Behavior Therapy

CHAPTER 15: THERAPY Jacquelyn Eisen and Maya Strauss

HISTORY OF TREATMENT Bleeding  Drilling Holes in Head  Administering Electric Shocks 



A trained therapist uses psychological techniques to assist someone seeking to overcome difficulties achieve personal growth.

DORTHEA DIX 

“I…call your attention to the state of the insane persons confined within the common weath, in cages”

MENTAL HEALTH HOSPITALS EMPTYING Introduction of therapeutic drugs  Community based treatment programs. 

THERAPY 

Pyschotherapy Integration: Attempts to combine a selection of assorted techniques into a single, coherent system

THERAPY 

Eclectic Approach: an approach to psychotherapy that, depending on the client’s problems, uses techniques from various forms of therapy

THERAPY Psychotherapy: treatment involving psychological techniques; consists of interactions between a trained therapist and someone seeking to overcome psychological difficulties or achieve personal growth.  4 Major Theories: 

Psychoanalytic  Humanistic  Behavioral  Cognitive 

THERAPY- PSYCHOANALYSIS 

Psychoanalysis Freud believed the patient’s free associations, resistances, dreams, and transferences – and the therapist’s interpretations of them – released previously repressed feelings, allowing the patient to gain self-insight  use has rapidly decreased in recent years 

Neo-Freudians: psychologists today who use psychoanalysis

FREUD & PSYCHOANALYSIS Hypnosis is unreliable  Goal: unearth the past in hope of unmasking the present 

THERAPY- PSYCHOANALYSIS Free Association: say whatever comes to mind  Interpretation: the analyst’s noting supposed dream meanings, resistances, and other significant behaviors in order to promote insight  Transference: the patient’s transfer to the analyst of emotions linked with other relationships 



love or hatred for a parent

THERAPY - PSYCHOANALYSIS Resistance: blocking from consciousness of anxiety-laden material  Latent Content: Underlying but censored, meaning of a dream. 

THERAPY - PSYCHOANALYSIS Goal of dream analysis: determine the meaning of dreams  Criticism: interpretations cannot be proven or disproven 

 

Rebuttal: It helps the patients.

Costly: 3 times a week at $100 an hour 

More costly than psychodynamic because there is more sessions

THERAPY 

Psychodynamic theory: Drives from psychoanalysis, views individuals as responding to unconscious forces and childhood experiences. Seeks to enhance self insight.

THERAPY 

Interpersonal Psychotherapy: A brief variation of psychodynamic therapy, has been effective in healing depression. 

Helps people gain insight into roots of their difficulties.

HUMANISTIC THERAPY Aim is to boost self-fulfillment.  Similarity between this and psychodynamic: 



Attempt to reduce inner conflicts by providing new insight

HUMANISTIC VS. PSYCHOANALYSIS THERAPISTS Present and future vs. past  Conscious vs. unconscious  Responsibility vs. hidden determinants  Promote growth vs. cure illness 

HUMANISTIC THERAPY 

Insight Therapies: Aim to improve psychological functioning by increasing client’s awareness of underlying motives and defenses.

HUMANISTIC THERAPY 

Client-Centered Therapy humanistic therapy developed by Carl Rogers  therapist uses techniques such as active listening within a genuine, accepting, empathic environment to facilitate clients’ growth  GAE (genuine, accepting, empathy) 

NON-DIRECTIVE THERAPY VS. PSYCHOTHERAPY 

Feedback (insight)

CARL ROGERS “Thank god, somebody heard me. Somebody knows what it is like to be me.”  Goal: accept and understand the client  3 Hints that Rogers gives for us to actively listen more: 

Paraphrase  Invite clarification  Reflect feeling 

HUMANISTIC THERAPY 

Active Listening: empathic listening in which the listener echoes, restates, and clarifies 



ERSC (England rugby supporters club)

Unconditional Positive Regard: Caring, accepting, non-judgmental attitude, Rogers believed to be conducive to developing self-awareness and self acceptance.

