Learning and thinking: behavioral and cognitive therapies

Transcript

SoheeHere's a case reported in 1924. A little boy named Peter is terrified of rabbits. A psychologist named Mary Cover Jones sits him down for his afternoon snack, and puts a caged rabbit on the far side of the room.

RyanAnd over the next several days, while Peter eats, she moves the rabbit a little closer. And a little closer. After two months, Peter is holding the rabbit and petting it while he eats.

SoheeWelcome to EPPP Prep, the podcast. I'm Sohee.

RyanI'm Ryan. Today, the first big family of treatment models: behavioral and cognitive therapies. These are the ones with the most technique names, so it's a heavy vocabulary day. We'll go slowly.

SoheeStart with the definition. The OpenStax psychology textbook says that in behavior therapy, a therapist employs principles of learning to help clients change undesirable behaviors, rather than digging deeply into one's unconscious.

RyanAnd it uses both classical and operant conditioning. That split is the first thing the exam checks. Which conditioning is behind which technique?

SoheeClassical first. Therapists in this tradition see dysfunctional behaviors as conditioned responses. The textbook's example is Emmie, eight years old, who wets the bed. She sleeps on a moisture-sensitive pad hooked to an alarm.

RyanWhen moisture touches the pad, the alarm wakes her. Repeat it enough, and she develops an association between urinary relaxation and waking up, and the bedwetting stops. That's classical conditioning.

SoheeThen the big umbrella term: counterconditioning. A client learns a new response to a stimulus that has previously elicited an undesirable behavior. The textbook names two counterconditioning techniques: aversive conditioning and exposure therapy.

RyanAversive conditioning uses an unpleasant stimulus to stop an undesirable behavior. Smoking, nail biting, drinking. The textbook example is Antabuse. Drinking alcohol after taking it brings nausea, vomiting, a racing heart, a severe headache.

SoheePaired repeatedly, alcohol becomes associated with unpleasant feelings, and the desire to drink drops. The text says it replaces the original pleasure response with an unpleasant one.

RyanExposure therapy goes the other direction. It treats fear or anxiety by presenting the object or situation that causes the problem, with the idea that the person will eventually get used to it. In reality, in imagination, or in virtual reality.

SoheeAnd that's Peter. The textbook says exposure therapy was first reported in 1924 by Mary Cover Jones, considered the mother of behavior therapy. Her goal was to replace Peter's fear with relaxation, a response that is incompatible with fear.

RyanThirty years later, Joseph Wolpe, in 1958, refined her technique into systematic desensitization.

SoheeHere's the recipe. The person builds a hierarchy of anxiety, from the least anxiety-producing stimulus up to the feared object. Relaxation techniques are taught beforehand and used during the graduated exposures. And the idea is that a person cannot be nervous and relaxed at the same time.

RyanThe textbook's example is Jayden, afraid of elevators, whose new job is on the twenty-ninth floor. He builds a hierarchy, learns progressive muscle relaxation, then imagines each step, starting with standing in front of the elevator thinking about pressing the call button.

SoheeIf a scene makes him anxious, he lifts a finger, returns to relaxation, and repeats it until the scene no longer bothers him. Then they move up the ladder, and eventually from imagination to real elevators.

RyanSo the exam distinction. Systematic desensitization has three ingredients: a hierarchy, relaxation training, and gradual pairing. If an answer leaves out the relaxation, or starts at the top of the fear hierarchy, it isn't systematic desensitization as the textbook describes it.

SoheeAnd when real exposure is impractical, expensive, or embarrassing, there's virtual reality exposure. The textbook says it has been used effectively for fear of public speaking, claustrophobia, fear of flying, and post-traumatic stress disorder.

RyanThe National Institute of Mental Health, NIMH, describes exposure therapy as a type of cognitive behavioral therapy for anxiety disorders. A person spends brief periods in a supportive environment learning to tolerate the distress caused by certain items, ideas, or imagined scenes, until over time the fear goes down.

SoheeNow operant conditioning. One popular operant intervention is the token economy. A controlled setting where people are reinforced for desirable behaviors with tokens, like poker chips, exchanged for items or privileges.

RyanThe textbook says token economies are often used in psychiatric hospitals. Patients earn tokens for making their beds, brushing their teeth, coming to the cafeteria on time, socializing, and trade them for things like extra TV time or a private room.

SoheePause and think. Name the conditioning type for each. The bell-and-pad alarm for bedwetting. Antabuse for drinking. Tokens on a hospital ward.

