

Why: Therapy can be harmful to individuals (iatrogenic effects) and our first priority as helping professionals is to do no harm. ESTs are one important way of gathering evidence to understand both if the treatment works and if there are negative impacts from said treatment.

Clinical example: A patient presents with what the therapist suspects, after assessment, is bipolar I disorder. The therapist values practicing based on the most recent research and evidence and wants to ensure any course of therapy meets the APA’s criteria for evidence-based treatment. She consults the Div 12 website and finds that psychoeducation has strong research support for treating mania and modest support for treating depression and incorporates it into her treatment plan.

Question 22

Avoidance/Escape

Answer 22

Part of: behavioral therapy

What: a common response to anxiety-provoking situations in which an individual avoids or escapes from the unpleasant feelings a stimulus provokes

Why: avoidance can often reinforce maladaptive behaviors and emotions via negative reinforcement. Preventing avoidance can be the key to therapeutic change for particular disorders such as phobias and PTSD.

Clinical example: A patient presents with a fear of doctors after experiencing a traumatic emergent visit to a hospital. It has prevented her from seeking medical care for herself and her children when needed. Her avoidance of the doctors has negatively reinforced her anxiety surrounding doctors because she has not had the opportunity to confront the fear associated with the experience or had experiences that differ from her traumatic ER visit.

Question 23

Exposure with Response Prevention (ERP)

Answer 23

Part of: Behavior therapy

What: a specific procedure that can be added to exposure therapy in which during exposure, a client is prevented from engaging in maladaptive avoidance behaviors that typically reduce their anxiety such as compulsions (counting) or using substances or avoidance

Why: Maladaptive avoidance behaviors like compulsions can reinforce behavioral patterns that are distressful to clients. Exposing them to anxiety-provoking stimuli in a controlled way and preventing them from engaging in avoidance behaviors are critical to the success of exposure therapies which are empirically proven to help clients with anxiety disorders

Clinical example: A client presents with OCD. He is plagued by thoughts of infestation of germs and is constantly fearful of contracting a terrible virus. He washes his hands to the point that they are red and cracking and often is late to work because of compulsive cleaning of his house. His therapist recommends exposure with response prevention. The client must touch a garbage can (site of many potential germs) and then avoid washing his hands until his anxiety wanes.

Question 24

Extinction

Answer 24

Part of: Behavioral therapy and both respondent and operant conditioning

Who: Pavlov/Skinner

What: in Classical conditioning, extinction is a phase in which the CS no longer elicits the CR after repeated presentations of the CS without the UCS. In other words, the association between the CS and UCS is broken and the CR is extinguished. In Operant Conditioning, extinction of a behavior happens when the behavior is no longer reinforced and, thus, gradually stops occurring

Why: Extinction is an important process for helping patients de-associate specific stimuli that produce anxiety, fear, or other maladaptive behavior or psychological patterns

Clinical Example: a parent brings her child to therapy for frequent outbursts at home especially during dinner and before bed. The child often hides under the table or intentionally throws his food on the floor. When asked what the parents do in response to the outbursts, they report picking the child up, cuddling them, and sometimes laughing at their silly behavior. The therapist explains that the child has come to associate his behavior with positive consequences and asks the parents to ignore his outbursts going forward in an attempt to break the association between outbursts and positive consequences. Eventually, the child learns he will not receive attention. This is the process of extinction.

Question 25

Extrinsic and Intrinsic Reinforcers

Answer 25

Part of: Operant conditioning/Behavior Therapy

Who: Skinner

What: Extrinsic reinforcers are things that are external to an individual that increases the likelihood of behavior such as praise, money, or candy. Intrinsic reinforcers are things that happen within an individual in response to a behavior that makes the behavior more likely. For example, feeling a sense of pride in a project after working hard is an intrinsic reinforcer.

Why: Extrinsic reinforcers can be critical for helping to change behavior, but often behavior is not reinforced extrinsically. For long-term behavior change, intrinsic reinforcers should be identified and utilized.

Clinical example: An individual with a substance use disorder enters an in-patient treatment program the employs a token economy. Specific behaviors like attending daily group and individual therapy and negative urine tests are rewarded with tokens that can be traded for items from the dispensary or extra privileges. These are extrinsic reinforcers. Over time, the individual starts feeling more understood in therapy, feels a sense of comradery in group sessions, and pride in her ability to remain clean. These are intrinsic reinforcers that she can carry with her into the real world.

Question 26

Functional Analysis

Answer 26

Part of: behavioral psychology

What: a form of assessment that applies the laws of operant and respondent conditioning to establish relationships between environmental stimuli or antecedents, behaviors, and consequences (ABCs); the primary way behaviorists identify and assess the purpose and meaning of a client’s behavior

Typically done using the ABCPA model that investigates:

• The Antecedent setting characteristics (conditions under which the problem occurs) - Setting, day/time, social context can be other behaviors, cognitions, or emotions
• The Behavior - explicitly identified; Overt behavior, thoughts, associated feelings; pt IFR; frequency
• The behavior’s Consequences - what happens following bx
• Person variables - Expectations, skills/competencies, goals, evaluation, self-talk
• Assets -What does the person do well?

This type of analysis classifies problems as behavioral excesses, behavioral deficits, inappropriate stimulus control, or inadequate reinforcement.

The Essential features of functional analysis are:

• Individualized
• Focused on present
• Directly samples relevant bxs
• Has a narrow focus
• Is integrated with therapy

Why: Using functional analysis allows patients and therapists to identify observable, personal stimuli and maintaining consequences to distressing behavioral patterns, and develop personalized interventions to help shift those patterns. Knowing the specific thoughts and emotions that precede or follow a maladaptive behavior is a powerful tool for breaking those patterns.

