501 - Cog and Behavioral Change Flashcards
acceptance and commitment therapy (ACT)
WHAT: 3rd generation behavioral therapy
Believes psychopathology comes from experiential avoidance, over-control, or unwillingness to remain in direct contact with painful experiences.
Goal = accept painful thoughts and feelings, create psychological flexibility thru mindfulness + behavioral therapy skills, align behaviors with beliefs/values to reduce dissonance
Therapeutic Components:
- be here and now (be present)
- defusion (detaching from thoughts) - acceptance (acceptance neg thots + emotions)
- self-as-context (you are the observer of your cognitions)
- values (goals + activities/beliefs that matter to you)
- committed action (doing what you need to move forward + live by your values)
EXAMPLE: A client comes to therapy with symptoms of depression. The client describes often feeling ashamed of not spending time with her friends. She often beats herself up over feeling sad and lacking motivation. The ACT therapist will guide the client in accepting their emotions as valid and experiencing them without judgment through defusion exercises. The client and therapist work to reveal that the client values her friendships, and may collaborate on behavioral goals that align with that value, such as calling a friend, even if the client doesn’t feel like it. By making a commitment to live by her values, the client may eventually create a more fulfilling life and decrease her depressive symptoms.
ambivalence
WHO:
WHEN/WHERE: Derived from the Cognitive Dissonance Theory. Also a part of motivational interviewing.
WHAT: Ambivalence occurs when a person has conflicting/contradictory feelings, thoughts, or attitudes toward a situation. It often arises when clients are contemplating change/dealing with the pros or cons of changing versus not changing.
The therapist should direct the clients through each option, and pick the one that best aligns with their values and goals.
WHY: Ambivalence helps to facilitate change. It creates cognitive dissonance, which is an uncomfortable state only resolved by making a decision. It allows clients to gain insight into their motivations, values, and internal conflicts.
EXAMPLE: A client, Steve, has come into therapy at the request of his wife. She has become concerned about Steve’s drinking habits, to the point of moving out of the house. His wife refuses to go back until he stops drinking. Steve doesn’t see any issue with his drinking habits, but he cares about his marriage and doesn’t want to lose his wife. He is in a state of ambivalence now, as his beliefs and values are not aligning.
anxiety/fear hierarchy
WHEN: used in exposure therapies
WHO: Useful in treating patients with phobias or panic disorder
WHAT: A list of anxiety inducing stimuli ranked using subjective units of distress (SUDs). The list should be ordered from the lowest anxiety provoking stimulus (lowest SUDs score) to the most anxiety provoking stimulus (highest SUDs score). The client is exposed to the lowest item on their list until the fear response is extinguished.
WHY: The fear hierarchy is useful in exposure therapies to create a visual plan for the client, to track/display progress, and allows patients to gradually move towards their goal.
EXAMPLE: A woman comes to therapy with a phobia of clowns. The client and therapist work to create a fear hierarchy starting with imagining a clown, with being in the same room as a clown having the highest SUDs rating. The client begins with imagining a clown until she no longer feels anxiety, and then moves up to the next item in her hierarchy.
assets
WHEN: Assets of a client are considered during a behavioral analysis.
WHERE: Can be used to help clients overcome behavioral problems.
WHAT: What the client does well. Positive aspects of or behaviors a client has/does. Used to help overcome behavioral problems. They can be internal (positive values, social competence) or external (social support, stable job).
WHY: Assets can help clients overcome challenges and achieve (behavioral) goals. They highlight positive aspects of a client, which may increase self-confidence/esteem and self-efficacy. In turn, highlighting assets may make the treatment plan more successful.
EXAMPLE: A client is struggling with depression. Their mood and energy have been low, and they say making dinner for themselves has become difficult. During the assessment, the client reveals they have a love of cooking and trying new recipes. Their love of cooking can be used/incorporated into their behavior plan to increase the meals they make for themselves.
automatic thought
WHO: Part of Aaron Beck’s cognitive therapy.
WHEN: The client and therapist monitor and categorize dysfunctional automatic thoughts. Patient taught to see automatic thoughts as hypothesis to be tested.
WHAT: Spontaneous thoughts that seem plausible. Often occurs in response to a trigger (event, situation). May include cognitive distortions (dichotomous thinking, emotional reasoning).
