Tag Archives: Behavior Therapy

Parenting, Personal Reflections

Doing Behavior Modification Right

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Toilet Drinking Ed

Opposite Day was on January 25th and, sadly, I forgot to celebrate it. Maybe that’s for the best now that it feels like we’re living in an opposite world where, as parents, we need to constantly monitor and compensate for what our children see and hear on social media, television, the news, and from the President.

About a decade ago I “invented” the term: “Backward behavior modification.” It’s sort of like Opposite Day in that it captures the natural (but unintentional) tendency for parents to provide positive reinforcement for their children’s negative and undesirable behavior. As a part of backward behavior modification, parents also often ignore their children’s positive behaviors.

Celebrating Opposite Day requires creativity, mental effort, and planning. Saying the opposite of what you mean is difficult. In contrast, backward behavior modification is all natural, but unhelpful. As parents, we seem to do it automatically. It requires creativity, mental effort, and planning to do behavior modification in the right direction.

The latest episode of the Practically Perfect Parenting Podcast is all about how parents can do behavior modification in the right direction. Now, don’t get me wrong . . . I’m not a BIG proponent of mechanistic, authoritarian behavior modification. However, as Dr. Sara and I talk about on the PPPP, behavior modification is a tool that most parents, at least on occasion, should have in their toolbox.

Here’s a link to the podcast on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

Here’s another link to the podcast on Libsyn: http://practicallyperfectparenting.libsyn.com/

Here’s the official podcast description:

Behavior Modification: To Use or Not to Use—That is the Question!

Parenting is difficult. Parenting is also wonderful. As parents, most days we’re reminded of parenting challenges and joys. In today’s episode, Dr. Sara and Dr. John talk (and John dons his professorial persona and talks too much). Sara and John they talk about adding the crucial tool of behavior modification to your parenting toolbox. Don’t worry, we know how the idea of “behavior modification” can feel to parents; it can feel too sterile and mechanistic. The expectation isn’t for you to use behavior modification all the time, but instead to be able to use it when you need it. Even more importantly, our hope is for you to learn how to use it effectively. To help fulfill our hopes, Sara tells a story of behavior modification gone wrong and John and Sara share tips for using behavior modification effectively.

Don’t forget to like the PPPP on Facebook: https://www.facebook.com/PracticallyPerfectParenting/

And now we’re on Twitter. You can follow us there:  https://twitter.com/PPParentPod

Counseling and Psychotherapy Theory and Practice

Behavior Therapy and Spirituality

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1974 Football Cropped II

The whole idea of integrating behavior therapy with religion and spirituality might seem odd or off or impossible. But here in Theories Land, we don’t believe in the impossible. In fact, many religious folks do just fine with behavior therapy and many behavior therapists do just fine with religious folks. If you think about it, for behaviorists, the focus is purely on problematic behaviors. In some ways, this naturally leads to an acceptance of all people . . . .

Put another way, for behaviorists, there’s no room or need for discrimination based on race, sexuality, or religion. Behaviorists work with all people to help them with their problem behaviors.

Rather than digressing into the political, let’s refocus on behavior therapy and spirituality. Here’s the short section from the 3rd edition of Counseling and Psychotherapy Theories in Context and Practice. If you feel moved (by the spirit, or anything else), please let me know what you think.

************

Strict behaviorists don’t believe in the utility of cognition. The clients’ problems are behaviors. Behavioral treatments involve new learning to facilitate behavior change. If you stick with the perspective that cognition is irrelevant—which is the perspective we’re sticking with in this chapter—then client religious or spiritual beliefs are also not relevant.

Considering religious and spiritual beliefs as irrelevant doesn’t imply disrespect for religious and spiritual beliefs. Behaviorists are respectful of beliefs, but the focus of therapy would be on behaviors—these behaviors could include religious or spiritual behaviors. If you’re following the logic here, then you can see that behavior therapy is 100% compatible with religion and spirituality.

The focus of behavior therapy with religious and spiritual clients would be on behaviors that are related to religion and spirituality. From a behavioral model, the question is, “Are your religious/spiritual behaviors causing you distress or contributing to your well-being?” The good news about this is that behavior therapy is an evidence-based approach for modifying behavior, including the development of positive and healthy habits (and behaviors commonly thought of as representing self-control and self-discipline). The focus on enhancing self-control and self-discipline is a good fit for clients with religious or spiritual orientations (Shapiro, 1978).