Clinical example: A client presents with symptoms of depression and reports having no desire to socialize or participate in hobbies she used to enjoy. A functional analysis of the client’s presenting problems reveals that often before she is supposed to attend social events, she experiences thoughts like “I’m no fun to be around” and “who would want to hang out with me.” This leads to feelings of worthlessness and sadness and often the client chooses to stay home. After making that choice, she feels lonely and sad. The therapist recommends scheduling time to participate in at least 2 social events per week, even when plagued by negative thoughts. The client does and experiences positive reinforcement from attending the events such as feelings of friendship and having fun. The thoughts that typically precede her decisions to stay home start to diminish as do her symptoms of depression.

EXAMPLE: A 35-year-old woman has come to treatment for a problem overeating. The therapist conducts a functional analysis by examining the problem bx. The behavior (B) is overeating - considered a behavioral excess. The Antecedents (A) that she reports are feeling stressed or upset frequently at night time. The reinforcing consequences (C) of the behavior is the pleasure that comes from eating and the distraction from the upsetting emotions. However, she is also experiencing the negative consequence of gaining weight. The therapist and client come up with the list of client assets and person variables that will help in the treatment plan.

Question 27

Generalization and Discrimination

Answer 27

Part of: phase of Respondent/Classical conditioning/behavioral psychology

Who: Pavlov

What: generalization is when an organism learns to respond to similar stimuli in the same way. For example, if an individual was bitten by a dog and learned to associate fear with the presence of dogs, but also became afraid of all four-legged animals, that is generalization. Discrimination is the ability of an organism to distinguish between and respond differently to similar stimuli. For example, if an individual was bitten by a dog and learned to fear dogs, but did not fear other 4-legged animals, that is discrimination.

Generalization is when the CR occurs in the presence of other stimuli that are similar in some way to the original US.

Discrimination is the ability to differentiate between similar stimuli; when the CR occurs only in response to the original stimulus

Why: Discrimination and generalization can help therapists develop treatment plans for several psychological disorders. Understanding what stimuli create specific responses in an individual can help in the development of an effective treatment plan.

Clinical Example: An individual presents with anxiety surrounding interacting with strangers. She reports that a few years prior, a stranger at a party had verbally accosted her while drunk and scared her so bad she no longer feels comfortable engaging with people she doesn’t know. However, this is limiting her social life in ways that are impactful. The therapist explains that she has generalized the fear response she had in response to the attack to every situation that involves meeting new people. The therapist works with the client to help her learn to discriminate their fear response between situations that are dangerous and not dangerous.

EXAMPLE: In the classic “Little Albert” experiment, Watson conditioned baby Albert to fear a white rat. Sometime after, researchers noticed that baby Albert was also fearful of other white fluffy things like rabbits, dogs, Santa Claus’s beard, etc. Albert had generalized his fear to other similar stimuli. If baby Albert began only showing fear in response to the white rat, he would be demonstrating discrimination.

Question 28

Exposure Therapy

Answer 28

Part of: a group of first-generation behavioral therapy used to treat anxiety disorders

Who: Joseph Wolpe (Systematic Desensitization - first Exposure therapy)

What: A method of treatment for treating anxiety disorders in which a client is exposed to the anxiety-provoking stimuli in a safe and controlled environment

Based on respondent (something paired with scary event now client fears it) and operant conditioning (avoidance reinforces the fear)

2 central features:

• anxiety MUST be induced during exposure
• client MUST remain in the anxiety-provoking situation long enough for their discomfort to peak and begin to decline - prevent cognitive avoidance
  
  • A general rule of thumb is a 50% reduction in SUDs (sub. units of distress)

Types of exposure: in vivo, VR, or imaginal; prolonged (high intensity, long period) or graduated (fear hierarchy & short period); can include the use of competing response (like in SD - PMR) or not

Used for specific phobias, PTSD, OCD, anxiety disorders, etc.

Specific techniques: SD, Flooding, Interoceptive Exposure (panic disorder), cue exposure, exposure with response prevention

Why: Exposure therapies help clients face their fears, learn to tolerate the stress of those fears, and prevent the fear from controlling aspects of their lives

Clinical Example: A client presents with OCD. He is plagued by thoughts of infestation of germs and is constantly fearful of contracting a terrible virus. He washes his hands to the point that they are red and cracking and often is late to work because of compulsive cleaning of his house. His therapist recommends exposure therapy with response prevention. The client must touch a garbage can (site of many potential germs) and then avoid washing his hands until his anxiety wanes.

Question 29

Iatrogenic effects

Answer 29

Part of: evaluations of treatment options

What: Harmful or problematic effects of therapy or specific treatment that clients may experience. For example, therapists who deliver DID-oriented therapy have been shown to induce new alters in their clients. Why: Understanding iatrogenic effects is critical for therapists whose mission is to do no harm. If a therapeutic technique is demonstrated via research to harm clients, therapists can avoid subjecting patients to harm.

Clinical example: A teenage client is brought to therapy by their parents who suspect they are gay. They tell you they have heard of a type of therapy called Conversion Therapy which can help individuals shed homosexual impulses. You inform the parents that Conversion Therapy has been shown to have iatrogenic or harmful effects on patients.

Question 30

Imaginal exposure

Answer 30

Part of: a mode of exposure therapy

Who:

Where: Behavioral Therapy

What: a type of exposure that involves imagining in one’s mind coming into contact with a source of fear or anxiety. Th client has no direct contact with source of fear

Why: Imaginal exposure can be a pragmatic and effective way of exposing clients to sources of fear or anxiety that can’t or shouldn’t be reproduced in vivo.

