Cognitive-behavioral Interventions
Lecture 1
Exposure therapy
- Theoretical background
- Procedural variations
- Examples
- Research issues
Cognitive restructuring
- Theoretical background
- Procedural variations
- Examples
- Research issues
Exposure therapy
Classical conditioning = a type of learning in which a stimulus acquires the capacity to evoke
a reflexive response that was originally evoked by a different stimulus
Little albert: after conditioning, the sight of the rat made Albert scream – after a while Albert
began to show similar terrified behaviors to Watson’s face.
The fear evoked by the white, furry rat had generalized to other white, furry things, like
Watson’s beard (similar stimulus).
Maintenance of fear
- We’ve learned so far that classical conditioning can lead to the onset of (pathological)
fear
- The process of operant conditioning is needed to explain the maintenance of fear
Why do people remain anxious over time? Despite negative side effects operant
conditioning. (Skinners’ maze)
Functional analysis: you have this problem, why do you have it despite negative consequents
positive consequents of learned behavior
Two-factor model Mowrer
,Studying avoidance learning
Escape reaction avoidance reaction
Emotional processing theory (EPT)
- These early learning accounts were expanded by integrating Lang’s concept of the
‘fear structure’ to create a comprehensive model for understanding pathological
anxiety
o The fear-structure is an anxiety memory in which representations of stimuli,
responses, and meanings are stored
- In anxiety disorders, stimulus representations are linked to danger and strong
responses
Consequences for therapy
- Effective therapy = correct fear-structure
Demands:
- Fear-structure has to be activated! The patient must experience anxiety during
therapy
- New information, incompatible with old information, must be introduced in fear
structure
What is exposure therapy?
- Exposure therapy purposefully generates anxiety by exposing an individual
repeatedly to fear provoking stimuli
- In the absence of repeated aversive outcomes
- Which leads to extinction through inhibitory learning
Excitatory memory effect AND inhibitory memory effect ARE IN retrieval competition
A high level of anxiety is expected. This expectancy leads to avoidance. Avoidance brings
short-term relief, but high expected anxiety is maintained.
In exposure, through time, anxiety levels become less and less. Repeating exposure is
important, not in 1 session. The more you practice, the more the anxiety will decrease
(anxiety-curve)
3 types of exposure
In vivo exposure: exposure to external feared stimuli
In vitro/imaginal exposure: exposure to imaginal stimuli
Interoceptive exposure: exposure to physical (internal) stimuli
When? Specific phobias, panic disorder, social anxiety disorder, generalized anxiety disorder,
obsessive compulsive disorder, trauma (PTSD)
Variations
Massed versus spaced exposure (between session)
Must ET be conducted at its max lengths? (e.g. 3-4 hours a day, 5 days a week)
- Pro massed ET: quick improvement enhances motivation / less opportunity for
avoidance
, - Pro spaced ET: less return of fear / more acceptable and practical to patients (most
used in NL, current practice)
Should ET be as intense as possible or gradual?
- Flooding: exposes the person to the most anxiety-producing stimulus
o Pro: quicker results
- Graduated exposure: begins with the least fearful stimulus
o Pro: less dropout and non-compliance than flooding (practiced mostly)
Attention versus distraction
Distraction: regulates too high levels of anxiety (positive effect on short term), but also acts
as cognitive avoidance (hampering anxiety activation and habituation) negative effect on
long term
The long-term effects of focused attention during ET are favorable to the effects of
distracted exposure
Therapist-aided versus self-directed ET
- Is the aid of another person (therapist/family member) necessary for successful ET?
- Therapist or spouse-aided ET somewhat more effective that self-directed ET
- Practice: involvement of others in first phase of ET
In vivo versus in vitro…
Is exposure in vivo just as effective as in vitro?
- In vivo ET is more effective than in vitro ET. Every therapy should include exposure in
vivo!
- Imaginal exposure to motivate patients to start in vivo exposure and in case of
exposure to special stimuli (e.g. reexperiences in PTSD or fear of flying).
New: virtual reality
Arachnopohobia = spinnenfobie
Case description: low back pain patient with fair of movement
Female, married, 48 yrs, working in a bakery
Intermittent pain from age 35, more continuous from age 44
Present pain started when taking a cake from the shop counter
Illness attribution of damage to the spine
Stabbing pain persists after 2 weeks of bed rest
Pain occurs after making specific movements which are now avoided
Physiotherapy, manual therapy and neurological investigations gave no relief
Ultimate fear: some movements will further injure her spine and result in permanent
invalidity
Hierarchy on the basis of the photograph series of daily activities (PHODA) 0 – 100
What can/could you do? And what would be difficult? 0, 10, 20, work way up
Some new insight on extinction
- Extinction is not unlearning: pavlovian associations are forever
Lecture 1
Exposure therapy
- Theoretical background
- Procedural variations
- Examples
- Research issues
Cognitive restructuring
- Theoretical background
- Procedural variations
- Examples
- Research issues
Exposure therapy
Classical conditioning = a type of learning in which a stimulus acquires the capacity to evoke
a reflexive response that was originally evoked by a different stimulus
Little albert: after conditioning, the sight of the rat made Albert scream – after a while Albert
began to show similar terrified behaviors to Watson’s face.