Researchers have explored the relationship between behavioral activation and client values. In one study, it was found that when individuals with high intrinsic religious values engaged in a greater frequency of religious behaviors, they reported reduced depressive symptoms (Agishtein et al., 2013). Conversely, for individuals with low intrinsic religious values, increasing religious behaviors were associated with more depressive symptoms. In conclusion, despite disregard for religious/spiritual beliefs, a strict behavioral approach can be used to increase or decrease specific religious and spiritual behaviors. . . and increasing or decreasing specific religious and spiritual behaviors may be therapeutic—depending on the individual client and his/her/their situation.

 

Counseling and Psychotherapy Theory and Practice

Behavioral Activation Therapy: Let’s Just Skip the Cognitions

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This is a short excerpt from the text: Counseling and Psychotherapy Theories in Context and Practice

It describes a research-based behavioral approach to counseling and psychotherapy.

Over half a century ago, Skinner suggested that depression was caused by an interruption of healthy behavioral activities that had previously been maintained through positive reinforcement. Later, this idea was expanded based on the initial work of Ferster (1973) and Lewinsohn (1974; Lewinsohn & Libet, 1972). The focus was on observations that:

“. . . depressed individuals find fewer activities pleasant, engage in pleasant activities less frequently, and obtain therefore less positive reinforcement than other individuals.” (Cuijpers, van Straten, & Warmerdam, 2007, p. 319)

From the behavioral perspective, the thinking goes like this:
1.   Observation: Individuals experiencing depression engage in fewer pleasant activities and obtain less daily positive reinforcement.

2.   Hypothesis: Individuals with depressive symptoms might improve or recover if they change their behavior (while not paying any attention to their thoughts or feelings associated with depression).

Like the good scientists they are, behavior therapists have tested this hypothesis and found that behavior change—all by itself—can produce positive treatment outcomes among clients with depression. The main point is to get clients with depressive symptoms to change their behavior patterns so they engage in more pleasant activities and experience more positive reinforcement
Originally, behavioral activation was referred to as activity scheduling and used as a component of various cognitive and behavioral treatments for depression (A. T. Beck, Rush, Shaw, & Emery, 1979; Lewinsohn, Steinmetz, Antonuccio, & Teri, 1984). During this time activity scheduling was viewed as one piece or part of an overall cognitive behavior treatment (CBT) for depression.
However, in 1996, Jacobson and colleagues conducted a dismantling study on CBT for depression. They compared the whole CBT package with activity scheduling (which they referred to as behavioral activation), with behavioral activation (BA) only, and with CBT for automatic thoughts only. Somewhat surprisingly, BA by itself was equivalent to the other treatment components—even at two-year follow-up (Gortner, Gollan, Dobson, & Jacobson, 1998; Jacobson et al., 1996).

As is often the case, this exciting research finding stimulated further exploration and research associated with behavioral activation. In particular, two separate research teams developed treatment manuals focusing on behavioral activation. Jacobson and colleagues (Jacobson, Martell, & Dimidjian, 2001) developed an expanded BA protocol and Lejuez, Hopko, Hopko, and McNeil (2001) developed a brief (12 session) behavioral activation treatment for depression (BATD) manual and a more recent 10 session revised manual (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011).

Implementation of the BATD protocol is described in a short vignette later in the behavioral theory and therapy chapter in the text: Counseling and Psychotherapy Theories in Context and Practice by John and Rita Sommers-Flanagan. See: http://www.wiley.com/WileyCDA/WileyTitle/productCd-0470617934.html

Or, on Amazon: http://www.amazon.com/John-Sommers-Flanagan/e/B0030LK6NM/ref=ntt_dp_epwbk_1

Several people engaging in behavioral activation therapy at a wedding.