Clinical example: A client presents with trauma caused by serving time in the second Iraq war. Part of his symptoms include re-experiencing a specific firefight in which he saw two close friends get shot and die. His therapist recommends imaginal exposure as a safe and ethical way to expose the client to the memories he is re-experiencing.

Question 31

In vivo exposure

Answer 31

Part of: a mode of exposure therapy

Who:

Where: Behavioral Therapy

What: a process in which a client is exposed to a source of fear or anxiety in real life or in person.

Why: in vivo exposure, when pragmatic and ethical, is an effective way of treating fear or anxiety-based disorders. Exposure in the real world to a feared stimuli provokes enough anxiety for the client to learn that they are capable of facing their fears.

Clinical example: A client presents with a fear of flying that meets DSM criteria for a phobia. The issue has prevented her from visiting her children who live in different parts of the country. Because imaginal exposure has not proven successful in her case and she has the means, her therapist recommends a course of in vivo exposure. She actually joins the client on a short flight and helps the client practice breathing techniques to manage her anxiety during the flight.

EXAMPLE: You’re working with a client that has an intense fear of snakes. After discussing it with the client, you both agree that in vivo exposure is the way to go. You instruct the client to handle a snake for increasing amounts of times in the next several sessions as part of the treatment for the phobia.

Question 32

Learned Helplessness

Answer 32

Part of: Classical or Respondent Conditioning/Behavioral Therapy

Who: Seligman

What: a behavioral pattern or issue created by non-contingent reinforcement; learned helplessness can occur when someone is exposed to frequent, uncontrollable punishment no matter what they do. This produces apathy, passivity, and even depression. Seligman discovered it in classical conditioning experiments with dogs in which he conditioned them to receive non-contingent shocks. After, even if they could escape the shocks, they would just lay down instead.

A condition in which a person suffers from a sense of powerlessness, arising from a traumatic event or persistent failure to succeed. The person learns it’s helpless in aversive situations, that control is lost, and so it gives up.

Clinical Example: A parent brings in their child who has recently expressed extreme anxiety about going to school. Upon further questioning, the therapist finds that the child has struggled exams and assignments. He pays attention in class, asks questions, and does all his homework but his scores remain low. He has concluded that he is not smart and will likely fail at all academic pursuits. His academic behavior has not been rewarded and he has developed learned helplessness with regards to his academic abilities.

Question 33

Learning-performance distinction

Answer 33

Part of: behavioral/experimental psychology

Who: Tolman’s animal experiments with rats in a maze, different contingencies for different groups based on errors made (meant to assess) learning

What: a concept in behaviorism that stresses the difference between the learning of a behavior and the actual performance of the behavior.

• Learning/acquisition is primarily an internal cognitive process requiring attention and retention - it is a change in the ability and potential to do the behavior
• Performance is primarily an external process - it requires reproduction and motivation

Tolman’s animal studies indicate that rewards seem to affect performance over learning. Thought rats developed a “cognitive map” of the maze. Group 3 (no food reward for first ten days, rewarded on 11th day). Very quickly (i.e. much faster than acquisition in the always reinforced group), the animals’ performance matched that of the animals which had always been reinforced.

Tolman called this latent learning- the animals that were not always reinforced were learning, but because they had no food motivation to complete the task, their performance was not indicative of what they had learned.

Why: When designing interventions for clients it is critical to understand if a behavior they want to change is not being performed because they haven’t learned it or are not sufficiently motivated to perform it.

Clinical Example: A parent brings their child in for problems at home and at school. The child constantly loses homework or fails to complete it. Even when she does complete it and brings it to school, she fails to turn it in. Upon further inquiry, the therapist assesses that the child has learned the expectations for homework but is failing to perform those expectations. She designs a rewards-based intervention to help motivate her to complete homework on time, keep it in her folder, and turn it in on time.

Question 34

Meta-analysis

Answer 34

Part of: a statistical procedure or technique

Who:

Where: Psych research methodology

What: a research technique that integrates and compares empirical findings from multiple studies in order to determine if and to what degree a treatment is effective. Meta-analyses use a statistical measure called effect size to assess the degree of change a particular treatment induces, on average, in participants. Purpose is to combine multiple effect sizes: a quantitative measure of the strength of a phenomenon; refers to magnitude of an effect

Why: provides more comprehensive evidence of the effectiveness of a treatment

Clinical example: A therapist is looking for evidence of a particular treatment for a patient with social anxiety disorder. She locates a meta-analysis that estimates the impact of the treatment by comparing 15 experimental studies over the past 10 years. The meta-analysis found that the treatment produced a modest degree of change (.56) in patients that received it.

Question 35

Mindfulness

Answer 35

Part of: a core theme of 3rd generation behavior therapies like ACT, DBT, and MBCT

Who:

Where: 3rd generation behavior therapy which emphasizes acceptance of psychological discomfort

What: The ability to pay attention to the present moment without judgment.

Why: some pain and suffering is unavoidable in life and our responses to that pain can enhance and prolong it. If individuals are constantly wrestling with negative feelings or trying to avoid or get rid of them, it can lead to further suffering. Mindfulness teaches us to notice the thoughts and feelings that accompany suffering without wrestling with them or judging them.

Clinical Example: A patient presents with an increase in anxiety. She says the smallest things can send her into a panic and she’s finding it difficult to complete even small tasks like dishes and laundry. She says when she starts to feel anxious the dread accompanying the physiological sensations is paralyzing. She often has a drink to take the edge off, only to find the anxiety return even stronger the next day. Her therapist recommends practicing mindfulness through 5-minute daily meditations. He explains that anxious feelings will arise in everyone and that the ability to notice those sensations and the thoughts that accompany them without judgment will likely result in the sensations passing through quickly. He explains her avoidance of the feelings and attempts to subdue them with alcohol may be prolonging them and even strengthening them.

