Why Focus on Theory?

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Why Focus on Theory?

• Guide your interventions to be maximally
  effective/efficient for unique clients and
  situations
• Empirical studies (and ESTs) are never sufficient
• can never be enough studies
• research findings always require interpretation
• there are always exceptions (moderators)
• Very often therapists need to improvise
• if fewer sessions than recommended
• if client does not respond to standard procedures
• if client does not cooperate (e.g., culture,
  world-view)
• if client has a problem not in DSM, atypical,
  or NOS
• Allows for technical eclecticism
• Orient clients (expectancies and collaboration)

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Becoming a Good Therapist

• Learn principles of behavior and behavior change
• Learn techniques, observe therapy
• Practice, practice, practice!
• Have CBT supervisors view your videotapes and
  give you feedback
• Incorporate new research (PSY6023)

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Specific things to learn

• How to do a thorough person-specific analysis of
  proximal causes
• Understand effective ways to change problematic
  thinking and emotions
• Understand treatment failures
• failures to generalize to real world
• return of problem behaviors/emotions

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What is Behaviorism?

• 1. Principles of learning derived from science
• 2. Does not acknowledge internal diseases
• 3. Leads to superficial change (symptom
  substitution)
• 4. A set of technical language that alienates
  others
• 5. It is coercive/controlling, limits free will
• 6. It oversimplifies human complexities
• 7. Is too deterministic, claiming that responses
  are only determined by immediate stimuli (S-R)
• 8. It feels dehumanizing, ignoring most thinking
  and feeling and the uniqueness of each person

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Behaviorism Myths

• 3. Little evidence for symptom substitution
• 5. It is generally not coercive/controlling
• 5. It does not limit free will
• 6. Behavioral theory is complex in considering a
  variety of causes including thinking
• 7. No longer a stimulus-response theory
• 8. It does not have to feel dehumanizing, if so
  it is based on your thinking and/or conditioning
• 8. It does not ignore thinking and feeling and
  very much considers uniqueness of each person

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Which Therapy Orientation?

• 1. Free association
• 2. Free responses to ambiguous auditory stimuli
• 3. Analysis of patients feelings toward therapist
  and how they resemble feelings toward others

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The Functions of CBT

• 1. Increase abilities for effective behavior to
  live a valued life
• 2. Improve motivation and salience of true goals
• 3. Decrease thoughts/emotions that interfere with
  effective behaviors or quality of life
• 4. Increase distress tolerance and acceptance
• 5. Restructure the environment to promote
  effective behaviors (antecedents and
  consequences)
• 6. Ensure generalization to natural environment

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What is CBT?

• Interventions guided by CBT theories
• Functional analysis
• Problem solving
• 1. Skills training
• 2. Cognitive modification
• 3. Exposure strategies
• 4. Mindfulness/meditation
• 5. Contingency management
• 6. Homework

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The Therapists Influence

• Verbal teaching (didactic/instruction)
• Modeling (intentional and inadvertent)
• Reinforcement and punishment
• verbal
• nonverbal (intentional and inadvertent)
• careful observation the counting horse
• natural versus arbitrary

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The Therapists Influence

• Modeling
• Negative judgment of others (validation)
• Positive judgment (praise)
• Failure model (validation)
• Reinforcement
• of judgment (by laughing)
• of self-criticism (by reassuring or praise)
• of suicidality (by providing more help)

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The Teachers Influence

• Verbal teaching (didactic/instruction)
• Modeling (intentional and inadvertent)
• Reinforcement and punishment
• Verbal
• Nonverbal (intentional and inadvertent)

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What are Effects of These Consequences?

• Praise
• Being yelled at and criticized
• Food
• Physical pain
• Fear
• Gaining weight (obesity)
• Time-out from recess (child)
• Beep (stacked squares) SEraser

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Function Varies Considerably

• Function (causal relations) depends on
• the disorder
• the person (genetics learning history)
• external context (physical or interpersonal)
• recent external events/stimuli
• internal context
• biological changes (e.g., hunger)
• emotions
• mental perspective or thinking
• drug intoxication

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What is CBT?

• Interventions based on a commitment to the
  scientific analysis of
• causes of psychopathology
• change strategies
• efficacy/effectiveness
• mechanisms of change
• operational definitions of causes, behaviors, and
  change processes

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What is CBT?

• CBT is driven by science
• CBT is diverse and evolving
• CBT is active and collaborative
• self-monitoring
• learning new coping skills and behaviors
• practice in and out of sessions

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What is CBT?

• What is behavior therapy?
• What is radical behaviorism?
• What is (applied) behavior analysis?
• What is cognitive therapy?
• What is cognitive-behavior therapy?
• Whats the difference??

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History of CBTThe Pendulum Swings

• Introspection psychology problematic
• 1st wave of CBT
• Watson extreme behavioral
• Skinner radical behavioral, less extreme
• 2nd wave of CBT Cognitive revolution
• 3rd wave of CBT
• contextual approaches
• integrative approaches

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History of CBTYour Mentorship Lineage

• William James
• Albert Bandura (Stanford)
• Gerald Davison (USC)
• Marsha Linehan
• Milton Brown
• you

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Early Behavioral Theory

• Behavior is controlled by its Antecedents and
  Consequences

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To a BehavioristAll forms of behavior can
cause other behaviorsCognitions are not
causes
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Stimulus Control

• Current stimuli can control current responses
• bell gt salivation
• white rat gt fear
• close gt contraction of pupils
• bedroom gt alertness anxietyworry
• being in any car gt sleepiness sleep
• size of plate gt amount of food eaten
• darkness (outside) gt TV (no chores)

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Stimulus Control

• Control responses by controlling antecedents
• remove conditioned stimuli
• remove discriminative stimuli
• remove opportunities to behave
• prevent problematic conditioning
• Examples
• remove binge foods (cigarettes) from home
• rearrange the space in which eating occurs
• rearrange the space in which person sleeps
• do not read or watch TV in bed

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Why the Cognitive Revolution?

