1 Why Focus on Theory? • Guide your interventions to be maximally effective/efficient for unique clients and situations • Empirical studies (and ESTs) are never sufficient – can never be enough studies – research findings always require interpretation – there are always exceptions (moderators) • Very often therapists need to improvise – if fewer sessions than recommended – if client does not respond to standard procedures – if client does not cooperate (e.g., culture, world- view) – if client has a problem not in DSM, “atypical”, or “NOS” • Allows for technical eclecticism • Orient clients (expectancies and collaboration)
Why Focus on Theory?. Guide your interventions to be maximally effective/efficient for unique clients and situations Empirical studies (and ESTs) are never sufficient can never be enough studies research findings always require interpretation there are always exceptions (moderators) - PowerPoint PPT Presentation
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1
Why Focus on Theory?• Guide your interventions to be maximally
effective/efficient for unique clients and situations• Empirical studies (and ESTs) are never sufficient
– can never be enough studies– research findings always require interpretation– there are always exceptions (moderators)
• Very often therapists need to improvise– if fewer sessions than recommended– if client does not respond to standard procedures– if client does not cooperate (e.g., culture, world-view)– if client has a problem not in DSM, “atypical”, or “NOS”
• Allows for technical eclecticism• Orient clients (expectancies and collaboration)
2
Becoming a Good Therapist
1. Learn principles of behavior and behavior change
2. Learn techniques, observe therapy
3. Practice, practice, practice!
4. Have CBT supervisors view your videotapes and give you feedback
5. Incorporate new research (PSY6023)
3
Specific things to learn
1. How to do a thorough person-specific analysis of proximal causes
2. Understand effective ways to change problematic thinking and emotions
3. Understand treatment failures– failures to generalize to real world– return of problem behaviors/emotions
4
What is Behaviorism?
1. Principles of learning derived from science
2. Does not acknowledge internal “diseases”
3. Leads to superficial change (symptom substitution)
4. A set of technical language that alienates others
5. It is coercive/controlling, limits free will
6. It oversimplifies human complexities
7. Is too deterministic, claiming that responses are only determined by immediate stimuli (S-R)
8. It feels dehumanizing, ignoring most thinking and feeling and the uniqueness of each person
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Behaviorism Myths
3. Little evidence for symptom substitution
5. It is generally not coercive/controlling
5. It does not limit free will
6. Behavioral theory is complex in considering a variety of causes including thinking
7. No longer a stimulus-response theory
8. It does not have to feel dehumanizing, if so it is based on your thinking and/or conditioning
8. It does not ignore thinking and feeling and very much considers uniqueness of each person
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Which Therapy Orientation?
1. Free association2. Free responses to ambiguous
auditory stimuli3. Analysis of patients feelings
toward therapist and how they resemble feelings toward others
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The Functions of CBT
1. Increase abilities for effective behavior to live a valued life
2. Improve motivation and salience of true goals
3. Decrease thoughts/emotions that interfere with effective behaviors or quality of life
4. Increase distress tolerance and acceptance5. Restructure the environment to promote
effective behaviors (antecedents and consequences)
6. Ensure generalization to natural environment
8
What is CBT?
Interventions guided by CBT theories– Functional analysis– Problem solving
1. Skills training
2. Cognitive modification
3. Exposure strategies
4. Mindfulness/meditation
5. Contingency management
6. Homework
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The Therapist’s Influence
• Verbal teaching (didactic/instruction)
• Modeling (intentional and inadvertent)
• Reinforcement and punishment– verbal– nonverbal (intentional and inadvertent)
• careful observation: the counting horse
– natural versus arbitrary
The Therapist’s Influence
• Modeling– Negative judgment of others (validation)– Positive judgment (praise)– Failure model (validation)
• Reinforcement– of judgment (by laughing)– of self-criticism (by reassuring or praise)– of suicidality (by providing more help)
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The Teacher’s Influence
• Verbal teaching (didactic/instruction)
• Modeling (intentional and inadvertent)
• Reinforcement and punishment– Verbal– Nonverbal (intentional and inadvertent)
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• Praise• Being yelled at and criticized• Food• Physical pain• Fear• Gaining weight (obesity)• Time-out from recess (child)• Beep (stacked squares) SEraser
What are Effects of These Consequences?
