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Presenter Dr PAVAN KUMAR K Chair person Ms NEETHI NAROTH
The modern meaning, “the treatment of disorders of the mind or personality by psychological or psychophysiological methods” (Frederik van Eeden, 1892)
Wolberg in 1967 defined..
Treatment by psychological means of the problems of an emotional nature, in which a trained person deliberately establishes a professional relationship with the patient with the object of removing, modifying or retarding the existing disturbing symptoms, modifying disturbed patterns of behavior and promoting positive personality development and growth
employ language and communication and the relationship with a skilled therapist as their means of producing change. enhance self acceptance, empower the patient to make life changes and help patient to cope with enviroment more effectively
Empathetic and non-judgemental stance towards the patient Awareness of the importance of the setting in which therapy takes place Use of the therapeutic relationship between the therapist as both diagnostic and therapeutic agent
Classification of Psychotherapies
according to how many persons are involved in the treatment an individual a group a couple a family therapy
existential rational emotive therapies. Skinner‟s behavior modification therapy.Based on the content and methods (karasu 1977) Dynamic psychotherapies (classical. Bandura‟s social learning therapy) Experiential or humanistic psychotherapies (client centered. transactional analysis) . neo-Freudian psychoanalysis . psychoanalytically oriented psychotherapies) Behavioral therapies (Wolpe‟s systematic desensitization.
suggestive hypnosis . emotional catharsis .Wolberg in 1967 classified Supportive psychotherapy Strengthening of existing defences. Pressure and coercion. Externalisation of interest. persuation. Reassurances. adaptive equlibrium Guidance. better mechanisms of maintaining control.
Reductive psychotherapy Efforts at readjustment . directive therapy and family therapy . conditioning therapy.goal modifications and living upto existing creative potentials Behavior therapy.
psychoanalytically oriented psychotherapy . Reconstructive psychotherapy Insight into unconcious conflicts Classical and neofreudian psychoanalysis.
BEHAVIOR THERAPY Techniques based on learning theory used in order to extinguish maladaptive behaviors and substitute more adaptive ones .
L. Thorndike‟s research on animal learning (rewarding and punishing) Joseph Wolpe‟s systematic desensitization Eysenck‟s description of BT as applied science Skinner‟s operant conditioning paradigms Bandura‟s social learning theories . B.HISTORY Ivan Pavlov‟s research Rise of behaviorism by Watson The first figure in the United States directly linked with the development of behaviorism in the early 1900s was J. Watson E.
demonstrating the application of classic conditioning principles to the acquisition or learning of fear. the classic case of “Little Albert” was published.Alexander Maconochie . Australia.aversion therapy modify drinking behavior by putting spiders at the bottom of a drinker's glass.token economy – prisoners awarded points for positive behaviors in a penal colony at Norfolk Island. In 1920. early 19th century . .Pliny the Elder . 1st century.
. Principles of operant conditioning by B. Skinner and his colleagues .applied to the treatment of psychiatric disorders. In mid-1950s. F. another set of investigators demonstrated the use of a belland-pad technique for treating enuresis. or bed-wetting. Fourteen years later.
and expectations in the development of psychological or psychiatric disorders development of treatments that target these internal components of behavior more directly . BT had another surge in growth with the addition of attention to cognitions and the development of cognitive–behavioral therapy (CBT). People learn by observing the actions of others in their environments. During the 1970s. emphasized the roles of thoughts. Based on Albert Bandura's social learning theory. images.
BEHAVIOR THERAPY Basic Assumptions – – – – Overt behavior holds primacy Maladaptive behavior is learned in the same way as adaptive behavior Assessment and evaluation is key Treatment is active. directive and collaborative .
Based on the principles and procedures of the scientific method Learning new behaviors is the core of the therapy Interventions tailored to fit individual needs Therapy deals with client‟s current problems and the factors influencing them Does not deal with historical determinants Behavior therapy does not provide insight Conclusions are made based on what is observed Treatment goals are stated in concrete and objective terms .
