CBT CARDS
Modifying Beliefs
You generally can't modify the belief completely. When the client only believes it 30% you can generally stop. 1.Socratic questioning to modify beliefs 2.Behavioral experiments to test beliefs (e.g. if I ask for help others will belittle me). 3.Cognitive continuum to modify beliefs (e.g. not a good student to a failure). 4.Acting as if (e.g. what would you be doing). 5.Self-disclosure to modify beliefs.
Operant conditioning
(sometimes referred to as instrumental conditioning) is a method of learning that occurs through rewards and punishments for behavior. Through operant conditioning, an association is made between a behavior and a consequence for that behavior -Behavior which is reinforced tends to be repeated (i.e., strengthened); behavior which is not reinforced tends to die out-or be extinguished (i.e., weakened).
Know the shared/unique characteristics of behavior therapist.
-The focus isn't on helping the client develop insight, they work on problematic patterns of behaviors. Ex: eliminating fear of flying, compulsive rituals, changing poor eating habits, working with the parents to not give in to the child causing the child to continue the problematic bx -They are more directive, use modeling, demonstrate alternative behaviors, ask clients to learn new skills, and assign HW. Learning new skills and unlearning old behavior is emphasized. Focused on achieving goals. Instruction, education, trying particular exercises, HW, repeated assignments to measure progress towards goals are all part of therapy. -The duration and setting can be different. Treatment is shorter (10-15 sessions), may be longer than 50mins and take place outside the office. -Strongly rooted in empirical research. This means therapy will change over time if research demonstrates there's a better technique to treat that behavior.
LIMITED EFFECTS OF PUNISHMENT
1. Punishment does not teach appropriate behaviors 2. Must be delivered immediately & consistently 3. May result in negative side effects 4. Undesirable behaviors may be learned through modeling (aggression) 5. May create negative emotions (anxiety & fear) 6. Can lead to abuse
Difficulties in Eliciting Automatic Thoughts
1.Ask them how they are/were feeling and where in their body they experienced the emotion. 2.Elicit a detailed description of the problematic situation. 3.Request that the patient visualize the distressing situation. 4.Suggest that the patient role-play the specific interaction with you. 5.Elicit an image. 6.Supply thought opposite to the ones you hypothesize actually went through their minds. 7.Ask for the meaning of the situation. Phrase the question differently.
Know how to define a positive reinforcer.
A reinforcer is anything that occurs in conjunction with an act, tends to increase+++ the probability that the act will occur again. Negative -Something that the subject wants to avoid- a blow, a frown, an unpleasant sound. Positive -something the subject wants, such as food, petting, or praise.
CBT - You will be given an vignette and will be required to discuss the following: the client's primary problem using CBT language; formulate the target problem into a statement using the CBT model (ABC); examples of how you would use guided discovery - what you would actually say to the client; identify the client's core belief; identify and label two automatic thoughts; an alternative response to one of the automatic thoughts; and a description of the homework you would provide.
A. The client's primary problem using CBT language B. f. ormulate the target problem into a statement using the CBT model (ABC) C. examples of how you would use guided discovery - what you would actually say to the client Guided discovery is used to evaluate ct's thinking and identify cognitive dysfunctions FIRST identify cognitive dysfunction. THEN ask socratic questioning of guided discovery: 1. What is the evidence that your thought is true? What is the evidence on the other side? 2. What is an alternative way of viewing this situation? 3. What is the worst that could happen, and how could you cope if it did? What's the best that could happen? 4. What's the most realistic outcome of this situation? What is the effect of believing your automatic thought, and what could be the effect of changing your thinking? 5. If your [friend or family member] were in this situation and had the same automatic thought, what advice would you give him or her? 6. What should you do? identify the client's core belief identify and label two automatic thoughts To Identify: ask a basic question, "What is going through your mind right now?" "What was going through your mind?" Want to psychoeducate ct on what an automatic thought is: the things we tell ourselves that elicits emotion (i.e. sadness when we tell ourselves "I'll never be like [this person]") an alternative response to one of the automatic thoughts a description of the homework you would provide Generally, homework looks like either of these 2: 1. Behavioral changes as a result of problem solving and/or skills training in session (e.g. problem of isolation might lead to behavioral solution of calling friends). 2. Identifying automatic thoughts and beliefs when patients notice a dysfunctional change in affect, behavior, or physiology and then evaluating and responding to their cognitions in more appropriate ways.
Understand superstitious behavior
Accidental reinforcement - The behavior is unrelated to the consequence but the subject still exhibits the behavior as if it's required for the reinforcement. Ex: wearing a lucky shirt, eating grapes at new years for midnight Becoming aware that it has no relationship to the reinforcer is how we get rid of the superstitious behavior.
In taking an evidenced based practice approach we consider which of the following?
All are correct
Which of the following are true regarding the question - Is therapy effective?
All are correct
Which of the following is(are) part of case conceptualization in CBT?
