Cognitive-Behavioral Therapies, Part II PSYC 4500: Introduction to Clinical Psychology Brett Deacon, Ph.D. November 29, 2012

Questions for Herbert et al. (2000) response paper, due Tuesday 12/3 1. Why do think EMDR has become so popular among therapists? 2. What can be concluded about EMDR from the observation that component studies generally find that imagery without eye movements is as effective as standard EMDR? 3. Which one of the FiLCHeRS (essential features of science) do you find most troublesome about EMDR?

From Last Class CBT, theory and practice Behavior and cognitive modification techniques A →B →C model Albert Ellis with Gloria

REBT Video of Albert Ellis with Gloria Pay attention to A-B-C model, identifying, and disputing beliefs What’s it like to be a patient in REBT? What’s it like to be a therapist in REBT? A disclaimer about Albert Ellis

Basics of CBT Determine cognitive and behavioral factors that are contributing to the problem Develop cognitive and behavioral strategies to address them

Cognitive Techniques By definition, anxiety disorders involve fears that are at least somewhat irrational Therapist teaches clients how to think accurately about feared stimuli so they will only be as afraid as the facts warrant Thinking is most useful when it is believable and leads to a more realistic appraisal of danger and the ability to cope with feared stimuli

Accurate vs. Positive Thinking Actual quote from a therapist in a patient’s medical chart: “The importance of cognitive interventions was also discussed. In this regard, the patient was encouraged to develop a working list of positive cognitions to draw upon when beginning to feel and think anxiously. She cited initial examples of enjoying thinking about movies, spending time with her mother, or being at home. She was encouraged to expand upon these topics, including specifics, e.g. specific movie scenes, places in the home, etc. The patient was encouraged to write down her list of alternative cognitions and thoughts to keep with her, and to utilize and refer to when feeling more anxious, e.g. at school.” Is this a helpful cognitive therapy technique?

CBT for Anxiety Disorders Basic clinical strategies in CBT for anxiety Education Cognitive modification techniques Behavior modification techniques: exposure and fading of safety behaviors Integrating these: “behavioral experiments”

Cognitive Techniques I know nothing bad will happen when I _____ (encounter feared stimuli), but….. “Head” vs. “gut”-level understanding Simply talking about probabilities of danger is not as convincing as direct evidence from personal experience Are cognitive techniques necessary?

Basic Methods of Conducting Exposure Systematic desensitization (SD): Relaxation training Constructing a fear hierarchy Relaxing while imagining each step in the hierarchy Why SD is rarely used anymore Graduated exposure in vivo (graduated real-life exposure) Flooding (ungraduated real-life exposure)

Types of Exposure In vivo exposure - confronting feared stimuli in the environment (situations and objects) Imaginal exposure - confronting feared mental stimuli such as thoughts, worries, and memories Interoceptive exposure - confronting feared body sensations Some examples will follow in video clips

Exposure Hierarchy for a Patient Afraid of Acquiring Cancer Exposure Situation Estimated SUDS Thinking about having a deadly disease 95 Reading articles/watching TV about deadly diseases 90 Touching objects in public restrooms 85 Riding crowded elevators with medical patients 75 Touching objects in emergency room waiting area 70 Smoking a cigarette 60 Handling pets 55 Running 50 Hyperventilation 50

Exposure Hierarchy for a Patient Afraid of Negative Evaluation Exposure Situation Estimated Anxiety Ask a woman out on a date 95 Take dance lessons 95 Go to a bar 80 Online dating 50 Write letters/ s to friends/family 55 Work out in crowded gym 25 Committing social mishaps 20 Asking friends to get together 10

Exposure Hierarchy for a Patient Afraid of Panic-Related Body Sensations Exposure Situation Estimated Anxiety Hyperventilation 90 Breathing through a straw 85 Running in place 85 Shaking head from side to side 80 Spinning in chair 80 Swallowing rapidly 70

Exposure Therapy for Snake Phobia video clip Look for educational, cognitive, and behavioral techniques What it’s like to be a therapist using this approach? What it’s like to be a patient in this therapy? Is it torture?

Pediatric OCD Treatment Study (POTS I): Penn, Duke, & Brown CBT + SER n = 28 CBT n = 28 SER n = 28 PBO n = Week Treatment Phase 16 Week Follow-up Phase for Treatment Responders

Pediatric OCD Treatment Study Team (2004). JAMA Site x Treatment Interaction

Psychotherapist Outcomes for CBT: Pre- and Post-TX CY-BOCS Therapists account for 8.0% of variance within CBT, NS