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Function (causal relations) depends on• the disorder• the person (genetics + learning history)
– biological changes (e.g., hunger)– emotions– mental perspective or thinking– drug intoxication
Function Varies Considerably
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What is CBT?
Interventions based on a commitment to the scientific analysis of:
• causes of psychopathology• change strategies
– efficacy/effectiveness– mechanisms of change
• operational definitions of causes, behaviors, and change processes
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What is CBT?
• CBT is driven by science
• CBT is diverse and evolving
• CBT is active and collaborative– self-monitoring– learning new coping skills and behaviors– practice in and out of sessions
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What is CBT?
What is behavior therapy?
What is radical behaviorism?
What is (applied) behavior analysis?
What is cognitive therapy?
What is cognitive-behavior therapy?
What’s the difference??
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History of CBT:The Pendulum Swings
• Introspection psychology – problematic
• 1st wave of CBT– Watson – extreme behavioral– Skinner – “radical” behavioral, less extreme
• 2nd wave of CBT: Cognitive revolution
• 3rd wave of CBT:– contextual approaches– integrative approaches
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History of CBT:Your Mentorship Lineage
• William James
• Albert Bandura (Stanford)
• Gerald Davison (USC)
• Marsha Linehan
• Milton Brown
• you
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Early Behavioral Theory
Behavior is controlled by its Antecedents and Consequences
To a Behaviorist:
All forms of “behavior” can cause other “behaviors”
“Cognitions are not causes”
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Current stimuli can control current responses
• bell => salivation
• white rat => fear
• “close” => contraction of pupils
• bedroom => alertness + anxiety+worry
• being in any car => sleepiness + sleep
• size of plate => amount of food eaten
• darkness (outside) => TV (no chores)
Stimulus Control
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Stimulus ControlControl responses by controlling antecedents:• remove conditioned stimuli• remove discriminative stimuli• remove opportunities to behave• prevent problematic conditioning
Examples:• remove binge foods (cigarettes) from home• rearrange the space in which eating occurs• rearrange the space in which person sleeps• do not read or watch TV in bed
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Why the Cognitive Revolution?
Evidence against behavioral theories:
• lack of S-R consistencies between people– individuals respond differently to same stimuli
• intermittent reinforcement effects
• observational learning
• cognitions/awareness correlate with learning
• cognitive dissonance effects
• overjustification effects (rewards)
24
ABC’s of Cognitive Therapy
AActivating
Event
BBelief
C Consequence(emotion/behavior)
Thoughts and beliefs determine emotions and behavior.
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ABC’s of Cognitive Therapy
Examples:
• student getting bigger belly
• person hunched over at Home Depot saying “Don’t kill yourself…”
• letter from Board of Psychology
• at Target, I turned around and my daughter was gone
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The Big Debate
The Role of Cognition (B) in Dysfunctional Emotions
and Behaviors (C)
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Cognitive Mediation of Emotions and Behaviors
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John Watson’s Behaviorism
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Insisting always cognitive mediation:
• impedes search for other causes– external antecedents/context– cognitive learning in context– role of mental context vs. cognitive content– consequences for problem and target
behaviors
• clients fabricate plausible thoughts
Disadvantages of Early Models
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Modern CBT Theory
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The Failure of Catharsis
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A Reformulation of Differences
Pure “Behavior” Therapy• John Watson (pure externalism)
Behavioral-Cognitive Therapy• B.F. Skinner (the least cognitive)
• Steven Hayes (contextual Skinnerian)
• Albert Bandura (50-50)
• Arthur Staats (50-50)
Cognitive-Behavioral Therapy (the most cognitive)
• Aaron T. Beck• Albert Ellis (more behavioral than Beck)
Three Ways to Reduce Suffering and Stop Problem Behaviors
1. Change problematic thoughts
2. Reduce negative emotions
3. Change the way you relate to your thoughts and emotions (internal context)
3rd Wave of CBT
• Acceptance and Commitment Therapy
• Dialectical Behavior Therapy
• Mindfulness-based Cognitive Therapy
• Mindfulness-based Stress Reduction
• Mindfulness-based Relapse Prevention
• Mindfulness-based Therapy for GAD
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1. Classical (respondent) conditioning
2. Operant (instrumental) conditioning
…to help us effectively navigate our world– make use of signals effectively prepare us for
important events and opportunities
Two Primary Forms of Learning
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1. Classical (respondent) conditioning
2. Operant (instrumental) conditioning
Both usually co-occur and interact
Both signals and responses:– can occur outside of awareness– can be inside or outside the person
Two Primary Forms of Learning
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UCS = important evocative stimuli, usually not learned (e.g., injury or food)
UCR = “natural” response to a UCS
CS = stimuli (usually neutral) that acquire potential to elicit a new response
CR = the learned response
Respondent Conditioning
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Original Theory: stimulus substitution
1.A previously neutral stimulus functions as the evocative stimulus with which it has been paired
2.The response transfers to the neutral stimulus such that it is no loner neutral
3.The number temporal pairing of CS-UCS determines the CR strength
Respondent Conditioning
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Pavlovian Experimental Apparatus
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Little Albert Experiment
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Respondent Conditioning
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Respondent ConditioningCS UCS UCR CR .