Dancing

 

Counseling and Psychotherapy Theory and Practice

How to Use the Six Column CBT Technique

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A Description of the Six Column CBT Technique

In contrast to popular belief, CBT requires counselors to be warm and compassionate. Also, the focus of CBT is on experiential psychoeducation. Aaron Beck emphasized collaborative empiricism. Never forget that term. Collaborative empiricism is the bedrock of good CBT. It emphasizes the process of counselors and clients working together to test the accuracy and usefulness of specific thoughts and behaviors. As a therapeutic process, collaborative empiricism is also central to Person-Centered and Motivational Interviewing approaches. Remember: We want the client to have a central role in determining the usefulness and dysfunctionality of his or her cognitions and behaviors.

The six column technique is simply a procedure that helps clients and counselors organize, explore, and discover how situations, thoughts/beliefs, emotions, behaviors, and emotional/interpersonal/psychological outcomes are inter-related. This is my own particular version of the six column technique. It’s derived from the work of Aaron Beck, Albert Ellis, Judith Beck, and other cognitive behavioral therapists. You can see a short clip of me using this technique at: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118402537.html

Here’s a description of the six columns:

Column #1: The Situation

BE THINKING ABOUT LINKING EMOTIONS TO SPECIFIC SITUATIONS

It may be that you’ll begin with whatever emotional distress the client is experiencing or reporting. Or you may begin with thoughts and beliefs that are clearly linked to specific client emotions and behaviors. Or you may begin with the situation or “trigger” for the cognitions and subsequent emotions.

Here’s an example of a situation as reported by a client:

“My in laws are staying in my home     .”

“They’re messy and lazy and I have to pick up after them”

Column #2: Automatic Thoughts and Automatic Behaviors

HELP CLIENTS SEE THAT AUTOMATIC THOUGHTS ARE OFTEN THE BRIDGE BETWEEN SITUATIONS AND EMOTIONS

Here are some examples of the automatic thoughts the clients thinks when she faces the previously described situation:

“They’re old enough to pick up after themselves.”

“Sometimes I stand in front of the television they’re watching to block their view as I pick their stuff up.”

Sometimes if “she” says she’ll do the dishes, I say, “No thanks. I want them to get done in the next two weeks.”

REMEMBER THAT AN EXPLORATION OF YOUR CLIENTS AUTOMATIC THOUGHTS AND BEHAVIORS OFTEN WILL SHED LIGHT ON DEEPER CORE BELIEFS ABOUT THE SELF, THE WORLD, AND THE FUTURE.

Column #3: Emotions and Sensations

SOMETIMES IT IS VERY NATURAL TO START HERE BECAUSE YOUR CLIENT’S EMOTIONS AND SENSATIONS MAY BE A WAY THAT THE MIND AND BODY ARE VOICING HIS OR HER DISTRESS (or you may find the best entry point into the six column technique is somewhere else)

Here are the ratings and descriptions the client provided for column #3:

Anger = 75 (on a 0-100 scale with 0 = totally mellow and 100 = explosive distress)

Discomfort = 75

EMOTIONS AND SENSATIONS MAY BE WHAT IS MOST TROUBLING TO CLIENTS AND THAT’S WHY THEY’RE TYPICALLY RE-EXAMINED IN COLUMN #6: NEW OUTCOMES

Column #4: Helpful Thoughts

HELPFUL THOUGHTS ARE ALSO SOMETIMES REFERRED TO AS “COOL THOUGHTS.” THIS IS ESPECIALLY TRUE WHEN WORKING WITH ANGER AND AGGRESSION BECAUSE COOL THOUGHTS HELP CALM OR COOL OFF THE ANGER AND REDUCE THE POTENTIAL FOR AGGRESSION.

Here are some thoughts that the client identified as helpful. Helpful thoughts are often seen as adaptive or more accurate or more “rational” (which is an Albert Ellis term).

“This is important for my husband.”

“I can see this as a challenge for me to become more direct and assertive.”

“They mean well.”

A WAY OF ASKING ABOUT HELPFUL THOUGHTS IS TO JUST ASK DIRECTLY: WHAT ARE SOME THOUGHTS OR BELIEFS THAT YOU THINK WOULD BE HELPFUL TO YOU IN THIS SITUATION? YOU MAY NEED TO HELP CLIENTS WITH THIS BY PROVIDING EXAMPLES . . . BUT NOT BY TELLING THEM WHAT THEY SHOULD THINK. ENCOURAGE THEM TO FIND THEIR OWN WORDS.

