Behavioral Aspects of CBT

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In some cases the primary changes that need to be made are behavioral.Behavioral therapy is psychological treatment that is based on principles of learning. The most direct approach is through operant conditioning using reward or punishment. Reinforcement may be used to teach new skills to people, for instance, those with autism or schizophrenia (Granholm et al., 2008; Herbert et al., 2005; Scattone, 2007). 1 If the patient has trouble dressing or grooming, then reinforcement techniques, such as providing tokens that can be exchanged for snacks, are used to reinforce appropriate behaviors such as putting on one’s clothes in the morning or taking a shower at night. If the patient has trouble interacting with others, reinforcement will be used to teach the client how to more appropriately respond in public, for instance, by maintaining eye contact, smiling when appropriate, and modulating tone of voice.

As the patient practices the different techniques, the appropriate behaviors are shaped through reinforcement to allow the client to manage more complex social situations. In some cases observational learning may also be used; the client may be asked to observe the behavior of others who are more socially skilled to acquire appropriate behaviors. People who learn to improve their interpersonal skills through skills training may be more accepted by others and this social support may have substantial positive effects on their emotions.

When the disorder is anxiety or phobia, then the goal of the CBT is to reduce the negative affective responses to the feared stimulus. Exposure therapy is a behavioral therapy based on the classical conditioning principleof extinction, in which peopleare confronted with a feared stimulus with the goal of decreasing their negative emotional responses to it (Wolpe, 1973). 2 Exposure treatment can be carried out in real situations or through imagination, and it is used in the treatment of panic disorder, agoraphobia, social phobia, OCD, and posttraumatic stress disorder (PTSD).

In flooding, a client is exposed to the source of his fear all at once. An agoraphobic might be taken to a crowded shopping mall or someone with an extreme fear of heights to the top of a tall building. The assumption is that the fear will subside as the client habituates to the situation while receiving emotional support from the therapist during the stressful experience. An advantage of the flooding technique is that it is quick and often effective, but a disadvantage is that the patient may relapse after a short period of time.

More frequently, the exposure is done more gradually.Systematic desensitization is a behavioral treatment that combines imagining or experiencing thefeared object or situation with relaxation exercises (Wolpe, 1973). 3 The client and the therapist work together to prepare a hierarchyof fears, starting with the least frightening, and moving to the most frightening scenario surrounding the object Table 13.1

The patient then confronts her fears in a systematic manner, sometimes using her imagination but usually, when possible, in real life.

Desensitization techniques use the principle of counterconditioning, in which a second incompatible response (relaxation, e.g., through deep breathing) is conditioned to an already conditioned response (the fear response). The continued pairing of the relaxation responses with the feared stimulus as the patient works up the hierarchy gradually leads the fear response to be extinguished and the relaxation response to take its place.

Behavioral therapy works best when people directly experience the feared object. Fears of spiders are more directly habituated when the patient interacts with a real spider, and fears of flying are best extinguished when the patient gets on a real plane. But it is often difficult and expensive to create these experiences for the patient. Recent advances in virtual reality have allowed clinicians to provide CBT in what seem like real situations to the patient. In virtual realityCBT, the therapist uses computer-generated, three-dimensional, lifelike images of the feared stimulus in a systematic desensitization program. Specially designed computer equipment, often with a head-mount display, is used to create a simulated environment. A common use is in helping soldiers who are experiencing PTSD return to the scene of the trauma and learn how to cope with the stress it invokes.

Some of the advantages of the virtual reality treatment approach are that it is economical, the treatment session can be held in the therapist’s office with no loss of time or confidentiality, the session can easily be terminated as soon as a patient feels uncomfortable, and many patients who have resisted live exposure to the object of their fears are willing to try the new virtual reality option first.

Aversion therapy is a type of behavior therapy in which positive punishment is used to reduce the frequency of an undesirable behavior. An unpleasant stimulus is intentionally paired with a harmful or socially unacceptable behavior until the behavior becomes associated with unpleasant sensations and is hopefully reduced. A child who wets his bed may be required to sleep on a pad that sounds an alarm when it senses moisture. Over time, the positive punishment produced by the alarm reduces the bedwetting behavior (Houts, Berman, & Abramson, 1994). 4 Aversion therapy is also used to stop other specific behaviors such as nail biting (Allen, 1996). 5

Alcoholism has long been treated with aversion therapy (Baker & Cannon, 1988). 6 In a standard approach, patients are treated at a hospital where they are administered a drug, antabuse, that makes them nauseous if they consume any alcohol. The technique works very well if the user keeps taking the drug (Krampe e t al., 2006), 7 but unless it is combined with other approaches the patients are likely to relapse after they stop the drug.