T1 bell => orientingT2 food => salivationT3 bell+food => salivationT4 bell => salivation
T1 rat => orientingT2 noise => startle/fearT3 rat + noise => startle/fearT4 rat => fear/crying
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Generalization Gradient
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• Salivation can be conditioned to almost any neutral stimulus—buzzers, lights, touches
• One dog was conditioned to salivate when it received an electric shock. At first the shock was very weak so as to be barely perceptible. As the shock was increased in strength it was found that a very strong shock produced no sign of pain or displeasure. There was no quickening of the heartbeat or breathing which usually accompanies an unpleasant event. Instead the shock was followed by mouth-watering and tail wagging.
Respondent Conditioning
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Respondent Conditioning
CS UCS UCR CR .
T1 bell => orienting
T2 light => pupils contract
T3 bell+light => pupils contract
T4 bell => contraction
CS can also be the spoken word “contract,” which can cause the pupils to contract
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Learning principles apply to both overtbehaviors and private behaviors
• Internal/private stimuli can become CS– thinking– emotions– heart beat
• reinforcement and punishment can alter:– internal responses
• thinking• emoting
– involuntary or reflexive behaviors• cough• bruxism
Conditioning effects depend on many factors…based on what is useful
Rescorla-Wagner Theory
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Conditioning is not a stupid process by which the organism willy-nilly forms associations between any two stimuli that happen to co-occur. Rather, the organism is better seen as a strategic information seeker striving to predict its world to increase good outcomes and avoid harm. If one thinks of classical conditioning as developing between CS and US under just those circumstances that would lead a scientist to conclude that the CS causes the US, one has a surprisingly successful heuristic for remembering the facts of what it takes to produce associative learning.
Rescorla-Wagner Theory
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Rescorla-Wagner Theory
Stimuli only become signals when
• they give the person time to prepare– CS precedes the UCS (forward conditioning)
• meaningful associations form– US-CS contingency is necessary (depends on)– CS predicts that things will get better or worse– US-CS contiguity is not sufficient
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CS signal a change in the probability or severity of a UCS
–the UCS depends on the CS (to some extent)–the UCS is contingent upon the CS–expectation things will get better or worse
Thus, no CR will develop if:–CS => UCS frequently AND–UCS occurs as frequently in the absence of the CS
US-CS Contiguity is Not Sufficient Contingency is Necessary
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Conditioning occurs when the organism is surprised…
and there are stimuli that can make the surprising situation more predictable (expectancies – “if…then…”)
Rescorla-Wagner Theory
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US-CS Contiguity is Not Sufficient Contingency is Necessary
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Behavior-Consequence Contiguity is Not Sufficient Contingency is Necessary
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US-CS Contiguity is Not Sufficient for Conditioning to Occur
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US-CS Contiguity is Not Sufficient for Conditioning to Occur
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Outdated Theories ofRespondent Conditioning
Stimulus substitution theory is limited:
• CR often differs from UR
• sometimes CR is opposite to UR
• different CS (paired with same US) have different CRs
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Outdated Theories ofRespondent Conditioning
Different CS (associated with same US) have different CRs
CS UCS CR / UCRshock quick burst of activity
sound less activityvisual evade/block
food swallowingsound more activity (general)visual pecking
Milton Brown
CR after conditioning
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UCS CS UCR CR .
heroin euphoria
analgesia
needle dysphoria
garage hypergesia
sad*
* Interoceptive conditioning
Respondent Conditioning
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Respondent Conditioning of an Opponent Process
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Operant Conditioning
Is a stimulus added or removed as a consequence?
