CognitiveBehavior Therapy

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Chapter 13 Treatment of Psychological Disorders
to feared stimuli, flooding and other similar methods are also called exposure
techniques.)
Some unwanted behaviors, such as excessive gambling or using
addictive drugs, can become so habitual and temporarily rewarding that they must be
made less attractive if a client is to have any chance of giving them up. Methods for
reducing the appeal of certain stimuli are known as aversion therapy. The name reflects
the fact that these methods rely on a classical conditioning process called aversion
conditioning to associate shock, nausea, or other physical or psychological discomfort
with stimuli, thoughts, or actions the client wants to avoid (e.g., Bordnick et al., 2004).
Because aversion conditioning is unpleasant and uncomfortable, because it may not
work with all clients (Flor et al., 2002), and because its effects are often temporary, most
behavior therapists use this method relatively rarely, only when it is the best treatment
choice, and only long enough to allow the client to learn more appropriate alternative
behaviors.
Aversion Therapy
psychology
applying
TREATING FEAR
THROUGH FLOODING
Flooding is designed to
extinguish anxiety by allowing it to occur
without the harmful consequences the
person dreads. This man’s fear of flying is
obvious here on takeoff, but it is likely to
diminish during and after an uneventful
flight. Like other behavioral treatments,
flooding is based on the idea that phobias and other psychological disorders are
learned and can thus be “unlearned.”
Some therapists prefer more gradual
exposure methods similar to those of in
vivo desensitization, which start with
situations that are lower on the client’s
fear hierarchy (Back et al., 2001; Fava
et al., 2001; Fritzler, Hecker, & Losee,
1997).
Sometimes the only way to eliminate a dangerous or disruptive behavior is to punish it with an unpleasant but harmless stimulus, such as a shouted “No!”
or a mild electric shock. Unlike aversion conditioning, in which the unpleasant stimulus occurs along with the behavior that is to be eliminated (a classical conditioning
approach), punishment is an operant conditioning technique; it presents the unpleasant stimulus after the undesirable response occurs.
Before using electric shock or other forms of punishment, behavior therapists are
required by ethical and legal guidelines to ask themselves several important questions:
Have all other methods failed? Would the client’s life be in danger without treatment?
Has an ethics committee reviewed and approved the procedures? Has the adult client
or a close relative of a child client agreed to the treatment (Kazdin, 1994a)? When the
answer to these questions is yes, punishment can be an effective, sometimes life-saving,
treatment—as in the case illustrated in Figure 5.12 in the chapter on learning. As with
extinction and aversion conditioning, punishment works best when it is used just long
enough to eliminate undesirable behavior and is combined with other behavioral methods designed to reward more appropriate behavior.
Punishment
Cognitive-Behavior Therapy
aversion conditioning A method for
reducing unwanted behaviors by using
classical conditioning principles to create a negative response to some
stimulus.
punishment The presentation of an
aversive stimulus or the removal of a
pleasant one following some behavior.
rational-emotive behavior therapy
(REBT) A treatment that involves
identifying illogical, self-defeating
thoughts that clients have learned, then
helping clients replace these thoughts
with more realistic and beneficial ones.
Like psychodynamic and humanistic therapists, most behavior therapists recognize that
depression, anxiety, and many other behavior disorders can stem from how clients think
about themselves and the world. And like other therapists, most behavior therapists try
to change clients’ troublesome ways of thinking, not just their overt behavior. Unlike
other therapists, however, behavior therapists rely on learning principles to help clients
change the way they think. Their methods are known collectively as cognitive-behavior
therapy (Dobson, 2001; O’Donohue, Hayes, & Fisher, 2003). Suppose, for example, that
a client has good social skills but suffers intense anxiety around other people. In a case
like this, social skills training would obviously be unnecessary. Instead, the behavior
therapist would use cognitive-behavioral methods designed to help the client identify
habitual thoughts (such as “I shouldn’t draw attention to myself ”) that create awkwardness and discomfort in social situations. Once these cognitive obstacles are brought
to light, the therapist describes new and more adaptive ways of thinking—and encourages the client to learn and practice them. As these cognitive skills develop (e.g., “I have
as much right to give my opinion as anyone else”), it becomes easier and more rewarding for clients to let these new thoughts guide their behavior (Meichenbaum, 1995).