Therapy is a collaboration between therapist and client Therapists treat symptoms rather than causes Therapy involves control and manipulation by the therapist Therapists use empirically supported techniques Therapists are ethical in their practice Therapists examine effectiveness of their procedures in terms of generalizability and durability of change Treatment is as brief as possible .
learn coping skills. role-playing Several behavioral techniques are often combined in a treatment package to increase efficacy of treatment . Clients are expected to be active Clients have control and freedom Clients can monitor and manage their interventions Clients „do something‟ to bring about a change: engage in new behaviors Clients monitor their behavior outside of sessions.
3.Aspects of Behavior Therapy 1. 2. Classical Conditioning Operant Conditioning Social Learning Approach .
Skinner Donald Meichenbaum Contingency Management – Cognitive-Behavior Modification – .Behavior Therapy: The 3 Cs Counterconditioning – Joseph Wolpe B.F.
Classical Conditioning Clinical Applications .
Pavlov‟s dogs Pavlov demonstrated that.g. e. The result is that eventually the neutral stimulus alone elicits the response.. . over time..Classical Conditioning A neutral stimulus is repeatedly paired with a stimulus that naturally elicits a particular response. a dog salivating).g...g. repeated pairings of one stimulus (e.g. a bell ringing) with another (e. the presentation of food) could elicit a reliable response (e.
Conditioned response .Conditioned stimulus-previously neutral stimulus that.Unconditioned stimulus which naturally. through repeated paring with UCS. without learning elicits….Conditioning Paradigm Terminology UCS. elicits a …. UCR.Unconditioned response-reflex CS. CR.
Conditioning Paradigm UCS------------------------------UCR Meat Salivation : : : : CS-------------------------------- CR Bell ringing Salivation .
( the dog learns that the bell no longer means food will follow). occurs when CS is repeatedly not followed by the US. Requires 3-15 pairings EXTINCTION The loss of association between the CR and the CS. . ACQUISITION The development of the association between the UR and the US producing the CR.
(CR) (eg. to a buzzer as well as bell) HIGHER –ORDER CONDITIONING demonstrate the CR to new stimuli by pairing them with the CS (pairing bell with a light stimulus.dog becomes conditioned to salivate to light) . GENERALISATION similar stimuli to the initial CS produce the response.
. SPONTANEOUS RECOVERY During extinction trials following a rest period the CR often briefly reappears. This behavior will extinguish rapidly if the UCS does not follow quickly HABITUATION The subject becomes accustomed to and less responsive to a stimulus after repeated exposure.
TECHNIQUES BASED ON CLASSICAL CONDITIONING CONCEPTS Systematic desensitization Invivo desensitization Exposure therapy Therapeutic-Graded Exposure Flooding .
Systematic Desensitization Developed by Joseph Wolpe Also known as reciprocal inhibition Based on counterconditioning or respondent conditioning Follows directly from the work of Pavlov Pair relaxation with CS .
patients attain a state of complete relaxation and exposed to the stimulus that elicits the anxiety response. in a psychophysiological state that inhibits anxiety. The learned relaxation state and the anxiety-provoking scenes are systematically paired in treatment. a process called reciprocal inhibition. The negative reaction of anxiety is inhibited by the relaxed state. . person overcomes maladaptive anxiety by approaching the feared situation gradually.
Indications Systematic desensitization works best in cases of a clearly identifiable anxietyprovoking stimulus. compulsions. and certain sexual disorders treated successfully with this technique. obsessions. Phobias. .
Systematic Desensitization: Components Relaxation training Anxiety hierarchy Desensitization proper .
beginning with the small muscle groups of the feet and working cephalad or vice versa. Mental imagery is a relaxation method in which patients are instructed to imagine themselves in a place associated with pleasant relaxed memories. increased peripheral blood flow. . yoga and Zen. and neuromuscular stability.Relaxation training Progressive muscle relaxation(Edmund Jacobson) Patients relax major muscle groups in a fixed order. Relaxation produces physiological effects opposite to those of anxiety(adrenergic stress responses ): slow heart rate.
.Anxiety Hierarchy creating a hierarchy list of 10 to 12 scenes about a feared situation Ordered from least to most anxiety provoking Example: an acrophobic hierarchy may begin with a patient's imagining standing near a window on the second floor and end with being on the roof of a 20-story building. leaning on a guard rail and looking straight down.
items on the hierarchy get physically closer or get closer in terms of time Thematic .Items on the hierarchy share a basic theme .Types of Hierarchies Spatial-temporal.