All are correct
Understand the theory and components of classical conditioning
Automatic and reflexive responses, not voluntary behaviors. A form of learning whereby a conditioned stimulus (CS) becomes associated with an unrelated unconditioned stimulus (US) in order to produce a behavioral response known as a conditioned response (CR). The conditioned response is the learned response to the previously neutral stimulus. A stimulus in the environment has produced a behavior / response which is unlearned (unconditioned) and therefore is a natural response which has not been taught. Then we have another stimulus which has no effect on a person and is called the neutral stimulus (NS). The NS could be a person, object, place, etc. The NS does not produce a response until it is paired with the unconditioned stimulus. A stimulus which produces no response (neutral) is associated with the unconditioned stimulus at which point it now becomes known as the conditioned stimulus (CS). Now the conditioned stimulus (CS) has been associated with the unconditioned stimulus (UCS) to create a new conditioned response (CR) conditioned stimulus + unconditioned stimulus = a conditioned response Once you are classically conditioned you can make associations and generalize it to other things (generalization) You can also discriminate and ignore other things that aren't like the unconditioned stimulus (discrimination). We want people to discriminate btw what we want and what we don't want* breaking the connection btw the condition stimulus and the unconditioned stimulus is what Extinguishes that certain behavior you are trying to get rid of (that conditioned response). Once someone has recovered, they can go back to having a conditioned response (Spontaneous Recovery)
-Spontaneous recovery:
The reappearance of a response (a Conditioned Response; CR) that had been extinguished.
Be able to describe Behavior Activation and what the research shows about this technique.
Behavior Activation: a type of hw given in CBT A key part of treating someone with depression is getting them active. These clients are often reinforcing depressive bxs unknowingly. Gets person moving again, schedule their activities day by day -Importance of scheduling activities -Depressed clients have often decreased pleasurable activities and increased behaviors that maintain or increase their depression (i.e. staying in bed, watching television, sitting around). -Clients often believe that they cannot change how they feel emotionally. -Helping clients become more active and giving themselves credit for their efforts is a key component of CBT. Research says Behavior Activation works on its own w/o the rest of CBT (stand-alone model) Challenges the idea that medication is required to treat moderately to severely depressed patients Challenges the idea that directly modifying cognition is necessary to treat depression Behavioral Activation 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 people's 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
Punishment is the preferred method of untraining.
False
The best type of research evidence for a treatment are randomized controlled double blind studies?
False
Differences between classical and operant conditioning
CC -the learner is the object -pairs two stimuli -works with involuntary responses OC -the learner is subjected to the consequences -pairs behavior and response -works with voluntary behaviors ÒWhat is being conditioned - in CC it is a NS and in OC a desired behavior is pared with a consequence ÒIn CC the stimulus comes before the response/behavior but in OC a behavior comes first and is rewarded or punished ÒIn CC the response/behavior is involuntary and in OC the behavior is voluntary EX DV ÒBeing abused causes fear - spouse is paired with the abuse - spouse becomes conditioned with fear (CC) Ò ÒFollowing an DV episode the abuser increases the use of reinforcement to resolve the incident with the victim (OC) ÉProle of the partial reinforcement effect ÉRole of punishment
CBT Skills and Action Plans
Cognitive Strategies ÉPsychoeducation ÉMonitoring, questioning, and responding to automatic thoughts (Daily Thought Record) ÉWeighing the pros and cons (problem solving) ÉWorksheets and Experiential Techniques (e.g., Downward Arrow) ÉBehavioral experiments ÉBibliotherapy Behavior Strategies ÉBehavioral activation ÉExposure ÉGraded Task Assignment ÉModeling and Role Play ÉSkills (e.g., emotional regulation) ÉSocial Skills Training ÉRelaxation and Visualization
Which of the following is not considered a behavior treatment_
Cognitive restructuring
systematic desensitization
Commonly used to treat fear, anxiety disorders and phobias. Using this method, the person is engaged in some type of relaxation exercise and gradually exposed to an anxiety-producing stimulus, like an object or place
When selecting a reinforcer for a desired behavior, you want to pick the largest one possible.
False
APA Definition of Evidence-Based practice and how you would use this approach in developing a treatment approach.
Def: "Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences." best available research evidence: Adopt a scientific view of clinical social work Knowledge of applied research design and methods Strategies for accessing best available research Ability to evaluate relevant evidence patient preferences and values: View behavioral health interventions as a collaborative endeavor Knowledge of specific culturally diverse groups Ability to ascertain client/patient values and preferences Respond effectively to client/patient preferences and values Clinical expertise Understand role and limits of clinical judgment Skills in relationship building Assessment and diagnostic skills Skills to implement EST's (e.g., specific therapeutic techniques) Integration of EST with client characteristics EST: empirically supported txs 5 Steps: Ask: formulate the question... ex- what is the best treatment for someone who has a borderline personality diagnosis? Acquire: evidence - search for answers... ex- find peer reviewed, randomized controlled double blind studies, systematic review, meta-analysis, all the information you can gather to find out what's the best treatment. Appraise: the evidence for quality and relevance Apply the results Assess the outcome (i.e. every session to see if EBP is working)
A client comes to see you for depression. In talking with the client, you discover that she recently lost her job of 10 years due to poor work performance. The client reports that she is worthless and has been crying for long periods of time for most of the day. Based on the ABC Model what is the emotional or behavioral consequence?
Depression
CBT
Developed by Aaron Beck CBT's theory is that dysfunctional thinking (which influences the patient's mood and behavior) is common to all psychological disturbances Believes that core beliefs are fundamental and deep, the person automatically/subconsciously views the world with these developed core beliefs (similar to schemas) we want the person to discover these core beliefs -emphasis on dysfunctional thinking vs irrational belief -less directive / confrontational approach - focus on the current behavior first instead of the core belief -stresses the quality of the therapeutic relationship
A child becomes classically conditioned to fear a nurse wearing scrubs because the sight of the nurse is paired with getting a shot. At first when the child sees a different person wearing scrubs in a store she becomes fearful. However, over time she no longer shows fear of people wearing scrubs outside of the doctor's office but still has the reaction when she sees nurses in the doctor's office. This is an example of which principle.
