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Behavioral Analysis > Quiz 3 > Flashcards

Quiz 3 Flashcards

1
Q

How should you conduct a chain analysis?

A

After identifying vulnerabilities prior to the chain analysis, in excruciating detail, understand all links before and after the target behavior.
If this is done properly –> a solution analysis can be done.

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2
Q

What is a solution analysis?

A

The process of identifying what can be done differently before or after to increase or decrease the emotions, thoughts, behaviors, or external factors being experienced
Ex. identifying exit ramps: “how could you think differently about this?”

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3
Q

Are all exposures behavioral experiments?

A

YES. all exposures are behavioral experiments but not all behavioral experiments are exposures.
Ex. a behavioral experiment might be information seeking i.e. how many plane crashes happen each year.

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4
Q

What is the definition of a behavioral experiment?

A

They are planned, experiential activities based on experimentation or observation, which are undertaken by patients in or between CBT sessions.

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5
Q

What is the purpose of a behavioral experiment?

A

To encourage the client to act in a values-driven way despite their anxiety.
Good for hypothesis testing - negative beliefs and alternative beliefs
Discovery when there is no clear hypothesis - finding out what happens

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6
Q

What to do if the same B.E. is conducted with no change?

A

Might be conceptualizing the client wrong. A philosophical approach (REBT) might work better (i.e. “who says you have to always be smart/confident?” and coming up with a B.E. where they actually say something incompetent and seeing how they handle it compared to their expectations.

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7
Q

Types of concerns that can be used to design a behavioral experiment.

A

I cannot tolerate not knowing if I locked the door to my house.
If I have a panic attack while driving, I will lose control and crash.
If I think about something bad happening to another person, it will happen.

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8
Q

What can we get from behavioral experiment “failures”?

A

Teaches person that they can handle challenges, that people can be trusted.

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9
Q

What can you do when people say they’re not feeling well enough to do a behavioral experiment?

A

Who says you’re always going to feel 100% comfortable? Have you ever done other things when you’re not feeling totally comfortable? What did you do? How did you handle that?

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10
Q

What should you do BEFORE a behavioral experiment?

A

Conduct a CB assessment
Case formulation and feedback
Discussion with client of cognitive behavioral approach. –> CB model, collaborative empiricism, value of personal experience in learning

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11
Q

Types of behavioral experiments

A

Active
Observational - go to the park and watch people
Surveys - ask friends “if this happens, then what?”
Gathering information from other sources - internet search, etc.

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12
Q

The learning circle in a behavioral experiment.

A

Plan –> experience –> observe –> reflect –> back to plan

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13
Q

Planning phase of behavioral experiment

A

Clarify purpose, specify prediction, specify alternative (if applicable), rate degree of belief in prediction/alternative, specify how outcome will be addressed, how the experiment will be conducted, identify potential confounding behaviors (preventing yes, buts), ensure no lose outcome (test of probability and cost)
*identify safety behaviors that should not be used in experiment

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14
Q

Experiencing phase of behavioral experiment.

A

Client understands purpose and how to conduct experiment and is prepared to fully engage, be flexible, confidentiality is addressed when applicable, what to do when it doesn’t turn out well

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15
Q

Observation phase of the behavioral experiment

A

Focus attention on observing information relevant to the validity of the prediction, watch out for biased interpretation (yes, buts) keep a written record of the outcome if applicable

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16
Q

Reflection phase of behavioral experiments

A

determine what was learned and implications for prediction tested, assess for conditional learning (yes, buts) that might interfere with generalization, clarify how much belief in initial prediction remains to be targeted.
Cognitive therapy portion - “was anything surprising about what happened?” Discrepancy between predicted and actual outcome; corrective learning - might take time to change core belief.

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17
Q

Planning again phase in behavioral experiment

A

what does the outcome of the previous experiment mean going forward? what additional learning is needed? what should the next experiment be? what experiments would allow for the maximum possible learning?

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18
Q

Possible outcomes of behavioral experiment.

A
  1. It goes better than expected.
  2. It goes poorly but they can handle it.
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19
Q

What are two habit disorders?

A

Body-focused repetitive behaviors - 5% of the population, voluntary behaviors (not tics)
Tic disorders

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20
Q

What are three body focused repetitive behaviors?

A

Trichotilomania
Excoriation
Onychophagia

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21
Q

What is trichotilomania

A

Causes people to pull out the hair from their scalp, eyelashes, eyebrows, and other parts of the body resulting in noticeable bald patches.