Spatial-temporal hierarchy A temporal hierarchy for a public speaking phobia: Someone asks you to give a speech in two months Writing the speech a month before Rehearsing the speech a week before The morning of the speech Reciting the speech while dressing Approaching the auditorium Walking up to the podium Giving the speech .
A spatial hierarchy for a Cynophobia Seeing a dog go by in a car Seeing a dog in a yard on a leash and behind a fence Dog poking nose through the fence Passing a leashed dog across the street Passing a leashed dog on same side of street .
Thematic hierarchies public speaking phobia Telling a joke to several friends Making an announcement to a group of coworkers Speaking at a meeting Speaking at company banquet Giving the main address at a stockholder‟s convention .
After two presentations without anxiety move to next item . present item a second time.Desensitization Proper Get client in a relaxed state Present first item on hierarchy to imagine in a very detailed and clear way If no anxiety is signaled.
If anxiety still occurs go back to earlier step or reconstruct hierarchy.If item raised anxiety Return to relaxation. Present item again. Continue up the hierarchy until all items can be imagined without anxiety .
almost all patients can relax adequately. treatment itself seems to proceed more rapidly than without the drugs. ultrarapidly acting barbiturate sodium methohexital or diazepam is given intravenously in subanesthetic doses. Advantages preliminary training in relaxation can be shortened.Adjunctive Use of Drugs Clinicians have used various drugs to hasten relaxation. .
In-Vivo Desensitization Instead of imagining a situation. the client actually confronts gradually more anxiety producing stimuli .
In-Vivo Desensitization Instead of imagining a situation. . the client actually confronts gradually more anxiety producing stimuli same principles as systematic desensitization (counterconditioning treatment).
In-Vivo Desensitization Instead of imagining a situation. the client actually confronts gradually more anxiety producing stimuli same principles as systematic desensitization (counterconditioning ). basic difference is that Progressive Muscle Relaxation is not typically used with stimulus because complete muscle relaxation is not possible when the patient is using muscles in real-life situations .
Exposure Therapy Patients expose themselves to feared objects or situations Exposure can be real (invivo) or imagined (invitro) .
Exposure Therapy: Necessary Factors Long exposure Repeated exposure until fear dissipates Graduated exposure Attention to fear object Anxiety must be present .
Patients afraid of cats. might progress from looking at a picture of a cat to holding one. except that relaxation training is not involved and treatment is usually carried out in a real-life context. . Exposure is graded according to a hierarchy. individual must be brought in contact with (i. for example.Therapeutic-Graded Exposure similar to systematic desensitization..e. be exposed to) the warning stimulus to learn firsthand that no dangerous consequences will ensue.
there is no hierarchy Person confronts most upsetting situation right away . however.Flooding or therapeutic extinction An exposure procedure that harnesses the extinction process and reduces Abandons the hierarchy similar to graded exposure in that it involves exposing the patient to the feared object in vivo.
Flooding ( implosion) based on the premise that escaping from an anxietyprovoking experience reinforces the anxiety through conditioning. . clinicians can extinguish the anxiety and prevent the conditioned avoidance behavior by not allowing patients to escape the situation.
No relaxation exercises are used. as in systematic desensitization or graded exposure. Patients experience fear. as in systematic desensitization.. Clinicians encourage patients to confront feared situations directly. which gradually subsides after a time . without a gradual buildup.FLOODING contd.
called imaginal flooding. not in real life Disadvantage of Sudden Intense Anxiety provoking . the feared object or situation is confronted only in the imagination. In a variant.FLOODING specific phobias contraindicated when intense anxiety would be hazardous to a patient (heart disease or fragile psychological adaptation).
Over time. .g.Exposure and response prevention In most cases. the patient would be asked to look directly at the audience and not at the floor.. anxious emotional response will be reduced. looking at the floor during a speech can serve to reduce social anxiety. during exposure. although the patient remains in the fearproducing situation. avoidance behaviors that reduce fear need to be prevented e. flooding (exposure) is accompanied by response prevention (RP) For exposure to produce extinction. to incorporate RP.