• Evidence against behavioral theories
• lack of S-R consistencies between people
• individuals respond differently to same stimuli
• intermittent reinforcement effects
• observational learning
• cognitions/awareness correlate with learning
• cognitive dissonance effects
• overjustification effects (rewards)

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ABCs of Cognitive Therapy

• Thoughts and beliefs determine emotions and
  behavior.

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ABCs of Cognitive Therapy

• Examples
• student getting bigger belly
• person hunched over at Home Depot saying Dont
  kill yourself
• letter from Board of Psychology
• at Target, I turned around and my daughter was
  gone

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The Big Debate
The Role of Cognition (B) in Dysfunctional
Emotions and Behaviors (C)
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Cognitive Mediation of Emotions and Behaviors
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John Watsons Behaviorism
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Disadvantages of Early Models

• Insisting always cognitive mediation
• impedes search for other causes
• external antecedents/context
• cognitive learning in context
• role of mental context vs. cognitive content
• consequences for problem and target behaviors
• clients fabricate plausible thoughts

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Modern CBT Theory
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The Failure of Catharsis
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A Reformulation of Differences

• Pure Behavior Therapy
• John Watson (pure externalism)
• Behavioral-Cognitive Therapy
• B.F. Skinner (the least cognitive)
• Steven Hayes (contextual Skinnerian)
• Albert Bandura (50-50)
• Arthur Staats (50-50)
• Cognitive-Behavioral Therapy (the most cognitive)
• Aaron T. Beck
• Albert Ellis (more behavioral than Beck)

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Three Ways to Reduce Suffering and Stop Problem
Behaviors

• 1. Change problematic thoughts
• 2. Reduce negative emotions
• 3. Change the way you relate to your thoughts and
  emotions (internal context)

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3rd Wave of CBT

• Acceptance and Commitment Therapy
• Dialectical Behavior Therapy
• Mindfulness-based Cognitive Therapy
• Mindfulness-based Stress Reduction
• Mindfulness-based Relapse Prevention
• Mindfulness-based Therapy for GAD

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Two Primary Forms of Learning

• 1. Classical (respondent) conditioning
• 2. Operant (instrumental) conditioning
• to help us effectively navigate our world
• make use of signals effectively prepare us for
  important events and opportunities

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Two Primary Forms of Learning

• 1. Classical (respondent) conditioning
• 2. Operant (instrumental) conditioning
• Both usually co-occur and interact
• Both signals and responses
• can occur outside of awareness
• can be inside or outside the person

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Respondent Conditioning

• UCS important evocative stimuli, usually not
  learned (e.g., injury or food)
• UCR natural response to a UCS
• CS stimuli (usually neutral) that acquire
  potential to elicit a new response
• CR the learned response

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Respondent Conditioning

• Original Theory stimulus substitution
• A previously neutral stimulus functions as the
  evocative stimulus with which it has been paired
• The response transfers to the neutral stimulus
  such that it is no loner neutral
• The number temporal pairing of CS-UCS determines
  the CR strength

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Pavlovian Experimental Apparatus
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Little Albert Experiment
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Respondent Conditioning
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Respondent Conditioning

• CS UCS UCR CR .
• T1 bell gt orienting
• T2 food gt salivation
• T3 bellfood gt salivation
• T4 bell gt salivation
• T1 rat gt orienting
• T2 noise gt startle/fear
• T3 rat noise gt startle/fear
• T4 rat gt fear/crying

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Generalization Gradient
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Respondent Conditioning

• Salivation can be conditioned to almost any
  neutral stimulusbuzzers, lights, touches
• One dog was conditioned to salivate when it
  received an electric shock. At first the shock
  was very weak so as to be barely perceptible. As
  the shock was increased in strength it was found
  that a very strong shock produced no sign of pain
  or displeasure. There was no quickening of the
  heartbeat or breathing which usually accompanies
  an unpleasant event. Instead the shock was
  followed by mouth-watering and tail wagging.

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Respondent Conditioning

• CS UCS UCR CR .
• T1 bell gt orienting
• T2 light gt pupils contract
• T3 belllight gt pupils contract
• T4 bell gt contraction
• CS can also be the spoken word contract, which
  can cause the pupils to contract

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• Learning principles apply to both overt
• behaviors and private behaviors
• Internal/private stimuli can become CS
• thinking
• emotions
• heart beat
• reinforcement and punishment can alter
• internal responses
• thinking
• emoting
• involuntary or reflexive behaviors
• cough
• bruxism

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Verbal Conditioning

• Command your pupils to contract
• Command your temperature to drop

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Interoceptive Conditioning

• Exteroceptive conditioning
• Ex overtly spoken words CONTRACT
• Interoceptive conditioning
• Ex sub-vocal speech CONTRACT

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Rescorla-Wagner Theory

• Our brains are not stupid!!
• Conditioning is not simplistic.
• Conditioning effects depend on many factors
• based on what is useful

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Rescorla-Wagner Theory

• Conditioning is not a stupid process by which the
  organism willy-nilly forms associations between
  any two stimuli that happen to co-occur. Rather,
  the organism is better seen as a strategic
  information seeker striving to predict its world
  to increase good outcomes and avoid harm. If one
  thinks of classical conditioning as developing
  between CS and US under just those circumstances
  that would lead a scientist to conclude that the
  CS causes the US, one has a surprisingly
  successful heuristic for remembering the facts of
  what it takes to produce associative learning.