Discrimination
Guidelines/tools for effective exposure
Exposure works best when it is predictable no surprises/forcing psychoeducation to explain the plan, help ct feel in control and know what to expect Longer exposure the longer it is, the more fear is decreased make sure that fear is decreasing or else you're reinforcing that the fear doesn't go away even after exposure Intense enough to trigger a fear response fear response needs to occur (just enough) in order to treat it, but not too overwhelming Exposure sessions should be spaced close together i.e. 10 daily exposure sessions instead of 10 weekly exposure sessions Homework comes into play here to make sure ct is working on reducing fear bx daily Varying the stimulus across exposure practices i.e. fear of bridges -- practicing facing fear of multiple types of bridges, not just one bridge (short, long, bumpy, smooth bridges) Conducting exposure practices in multiple contexts different settings (i.e. facing fear of spiders at work, home, outside, etc.) Focus on the feared stimulus during the practice don't use distraction during exposure; don't want ct to use distraction b/c they'll take their mind off of the fear, but we want them to face the fear instead of avoiding it
Know the different types of exposure-based treatments, which ones are best for which disorders. Also know the guidelines and tools for effective exposure. When it should and should not be used (e.g. know flooding, systematic desensitization, in-vivo desensitization, fear hierarchy, aversion therapy)
Exposure-based txs In vivo exposure - exposing a person to his or her feared object in real life method of choice; gold standard Imaginal exposure - involves having a client imagine being in a feared situation Typically used for fear of thoughts, images, memories; for those unwilling to do in vivo exposure Interoceptive exposure - involves repeatedly exposing oneself to feared sensations using a series of exercise such a hyperventilation designed to reduce feelings of panic/panic attacks; for people who have a fear of dying due to activation exposes you to feelings of anxiety that your body goes through, helping you learn that you won't die from these bodily feelings; helps people be less fearful of these activations Virtual reality exposure - using three-dimensional computer-generated images projected on the inside of a visor worn in front of the eyes.
This occurs when you stop reinforcing a problematic behavior. For example, a mom ignores and stops giving attention to her child when he whines.
Extinction
An example of an automatic thought is, "I feel sad?"
False
CBT is very directive with little collaboration with the client.
False
Phobias are thought to results from classical conditioning but are generally unresponsive to counterconditioning treatments.
False
Positive punishment has the affect of increasing positive behavior?
False
If a child becomes classically conditioned to fear a nurse wearing scrubs because the sight of the nurse is paired with getting a shot; what principle explains the child's fear of seeing a different person wearing scrubs in a store?
Generalization
*-Punishment:
Involves providing adverse consequences (e.g. physical discipline, harsh words, criticism) or the removal of positive events (e.g. privileges, points, time out from reinforcement) for the negative behavior. Anything that, occurring in conjunction with an act, tends to decrease the probability that the act will occur again
Which of the following is a benefit of Socratic questioning?
It involves and empowers the client in the learning process
A client comes to see you for depression. In talking with the client, you discover that she recently lost her job of 10 years due to poor work performance. The client reports that she is worthless and has been crying for long periods of time for most of the day. Based on the ABC Model what is the activating event?
Loss of job
The First Therapy Session
Main goal is to inspire hope - through psychoeducation (research shows...), reviewing the treatment plan, and directly expressing your confidence that you can help
Social learning theory (modeling).
Modeling (Bandura) Social worker models skills The social worker leads a discussion around the modeling that has occurred The client behaviorally rehearses the new skill The client and social worker process the behavioral rehearsal helps ct navigate a new bx for them that they aren't very confident in/ fearful of (i.e. interviewing)
Be able to identify the major developer of classical conditioning
Pavlov
Positive Punishment:
Presenting an unfavorable outcome or event following an undesirable behavior (i.e. spanking)
Definition and purpose of a functional assessment.
Pretty much on top of the assessment, we want to assess for the specific problem the individual is dealing with. -S -O -R -C
-Extinction burst:
Previously reinforced or learned behavior temporarily increases when the reinforcement for the behavior is removed. Enables one to move more rapidly toward one's goal bx. i.e. A dog barks on command, but no treat arrives, the dog then intensifies its bark to try again (a more vigorous response)
If an automatic thought is true, what is the best course of action?
Problem solving
Which is the main goal of the first therapy session?
Providing hope
Be able to describe the main CBT treatment components for treating someone with Major Depression Disorder (see reading and sample we did in class).
Psychopharmacology Behavior Cognitive Treatment Symptom reduction How you talk about CBT, get them excited You want them to have a reduction in symptoms in that first session; use a little CBT to do that, psychoeducation Behavioral activation Get depressed people moving, schedule those activities b/c they're more likely to do it Psychoeducation and socializing the patient to cognitive therapy Explain CBT model, use CBT language in a way that makes sense to them Cognitive restructuring Doing this in session before giving hw Self-help homework to get them to continue the work b/c they've already experienced it in session
Which of the following is not one of the three types of automatic thoughts that we typically work with in CBT?
Rational thoughts
Fixed ratio schedule:
Reinforcement occurs after a fixed number of responses have been emitted since the previous reinforcement. An organism trained on this schedule typically pauses for a while after a reinforcement and then responds at a high rate. If the response requirement is low there may be no pause; if the response requirement is high the organism may quit responding altogether. Therefore, a response is reinforced only after a specified number of responses. Ex. If the group member uses appropriate social interaction in group three times they can choose the song. A factory worker gets a break for every 15 widgets they make.