ERP also is used for the treatment of eating disorders. RP is a part of almost all anxietyreduction treatment programs that use exposure. the treatment of choice for OCD. In ERP. . patients are exposed to the feared stimuli and obsessions while rituals/obsessions that typically serve to reduce anxiety are prevented.
hyperventilating) The goal is to change patient‟s misinterpretation of uncomfortable physical sensations as signs of imminent catastrophe Used in the treatment of panic disorder .g. breathing through straw.Interoceptive exposure Patients do things that will induce feared physical sensations(e..
Operant or Instrumental Conditioning .
perhaps randomly at first. . Skinner) Developed by Thorndike and Skinner Basic principle – if a response to a stimulus produces positive consequences for the individual it will tend to be repeated. the probability of the response’s future occurrence is changed.while if it is followed by negative consequences it will tend not to be repeated A response is emitted.F. and this results in consequences. Hence.Operant or Instrumental Conditioning (B.
behavior change) 1) Antecedent 2) Behavior 3) Consequence . The ABC Model Three things necessary for Operant Conditioning (i.e.
Operant Conditioning 1) Reinforcement Positive Reinforcer Negative Reinforcer 2) Punishment Positive punishment Negative punishment .
Operant Conditioning Increases Behavior Present Stimulus Remove Stimulus Positive Reinforcement Negative Reinforcement Decreases Behavior Positive Punishment Negative Punishment .
Example: Scheduled exams Delivers reinforcement after unpredictable time periods Example: Pop Quizzes Variable interval schedules – – .Intermittent (or partial) Reinforcement Not every response is reinforced Yields a stronger response ultimately Fixed ratio schedule – – Delivers reinforcement after a fixed number of responses and produces high response rate Example: Commission Work Yields the highest rates of response and greatest resistance to extinction. Example: Gambling Variable ratio schedule – – Fixed interval schedule – – Reinforces the next response which occurs after a fixed period of time elapses.
Schedule Effect ______________________________________________ Fixed Ratio (Relatively fast rate of response) ______________________________________________ Fixed Interval (Response rate drops to almost zero after reward. Picks up rapidly before next reward) _______________________________________________ Variable Interval (Slow steady response) _______________________________________________ Variable Ratio (Constant high rate of response. May be difficult to break) .
B and C Implement functional treatments . Functional Assessment Understanding the behavior in terms of the function it serves Identify the A.Operant Conditioning Techniques 1.
Contingency contracts formal written agreement Shaping the process in which complex terminal behaviors are reinforced in approximate successive stages .
Techniques based on operant conditioning concepts Behavior modification Token Economy Aversion therapy .
. punishment) in the process of behavior change..Contingency Management defined as the general application of operant principles (e. reinforcement.g.
how to use time outs and response costs.Child management training The most empirically established form of contingency management is child management training (CMT). . a structured program that teaches basic disciplinary skills to parents in group settings Include : how to attend to a desirable behavior to increase its frequency and ignore undesirable behaviors to decrease their frequency .
used successfully with a range of behavioral problems. including oppositional and disruptive behavior. . aggression. eating disorders. and homework completion.
the location where time out occurs. and what behavior the child is required to exhibit before time out. . When applying time out. the therapist must consider the duration of the timeout interval.Time out Time out is punishment by the removal of positive reinforcement.
achievable intermediate steps Utilized in behavioral disturbance in children and patients with learning difficulty .Behavior modification Based on operant conditioning Behavior may be shaped towards the desired final modification through the rewarding of small .
Token Economy .
etc. that function as money Exchanged for back-up reinforcers Token economy: reinforcement system based on token . tickets. points. checkmarks.Token Economy Tokens: poker chips. stars. coins.
patients with mental disorder receive a reward for performing a desired behavior. In inpatient hospital wards. such as tokens that they can use to purchase luxury items or certain privileges. or praise. . such as food. tends to be strengthened and to occur more frequently than before the reward. avoidance of pain. behavioral response is followed by a generally rewarding event.