BEHAVIOR THERAPY Behavior Therapy: therapy that applies learning principles to the elimination of unwanted behaviors  Counter conditioning: uses classical conditioning to evoke new responses to stimuli that trigger unwanted behaviors 

MARY COVER JONES Systematic Desensitization  Peter is afraid of rabbits  Caged rabbit when he eats  closer each day  2 months later, Peter has a rabbit in his lap while eating  Didn’t get credit because she’s a woman 

BEHAVIOR THERAPY: MALADAPTIVE BEHAVIORS 

Treating phobias and sexual disorders 

Learned behaviors replaced by constructive behaviors

MOWRER 

Conditioning: Don’t wet the bed 

Wet the bed  Alarm

¾ of the time it was effective  Boosts self image 

BEHAVIOR THERAPY 



Exposure Therapy: treat anxieties by exposing people (in imagination or reality) to the things they fear and avoid EX:

BEHAVIOR THERAPY 

Systematic Desensitization type of counter conditioning  associates a pleasant, relaxed state with gradually increasing anxiety-triggering stimuli  commonly used to treat phobias 

BEHAVIOR THERAPY 

Progressive relaxation: relax one muscle group after another until completely relaxed

BEHAVIOR THERAPY 

Virtual Reality Exposure Therapy: Progressively exposes people to simulations of their greatest fear (ex: spiders, flying, speaking) 

It feels like it’s real so it gives a greater relief from fears.

BEHAVIOR THERAPY 

Aversive Conditioning type of counter-conditioning that associates an unpleasant state with an unwanted behavior  Nausea pill in alcohol  don’t want alcohol anymore  Short term solution 

MENUSTIK (1983) 

Drinking Aversion & Cognitive Influence  At

a bar versus the therapist’s office, they know that they can drink without the fear of nausea

BEHAVIOR THERAPY 

Behavior Modification: Reinforcing desired behaviors and withholding reinforcement for undesired behaviors or punishing them

REAL LIFE POSITIVE REINFORCEMENT In school, children behave more rationally  Intellectual disability kids can care for themselves  Kids with autism can learn to interact 

LOVAAS (1987) Uncommunicative autistic toddlers need intense treatment  Many improve 

BEHAVIOR THERAPY 

Token Economy  

an operant conditioning procedure that rewards desired behavior patient exchanges a token of some sort, earned for exhibiting the desired behavior, for various privileges or treats

BEHAVIOR THERAPY 

Token Economy Criticisms: How durable is the behavior?  Is it right to control others behaviors? 



We should: 

Shift patients towards other rewards

COGNITIVE THERAPY 

Cognitive Therapy teaches people new, more adaptive ways of thinking and acting  based on the assumption that thoughts intervene between events and our emotional reactions  Teach more constructive ways of thinking 

AARON BECK Originally trained in Freudian techniques  Now is a cognitive therapist  Reverse clients creating bad beliefs about themselves 

MEICHENBAUM Stress inoculation training  Teaches people to reconstruct their thinking in stressful situations  Advice to someone that studies hard, but is extremely negative prior to testing: 



Relax

SELIGMAN (2002) 

After being trained to dispute their negative thoughts, depression-prone children and college students exhibit a halved rate of future depression

COGNITIVE THERAPY 

Cognitive Behavior Therapy: popular integrated therapy that combines cognitive and behavior therapies 

Changing self defeating thinking and behavior

SCHWARTZ (1996) OCD people re-labled their compulsive thoughts  Have an urge versus actually doing it 

COGNITIVE THERAPY



The Cognitive Revolution

COGNITIVE THERAPY 

A cognitive perspective on psychological disorders

COGNITIVE THERAPY



Cognitive therapy for depression

COGNITIVE THERAPY 

Cognitive-Behavioral Therapy: 

a popular integrated therapy that combines cognitive therapy (changing self-defeating thinking) with behavior therapy (changing behavior)

GROUP AND FAMILY THERAPIES 

Benefits   

Price (more than one person) Find others with similar problems Get feedback as they try things out

GROUP AND FAMILY THERAPIES 

Family Therapy: treats the family as a system, views an individual’s unwanted behaviors as influenced by or directed at other family members

GROUP AND FAMILY THERAPIES 

Goals:  Heal

relationships

 Mobilize



family resources

Success:  Helps

families cope with disorders

GROUP AND FAMILY THERAPIES 

Support Groups Anorexia  AIDS  Illness  Hearing loss 



No Support Groups Ulcers  Migraine  Hypertension  Vision loss 

GROUP AND FAMILY THERAPIES 

AA 114,000 groups  2 million+ members  Effectiveness: 