Does the behavior increase or decrease?
add remove
increase
decrease
Ex. negative reinforcement – increase in the probability of a behavior occurring in the future when removing an aversive stimulus after the behavior occurs.
positive
reinforcment
negative
reinforcment
positive punishment
negative
punishment
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Two-Factor Theory:UCS are Primary Reinforcers
CS are Conditioned Reinforcers
Antecedents:
• sight of food (CS) elicits salivation
• sight of food (SD) elicits eating behavior
Consequences:
• food in mouth (UCS) elicits salivation (UCR)
• food in mouth (SR) reinforces eating
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Two-Factor Theory:UCS are Primary Punishers
CS are Conditioned Punishers
Antecedents:
• light (CS) elicits fear (HR increase)
• light (SD) elicits fleeing
Consequences:
• shock (UCS) elicits fear (HR increase)
• shock (SP) punishes staying
• escape from shock (SR) reinforces fleeing
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Operant Conditioning in Context:Discriminative Stimuli
Skinner’s three-term contingency: A-B-C
• Discriminative stimuli (A) are the specific stimuli that signal that specific behaviors (B) will be reinforced or punished (C)
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Operant Conditioning
• Negative reinforcement and positive reinforcement are often indistinguishable
• Positive punishment is usually followed by neg. reinforcement of an opposite behavior
• Negative punishment is usually followed by pos. reinforcement of an opposite behavior
• SD and consequences are often CS
Change the Environment
• Stimulus control• Contingency management
• How and where?– in client’s natural environment– in therapy sessions– dragging out new behavior in sessions– contingency contracts (not natural)– therapy vacation/termination
Change the Environment
What responses get reinforced? How?
Internal or external reinforcement?
– depression
– substance abuse
– anxiety disorder
– anger
What consequences should change?
Alternative ways to get reinforcers?
Change the Environment
Contingency management in therapy–adolescent contract
–LA sliding scale contract
–LA getting more exercise and regulating sleep
–make phone calls more available
–end non-productive phone calls
First Contingency Contract
2 pts exercise < 8 am (time stamp receipts)
1 pt exercise > 8 am
1 pt work < 8 am (3 pts max)
points session fee
1 200
4 140
5 80
7 20
0 $0
2nd Contingency Contract
Cardio exercise machine (verified with photo)any level of intensity< 8 am $4 per minute (fee reduction)> 8 am $1 per minute
Target Behaviors• work before 7am (verified with printout)
• babysitting nephews at their house before 7am (verified via caller ID phone call)
• exercise < 8 am (verified by photo emailed by 8:30am)
Daily fees (for 7 mornings prior to session)• $50 if no babysitting and no work before 8 am.• $20 when begin babysitting or work 7 am - 8 am.• $0 when begin babysitting or work before 7 am• fee reduction of $60 per mile (< 8 am) on cardio
exercise machine
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Contingency Management
UAs: 3 days/wk, 2 days/wk, 1 day/wk
Voucher Method• $1 each time abstinent, increase $1.50 each time• reset to $1 if positive, refusal, or missed• 2 weeks of negatives reinstates highest reward• $10/wk bonusLottery Prize Method (variable ratio schedule)• 50% chance of money or “Good job, try again”• usually $1 or $20, and 1/500 chance for $100• each time abstinent one extra draw
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Contingency Management
Cost per patient for six weeks outpatient treatment
$175 - Standard $375 - Voucher Method ($100 paid to patient)$350 - Lottery Prize Method ($80 paid to patient)
• no opportunity for extinction when there is no longer any UCS
Avoidance of punishment = reinforcement
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Two-Factor Fear Theory
The Avoidance Paradox:
• How could an absence of a stimulus reinforce a response?