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Rescorla-Wagner Theory

• Stimuli only become signals when
• they give the person time to prepare
• CS precedes the UCS (forward conditioning)
• meaningful associations form
• US-CS contingency is necessary (depends on)
• CS predicts that things will get better or worse
• US-CS contiguity is not sufficient

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US-CS Contiguity is Not Sufficient Contingency is
Necessary

• CS signal a change in the probability or severity
  of a UCS
• the UCS depends on the CS (to some extent)
• the UCS is contingent upon the CS
• expectation things will get better or worse
• Thus, no CR will develop if
• CS gt UCS frequently AND
• UCS occurs as frequently in the absence of the CS

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Rescorla-Wagner Theory

• Conditioning occurs when the organism is
  surprised
• and there are stimuli that can make the
  surprising situation more predictable
  (expectancies ifthen)

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US-CS Contiguity is Not Sufficient Contingency is
Necessary
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Behavior-Consequence Contiguity is Not Sufficient
Contingency is Necessary
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US-CS Contiguity is Not Sufficient for
Conditioning to Occur
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US-CS Contiguity is Not Sufficient for
Conditioning to Occur
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Outdated Theories ofRespondent Conditioning

• Stimulus substitution theory is limited
• CR often differs from UR
• sometimes CR is opposite to UR
• different CS (paired with same US) have different
  CRs

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Outdated Theories ofRespondent Conditioning

• Different CS (associated with same US) have
  different CRs
• CS UCS CR / UCR
• shock quick burst of activity
• sound less activity
• visual evade/block
• food swallowing
• sound more activity (general)
• visual pecking

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Respondent Conditioning

• UCS CS UCR CR .
• heroin euphoria
• analgesia
• needle dysphoria
• garage hypergesia
• sad
• Interoceptive conditioning

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Respondent Conditioning of an Opponent Process
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Operant Conditioning

• Is a stimulus added or removed as a consequence?
• Does the behavior increase or decrease?
• add remove
• increase
• decrease
• Ex. negative reinforcement increase in the
  probability of a behavior occurring in the future
  when removing an aversive stimulus after the
  behavior occurs.

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Two-Factor TheoryUCS are Primary Reinforcers
CS are Conditioned Reinforcers

• Antecedents
• sight of food (CS) elicits salivation
• sight of food (SD) elicits eating behavior
• Consequences
• food in mouth (UCS) elicits salivation (UCR)
• food in mouth (SR) reinforces eating

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Two-Factor TheoryUCS are Primary PunishersCS
are Conditioned Punishers

• Antecedents
• light (CS) elicits fear (HR increase)
• light (SD) elicits fleeing
• Consequences
• shock (UCS) elicits fear (HR increase)
• shock (SP) punishes staying
• escape from shock (SR) reinforces fleeing

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Operant Conditioning in ContextDiscriminative
Stimuli

• Skinners three-term contingency A-B-C
• Discriminative stimuli (A) are the specific
  stimuli that signal that specific behaviors (B)
  will be reinforced or punished (C)

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Operant Conditioning

• Negative reinforcement and positive reinforcement
  are often indistinguishable
• Positive punishment is usually followed by neg.
  reinforcement of an opposite behavior
• Negative punishment is usually followed by pos.
  reinforcement of an opposite behavior
• SD and consequences are often CS

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Change the Environment

• Stimulus control
• Contingency management
• How and where?
• in clients natural environment
• in therapy sessions
• dragging out new behavior in sessions
• contingency contracts (not natural)
• therapy vacation/termination

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Change the Environment

• What responses get reinforced? How?
• Internal or external reinforcement?
• depression
• substance abuse
• anxiety disorder
• anger
• What consequences should change?
• Alternative ways to get reinforcers?

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Change the Environment

• Contingency management in therapy
• adolescent contract
• LA sliding scale contract
• LA getting more exercise and regulating sleep
• make phone calls more available
• end non-productive phone calls

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First Contingency Contract

• 2 pts exercise lt 8 am (time stamp receipts)
• 1 pt exercise gt 8 am
• 1 pt work lt 8 am (3 pts max)
• points session fee
• 1 200
• 4 140
• 5 80
• 7 20
• 0 0

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2nd Contingency Contract

• Cardio exercise machine (verified with photo)
• any level of intensity
• lt 8 am 4 per minute (fee reduction)
• gt 8 am 1 per minute
• minutes session fee EXAMPLES
• 0 200
• 30 (lt 8 am) 80
• 50 (lt 8 am) 0
• 50 (gt 8 am) 150
• 120 (gt 8 am) 80

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New Contingency Contract

• Target Behaviors
• work before 7am (verified with printout)
• babysitting nephews at their house before 7am
  (verified via caller ID phone call)
• exercise lt 8 am (verified by photo emailed by
  830am)
• Daily fees (for 7 mornings prior to session)
• 50 if no babysitting and no work before 8 am.
• 20 when begin babysitting or work 7 am - 8 am.
• 0 when begin babysitting or work before 7 am
• fee reduction of 60 per mile (lt 8 am) on cardio
  exercise machine

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Contingency Management

• UAs 3 days/wk, 2 days/wk, 1 day/wk
• Voucher Method
• 1 each time abstinent, increase 1.50 each time
• reset to 1 if positive, refusal, or missed
• 2 weeks of negatives reinstates highest reward
• 10/wk bonus
• Lottery Prize Method (variable ratio schedule)
• 50 chance of money or Good job, try again
• usually 1 or 20, and 1/500 chance for 100
• each time abstinent one extra draw

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Contingency Management

• Cost per patient for six weeks outpatient
  treatment
• 175 - Standard
• 375 - Voucher Method (100 paid to patient)
• 350 - Lottery Prize Method (80 paid to patient)
• 12 weeks of intervention in research studies