WHY: Automatic thoughts can be maladaptive and persistant and need to be challenged. These distortions contribute to the maintenance of one’s anxiety/depression.
ATs are considered within the downward arrow technique to help uncover assumptions and schemas the client may have, and later help to get to the client’s core beliefs.
EXAMPLE: A client believes her coworkers at her new job don’t like her because they laugh each time she walks by, and she believes they must be making fun of her. The therapist points out that the client is personalizing and jumping to conclusions. The therapist may utilize this automatic thought within the downward arrow technique. Additionnally, the therapist and client may generate a way to test the hypothesis of ‘my coworkers do not like me’.
behavioral activation therapy
WHO: Based on Lewhinson’s theory of depression
WHERE: Discussed during cognitive and behavioral therapy regarding behavioral change.
WHAT: Says that psychopathology is from ineffective problem-solving skills/ineffective social behavior. This often results in negative consequences. Activities may include things enjoyed before depression, things related to values, or even everyday items that get pushed aside. BAT occurs through self-monitoring moods and activities the client did/does/would enjoy, scheduling the activities, and mastery + pleasure rating after engaging in the activity.
WHY: BAT is significant as it provides a way for clients to gradually improve their quality of life, and gradually decrease avoidance and isolation behaviors. Social support is important in general, but especially for those who struggle with mental health.
EXAMPLE: A client, Sarah, comes into therapy because she is struggling with depression. Sarah reports fatigue, a low mood, low motivation, and decreased interest in things she once enjoyed. Sarah has a full-time job. She says she dreads coming from work because she feels too tired to do anything but sit on the couch until bedtime and feels guilty for the inactivity. Sarah tells the therapist she used to love painting, and would do it almost daily. The therapist may suggest that Sarah begins drawing in a sketchbook each day after work. Sarah implemented this for a few weeks and reported that she has begun looking forward to coming home after work since she knows she has an enjoyable activity to look forward to.
behavioral parent training/therapy
behavioral therapy
WHO: Based on Pavlov’s theory of classical conditioning and was developed in response to psychoanalysis.
WHERE: BT is used in the treatment of disorders such as substance abuse, eating disorders, insomnia, or anxiety.
WHAT: A form of psychotherapy that employs learning and conditioning principles to modify (increase or decrease) certain behaviors or behavioral patterns.
BT is collaborative, brief, active, present-focused, and learning-focused. BT produces individualized treatment plans with a stepwise progression. It targets observable behaviors, their antecedents/triggers, and the consequences that follow. The underlying causes of the behaviors are not explored.
Variations of BT include schedules of reinforcement, behavioral activation therapy, and systematic desensitization.
The steps of BT are clarifying the problem, formulating initial goals for therapy, identifying the target behavior, designing a treatment plan, evaluating the success of the plan, and identifying the next target behavior.
WHY: BT is a short-term treatment option, so clients often see change more quickly compared to other forms of therapy. It is often low-cost, allowing it to be accessible to more populations. It is effective in helping clients develop concrete goals, learn skills, and identify helpful coping strategies. It may also bring awareness to and provide insight into clients’ behavioral patterns.
EXAMPLE: A client in therapy, Gina, expresses that she has a habit of biting her nails and wants to stop this behavior. She identified the triggers of having an urge to bite her nails as hunger, boredom, anxiety, and feeling roughness on the nail or cuticle. Gina and the therapist formulated a plan that included strategies for recognizing triggers and instead engaging in a behavior that is incompatible with nail biting. These may include chewing gum, using a stress/fidget toy, or keeping her hands in her pockets. Additionally, Gina and her therapist may establish rewards if Gina reaches certain milestones (no nail biting for x hours, etc.). This plan provides behaviors to replace the target behavior, as well as provides incentives to not engage in the target behavior.
chaining
WHO:
WHERE: Used to teach behaviors that are not in the repertoire of the learner. Typically used with clients who have ASD or intellectual disabilities.
WHAT: Procedures used in behavioral therapy to teach a behavior that is complex/has multiple steps that must be done in a specific order/sequence. One behavior is taught at a time, and then later chained together. Each response serves as a cue for the next one and the last response of the chain is reinforced.
