Behavior Therapy Exam 2

Stimulus Control: Prompting

Prompting: provides people with cues (prompts) that remind or instruct them to perform a behavior or indicate that it is appropriate to perform a behavior Four types of prompts: 1. Verbal- telling clients what they are expected to do 2. Environmental-cues in the environment, such as signs, that remind clients to perform behaviors 3. Physical-a client is physically directed to perform a behavior. Ex. Hand over hand prompt 4. Behavioral-one behavior cues another behavior Ex. A wife's crying cues the husband to respond with sympathy Guidelines for administering prompts: 1. Administer the prompt just before it is appropriate to perform the target behavior 2. Make the prompt salient so that the client is aware of it 3. Make the prompt specific and unambiguous 4. Have the prompt remind clients about the consequences of engaging in the desired behavior 5. Follow up prompts with reinforcement for engaging in the prompted behavior -As the client performs the behavior more frequently, prompts become less necessary and are gradually withdrawn= fading

Cognitive Techniques: Self-help hw assignments

Self-help homework assignments - more likely to apply what they have learned to outside lives, each assignment should be designed for the particular patient, when the client does not complete hw, the therapist looks w/the patient for where the difficulty lies.

Stimulus Control: Setting Events

Setting events: environmental conditions that influence the likelihood that certain behaviors will be performed -what a setting event is identified as a maintaining antecedent of a target behavior, the setting event is modified to create the desired change in the behavior -therapy interventions that accelerate behaviors, stimulus control procedures can be very efficient because they can be easily implemented with little time and effort

IBCT: Treatment (2)

Unified Detachment from the Problem -allows partners to "step back" from their problems and describe them without placing blame-or responsibility for change-on either partner -a dialogue in which they use nonjudgmental terms to describe the conflict, what factors usually trigger their reactions, and how they can defuse or override the conflict in the future -by detaching from the problem, they can discuss their conflict without becoming emotionally "charged" by it Tolerance Building: Help one partner build tolerance for the other partner's "offending" behavior -by building tolerance, partners ideally experience a reduction in the pain caused by the behavior -one strategy is through positive reemphasis, or focusing on the positive aspects of the behavior -another strategy is to focus on the ways these differences complement each other -a third technique is to prepare couples for inevitable slipups and lapses in behavior

Cognitive Model of Depression

- Assumes that cognition, behavior and biochemistry are all important components of depressive disorders. The cognitive therapist intervenes at the cognitive, affective and behavioral levels. When we change depressive cognitions, we simultaneously change the characteristic mood, the behavior and the biochemistry of depression - There are indications that cognitive therapy works by virtue of changing beliefs and information processing proclivities and that different aspects of cognition play different roles in the process of change

Behavioral Activation (BA) for Depression

- BA is a structured, brief psychosocial approach that aims to alleviate depression and prevent future relapse by focusing directly on behavior change - BA is based on the premise that problems in vulnerable individuals' lives, and their behavioral responses to such problems, reduce their ability to experience positive reward from their environment - The treatment aims to increase activation systematically in ways that help clients to experience greater contact with sources of reward in their lives and to solve life problems. - The treatment procedures focus directly on activation, and on processes that inhibit activation, such as escape and avoidance behaviors and ruminative thinking, to increase experiences that are pleasurable or productive and improve life context.

3 Types of Environments

- Chaotic family - Perfect family - Ordinary family (doesn't necessarily have to be dysfunctional if the person has a high biological vulnerability towards emotional sensitivity)

Motivational Interviewing

- Effective for problem drinkers - Brief intervention designed to facilitate behavior change by helping clients to identify personal values and goals and to examine whether drug use may conflict with those values and goals, and to explore how to resolve any ambivalence and ongoing drug use

Ferster: Effects of Inc. in Aversive Consequences

- Ferster observed that increases in aversive consequences following behavior typically lead depressed individuals to become preoccupied with escape and avoidance. > more energy is expended attempting to avoid or escape from anticipated aversive consequences than in attempting to contact potential positive reinforcers in the environment.

Ferster: Two Consequences that Facilitate Depression

- Ferster reasoned that this decrease in response-contingent positive reinforcement produces two further consequences that facilitate depression: > First, when people's efforts do not result in reward, they often become more focused on responding to their own deprivation than to potential sources of positive reinforcement in the environment • i.e, the classic "turning inward" that is often seen in depression—when individuals learn that their own behavior is an unreliable predictor of positive consequences in their environment (so they spend less time attending to contingencies in that environment) > Second, there is a narrowing of individuals' repertoire of adaptive behaviors. • i.e., fewer and fewer behaviors are being maintained by positive reinforcement. Individuals may adopt extremely passive repertoires (e.g., "doing nothing"), because they have learned that their active attempts to become engaged in life do not produce positive consequences.

Contingency Management

- Reinforcing and punishing consequences are systematically used to increase abstinence from drug use or to improve other therapeutic goals - Voucher systems are interventions for clients with illicit drug use disorders

Behavioral Couple Therapy

- Therapy typically emphasizes improved communication skills. - Couples are taught how to negotiate for change in each other's behavior to make the relationship more reinforcing. - Usually a contract is signed where the client agrees to abstain from drug use and or to comply with a recommended medication regimen

Cognitive-behavioral/relapse prevention therapy

- This approach entails functional analysis training through which clients learn to identify environmental antecedents and consequences that influence their drug use. - Skills training is used to train how to rearrange one's environment to alter the probability of drug use by either avoiding high-risk settings or managing them effectively when contact cannot be avoided. - Cognitive strategies are used to identify and modify unrealistic expectations about drug use, to cope with craving for drugs use, and to change thinking patterns that increase the likelihood of drug use. - Social skills training helps clients cope with social anxiety or when particular skills deficits limit clients' access to alternative, healthier sources of reinforcement