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Escape ConditioningPunishment Neg.
Reinforcement
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Negative Reinforcement

• Escape Negative reinforcement
• escape from punishment and UCS/CS
• punishment for not escaping
• no opportunity for extinction when there is no
  longer any UCS
• Avoidance of punishment reinforcement

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Two-Factor Fear Theory

• The Avoidance Paradox
• How could an absence of a stimulus reinforce a
  response?
• Solution
• escape from fear CR is negative reinforcer

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Evidence for Two-Factor Theory

• Escape from CS decreases fear CR
• Increasing fear (CR) increases avoidance
• adding conditioned fear stimuli
• Decreasing fear decreases avoidance
• adding conditioned inhibitors (safety signals)

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Problems with Two-Factor Theory

• Not all fears begin with classical conditioning
• Fear extinction should occur after CS repeated
  without UCS
• extinction only to brief CS exposure if escape
• Fear decreases as avoidance (of UCS) becomes
  stronger/quicker over time
• avoidance without noticeable fear
• increasing sense of control and predictability

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Two-Factor Fear Theory

• The Avoidance Paradox
• How could an absence of a stimulus reinforce a
  response?
• Solutions
• CS are conditioned/secondary punishers
• escape from CS is negative reinforcer
• CS is an SD
• safety signals are conditioned positive
  reinforcers

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One-Factor Theory

• Avoidance responses can be learned without
  respondent conditioning (CS or CR)
• Sidman non-signaled avoidance task
• no obvious CS to avoid
• pressing a bar delays a shock for 30 sec
• 10 vs. 30 probability of shock every 2 sec

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Agenda class 4

• Pratice midterm exam
• Your examples
• Reading quiz
• Review FA instructions and examples
• SuperNanny videos
• Your projects
• New videos

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Behavioral Conceptualization of Hypothetical
Constructs

• Non-behavioral explanations
• internalize and externalize
• need
• projection
• catharsis (emotional release)
• rejection sensitivity is the reason why some
  people are exceptionally distressed by rejection

84
Behavioral Conceptualization of Hypothetical
Constructs

• Report the times of day the behavior occurs
• Give specific examples of thoughts
• Focus on consequences that actually explain why
  the behavior occurs. Do not list hypothetical
  long-term consequences

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Behavioral Problem Definition

• 1. stressed
• 2. tardiness
• 3. procrastination
• 4. biting nails "is not that strong"
• 5. driving "well above" the speed limit
• 6. unexpectedly heavy traffic is cause of
  arriving late (target should be time at leaving
  the house)
• Review the Target sections of previous
  students functional analyses

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Behavioral Analyses

• Estimate the probabilities of the response (e.g.,
  every time?) when the various "triggers" occur
• Conditional probabilities
• P(AB) vs. P(BA)

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Therapeutic Exposure

• Learned emotional responses will be eliminated
  when
• there is repeated/prolonged exposure to all
  triggers (and variations thereof)
• in all contexts
• as long as the person does not escape
• and nothing bad happens.
• Is it feasible?

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Therapeutic Exposure

• (prolonged non-reinforced exposure and response
  prevention)
• Expose
• repeated avoided behaviors
• enter avoided situations
• present avoided stimuli
• actual stimuli (in vivo)
• imagery (simulation)

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Emotional Processing Theory

• Activate the emotion schema
• e.g., danger
• therefore, arousal should be high
• Introduce incompatible information
• e.g., safety (disconfirm danger)
• (active cognitive processing)

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Extinction

• Reversal (decrease) of learned responses
• reverse classical conditioning
• reverse operant responses
• Extinction is new learning not un-learning
• does not erase previous learning
• decrease in response depends on context
• original conditioning often overrides extinction

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Respondent Extinction

• Conditioned stimuli occur
• Emotionally-evocative stimuli no longer follow
• UCS
• 1st-order CS (to extinguish 2nd-order CS)

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Reinforced Fear

• Reacquisition re-pairing of CS and UCS
• Reinstatement recurrence of UCS reactivates the
  CR, even if no additional pairing

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Reacquisition of Fear

• CS1 light
• CS1 gt shock (10 times, 100 amps)
• CS1 gt fear (9/10)
• CS1 gt no shock (100 times)
• CS1 gt no fear (2/10)
• CS1 gt shock (1 time , 50 amps)
• CS1 gt fear (8/10)

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Respondent Habituationvs. Extinction

• Habituation is a decrease in CR and UCR due to
  simple repetition of CS and UCS
• person gets used to the stimulus
• satiation is habituation to positive stimuli
• Extinction only explains reduction in CR
• lack of stimuli that could reinforce CR

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Habituation or Extinction?

• No longer bothered by Sushi after many Sushi
  meals
• Less excitement after many years in a
  relationship
• Child becomes less afraid of water by staying in
• Water seems less cold after staying in a while
• Repeatedly petting a dog reduces fear
• Praise becomes less effective if it is used too
  much
• Criticism becomes less effective if it is used
  too much
• Whipping becomes less effective punishment

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PTSD Fear Schema
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What do PTSD Patients Avoid?