Variable ratio schedule:
Reinforcement occurs after a variable (unpredictable) number of responses have been emitted since the previous reinforcement. This schedule typically yields a very high, persistent rate of response. In simpler words, it can occur when a response is reinforced after an unpredictable number of responses. Ex. the number of responses the group member must demonstrate appropriate social interaction in order to reach the goal changes without the client knowing. Maybe today's group is three times and tomorrow's group is 5 times. i.e. slot machines Ratio - number of responses Interval - time
Understand the various schedules of reinforcement (intermittent and continuous; fixed interval/ratio and variable interval/ratio). Fixed interval schedule:
Reinforcement occurs following the first response after a fixed time has elapsed after the previous reinforcement. This schedule yields a "break-run" pattern of response; that is, after training on this schedule, the organism typically pauses after reinforcement, and then begins to respond rapidly as the time for the next reinforcement approaches. So, the first response is rewarded only after a specified amount of time has elapsed. Ex. iIf the client shows up on time to group three weeks in a row they get to choose the song
Variable interval schedule:
Reinforcement occurs following the first response after a variable time has elapsed from the previous reinforcement. This schedule typically yields a relatively slow, steady rate of response that varies with the average time between reinforcements. Occurs when a response is rewarded after an unpredictable amount of time has passed. Very resistant to extinction Ex. the number of times the client must show up to group on time varies over time. So they get rewarded after showing up on time for three weeks, then the next time they don't get rewarded until after 5 weeks.
Punishers (weakens behaviors):
Responses from the environment that decrease the likelihood of a behavior being repeated. Punishment weakens behavior.
Understand shaping (laws of shaping and special considerations)
Shaping - Consists of taking a very small tendency in the right direction and shifting it, one small step at a time, toward an ultimate goal (learning a new skill/bx) i.e. learning tennis, changing bx -- stop smoking Things to consider: One effect of shaping is increasing attention span Young subjects should be asked no more than 3-4 repetitions of a given behavior Some skills are more easily learned at particular stages of development 1. Raise the criteria in increments so the subject always has a chance of reinforcement It's best to raise the criteria at whatever intervals it takes to make it easier for the subject to improve steadily. Constant progress will get you to your ultimate goal faster than forcing rapid progress. 2. Shape one aspect of the behavior at a time, not two simultaneously. It's best to first get to your first goal before you work on another behavior you want to change. Otherwise it can get confusing if you are trying to change two behaviors at once. 3. Put the current level of response onto a variable schedule of reinforcement before adding or raising the criteria. -Variable means that sometimes you will reinforce the behavior and others not. Your subject has to be able to tolerate an occasional failure per se, without stopping the behavior altogether. Learning to tolerate an intermittent schedule makes the behavior more resistant to extension. 4. When introducing a new criterion or aspect of the behavioral skill, temporarily relax the old ones -sometimes, when you're introducing a new criterion the subject might temporarily forget the past behavior. They might just need a little time to assimilate and the mistakes will usually clear up. It's best not to reprimand during these times. 5.Stay ahead of your subject -Plan your shaping program so that if your subject makes an unexpected leap forward, you will know what to reinforce next. This kind of breakthrough is a golden opportunity to make a lot of progress in a hurry- so be prepared. 6.Don't change trainers in midstream -If you do change the trainer you risk major slow downs and confusion. We can have different trainers for different behaviors but every trainer must work on one behavior at a time and till the goal is met. 7.If one shaping procedure doesn't produce progress, try another -We don't have to stick to a system that isn't working. Choose something else. 8.Don't interrupt a training session -A trainer should focus all of their attention on the trainee until the session is over. That way you don't miss moments when you should be reinforcing. 9. If a learned behavior deteriorates, review the shaping The best way to fix this is to recall the original shaping procedure and go through it all over again very rapidly. 10. Quit while you're ahead -Move on at a high note. As soon as some progress has been achieved. The last behavior that was accomplished is what will be remembered so we want to make sure it was good, worthy of reinforcement.
When it should/not be used
Should phobias, OCD, fear-based problems Should not PTSD flooding-Used to treat people with fears or phobias. In flooding, the person with the fears is exposed to the thing that frightens them for a sustained period of time. The idea behind it is that, by exposing you to your fear, you will eventually see it as less fear-producing
Be able to identify the major developer of operant conditionin
Skinner
Which of the following is not required for modeling to be effective?
Stimulus control
Complete stimulus control is met under 4 conditions:
The behavior always occurs immediately upon presentation of the conditioned stimulus (the dog sits when told to). The behavior never occurs in the absence of the stimulus (during a training or work session the dog never sits spontaneously). The behavior never occurs in response to some other stimulus (if you say "lie down," the dog does not offer the sit instead). No other behavior occurs in response to the stimulus (where you say "sit," the dog does not respond by lying down).
All of the following are considered the common factors in therapy except_
The treatment environment
Know the common factors and the importance of each (be able to put them order).
There are 4 of them: 1. Client factors and extra-therapeutic events (40%): What the client brings to therapy and what influences their life outside of eat. Ex: their faith, support systems, new job, strengths 2. Relationship factors (30%): refers to a wide range of relationship-mediated variables found among therapies no matter the therapists' theoretical orientation. The amount of caring, empathy, encouragement, the therapeutic alliance, the client's capacity to work with the therapist. All of this matters heavily in therapy. We have a huge control over how well we can relate to a client. 3. Expectancy and placebo effects (15%): We have control of this as well* This is offering hope to the client that this therapy will help. The therapeutic enterprise carries the expectation that the client will be helped. 4. Technique/model factors (15%): Using a specific technique or model that has been proved to be helpful in treating the client's symptoms/disorder. i.e. miracle question, CBT, etc. There is little evidence that one school or technique is superior over another
Interventions based on CC:
These are aimed to break the associations formed due to classical conditioning. systematic desensitization: Commonly used to treat fear, anxiety disorders and phobias. Using this method, the person is engaged in some type of relaxation exercise and gradually exposed to an anxiety-producing stimulus, like an object or place flooding: Used to treat people with fears or phobias. In flooding, the person with the fears is exposed to the thing that frightens them for a sustained period of time. The idea behind it is that, by exposing you to your fear, you will eventually see it as less fear-producing aversion therapy: exposed to the stimulus while simultaneously exposed to some form of discomfort. Ex: putting unpleasant tasting liquids on your fingernails so you don't bite them.