Alcohol Use Disorders VIII. Early Sobriety Strategies

- help maintain abstinence A. Stimulus Control: designed to alter environmental cues for drinking by avoiding the cue, rearranging it, or implementing different responses in the same environment B. Dealing with Urges: helpful to provide client with a framework for understanding that urges are learned responses to drinking situation and that urges abate if unfulfilled C. Addressing Cognitive Distortions about Alcohol: often hold positive expectancies about he effects of alcohol D. Alternative/Distractive Behaviors: discussions about alternatives to drinking that are both time-occupying and mentally or physically absorbing E. Identifying Alternative Ways to Obtain Reinforcers F. Drink Refusal Skills: teaching them how to refuse drinks

Alcohol Use Disorders XI. Long-Term Maintenance

- identifying high-risk situations for drinking, developing alternative strategies to cope with high-risk situations, enhancing self-efficacy for coping, dealing with positive expectancies about the use of alcohol, and facilitating the development of a balanced lifestyle - addressing the possibility of relapse and developing preventative and responsive strategies related to relapse

Cognitive Triad of Depression

- negative view of themselves, their environment and of the future; they consistently distort their interpretations of events, so that they maintain negative views of themselves, the environment and the future. - An important predisposing factor for many patients w/depression is the presence of early schemas - focusing on core schemas is a key to effective short term therapy

Early Maladaptive Schemas (EMSs)

- predispose depressed patients to distort events in a characteristic fashion, leading to a negative view of themselves, the environment and future - they have several defining characteristics that are a priori truths about oneself and/or the environment, self-perpetuating and resistant to change, dysfunctional, often triggered by some environmental change, tied to high levels of affect when activated and usually result from an interaction of the child's innate temperament with dysfunctional developmental experiences with family members or caretakers - See p261-263 for EMSs with associated schema domains (main categories: disconnection and rejection, impaired autonomy and performance, impaired limits, other-directedness, overvigilance and inhibition)

Alcohol Use Disorders IV. Selection of Tx Modalities

- six major treatment modalities are available A. Self-Help Groups: AA is the most common, SMART is a cognitive-behavioral self-help group approach B. Individual Therapy: outpatient basis C. Group Therapy: interaction among group members provides opportunities for modeling, feedback, and behavioral rehearsal D. Couple Therapy: involving the spouse/partner increase the probability of a positive outcome E. Family Therapy F. Intensive Treatment Programs -Self-Help groups may be a good method, but clinicians must assess when a client would be a good candidate for self-help groups -socially anxious clients may not be good candidates

Stimulus Control: Antecedents that Elicit Behavior

-Antecedents (the A in ABC) "set the stage" for behaviors to occur -In some cases, existing antecedents elicit an undesirable behavior---stimulus control procedures are used to change the antecedents: Prompts or setting events

Couple Distress (Barlow Ch 16)

-Couple distress is not a disorder, but rather a condition that may be a focus of clinical attention—V code -couple distress can initiate, exacerbate, and complicate DSM disorders -Barlow recommends the Integrative Behavioral Couple Therapy (IBCT) approach -the term "couple therapy" refers to clinical approaches for improving the functioning of two individuals within the context of their relationship to one another

Alcohol Use Disorders - Comorbidity

-a high percentage of those diagnosed with alcohol abuse or dependence also experience other psychological problems, such as psychological disorders, cognitive problems, physical health problems, interpersonal problems

IBCT: Assessment

-assessment comprises at least one conjoint session with the couple, followed by individual sessions with each partner -includes both the couple's history and individual histories

IBCT: Stages of Therapy

-clear distinction between the assessment phase and the treatment itself -objective measures may be used to assess initially and to monitor progress - Assessment, Feedback, and Treatment

IBCT: Feedback

-following information gathering, the therapist develops the couple's formulation -feedback is used to describe the proposed treatment based on the formulation

Alcohol Use Disorders III. Selection of Tx Setting

-information from the assessment of drinking, problem areas, and motivation is used to determine the appropriate setting in which to initiate treatment A. Need for Detoxification: if a client is physically dependent on alcohol, then he or she will experience withdrawal symptoms---therefore detox may be a good option B. Medical Problems: should take into account these C. Treatment History: examine the client's previous treatment history — attempts to quit, relapse, dropping out of treatment D. Previous Quit Attempts: outpatient treatment is more likely to be successful for a client who has stopped successfully on his own before E. Social Support Systems: F. Personal Resources: client's personal psychological resources G. Other Psychological Problems: assess these problems but also determine level of care based on the appropriate setting H. Attitudes about Treatment: commitment to change and desire to change I. Practical Concerns: employment, transportation, child care, etc. J. Personal Preferences: client's preferences about the treatment

Alcohol Use Disorders XII. Managing Complicating Conditions

-knowledge of services and agencies in the local community, and the development of working relationships with these agencies helps get the client access to services that they need

Theoretical Model of Alcohol Use Disorders

-multidimensional, as in there is more than one effective treatment for alcohol problems -among the treatments with the best support are brief and motivationally focused interventions, cognitive-behavioral treatment, 12-step facilitation treatment, behavioral couple therapy, cue exposure treatment, and community reinforcement approach -a key therapist responsibility is to help a client find a treatment approach and setting that is effective for him -another responsibility is to enhance the client's motivation to continue to try

Alcohol Use Disorders V. Enhancing and Maintaining Motivation to Change

-once a decision has been made about the level of care and the client has entered treatment, the clinician must continue to focus on motivation for the client

Alcohol Use Disorders II. Assessment

-once the client has entered treatment, the therapist should begin with an initial assessment of drinking, other drugs, and problems in areas of functioning A. Drinking Assessment: a clinical interview is used to assess drinking history and client perceptions of his or her current drinking B. Assessment of Other Problem Areas C. Assessment of Motivation: should consider reasons why the client is seeking treatment, the client's treatment goals, client's stages of readiness of change, degree to which the client sees negative consequences of his or her drinking D. Functional Analysis: used to indentify antecedents to drinking E. Partner Assessment: questionnaires and self-recording cards can be used to assess how the client's partner has coped with the drinking

Administering Reinforcers

-reinforcers can be administered by: other people, clients themselves, or a natural consequence for their behavior A reinforcement schedule is a rule that specifies which occurrences of a target behavior will be reinforced, and reinforcers are administered on two schedules: - Continuous Reinforcement Schedule: a behavior is reinforced every time a person engages in nit - Intermittent Reinforcement Schedule: only some of the occurrences of the target behavior are reinforced Ex. Interval or Ratio *Continuous reinforcement is most useful when the client is first learning to perform a target behavior. Once the behavior is established, the client is usually switched to an intermittent schedule