Question 36

Modeling

Answer 36

Part of: Social Learning Theory/Behaviorism

Who: Albert Bandura

What: a type of learning in which an organism encodes the performance of new behaviors by observing others.

Why: Bandura expanded our knowledge of the way organisms learn. Many behaviors are learned by observation, not always through direct experience. In turn, this expanded potential therapeutic options for individuals trying to learn new skills to help with psychological distress.

Clinical Example: A parent brings his two children to therapy to get help with some problematic behavior including tantrums. The older child often throws them when he does not get his way, often resulting in his parents giving in to quiet him down. Now, the younger child is starting to throw them as well. The therapist explains that the younger child is likely modeling his older sibling. He sees that the behavior (tantrums) often leads to positive outcomes and decides to try it for himself.

EXAMPLE: A couple brings their child into therapy due to violent outbursts in school. It was discovered that through the process of modeling, the young boy had learned violent behavior from his father. He learned that violence is the best way to get your way. This served as proper motivation for the behavior to continue.

Question 37

Motivational Interviewing

Answer 37

Part of: behavioral theory

Who: Miller & Rollnick

What: a method for helping clients who find themselves ambivalent about behavior change explore the pros and cons of changing or sticking with the status quo in a nonjudgmental setting; often used for substance use disorders and eating disorders

3 essential elements:

• It is a type of conversation about change
• It is collaborative
• It is evocative - seeks to call forth an individual’s own reasons and motivation to change

Why: decisions to change or not that come from within a client and are motivated by their specific reasons to change or not are more effective and longer-lasting.

Clinical Example: A client comes to therapy because they fear their alcohol use has gotten out of control. However, they express that they don’t think they have a “drinking problem” and really like drinking sometimes. Getting the sense that the client is ambivalent about changing her behavior, the therapist decides to use motivational interviewing to help the client understand the pros and cons of continuing with the status quo and the pros and cons of changing their drinking behavior.

Question 38

Multiple Baseline design

Answer 38

Part of: a type of outcome research design, case study

Where: Psychological Research

What: A type of outcome research design in which the start of treatment is staggered in order to control for confounding variables. They can assess the impact of treatment across multiple target behaviors, across multiple clients, or across multiple settings.

Why: Employing multiple baseline design is a way to allow for more control over potential confounding variables and strengthen the evidence for a particular treatment. These designs are useful when reversal studies are not ethical or feasible and/or when experimental design is not possible.

Clinical Example: A researcher interested in a new psychological treatment for depression designs a pilot study using a multiple baseline design. The researcher has 5 participants, measures their Sx of depression prior to treatment (baseline), then staggers a start time for each participant, and measures depression Sx post-treatment. This allows the researcher to better determine if the treatment is responsible for the shift in the dependent variable in participants.

Question 39

Negative Reinforcement

Answer 39

Part of: a consequence for a particular behavior

Who: B.F. Skinner

Where: Operant Conditioning/Behavior Therapy

What: a consequence for a behavior that removes something aversive following the behavior which increases the likelihood the behavior will occur in the future

Why? understanding negative reinforcement is critical to understanding how specific maladaptive behaviors are maintained and strengthened, even if those behaviors ultimately cause an organism to suffer.

Clinical example: A client presents with anxiety surrounding entering her bathroom. She recently fainted in the room and hit her head, causing her to bleed a lot and resulting in a visit to the ER. Since then, the room has made her uncomfortable and she has avoided going in it. The therapist explains that her anxiety is being maintained by her avoidance of the room via the process of negative reinforcement. Because the room causes her feelings that are unpleasant, her avoidance of the room itself is strengthened by the removal of that unpleasant feelings.

Question 40

Operant Conditioning

Answer 40

Part of: a method of learning

Who: B.F. Skinner

Where: Behaviorism

What: a type of learning process through which the occurrence and/or form of a behavior is changed via processes of reinforcement or punishment

Why: Operant conditioning, or the processes that shape our behavior, can help therapists develop personalized and effective treatment plans for people who want to change maladaptive behavioral patterns. Operant conditioning was also an important paradigm shift in the study and practice of psychology away from the unconscious and unobservable forces to observable and measurable behaviors.

Clinical Example: Therapists often use the principles of operant conditioning to help clients change unwanted or distressing behaviors. If a client wants help reducing her drinking behavior, the therapist may recommend she develop a reward system. For each day she has less than 2 drinks, the client will receive a reward, thus strengthening her moderate behavior.

Question 41

Outcome Expectancies

Answer 41

Part of: a belief about what we think we can do, a person variable

Who: Mischel

Where: Mischel’s cognitive-affective system

What: Expectancies are part of Mischel’s cognitive-affective System which emphasizes the dynamic forces that interact to lead to specific behaviors. How we think, feel, and what we believe all impact how we behave and our interpretations of our behavior and the outcomes. Outcome expectancies refer to our beliefs about whether or not a behavior will produce a specific outcome.

Why: Understanding and identifying outcome expectancies can help therapists and clients understand and change specific behavioral patterns. This is all part of the expansion of behaviorism to include the cognitive realm and accept that how we think, not just environmental consequences, play a role in how we behave.

Clinical Example: A client presents with anxiety surrounding school performance. She is in her second semester at college and always believed herself to be a capable student. However, she did not perform well her first semester and has concluded that no matter what she does, she will not be able to get a good GPA in college. Therefore, she has stopped attending class and studying. Her therapist identifies the belief that “no matter what she does, she will not perform well” to be an outcome expectancy influencing her current behavior.