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22
Q

What is excoriation?

A

Skin picking, causes people to repetitively touch, rub, scratch, pick at, or dig into their skin, resulting in skin discoloration, scarring, and even severe tissue damage and disfigurement.

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23
Q

What is onychophagia

A

Nail biting disorder, causes people to bite their nails past the nail bed and chew on cuticles until they bleed leading to soreness and infection.

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24
Q

What is a tic?

A

A sudden, rapid, recurrent, non-rhythmic, stereotyped motor movement or vocalization.
Involuntary movements, sounds, or words that are “sudden, rapid, recurrent, nonrhythmic”
Can be simple or complex -
1. just vocal or just motor
2. motor and vocal (complex)
3. complex motor

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25
Q

Habit reversal training Components

A
  1. awareness training - recognizing when they’re ticking
  2. Development of a competing response - less noticeable, can be carried out for more than a few minutes
  3. Building motivation - make a list of the problems caused by tics, all the bad things it brings
  4. Generalization of new skills - practice the skills in new contexts and locations
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26
Q

What to do during exposure / if client attempts to engage in a safety behavior?

A

Have the client explain the purpose of the experiment and then challenge safety behavior by having them do something different (instead of pulling pillow away from face, move it closer to face)
periodically ask her to notice how she’s feeling

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27
Q

Why choose exposure therapy?

A

Appears to be the primary, active ingredient in CBT for anxiety disorders. –> just as effective as more complex CBTs; particularly true for PTSD, OCD, Social anxiety, cognitive therapy alone is not as effective as combined CBT treatments
Exposure is effective for ALL anxiety disorders –> cognitive therapy has only been shown to work for some anxiety disorders and not specific phobias or OCD.

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28
Q

Active ingredients in adult CBT according to Adams et al. (2015)

A

Strong effect sizes for CBT and BT with little difference adding the cognitive component to the behavioral component for specific disorders (i.e. PTSD)

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29
Q

Active ingredients in child CBT according to Ale, et al. (2015)

A

Examination concluded that adding relaxation and anxiety management strategies prior to exposures did not improve outcomes for exposure-based treatment.
More gold-standard clinician based outcomes measures need to be implemented to assess efficacy of adding anxiety management strategies to exposure therapy in order to increase efficacy of CBT for CADS to that of ERP for OCD.

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30
Q

How effective is exposure therapy?

A

60-85% of anxiety disorder clients who receive exposure therapy show clinically significant improvement. –> 68% remit from PTSD; 77% of panic disorder no longer experience panic attacks; 83% of OCD show significant improvement

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31
Q

Reasons to choose exposure therapy.

A

Brief - 12-16 sessions total and efficient.
Can be effectively implemented by clinicians with little prior CBT training or experience.

32
Q

Examples of exposure therapy challenges.

A

Treatment refusal - 30%
Attrition - 15-30%
Limited response rates - 40-50%
Fear returns - 19-62%

33
Q

Does exposure therapy lead to client drop out?

A

No. Dropout rate is less than that or the same as other treatments.
Exposure - 20%
CBT or SIT - 22%
Combined exposure and other CBT - 27%
EMDR - 19%

34
Q

Does exposure therapy make clients worse?

A

Symptom exacerbation due to exposure therapy is extremely rare.
<5% of clients show increase in PTSD symptoms.
Among severe BPD clients receiving DBT + an exposure-based PTSD protocol:
0% showed an increase in PTSD symptoms.
<10% had increase in suicide risk or urge to self-harm following exposure.
suicide risk and self-harm may be lower than in standard DBT.

35
Q

Important to remember about exposure difficulty…

A

If exposure is too easy, it’s less potent.
less experienced, anxious clinicians less likely to do more difficult exposures

36
Q

What is a normal fear?

A

Perception of real threat and disappears when the danger is removed.

37
Q

What is a problematic fear?

A

it is disruptively intense (excessive response)
Responses are resistant to modification.
it occurs when there is minimal risk of actual threat or danger.

38
Q

How is fear acquired? - Classical conditioning

A

A negative event is paired with a previously neutral object or situation

39
Q

How is fear acquired? - vicarious learning

A

Observing another person be hurt or afraid in a specific situation.

40
Q

How is fear acquired? - informational transmission

A

being told that specific objects or situations are dangerous (by others or media)

41
Q

How is fear maintained?

A

Avoidance of things that elicit anxiety:
internal cues - thoughts, memories, physical sensations, emotions
external cues - people, places, objects, smells, situations

42
Q

What are avoidance behaviors?