Etiology of Couple Distress

-relationship distress develops as a result of two basic influences 1.Reinforcement Erosion=the phenomenon whereby behaviors that were once reinforcing become less reinforcing with repeated exposure 2. Emergence of Incompatibilities: may develop over time Ex. Partner A wants to save money, Partner B wants to spend money freely

Application of IBCT

-the most important organizing principle is the formulation, which is the way the therapist conceives of and describes the couple's problem in terms of the partners'' differences, incompatibilities, and associated discord -formulation is based on functional analysis of the couple's problems and includes three components: 1. a theme=description of the couple's primary conflict 2. polarization process=the destructive interaction that ensues when a distressed couple enters in a theme-related conflict---often become polarized on conflicting sides of an issue 3. mutual trap=the outcome of the polarization process, it typically leaves the partners feeling "trapped" in the conflict

Two Basic Principles of IPT

1) defines depression as a medical illness and explains that the patient has a common illness that comprises a discrete and predictable set of symptoms, thus making the symptoms seem less overwhelming and more manageable (the etiology is depressed and multidetermined: it may comprise biology, life experiences and family history among other factors) - the IPT therapist emphasizes that depression is a medical illness that is treatable and not the patient's fault 2) the patient's depression is connected to a current or recent life event - stressful life events can precipitate depressive episodes in vulnerable individuals and depression can make it difficult for individuals to manage stressful life events - by solving an interpersonal crisis, the patient can improve his or her life situation and simultaneously relieve depressive symptoms

4 Interpersonal Problem Areas

1. Grief 2. Role disputes: a conflict with a significant other 3. Role transitions: change in life status 4. Interpersonal deficits: used as focus of IPT for MDD when a patient reports no recent life events and lacks any of the first 3 problem areas

DBT: Modes of Treatment

1. Individual Therapy o In a nut shell, it is used to help problem-solve any barriers to using the skills taught in group skills training (as well as other targets above...with skills deeply ingrained) 2. Skills Training o Typically done in a group format, but can be done individually o Helps the client with skills acquisition o The main focus of the skills group is to teach skills, accordingly the targets are different: - Primary target: Therapy-destroying behaviors (e.g., threatening suicide in group, property damage, fighting) - Secondary target: increasing skills acquisition - Tertiary target: decreasing therapy interfering behaviors (e.g., refusing to talk during group, etc) 3. Telephone consultation o Many clients may not have the skills (mostly at first) to use to help them during a crisis. As such, the therapist is available to the client 24/7 via a paging system. The gist of this is that clients are to try to use the skills by themselves and if they need help, then page their therapist o The main focus here is to help the client to generalize the skills to his or her environment 4. Consultation team o This is basically where the therapists consult with other DBT therapists to get encouragement and to prevent burnout (therapy for the therapist, in a sense)

Process of IPT

1. Initial phase (sessions 1-3) a. Diagnosing MDD b. The sick role: therapist gives the patient the sick role - a temporary role intended to help the patient recognize that she suffers from an illness that comprises a distinct set of symptoms that compromise functioning c. Identification of interpersonal problem areas d. Explanation of the treatment contract and the IPT approach 2. Middle phase (sessions 4-9) a. Each session begins with "how have you been feeling since we last met?" - links the mood to a recent event 3. Termination phase (10-12) - review progress

Characteristics of IPT

1.a.i.1. Time limited and focused - focus on 1 or at most 2 problem areas at beginning of tx 1.a.i.2. Empirically grounded 1.a.i.3. Diagnosis targeted 1.a.i.4. A here and now focus 1.a.i.5. Focuses on interpersonal problems 1.a.i.6. Focuses on the interrelationship between mood and current life events 1.a.i.7. Emphasizes eliciting affect - helps the patient to better identify what she is feeling, validates emotions such as anger and disappointment as normal and useful interpersonal signals and helps the patient to use such emotion as a guide

Biosocial Theory: Invalidating Environment (2)

2. INTERMITTENTLY REINFORCES emotional escalation • Environment does not teach individual to: - Accurately express emotions - Communicate pain effectively • Instead, environment teaches individual to: - Oscillate between emotional inhibition and extreme emotional styles

Biosocial Theory: Invalidating Environment (3)

3. OVER-SIMPLIFIES ease of problem solving and meeting goals • Environment does not teach individual to: - Tolerate distress - Solve difficult problems in living - Use shaping and other behavioral strategies to effectively self-regulate own behavior • Instead, environment teaches individual to: - Respond with high negative arousal to failure - Form unrealistic goals and expectations - Hold perfectionistic standards

Alcohol Use Disorders I. Case Identification and Entry into Treatment

A. Case Identification and Screening: standard questions should be identified to screen clients whether or not they have a drinking problem: CAGE screening B. Motivating a Drinker to enter Treatment: motivational interviewing techniques may help with the initial challenge of simulating the client to initiate change

Alcohol Use Disorders IX. Coping Strategies

A. Dealing with Negative Affect: comorbidity with other psychiatric disorders is high; in focusing on negative affect, a careful assessment of the causes is essential---negative affect associated with another disorder should be treated in accord with approach to that disorder B. Lifestyle Balance and Pleasurable Activities: lifestyle changes that enhance positive experience s and allow for a blance between responsibilities and pleasure

Alcohol Use Disorders X. Partner/Family Involvement and the Social Context of Tx

A. Information: clients who are referred or coerced may be reluctant to provide full info about their drinking---therefore collect info from referring agencies B. Responses to Drinking and Abstinence: the establishment of a network that provides differential reinforcement for abstinence and applies negative consequences for drinking C. Decreasing Cues for Drinking:: significant others also may engage in behaviors that cue further drinking D. Support for Abstinence: significant others can provide many kinds of support to clients---helping implement changes, support avoiding high-risk situations E. Relationship Change: for many clients, interactions with their friends cue drinking—changing those interpersonal relationships may be helpful F. Accessing New Social Systems: it is important to access new systems that either reinforce abstinence of are incompatible with heavy drinking