Question 42

Outcome vs. Process Research

Answer 42

Part of: a method of testing or evaluating therapeutic techniques

Who:

Where: Psych research methodology

What: Outcome research measures the effectiveness of a specific treatment on a dependent variable of interest. It answers the question, “does this treatment work?”

Process research tries to assess why the treatment works or the specific mechanism(s) of change. It seeks to answer the question, “how does this treatment work?”

Why: Understanding whether a treatment works (outcome research) is crucial for an ethical mental health practice. It guides our interventions and ensures we are helping to the greatest extent possible. Process research allows us to understand which specific pieces or combinations of pieces of a therapeutic treatment create the desired effect. That way, we are delivering with efficiency as well and removing aspects of interventions that have no measurable impact.

Clinical Example: EMDR has been demonstrated to be an efficacious intervention for PTSD in some outcome research. However, process research, specifically dismantling studies, have lent evidence to the idea that the exposure component of EMDR rather than the eye-movement is responsible for the efficaciousness of the treatment.

Question 43

Parent-Child Training Therapy

Answer 43

Part of: a behavioral management system for parents

Who:

Where: Behavior Therapy

What: Parent training programs involve increasing positive reinforcement to improve the negative cycle in parent-child relationships. They also train parents to decrease their reinforcement of undesired behaviors by actively ignoring them. They also involve discipline or punishment of undesirable behaviors but ONLY after the relationship has improved.

Why: Often parents don’t understand the role they are playing in reinforcing behaviors in their child that are undesirable or problematic. When this happens, it can produce a toxic dynamic that is difficult to break out of and can do damage to the parent-child relationship. Parent-Child Training Therapy can help break these toxic patterns.

Clinical Example: A parent and their son enter therapy for help with problem behaviors at home. The child often does not follow instructions, is defiant, whines or complains, and screams when she doesn’t get her way. The parent feels constantly upset by these behaviors and focuses on them almost entirely. He criticizes his daughter and threatens to take away her privileges constantly. Their relationship feels like a constant tug of war, a never-ending cycle of negativity. The therapist recommends parent-child training therapy to help increase the amount of positive reinforcement the parent is giving for desirable behavior and help heal the parent-child relationship.

Question 44

Positive Reinforcement

Answer 44

Part of: a consequence for a particular behavior

Who: B.F. Skinner

Where: Operant Conditioning/Behavior Therapy

What: a consequence for a behavior that adds something desirable after the behavior which increases the likelihood the behavior will occur in the future

Why? understanding positive reinforcement is critical to understanding how specific maladaptive behaviors are maintained and strengthened, even if those behaviors ultimately cause an organism to suffer.

Clinical example: A client presents with insomnia and depression-like symptoms. She reports having trouble sleeping. After asking about her sleep habits, the client reports that she often stays up late into the night and falls asleep while watching tv. Then, when moving to bed she has trouble getting back to bed. She says she has tried to change this habit but not had much success. The therapist recommends positively reinforcing different sleep habits in order to shift her behavior. She asks the client to reward herself every time she turns off the tv and moves to her bed by midnight.

Question 45

Premack Principle

Answer 45

Part of: a process of reinforcement used to increase the frequency of a behavior

Who: David Premack

Where: Operant conditioning/Behavior Therapy

What: In operant conditioning, the Premack principle refers to a process by which one attempts to increase the frequency of a particular behavior by making the performance of a more frequently occurring behavior to be contingent upon it. Essentially probable behaviors serve as reinforcement for less probable behaviors. For example, if someone wanted to develop a meditation practice, but had trouble making it a habit, they could make something they do frequently like brushing their teeth, contingent upon the performance of meditation. I can’t brush my teeth until I have meditated.

Why: This principle is useful when it is difficult to identify or manipulate reinforcers in the natural environment.

Clinical Example: A parent and child seek help with problem behaviors at home. The child often refuses to eat dinner, clean up her toys, and finish her homework. The stress of forcing these behaviors often results in tension and conflict between the parents and the child. The therapist recommends using the Premack principle to reinforce the problem behaviors. She asks what behaviors the child finds naturally rewarding or does often. The parents report that playing with neighborhood friends and watching tv are behaviors the child engages in each day. The therapist recommends making those behaviors contingent upon the performance of the less desirable behaviors.

Question 46

Problem Solving Therapy

Answer 46

Part of: a cognitive-behavioral therapeutic approach or process

Who: D’Zurilla and Goldried

Where: Cognitive-behavorial coping skills training

What: a form of therapy that employs behavioral principles to both help clients identify and manage their presenting problem as well as develop skills to help them cope with future problems.

Clients use a series of systematic steps for solving a problem for which they specifically have sought treatment:

1. Problem Identification and description
2. Goal identification
3. Generate solutions to achieve goals
4. Decide which solution to employ first
5. Implement the solution
6. Evaluate the effectiveness of the solution

Why: Problem solving therapy is useful for treating a wide range of presenting problems. It teaches clients skills for coping with stressors that are bound to show up in life and, therefore, may not only help them solve their immediate problem but help them develop a sense of self-efficacy and process for dealing with the inevitable stressors of life going forward.

Clinical example:

A single mother presents with tiredness, sadness, and loss of interest in both her job and her friends. Her therapist recommends PST to help her explore the life problems that are distressing her and she identifies three:

her aged mother who insists on living on her own despite being approved for supported care

her daughter (Anne, aged 22 years), who has not spoken to her for 3 years

her job insecurity as a single parent and provider for three adolescent children.