A

Anything that decreases anxiety, increases sense of safety, or alleviates uncomfortable physical sensations.

43
Q

How else is fear maintained?

A

Problematic or unhelpful beliefs.
Overestimation of the likelihood of negative outcomes.
Overestimation of the severity of negative outcomes - they’re going to laugh at me
Negative beliefs about anxiety - It’s dangerous to feel this anxious
Negative beliefs about oneself - I can’t handle feeling this way.

44
Q

How does generalization happen in exposure therapy?

A

exposure –> reduction in fear of spiders –> reduction in fear of heights.

45
Q

The cycle of fear maintenance

A

Avoidance –> unhelpful beliefs –> continued avoidance

46
Q

Rationale for exposure

A

Corrective learning:
1. Feared outcomes are unlikely to happen.
2. Negative outcomes are unlikely to be catastrophic.
3. Anxiety can be tolerated and decreases over time.
4. Able to cope effectively with stressful situations.

47
Q

Emotional Processing theory

A

Goal = corrective learning
Between-session habituation - lower anxiety at start point of each session.
Within-session habituation - lower from beginning to end of session (does not correlate with out of session improvement)

48
Q

Inhibitory Learning Model

A

Fear can’t be destroyed, just suppressing it.
Non-threat blocks threat expectancy –> if dog barks or snaps at you the fear might return
Goal to help client automatically retrieve neutral meaning of stimulus *increase the accessibility of the non-threat meaning (practice in as many contexts as possible)

49
Q

What’s the downside of habituation?

A

Focus on removing anxiety rather than being able to tolerate it

50
Q

Imaginal exposure procedures.

A

Have the client describe in present-tense, real time exactly what happened. “I woke up to the smell of smoke…etc.”
Questions to ask - How anxious are you? What’s the chance the feared outcome will happen? How do you think you will be able to handle the feared outcome?

51
Q

Exposure from an ACT Framework. How to address unhelpful urges.

A

De-emphasizing habituation as goal and moving toward inhibitory new structure.
Use it as a reverse compass –> when the urge tells us to pull away, pull the feared object closer.
“Are we going to listen to the dictator all the time or take our life back?”
Thank the “alarm” for being there and then ignore it.

52
Q

Four goals of exposure?

A
  1. Violate negative expectancies of harm.
  2. de-contextualize inhibitory associations. - eliminate the rules around exposure (i.e. I can’t do it because I’m not feeling well)
  3. Promote distress tolerance. - increase ability to tolerate distress.
  4. Promote self-efficacy.
53
Q

What are the core elements of exposure?

A
  1. Cue
  2. Corrective learning
  3. Response prevention - preventing hand washing after putting hand in toilet
54
Q

What is a cue?

A

Deliberate and planned exposure to a stimulus that elicits fear.
Exposure to the feared stimulus is typically repeated across sessions as homework, prolonged (30-45 minutes)

55
Q

What is corrective learning?

A

Goal is “non-reinforced” exposure - as in no relief from anxiety
Important to notice pre-avoidance behaviors (i.e. body tensing, slouching)
Should occur in absence of actual threat. Safety can’t be guaranteed but must ensure exposure tasks are minimal to low risk.

56
Q

What is response prevention?

A

Must block avoidance and escape responses for new learning to occur
Involves preventing overt and covert strategies of avoidance:
cognitive (dissociation, distraction)
emotional (numbing, secondary emotions)
behavioral (not looking at the cue, leaving the exposure situation, compulsions and rituals)
Block action urges and expression associated with problematic emotions (i.e. avoiding eye contact)

57
Q

How is exposure therapy collaborative?

A

Clients are active collaborators in selecting exposure tasks.
They are never forced into doing exposure tasks.
They can choose not do do an exposure task.
They can choose to stop in the middle of an exposure task –> use principle of “controlled escape” - encouraging clients to take a break and remain present in the exposure (i.e. briefly looking at the wall when they should be looking at a spider)

58
Q

Describe an In Vivo Exposure and when it is typically used?

A

Exposure to the feared stimulus in real life
Typically used for:
People - strangers, people who resemble abusers.
Places - crowded stores, hospitals, schools
Things - animals, doorknobs, smell of beer, certain songs
Activities - public speaking, being hugged, driving

59
Q

What is an imaginal exposure and when is it typically used?