Spiegler & Guevremont Chapter 6: Acceleration Behavior Therapy

Acceleration Behavior Therapy -To treat client's problems, behavior therapies modify maintaining antecedents, maintaining consequences, or both

Development of BA

BA was developed by Ferster, carried on by Lewinsohn, and adopted by Beck and colleagues in the 70's (Beck focused more on adding it to his cognitive therapy for depression)

IBCT: Treatment (3)

Behavior Exchange: -the primary goal of behavior exchange is to increase the proportion of a couple's daily positive behaviors and interactions The three basic steps: 1. identify behaviors that each partners can do for the other that would increase satisfaction 2. increase the frequency of those behaviors in the daily repertoire 3. debrief the experience of providing and receiving positive behaviors

IBCT: Treatment (1)

Building Emotional Acceptance -talk about recent negative and positive events -discussions centered around upcoming events Empathic Joining: the process by which partners cease to blame one another for their emotional suffering and instead develop empathy for each other's experience -reformulate the problem as a result of common differences rather than deficiencies in either partner -emphasize the pain that each partner is experiencing rather than the pain each is delivering

IBCT: Treament (4)

Communication and Problem-Solving Training: -poor communication may exacerbate or even cause many problems -the goal of communication and problem-solving training is to teach couples how to discuss their problems and to negotiate change without resorting to such destructive tactics -couples are taught both "speaker" and "listener" skills -once taught these skills, they are instructed to practice Three problem-solving skills: 1. taught to define the problem as specifically as possible by specifying the behavior of concern and circumstances surrounding it 2. once defined, the couples can begin working toward problem solution 3. couples learn structuring skills for their problem-solving discussions

DBT: Dialectical Dilemmas

Dialectical Dilemmas • At one end of each dimension is the behavior that theoretically is most directly influenced biologically via deficits in emotion regulation (thesis). At the other end is behavior that has been socially reinforced in the invalidating environment (antithesis) THESIS ANTITHESIS • Unrelenting crises----------------------Inhibited grieving • Emotional vulnerability----------------Self-invalidation • Active passivity--------------------------apparent competence

Cognitive Techniques: Eliciting automatic thoughts

Eliciting automatic thoughts (thoughts that intervene between outside events and the individual's emotional reactions to them) - therapists ask clients what thoughts went thru their minds in response to particular events

Ferster's Primary Assumption

Ferster's primary assumption was that depression is the result of a learning history in which the actions of the individual do not result in positive reward from the environment, or in which the actions are reinforced because they allow the individual to escape from an aversive condition. Over time, behavior that would typically produce positive consequences ceases to do so.

# Sessions for Dep Tx

Frequency and duration: 15-25 (50 min) sessions at weekly intervals with more seriously depressed clients usually requiring 2x week meetings for 1st 4-5 weeks

Efficacy of Tx for Depression

In research where interventions have been adequate, cognitive therapy generally has been shown to be equivalent in efficacy to antidepressant medications Patients treated w/CT and medication fare far better in terms of relapse than do patients treated w/meds alone & CT has been found to be effective in reducing both residual symptoms and relapse after the termination of medication

Cognitive Techniques: Questioning

Questioning: use questions to explore approaches to problems, to help the patient to weight advantages and disadvantages of possible solutions, to examine the consequences of staying with particular maladaptive behaviors, to elicit automatic thoughts, and to demonstrate EMSs and their consequences

Reinforcement: Consequences that Accelerate Behaviors

Reinforcement: occurs when the consequences of a behavior increase the likelihood that the person will repeat the behavior -an individual receives the reinforce only if he or she engages in the behavior----the reinforce is contingent upon the behavior being performed Reward: pleasant or desirable consequences of a behavior that do not necessarily make it more likely that the person will perform the behavior again ***Reinforcement ALWAYS increases the frequency of behavior Positive Reinforcement: when a pleasant or desirable stimulus is presented (added) as a consequence of a person's performing a behavior Negative Reinforcement: when an unpleasant or undesirable event is removed, avoided, or escaped from (subtracted) as a consequence of a person's performing a behavior Punishment: occurs when the consequences of a behavior decreases the likelihood that the person will repeat the behavior -Punishment weakens rather than strengthens a behavior Positive Punishment: presenting (adding) an unpleasant or undesirable consequence Negative Punishment: removing (subtracting) a pleasant or desirable consequence

Depression Relapse Rates

Relapse: recurrence is a major problem for individuals w/depression - at least 50% of those who suffer from 1 episode will have another within 10 years & those w/2 episodes have a 90% chance of having a 3rd (others estimated 85% of patients w/depression are likely to experience recurrences) -Another alternative for relapse prevention is mindfulness based cognitive therapy (MBCT) - draws from the acceptance and medication strategies from DBT

Cognitive Techniques: Testing automatic thoughts

Testing automatic thoughts with nonchronic patients - approach the thought as a testable hypothesis (collaborative empiricism)

Seven Major Considerations of Alcohol Use Tx Model

The treatment model takes into account seven major considerations: 1. Problem severity: chronic, relapsing disorder with relapses occurring even after extended periods of abstinence 2. Concomittant life problems: problems in multiple areas of life functioning-physical, psychological, familial, social, occupational, legal---assessment of these is crucial 3.Client expectations: accurate expectations about the intensity of their treatment and the probable cause of their problems 4. Motivation and therapeutic relationship: clients vary in the degree to which they recognize their drinking is problematic and in their readiness to change. -Motivational Model: suggest that individuals initiate change when the perceived costs of the behavior outweigh the perceived benefits, and when they can anticipate some benefits from behavior change---Use the DiClemente model of stages of readiness -clients' apparent stage of change and their self perception of their problems should guide a clinician's initial approach to treatment planning 5. Variables maintain the current drinking pattern: assumes that drinking can best be treated by examining current factors maintaining drinking rather than historical factors—use S-O-R-C 6. Social support systems: the availability of general social support is crucial to successful treatment 7. Maintenance of change: individuals with severe alcohol use disorders have a high probability of relapse -use the relapse prevention (RP) model---focuses on the interplay among environment, coping skills, and cognitive and affective responses in maintaining successful change