• Conditioned stimuli (fear schema)
• classically conditioning
• higher order conditioning
• semantic conditioning
• Fear and other emotions
• Symbolic and verbal stimuli
• Mental images of catastrophes

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Extinction Depends on Context

• Extinguished responses return when the extinction
  context differs from the new context
  (conditioning is more general)
• time
• previous events
• physical setting or other stimuli
• biological states
• emotional states

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Extinction Depends on Context

• Extinguished responses (respondent and operant)
  return when the extinction context differs from
  the new context
• spontaneous recovery (AAA)
• renewal (ABA, ABC, AAB)

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Extinction Depends on Memory

• We never forgot our past harm
• We easily forget our past safety
• Memory enhancers
• D-cycloserine
• Extinction reminders

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Extinction Depends on Context

• Renewal Types
• 1 2 3
• Conditioning A A A
• Extinction B A B
• Re-exposure A B C
• to CS/SD
• There are three settings or contexts A, B, C

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Renewal Examples

• extinction context renewal context
• jumping barrier added barrier removed
• no drug lever removed drug lever added
• SuperNanny present SuperNanny gone
• male therapist in office at clients home
• greyhound did not bite bulldog
• Black friendly in suburb in ghetto

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Conditioned InhibitionSafety Signals

• J.P. Segundo
• cats were given painful electric current
• a sound (CS) occurred when electricity was turned
  off (-UCS)
• UCR relaxation
• CR sound elicited relaxation even when current
  was not turned off

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Renewal of Avoidance Extinction
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ABA Renewal

• CS1 (light) gt UCS (shock) gt CS2 (sound)
• CS1 gt fear
• CS2 gt relaxation
• CS1 CS2 gt no shock (extinction)
• CS1 CS2 gt no fear
• CS1 gt fear

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Renewal (Internal Context)

• CS1 (light) gt UCS (shock)
• CS1 gt fear
• CS1 CS2 (caffeine) gt no shock
• CS1 CS2 gt no fear (extinction)
• CS1 gt fear
• CS1 gt no shock (extinction)
• CS1 CS2 (caffeine) gt fear

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ABA Renewal

• CS1 (outside) gt UCS (vomit)
• CS1 (outside) gt fear gt pills gt less fear
• pills gt relaxation
• CS1 pills gt extinction (no fear)
• CS1 gt fear

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Safety SignalsExplanations for Safety

• Safety is attributed to the safety signal, not
  the CS
• Therefore, the perceived danger of the CS is not
  disconfirmed

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Reinstatement of Fear

• CS1 light, CS2 sound
• CS1 gt shock (10 times, 100 amps)
• CS1 gt fear (9/10)
• CS1 gt no shock (100 times)
• CS1 gt no fear (2/10)
• CS2 gt shock (1 time , 100 amps)
• CS1 gt fear (5/10)

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SuperNanny

• mutual coercion (negative reinforcement)
• stimulus control (structure)
• non-contingent reinforcers (estab. oper.)
• extinction (no pay off for bad behavior and not
  getting out of demands)
• negative reinforcement (time out)
• extinction (for getting off time out)
• extinction for leaving bed

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ABA Bird Feeding Renewal

• MOVE OPERANT RENEWAL SLIDES TO A MUCH EARLIER
  LECTURE

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ABA Child Tantrum Renewal

• 1 Parents extend bed time (before SuperNanny)
• 2 With help from SuperNanny, parents do not
  extend bedtime
• 3 After SuperNanny leaves, parents ask for bed
  time and child tantrums

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AAB Child Tantrum Renewal

• 1 Parents extend bed time
• 2 Parents do extinction
• 3 Babysitter ask for bed time and child tantrums
• 1 Parents extend bed time at home
• 2 Parents do extinction at home
• 3 Parents ask for bed time on vacation and child
  tantrums

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Distraction and Safety Behaviors

• 1. Safety behaviors and distraction can impede
  emotional processing
• 2. Safety behaviors and distraction can enhance
  emotional processing

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Advantages of Modern Integrative CBT Theory

• Is flexible for different cases
• Encourages examination of many causes
• More opportunities for intervention
• Considerable empirical support
• Guides effective interventions

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Stimulus Control

• Current stimuli can control current responses
• bell gt salivation
• white rat gt fear
• close gt contraction of pupils
• bedroom gt alertness anxietyworry
• being in any car gt sleepiness sleep
• size of plate gt amount of food eaten
• darkness (outside) gt TV (no chores)

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Problems with Reinforcement

• Therapists lack of awareness of mutual influence
  or of behaviors needing to be reinforced
• Inadvertent reinforcement of problems
• Inadvertent failure to reinforce progress

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Generalization Gradient
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Reinforcement Example

• cues (SDs)
• same physical position
• I repeat word/number when she reaches toward the
  wrong one
• she looks at my facial expression
• she looks at where I am looking

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Newer Theories ofRespondent Conditioning

• Conditioning does not simply result from repeated
  temporal pairing of stimuli
• high base-rate occurrence of UCS (without CS)
  reduces strength of CR
• high base-rate occurrence of CS (without UCS)
  reduces strength of CR
• depends on other stimuli and context
• some stimuli are harder to condition
• CS can be paired with absence of UCS

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Ways to Change Learned Emotional Responses

• Cognitive restructuring
• Therapeutic exposure to emotion triggers
• Counter-conditioning (reciprocal inhibition)
• problematic stimuli/responses paired with other
  competing/opposite stimuli/responses
• emotion regulation behaviors
• opposite actions (e.g., approach, confidence)
• Cognitive dissonance induction

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Orienting to Exposure

• Habituation
• Emotional processing
• role of safety signals
• Self-efficacy (confidence and control)
• Generalization (prevent renewal)
• Opposite action

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Exposure Rationale

• Brain tricks us into believing overly fearful
• protects us by overgeneralizing perceived danger
• reminders, memories, and images seen as dangerous
• emotion brain areas different than logical areas
• Desensitize or get used to triggers
• give examples
• Practice tolerating or coping with triggers
• Get brain to realize that many situations,
  reminders, memories, images are not dangerous
• needs convincing information from a new
  experience
• needs enough time for safety info to sink in to
  the gut
• we must talk to the emotional part of the brain
• We can act into new emotions

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Resistance to Exposure Therapy

• Client Questions
• Why should it help when I already get triggered
  all the time?
• Why should I repeat negative thoughts when I will
  just end up believing them more and get more
  upset?