She describes feeling overwhelmed by these problems and the sense that there are no solutions. She decides to start with concerns about Anne and focus on their lack of contact, which followed conflict 3 years ago when Anne abruptly left home. As Caroline talks through the problem she is able to clarify the major problem as a concern regarding Anne’s safety as she does not trust her daughter’s partner. While she would like the relationship restored, she identifies her goal as finding out if Anne is okay. She brainstorms a number of ways to achieve her goal. These include contact through one of Anne’s sisters and sending a personal birthday card including an invitation to meet for coffee.

Caroline decides to send a special birthday card. She feels empowered experiencing a sense of being able to do something to address one of her problems. Follow up in 10 days is arranged to assess outcomes including her affect and to further reinforce problem solving skills

Question 47

Primary/Secondary Reinforcer

Answer 47

Part of: types of positive reinforcement

Who: B.F. Skinner

Where: Operant conditioning/Behavior therapy

What: Primary reinforcers have to do with fulfilling a biological need. Things like food, drink, shelter, and pleasure are all examples of primary reinforcers. Secondary reinforcement occurs when a particular stimulus reinforces a certain behavior via association with a primary reinforcer. These include money, good grades in school, tokens, stars and stickers, and praise.

Why: Utilizing secondary reinforcement allows one to continue to reinforce desirable behavior even if the subject does not have any biological needs that could be satiated with primary reinforcers at the moment. This offers the opportunity to deliver reinforcement at any time. Secondary reinforcers must be associated with primary reinforcers in order to be effective.

Clinical example: A patient participates in an outpatient addiction program to help her quit using opioids. The program includes a token economy, using coins as secondary reinforcers for clean urine samples that clients can later exchange for gift cards to local stores and restaurants (primary reinforcers).

Question 48

Punishment

Answer 48

Part of: an active, immediate consequence of a particular behavior

Who: B.F. Skinner

Where: Operant conditioning/Behavior Therapy

What: an aversive consequence following a behavior that makes the behavior less likely to occur in the future.

Why: punishment is a powerful and often quick way to reduce the likelihood of a behavior. However, punishment can often have undesirable emotional consequences such as anger or aggression and modeling of the behavior which can lead to future problems.

Clinical Example: A parent and child seek help with problem behaviors at home. The child often refuses to eat dinner, clean up her toys, and finish her homework. The stress of forcing these behaviors often results in tension and conflict between the parents and the child. Often the parent responds by yelling at the child or to try to get her to understand the importance of the behaviors, a punishment strategy. The therapist recommends trying reinforcement of the desired behaviors as a strategy rather than punishing the undesirable behaviors.

Question 49

Reactivity of self-monitoring*

Answer 49

Part of: a phenomenon produced by self-monitoring

Who:

Where: Cognitive-behavioral psychology

What: a phenomenon produced by the data collection technique of self-monitoring in which the target behavior shifts in frequency or reacts to the process of tracking.

Why: The phenomenon of reactivity can be used therapeutically. Encouraging individuals to simply track the behavior(s) they want to change often results in a positive impact on those target behaviors. It is also critical to understand that self-monitoring data may be unreliable because of reactivity.

Clinical Example: A client presents with anxiety related to a perceived inability to stay organized and on schedule. She often shows up late to work and without important documents she needs. She estimates that she is late to work 4/5 days per week. Her therapist asks her to start a self-monitoring practice. She is to record both if she is late and how late she is. The client notices that the first week she is only late 2 days and by less than 10 minutes. Her therapist encourages her to continue self-monitoring and explains that often there is a reactive effect to self-monitoring.

Question 50

Reciprocal Determinism (P-E-B)

Answer 50

Part of: an assumption of Social Learning Theory

Who: Bandura

Where: Social Learning Theory/Behavioral Psychology

What: An assumption of Bandura’s Social Learning Theory that states there is a reciprocal relationship or three-way interaction between a person (how they think and feel), their behavior, and the environment. In other words, all the different categories have influences on one another.

Why: Understanding the dynamic nature of the environment, individuals, and their behaviors is critical to both understanding the function or purpose of particular behaviors in an individual’s life and to developing effective therapeutic interventions.

Clinical example: A parent brings their child in who is having trouble behaving appropriately at school. The child constantly interrupts class and gets out of her seat, disturbing classmates. While the parent wants to talk about the problem behavior, the therapist wants to understand the environmental and personal factors at play. They explain to the client about the reciprocal determinism or the 3-way interaction between a person, their behavior, and the environment and that understanding how these operate will help develop effective strategies for behavioral change.

EXAMPLE: Larry enters therapy with feelings of depression and low self-esteem due to being unsuccessful in his work. The therapist educates his client about reciprocal determinism and explains the dynamic relationship between his thoughts, the environment, and his behavior. He says that the environment is a factor in shaping human behavior, but we also have choices. Larry suggests that he can find a job at which he can succeed, (change the environment) which in turn will influence his thoughts about himself which may influence his depressive symptoms (behavior).

Question 51

Reinforcer

Answer 51

Part of: a consequence for a behavior

Who: B. F. Skinner

Where: Operant Conditioning/Behavioral Psychology

What: a reinforcer is a consequence that follows a behavior and increases the likelihood the behavior will occur in the future.

Why: Understanding how consequences maintain specific behaviors is a powerful tool for creating positive behavioral change. Knowing what naturally reinforces undesirable behaviors can help clients understand the behavior and how to change it. In addition, rewarding adaptive behaviors that are less likely to occur can lead to positive behavior changes for clients as well.