Integrative Behavioral Couple Therapy (IBCT)

Three developments in IBCT are directed toward making treatment more enduring and more broadly applicable: 1. a focus on the couple's relational "themes" rather than on specific target behaviors -focus on the couple's relationship themes—that is their long-standing patterns of disparate yet functionally similar behaviors -focus is on broader "themes" in the couple's history; that is, developing shared understanding of the many circumstances in which both people have felt disappointed 2. an emphasis on "contingency-shaped" versus "rule-governed" behavior -with "contingency-shaped" behavior, naturally occurring events in the situation serve to elicit and reinforce the desired behavior -try to discover the events that function to trigger desired experiences in each partner, then attempt to orchestrate these events 3. focus on emotional acceptance - the primary goal is to promote each partners' acceptance of the other and their differences. Rather than trying to eliminate a couple's long-standing conflicts, the goal is to help them develop a new understanding of their apparently irreconcilable differences, and use these differences to promote intimacy, empathy, and compassion - couples try to understand each other's behavior before deciding whether and how they might modify it - hopefully the partners will modify his or her emotional reaction to each others "problem behaviors"

Interpersonal psychotherapy/IPT

Time-limited, diagnosis-targeted, pragmatic, empirically supported treatment that was originally developed to treat outpatients with major depression • IPT focuses on current or recent life events, interpersonal difficulties and symptoms - thru the use of the medical model and by linking mood symptoms to recent life events, the IPT therapist helps the patient to feel understood • IPT aids recovery from depression by relieving depressive symptoms and by helping the patient to develop more effective strategies for dealing with current interpersonal problems related to the onset of symptoms

Schema therapy (dep)

an integrative therapy with elements of cognitive, behavioral and emotion focused therapies. The focus of treatment is on the relationship w/the therapist, daily life events and early life trauma or adverse family relationships. - When basic needs are not met, early maladaptive schemas within the individual are likely to develop (extremely stable and enduring themes that develop and are elaborated upon thru out the individual's lifetime and that are dysfunctional to a significant degree) - Schemas are constructions of reality which are deeply held emotion-based beliefs that develop as the result of concrete experiences with the environment, particularly those early in life with significant others; once developed, they are mostly outside of awareness and remain dormant until a life event stimulates one or more schemas. Once schemas are activated, the individual automatically processes information (cognitive, behavioral, affective, and interpersonal) in ways accordant w/the schemas

CBASP: Cognitive behavioral analysis system of psychotherapy

an integrative, time-limited treatment that contains elements of cognitive, behavioral, interpersonal, and psychodynamic psychotherapies; change is brought about thru a contingency program that relies on negative reinforcement. First, contingencies between behaviors and consequences are exposed, then, as a result of positive changes in behavior, discomfort and distress are reduced or eliminated. 3 techniques are used to bring about change: situational analysis, interpersonal discrimination exercise, and behavioral skill training/rehearsal

DR of Competing behaviors

engaging in a competing acceleration target behavior reduces, but does not eliminate, the opportunity to simultaneously engage in the undesirable behavior (ex: jogging competes with snacking, but it is still possible to snack on the run)

Premack Principle

higher probability (more frequent) can serve as reinforcers for lower probability (less frequent) behaviors

Alcohol Use Disorders: VII. Developing a Functional Analysis

includes both a structured and a qualitative dimension, including interviewing, questionnaires, and self-recording

Alcohol Dependence

individual meets at least three of seven criteria related to impaired control; a persistent desire or attempts to cut down or stop; using larger amounts over time or amounts than intended, physical tolerance, physical withdrawal, neglect of other activities, increased time spent using, and continued use despite knowledge of problems

Biosocial Theory: Invalidating Environment (1)

o BPD may emerge when a person has a biological predisposition to emotional sensitivity and an "invalidating environment" o From my own notes on DBT to explain the invalidating environment (which map onto what the chapter talks about: Characteristics of an invalidating environment 1. INDISCRIMINATELY REJECTS and PUNISHES communication of emotions and emotional displays • Environment does not teach individual to: - Effectively regulate emotions - Trust experiences as valid responses to events • Instead, environment teaches individual to: - Actively self-invalidate and search social environment for cues about how to respond

Five Domains of Diagnostic Criteria for BPD

o First, individuals with BPD generally experience emotional dysregulation and instability. Emotional responses are reactive, and the individuals generally have difficulties with episodic depression, anxiety, and irritability, as well as problems with anger and anger expression. o Second, individuals with BPD have patterns of behavioral dysregulation, as evidenced by extreme and problematic impulsive behavior. As noted earlier, an important characteristic of these individuals is their tendency to direct apparently destructive behaviors toward themselves. Attempts to injure, mutilate, or kill themselves, as well as actual suicides, occur frequently in this population. o Third, individuals with BPD sometimes experience cognitive dysregulation. Brief, nonpsychotic forms of thought and sensory dysregulation, such as depersonalization, dissociation, and delusions (including delusions about the self), are at times brought on by stressful situations and usually cease when the stress is ameliorated. o Fourth, dysregulation of the sense of self is also common. Individuals with BPD frequently report that they have no sense of a self at all, feel empty, and do not "know" who they are. o Finally, these individuals often experience interpersonal dysregulation. Their relationships may be chaotic, intense, and marked with difficulties. Even though their relationships are so difficult, individuals with BPD often find it extremely hard to relinquish relationships. Instead, they may engage in intense and frantic efforts to prevent significant individuals from leaving them.