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Systematic DesensitizationRelaxation does
improves outcomeswhen added to intermittent
imaginal exposure1 gt 2
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Systematic Desensitization

• Imaginal exposure can reduce fear without any
  relaxation training
• Relaxation sometimes does reduce fear more than
  graded imagery alone
• when therapist controls progress up the hierarchy
• when there are few treatment sessions
• when there is short duration of exposure trials
• Most studies have shown that the timing of
  relaxation does not influence outcomes

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Systematic Desensitization

• In animal studies
• exposure to CS is necessary and sufficient for
  fear reduction
• graded exposure vs flooding has comparable
  outcomes
• offering food during exposure can help OR impede
  fear reduction
• helpful if the food helps the animal get more
  exposure

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Exposure Relaxation

• For fear reduction
• prolonged exposure is most effective
• adding relaxation does not help
• 1 2 gt 3

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Exposure Relaxation

• It is possible that relaxation
• increases collaboration and willingness
• gets more exposure
• makes desensitization occur more quickly

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Exposure Cog.Restructuring

• For fear reduction
• adding cognitive restructuring does not help
• 1 2 gt 3

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What is the most effective way to change a
negative schema?

• How to solve the head vs. gut problem?
• Is cognitive processing necessary?
• rational disputation or experiential/emotional?
• Are passive learning experiences sufficient if
  the person gets important new info?
• Is active coping necessary?
• Are new actions necessary?

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Unified Protocolfor Treating Emotion Disorders

• Psychoeducation (attitude toward emotion)
• Antecedent cognitive reappraisal
• cognitive restructuring during episodes can be
  form of avoidance
• encourage cognitive flexibility
• get clients into avoided situations
• Prevention of emotional avoidance
• increase emotion awareness and tolerance
• Changing emotion-driven behaviors

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Opposite Action for Unjustified Emotions
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Opposite Action

• Not avoiding
• prolonged exposure and response prevention
• Actively approach (and choose)
• behavioral activation mastery experiences
• Opposite associations (counter-conditioning)
• Opposite emotions (reciprocal inhibition)
• Opposite verbal behavior
• Opposite nonverbal behavior
• confidence
• voice
• face

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New Behavior Changes Cognition

• On the one hand, explanations of change
  processes are becoming more cognitive.
• On the other hand, it is performance-based
  treatments that are proving most powerful in
  effecting psychological changes. Regardless of
  the method involved, the treatments implemented
  through actual performance achieve results
  consistently superior to those in which fears are
  eliminated to cognitive representations of threat
  (Bandura, 1977, p. 78)

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Modern CBT Theory
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Modern Behavioral Theory
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New thinking prompts new behaviors that lead to
more reinforcers and fewer punishers, which
changes depressive affect
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New behaviors lead to more reinforcers and fewer
punishers, which changes belief, which changes
depressive affect
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Counter-Conditioning

• Activate the conditioned responses
• Present stimuli that elicit different responses
• candy gt pleasure
• Engage in behaviors that elicit opposite
  responses (reciprocal inhibition)
• relaxation is incompatible with fear
• approach is opposite to fear, shame

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Counterconditioning

• CS UCS UCR CR .
• T1 rat gt orienting
• T2 noise gt startle/fear
• T3 rat noise gt startle/fear
• T4 rat gt fear/crying
• CS UCS UCR CR .
• T4 rat candy gt fear reduction
• T4 rat gt pleasure

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Reciprocal Inhibition TheoryFear Reduction

• Activate the conditioned fear responses
• Elicit incompatible responses to fear
• relaxation
• humor
• curiousity
• sexual pleasure
• HRV
• anger?
• (choose to) approach (with confidence)

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Systematic DesensitizationRelaxation does
improves outcomeswhen added to intermittent
imaginal exposure1 gt 2
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Reciprocal Inhibition TheoryAnger Reduction

• Activate the conditioned anger responses
• Elicit incompatible responses to anger
• empathy
• kindness

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Opposite Action
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Opposite Action

• Examples
• slow breathing
• nodding (head phone study)
• smiling (facial feedback)
• eat fried grasshoppers
• opposite political speech
• self-esteem
• snake exposure therapy commitment
• obesity study gains maintained 2 years

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Cognitive DissonanceCognitive Theory

• When we do act contrary to our beliefs and there
  are insufficient reasons for doing so we are
  uncomfortable (for lying, time, effort)
• To reduce the discomfort we change our beliefs so
  that we convince ourselves that there really was
  no discrepancy
• Ex self-attribution (personal explanation)
• I did it because I wanted to (intrinsic
  interest)
• I said it because its true

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Cognitive Dissonance Induction

• Counter-attitudinal role-playing
• elicit opposite public behaviors
• speech
• nonverbal behavior
• attitude act as if
• elicit discomfort and maximize effort
• low pressure high choice
• encourage internal attributions

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Cognitive Dissonance Induction

• Reduce avoidance
• increase emotional processing
• increase mastery and confidence
• solve problems and increase reinforcers
• Facial feedback
• Cognitive dissonance
• operant conditioning of consistency
• Classical conditioning
• smile (nodding) is CS for liking/agreement

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Cognitive DissonanceBehavioral Theory

• We reinforce each other for consistency
• we want others to be predictable
• We get punished for
• lying or breaking promises
• hypocrisy
• flip-flopping (John Kerry)
• Only if observed by others and if no observable
  external control or valid reasons

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Albert Bandura

• Observational learning (modeling)
• Attention
• Retention
• Reproduction
• Motivation
• past consequences
• promised consequences
• vicarious consequences

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Albert Bandura

• Self-regulation (self-control)
• Self-observation
• Standards of performance
• Self-administered consequences

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Cognitive-Affective Personality System