Column #5: Helpful Behaviors

SIMILAR TO THE PRECEDING COLUMN, WE CAN THINK OF BEHAVIORS AS “HOT” OR “COOL” BEHAVIORS. HOT BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS WORSE; COOL BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS BETTER.

Here are some behaviors the clients said she thought might be helpful:

“I could sit down and talk with them about picking up their messes at a regular time.”

“I could ask my husband to talk with them.”

“I could go to a Yoga class two nights a week.”

WHEN IT COMES TO BOTH HELPFUL THOUGHTS AND HELPFUL BEHAVIORS, IT’S USEFUL TO THINK OF THEM AS OCCURRING (A) BEFORE, (B) DURING, OR (c) AFTER THE SITUATION ARISES. SOME BEHAVIORS (E.G., GETTING ENOUGH SLEEP) HELP THE SITUATION AS A PROACTIVE OR PREVENTATIVE ACTION. OTHER BEHAVIORS (E.G., DEEP BREATHING) MAY BE CRUCIAL DURING THE SITUATION. STILL OTHER BEHAVIORS (E.G., VENTING TO A FRIEND OR PROVIDING SELF-REINFORCEMENT) MAY BE HELPFUL AFTER THE SITUATION IS OVER.

Column #6: New Outcomes

AFTER IMPLEMENTING THE HELPFUL COGNITIONS AND HELPFUL BEHAVIORS, IT’S A GOOD IDEA TO RE-EVALUATE THE CLIENT’S EMOTIONS AND SENSATIONS (OR DISTRESS).

In this case, the client provided the following ratings:

Anger = 40

Discomfort = 40

ONE OF THE GOALS OF CBT IS TO REDUCE DISTRESS AND REDUCE SYMPTOMS AND MAKE LIFE A LITTLE BETTER. YOU MAY NOT CREATE VAST IMPROVEMENTS, BUT IMPROVEMENTS ARE IMPROVEMENTS. THIS IS ALSO JUST THE BEGINNING OF CBT (OR WHATEVER APPROACH YOU’RE USING) BECAUSE THE WHOLE POINT IS THAT LIFE IS AN EXPERIMENT AND THAT WE COLLABORATIVELY AND INTERACTIVELY ARE HELPING CLIENTS TRY OUT NEW THOUGHTS AND BEHAVIORS THAT MAY (OR MAY NOT) LEAD TO IMPROVEMENT. AND IF THE IMPROVEMENT ISN’T OPTIMAL . . . THE CBT WAY IS TO GO BACK TO THE BEGINNING AND REWORK THE PROCESS TO SEE IF FURTHER IMPROVEMENTS CAN OCCUR.

CBT Tips

Here are a few tips on how to integrate CBT in your work.

Some counselors or mental health professionals resist using CBT and complain that it’s too sterile or too educational or not focused enough on feelings. Basically, I think this is a cop-out similar to CBT folks who say that person-centered therapy is ineffective. My belief (and I think it’s rational and so it must be (smiley face) is that when mental health professionals don’t understand how to implement a particular approach, they blame the approach rather than admitting their lack of knowledge or skill. Instead, I encourage you to try this six column CBT model, but use it with whatever other model you prefer. In other words, you can be a person-centered CBT person or an existential CBT person . . . especially if you just use this six column technique as a means for exploring and understanding different dimensions of your client’s personal experience.

Goal-setting is essential to counseling. From the CBT perspective, goal-setting is initiated by generating a problem list. However, your IR clients may not have a problem listJ. That’s why you may need to use your excellent active listening skills to help your clients focus in on a distressing emotion. Then you can begin with the distressing or disturbing emotion and build the six columns from there.

Good CBT involves adopting an experimental mindset (never forget collaborative empiricism). All you’re doing is helping your client look at his/her daily experiences and identify patterns. It helps to organize the client’s experience into Situation, Automatic Thoughts/Behaviors, Emotions and Sensations, Helpful (Cool) Thoughts, Helpful (Cool) Behaviors, and New Outcomes. You can explore these common dimensions of human experience collaboratively.

It’s very important to know and remember that giving behavioral assignments can be disastrous. This is part of why a good CBT counselor is better than a technician. If you’re brainstorming possible helpful behaviors, your client (and you) may zero in on a behavior that, if enacted, has a strong possibility of a negative outcome. New behaviors expose clients to risk. The risk may be worth it; but there also may be too much risk.