The fear evoked by the white, furry rat had generalized to other white, furry things, like
Watson’s beard (similar stimulus).
Maintenance of fear
- We’ve learned so far that classical conditioning can lead to the onset of (pathological)
fear
- The process of operant conditioning is needed to explain the maintenance of fear
Why do people remain anxious over time? Despite negative side effects operant
conditioning. (Skinners’ maze)
Functional analysis: you have this problem, why do you have it despite negative consequents
positive consequents of learned behavior
Two-factor model Mowrer
,Studying avoidance learning
Escape reaction avoidance reaction
Emotional processing theory (EPT)
- These early learning accounts were expanded by integrating Lang’s concept of the
‘fear structure’ to create a comprehensive model for understanding pathological
anxiety
o The fear-structure is an anxiety memory in which representations of stimuli,
responses, and meanings are stored
- In anxiety disorders, stimulus representations are linked to danger and strong
responses
Consequences for therapy
- Effective therapy = correct fear-structure
Demands:
- Fear-structure has to be activated! The patient must experience anxiety during
therapy
- New information, incompatible with old information, must be introduced in fear
structure
What is exposure therapy?
- Exposure therapy purposefully generates anxiety by exposing an individual
repeatedly to fear provoking stimuli
- In the absence of repeated aversive outcomes
- Which leads to extinction through inhibitory learning
Excitatory memory effect AND inhibitory memory effect ARE IN retrieval competition
A high level of anxiety is expected. This expectancy leads to avoidance. Avoidance brings
short-term relief, but high expected anxiety is maintained.
In exposure, through time, anxiety levels become less and less. Repeating exposure is
important, not in 1 session. The more you practice, the more the anxiety will decrease
(anxiety-curve)
3 types of exposure
In vivo exposure: exposure to external feared stimuli
In vitro/imaginal exposure: exposure to imaginal stimuli
Interoceptive exposure: exposure to physical (internal) stimuli
When? Specific phobias, panic disorder, social anxiety disorder, generalized anxiety disorder,
obsessive compulsive disorder, trauma (PTSD)
Variations
Massed versus spaced exposure (between session)
Must ET be conducted at its max lengths? (e.g. 3-4 hours a day, 5 days a week)
- Pro massed ET: quick improvement enhances motivation / less opportunity for
avoidance
, - Pro spaced ET: less return of fear / more acceptable and practical to patients (most
used in NL, current practice)
Should ET be as intense as possible or gradual?
- Flooding: exposes the person to the most anxiety-producing stimulus
o Pro: quicker results
- Graduated exposure: begins with the least fearful stimulus
o Pro: less dropout and non-compliance than flooding (practiced mostly)
Attention versus distraction
Distraction: regulates too high levels of anxiety (positive effect on short term), but also acts
as cognitive avoidance (hampering anxiety activation and habituation) negative effect on
long term
The long-term effects of focused attention during ET are favorable to the effects of
distracted exposure
Therapist-aided versus self-directed ET
- Is the aid of another person (therapist/family member) necessary for successful ET?
- Therapist or spouse-aided ET somewhat more effective that self-directed ET
- Practice: involvement of others in first phase of ET
In vivo versus in vitro…
Is exposure in vivo just as effective as in vitro?
- In vivo ET is more effective than in vitro ET. Every therapy should include exposure in
vivo!
- Imaginal exposure to motivate patients to start in vivo exposure and in case of
exposure to special stimuli (e.g. reexperiences in PTSD or fear of flying).
New: virtual reality
Arachnopohobia = spinnenfobie
Case description: low back pain patient with fair of movement
Female, married, 48 yrs, working in a bakery
Intermittent pain from age 35, more continuous from age 44
Present pain started when taking a cake from the shop counter
Illness attribution of damage to the spine
Stabbing pain persists after 2 weeks of bed rest
Pain occurs after making specific movements which are now avoided
Physiotherapy, manual therapy and neurological investigations gave no relief
Ultimate fear: some movements will further injure her spine and result in permanent
invalidity
Hierarchy on the basis of the photograph series of daily activities (PHODA) 0 – 100
What can/could you do? And what would be difficult? 0, 10, 20, work way up
Some new insight on extinction
- Extinction is not unlearning: pavlovian associations are forever
