Behavioural Assessment? (initial assessment, monitoring progress, modifying treatment)

What are the behaviour therapy techniques?

These techniques are used to decrease problem or dysfunctional behaviour (usually excesses) or to increase or learn desirable or functional behaviour. It is particularly effective for the treatment of externalizing disorders and for developing prosocial and basic living skills in children or in adults with an intellectual handicap.

Behaviour modification starts with a thorough behavioural analysis, which involves specifying and measuring the behaviours to be altered, and identifying the antecedents and consequences controlling these behaviours.

This analysis is followed by a systematic program which may include altering the stimuli triggering the unwanted behaviour, shaping up new adaptive (competing) behaviour, and contingency management (using reinforcers for increasing desirable behaviour and costs to decrease the unwanted/dysfunctional behaviour).

After changing particular behaviours, techniques for generalization and maintenance of gains are discussed, along with relapse prevention.

Does it work?

Behavioural interventions are an important component of treatment for a variety of disorders. The specific evidence is discussed in relation to the techniques outlined below.

How do you do it?

Some of the key behavioural interventions and how you do them are outlined below.

Exposure techniques

What is it?

Exposure techniques are used for all anxiety disorders, particularly the phobias. Essentially, exposure involves confronting the feared situation/event/activity so that the fear decreases, or ideally, extinguishes.

Graded exposure is the most commonly used exposure technique. It involves identifying a patient's fears, and constructing a hierarchy of the least to most feared situations. A graded approach is necessary because of the fear it provokes and few people would be willing to confront this immediately and directly when commencing treatment.

Therefore, the individual enters the anxiety provoking situations in graded steps so that anxiety is evoked, but not overwhelmingly so. The individual is then instructed to stay in the situation until their anxiety decreases. By remaining in the situation until the fear subsides, the person learns that it is groundless.

Systematic desensitization is similar in that it involves exposure to a hierarchy of feared objects or situations (often in imagination) while using slow breathing, and/or other relaxation techniques, and cognitive coping self-statements to cope with the anxiety experienced.

On exposure, the person is assisted to implement the learned relaxation techniques and use the coping self-statements until the fear subsides. Desensitisation is most often used when it is impossible to confront the fear (e.g., fear of flying) but few GPs will have the time or experience and should refer patients that need this to a Clinical Psychologist.

Does it work?

There are many studies of the use of graded exposure in simple and specific phobias and in agoraphobia with follow up studies showing that the benefit is long lasting (e.g., Munby & Johnston, 1980). Exposure is now used as a component of treatment in social phobia (with cognitive therapy) (Taylor, 1996), in obsessive compulsive disorder (with response prevention) (Abramowitz, 1997), in generalised anxiety disorder (with problem solving and relaxation) (Ladouceur, et. al, 2000) and in posttraumatic stress disorder with exposure both to the memories and to situations evoking the memories (Foa et al., 1991).

How do you do it?

Graded exposure in vivo.

1. It is important to provide a good rationale to the patient when you introduce graded exposure into treatment. The patient will usually find the idea of confronting feared situations quite daunting. Typically, these are situations the patient would have spent a great deal of time prior to treatment trying to avoid and so this will be an unpleasant task.

Therefore, a good rationale is crucial before beginning any exposure tasks and if explained properly, the likelihood of the patient actually carrying out the exposure tasks and complying with treatment is increased.

For example,

'One way of overcoming fear provoking situations that you have avoided in the past is to confront these situations in a gradual manner. I know you get very anxious when X happens (e.g., you see a spider, you give a speech), so I'm not going to ask you to confront your most feared situation straight away. Instead, over the next few weeks, I will be asking you to do a number of tasks that will start off quite easy and get harder, until you are able to do X (most feared situation). While you may still find X difficult, every time you enter an anxiety-provoking situation, your fear should decrease (refer to specific everyday examples such as learning to drive). The more times you so this, the easier it will get, and eventually you will learn that nothing bad will happen to you. Eventually, you should be able to confront your feared situation without overwhelming anxiety'.

2. The next step is to develop an exposure hierarchy in collaboration with your patient. Ask the patient to write down all the situations/events/activities he or she avoids.

Direct the patient to think of situations that range from :

extreme anxiety 95-100/100 (where a large number indicates extreme distress in the situation) through to
mild 10/100 (where a lower number indicates mild distress in the situation).

Feared situations are seldom simple, for example a person with agoraphobia might fear train travel because they are getting further from home (and help) but also fear crowded trains because escape would not be possible. While only the patient knows the detail of what they fear, the clinician must ensure that the exposure situations address the complexity of the fears.

3. Next decide upon approximately 10 situations (if the hierarchy is too small then opportunities for improvement is limited) which will be able to be implemented as part of the patient's exposure plan. When deciding on situations that are appropriate, try to choose scenes that are specific (e.g., 'catch bus from A to B at 9:00am Tuesday morning', rather than 'catch the bus') and detailed (e.g., 'have a conversation' is too vague).

