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Chapter: Essentials of Psychiatry: Cognitive and Behavioral Therapies

Behavioral Techniques

In CBT, behavioral methods are usually integrated with cogni-tive restructuring in a comprehensive treatment plan.

Behavioral Techniques


In CBT, behavioral methods are usually integrated with cogni-tive restructuring in a comprehensive treatment plan. Behavioral strategies may be given a greater emphasis earlier in therapy with more severely symptomatic patients such as those with intense depression, bipolar symptoms, or schizophrenia (Beck et al., 1979; Thase and Wright, 1991; Kingdon and Turkingdon, 1995; Basco and Rush, 1996; Scott and Wright, 1997). Some cogni-tive–behavior therapists may rely primarily on behavioral inter-ventions for conditions such as obsessive–compulsive disorder (OCD) or simple phobias. Commonly used behavioral strategies are described here in alphabetical order.


Activity Scheduling, Graded Tasks and Mastery–Pleasure Exercises


One key to the behavioral approach for treatment of depression is the interruption of the downward spiral linking mood, inactiv-ity and negative cognition (Beck et al., 1979; Lewinsohn et al., 1982) (Figure 69.6). Completing an activity schedule is often the first behavioral homework assignment used in CBT (Beck and Greenberg, 1974). Depressed patients are asked to begin to keep a daily log that is used to chart the relationship between their moods and their activities (Figure 69.7).


The nature of the activities is examined, and deficits in activities that might elicit pleasure or feelings of competence are identified. Next, assignments are made to engage in discrete pleasurable activities (or, in the case of an anhedonic individ-ual, activities that were rewarding before becoming depressed). If needed, a “menu” of reinforcers can be generated by having the patient fill out a Pleasant Events Schedule (Lewinsohn et al., 1982). Following operant principles, activities that have been “high-grade” reinforcers in the past are scheduled during times of low moods or decreased activity. Next, subjective ratings of



mastery or competence and pleasure are added to the activity schedule by use of a simple scale (i.e., 0–5), to avoid the tendency of dichotomous thinking. In this way, achieving a small degree of pleasure or mastery during a scheduled activity may be framed as an accomplishment, particularly early in the course of therapy.


Breathing Control


An important component of CBT for anxiety disorders involves teaching the patient breathing exercises that may be used to counteract hyperventilation and/or reduce tension (Clark et al., 1985). Slow, deep breathing can have a calming effect not unlike progressive muscle relaxation (Bernstein and Borkovec, 1973). These exercises also help to distract the patient from autonomic cues. After initial instruction and practice, the breathing skills are then applied in progressively more anxiety-provoking situations.


A note of caution is in order when teaching patients breath-ing control exercises. We have seen many patients who have misunderstood instructions and who have developed a pattern of deep overbreathing in response to stress. Instead of helping reduce anxiety, their breathing changes may increase the chances of hyperventilation. Thus, we typically recommend that patients be taught about the pace and form of normal breathing patterns. Next clinicians can model normal, calm breathing as compared with overbreathing during an anxiety attack. The second hand of a watch can be used to time breaths so that they can be slowed to a normal rate. Positive, calming images can also be used to reduce anxiety during the breathing exercises. Finally, we suggest that patients practice breathing exercises regularly to gain mastery of this anxiety management technique.


Contingency Contracting and Behavior Exchange


These strategies use the principles of operant conditioning (Skinner, 1938) to modify the probability of occurrence of either undesired or desired behaviors. An excellent introduction to these methods is presented by Malott and colleagues (1993). One key to applied behavioral analysis is control over the contingencies or reinforcers. Another important factor is that the terms of the contract are negotiated and should be specific and relatively straightforward. The positive contingency or reinforcer should be desirable and available shortly after the terms of the contract have been met. A paycheck is a good example of a contingency contract. Another common strategy is to chain, or pair, a high-frequency behavior (e.g., reading, watching television, or listening to music) to a low-frequency one (e.g., doing paperwork, doing housework, spending time with the children). Contingencies should generally start out relatively “rich” (e.g., 1 hour of video game time after 15 minutes of paperwork) and may be progressively “thinned” in time (Malott et al., 1993). Punishments or “response cost” contingencies are less widely used because of their negative affective responses (Azrin and Holz, 1966).


Behavioral contracts may be particularly useful for assisting patients with medication adherence. For example, thetherapist may help the patient identify barriers to taking medica-tion as prescribed and then work out behavioral solutions which are written in contract form. Behavioral methods may include pairing medication taking with routine activities such as brush-ing teeth or meals, reminder systems and reinforcement from sig-nificant others. We recommend explicit discussion of adherence problems and mutual agreement on a plan for taking medications when patients have difficulty in following the pharmacotherapy plan.


Desensitization and Relaxation Training


Systematic desensitization (Wolpe, 1958) was one of the first behavioral strategies to gain wide acceptance. Systematic desensitization relies on exposure through a progressive hierarchy of fear-inducing situations. This procedure may use pairing of progressive deep muscle relaxation and visualization of the target behavior to decondition fearful responses. Systematic desensitization is useful for treatment of simple phobias, social phobia, panic attacks and generalized anxiety (Wolpe, 1982). Some evidence suggests that the active ingredient of systematic desensitization is exposure to the feared situation, first in imagination and later in reality, rather than an actual counterconditioning through the relaxation response (Kazdin and Wilcoxin, 1976). Progressive deep muscle relaxation is also useful as a self-directed coping strategy and for treatment of sleep-onset insomnia (Goldfried and Davison, 1994; Bernstein and Borkovec, 1973).