There are two types of chaining: forward and backward. In both types, the therapist first conducts a task analysis that breaks down the chain into stimulus-response components. In forward chaining each step is taught within the complex behavior. The learner is reinforced after each step. The learner does not learn the next step until the previous one has been mastered.
In backward chaining, the entire sequence is taught at once with assistance/coaching for each step. Assistance/coaching is removed from the last step in each new trial. The last step performed independently is reinforced.
WHY: Chaining is important as it teaches clients to become proficient in new, complex/multistep behaviors. Each behavior in the task analysis offers clear instruction to the learner of what is expected of them. It allows the therapist to monitor progress of each step, and adjust the procedure or provide assistance where needed. As clients complete each step and learn new behaviors, it aids in confidence and self-efficacy. This serves as reinforcement to try learning additional skills and to use their newly learned skills in other contexts.
EXAMPLE: A child with ASD is being taught to wash their hands independently using backward chaining. The therapist creates a task analysis for hand washing: turn the water on, put soap on hands, rub hands together, rinse hands, turn the water off, and dry hands. First, the therapist assists the child in completing all the steps by guiding their hands and verbally coaching them through the procedure. Then, the therapist will guide and coach them through all the steps except for the last one (hand drying). If the learner successfully dries their hands independently, they are reinforced. During the next trial, assistance will be removed from turning the water off as well. This is repeated until the learner masters all steps of the procedure.
classical/respondent conditioning
WHO: Developed by Pavlov
WHAT: A form of associative learning in which a neutral stimulus (NS) is paired with a stimulus that naturally and involuntarily elicits a response from the subject, known as the unconditioned stimulus (UCS) and the unconditioned response (UCR). The NS is presented first, then the USC is presented. This is repeated until the NS elicits a response without the UCS being presented, making the NS a conditioned stimulus (CS). The response elicited from the CS is known as the conditioned response (CR).
WHERE: Often used to treat phobias or panic disorders.
WHY: Classical conditioning is significant as it demonstrates the way learning (learned responses) can impact one’s emotions, cognitions, and behaviors. The principles of classical conditioning help to explain and predict the behaviors. Classical conditioning is effective in modifying automatic and involuntary, but learned, behaviors, such as fear and anxiety.
EXAMPLE: Jane comes to therapy following a mugging. It occurred when she was in a parking garage alone and the experience was traumatizing for her. As a result, she can not enter a parking garage without feeling intense fear and anxiety. This is an issue as Jane uses this parking garage each day for work. She has been having to leave earlier in the morning to allow time for her to find alternative parking. The therapist explains in this case, the mugging is a UCS with a UCR of fear and anxiety. It is a natural response that was not learned. The parking garage is now a CS and the fear Jane feels when entering a parking garage is now a CR. Before the mugging, Jane had no issue parking her car before work. However, because of the pairing of the CS (parking garage) with the mugging (UCS), the parking garage now elicits a CR (fear and anxiety). The CR would otherwise not occur without this learned association.
cognitive fusion
WHO:
WHERE: Is associated with/a component of ACT
WHAT: Cognitive fusion is when someone is so ‘fused’ with their thoughts, they tend to take them literally/see them as truth. Cognitive fusion can contribute to psychopathology and symptoms.
When a person is experiencing cognitive fusion, they may pay too much attention to the contents of their mind (thoughts, assumptions, beliefs, etc.) and make decisions/take actions based on their internal experience, rather than what’s actually happening in their environment.
WHY:
EXAMPLE: A therapy client, Dan, is telling his therapist that he’s anxious about his approaching college finals.
He said he hasn’t bothered studying much since he believes he’s not good at memorizing notes and bad at school in general. The therapist may intervene and remind Dann that just because he believes these things about himself, does not mean they’re true. The therapist may offer alternative beliefs, such as trying a different method of studying to aid in retention.
cognitive restructuring
WHO: Part of Beck’s cognitive therapy
WHERE: Used in the treatment is several disorders, such as depression and anxiety
WHAT: Cognitive restructuring involves teaching the skill of and collaborating with clients to identify and modify maladaptive/distorted cognitions, and replace/substitute them with more healthy ones.
CR is based on the rationale that some clients’ symptoms/problems are maintained by an excess of maladaptive thoughts.
Crucial questions asked during CR: What is the evidence for/against this belief? What are alternative interpretations of this event? What would it mean if this belief is true?