Project Match  Moos + Moos 

GROUP AND FAMILY THERAPIES 

Characteristics of a 12 Step Program Members admit powerlessness  Seek help  Take the message to others 

GROUP AND FAMILY THERAPIES 

Support groups reflect: Longing for community  Connectedness 

REMEMBER:

INCREASE 1991 TO 2004 25% increase  Justified placing hope in psychotherapy 

CLIENT TESTIMONIALS TELL US… 

We can affirm its effectiveness

PSYCHOTHERAPY CRTICISMS Often enter therapy in crisis  People may need to believe it’s worth it.  Speak kindly of therapist. 

JOAN MCCORD: 500 MA BOYS 

Years later the kids say that without therapy many of them would be in jail.



Clinician’s perspective could often be inflated when judging whether the treatment was effective because they treasure compliments.

EVALUATING PYSCHOTHERAPIES 

Placebo effect: power of belief in a treatment.

EVALUATING PSYCHOTHERAPIES 

Regression toward the mean 

tendency for extremes of unusual scores to fall back (regress) toward their average

EVALUATING PSYCHOTHERAPIES 

Meta-analysis 

procedure for statistically combining the results of many different research studies

EVALUATING PSYCHOTHERAPY 

Examples of Regression to the Mean: Students who higher than usual on a test will be closer to the average the second time  ESP loses power second time  Bad half and a normal second half (game) 



Why someone would attribute a therapist for their success when it isn’t: 

Start out better then eventually go back to normal.

PHYSICIANS, BLEEDING, & TYPHOID FEVER 

The control group improved on bed rest

HANS EYSENCK 

Effectiveness of Psychotherapy: 



2/3 receiving psychotherapy for non-psychotic disorders improved remarkably

Problems: 

His sample was small (only 24 studies of psychotherapy outcomes in 1952)

EVALUATING PSYCHOTHERAPIES 

Best way to study outcome research: 

Randomized clinical trials 

Randomly assign people on waiting list and later evaluate everyone.

SMITH (1980) Clients end up 80% better than those not treated  5 Subsequent studies: 



Those not undergoing therapy often improve, but those undergoing therapy are more likely to improve.

PSYCHOTHERAPY IS COST EFFECTIVE Search for other treatment drops  Boosts well being  Reduces long term cost 

BEHAVIORAL PROBLEMS THAT BENEFITTED FROM BEHAVIORAL CONDITIONING THERAPIES Bed-wetting  Phobias  Marital Problems  Compulsions  Sexual Disorders 

COGNITIVE THERAPY EFFECTIVENESS Coping with Depression’  Lowering suicide risk 

I DON’T RECOMMEND.., Energy Therapies  Recovered-Memory Therapies  Facilitated Communication  Crisis Debriefing  Rebirthing Therapies 

DEFINING: 

Evidence-Based Practice: clinical decision making that integrates best available research with clinical expertise and patient characteristics and preferences.

EVALUATING PSYCHOTHERAPIES

EVALUATING PSYCHOTHERAPIES



To whom do people turn for help for psychological difficulties?

EVALUATING PSYCHOTHERAPIES Number of persons

Average untreated person

Poor outcome

80% of untreated people have poorer outcomes than average treated person

Average psychotherapy client

Good outcome

EVALUATING PSYCHOTHERAPIES

EVALUATING ALTERNATIVE THERAPIES EMDR (Eye movement desensitization and reprocessing): therapy illustrating the differences between scientific and pseudo scientific therapy techniques  Francine Shapiro – walking in a park and observing anxious thoughts vanish as her eyes spontaneously darted about. 