Alcohol Abuse

problems in at least one of four areas including failure to fulfill major social role obligations at work, home, or school; drinking repeatedly in a manner that creates harm; incurring alcohol-related legal consequences; or continued use despite know problems

Alcohol Use Disorders VI. Selection of Drinking Goals

the final major area to consider in treatment planning is the selection of drinking goals---may be abstinence of drinking in moderation

DR of Incompatible behaviors

the acceleration and deceleration target behaviors cannot occur simultaneously

Shaping

the components of a target behavior are reinforced rather than the complete target behavior. Successively closer approximations of the total behavior are reinforced so that finally the complete behavior is being reinforced

Dialectical Dilemma: Emotional Vulnerability/Self-Invalidation

• Biologically influenced emotional vulnerability as the thesis (e.g., the sense of being out of control or falling into the abyss) and socially influenced self-invalidation as the antithesis (e.g., hate and contempt directed toward the self, dismissal of one's accomplishments) • Along this dimension of behavior, clients with BPD often vacillate between acute awareness of their own intense, unbearable, and uncontrollable emotional suffering on the one hand, and dismissal, judgment, and invalidation of their own suffering and helplessness on the other • With self-invalidation, one's own emotional experiencing and dysregulated responses are invalidated

Drug Abuse & Dependence: Basic Info from Barlow

• The criteria for drug abuse and dependence represent a cluster of behavioral and physiological signs and symptoms resulting from a pattern of continued drug use despite significant drug-related problems. (Tables 13.2 and 13.3 on pages 549-550 list out the DSM criteria for Substance Abuse and Dependence) • Evidence suggests that more severe drug dependence is associated with poorer treatment outcome. • Severity is influenced by frequency of use, amount of drug used, and route of administration, among others factors. These factors are positively associated with tolerance

Dialectical Dilemma: Active Passivity/Apparent Competence

• "Active passivity" may be defined as passivity in solving one's own problems, while actively engaging others to solve one's problems. It can also be described as passivity that appears to be an active process of shutting down in the face of seeing problems coming in the future. • "Apparent competence" refers to the tendency of other individuals to overestimate the capabilities of the individual with BPD. Thus, this characteristic is defined by the behavior of the observer rather than the behavior of the individual with BPD. This failure to accurately perceive their difficulties and "disability" has serious effects on individuals with BPD. Not only do they not get the help they need, but also their emotional pain and difficulties may easily be invalidated, leading to a further sense of being misunderstood.

Other notes on BA: Part 1

• 12- to 24-session formats over 16 weeks (sometimes twice per week during the first 8 weeks and once per week during the last 8 weeks) • BA has also been applied in a group format • The major work of therapy in BA occurs between treatment sessions (homework) • Scheduling specific behaviors is beneficial • Graded task assignment is for clients to learn how to break down tasks and grade them appropriately in a stepwise progression from simple to complex (to help with success)

Efficacy of DBT Compared to Other Tx

• Although several treatments (psychodynamic, CBT) have shown efficacy in the treatment of individuals with BPD, DBT has the most empirical support at present and is generally considered the frontline treatment for the disorder.

Behavioral and Cognitive-Behavioral Therapies For Illicit Drug Abuse and Dependence (2)

• At least four empirically based, prototypical behavioral and cognitive-behavioral interventions are used in the treatment of illicit drug use disorders o Cognitive-behavioral/relapse prevention therapy o Contingency management o Motivational interviewing o Behavioral couple therapy - It is common practice to provide multi-element treatments for illicit drug use disorders that incorporate many of the specific interventions above

Course of Treatment in BA

• BA is a theory-driven as opposed to a protocol-driven treatment - does not follow a required session-by-session format, but follows a general course over time • The following activities are covered: o Orienting to treatment (table 8.1 has the key points listed) o Developing treatment goals - the ultimate goal is to help clients modify their behavior to increase contact with sources of positive reinforcement - must first address basic avoidance patterns then address short- and long-term goals (basically start small and work your way up) o Individualizing activation and engagement targets - What activation strategies may work for one client may not work for another client - A huge component of BA is functional analysis, which involves identifying for each client the variables that maintain the depression and are most amenable to change - Must find out the following: • What is maintaining the depression? • What is getting in the way of engaging in and enjoying life? • What behaviors are good candidates for maximizing change? o Repeatedly applying a troubleshooting activation and engagement strategies o Reviewing and consolidating treatment gains - the main focus here is relapse prevention by reviewing and consolidating gains the client has made

Behavioral and Cognitive-Behavioral Therapies For Illicit Drug Abuse and Dependence

• Based on the behavioral and cognitive-behavioral frame drug use is considered learned behavior that is maintained, at least in part, by the reinforcing effects of the pharmacological actions of drugs in conjunction with social and other nonpharmacological reinforcement derived from the drug-abusing lifestyle. • Empirical research suggests that abused drugs function as reinforcers in humans and in animals. Also through respondent and operant conditioning, environmental events that previously have been paired with drug use reliably lead to drug-seeking behavior. In all empirical research supports a theoretical position that reinforcement and other principles of learning are fundamental determinants of drug use, abuse, and dependence • Treatment is designed to assist in reorganizing the physical and social environments of the use. The goal is to weaken systematically the influence of reinforcement derived from drug use and the related drug-abusing lifestyle and to increase the frequency of reinforcement derived from healthier alternative activities, especially those that are incompatible with continued drug use.

Symptom Reduction (dep)

• Behavioral techniques: used throughout course of CT, generally concentrated in earlier stages of treatment. Especially necessary for more severely depressed. Behavioral techniques have the goal of modifying automatic thoughts. • Most common: Scheduling activities that include both mastery and pleasure exercises, cognitive rehearsal, self-reliance training, role playing and diversion techniques