Avoid asking questions like: “Have you thought about talking directly to your in-laws?” This sort of question implies that your client should talk directly to the in-laws. It’s better to step back and brainstorm behavioral options with your client. Then, emphasize that behavioral goals must always be in the client’s control. Then, after your nice list of behavioral options has been generated, you can look at the different options and engage in “consequential thinking.” In other words, you ask your client to explore the possibilities of what is likely to happen if: “You (the client) directly confront the in-laws about their messy behaviors? “ (See sample six column worksheet).

There are many ways you can get to your client’s underlying core beliefs or cognitive dynamics. For example, you could ask: “What stops you from telling them to pick up after themselves?” The client might respond with a different emotion and new content (e.g., I’m afraid of getting into a conflict). You can pursue this further: “What is it about being in conflict makes it scary?” She might say, “I’m afraid my husband will side with them and leave me.” As a consequence, this conflict is viewed as something she needs to manage independently and gets at a deeper schema: “I must keep the peace and deal with everything or bad things (e.g., abandonment) will happen.” There are two problems with this: (a) If she overfunctions she feels angry and acts passive-aggressively; and (b) there may be truth to this schema/belief. This is why we can’t just push her into being assertive. We must always keep the corrective emotional experience rule in mind. New behavioral opportunities need to be free from the likelihood of re-traumatization.

Parenting

Backward Behavior Modification

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Understanding backward behavior modification is very important for parents and for professionals who work with parents. In the following short excerpt from our book, “How to Listen So Parents will Talk and Talk so Parents will Listen” we introduce the concept. If you have an opinion about this concept, be sure to comment and share your perspective.

Backward Behavior Modification: Using Boring, Natural, and Logical Consequences and Passionate and Surprise Rewards

As we alluded to in Chapter 4, backward behavior modification is endemic. Not only do parents tend to pay more attention to negative and undesirable behaviors than they do to positive and desirable behaviors, they also tend to do so with greater force or affect—which further complicates the situation. As noted previously, we learned about this complicated problem directly from teenagers who were in trouble for delinquent behaviors (see Chapter 4).

If parents engage in too much anger, yelling, or passion when their children misbehave, several problems can emerge: (1) The child will experience her parent’s passion as reinforcement for misbehavior; (2) the child will feel powerful and in-control of her parent (which is quite strong positive reinforcement); or (3) the parent will feel controlled by the child, or out-of-control, both of which further escalate the parent’s emotional behavior.

To address backward behavior modification problems, we teach parents how to use “Boring Consequences and Passionate Rewards.” The opening case in Chapter 1 is an example of the power of boring consequences. If you recall, the parents of Emma, a very oppositional nine-year-old, reported their “family was about to disintegrate” because of continuous power struggles. However, when they returned for their second consultation session, their family situation had transformed largely as a function of boring consequences. In Chapter 1, we quoted the father’s report on how he found boring consequences to be tremendously helpful. Emma’s mother was similarly positive:

Thinking about and then giving boring consequences helped us see that it was about us and not about our daughter. Before, she would misbehave and we would know she was going to misbehave and so we would go ballistic. Giving boring consequences suddenly gave us back our control over how we reacted to her. Instead of planning to go ballistic, it helped us see that going ballistic wasn’t helping her and wasn’t helping us. It felt good to plan to be boring instead. And the best thing about it was how it made the whole process of giving out consequences much shorter.

The inverse alternative to boring consequences is the practice of passionate rewards. Parents can be encouraged to intentionally pay positive and enthusiastic attention to their children’s positive, desirable, and prosocial behaviors. Passionate rewards include parental responses such as:

  • Applause or positive hoots and hollers
  • Verbal praise (“I am so impressed with your dedication to learning Spanish”)
  • Pats on the back, shoulder massages, and hugs
  • Family gatherings where everyone dishes out compliments

Passionate rewards are especially important for preadolescent children. As you may suspect, because of increased self-consciousness accompanying adolescence, passionate hugs and excessive compliments for a 14-year-old may function as a punishment rather than a reinforcement—especially if the hugging and hooting occurs in front of the 14-year-old’s peers.