Understand the 6 levels of validation (e.g. you will be asked to give an example of at least two different levels of validation).Validating means validating something that is valid, not something made up to make the client feel better.
These levels build upon each other. Also in article from module 2* Listening and Observing: Listening to and observing what the client is saying, feeling, doing, as well as their non-verbal cues. We have to show that we are actively listening, interested in what they are saying. Ex: tell me more, what were you thinking then, could you explain that? Shows that ct's rendition of the story is important. Accurate Reflection: Reflecting back to the client their own feelings, thoughts, assumptions, and behaviors. We convey that we understand by hearing and repeating what the client says, seeing how the client does... how they respond. It's best to use the client's words in "accurate reflection". Articulating the Unverbalized: This is what the client doesn't tell you but more like the conclusions that you are drawing based on what they have told you has happened to them. We pretty much summarize and hypothesize back to the client what we assume is going on based on what they've shared in therapy. But ask for clarification if you get it wrong. Validating in Terms of Sufficient (but not necessarily valid) causes: Based on the notion that all behavior is caused by events occurring in time and thus in principle is understandable. So therefore, we can understand our client and why they did something based on their background and their life circumstances. Validating as reasonable in the moment: This is when the therapist justifies the behavior as reasonable, well grounded, justifiable based on what happened. Finding the kernel of truth/validity that you can go on. Ex: someone treated you poorly and therefore you want to get back at them. *the behavior was reasonable at the moment. Treating the person as valid-radical genuineness: Accept the person as he/she is. We are recognizing their strengths and believe in their capacity to change. We treat them as capable, effective and able to handle what they need to handle. If you accept the person as is, they are more open to seeing a pathway of change for themselves.
Understand the process and problems with punishment and extinction including the concepts of spontaneous recovery and extinction burst. -Extinction:
This refers to extinguishing the behavior. It dies down by itself when it is not reinforced. Behavior that produces no results- not good results or bad results, just no results-will probably extinguish. We should be ignoring the behavior but not the person if we want to extinguish a behavior. If the behavior produces no results (good/bad) it will be seen as unproductive and therefore extinguished. Positive Punishment: Presenting an unfavorable outcome or event following an undesirable behavior (i.e. spanking) Negative Punishment: When a certain desired stimulus/item is removed after a particular undesired behavior is exhibited (i.e. taking away child's phone) LIMITED EFFECTS OF PUNISHMENT Punishment does not teach appropriate behaviors Must be delivered immediately & consistently May result in negative side effects Undesirable behaviors may be learned through modeling (aggression) May create negative emotions (anxiety & fear) Can lead to abuse -Spontaneous recovery: The reappearance of a response (a Conditioned Response; CR) that had been extinguished. -Extinction burst: Previously reinforced or learned behavior temporarily increases when the reinforcement for the behavior is removed. Enables one to move more rapidly toward one's goal bx. i.e. A dog barks on command, but no treat arrives, the dog then intensifies its bark to try again (a more vigorous response)
A client comes to see you for depression. In talking with the client, you discover that she recently lost her job of 10 years due to poor work performance. The client reports that she is worthless and has been crying for long periods of time for most of the day. Based on the ABC Model what is the belief?
Thoughts of worthlessness
Know everything about reinforcement (timing, size, scheduling, etc.).
Timing: Reinforcing too early or too late is ineffective. Whether you are negatively or positively reinforcing, the reinforcement should stop once the desired result is achieved. Otherwise it is neither reinforcing or providing information. Timing is information to the learner of exactly what you want Size: The size of a reinforcement should be as small as you can get away with. If for example you are training a dog to do a trick and using food as a reinforcer, you should provide small snacks, not snacks that the dog can get full with. This allows for more reinforcements per session and also cuts the waiting time since the amount can be consumed faster and you can get back to training. For people, most of the time, harder jobs get bigger rewards. Scheduling: Constant reinforcement is needed only in the early learning stages. Then, a variable schedule of reinforcement is far more effective than a constant predictable schedule (i.e. Slot machines)
Core beliefs are central ideas about the self, others, and the world that develop early on and are influenced by our genetic predispositions and experiences with others and circumstances over the lifespan?
True
Core beliefs, dysfunctional assumptions, and negative automatic thoughts are the main types of cognitions addressed in CBT.
True
Development of an action plan starts during the evaluation session.
True
In operant conditioning we often say that behavior is controlled by its consequences. It can also be said that antecedents can also control behavior. For example, a teacher walks into a classroom and the class is quiet and attentive. The attention of the students is controlled by the teacher's presence.
True
Making an activity plan is a key and critical part of developing a CBT treatment plan for someone with Depression.
True
Shaping consists of taking a very small tendency in the right direction and shifting it [through reinforcement], one small step at a time, toward an ultimate goal.
True
Systematic desensitization is a type of counterconditioning.
True
The development of a competing response is a key component of Habit Reversal Training?
True
We typically start working with automatic thoughts as they are most accessible to the client's awareness?
True
] One of the major barriers to implementing an Evidenced Based Practice (EBP) approach is the poor fit between the EBP and the clinician's needs.
True
Know the various untraining methods and which ones are and are not recommended.