Advantages of Tokens Maintain behavior at a high level Bridge delay between response and reinforcement Less subject to satiation Easily administered Permits administration of a single reinforcer .
g. fining a child for swearing) .Token Economy: Achievement Place Residents earned redeemable tokens Receipt of tokens contingent on good behavior Undesirable behavior punished through response costs ie the removal or withdrawal of a reinforcer/reward following inappropriate or problem behavior (e..
Disadvantages of Token Economies Requires that goals be concrete and specific Can lead to dependency if weaning not done Requires a great deal of structure and organization by the administrator Can be costly if tangible reinforcers used May prevent or distract administrator from learning more appropriate strategies for controlling behavior May be easily abused Requires much time and attention .
Aversion Therapy Conditioned stimulus is paired with a stimulus that elicits a negative response .
the response is eventually inhibited and extinguished.AVERSION THERAPY When a noxious stimulus (punishment) is presented immediately after a specific behavioral response theoretically. and Verbal aversion (also known as covert sensitization). aversive conditioning stimuli: Chemical aversion. . administered via the olfactory or gustatory systems Electrical aversion (sometimes called faradic aversion).
and social disapproval Aversion therapy has been used for alcohol abuse. corporal punishment. substances that induce vomiting. Many types of noxious stimuli are used: electric shocks. and other behaviors with impulsive or compulsive qualities . used in some cultures in the treatment of opioid addicts . paraphilias.
AVERSION RELIEF Punishment procedure in which aversive stimulus is presented concurrently with negative stimulus or response. Both are simultaneously terminated contingent upon the presentation of positive stimulus or response Commonly used in the treatment of sexual deviations or ego dystonic homosexuality .
Covert Sensitization Pairing of object or situation with an aversive scene that is imagined .
Given in such quantities the subject not only tires of the reinforcer but also becomes repelled by it. Smoking. and acting-out behaviors A major problem is that if satiation does not occur the behavior becomes entrenched . eating.SATIATION A mild aversive technique that uses an excess amount of reinforcement to make the undesired reinforcer lose its effectiveness.
depression is at least partially maintained by a lack of positive reinforcement. which in turn results in a loss of reinforcement from pleasurable events or activities Initial behavioral interventions for depression focused on increasing access to pleasant and therefore reinforcing events through the daily scheduling of pleasant activities .Behavioral Activation From a behavioral perspective. Severely depressed mood leads to behavioral withdrawal.
Behavioral Activation Treatment for Depression BATD Lejeuz and his colleagues Matching law. states that behaviors are allocated to various alternatives on the proportion of reinforcers obtained from the various alternatives. .
with equivalent outcomes to antidepressant . and reduce depressed behavior Recent data suggest that behavioral activation leads to greater improvement than CBT in depressive symptoms for patients with major depression. depression persists because depressed behavior is highly reinforced than nondepressed behavior BATD increases the individual's exposure to the positive outcome of healthy behavior.
used in posttraumatic stress disorders and phobias .Eye Movement Desensitization and Reprocessing Saccadic eye movements are rapid oscillations of the eyes that occur when a person tracks an object that is moved back and forth across the line of vision. A few studies have demonstrated that inducing saccades while a person is imagining or thinking about an anxiety-producing event can yield a positive thought or image that results in decreased anxiety.
Social Learning Approach Gives prominence to the reciprocal interactions between an individual‟s behavior and the environment .
Observational Learning Bandura . modeling (learning by watching another person perform a behavior). and behavior rehearsal (acting out a behavior to learn it and refine it as a skill). Observational learning occurs through vicarious reinforcement (being influenced by seeing somebody else get reinforced). .a leading social learning theorist of the 1960s and 1970s emphasized observational learning.
Person can learn new behavior 2. Behavior that is inhibited becomes less frequent Participant Modeling .Social Learning Techniques Modeling: learning by observing others Serves two purposes: 1.
Vicarious Learning observing other people‟s behaviors being rewarded or punished leads to reinforcement of those behaviors in an observer .
ROLE-PLAYING the rehearsing of speech and actions while pretending to be in a particular situation or in a set of circumstances .Behavioral Rehearsal COVERT MODELING imaginal practice of a desired behavior and is essentially role-playing in the imagination( ie covert).