Clinical example: A client presents with trouble quitting smoking. Upon assessment, the client discusses what she sees as the benefits of smoking. She says she likes the break it provides during work and that it makes her feel more relaxed. Her therapist explains that these consequences are reinforcing the behavior she wants to change. She recommends taking the same breaks at work but replacing smoking with a behavior that is more adaptive like having a cup of coffee.

Question 52

Schedules of Reinforcement

Answer 52

Part of: a plan for when and how often

Who: B.F. Skinner

Where: Operant Conditioning/Behavioral Psychology

What: A schedule of reinforcement is a plan for when and how often to provide a reinforcer for a particular behavior. There are 5 different schedules including continuous reinforcement (CRF) in which a behavior is reinforced every time it occurs, fixed ratio (FR) in which a behavior is rewarded after it is successful performed a specific and set number of times, fixed interval (FI) in which a behavior is reinforced after it is performed successfully in a specific time period, variable ratio (VR) in which a behavor is reinforced after a behavior is performed a random and varying number of times, and variable interval (VI) in which a behavior is reinforced after a time period that varies.

Why: Different schedules of reinforcement are important for different stages or goals for behavior change. A CRF schedule is the most effective way to shape a new behavior, but if reinforcement stops, the behavior will extinguish quickly. Behaviors that are reinforced on VI and VR schedules are often very difficult to extinguish.

Clinical Example: A client presents with issues surrounding her gambling. She explains that she goes to the casino with a plan on how much she can spend, but often ends up draining her credit card. As part of her treatment, her therapist provides psychoeducation and explains why gambling is such a difficult behavior to change. She explains that gambling is reinforced on a variable ratio schedule, meaning that you win a jackpot or hand after a varied number of tries. This type of reinforcement leads to behaviors that can be difficult to extinguish.

Question 53

Self-efficacy and Outcome expectancies

Answer 53

Part of: beliefs that impact behavior; person variables; components of Mischel’s cognitive-affective system

Who: Mischel

Where: Mischel’s cognitive-affective system/Behavioral Therapy

What: Self efficacy is one’s beliefs in their ability to perform some particular behavior. For example, I am athletic and quick to learn new sports is an example of a belief about self-efficacy in the realm of athletic performace. Outcome expectanices are beliefs about the outcome of a particular behavior. For example, if I engage in some athletic endeavor, I will likely win. Our beliefs about outcomes are fundamental to behavioral change and can be directly influenced by our self-efficacy in a particular behavioral realm.

Why: Both self-efficacy and outcome expectancies expand on ideas in behavioral therapy surrounding what elicits and maintains specific behaviors. Our cognitions and beliefs about our own abilities and the future influence our behavior in meaningful ways.

Clinical Example: A client presents with anxiety surrounding school performance. She is in her second semester at college and in the past believed herself to be a capable student (self-efficacy). However, she did not perform well her first semester and has concluded that no matter what she does, she will not be able to get a good GPA in college (outcome expectancy). Recently, she no longer believes she is a capable student (self-efficacy). Therefore, she has stopped attending class and studying. Her therapist identifies the belief that “no matter what she does, she will not perform well” to be an outcome expectancy influencing her current behavior.

Question 54

Self-Reinforcement

Answer 54

Part of: a step in self management; self-administered consequence for the performance of a target behavior

Who:

Where: Self management/Behavioral Therapy

What: self-administered manipulation of consequences for a particular behavior.

Why: reinforcing a target behavior is a powerful way to ensure the behavior becomes habituated or difficult to extinguish.

Clinical Example: A client presents with symptoms of restlessness and depression. Upon assessment, it is clear that the client has spent an increased amount of time on social media and that seems to be contributing to her symptoms. She’s motivated to spend less time scrolling so her therapist recommends instituting a self management program which include stimulus control (removing social media apps from her phone; leaving her phone in a room when engaging in other activities) and self-reinforcement. If the client spends less than 60 minutes scrolling in a particular day, she moves $5 into a special account she’s using to save $ for an upcoming vacation.

Question 55

Shaping

Answer 55

Part of: A process for learning or changing a behavior

Who: B. F. Skinner

Where: Operant Conditioning/Behavioral Therapy

What: the process of training an organism to perform a target behavior by reinforcing any responses, called successive approximations, that are similar to the desired response.

used to establish a new behavior, not in the client’s repertoire, Each approximation of the behavior is reinforced

• Done by dividing bx at hand into a series of smaller steps
• Reinforce for bxs that are more and more similar to desired bx
• Eventually person only reinforced for desired bx

Why: Shaping can be a powerful way to teach behaviors that are not instinctual or complex.

Clinical Example: A child with autism is working towards the target behavior of sitting in his seat during lectures. A therapist recommends a shaping technique to teach seated behavior after she had determined that the child was currently remaining in his seat a mean of 2 minutes during lecture. They analyzed approximations of the target behavior and planned to reinforce those behaviors as follows:

• Reinforcing when Jason sits in his seat for a 3 minutes
• Reinforcing when Jason sits in his seat for 5 minutes
• Reinforcing when Jason sits in his seat for 10 minutes
• Reinforcing when Jason sits in his seat for 15 minutes
• Reinforcing when Jason sits in his seat for 20 minutes (the targeted time)

Question 56

Social Skills Training

Answer 56

Part of: a type of therapy or a component of many behavioral therapies

Who:

Where: Behavioral therapy

What: Social skills are behaviors that are socially rewarding such as listening, smiling, turn-taking, eye contact, affect. Social skills training is used to teach or improve the social skills of individuals.

Why: Social skills are important because improving one’s social skills can increase an individual’s self-esteem and the likelihood of acceptance by peers. Deficits in social skills can lead to negative consequences and create maladaptive patterns of thinking and behavior that can lead to psychological suffering.