Untraining - using reinforcement to get rid of bx you don't want 8 methods: Methods 1-4: not recommended, Methods 5-8: recommended 1-4 not reccomended Method 1: "Shoot the animal." (this definitely works. You will never have to deal with that particular behavior in that particular subject again.) not recommended, not effective for dealing with the problem, usually not practical/humane i.e. kicking out an annoying roommate, shooting/selling a dog that barks too much, making kids walk home who are too noisy in car Method 1 teaches the subject nothing b/c there is no modifying the bx or relearning about the bx Method 2: Punishment (Everybody's favorite, in spite of the fact that it almost never really works.) seldom effective and loses effect w/ repetition i.e. yell/scold annoying roommate, hit the dog that barks too much w/ water from hose, yell/threaten loud kids in car Method 2 also teaches the subject nothing b/c it does not cause any improvement to occur Method 3: Negative reinforcement (Removing something unpleasant when a desired behavior occurs.) not highly recommended; making a practice of using negative reinforcement puts you at risk for all the unpredictable fallout of punishment: avoidance, fear, resistance, passivity i.e. disconnect cable/internet until roommate empties her laundry, then reconnect it when she empties laundry. Shine a light on barking dog, turn off light when dog stops barking. Stop the car when kids are noisy, start driving again when kids become quiet Method 4: Extinction; letting the behavior go away by itself for lack of reinforcement not recommended, not effective; one cannot always count on extinguishing bx in another by ignoring it. But it is good for whining, sulking, or teasing i.e. wait for roommate to "grow up", let dog stop barking on its own (although this may never happen), let kids get tired of being noisy 5-8 reccomended Method 5: Train an incompatible behavior, that is, another bx that is physically incompatible with the unwanted bx. (This method is especially useful for athletes and pet owners.) recommended; diversion, distraction, and pleasant occupations are good alternatives during tense moments i.e. buy a laundry hamper, reward roommate for putting laundry in it, do laundry together making it a social occasion. Train dog to lie down cuz it can't really bark when it's lying down, reward with praise. Sing songs w/ kids, play a game to reduce distracting noise. athletic i.e. take a faulty tennis swing and train an alternative tennis swing from scratch. Muscles will begin to learn a new pattern incompatible with the faulty pattern Method 6: Put the behavior on cue. -- that is, when one learns to offer the bx in response to some kind of cue and only then. (Then you never give the cue so bx won't happen) effective sometimes, and sometimes an instantaneous cure i.e. have a laundry fight seeing who can make the bigger mess, then roommate will see what a mess it is a clean up on own. Train dog to bark on command, speak for food/reward so dog has no other reason to bark. Put kid's noise making under stimulus control -- have them make noise on command only. Method 7: "Shape the absence" ; reinforce anything and everything that is not the undesired behavior. (A kindly way to turn disagreeable relatives into agreeable relatives.) often the best way to change deeply ingrained bx i.e. Buying beer/inviting friends over when roommate does their laundry. Go out and reward dog when it's been quiet for 10-, 20-, 60-minutes, and so on. Wait for kids to be quiet, and immediately compliment/reward them. Method 8: Change the motivation. (This is the fundamental and most kindly method of all.) BEST OF ALL THE METHODS/HIGHLY RECOMMENDED/MOST KIND METHOD i.e. Hire maid to do laundry so neither you nor roommate have to cope. Barking dogs are lonely, frightened, or bored, so give exercise and attention to dog so it gets tired enough to not bark. Noisy kids in car could be due to hunger and fatigue, so provide juice, cookies, pillows, comfort for kids in car; can also give them exercise to tire them out before entering the car since active kids can be restless/noisy when not given the opportunity to play.
When a parent sometimes gives into their child's temper tantrums by giving the desired object, what type of reinforcement schedule is being used.
Variable ratio schedule
Negative Punishment:
When a certain desired stimulus/item is removed after a particular undesired behavior is exhibited (i.e. taking away child's phone)
in-vivo desensitization
a technique used in behavior therapy, usually to reduce or eliminate phobias, in which the client is exposed to stimuli that induce anxiety. The therapist, in discussion with the client, produces a hierarchy of anxiety-invoking events or items relating to the anxiety-producing stimulus or phobia. The client is then exposed to the actual stimuli in the hierarchy, rather than asked simply to imagine them.
Know and be able to identify the different cognitive distortions (e.g. all-or-nothing thinking, catastrophizing, discounting the positives, emotional reasoning, labeling, magnifying and minimizing, mental filtering, mind reading, overgeneralizing, personalization, should statements, and tunnel vision)
all-or-nothing thinking Thinking in extremes, such as all good or all bad, with nothing in the middle. Black and white thinking, saint or sinner catastrophizing Believing one knows what the future holds, while ignoring other possibilities discounting the positives Deciding that if a good thing has happened, then it couldn't have been very important. emotional reasoning Believing that something must be true, because it feels like it is true. labeling Creating a negative view of oneself based on errors or mistakes that one has made (e.g. bad mother, idiot). It is a type of overgeneralizing which affects one's view of oneself. magnifying A cognitive distortion in which an imperfection is exaggerated into something greater than it is. minimizing Making a positive event much less important than it really is. mental filtering Focusing on one negative aspect of a situation in deciding how to understand it (e.g. "The reason I haven't received a phone call from the job I applied to is that they have decided not to offer it to me."). Not seeing the whole picture mind reading Believing that we know the thoughts in another person's mind with little evidence. overgeneralizing Drawing sweeping inferences (e.g. "I can't control my temper.") from a single instance. personalization You believe others are behaving negatively because of you, without considering more plausible explanations for their behavior. should statements Telling oneself that one should do - or should have done - something, when it is more accurate to say that one would like to do - or wishes one had done - the preferred thing. tunnel vision When you only see the negative aspects of a situation.