WHY: Cognitive restructuring can help clients change the way they think. Cognitions influence one’s behavior and emotions. By replacing a stress-causing cognition with a more healthy one, the person’s emotions and behaviors are likely to change in a positive way as well. Teaching CR aids in one’s ability to emotionally regulate. Being able to recognize and invalidate harmful thoughts fosters self-efficacy and confidence, as it puts the client in the position to influence events and outcomes in their life.
EXAMPLE: A therapy client, Jane, is in session and telling the therapist about her new job. She says she has been unsuccessful in making friends with her coworkers because they don’t like her and think she is incapable. The therapist identifies these are faulty cognitions and works with Jane to restructure them. The therapist may ask Jane what evidence she has that the coworkers don’t like her. Then, ask if there are any other explanations for why they may have laughed as you were walking past. Jane and the therapist will collaborate in finding different and more healthy beliefs to replace the faulty ones with.
cognitive therapy
WHO: A form of psychotherapy created by Aaron Beck. In cognitive therapy, cognitions are believed to be the origin of psychopathology.
WHAT: CT assumes that cognitions can be observed, monitored, counted, altered, and that they may impact (physical) behavior.
In CT, the therapist brings awareness to the client’s faulty assumptions/maladaptive beliefs. The therapist and client work to correct faulty assumptions/maladaptive beliefs by finding evidence that contradicts them. There are three levels of cognitive distortions, which are triggered by events: automatic thoughts assumptions, and schemas/core beliefs. Automatic thoughts are spontaneous and appear to be plausible. ATs include overgeneralization, catastrophizing, and emotional reasoning. Assumptions are abstract ideas that have generalized rules, such as ‘if… then…” statements. Schemas/core beliefs, the deepest and most ingrained level of cognition, are cognitive structures that organize and process information.
WHERE/WHEN: CT is most commonly used to treat anxiety and depression.
EXAMPLE: For example, a client comes to therapy with anxiety about starting a new job. The client claims her coworkers don’t like her because they laugh each time she passes by their desks, meaning they must be making fun of her. The therapist will identify this belief as faulty/distorted, and work with the client to find evidence to disprove it. Additionally, the therapist may use the downward arrow technique to learn about and eventually change the client’s schemas/core beliefs.
cue exposure therapy
WHO: A form of exposure therapy with response prevention. Based off of Pavolv’s classical conditioning.
WHERE: Used in the treatment of phobias, substance abuse, OCD, or eating disorders.
WHAT: In CET, a client is exposed to a cue/trigger that is associated with their addictive/problematic behaviors, but is prevented from engaging in the behavior.
In terms of classical conditioning, the client is exposed to once neutral cues but now serves as a cue/trigger (a conditioned stimulus) to engage in the target behavior. Coping strategies, such as relaxation training, may be taught to substitute for the clients’ addicitive/problematic behaviors.
The goal of CET is to decrease responsiveness to the cues through the principles of extinction.
WHY: CET offers progress to be easily tracked by both therapist and client, and they can witness responsiveness decrease to cues. Witnessing a reduction in responsiveness may also increase confidence and self-efficacy. The skills learned in CET allow for long-term maintenance, as clients are able to generalize skills in different contexts to a variety of cues, even after treatment ends– promoting independence and autonomy.
EXAMPLE: Jane is in therapy for her OCD. She struggles with compulsive behaviors, such as feeling as if she needs to flick a light switch on and off six times before leaving a room. If she doesn’t do this, she feels strong compulsions to go back to the room and ‘fix’ it, or else she feels dread and anxiety. Her therapist suggests cue exposure. The therapist asks Jane to turn off the light in the therapy room, and then the two of them step outside. The therapist prevents Jane from reentering the room to turn the light switch on and off.
decision-balance matrix
WHO:
WHERE: Used in motivational interviewing
WHAT: A DBM is a technique used to help reduce ambivalence in clients, especially when they are engaging in behavior that is harmful to their health. In a DBM, the therapist gathers information on the pros and cons of continuing and discontinuing a behavior. The goal of DBM is to facilitate cognitive dissonance (discomfort due to holding two conflicting beliefs, values, or attitudes). The discomfort serves as motivation for the client to resolve their ambivalence by making a decision.
It also serves as an informal measurement of a client’s readiness to change.