FRANCINE SHAPIRO & EMDR Tested 22 people by moving finger in front of eyes: reductions in stress after one session  Amount Trained: 

 

Countries that use it: 



70,000 70

Credibility: Chambless  Bisson & Andrews 

EMDR SKEPTICS 

Eye movement is not therapeutic

EVALUATING ALTERNATIVE THERAPIES 

Seasonal Affective Disorder: Winter time depression  



Oversleeping Gaining weight

Light Therapy Works: 90 minutes of light vs. none – those with light were more improved  30 minutes of exposure is relief  Morning light works best 

COMMONALITIES AMONG PSYCHOTHERAPIES 

Hope for demoralized people 

Participant’s beliefs may function as a placebo

New perspectives  Empathetic, trusting, caring relationship  New attitude  open to making changes 

THERAPISTS 

effective therapists are empathic people who seek to understand another’s experience; who communicate their care and concern to the client; and who earn the client’s trust and respect through respectful listening, reassurance, and advice.

COGNITIVE, PSYCHODYNAMIC, INTERPERSONAL 

The empathic therapists of both persuasions would help clients evaluate themselves  link one aspect of their life with another  gain insight into their interactions with others. 

THERAPISTS 

Therapeutic Alliance: emotional bond between therapists and their client

THERAPISTS 

Paraprofessional Attribute: 



New perspective offered by a caring person

People that need/seek therapy: Feel supported by close relationships  Enjoy friendship 



Therapists attempt to enhance: 

Sensitivity, openness, personal responsibility, and sense of purpose

THERAPIES AND MINORITIES Immigrant problems: different kind of culture  Problems from a minority viewpoint: reluctant to use mental health services  Asian American viewed therapists from a collectivist background as more empathetic and had a stronger alliance. 

If religious, find a therapist with a similar religion as you.

Albert Ellis Rational-emotional therapy  Nothing is supreme (vs. Bergin who thought God is supreme and everything else is virtue)  Most important: psychotherapists personal beliefs influence their practice 

THERAPISTS AND THEIR TRAINING 

Clinical psychologists Most are psychologists with a Ph.D. and expertise in research, assessment, and therapy, supplemented by a supervised internship  About half work in agencies and institutions, half in private practice 

THERAPISTS AND THEIR TRAINING 

Clinical or Psychiatric Social Worker A two-year Master of Social Work graduate program plus postgraduate supervision prepares some social workers to offer psychotherapy, mostly to people with everyday personal and family problems  About half have earned the National Association of Social Workers’ designation of clinical social worker 

THERAPISTS AND THEIR TRAINING 

Counselors Marriage and family counselors specialize in problems arising from family relations  Pastoral counselors provide counseling to countless people  Abuse counselors work with substance abusers and with spouse and child abusers and their victims 

THERAPISTS AND THEIR TRAINING 

Psychiatrists Physicians who specialize in the treatment of psychological disorders  Not all psychiatrists have had extensive training in psychotherapy, but as M.D.s they can prescribe medications. Thus, they tend to see those with the most serious problems  Many have a private practice 

BIOMEDICAL THERAPIES 

Biomedical therapy: prescribed medications or medical procedures that act directly on the patient’s nervous system.

*only psychiatrists can offer

COMPARISONS 

Psychotherapy is to psychological disorders as biomedical therapy is to serious disorders.

BIOMEDICAL THERAPIES Psychopharmacology: study of the effects of drugs on mind and behavior  Lithium: chemical that provides an effective drug therapy for the mood swings of bipolar (manicdepressive) disorders (salt) 

BIOMEDICAL THERAPIES 

The emptying of U.S. mental hospitals

BIOMEDICAL THERAPIES 

Enthusiasm diminishes after any new treatment… Normal recovery among untreated patients  Recovery due to placebo 

BIOMEDICAL THERAPIES 

Double-Blind Procedure is used to establish the legitimacy of the drug. (No bias at all)

BIOMEDICAL THERAPIES 

Psychoses: disorders in which hallucinations or delusions indicate some loss of contact with reality 

Drugs that calmed people from this were found accidentally.

BIOMEDICAL THERAPIES

DRUG THERAPIES 

Antipsychotic drugs: drugs used to treat schizophrenia and other forms of severe thought disorder. Chlorpromazine (Thorazine) – dampens responsiveness to irrelevant stimuli  Mimics dopamine – occupies receptor sites and blocks activity 



Reinforces that too much dopamine  schizophrenia

BIOMEDICAL THERAPIES

DRUG THERAPIES 

Tardive Dyskinesia: involuntary movements of the facial muscles, tongue, and limbs; a possible neurotoxic side effect of long-term use of antipsychotic drugs that target certain dopamine receptors. 