Solution:
• escape from fear CR is negative reinforcer
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Evidence for Two-Factor Theory
• Escape from CS decreases fear CR
• Increasing fear (CR) increases avoidance– adding conditioned fear stimuli
• Decreasing fear decreases avoidance– adding conditioned inhibitors (safety signals)
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Problems with Two-Factor Theory
• Not all fears begin with classical conditioning
• Fear extinction should occur after CS repeated without UCS*– extinction only to brief CS exposure if escape
• Fear decreases as avoidance (of UCS) becomes stronger/quicker over time– avoidance without noticeable fear– increasing sense of control and predictability
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Two-Factor Fear Theory
The Avoidance Paradox:• How could an absence of a stimulus
reinforce a response?
Solutions:• CS are conditioned/secondary punishers• escape from CS is negative reinforcer• CS is an SD• safety signals are conditioned positive
reinforcers
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One-Factor TheoryAvoidance responses can be learned without
respondent conditioning (CS or CR)• Sidman non-signaled avoidance task
– no obvious CS to avoid– pressing a bar delays a shock for 30 sec– 10% vs. 30% probability of shock every 2 sec
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Pratice midterm examYour examplesReading “quiz”Review FA instructions and examplesSuperNanny videosYour projectsNew videos
Agenda – class #4
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Behavioral Conceptualization of Hypothetical Constructs
Non-behavioral “explanations”
• internalize and externalize
• “need”
• projection
• catharsis (emotional “release”)
• “rejection sensitivity” is the reason why some people are exceptionally distressed by rejection
84
Behavioral Conceptualization of Hypothetical Constructs
Report the times of day the behavior occurs
Give specific examples of thoughts
Focus on consequences that actually explain why the behavior occurs. Do not list hypothetical long-term consequences
85
1. “stressed”
2. “tardiness”
3. “procrastination”
4. biting nails "is not that strong"
5. driving "well above" the speed limit
6. “unexpectedly heavy traffic is cause of arriving late (target should be time at leaving the house)
Review the “Target” sections of previous students’ functional analyses
Behavioral Problem Definition
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Estimate the probabilities of the response (e.g., every time?) when the various "triggers" occur
Conditional probabilities:
P(A|B) vs. P(B|A)
Behavioral Analyses
87
Therapeutic Exposure
Learned emotional responses will be eliminated when……there is repeated/prolonged exposure to all triggers (and variations thereof)…in all contexts…as long as the person does not escape…and nothing bad happens.
Is it feasible?
88
Therapeutic Exposure
(prolonged non-reinforced exposure and response prevention)
Expose
• repeated avoided behaviors
• enter avoided situations
• present avoided stimuli– actual stimuli (in vivo)– imagery (simulation)
89
Emotional Processing Theory
• Activate the emotion schema– e.g., “danger”– therefore, arousal should be high
• Extinction is new learning not “un-learning”– does not erase previous learning– decrease in response depends on context– original conditioning often overrides extinction
Reinstatement – recurrence of UCS reactivates the CR, even if no additional pairing
93
Reacquisition of Fear
CS1 = light
CS1 => shock (10 times, 100 amps)
CS1 => fear (9/10)
CS1 => no shock (100 times)
CS1 => no fear (2/10)
CS1 => shock (1 time , 50 amps)
CS1 => fear (8/10)
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• Habituation is a decrease in CR and UCR due to simple repetition of CS and UCS– person “gets used to” the stimulus– satiation is habituation to positive stimuli
• Extinction only explains reduction in CR– lack of stimuli that could reinforce CR
Respondent Habituationvs. Extinction
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No longer bothered by Sushi after many Sushi meals
Less excitement after many years in a relationship
Child becomes less afraid of water by staying in
Water seems less cold after staying in a while
Repeatedly petting a dog reduces fear
Praise becomes less effective if it is used too much
Criticism becomes less effective if it is used too much
• Brain tricks us into believing overly fearful– protects us by overgeneralizing perceived danger– reminders, memories, and images seen as dangerous– emotion brain areas different than logical areas
• Desensitize or “get used to” triggers– give examples
• Practice tolerating or coping with triggers• Get brain to realize that many situations,
reminders, memories, images are not dangerous– needs convincing information from a new experience– needs enough time for safety info to “sink in” to the gut– we must “talk to” the emotional part of the brain
• We can “act into” new emotions
Exposure Rationale
Resistance to Exposure Therapy
Client Questions:
Why should it help when I already get triggered all the time?