RyanBell-and-pad is classical. Antabuse is classical too, it's aversive counterconditioning. The token economy is operant, because it reinforces behavior with consequences. The trap is calling Antabuse a punishment procedure. The textbook frames it as a conditioned aversion, a classical pairing.

SoheeLet's move from behavior to thought. Cognitive therapy, developed by psychiatrist Aaron Beck in the 1960s. His initial focus was depression.

RyanThe textbook's one-sentence version: how you think determines how you feel and act. Cognitive therapists help clients change dysfunctional thoughts in order to relieve distress, by seeing how they misinterpret situations. That misinterpretation is called a cognitive distortion.

SoheeIts example is Ray, who failed one Psychology 101 test and concluded he'll fail the course and probably flunk out of college. His therapist helps him challenge those beliefs, look at their illogical basis, and replace them with more rational ones.

RyanThen there's Albert Ellis. The textbook says one of the first forms of cognitive-behavioral therapy was rational emotive therapy, founded by Ellis, which grew out of his dislike of Freudian psychoanalysis. And behaviorists like Joseph Wolpe influenced him.

SoheeSo Beck goes with cognitive therapy, and Ellis goes with rational emotive therapy. Exams love to swap them.

RyanCognitive-behavioral therapy, CBT, puts both halves together. It aims to change cognitive distortions and self-defeating behaviors. And the textbook says CBT therapists focus much more on present issues than on a client's childhood or past.

SoheeOne CBT tool is the ABC model. A is the action, sometimes called the activating event. B is the belief about the event. C is the consequences of that belief.

RyanAnd here's a trap. B is belief, not behavior. In the textbook example, Jon and Joe are both turned down at a party. Jon tells himself he's a loser, gets depressed, and stops going to parties. Joe decides he had bad breath, buys a toothbrush, and goes to the next party.

SoheeSame activating event, different beliefs, different consequences.

RyanThe textbook names three distortions to know. All-or-nothing thinking, which is black or white. Overgeneralization, taking one small situation and making it huge. And jumping to conclusions, assuming people are reacting negatively to you without evidence.

SoheeNIMH also describes cognitive restructuring for post-traumatic stress disorder. It helps people make sense of the traumatic event, especially when they remember it differently from how it happened, or feel guilt or shame about something that isn't their fault.

RyanOkay, the evidence, since this is also a comparative efficacy topic. A big review by Stefan Hofmann and colleagues in Cognitive Therapy and Research surveyed 106 meta-analyses of CBT.

SoheeThe core premise they describe is that mental disorders and distress are maintained by cognitive factors. In Beck's model, maladaptive cognitions include schemas about the world, the self, and the future, which give rise to automatic thoughts in particular situations.

RyanTheir findings: the strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or controls. CBT showed higher response rates in seven, and only one reported lower response rates.

SoheeAnd their conclusion, word for word: in general, the evidence-base of CBT is very strong.

RyanBut listen to the qualifier, because it matters for the next episodes. Except for children and elderly populations, they found no meta-analyses of CBT on specific subgroups, such as ethnic minorities and low income samples.

SoheeSo strong support, with real gaps in who has been studied. And whether CBT beats other established therapies is a separate question. We'll take that on in the episodes on comparative efficacy.

RyanPause and think, last one. A client says: my boss didn't reply to my email, so she must be planning to fire me. Which distortion, and which part of the ABC model is it?

SoheeJumping to conclusions, assuming a negative reaction without evidence. And it's the B, the belief about the activating event, which drives the consequence, her anxiety.

RyanRecap. Behavior therapy applies learning principles. Classical techniques include the bell-and-pad and counterconditioning: aversive conditioning and exposure.

SoheeMary Cover Jones reported exposure in 1924 with Peter. Wolpe's systematic desensitization in 1958 adds a hierarchy and relaxation, because you can't be nervous and relaxed at once.

RyanToken economies are operant. Beck developed cognitive therapy, Ellis developed rational emotive therapy, and CBT targets distortions and self-defeating behavior, focusing on the present. ABC: activating event, belief, consequences.

SoheeAnd Hofmann's review calls CBT's evidence base very strong, strongest for anxiety disorders, somatoform disorders, bulimia, anger and general stress, with gaps for minority and low income samples.

RyanThat's a lot of names. If they blur, go back to Peter and the rabbit. Slow steps, a calm body, and a fear that shrinks. That's a fine way to study, too.

SoheeThanks for listening to EPPP Prep.

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