COGNOBEHAVIORAL THERAPY Hallym Sacred Hospital Department of Psychiatry Kim Se Joo

BEHAVIORAL THERAPY

Behavioral Therapy Focus on ameliorating of people’s maladaptive behavior Without theorizing about their inner conflicts All behaviors - learned, conditioned Undesirable behaviors can be unlearned or unconditioned replaced by new and adaptive behaviors Based on learning theory Classical conditioning Operant conditioning

Classical Conditioning I

Classical Conditioning II

Operant Conditioning

Reciprocal Inhibition By Joseph Wolpe Anxious behavior or persistent habits - learned in anxiety generating situation A response inhibitory to anxiety in anxiety evoking stimuli  connection between stimuli & anxiety response Relaxation - incompatible with anxiety  inhibit anxiety

Some Methods of Behavioral Therapy Systemic desensitization Behavior modification method Exposure treatment Aversion therapy Participant modeling Assertiveness & social skill training

Systemic Desensitization Based on counterconditioning 3 steps Relaxation training Hierarchy construction Desensitization of the stimulus Indications Phobias, obsession, compulsion, certain sexual disorders

I. Hierarchy Construction – Systemic desensitization Looking at a picture of a dog in a children’s toy dog. Seeing a poodle on a lead 10 yards away …. 5 yards away …. Passing by Touching a puppy behind a wire mesh in the market. Looking at the neighbor’s spanie,Kim, held in the arms of its mistress. Touching Kim when the dog is quiet and held in the arms of its mistress. Touching Kim when the dog is quiet. ………… Feeding Kim a biscuit. ……… Kim running toward the patient. ………… Dogs fighting

II. Relaxation Training - Systemic desensitization physiological effects opposite those of anxiety  HR, peripheral blood flow,  N-M stability Progressive muscular relaxation Hypnosis Mental imagery Yoga, Zen, etc.

III. Desensitization – systemic desensitization Proceed systematically through the list from the least to the most anxiety-provoking scene while in a deeply relaxed state Can vividly imagine the most anxiety provoking scene  experience little anxiety in the corresponding real-life situations

Behavior Modification Technique Reinforcement Based on operant conditioning human behavior - learning or extinction according to balance between reward and punishment Rewarded behavior - be strengthened and occur more frequently Token economy(e.g. chronic schizophrenia) Effect of reinforcement positive > negative reinforcement Irregular, unpredictable > regular, predictable

Exposure Treatment Grade exposure Flooding Implosion No relaxation training Real life context Flooding Escaping from an anxiety-provoking experience reinforces the anxiety through conditioning No Systemic desensitization, graded exposure, relaxation training Experience fear  gradually subside  calm & feeling a sense of mastery Implosion Variant of flooding, only in imagination not in real life

Aversion Therapy Specific behavior response - immediately noxious stimulus(punishment)   response Noxious stimuli Electrical shock, vomiting inducing substance, corporal punishment, social disapproval, etc. Indication - alcohol abuse, paraphilia & other impulsive or compulsive behavior Negative stimulus is paired with behavior   behavior But, the effects are still controversial

Participant Modeling Learn a new behavior by imitation, primarily by observation, without having to perform the behavior until they feel ready Phobic children - placed with other children of their own age and sex who approach the feared object or situation Agoraphobia, etc.

COGNITIVE THERAPY

Theoretical Basis Aaron Beck “Individual’s affect and behavior are largely determined by the way in which he structures the world” Dysfunctional thinking  psychological problems Cognitive triad of depression Negative self-perception Tendency to experience the world as negative Negative expectation of future

General Consideration Short term structure therapy(15~25 sessions) Active collaboration between patient & therapist Oriented toward current problems & resolution Indications Depressive disorder, GAD, panic disorder, phobia, anorexia, hypochondriasis, somatoform disorder, paranoid personality, OCD, suicidal behavior, etc.

