These techniques are used to decrease problem or dysfunctional behaviour (usually excesses) or to increase or learn desirable or functional behaviour.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.
~~~~~
Source: Evidence-based Focussed Psychological Interventions
http://www.crufad.com/phc/fps.htm
What is it?
This technique is mainly used to assist patients with depression. Activity scheduling is a useful strategy to teach patients who have both lost interest in doing things they enjoy and who find it difficult to do basic daily tasks.
It is particularly important to increase pleasurable activities when people feel depressed, as they feel less inclined to engage in activities that are a source of pleasure and satisfaction.
Similarly, when people are not involving themselves in activities they consider pleasant, this can make them feel depressed. This creates a vicious cycle and in order to break this pattern of inactivity patients need to learn how to keep active when they feel down.
Activity scheduling is a behavioural technique designed to mobilise the patient and to increase the range and frequency of pleasant activities engaged in. The overall aim is to teach patients how to increase their activities in a structured and organised manner, thereby increasing mood.
Activity is the key, and mastery of tasks, pleasant activities, or exercise should be reinforced.
Does it work?
Activity scheduling is an effective behavioural treatment for depression (see Lewinsohn & Gotlib, 1995).
How do you do it?
1. If a patient is not engaging in their usual activities, both routine (e.g., household duties) and pleasant (e.g., going to the movies), then it will be important to explain to the patient why they need to continue doing these activities.
For example, 'you've told me that you no longer have the energy or motivation to do what you need to do and you have stopped doing things you enjoy. People often don't feel motivated when they are feeling down and sometimes stop doing the things they need to do and also stop doing the things they enjoy. It is important that you don't stop doing these things as the less you do the worse you will feel, and the worse you feel the less you will do.'
2. Ask the patient to tell you what things they are doing now and write these down. Then, ask the patient to rate their sense of achievement and how much pleasure they derive from performing these activities (on a scale from 0 to 6, where 0 = no pleasure or sense of achievement, 6 = high pleasure and sense of achievement).
3. The next step is to ask the patient to list all the things they should be doing but are not doing at the moment (e.g., grocery shopping). Then ask the patient to list at least ten things they would like to be doing and used to enjoy (e.g., meeting a friend for coffee, for further suggestions refer to 'Pleasant things to do', Management of Mental Disorders (2000), page 225).
4. If possible, activities should be arranged hierarchically - easiest to hardest - and each week, beginning with the easiest items, one to two activities will be chosen. Where necessary, complex activities (e.g., starting a course) should be broken down into smaller steps.
5. Discuss with the patient that it is important to try and achieve a balance between pleasurable activities and activities that are not pleasant but must be done.
6. With the patient, show them how to plan their activities in a structured manner. You can do this by going through their day hour by hour for the coming week or use the handout in Management of Mental Disorders (2000), on page 223-224.
7. Make sure you start off slowly and only schedule 1-2 pleasant activities in the first week. Do not try and fill every hour of the day. Even if the patient only does one pleasant activity during the week, this is better than doing none at all and will help give the patient a sense of mastery. You can increase the number and range of activities in the coming weeks. Don't forget to remind the patient to rate their sense of pleasure (P) and achievement (A) after completing the activity.
8. Ask the patient to record any other activities that occur and were not pre-planned. Ask them to rate their (P) and (A) for these too.
9. Remind the patient to bring their activity schedule to their next appointment. Review what went well and what did not go so well. Provide encouragement and try to build on what was achieved the previous week.
10. Encourage the patient to continue planning their activities until they resume their normal routine.
Sample Activity Schedule [see source page.]
Tips:
encourage patient to set aside time to plan their day (e.g., the night before)
suggest that the patient start the day with activity that will provide both pleasure and achievement
explain how exercise has been shown to help alleviate depressed mood (e.g., Lane & Lovejoy, 2001) and try to encourage the patient to make time in their day for this activity
encourage the patient to be flexible - reschedule activities as needed and add other activities as they occur.
aim for quality not quantity (e.g., 15 minutes of walking is better than aiming for a 1 hour run).
References and recommended reading:
1. Lewinsohn, P. M. & Gotlib, I. H. (1995). Behavioral theory and treatment of depression. In E. E. Becker & W. R. Leber (Eds.), Handbook of depression (pp. 352-375). New York: Guilford Press.
2. Lewinsohn, P. M., Munoz, R. F., Youngren, M., & Zeiss, A. M. (1978). Control Your Depression. New York: Prentice Hall Press.
3. Lane, A. M. & Lovejoy, D. J. (2001). The effects of exercise on mood changes: the moderating effect of depressed mood. Journal of Sports Medicine & Physical Fitness. 41(4):539-45.
4. Tanner, S. & Ball, J. (2000). Beating the Blues. A Self-Help Approach to Overcoming Depression. Southwood Press.
5. Treatment Protocol Project (2000). Management of Mental Disorders (Third Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.
~~~~~
Source: Evidence-based Focussed Psychological Interventions
http://www.crufad.com/phc/fps.htm