• Encoding-interpretation
• Expectancies
• Values and Goals
• Self-regulation
• Competencies and Skills

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The Functions of CBT

• 1. Increase abilities for effective behavior to
  live a valued life
• 2. Improve motivation and salience of true goals
• 3. Decrease thoughts/emotions that interfere with
  effective behaviors or quality of life
• 4. Increase distress tolerance and acceptance
• 5. Restructure the environment to promote
  effective behaviors (antecedents and
  consequences)
• 6. Ensure generalization to natural environment

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Skills

• 1. Behavioral control
• self-talk
• self-management (e.g., stimulus control)
• 2. Emotion regulation
• 3. Distress tolerance
• 4. Interpersonal effectiveness

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Obstacles to New Learning and Emotion Extinction

• Failure to change the emotion schema
• failure to access schema
• new beliefs in the head but not the gut
• safety signals
• safety behaviors
• Other problems with generalization
• new learning occurred in limited internal or
  external contexts

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Maximizing New Learning and Emotion Extinction

• Change the emotion schema
• access schema by eliciting emotion
• prevent safety signals
• block safety behaviors (avoidance)
• Promote generalization
• new learning in all relevant contexts

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Generalizing New LearningState-Dependent
Learning

• Goal to increase a new effective behavior or
  coping response.
• People will be more able/likely to engage in new
  behaviors and coping responses in new contexts
  are similar to the contexts in which the
  responses were learned.

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Processing Modes

• Intellectual Emotional
• Verbal Nonverbal
• Explicit Implicit / Tacit
• Conscious Unconscious
• Semantic Procedural
• Propositional Implicational

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Generalizing New Learning and Emotion Extinction

• Practice in all relevant contexts
• bring therapy into real life
• (cued) homework practice
• extinction reminder (safety signal?)
• in vivo coaching via telephone
• bring real life into therapy
• activate relevant emotions (schemas)
• have a genuine relationship
• work on real problems that emerge in sessions

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Generalizing New Learning and Emotion Extinction

• First
• approach evocative stimulus (in vivo)
• elicit fear, sadness, shame, depression, anger
• hold, smell, and taste alcohol
• hear negative statements
• imagine (or talk about) upsetting scenarios
• describe traumatic event in detail
• Then practice
• adaptive thinking
• regulating emotions (e.g., relax)
• acting assertive
• inhibiting impulsive action or acting opposite

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Generalizing New Learning and Emotion Extinction

• Rehearse thoughts during relevant emotion
• Devils advocate
• therapist voices negative thinking
• Systematic Rational Restructuring
• patient imagines upsetting situation
• Stress Inoculation Therapy

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• There once was a man who hated his own
  footprints. In order to get away from the
  footprints, the man ran faster and faster. But
  the faster he ran, the more footprints he made.
  And finally, he ran himself to death.
• - Zhuangzi, 300 BC

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Three Ways to Reduce Suffering and Stop Problem
Behaviors

• 1. Change problematic thoughts
• 2. Reduce negative emotions
• 3. Change the way you relate to your thoughts and
  emotions (internal context)

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3rd Wave of CBT

• Acceptance and Commitment Therapy
• Dialectical Behavior Therapy
• Mindfulness-based Cognitive Therapy
• Mindfulness-based Stress Reduction
• Mindfulness-based Relapse Prevention
• Mindfulness-based Therapy for GAD

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Modern Behavioral Theory
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Mindfulness

• Keeping ones consciousness alive to the present
  reality Hanh
• Bringing ones complete attention to the present
  experience on a moment-to-moment basis Marlatt
• Paying attention in a particular wayon purpose,
  in the present moment, and nonjudgmentally
  Kabat-Zinn

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Meditation is OnlyOne Form of Mindfulness

• Forms of mindfulness practice
• Internal vs. external focus
• Focused vs. open awareness
• Isolated/sitting vs. integrated into life

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Mindfulness is NOT

• Buddhism
• Meditation
• Relaxation
• Thinking about what you notice
• Stopping thoughts

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Acceptance

• Experiencing events fully and without defense
  Hayes

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Acceptance

• Non-acceptance Pain Suffering
• Acceptance is NOT approval
• Acceptance is too hard!
• imagine accepting
• act as if you accept
• fully accept for even a moment
• Accept what is not true?

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Why Mindfulness?

• Differentiate facts vs. thoughts and judgments
• notice judgments and interpretations
• describe facts rather than judge or interpret
• Get unstuck from thoughts/memories
• pain with less suffering
• reduce rumination
• effective action despite contrary thoughts,
  feelings, or urges (slow down!)
• Exposure to primary emotions
• Effective distraction

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What is Your Brain Thinking?

• The thought ____ just popped into my mind
• I just felt like saying
• Dont take it personal!
• I just noticed ____ feeling arise within me
• Therapists should model this distancing

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Mindfulness-Based CT

• Kabat-Zinn MBSR applied to depression
• Works for depression relapse
• Works for depression in which thinking plays a
  prominent role
• Does not work for reactive depression

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Mindfulness-Based CT

• Study 1
• epis. MBCT TAU
• 1-2 54 31
• gt2 37 66
• Study 2
• MBCT TAU
• 1-2 50 20
• gt2 36 78

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Acceptance andCommitment Therapy

• Get out of your head and into your life

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Acceptance via Metaphors

• Quicksand
• Chinese finger traps
• The unruly child

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Question

• What is the relevance of ironic process theory
  for understanding and treating disorders of
  emotion?