Surprise rewards, presuming they’re provided in a socially tactful manner, are extremely powerful reinforcers for children of all ages. For example, with teenagers it can be very rewarding if parents suddenly and without advance notice say something like, “You know, you’ve been working hard and you’ve been so darn helpful that this weekend we’d like to give you a complete vacation from all your household chores or this $20 bill to go out to the movie of your choice with your buddies; which would you prefer?”

Surprise rewards are, in technical behavioral lingo, variable-ratio reinforcements. Across species, this reinforcement schedule has been shown to be the most powerful reinforcement schedule of all. Everyday examples of variable-ratio reinforcement schedules include gambling, golf, fishing, and other highly addictive behaviors where individuals can never be certain when their next response might result in the “jackpot.”

When coaching parents to use surprise rewards (variable-ratio reinforcement schedules), we emphasize that the surprise reward should be viewed as a spontaneous celebration of desirable behavior. Overall, we prefer this informal reinforcement plan over more mechanized sticker charts and reward systems (although we don’t mean to say that these more mechanized systems should never be used; in fact, when children are put in charge of their own reinforcement systems, these systems can be especially effective).

Counseling and Psychotherapy Theory and Practice

Imaginal or In Vivo Exposure and Desensitization

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Systematic desensitization is a form of exposure treatment. Exposure treatments are based on the principle that clients are best treated by exposure to the very thing they want to avoid: the stimulus that evokes intense fear, anxiety, or other painful emotions. Mowrer (1947) used a two-factor theory of learning, based on animal studies, to explain how avoidance conditioning works. First, he explained that animals originally learn to fear a particular stimulus through classical conditioning. For example, a dog may learn to fear its owner’s voice when the owner yells due to the discovery of an unwelcome pile on the living room carpet. Then, if the dog remains in the room with its owner, fear continues to escalate.

Second, Mowrer explained that avoidance behavior is reinforced via operant conditioning. Specifically, if the dog manages to hide under the bed or dash out the front door of the house, it’s likely to experience decreased fear and anxiety. Consequently, the avoidance behavior—running away and hiding—is negatively reinforced because it relieves fear, anxiety, and discomfort. Negative reinforcement is defined as the strengthening of a behavioral response by reducing or eliminating an aversive stimulus (like fear and anxiety).

Note that exposure via systematic desensitization and the other procedures detailed hereafter are distinctively behavioral. However, the concept that psychological health is enhanced when clients face and embrace their fears is consistent with existential and Jungian theory (van Deurzen, 2010; see online Jungian chapter: Link to be set up**).

There are three ways to expose clients to their fears during systematic desensitization. First, exposure to fears can be accomplished through mental imagery. This approach can be more convenient and allows clients to complete treatment without ever leaving their therapist’s office. Second, in vivo (direct exposure to the feared stimulus) is also possible. This option can be more complex (e.g., going to a dental office to provide exposure for a client with a dental phobia), but appears to produce outcomes superior to imaginal exposure (Emmelkamp, 1994). Third, computer simulation (virtual reality) has been successfully used as a means of exposing clients to feared stimuli (Emmelkamp et al., 2001; Emmelkamp, Bruynzeel, Drost, & van der Mast, 2001).

Psychoeducation is critical to effective exposure treatment. D. Dobson and K. S. Dobson (2009) state:

A crucial element of effective exposure is the provision of a solid rationale to encourage your client to take the risks involved in this strategy. A good therapeutic alliance is absolutely essential for exposure to occur. (p. 104)

Further, D. Dobson and K. S. Dobson (2009) provide a sample client handout that helps inform clients of the exposure rationale and procedure.