Why should I repeat negative thoughts when I will just end up believing them more and get more upset?
Systematic Desensitization
Relaxation does improves outcomeswhen added to intermittent imaginal exposure
1 > 2
Systematic Desensitization
• Imaginal exposure can reduce fear without any relaxation training
• Relaxation sometimes does reduce fear more than graded imagery alone– when therapist controls progress up the
hierarchy– when there are few treatment sessions– when there is short duration of exposure trials
• Most studies have shown that the timing of relaxation does not influence outcomes
Systematic Desensitization
In animal studies:
• exposure to CS is necessary and sufficient for fear reduction
• graded exposure vs flooding has comparable outcomes
• offering food during exposure can help OR impede fear reduction– helpful if the food helps the animal get more
exposure
Exposure + RelaxationFor fear reduction:
• prolonged exposure is most effective
• adding relaxation does not help
1 = 2 > 3
Exposure + Relaxation
It is possible that relaxation:
• increases collaboration and willingness
• gets more exposure
• makes desensitization occur more quickly
Exposure +Cog.Restructuring
For fear reduction:
• adding cognitive restructuring does not help
1 = 2 > 3
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What is the most effective way to change a negative schema?
How to solve the head vs. gut problem?
Is cognitive processing necessary?– rational disputation or experiential/emotional?
Are passive learning experiences sufficient if the person gets important new info?– Is active coping necessary?– Are new actions necessary?
“On the one hand, explanations of change processes are becoming more cognitive.
On the other hand, it is performance-based treatments that are proving most powerful in effecting psychological changes. Regardless of the method involved, the treatments implemented through actual performance achieve results consistently superior to those in which fears are eliminated to cognitive representations of threat (Bandura, 1977, p. 78)
136
Modern CBT Theory
137
Modern Behavioral Theory
138
New thinking prompts new behaviors that lead to more reinforcers and fewer punishers, which
changes depressive affect
139
New behaviors lead to more reinforcers and fewer punishers, which changes belief, which changes
depressive affect
140
Counter-Conditioning
• Activate the conditioned responses
• Present stimuli that elicit different responses– candy => pleasure
• Engage in behaviors that elicit opposite responses (reciprocal inhibition)– relaxation is incompatible with fear– approach is opposite to fear, shame
141
Counterconditioning
CS UCS UCR CR .
T1 rat => orienting
T2 noise => startle/fear
T3 rat + noise => startle/fear
T4 rat => fear/crying
CS UCS+ UCR CR .
T4 rat + candy => fear reduction
T4 rat => pleasure
142
Reciprocal Inhibition Theory:Fear Reduction
• Activate the conditioned fear responses
• Elicit incompatible responses to fear– relaxation– humor– curiousity– sexual pleasure– HRV– anger?– (choose to) approach (with confidence)
Systematic Desensitization
Relaxation does improves outcomeswhen added to intermittent imaginal exposure
1 > 2
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Reciprocal Inhibition Theory:Anger Reduction
• Activate the conditioned anger responses
• Elicit incompatible responses to anger– empathy– kindness
145
Opposite Action
146
Opposite ActionExamples:
• slow breathing
• nodding (head phone study)
• smiling (facial feedback)
• eat fried grasshoppers
• opposite political speech
• self-esteem
• snake exposure therapy commitment
• obesity study – gains maintained 2 years
147
Cognitive DissonanceCognitive Theory
• When we do act contrary to our beliefs and there are insufficient reasons for doing so we are uncomfortable (for lying, time, effort)
• To reduce the discomfort we change our beliefs so that we convince ourselves that there really was no discrepancyEx: self-attribution (personal explanation):– “I did it because I wanted to” (intrinsic interest)– “I said it because it’s true”
148
Cognitive Dissonance Induction
• Counter-attitudinal role-playing– elicit opposite public behaviors
• speech• nonverbal behavior• attitude: “act as if”
– elicit discomfort and maximize effort– low pressure; high choice– encourage internal attributions
149
Cognitive Dissonance Induction