CRA plus Vouchers

• CRA plus Vouchers (I don't think we really need to know this...) o The Community Reinforcement Approach plus vouchers is another type of treatment (used by the Chapter's authors for cocaine addiction) o In CRA therapist attempt to be very flexible with scheduling and goal setting, especially at the beginning of treatment o Therapist and clients develop an active, make-it-happen attitude throughout treatment o Active problem solving is a routine part of treatment. Therapist may even take clients to appointment or job offers! o CRA is delivered in twice-weekly 1-1.5 hour therapy sessions during the initial 12 weeks and once-weekly sessions for another 12 weeks. o Sessions focus on the following seven general topics: -How to recognize antecedents and consequences of their cocaine use, that is, how to functionally analyze their cocaine use - Develop a new social network that supports a healthier lifestyle and getting involved with enjoyable recreational activities that do not involve cocaine or other drug use - Various forms of skills training usually to address some specific skills deficit that may influence directly or indirectly clients' risk for cocaine use - Job club, an efficacious method to help chronically unemployed individual obtain employment - Clients with romantic partners who were not drug abusers are offered behavioral couple therapy - HIV/AIDS education is provided to all clients in the early stages of treatment - All who meet diagnostic criteria for alcohol dependence or report that alcohol use is involved in their use of cocaine are offered disulfiram therapy o Voucher program - Urine specimens and breath alcohol levels are collected on a fixed schedule throughout treatment - Clean specimens earn clients points which are worth the equivalent of $0.25 each. (money is never provided directly to clients) - Clients receive a "$10" bonus for each of three consecutive clean specimens - Therapist and clients jointly select retail items to be purchased in the community with the points - Purchases are approved by therapist if they are deemed to be in concert with individual treatment goals of increasing drug-free healthy activities - Voucher program is discontinued after first 12 weeks of program

Characteristics of Cognitive Therapy

• Collaboration between the therapist and patient • Interpersonal qualities: warmth, accurate empathy, and genuineness • Joint determination of goals for therapy • Regular feedback: including making sure the client understands the formulations • Collaborative empiricism (allowing the client to test hypotheses about beliefs)

Development of Dialectical Behavioral Therapy (DBT)

• DBT evolved from standard cognitive-behavioral therapy as a treatment for BPD, particularly for recurrently suicidal, severely dysfunctional individuals. The theoretical orientation to treatment is a blend of three theoretical positions: behavioral science, dialectical philosophy, and Zen practice. - Behavioral science, the principles of behavior change, is countered by acceptance of the client (with techniques drawn both from Zen and from Western contemplative practice); these poles are balanced within the dialectical framework.

Biosocial Theory: Emotion Dysregulation

• Emotion dysregulation o BPD is a pervasive disorder of emotion dysregulation o Emotion dysregulation - generally speaking, some people cry when a hallmark commercial comes on, others don't; people with BPD are the ones who let their emotions take control o Leads to immense emotional suffering

Process of Cognitive Therapy

• First few sessions: produce some symptom relief, reduce patient's suffering = rapport, collaboration and confidence in therapy; defining the problems and goals of therapy • Typical session: establish the agenda, determine the order, summarize at the end... • Progression of session content over time: structure stays same although content changes, explore specific thoughts and assumptions about situations/problems, and underlying schemas that may be related

IPT Compared to Other Psychotherapies

• IPT is less structured and assigns no formal homework (compared to CBT) - the CBT therapist defines depression as a consequence of dysfunctional thought patterns and attributes the patient's difficulties to them & the IPT therapist emphasizes that depression is a medical illness and relates difficulties to feeling depressed and to recent life events; IPT emphasizes eliciting affect rather than automatic thoughts • Some describe it as dynamic but it is not - IPT employs the medical model of illness whereas dynamic uses a conflict-based approach (+ several other examples in the book)

DBT: Thesis and Antithesis

• In dialectics, there is a thesis and an antithesis. You seek to find the truth in both positions to come to a middle-ground (called the synthesis). o Dialectics prove beneficial in the treatment, as it is a way to introduce oppositions in which both client and therapist can arrive at new meanings within old meanings, moving closer to the essence of the subject under consideration (rather than polarizing the client and therapist in an argument)

Development of IPT (Klerman, Weissman & colleagues, 1970s)

• Klerman, Weissman & colleagues developed IPT in the 1970s as a treatment arm for a pharmacotherapy study of depression; Developed bc stressful life events trigger depressive episodes in vulnerable individuals and depressive episodes compromise interpersonal functioning, making it difficult to manage stressful life events, and often triggering further negative life events o IPT was also built on the interpersonal theory of Adolph Meyer AND Harry Stack Sullivan and on the attachment theory of John Bowlby o The interpersonalists broadened the scope of psychiatry by emphasizing social, cultural and interpersonal factors o Sullivan stressed the role of interpersonal relationships in the development of mental illness and the use of interpersonal relationships to understand, assess and treat mental illness

Types of Positive Reinforcers

• Tangible reinforcers=material objects • Social reinforcers=attention, praise, approval, and acknowledgement from other people • Token reinforcers=symbolic items that have value because of what they can be exchanged for or what they stand for • Reinforcing activities such as watching tv -Social reinforcers have several advantages: easy to administer, don't cost anything, can be administered immediately after the person has performed the target, and they are natural reinforcers -Reinforcers are most effective when they are individualized -can be identified by questioning the clients or exposing clients to an array of general reinforcers and asking them to select those they would like to use

DBT Stages of Therapy and Treatment Goals: Pretreatment

• Pretreatment: Orienting and Commitment o First, DBT is presented as a supportive therapy requiring a strong collaborative relationship between client and therapist. DBT is not a suicide prevention program, but a life enhancement program in which client and therapist function as a team to create a life worth living. o Second, DBT is described as a cognitive-behavioral therapy with a primary emphasis on analyzing problematic behaviors and replacing them with skillful behaviors, and on changing ineffective beliefs and rigid thinking patterns. o Third, the client is told that DBT is a skills-oriented therapy, with special emphasis on behavioral skills training. The commitment and orienting strategies, balanced by validation strategies described later, are the most important strategies during this phase of treatment

DBT Stages of Therapy and Tx Goals: Stage 1

• Stage 1: Attaining Basic Capacities o The primary focus of the first stage of therapy is attaining behavioral control in order to build a life pattern that is reasonably functional and stable. o Targets of treatment - Primary target: life-treatening behaviors (including suicidal and Parasuicidal behaviors) - Secondary target: therapy-interfering behaviors (e.g., late to session, missing sessions, not following treatment plan, hostile attacks on the therapist) - Tertiary target: quality-of-life-interfering behaviors (e.g., substance abuse, eating disorder, homelessness, serious Axis I disorders).