Exposure and Flooding


The purpose of these strategies is to speed extinction of conditioned fear or anxiety responses. Behavioral theory dictates that fearfulness is reinforced by avoidance and escape behaviors (Rachman et al., 1986). Because the basis of the fear or phobia is irrational, the optimal strategy is to increase exposure to the feared activity without aversive consequences. In obsessive–compulsive disorder, the ritualistic behavior (e.g., handwashing or checking) is presumed to be reinforced by the relief of the anxiety associated with the compulsion (e.g., handwashing temporarily relieves the fear of contamination) (Rachman et al., 1986). In exposure, there are at least three means of fear reduction: autonomic habituation, recognition that the fear is irrational and explicit enhancement of morale or self-efficacy that accompanies mastering the previously dreaded activity.


In graded or progressive exposure, a hierarchy is estab-lished, ranging from least to most anxiety-provoking situations. The individual is taught one or more ways to cope with anxiety (e.g., relaxation or self-instruction), and with the help of the ther-apist, the items on the hierarchy are worked through, one item at a time. Mastery is predicated on maintaining a sufficient duration of exposure for the fear to extinguish or dissipate. In some cases, imagery (exposure in vitro) is used before moving to exposure to the actual feared stimulus. Exposure may also be enhanced by guided support (i.e., the therapist’s presence during the session) or by use of coping cognitions for the duration of the exposure exercise.


Flooding, which relies on the same principles, dispatches with the hierarchical approach. The individual is exposed to the maximal level of anxiety as quickly as possible. The rationale for this accelerated approach is that it may hasten autonomic habituation. To be effective, flooding needs to be accompanied by response prevention. In response prevention treatment of OCD, the individual agrees not to perform the compulsion de-spite strong urges to do so. Because obsessions are more private than compulsions, there can be less certainty that the individual has fully participated in response prevention exercises (Stern, 1978).


Simple phobias may be rapidly treated by an accelerated form of exposure referred to as participant modeling or contact desensitization. The therapist serves as a supportive coach or guide and assists the patient through a progressively more de-manding level of exposure to the feared situation. In most cases, lifelong fears of air travel, tunnels, heights, matches, dogs, water, or insects can be fully treated in a few hours of guided exposure.


Social Skills Training


Satisfactory interpersonal relationships require a complex set of skills, including reciprocity, respect for another’s opinion, appro-priate modulation of self-disclosure, the tempered ability to yield on some occasions and to set limits at other times, the natural use of social reinforcers, and the capacity to express anger and re-solve conflicts in a constructive manner (Lewinsohn et al., 1982; Hersen et al., 1984). Many people with psychiatric disorders suf-fer from either a state-dependent deterioration of these social skills or lifelong deficits of such skills. Once established, social skills deficits can increase the likelihood of experiencing stress-ful life events as well as “turn off ” family members and other sources of social support that may help to buffer people against stressors (Coyne et al., 1987).


Problems as diverse as underassertiveness, temper “atta-cks”, excessive self-disclosure, monopolistic conversational style, underreinforcement of significant others and splitting (i.e., playing one against another) are amenable to social skills train-ing. The methods employed include modeling (i.e., the therapist demonstrates a more effective alternative approach), role-playing and role reversal, behavior rehearsal and specific practice as-signments. Often, the interpersonal anxiety and lack of self-confidence that go hand in hand with social skills deficits lessen in response to successful mastery of targeted assignments.


Thought Stopping and Distraction


Automatic negative thoughts and repetitive, intrusive rumina-tions are sometimes too intense to address with purely cogni-tive interventions. The technique of thought stopping capitalizes on the individual’s ability to use a selectively narrowed atten-tional focus to suppress the intrusive cognitions. For example, a ruminative individual may be asked to visualize a large red “stop” sign, including its octagonal shape and white lettering. The command “Stop!” is paired with the image. The image and command are then used to interrupt a “run” of ruminations. At first, the technique is practiced in sessions at times when auto-matic thoughts or ruminations are mild. After initial success, the technique is next applied to more intensely disturbing cognitions. For individuals who find visualization difficult or ineffective, a rubber band may be worn on the wrist as a distractor. In a manner similar to that described before, the command “Stop!” is paired with a brisk snap of the rubber band.


Indications for Treatment


The cognitive and behavioral therapies are indicated as pri-mary treatments for adults suffering from several nonpsychotic, nonorganic disorders including major depressive disorder, dysthymic disorder, panic disorder, social phobia, OCD, post traumatic stress disorder (PTSD), generalized anxiety disorder and bulimia nervosa (Wright et al., 2002b). Cognitive and be-havioral therapies are also useful as adjunctive treatments for patients with bipolar disorder (Basco and Rush, 1996; Basco and Thase, 1998; Lam et al., 2000) and schizophrenia (Mueser, 1998; Kingdon and Turkington, 1995; Senky et al., 2000). Although not extensively studied, cognitive and behavioral therapies in-corporating coping skills training and relapse prevention strate-gies may also improve the outcome of individuals with substance abuse disorders (Wright et al., 2002b).


Cognitive and behavioral therapies, like most other types of treatment, have not been studied widely in patients with Axis II disorders. However, the CBT approach to problem specifica-tion and explicit training in coping skills may be well suited for treatment of individuals willing to work on changing these ha-bitual, ingrained patterns of thinking and behavior (Beck et al., 1990). Specific cognitive–behavioral formulations have been de-veloped for each of the personality disorders, and modifications of CBT methods have been described for working with patients with Axis II problems (Beck et al., 1990). Linehan’s model of CBT (dialectical behavior therapy) has been shown to be effica-cious in reducing parasuicidal behavior in patients with border-line personality disorder (Linehan et al., 1991, 1993).


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