A

Exposure to the feared stimulus in imagination
Designed to counteract avoidance of thoughts, memories, and images that elicit fear.
Clients typically describe the imagined situation out loud and record it
Typically used for:
post-traumatic events
feared outcomes that can’t be simulated in real life (i.e. burning in hell, contracting HIV)
Distressing mental images (i.e. sexual abuse of children)
As an early step in a fear hierarchy (i.e. imagining flying before getting on an airplane)

60
Q

What is an interoceptive exposure and when is it typically used?

A

Exposure to feared physical sensations
Designed to counteract avoidance of specific bodily cues that elicit fear.
Most often used to treat panic disorder.
Typically done via exercises that induce panic-type sensations:
difficulty breathing (i.e. breathe through a straw)
Increased heart rate (i.e. run in place)
Dizziness (i.e. spin in a chair)

61
Q

What are some good questions to ask prior to an exposure?

A

What will happen if _____?
How will it be if _____?
How likely is it that you will be able to handle it?

62
Q

What is In Virtuo Exposure?

A

AI or virtual reality exposure

63
Q

What is thought-action fusion?

A

If I have the thought I will actually jump off the balcony.

64
Q

What are the steps to making exposure work?

A
  1. Orienting clients to exposure treatment.
  2. Assessment and hierarchy construction.
65
Q

What’s the goal of explaining how fear is maintained?

A

For the client to understand how and why their anxiety is not going away and is likely getting worse over time
–> discuss the tradeoff, block the escape from discomfort so you can get the long-term benefits
Key points:
Anxiety is maintained by avoidance and unhelpful beliefs
Unhelpful beliefs –> anxiety about situations that are not actually dangerous
Avoidance only decreases anxiety in short-term

66
Q

How does avoidance increase anxiety in the long-term?

A

Because it prevents corrective learning

67
Q

How can we prepare clients to feel anxious?

A

“Can we view anxiety as a sign we’re moving in the right direction?”
Things may get harder before they get easier
It is normal to feel anxious during an exposure
Anxiety during exposure is a sign that it is being done correctly
Try not to resist or fight the anxiety, just allow the emotions to be there
Anxiety is temporary!

68
Q

How do we orient the client to the therapist’s role?

A

Role as a coach or cheerleader
DO’s:
help select and plan effective exposures
provide instruction and encouragement as needed during exposures
process exposures once they’re done
DON’Ts:
Say much during exposure
Show intense emotional responses during exposures
Provide excessive reassurance and soothing

69
Q

Orienting Do’s of Exposure therapy

A

Provide clear/detailed description of treatment rationale.
Spend sufficient time orienting.
Avoid using jargon.
Engage the client in a collaborative discussion.
Validate and normalize the client’s experience
Assess the client’s understanding.
For exposure - have them do easiest one in session and assign for homework. If they only feel safe doing it in session with the therapist have them practice in different places at different times

70
Q

Orienting Don’ts of exposure therapy

A

Lecture or be overly didactic
Minimize the difficulty of the exposure
Suggest their behaviors are “bad”
Overemphasize fear reduction (habituation) as the goal of exposure tasks.
Guarantee safety or promise that feared outcomes will not occur during exposure task.

71
Q

What are some assessment questions in exposure therapy?

A

What are the specific stimuli that trigger anxiety?:
feared situations
intrusive thoughts, images, memories
feared physical sensations
What are the feared consequences of exposure to these triggers?
What avoidance or safety behaviors are used to reduce anxiety?

72
Q

What is an exposure hierarchy?

A

A list of internal or external stimuli that are avoided because they cause anxiety. - typically 10-20 items that client must be willing to confront.
Each item is rated using the SUDs scale (0-100)
Can include in vivo, imaginal, and/or interoceptive exposure tasks
Clients may have more than one hierarchy - 1 for fear of contamination via bodily fluids and 1 for fear of contamination via environmental toxins

73
Q

How to choose exposure hierarchy items with a range of SUDs

A

consider varying:
distance to stimulus (looking at vs. touching)
stimulus intensity (vividness, number of stimuli present)
Length of time in contact with the stimulus
use of safety signals (presence of others)
Contexts (time of day, location)

74
Q

What are some guidelines for constructing hierarchies?

A

Be collaborative - involve client in identifying and selecting tasks.
Be specific - “throw away clutter” vs. “sort and throw away mail on the dining room table”
Each item on the hierarchy should have a clear rationale
Be creative - don’t limit yourself to what can be done in the office

75
Q
A

Behavioral Analysis (2 decks)

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