• Reduce avoidance– increase emotional processing– increase mastery and confidence– solve problems and increase reinforcers
• Facial feedback
• Cognitive dissonance– operant conditioning of consistency
• Classical conditioning– smile (nodding) is CS for liking/agreement
150
Cognitive DissonanceBehavioral Theory
• We reinforce each other for consistency– we want others to be predictable
• We get punished for:– lying or breaking promises– hypocrisy– “flip-flopping” (John Kerry)
• Only if observed by others and if no observable external control or “valid reasons”
151
Albert Bandura
Observational learning (modeling)
• Attention
• Retention
• Reproduction
• Motivation– past consequences– promised consequences– vicarious consequences
152
Albert Bandura
Self-regulation (self-control)
• Self-observation
• Standards of performance
• Self-administered consequences
153
Cognitive-Affective Personality System
• Encoding-interpretation
• Expectancies
• Values and Goals
• Self-regulation
• Competencies and Skills
154
The Functions of CBT
1. Increase abilities for effective behavior to live a valued life
2. Improve motivation and salience of true goals
3. Decrease thoughts/emotions that interfere with effective behaviors or quality of life
4. Increase distress tolerance and acceptance5. Restructure the environment to promote
effective behaviors (antecedents and consequences)
6. Ensure generalization to natural environment
155
Skills
1. Behavioral control– self-talk
– self-management (e.g., stimulus control)
2. Emotion regulation
3. Distress tolerance
4. Interpersonal effectiveness
156
Obstacles to New Learning and Emotion Extinction
• Failure to change the emotion schema– failure to access schema
• new beliefs in the head but not the gut
– safety signals– safety behaviors
• Other problems with generalization– new learning occurred in limited internal or
external contexts
157
Maximizing New Learning and Emotion Extinction
• Change the emotion schema– access schema by eliciting emotion– prevent safety signals– block safety behaviors (avoidance)
• Promote generalization– new learning in all relevant contexts
158
Generalizing New Learning:State-Dependent Learning
1) Goal to increase a new effective behavior or coping response.
People will be more able/likely to engage in new behaviors and coping responses in new contexts are similar to the contexts in which the responses were learned.
159
Intellectual Emotional
Verbal Nonverbal
Explicit Implicit / Tacit
Conscious Unconscious
Semantic Procedural
Propositional Implicational
Processing Modes
160
Generalizing New Learning and Emotion Extinction
Practice in all relevant contexts:
• bring therapy into real life– (cued) homework practice– extinction reminder (safety signal?)– in vivo coaching via telephone
• bring real life into therapy– activate relevant emotions (schemas)– have a genuine relationship– work on real problems that emerge in sessions
There once was a man who hated his own footprints. In order to get away from the footprints, the man ran faster and faster. But the faster he ran, the more footprints he made. And finally, he ran himself to death.
- Zhuangzi, 300 BC
Three Ways to Reduce Suffering and Stop Problem Behaviors
1. Change problematic thoughts
2. Reduce negative emotions
3. Change the way you relate to your thoughts and emotions (internal context)
3rd Wave of CBT
• Acceptance and Commitment Therapy
• Dialectical Behavior Therapy
• Mindfulness-based Cognitive Therapy
• Mindfulness-based Stress Reduction
• Mindfulness-based Relapse Prevention
• Mindfulness-based Therapy for GAD
166
Modern Behavioral Theory
Mindfulness
“Keeping one’s consciousness alive to the present reality” – Hanh
“Bringing one’s complete attention to the present experience on a moment-to-moment basis” – Marlatt
“Paying attention in a particular way…on purpose, in the present moment, and nonjudgmentally” – Kabat-Zinn
Meditation is OnlyOne Form of Mindfulness
Forms of mindfulness practice:
• Internal vs. external focus
• Focused vs. open awareness
• Isolated/sitting vs. integrated into life
Mindfulness is NOT
• Buddhism
• Meditation
• Relaxation
• Thinking about what you notice
• Stopping thoughts
Acceptance
“Experiencing events fully and without defense” – Hayes
Acceptance
Non-acceptance + Pain = Suffering
Acceptance is NOT approval
“Acceptance is too hard!”– imagine accepting– act as if you accept– fully accept for even a moment
Accept what is not true?