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Ironic Process Theory

• Operating process
• Intentionally create distracting mental content
• Is difficult because negative content is much
  more accessible than positive
• very effortful, requires a lot of cognitive
  resources
• Monitoring process
• automatic search for failure

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Harmful Effects of Rewards

• When the reward is
• tangible / arbitrary / excessive
• promised in advance or expected
• contingent upon task involvement or effort
• When the behavior is
• already occurring at a high rate
• Handout 14

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Effective Reinforcement

• Contingent on completion of a behavior
• Provides specific useful feedback
• Not coercive, judgmental, or tied to punishment
• Minimal reinforcement
• Intermittent reinforcement
• Natural reinforcement
• pay attention to what the client does
• be responsive (reinforce behavior that is useful)
• use your natural reactions (SISD)
• generalizable (available in many contexts)

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Natural Reinforcement

• Putting on a jacket keeps you warm
• Using a toilet keeps you clean and dry
• Complying with a request (not praise)
• Excitement (not praise)
• Dismay or demoralization
• Flow of a conversation/relationship
• Bored listener when a client rambles
• SISD positive or negative

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Natural Reinforcement

• Amber
• Reading games
• Reading lyrics
• Reading gets compliance from us
• Opponent process shivered awake right after
  dreaming about hot shower

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Behavior Self-Interpretation

• We make conclusions about ourselves based on our
  behaviors and relevant explanations for our
  behaviors given the environmental context
• Behavior-schema discrepancy is uncomfortable
  (dissonant) without external explanations
• We seek to reduce dissonance either by finding
  reasonable external explanations or by changing
  our view of ourselves.

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The Cognitive Revolution

• Aaron T. Beck
• Albert Ellis
• Julian Rotter
• locus of control
• Albert Bandura
• Social Learning Theory
• Social-Cognitive Theory
• Walter Mischel (Cervone Shoda)
• Cognitive and Affective Personality System

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Levels of Cognition

• Schemas (e.g., inferred or latent content)
• core beliefs
• cognitive-affective neural networks
• Cognitive processing
• schema activation (inferred)
• distortions (e.g., negative bias)
• attributional style
• Cognitive products (content in awareness)
• automatic thoughts
• attributional conclusions

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Schemas

• Many inter-related components
• stimulus elements
• meaning elements
• (core) beliefs
• emotion elements
• action tendencies (scripts)

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Fear Schema
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Activation of Schemas

• Ambiguous situations similar to aspects of
  schema
• similar stimuli (visual, touch, smell, etc.)
• similar behaviors of others (comments, visual
  appearance)
• similar emotions
• similar meaning

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Count the Fs

• FINISHED FILES ARE THE RE-
• SULT OF YEARS OF SCIENTIF-
• IC STUDY COMBINED WITH
• THE EXPERIENCE OF YEARS.

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Cognitive Distortions

• Overgeneralization
• Labeling
• All-or-nothing thinking (rigidity)
• Mental filter
• Ignoring/discounting the positives
• Jumping to conclusions
• Mind Reading
• Fortune Telling
• Exaggeration/Minimization
• Emotional reasoning
• "Should" statements (rigid rules)
• Personalizing/Blame

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Depressive Thinking

• Becks Cognitive Triad
• Distorted negative thinking about
• Self (low self-esteem)
• World
• nothing is meaningful or worthwhile
• Future
• hopelessness
• helplessness (low self-efficacy)

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Schema Activation

• Schema I am unlovable
• Situation boss gives corrective feedback
• Cog. processing Cog. Products
• jumping to conclusions He is criticizing me
• neg. attribution / label (because) I am a
  loser
• mind-reading (because) he hates me
• fortune telling I will get fired

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Schema Activation

• Schema I am unlovable
• Situation Partner ends romantic relationship to
  move away for graduate school. Relationship was
  very strong, but not long
• Cog. processing Cog. Products
• neg. attribution (because) I am fat / ugly
• judgmental label / filter I am fat / ugly
• should I should lose more weight
• fortune telling I will never find another

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Schemas

• Danger Schemas Phobias
• Interpersonal Schemas
• Racial prejudice
• Gender roles
• Self-Schemas
• Unlovability/Rejection
• Abandonment/Mistrust
• Defectiveness/Shame
• Helplessness/Dependence
• Subjugation/Self-sacrifice

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Schemas

• CBT primarily works by changing schemas
• (Outdated?) remnants of previous learning
• Elaborate well-organized cognitive-affective
  structures, or neural networks
• Function
• Make sense of situations with incomplete or
  ambiguous information
• Generate useful responses to situations

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Schema Activation

• Schema Black people are criminals
• Situation see person taking food from a store
  without paying
• Verbal response ??
• Schema Black people are dangerous
• Situation police officer sees person standing
  up from behind an object in an alley
• Motor response ??

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Schema Activation

• Schema Old people are slow and sickly
• Priming see old words
• Motor response slower walking down hall
• Schema Interrupting is rude, helping is nice
• Situation describing a nice friend
• Motor response offer help to someone else

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Three CBT Approaches to Treating Depression

• Cognitive restructuring (inside out approach)
• change the content of thoughts
• Behavioral activation (outside in approach)
• activity scheduling
• problem solving
• change the function/context of thinking
• function of avoidance
• context of literality (ACT defusion, mindfulness)
• make behavior depend less on thinking/mood

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Activity Scheduling in Cognitive Therapy

• Pleasurable activities
• Nothing is meaningful or worthwhile
• Mastery activities (self-efficacy)
• I am incapable of doing anything
• Behavioral experiments
• I am incapable of that
• It wont work out

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Evidence for Cognitive Theories

• Many correlational clinical studies
• Some analog experimental studies
• repeating negative statements (Velten)
• delay of gratification (cognitive
  transformations)
• self-efficacy manipulations
• Clinical experiments on misattribution
• insomnia
• social fears
• Cognitive therapy is effective

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Cognitive Therapy Mediation Studies

• 1) CT is based on cognitive theory
• thinking causes emotions and behavior
• 2) Change in CT is associated with cog