4. Then help the patient organise the situations from least to most feared. This is not always an easy process. However, there are not set rules for guiding this process, just try to arrange the hierarchy in a logical, ascending order. It may be helpful to write the scenes on separate cards and spend some time arranging these.

5. Ensure that a range of situations have been included in the hierarchy and that there are no sudden jumps in the levels of distress. If there are, have the person add intermediate situations or modify one of their items (if necessary, intermediate steps can be added in once the patient begins undertaking exposure tasks).

6. The next step is encouraging the patient to begin exposure. Ask them to enter one of the easiest situations on their own and remain until anxiety is halved, then instruct the patient to repeat this until there is little associated anticipatory anxiety about entering the situation. While there is no exact timeframe for how long the patient should remain in the situation, ideally, the patient should be encouraged to stay in the situation for as long as he or she can tolerate (within reason).

This should allow ample opportunity to learn that nothing bad will happen and that habituation to anxiety will occur. However, there are often practical constraints that need to be considered. Such constraints will often guide how long the exposure exercise will last. When a particular exposure exercise is brief (e.g., 'initiating a conversation with a stranger'), it should be repeated a number of times.

7. The patient should then move on to the next situation and repeat until less anxiety occurs.

8. The patient should do exposure at least three to four tasks per week and you should review progress weekly to ensure he or she is confronting their fears. Any success must be reinforced, even good effort at a task that was not successful is a reason for praise. Once mastery of a situation occurs patients will become pleased and proud and clinicians should reinforce this.

9. Motivation is often a problem, given the unpleasant nature of what you are asking the patient to do. At times, you will need to remind the patient of the rationale behind exposure and encourage him or her to continue to confront the feared situations until mastery is achieved.

Sample graded exposure hierarchy

Goal: To travel alone by train to the city and back

Situation                                                         Expected Anxiety
1. Travelling one stop, quiet time of day      15/100
2. Travelling two stops, quiet time of day     20/100
3. Travelling two stops, rush hour                 30/100
4. Travelling five stops, quiet time of day      45/100
5. Travelling five stops, rush hour                   55/100
6. Travelling eight stops, quiet time of day    65/100
7. Travelling eight stops, rush hour                 70/100
8. Travelling all the way, quiet time of day    85/100
9. Travelling all the way, rush hour                100/100

Tips:
· ensure that the patient does exposure repeatedly - even if they feel they have conquered their fears

· within reason, allow the patient to determine the rate at which they progress through their hierarchy

· sometimes several smaller hierarchies might be more workable than one large hierarchy, if there are distinct situations that require attention (e.g., attending social gatherings)

· you can also explain exposure to the patient as a 'behavioural experiment' that can be used to test out their fears. For example, if a patient says 'everyone will laugh at me', then you can set an exposure task that will allow them to test out this belief

· if a patient is extremely anxious or resistant prior to an exposure task then you can:
- modify their hierarchy
- add more intermediate steps into the hierarchy
- encourage the patient to do the task with a friend or partner

· keep in mind that a patient's progression through their hierarchy will not always run smoothly. At different times and for various reasons (e.g., lack of motivation, a change in personal circumstances), they will experience setbacks and it will be necessary to remind him or her about the rationale for exposure and encourage persistence with the hierarchy.

· it may helpful if you ask the patient to keep a diary, so he or she can record their anxiety levels and any problems that were encountered.

Special Issues in Obsessive Compulsive Disorder (to be added)

Special issues in Bulimia (to be added)

Special Issues in the treatment of sexual disorders (to be added)

References and recommended reading:

1. Abramowitz, J. S. (1997). Effectiveness of psychological and pharmalogical treatments for obsessive-compulsive disorder: A quantitative review. Journal of Consulting and Clinical Psychology, 65, 44-52.

2. Andrews, G., Crino, R., Hunt, C., Lampe, L. & Page, A. (1994). The Treatment of Anxiety Disorders. Melbourne: Cambride University Press.

3. Andrews, G. & Hunt, C. (1998). Treatments that work in anxiety disorders. Medical Journal of Australia, 168, 628-634. 4. Foa, E. B.; Rothbaum, B. O.; Riggs, D. S.; Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting & Clinical Psychology, 59, 715-723.
 
5. Ladouceur, R., Dugas, M. J., Freeston, M. H., Leger, E., Gagnon, E., & Thibodeau, N. (2000). Efficacy of a cognitive-behavioural treatment for generalised anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68, 957-964.

6. Munby, J. & Johnston, D.W. (1980). Agoraphobia: long-term follow-up of behavioural treatment. British Journal of Psychiatry, 135, 418-27.

7. Taylor, S. (1996). Meta-analysis of cognitive behavioural treatments for social phobia. Journal of Behaviour Therapy and Experimental Psychiatry, 27, 1-9.

8. Treatment Protocol Project (2000). Management of Mental Disorders (Third Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.

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Source: Evidence-based Focussed Psychological Interventions
http://www.crufad.com/phc/fps.htm