Why Mindfulness?
• Differentiate facts vs. thoughts and judgments– notice judgments and interpretations– describe facts rather than judge or interpret
• Get unstuck from thoughts/memories– pain with less suffering– reduce rumination– effective action despite contrary thoughts,
feelings, or urges (slow down!)
• Exposure to primary emotions• Effective distraction
What is Your Brain Thinking?
The thought ____ just popped into my mind– “I just felt like saying…”– Don’t take it personal!
I just noticed ____ feeling arise within me
Therapists should model this distancing
Mindfulness-Based CT
• Kabat-Zinn MBSR applied to depression
• Works for depression relapse
• Works for depression in which thinking plays a prominent role
• Does not work for reactive depression
Mindfulness-Based CT
Study 1
# epis. MBCT TAU
1-2 54% 31%
>2 37% 66%
Study 2
MBCT TAU
1-2 50% 20%
>2 36% 78%
Acceptance andCommitment Therapy
“Get out of your head and into your life”
Acceptance via Metaphors
• Quicksand
• Chinese finger traps
• The unruly child
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Question
What is the relevance of ironic process theory for understanding and
treating disorders of emotion?
179
Ironic Process Theory
• Operating process– Intentionally create distracting mental content– Is difficult because negative content is much
more accessible than positive– very effortful, requires a lot of cognitive
resources
• Monitoring process– automatic search for failure
180
Harmful Effects of Rewards
When the reward is
• tangible / arbitrary / excessive
• promised in advance or expected
• contingent upon task involvement or effort
When the behavior is
• already occurring at a high rate
Handout 14
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Effective Reinforcement
• Contingent on completion of a behavior• Provides specific useful feedback• Not coercive, judgmental, or tied to punishment• Minimal reinforcement• Intermittent reinforcement• Natural reinforcement
– pay attention to what the client does– be responsive (reinforce behavior that is useful)– use your natural reactions (SISD)– generalizable (available in many contexts)
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Natural Reinforcement
• Putting on a jacket keeps you warm
• Using a toilet keeps you clean and dry
• Complying with a request (not praise)
• Excitement (not praise)
• Dismay or demoralization
• Flow of a conversation/relationship
• Bored listener when a client rambles
• SISD – positive or negative
183
Natural Reinforcement
Amber
• Reading games
• Reading lyrics
• Reading gets compliance from us
Opponent process – shivered awake right after dreaming about hot shower
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Behavior & Self-Interpretation
We make conclusions about ourselves based on our behaviors and relevant explanations for our behaviors given the environmental context
Behavior-schema discrepancy is uncomfortable (dissonant) without external explanations
We seek to reduce dissonance either by finding reasonable external explanations or by changing our view of ourselves.
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The Cognitive Revolution
• Aaron T. Beck
• Albert Ellis
• Julian Rotter– locus of control
• Albert Bandura– Social Learning Theory– Social-Cognitive Theory
6 sessions of• in vivo exposure to alcohol• imaginal exposure to trigger events• coping skills (e.g., urge surfing, self-talk)Four conditions• CET + coping skills• CET + psychoeducation• Relaxation + coping skills• Relaxation + psychoeducation
234
Extinction of Alcohol Urges
235
Extinction of Alcohol Urges
236
Cue Exposure Therapy
237
Cognitive Restructuring
3 question technique
• What is the evidence for that thought?
• What are alternative interpretations?
• What’s really the worst thing that could happen? How could you deal with it?
Definite short-term effects on emotion.
Little evidence of direct long-term effects.
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Short-Term Effects of Thinking
• Repeating the primes elicits moderately depressed mood among normal participants.
• Unscrambling contextual questions led to less depressed affect (and less corrugator EMG)
Prime: “I feel very sad”• Have all my past feelings changed with time?Prime: “Many things I do turn out wrong”• Don’t I have both good and bad times?• What will I think about this 20 yrs from now?
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Cognitive Restructuring
How can it work even better for long-term change?
• What is the evidence for that thought?
• What are alternative interpretations?
• What’s really the worst thing that could happen? How could you deal with it?