Observational Learning as Therapy Participant Modeling patients learn a new behavior by imitation. without having to perform the behavior until they feel ready has been used successfully with agoraphobia by having a therapist accompany a patient into the feared situation . primarily by observation.
fear of flying. and claustrophobia. .Exposure to Stimuli Presented in Virtual Reality Advances in computer technology have made it possible to present environmental cues in virtual reality for exposure treatment acrophobia.
SST usually includes a focus on verbal and nonverbal behaviors (eye contact.Social Skills Training. speech latency) to learn how to interact with others more effectively Possession of the basic skills for conversation is essential to master social interactions and overcome maladaptive anxiety Five techniques are used for social skills training: (1) instruction in the skill. (2) modeling of the skill . and (5) positive reinforcement behavioral rehearsal is the critical element . (3) behavioral rehearsal (4) corrective feedback.
initiating. and being assertive). Interpersonal skill enhancement includes teaching verbal and nonverbal mechanics of successful social encounters (e. establishing and maintaining friendships. . and why to initiate and terminate interpersonal interactions.. where. and ending conversations. maintaining. two broad components: Social environment awareness (social perception) involves teaching the nuances of when.g.
job-seeking skills. It may also include more complicated skills. heterosocial skills. in individuals with medical conditions associated with interpersonal and environmental stress . in some cases. used effectively with adults and children with different psychological disorders and. and public speaking skills. such as anger management skills.
structured problem solving.Anxiety management training (stress Inoculation training) Anxiety is a normal response to stress The goal of SIT is to teach patients to understand dynamics of stress and to enhance their intrapersonal and interpersonal skills for managing stress Include breathing and relaxation training . . guided selfdialogue . behavioral rehearsal(covert modeling and role-playing). assertiveness training .
high stress-jobs. medical patients undergoing painful procedures.stress Inoculation training In PTSD. athletes .
Assertiveness Training enables a person to act in his or her own best interest. . to stand up for herself or himself without undue anxiety. and to exercise personal rights without denying the rights of others. Two situations frequently call for assertive behaviors: (1) setting limits on pushy friends or relatives and (2) commercial situations. such as countering a sales pitch or being persistent when returning defective merchandise. to express honest feelings comfortably.
They also are reinforced operantly because they serve to reduce stress .Habit Reversal Training designed to reduce repetitive behaviors (habits) such as hair pulling. nail biting. stuttering. and tics Habits become associated with various situations and cues through the process of classical conditioning.
Patients learn to engage in these competing behaviors to break the conditioned stimulus–habit cycle . relaxation training. This process involves identifying a motoric behavior that is incompatible with the habit and inconspicuous to others. Fist clenching is a commonly used. and reinforcement. competing response training. including awareness training. Competing response training is the core of HRT. habit control motivation. Done using a combination of procedures.
based on the idea that the autonomic nervous system can come under voluntary control through operant conditioning. using the feedback from the display as a guide.Biofeedback Biofeedback involves the recording and display of small changes in the physiological levels of the feedback parameter. (Neal Miller ) . Patients are instructed to change the levels of the parameter.
instruments are the electromyogram (EMG),; the electroencephalogram (EEG) the galvanic skin response (GSR) gauge, and the thermistor, which measures skin temperature (which drops during tension because of peripheral vasoconstriction). For example, a person can learn to raise the temperature of his or her hands to reduce the frequency of migraines, palpitations, or angina pectoris.
Biofeedback can be used by itself or in combination with relaxation. urinary incontinence to regain control over the pelvic musculature. rehabilitation of neurological disorders.
Strong empirical tradition and evidence Specific problems are identified and attacked Forces client to be explicit about goals Can be used with a variety of populations
CONTRIBUTIONS CONTRIBUTIONS Wide variety of techniques available Therapy stresses „doing‟ Techniques have been extended to more areas of human functioning than any other therapeutic approach Emphasis on research into and assessment of treatment outcomes .
Weaknesses Does not address broader human problems Does not integrate past Therapists can manipulate Difficult with certain groups May not emphasize the role of feelings enough .
Application – – – – – Anxiety disorders Sexual Disorders Marital problems Childhood Disorders / behavioral syndromes Eating Disorders .
THANK YOU .
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