Rational-Emotive Behavior Therapy One prominent form of cognitive-behavior
therapy is rational-emotive behavior therapy (REBT), which was developed by
Albert Ellis (1962, 1993, 1995; 2004a, 2004b). REBT aims first at identifying unrealistic
and self-defeating thoughts, such as “I must be loved or approved of by everyone” or “I
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must always be competent to be worthwhile.” After the client learns to recognize such
thoughts as these and to see how they can cause problems, the therapist uses suggestions, encouragement, and logic to help the client replace such thoughts with more
realistic and beneficial ones. The client is then given “homework” assignments to try these
new ways of thinking in everyday situations. Here is part of an REBT session with a
woman who suffered from panic attacks. She has just said that it would be “terrible” if
she had an attack in a restaurant and that people “should be able to handle themselves!”
Rational-emotive behavior therapy (REBT) focuses on altering
the self-defeating thoughts that Ellis believes underlie people’s behavior disorders. Ellis argues, for example, that
students do not get upset because they
fail a test but because they have learned
to believe that failure is a disaster that indicates they are worthless. Many of Ellis’s
ideas have been incorporated into various forms of cognitive-behavior therapy.
ALBERT ELLIS
cognitive therapy An organized
problem-solving approach in which the
therapist actively collaborates with
clients to help them notice how certain
negative thoughts precede anxiety and
depression.
Therapist: . . . The reality is that . . . “shoulds” and “musts” are the rules that other people hand down to us, and we grow up accepting them as if they are the absolute
truth, which they most assuredly aren’t.
Client: You mean it is perfectly okay to, you know, pass out in a restaurant?
Therapist: Sure!
Client: But . . . I know I wouldn’t like it to happen.
Therapist: I can certainly understand that. It would be unpleasant, awkward, inconvenient. But it is illogical to think that it would be terrible, or . . . that it somehow bears on your worth as a person.
Client: What do you mean?
Therapist: Well, suppose one of your friends calls you up and invites you back to that
restaurant. If you start telling yourself, “I might panic and pass out and people might make fun of me and that would be terrible,” . . . you might find you
are dreading going to the restaurant, and you probably won’t enjoy the meal
very much.
Client: Well, that is what usually happens.
Therapist: But it doesn’t have to be that way . . . . The way you feel, your reaction . . .
depends on what you choose to believe or think, or say to yourself. (Masters
et al., 1987)
Cognitive-behavior therapists use many techniques related to REBT to help clients
learn to think in more adaptive ways. Techniques aimed at replacing upsetting thoughts
with alternative thinking patterns were originally described by behaviorists as cognitive
restructuring (Lazarus, 1971). They help clients plan calming thoughts to use during
exams, tense conversations, and other anxiety-provoking situations. These thoughts
might include “OK, stay calm, you can handle this. Just focus on the task, and don’t
worry about being perfect.” Sometimes, these techniques are expanded to include stress
inoculation training, in which clients imagine being in a stressful situation and then
practice newly learned cognitive skills to remain calm (Meichenbaum, 1995; Sheehy &
Horan, 2004).
Beck’s Cognitive Therapy Behavior therapists seek a different kind of cognitive
restructuring when they use Aaron Beck’s cognitive therapy (Beck, 1976, 1995, 2005).
Beck’s treatment approach is based on the idea that certain psychological disorders can
be traced to errors in logic (e.g., “If I fail my driver’s test the first time, I will never pass
it”) and false beliefs (e.g., “Everyone ignores me”). Beck says that over time, these
learned cognitive distortions occur so quickly and automatically that the client never
stops to consider that they might not be true (see Table 13.2).
Cognitive therapy takes an active, organized, problem-solving approach in which the
therapist first helps clients learn to identify the errors in logic, false beliefs, and other
cognitive distortions that precede anxiety, depression, conduct problems, eating disorders, and other psychological problems (Beck & Rector, 2005; Drinkwater & Stewart,
2002; Hendricks & Thompson, 2005; Pardini & Lochman, 2003; Turkington, Kingdon,
& Weiden, 2006). Then, much as in the five-step critical thinking system illustrated
throughout this book, these thoughts and beliefs are considered as hypotheses to be
tested, not as “facts” to be uncritically accepted (Hatcher, Brown, & Gariglietti, 2001). In
other words, the therapist and client become a team of “investigators” as they plan ways
to test beliefs such as “I’m no good around the house.” For example, they might agree
on tasks that the client will attempt as “homework”—such as cleaning out the basement,