Basic Technique Didactic technique Cognitive technique Behavioral technique

Didactic Technique Cognitive appraisal (distorted) Event Emotion Behavior (maladaptive) Behavioral inclination (helpless & avoidance)

Cognitive Technique Eliciting Automatic Thoughts “She doesn’t like me.” when someone passes the person in the hall without saying hello. Testing Automatic Thoughts Goal - encourage the patient to reject inaccurate or exaggerated automatic thought after careful examination. Generating alternative explanations for events Identifying Maladaptive Assumptions “In order to be happy, I must perfect.” Such rules : inevitably disappointed & fail  depression Testing the Validity of Maladaptive Assumptions Always think of the worst.  Ask patient to calculate real probability

Cognitive Errors derived from Assumptions Overgeneralizing If it’s true in one case, it applies to any case that is even slightly similar Selective abstraction The only events that matter are failures, deprivation, etc. Excessive responsibility I am responsible for all bad things, failure, etc. Assuming temporal causality (predicting without sufficient evidence) If it has been true in the past, it’s always going to be true. Self reference I am the center of everyone’s attention. Catastrophizing Always think of the worst. Dichotomous thinking Everything is either one extreme or another

Situation Feelings Automatic Thoughts Maladaptive Assumptions “This is hopeless. I’ll never catch up with all the work!” Situation Feelings Overgeneralizing Selective abstraction Excessive responsibility Assuming temporal causality Self reference Catastrophizing Dichotomous thinking Specific Situation More Conscious Easy to refute General rule Less Conscious Difficult to refute Maladaptive Assumptions “My worth depends on my performance”

Find Situation Activate ATS List ATS Revise Thoughts Feel Better 상황 기분 자동사고 생생한 사고를 지지하는 증거 생생한 사고를 지지하지 않는 증거 새로운 관점(융통성) 기분을 재평가 Find Situation Activate ATS List ATS Revise Thoughts Feel Better Find MUAs Revise MUAs Longterm change

상황 기분 자동적 사고 생생한 사고를 지지하는 증거 생생한 사고를 지지하지 않는 증거 새로운 관점/융통성 있는 사고 딸네 집에서 딸과 사위, 두 명의 손주, 아내와 추수감사절을 보내고 운전해서 집으로 돌아오고 있었다 기분 슬픔 80% 자동적 사고 내가 오늘 그곳에 없었더라면 그들은 더 좋은 시간을 보낼 수 있었을 것이다 애들과 손자들은 나를 더 이상 필요로 하지 않는다 하루 종일 아무도 내게 관심을 보이지 않았다 생생한 사고를 지지하는 증거 예전에 나는 손녀의 구두끈을 매주곤 했는데 지금은 손녀가 스스로 하려고 한다 내 딸과 사위는 함께 삶을 꾸려나가고 나를 필요로 하지 않는다 열 다섯 살의 에이미는 오후 일곱시에 친구들을 만난다고 나갔다 3년 전만해도 그는 그처럼 큰 계획에는 내 도움을 청했고 내 도움을 필요로 했다. 생생한 사고를 지지하지 않는 증거 빌이 그들의 집에 새로운 방을 만드는 계획에 대해 내게 조언을 했다 내 딸이 정원에서 죽어가는 채소를 봐달라고 부탁했다 나는 딸에게 물이 부족한 것이라고 말할 수 있었다 나는 다섯 살난 손녀를 웃게 할 수 있었다 에이미는 그녀의 엄마가 십대에 어땠는지 내가 이야기해주는 것을 좋아하는 듯 했다 다섯 살난 내 손녀는 내 무릎에서 잠들었다. 새로운 관점/융통성 있는 사고 애들과 손자들은 예전에 하던 방식으로 내 도움을 필요로 하지는 않게 되었다 그렇지만 애들은 아직도 나와 함께 있는 것을 좋아하고, 내 조언을 구하기도 한다 나에게 과거에 하던 방식으로 끊임없이 관심을 표현하지는 않았지만, 하루 전체를 본다면 나에게 관심을 보였던 것이 사실이다 기분을 재평가하라 슬픔 30% 

Behavioral Technique Schedule activities Mastery and pleasure Patients keep record of the activities & review them with therapist Mastery and pleasure Patient are asked to rate the amount of mastery & pleasure their activities bring them Graded task assignment Cognitive rehearsal Imagine & rehearse the various step in meeting a challenge Self reliance training Become self reliant by doing simple things Role playing Diversion technique Physical activities, social contact, work, play, visual imagery

BIOFEEDBACK

Theory of Biofeedback Feedback about the body helps people try to change a function, for instance by relaxing Autonomic nervous system can be operantly conditioned by using appropriate feedback By means of instrument, information about the status of involuntary biological function(skin temperature, electrical conductance, muscle tension, BP, HR, brain wave activity)  learn to regulate one or more of these Person can learn to raise the temperature of his hands  reduce frequency of migraine, palpitation, or angina pectoris

Indications Tension headache Hypertension Psychosomatic disorder Somatoform disorder Anxiety disorder Various medical conditions