WHY: The DBM provides clarity and organization for a client so they can make a rational and informed decision. It fosters a sense of accountability and responsibility for the outcomes of the decision– in turn promoting autonomy and self-empowerment.
EXAMPLE: A client, Steve, has come into therapy at the request of his daughter. She has become concerned about Steve’s drinking habits, even though he says he doesn’t see any issue with it. The therapist inquires about the potential benefits and drawbacks if Steve were to continue drinking the way he does, as well as the benefits and drawbacks of Steve discontinuing his drinking. After the matrix is completed, Steve and the therapist evaluate all aspects and discuss Steve’s ambivalence and whether his readiness to change level has altered.
dialectical behavior therapy (DBT)
WHO:
WHERE: Used to treat depression, borderline personality disorder, suicidality, and self-harm
WHAT: DBT is a 3rd generation CBT. During session, there should be an accepting atmosphere that allows change in the client to occur. Empathic understanding and validation from the therapist is strongly emphasized– as it leaves the client more open and responsive to the therapist’s suggestions for change.
DBT problem-solves and creates change by employing techniques/procedures such as skills training, exposure therapies, contingency management, and cognitive restructuring.
There is a sense of trust and security between the therapist and the client, all while encouraging self-acceptance and growth without judgment.
Focuses on providing skills in 4 key areas:
- mindfulness skills (observing and being present for internal experiences, keeping a non-judgemental stance)
- interpersonal effectiveness skills (problem-solving, assertiveness vs aggressiveness)
- emotional regulation skills (observing and describing emotions–similar to mindfulness)
- distress tolerance (how to healthily cope with distress without self-destruction)
DBT often consists of both individual and group treatment sessions.
WHY: DBT emphasizes skill building as a core strategy of treatment. The generalization of skills learned in treatment, such as communication skills and coping with distress, allows for long-term maintenance. DBT also fosters a validating and supporting environment that promotes resilience and empowerment to clients to overcome adversity.
EXAMPLE: Maggie is a client in therapy who struggles with emotional regulation and maintaining her relationships. Maggie tells her therapist she doesn’t trust her boyfriend and has lashed out at him in the past because she believes he has been lying and cheating on her. Instead of the therapist asking what evidence Maggie has for that assumption, the therapist employs validation/acceptance strategies and may say something along the lines of “Your emotions and worries can be very upsetting, so it makes sense why you may have such a strong reaction to them. Maybe you could try communicating these worries to your boyfriend in a different way.”
The therapist is creating a space where Maggie feels safe to share things because she trusts her therapist not to pass judgment. This trust may extend into willingness, such as when the therapist suggests Maggie change her communication style.
differential reinforcement
WHO: Based on operant conditioning
WHERE: Used within behavioral therapy, or ABA therapy
WHAT: Differential reinforcement is a behavioral modification technique in which desired behaviors are selectively reinforced, while reinforcement is withheld following undesired behaviors.
Types of differential reinforcement schedules:
- differential reinforcement of other behaviors to decrease problem behavior (reinforcement is contingent upon the absence of the problem behavior in a set period of time, problem behavior is ignored)
- differential reinforcement of alternative behaviors to increase desired behavior and decrease problem behavior (reinforcing a behavior that is incompatible with the problem behavior, problem behavior is ignored)
- differential reinforcement of low rates of responding to reduce the occurrence of problem behavior (subject is reinforced if target behavior occurs less than a predetermined rate or frequency)
No positive punishment is used. Instead, reinforcers are withheld.
WHY: Differential reinforcement allows therapists to focus on a specific behavior to modify or shape it towards set goals. DR does not use positive punishment, meaning it can modify/discontinue certain behaviors without the negative consequences punishment brings. Additionally, differential reinforcement provides alternative behaviors (if not the desired behavior) for the subject to engage in. This allows for faster learning and less confusion, as compared to only using punishment when an undesired behavior occurs.
EXAMPLE: James is a first-grader with ASD
who has been disrupting the classroom by loudly tapping his pencil on the desk. After conducting a functional analysis, his therapist determined that this behavior was maintained by social reinforcement (his teacher and classmates paying attention to him). To decrease this behavior, the therapist decides to implement a DRO schedule in which James will receive praise for every 1 hour he does not disrupt the class with his pencil tapping.