Dopamine and serotonin receptors for negative symptoms

DRUG THERAPIES 

Antipsychotic drug side effects: 



Increase risk of obesity and diabetes

Positive Gain: 

Able to return to work and have near normal lives

DRUG THERAPIES 

Anti-anxiety Drugs: drugs used to control anxiety and agitation.

DRUG THERAPIES 

Anti-depressant Drugs: drugs used to treat depression; also increasingly prescribed for anxiety. Different types work by altering the availability of various neurotransmitters.

DRUG THERAPIES 

Anti-anxiety: Depress CNS activity  Xanax 



Psychological dependence, physiological dependence, withdrawal, insomnia, anxiety

DRUG THERAPIES 

Anti-depressants are standard drug treatment for anxiety disorders. Works on OCD.

DRUG THERAPIES Neurotransmitters serotonin and nonepinephrine by upping availability  Prozac partially blocks reuptake of serotonin. 

DRUG THERAPIES SSRI (Selective serotonin reuptake inhibitor): Prozac, Zoloft, Paxil  Most effective way to administer is by patch.  1987  2001, 70%  89% with SSRIs 

BARBER (2008) 11% women taking anti-depressants  5% men taking anti-depressants 

DRUG THERAPIES 4 weeks to work  Diminishes sexual desire  Delay because up serotonin = neurogenesis (new brain cells), reducing stress including loss of neurons 

DRUG THERAPIES 

Without drugs: Cognitive therapy  Exercise 



To hit it from above and below use both: Cognitive Therapy  Anti-Depressants 

DRUG THERAPIES 

Only the most severely depressed patients should take these meds.

DRUG THERAPIES There is no link between adolescent SSRI prescriptions and suicide.  Less suicides when treated with meds (long run) 

BIOMEDICAL THERAPIES Electroconvulsive Therapy (ECT): therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient  Introduced 1938  Originally 100 volts 

BIOMEDICAL THERAPIES: ECT Under anesthetic for 30 to 60 seconds of electric current.  Patients don’t remember it.  Works for 4 out of 5 people  Doesn’t cause brain damage. 

BIOMEDICAL THERAPIES: ECT 

It works because it calms the nerves that cause depression.

BIOMEDICAL THERAPIES 

Repetitive Transcranial Magnetic Stimulation (rTMS): the application of repeated pulses of magnetic energy to the brain; used to stimulate or suppress brain activity

BIOMEDICAL THERAPIES 

rTMS vs ECT: no seizures or memory loss

KLEIN (1999) 

67 Israelis with major depression: 50% stimulated patients improved  25% placebo patients improved 

KLEIN (1999) 

Worked because the stimulation energized depressed patient’s relatively inactive left frontal lobe.

MAYBERG 

8 out of 12 people implanted with electrodes and pacemaker stimulator experienced relief

BIOMEDICAL THERAPIES 

Psychosurgery: surgery that removes or destroys brain tissue in an effort to change behavior 

Not used often because its irreversible

BIOMEDICAL THERAPIES 

Lobotomy: now-rare psychosurgical procedure once used to calm uncontrollably emotional or violent patients

BIOMEDICAL THERAPIES Rosemary Kennedy had lobotomy done  Moniz won the Nobel prize  Abandoned in 1950: calming drugs available 

BIOMEDICAL THERAPIES Benefits: short and cheap  Bad Characteristics: produced lethargic, immature, uncreative person 

THERAPEUTIC LIFESTYLE CHANGES Brains/Bodies designed for physical activity and social engagement  Mind and Body 

AMISH & DEPRESSION BEING OBSOLETE 1. 2. 3. 4.

Strong Community Ties Sunlight Exposure Tons of Sleep Strenuous Physical Activity

ILARDI TEAM & REDUCING DEPRESSION Aerobic Exercise  Adequate sleep  Light exposure  Social Connection  Nutritional Supplement 

ALBEE (1986) 

Increase the risk of doing more than necessary

“IT IS BETTER TO PREVENT THAN TO CURE” 

Help those who haven’t had a chance 

Get a vaccine instead of a cure