Exposure treatment means gradually and systematically exposing yourself to situations that create some anxiety. You can then prove to yourself that you can handle these feared situations, as your body learns to become more comfortable. Exposure treatment is extremely important in your recovery and involves taking controlled risks. For exposure treatment to work, you should experience some anxiety—too little won’t be enough to put you in your discomfort zone so you can prove your fears wrong. Too much anxiety means that you may not pay attention to what is going on in the situation. If you are too uncomfortable, it may be hard to try the same thing again. Generally, effective exposure involves experiencing anxiety that is around 70 out of 100 on your Subjective Units of Distress Scale. Expect to feel some anxiety. As you become more comfortable with the situation, you can then move on to the next step. Exposure should be structured, planned, and predictable. It must be within your control, not anyone else’s. (p. 104)

Massed (Intensive) or Spaced (Graduated) Exposure Sessions

Behavior therapists continue to optimize methods for extinguishing fear responses. One question being examined empirically is this: Is desensitization more effective when clients are directly exposed to feared stimuli during a single prolonged session (e.g., one 3-hour session; aka massed exposure) or when they’re slowly and incrementally exposed to feared stimuli during a series of shorter sessions (such as five 1-hour sessions; aka spaced exposure)? Initially, it was thought that massed exposure might result in higher dropout rates, greater likelihood of fear relapse, and a higher client stress. However, research suggests that massed and spaced exposure desensitization strategies yield minimal differences in efficacy differences (Ost, Alm, Brandberg, & Breitholz, 2001).

Virtual Reality Exposure

Technological advancements have led to potential modifications in systematic desensitization procedures. Specifically, virtual reality exposure, a procedure wherein clients are immersed in a real-time computer-generated virtual environment, has been empirically evaluated as an alternative to imaginal or in-vivo exposure in cases of acrophobia (fear of heights), flight phobia, spider phobia, and other anxiety disorders (Krijn et al., 2007; Ruwaard, Broeksteeg, Schrieken, Emmelkamp, & Lange, 2010).

In a meta-analysis of 18 outcome studies, Powers and Emmelkamp (2008) reported a large effect size (d = 1.11) as compared to no treatment and a small effect size (d = .35) when compared to in vivo control conditions. These results suggest that virtual reality exposure may be as efficacious or even more so than in vivo exposure.

Interoceptive Exposure

Typical panic-prone individuals are highly sensitive to internal physical cues (e.g., increased heart rate, increased respiration, and dizziness). They become especially reactive when those cues are associated with environmental situations viewed as potentially causing anxiety (Story & Craske, 2008). Physical cues or sensations are then interpreted as signs of physical illness, impending death, or imminent loss of consciousness (and associated humiliation). Although specific cognitive techniques have been developed to treat clients’ tendencies to catastrophically overinterpret bodily sensations, a more behavioral technique, interoceptive exposure, has been developed to help clients learn, through exposure and practice, to deal more effectively with physical aspects of intense anxiety or panic (Lee et al., 2006; Stewart & Watt, 2008).

Interoceptive exposure is identical to other exposure techniques except that the target exposure stimuli are internal physical cues. There are at least six interoceptive exposure tasks that reliably trigger anxiety (Lee et al., 2006). They include:

  • Hyperventilation
  • Holding breath
  • Breathing through a straw
  • Spinning in circles
  • Shaking head
  • Chest breathing

Of course, before interoceptive exposure is initiated, clients receive education about body sensations, learn relaxation skills (e.g., breathing training), and learn cognitive restructuring skills. Through repeated successful exposure, clients become desensitized to previously feared physical cues (Forsyth, Fusé, & Acheson, 2009).

Response and Ritual Prevention

Mowrer’s two-factor theory suggests that, when a client avoids or escapes a feared or distressing situation or stimulus, the maladaptive avoidance behavior is negatively reinforced (i.e., when the client feels relief from the negative anxiety, fear, or distress, the avoidance or escape behavior is reinforced or strengthened; Spiegler & Guevremont, 2010). Many examples of this negative reinforcement cycle are present across the spectrum of mental disorders. For example, clients with Bulimia Nervosa who purge after eating specific “forbidden” foods are relieving themselves from the anxiety and discomfort they experience upon ingesting the foods (Agras, Schneider, Arnow, Raeburn, & Telch, 1989). Therefore, purging behavior is negatively reinforced. Similarly, when a phobic client escapes from a phobic object or situation, or when a client with obsessive-compulsive symptoms engages in a repeated washing or checking behavior, negative reinforcement of maladaptive behavior occurs (Franklin & Foa, 1998; Franklin, Ledley, & Foa, 2009; March, Franklin, Nelson, & Foa, 2001).