Clinical example: A client presents with problems surrounding social anxiety. She says she does not often engage in social interactions. The therapist notices she has trouble making eye contact with her when speaking and that she does not often see nonverbal behavioral expressions of warmth (smiling). She recommends social skills training and explains that learning to improve her ability to make eye contact and perform appropriate nonverbal affiliative expressions will likely increase the rewards she experiences in social situations, make her more likely to do so in the future, and ultimately decrease her anxiety in this realm.



Question 57

Spontaneous Recovery

Answer 57

Part of: a stage or phenonmenon in classical/respondent conditioning

Who: Pavlov

Where: Classical/Respondent Conditioning

What: the reappearance of a conditioned response that had already been extinguished.

Why: This phenomenon demonstrates that extinction is not the same thing as unlearning. While the response might disappear, that does not mean that it has been forgotten or eliminated.

Clinical Example: An individual presents with symptoms of PTSD following an armed robbery at her work. She had come to associate her work place with the experience and had extreme fear and anxiety. Her therapist recommended a form of exposure therapy, explaining that she if she were at work enough times without being robbed, the association she had made would become extinct. The therapy worked, but after a few weeks, the client reported experiencing anxiety when entering her workplace. The therapist explained that this was spontaneous recovery, a phenomenon that often occurs in this type of learning, and encouraged her to continue exposing herself to work.

EXAMPLE: A couple that you are counseling comes in one day frustrated after having used extinction to get rid of their toddler’s tantrums at night. They have seemingly returned just as strong. They feel inadequate and as though they have failed. Therapist explains the concept of spontaneous recovery and urges them to stick with it saying that it will dissipate again.

Question 58

Spontaneous Remission (revisit)

Answer 58

Part of: a phenomenon; a disappearance of symptoms

Who:

Where:

What: a reduction or disappearance of symptoms without any therapeutic intervention, which may be temporary or permanent.

Why:

Clinical Example: a person who has suffered from depression for several months suddenly notices/reports a significant decrease in symptoms despite no treatment interventions or logical explanation for the improvement. The therapist determines the client has experienced spontaneous remission.

Question 59

Successive Approximations

Answer 59

Part of: behaviors that approximate a target behavior

Who: B. F. Skinner

Where: Shaping/Operant Conditioning

What: Successive approximations are responses or behaviors that approach or are similar to some target behavior that is being learned by an organism. Successive approximations are reinforced in a learning procedure called shaping, and allows for organisms to learn new or complex target behaviors. For example, Skinner taught pigeons to turn in a circle by reinforcing successive approximations of the target behavior, and ignoring behaviors that were unrelated to the target.

Why: Shaping using successive approximations can be a powerful way to teach behaviors that are not instinctual or complex.

Clinical Example: A child with autism is working towards the target behavior of sitting in his seat during lectures. A therapist recommends a shaping technique to teach seated behavior after she had determined that the child was currently remaining in his seat a mean of 2 minutes during lecture. They analyzed sucessive approximations of the target behavior and planned to reinforce those behaviors as follows:

• Reinforcing when Jason sits in his seat for a 3 minutes
• Reinforcing when Jason sits in his seat for 5 minutes
• Reinforcing when Jason sits in his seat for 10 minutes
• Reinforcing when Jason sits in his seat for 15 minutes
• Reinforcing when Jason sits in his seat for 20 minutes (the targeted time)

Question 60

Systematic Desensitization

Answer 60

Part of: An exposure technique for reducing fear and/or anxiety

Who: Joseph Wolpe

Where: Behavioral therapy/exposure therapy

What: a first generation exposure therpay that included exposing clients to anxiety-provoking stimuli in a brief, graduated fashion and pairs exposure with relaxation training to inhibit the anxiety.

Why? Systematic desensitization was a theory and procedure that had high heuristic value and led to the development of one of the most effective genres of treatment for anxiety disorders.

Clinical example: A client presents with a fear of germs that is debilitating and causing problems at work. Her therapist recommends systematic desensitization that includes reciprocal inhibition in the form of progressive muscle relaxation. She works with the therapist to create a fear hierarchy, learn PMR, and is exposed systematically to the items on her fear hierarchy while engaging in PMR. She begins with the item that causing the least amount of personal distress and, once she can be exposed to that item without anxiety, she moves to the next item on her fear hierarchy.

Question 61

Token Economy

Answer 61

Part of: a behavioral management system

Who:

Where: Behavioral therapy/Operant Conditioning

What: a behavioral modification system that employs the principles of operant conditioning to motivate clients to avoid undesirable behaviors and perform desirable behaviors. Participants receive tokens for performing desired behaviors that can be used to purchase goods or privileges (backup reinforcers).

Why: Token economies are powerful behavioral motivators especially for behavior problems such as disruptive behaviors or substance use disorders that traditionally were dealt with using punishment or stigma. Token economies are flexible and can be implemented in a group setting or on an individual basis.

Clinical Example: According to Div 12 of the APA, token economies have strong research support for the treatment of schizophrenia. They are often employed in long-term care settings and residential centers provide tokens for self-care, medication compliance works skills, and participation in therapy.

Question 62

Schema

Answer 62

Part of: Cognitive Therapy

Who: Aaron Beck

What: internal cognitive structures that organize and process information; deepest, most ingrained level of cognition. AKA core beliefs - can be revealed using the downward error technique. Beck argued that core beliefs influence our thoughts about ourselves, the world, and the future.

Why: Uncovering an individual’s core beliefs or schema can be a powerful and effective way to develop an effective treatment program.

Clinical 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/core beliefs so that they can work to change them.