aversion therapy
exposed to the stimulus while simultaneously exposed to some form of discomfort. Ex: putting unpleasant tasting liquids on your fingernails so you don't bite them
Why did the dog not salivate to the examiner or something else in the room? Why the bell?
he bell is a reliable predictor but the other factors were not reliable. The bell is also salient or captures the dog's attention CC is used in addictions, anxiety disorders -- stress/overeating The reversal of CC (breaking conditioned responses) are in exposure therapies, systematic desensitization, aversion therapy, and response prevention
fear hierarchy
hierarchy of feared situations, from least to most feared. Goal is to conquer smaller fears (least anxiety provoking) before tackling on bigger fears
Reinforcers (strengthen behaviors):
responses from the environment that increase the probability of a behavior being repeated. Reinforcers can be either positive or negative. Positive reinforcement strengthens a behavior by providing a consequence an someone finds rewarding. Negative reinforcement strengthens behavior because it stops or removes an unpleasant experience.
Neutral operants:
responses from the environment that neither increase nor decrease the probability of a behavior being repeated.
Know terms such as stimulus, stimulus control, stimulus generalization, and stimulus control.
stimulus An object or event that evokes a response in someone Anything that causes some kind of behavioral response Stimulus generalization When a similar stimulus evokes the same responses as the stimulus that caused the reaction initially. Ex: Let's say you're scared of rattlesnakes. However,every time you see a snake, no matter what kind, it still freaks you out. Stimulus control Our behavior in the absence or presence of a particular stimulus. Ex: If a teacher has good stimulus control of his class, the kids will listen/behave. The teacher's presence is the stimulus which causes the kids to pay attention. Bad stimulus control is when the kids are not paying attention
In Pavlov's famous classical conditioning experiment with the food, the bell, the salivation, and the dog - which variable was the conditioned stimulus?
the bell
Types of Action Plans
vReading therapy notes vMonitoring automatic thoughts * vEvaluating and responding to automatic thoughts * vDoing behavioral experiments * vDisengaging from thoughts vImplementing steps toward their goals vEngaging in activities to lift affect vCredit lists vPracticing behavioral skills vEngaging in bibliotherapy vPreparing for the next therapy session
Increasing Action Plan Adherence
vTailor Action Plans to the individual vProvide or elicit the rationale vSet Action Plans collaboratively; seek the client's input and agreement vMake Action Plan easier rather than harder vProvide explicit instructions and materials vSet up a reminder system vBegin the Action Plan in session vAsk clients to imagine completing an Action Plan
Understand the theory and components of operant conditioning
voluntary behaviors
Structuring the First CBT Session
ÐPart One (Beginning) ×Do a mood check (when relevant check on other treatments) ×Set the agenda ×Ask for an update (since the evaluation) and review the Action Plan ×Discus the client's diagnosis and provide psychoeducation ÐPart Two (Middle) ×Identify aspirations, values and goals ×Do activity scheduling or work on an issue ×Collaboratively set a new Action Plan, and check on likelihood of completion ÐPart Three (End) ×Provide a summary ×Check how likely it is that the client will complete the new Action Plan ×Elicit feedback
Identifying and Responding to Automatic Thoughts (three types)
Ò Inaccurate thoughts that lead to distress and/or maladaptive behavior. ÒAccurate but unhelpful thoughts ÒThoughts that are part of the dysfunctional thought process
Socratic Questioning - bridge to next week
ÒAsk questions that reveal opportunities for change. ÒAsk questions that get results. ÒAsk questions that get patients involved in the learning process. ÒPitch questions at that level that will be productive for the patient ÒAvoid asking leading questions ÒUse multiple-choice questions sparingly ÒWatch video https://www.appi.org/wright É(See videos 5 Identifying AT and 8 Examining the Evidence) Ò
Automatic Thoughts and Core Beliefs
ÒAutomatic thoughts are the actual words or images that go through a client's mind in a given situation that leads to distress or unhelpful behavior. ÒCore beliefs are deeper and often unarticulated ideas or understanding that patients sometimes have about themselves, others, the world and their future
Identifying Emotions
ÒClients often confuse thoughts and emotions ÉFeelings are what you feel emotionally - usually they are one word, such as sadness, anger, anxiety etc. ÉThoughts are ideas that the client has ÉList of negative emotions ÉSad, down, lonely, unhappy Anxious, worried, fearful, scared, tense Angry, mad, irritated, annoyed Ashamed, embarrassed, humiliated Disappointed Jealous, envious Guilty Hurt Suspicious ÉRating degrees of emotion - If 100% is the saddest you have ever felt and 0% is completely not sad, how sad were you when.... ÉUse to guide to treatment - 25% may not be the thing to work on
Termination and relapse prevention
ÒConsider tapering treatment. ÒEncourage self-therapy sessions. ÒElicit the client's automatic thoughts about ending treatment. ÒMaybe share your thoughts about the ending of treatment. ÒEducate the client about how to recognize the signs of a setback or relapse.