It follows that, to be effective, exposure-based desensitization treatment must include response prevention. With the therapist’s assistance, the client with bulimia is prevented from vomiting after ingesting a forbidden cookie, the agoraphobic client is prevented from fleeing a public place when anxiety begins to mount, and the client with Obsessive-Compulsive Disorder is prevented from washing his or her hands following exposure to a “contaminated” object. Without response or ritual prevention, the treatment may exacerbate the condition it was designed to treat. Research indicates that exposure plus response prevention can produce significant brain changes in as few as three psychotherapy sessions (Schwartz, Gulliford, Stier, & Thienemann, 2005; Schwartz, Stoessel, Baxter, Martin, & Phelps, 1996).

 

Counseling and Psychotherapy Theory and Practice

A Black Friday Tribute to Mary Cover Jones and her Evidence-Based Cookies

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In honor of Black Friday and the opening of this blog, I’d like to sell you on why the story of Mary Cover Jones and her evidence-based cookies is one of the coolest in the history of counseling and psychotherapy.

Mary Cover Jones probably wasn’t big on shopping. That’s because she was a woman scientist in the 1920s. She was too busy working in John Watson’s lab (yes, this is the same John Watson who, at least according to historical accounts, turned out to be a bit of a turkey.)

Mary Cover Jones was amazing. She’s best known for her work with a young boy named “Little Peter.” When everyone else was focusing on how to create fear in humans (or out shopping for Black Friday bargains), Mary was discovering how children’s fears could be extinguished or eliminated.

Little Peter suffered from a specific fear. As silly as it sounds, he was deeply afraid of white bunnies. This fear had generalized to white rats, white cotton balls, and just about anything white and fluffy. Using cookies, Mary Cover Jones counter-conditioned the fear right out of Little Peter. She started by having Peter enjoy his favorite cookies in one corner of the room and gradually brought a caged white rabbit over to him until, eventually, Peter was able to eat cookies with one hand and pet the bunny with the other.

But Mary Cover Jones didn’t stop with Little Peter. Over time, she worked with 70 different institutionalized children, all of whom had big fears. Not only was she successful, but her conclusions (from 1924) still constitute the basic foundation for contemporary (and evidence-based) behavioral approaches to treating human fears and phobias. This is what she wrote toward the end of her 1924 article:

“In our study of methods for removing fear responses, we found unqualified success with only two. By the method of direct conditioning we associated the fear-object with a craving-object, and replaced the fear by a positive response. By the method of social imitation we allowed the subjects to share, under controlled conditions, the social activity of a group of children especially chosen with a view to prestige effect. [Other] methods proved sometimes effective but were not to be relied upon unless used in combination with other methods.” (M.C. Jones, 1924, p. 390)

Mary’s findings remain deeply profound. They have implications not only for how we treat children’s fears, but also for how to work effectively with resistant or reluctant teens and adults. In later blogs I’ll often be serving a batch of Mary’s evidence-based cookies in one form or another.

After her work with John Watson, Mary Cover Jones continued working in a research lab. She moved across the U.S. and 50 years after her publications on children’s fears, she reflected on her life and her work. Here’s what she said:

“[M]y last 45 years have been spent in longitudinal research in which I have watched the psychobiological development of our study members as they grew from children to adults now in their fifties… My association with this study has broadened my conception of the human experience.  Now I would be less satisfied to treat the fears of a 3-year-old, or of anyone else, without a later follow-up and in isolation from an appreciation of him as a tantalizingly complex person with unique potentials for stability and change.” (Jones, 1974, p. 186).

Just minutes before she passed away, Mary said to her sister, “I am still learning about what is important in life” (as cited in Reiss, 1990).

We should all strive to never stop learning about what’s important in life and therefore be more like Mary Cover Jones. Although the famous psychologist, Joseph Wolpe, dubbed her “the mother of behavior therapy” she was obviously much more than a behavior therapist. You can learn more about her (she would probably have liked that) from a web-based article by Alexandra Rutherford of York University at: http://www.psych.yorku.ca/femhop/Cover%20Jones.htm. Rutherford’s article was originally published in The Feminist Psychologist, Newsletter of the Society for the Psychology of Women, Division 35 of theAmerican Psychological Association, Volume 27, Number 3, Summer, 2000.

And, believe it or not, Mary Cover Jones is on Facebook. You should become her friend . . . just like I did.

Mary Cover Jones