DBT Stages of Therapy and Tx Goals: Stage 2

• Stage 2: Posttraumatic Stress Reduction o The aim of Stage 2 DBT is to reduce "quiet desperation," which can be defined as extreme emotional pain in the presence of control of action. o Stage 2 addresses four goals: - remembering and accepting the facts of earlier traumatic events - reducing stigmatization and self-blame commonly associated with some types of trauma - reducing the oscillating denial and intrusive response syndromes common among individuals who have suffered severe trauma - resolving dialectical tensions regarding placement of blame for the trauma

DBT Stages of Therapy and Tx Goals: Stage 3

• Stage 3: Resolving Problems in Living and Increasing Respect for Self o In the third stage, DBT targets the client's unacceptable unhappiness and problems in living. At this stage, the client with BPD has either done the work necessary to resolve problems in the prior two stages or was never severely disordered enough to need it. Although problems at this stage may still be serious, the individual is functional in major domains of living. The goal here is for the client to achieve a level of ordinary happiness and unhappiness, as well as independent self-respect. o Ultimately, the therapist must pull back and persistently reinforce the client's independent attempts at self-validation, self-care, and problem solving. Although the goal is not for clients to become independent of all people, it is important that they achieve sufficient self-reliance to relate to and depend on others without self-invalidating.

DBT Stages of Therapy and Tx Goals: Stage 4

• Stage 4: Attaining the Capacity for Freedom and Sustained Contentment o The final stage of treatment in DBT targets the resolution of a sense of incompleteness and the development of a capacity for sustained contentment. The focus on freedom encompasses the goal of freedom from the need to have one's wishes fulfilled, or one's current life or behavioral and emotional responses changed. Here the goals are expanded awareness, spiritual fulfillment, and the movement into experiencing flow.

Current Behavioral Activation (BA)

• The point of BA is not to engage in increased activation at random or activities that are "generally" thought to be pleasing or to improve mood (e.g., seeing a movie); in contrast, activation strategies are highly individualized and "custom tailored." • The role of the BA therapist is to act as a "coach" as the client implements the activation strategies, providing expert help in setting achievable goals, breaking difficult tasks down into manageable units, troubleshooting problems that arise, and maintaining motivation during the process of change. • The primary clinical target is avoidant behavioral repertoires • Research shows that BA and Cognitive therapy (CT) are similarly effective in treating depression • In comparison to anti-depressant medication (ADM), BA was as comparable to ADM and demonstrated better retention (thus, more cost-effective)

Chapter 7 SPIEGLER AND GUEVREMONT: DECELERATION BEHAVIOR THERAPY: DIFFERENTIAL REINFORCEMENT, PUNISHMENT, AND AVERSION THERAPY

• The preferred strategy for decelerating an undesirable behavior is to reinforce an acceleration target behavior that is an alternative to the deceleration target behavior, a procedure called differential reinforcement (DR). o To reduce a client's criticism of others, the client might be reinforced for complimenting others. (DR changes the deceleration behavior/criticizing indirectly by directly reinforcing the acceleration behavior/complimenting) o This works because the more the client engages in the alternative behavior, the less opportunity he has to engage in the deceleration target behavior. • The 4 major types of DR, from most to least effective are: - DR of Incompatible behaviors - DR of Competing behaviors - Any other behaviors: DR of other/alternative behaviors - DR of low response rates/Low frequency of the undesirable behavior

Other notes on BA: Part 2

• The therapist must address avoidance o essential to start from a collaborative stance o used basic problem-solving methods to address avoidance o help maintain a consistent focus on avoidance • The BA approach considers ruminating as a behavior that frequently prevents people from engaging fully with their activities and environments o In addressing rumination in BA, we are less interested in the particular content of ruminative thoughts than in the context and consequences of rumination. o BA therapists may ask clients who ruminate frequently to experiment with "attention to experience" practice, in which they deliberately focus their attention on their current activity and surroundings (AKA, mindfulness) • IF YOU TAKE NOTHING ELSE FROM THIS...JUST SCHEDULE PLEASANT EVENTS!

Dialectical Dilemma: Unrelenting Crises/Inhibited Grieving

• This highlights the tendency of the client with BPD to experience life as a series of unrelenting crises as opposed to the behavior of "inhibited grieving" • Individuals with BPD who experience unrelenting crises have lives that are often characterized as chaotic and in crisis. "Crisis" is defined as the occurrence of problems that are extreme, with significant pressure to resolve them quickly. • There are three typical scenarios that result in a pattern of unrelenting crisis. o First, individuals with extreme impulsivity and emotion dysregulation engage in behaviors that result in crisis situations. Poor judgment is a key element to assess when analyzing the impulsive behaviors of individuals with BPD. o Second, situations that do not start out as crises can quickly become critical due to the lack of resources available to many individuals with BPD. This may be due to socioeconomic status, or to lack of family or peer support. o Third, unrelenting crises can be due simply to fate or bad luck at a given moment, a phenomenon that is out of the person's control. • In "Inhibited grieving," "grief" refers to the process of grieving, including experiencing multiple painful emotions associated with loss, particularly traumatic loss, not just the one emotion of deep sadness or grief. Individuals with BPD may not be able to experience or process the grief related to the loss of the life they had expected for themselves, and ordinarily do not believe they will recover from the grief if they actually try to experience or to cope with it on their own

Assessing diagnostic, clinical, and functional domains (in BA)

• Want to get an accurate assessment of the client's functioning - This is done by using the SCID-I and II, BDI, etc to gain a diagnostic understanding - Also, functional capacity is largely important in BA, so need to gather detailed information about the impact of the client's depression on work, family, social, etc.

Assessment of Drug Abuse & Dependence

• When assessing for drug abuse and dependence it is important to schedule the client for an initial interview as soon as possible after the client has contacted you. Scheduling within 24hours of clinic contact significantly reduces attrition between the initial clinic contact and assessment interview, which is a substantial problem among those with drug use disorders. • During the intake interview and assessment it is important to be empathic and to convey a very upbeat "you can do it" message. • During assessment self-report questionnaires and semi-structured drug history interviews are used to collect information on current and past drug usage. You want to obtain detailed information regarding the duration, severity, and pattern of the client's drug use. (Such detailed information is essential for proper treatment planning) • Also during assessment phase you want to orient the client to what will happen in treatment and create an atmosphere of optimism