Emphasizing the Positive (providing Hope
ÒElicit patients' strengths from the intake ÒElicit positive data from the preceding week ("What positive things happened since I saw you last.") ÒShow that you view the patient as a valuable human being ("I think it is great the you...") ÒPoint out positive data you hear the patient discuss and ask what this data means about them
When Automatic Thoughts are True
ÒFocus on problem solving ÒInvestigate whether the patient has drawn an invalid or dysfunctional conclusion ÒWork on acceptance
Structure of the Evaluation Session
ÒGreet the client ÒCollaboratively decide who should be part of treatment ÒSet agenda and convey expectations ÒConduct the psychosocial assessment ÒSet broad goals ÒProvide tentative diagnosis, broad treatment plan, and educate the client about CBT ÒCollaboratively set an action plan ÒSet expectations for treatment ÒSummarize the session and elicit feedback
Evaluating an Automatic Thought
ÒHaving elicited an automatic thought, determined that it is important and distressing, and identify its accompanying reaction (emotional, physiological and behavioral) you may collaboratively decide with the client to evaluate it. You would rarely directly challenge the automatic thought for three reasons: Ò 1.You usually do not know in advance the degree to which any given automatic thought is distorted (e.g. The thought that no one wants to have dinner with a client could be valid). 2.A direct challenge can lead patients to feel invalidated (e.g. my therapist is telling me that I am wrong) 3.Challenging a cognition violates a fundamental principal of CBT, that of collaborative empiricism: You and the client together examine the automatic thought, test its validity and/or utility and develop a more adaptive response. Note: rarely are automatic thoughts completely erroneous Ò
Guided Discovery and the Socratic Method
ÒHelpful questions ÉWhat is the evidence that your thought is true? What is the evidence on the other side? ÉWhat is an alternative way of viewing this situation? ÉWhat is the worst that could happen, and how could you cope if it did? What's the best that could happen? What's the most realistic outcome of this situation? ÉWhat is the effect of believing your automatic thought, and what could be the effect of changing your thinking? ÉIf your [friend or family member] were in this situation and had the same automatic thought, what advice would you give him or her? ÉWhat should you do? Assessing the outcome of the evaluation process (e.g. change in the belief in the thought or in the degree of the emotion
Session Two and Beyond
ÒInitial Part of Session 2+ ÉDo a mood check ÉSet the agenda ÉObtain an update (positives and negatives) ÉReview Action Plan ÉPrioritize the agenda ÒMiddle Part of Session 2+ ÉWork on agenda item one and teach CBT skills in that context, assess need for further interventions, and discuss Action Plan items ÉWork on second and third agenda items (if time) ÒEnd of Session 2+ ÉProvide or elicit a summary ÉReview Action Plan for the coming week - start in session if possible ÉElicit feedback
Educating the client about Beliefs
ÒIt is important for clients to understand the following: ÒBeliefs, like automatic thoughts, are ideas, not necessarily truths, and can be tested and changed. ÒBeliefs are learned, not innate, and can be revised. There is a range of beliefs that the client could adopt. ÒBeliefs can be quite rigid and "feel" as if they're true—but be mostly or entirely untrue. ÒBeliefs originated through the meaning clients put to their experiences as youth and/or later in life. These meanings may or may not have been accurate at the time. ÒWhen relevant schemas are activated, clients readily recognize data that seem to support their core beliefs, while discounting data to the contrary or failing to process the data as relevant to the belief in the first place.
3 ways to identify maladaptive core belief
ÒLooking for central themes within automatic thoughts. Ò ÒUsing the "downward arrow" technique. Ò ÒWatching for core beliefs expressed as automatic thoughts.
Facilitating Change between Sessions
ÒSetting the client up to have a better week ÉHelp the client evaluate and respond to automatic thoughts that they are likely to experience between sessions. ÉHelp client devise solutions to their problems to implement during the week ÉTeach client new skills to practice during the week ÉAnything you want the client to remember should be and needs to be written down for them
Operant Conditioning - Uses
ÒSettings where you have control over reinforcement such as schools, hospitals, residential and group home treatment facilities, and shelters Ò ÒParent training - teaching parents how to work with their children Ò ÒCommunity reinforcement training for substance use disorders - tokens and rewards Ò ÒBehavior activation therapy for depression Ò ÒPervasive developmental disorders - Applied Behavior Analysis (ABA) Ò ÒHabit Reversal
• Know what Socratic questioning is.
ÒSocratic questioning involves asking the patient questions that stimulate curiosity and inquisitiveness. ÒInstead of just telling the client the didactic information or insight, the therapist tries to get the patient involved in the learning process and see the point on their own. ÒAlways more powerful when the client discovers insights themselves ÒA specialized form of Socratic questioning is guided discovery. ÒAspects of a good question (see next slide) ÒSample questions: What is the evidence for this thought? Against it? Are you basing this thought-on facts, or feelings? Are you seeing the thought as black and white, when in reality it is more complicated? Could you be misinterpreting the evidence? Are you making any assumptions? Ò
Behavioral Experiments
ÒSometimes Socratic questioning is not enough, and you need to put the client's automatic thought to the test. ÒThe behavioral experiments need to be designed collaboratively. ÒCan be done inside or outside of the session ÒExample (If I stay in bed all day, I will feel better.)
Review: Identifying and Responding to Automatic Thoughts
ÒThe selected automatic thought should be currently significantly distressing or unhelpful. ÒAutomatic thoughts should not be directly challenged. ÒUse Socratic questioning or alternative methods. ÒAssess the outcome
Behavioral Experiments - Follow-up
ÒWhat did you make of that experience?" or "What did you learn?" or "What do you conclude?" ÒWhat does this experience mean about you [or about other people or about how other people view you]? ÒWhat does this experience probably mean about the future?
Ð3 parts to the session Framework: Structuring a CBT Session
×Introductory part (doing a mood check, briefly reviewing the week, collaboratively setting an agenda for the session) ×Middle part (reviewing homework, discussing problems on the agenda, [cognitive restructuring, behavior technique, or skills building], setting new homework, summarizing) ×Final part (eliciting feedback) and starting homework
