Lecture 1
Psychological problems are based on faulty or unhelpful ways of thinking (cognitive), and on learned patterns of
unhelpful behavior (behavioral).
Behaviorsm: all behaviors are learned through conditioned interaction with the environment, focuses on the
observable.
- Classical conditioning → reflexive/associative/passive learning (involuntary behaviors) (UCS = dog
bite→ UCR - frightened, CS = sight of dog → CR = frightened).
- Operant conditioning → active learning based on consequences of voluntary behavior, through
reinforcements and punishments. Behavior that is reinforced tends to be repeated, no reinforcement =
weakened
Cognitivism: mental (unobservable) processes play a role in learning (does acknowledge the role of behavioral
processes).
Beliefs/thoughts are central and lead to certain behavior
Exposure: breaking through the typical pattern of avoidance, all about facing your irrational fears.
Anxiety in behavioral terms (two-process/factor model):
The fear is acquired by classical conditioning - the fear is maintained by operant conditioning. Avoidance is very
successful and reinforced, it takes away the negative feeling of fear.
→ therapy must not only promote extinction through confrontations with feared object, but also eliminate
avoidances that would prohibit extinction from occurring.
Anxiety in cognitive terms → set of erroneous beliefs about stimuli and resources. Avoidance is the
consequence of these erroneous beliefs. Avoidance + safety behaviors: no disconfirmation of beliefs.
Exposure therapy: repeated and systematic approach toward fear provoking stimuli in the absence of the
expected aversive outcomes.
Habituation based exposure:
Exposure is effective when: break the association between trigger (CS) and expected catastrophe (USC) and fear
(CR) = correct the fear structure to a non/correct fear structure.
- The fear structure has to be activated during the exposure. New information, incompatible with old
info, must be introduced in fear structure.
Correction of fear structure (emotional processing) is indicated by habituation.
Habituation: fear reduction during sessions and over course therapy.
Problems with this model:
- Habituation is not a reliable predictor of long-term treatment outcomes
- Successful outcomes occur despite lack of habituation
- Exposure is used to control anxiety, implicit messaging that anxiety is dangerous → future anxiety
symptoms interpreted as sign of danger/relapse.
Inhibitory learning theory
→ effective exposure therapy = form new, competing non-fear structure, not overriding current fear structure.
After exposure the fear and non-fear structure compete for retrieval. Do exposure in a variety of contexts, so the
non-fear structure will win more often and strengthen.
- Focus on cognitive learning, make it concrete and testable, learn that you can tolerate anxiety.
Behavioral Activation (BA) = breaking through the cycle of inactivity and withdrawal (typical for people with
depression).
,→ the structured scheduling of specific activities for the client to complete in their daily life that functions to
increase contact with positive reinforcement. Desirable things: meaning, connection. accomplishments.
Therapists hould help the client find which activities are related to better mood.
Lewinsohn → the essence of depression is inactivity (low rate of positive behavior), inactivity leads to less
opportunities to experience positive reinforcement (increasing depressed mood). To break through this cycle:
focus on increasing pleasant activities.
Component analysis study of CBT:
- Facilitative strategies (BA)
- Behavioral activation strategies (BA)
- Automatic thoughts strategies (CT)
- Core belief strategies (CT)
→ no difference in effectiveness of full CT package or only facilitative strategies and BA strategies. More
interest in BA.
BA’s Model of Psychopathology:
Depression often starts when there are changes in the environment (big life events) which leads to less positive
opportunities in their lives.
In this model, there is a focus on the cycle and not on the cause because this is a BA approach and not a
cognitive approach.
The ultimate focus on increasing positively reinforced behavior rather than decreasing negatively reinforced
behavior highlights that BA is a constructive therapy, fundamentally concerned with helping clients create rich,
meaningful lives, not simply reducing symptoms or eliminating problem behavior.
Possible reasons for loss of reinforcers:
- Lost due to environmental losses
- Lack of skills to obtain reinforcers
- Mismatch between individual and environment (extravert vs. introvert)
- Genetics and learned differences
BA’s model of treatment:
Goals of BA:
1. Increase engagement in adaptive activities (which often are those associated with the experience of
pleasure or mastery);
2. Decrease engagement in activities that maintain depression or increase risk for depression;
3. Solve problems that limit access to reward.
, In psycho-education it is important to mention:
- Vicious cycle that can develop between depressed mood, withdrawal and worsened mood.
- Suggest activation as a tool to break this cycle and support problem solving
- Emphasize an outside-in approach: act according to plan or goal rather than a feeling of internal state.
BA as a treatment includes monitoring of behavior → which activities associated with highest and which with
lowest mood.
Primary goal: schedule specific activities for the client to engage in to experience positive reinforcement.
Grading tasks:
- Assign simple to more complex tasks in a stepwise fashion
- Design assignments so that early success is guaranteed
Obstacles? → Problem Solving Skills, imaginary rehearsal.
Emotional Processing Theory (EPT): a framework for understanding anxiety disorders and the mechanisms
underlying exposure therapy. This theory specifies two conditions necessary for therapeutic fear reduction:
1. The fear structure must be activated for it to be available for modification.
2. New information that is incompatible with the pathological elements of the fear structure must be
available and incorporated into the pathological memory structure.
→ exposure
Lang’s bioinformation model: the fear network is a program for escaping or avoiding danger that includes
representations of feared stimuli, responses and the meaning of stimuli and responses.
In vivo exposure is currently considered the treatment of choice to treat specific phobias:
- Erroneous information regarding the feared object or situation.
- The exposure is designed to involve confrontation with the feared stimulus to activate the fear structure
and disconfirm negative expectations of harm.
- The large treatment gains following exposure treatments for specific phobias tend to be maintained or
improved over time.
In panic disorder:
- The fear structure is characterised by erroneous beliefs regarding bodily sensations which are perceived
as indicators of catastrophes.
- Exposure is designed to have individuals directly confront feared bodily sensations through
interoceptive exposure and situations that generate these sensations through in vivo exposure.
- The exposure procedures must eliminate safety signals (no medical team on sight).
The fear structure in social anxiety disorder is characterized by misconceptions regarding social interactions:
- Uses role-playing with confederates, which includes video and confederate feedback to help illustrate
to patients how they objectively appear to others and how others perceive them in social interactions. E
- Exposure appears to be a critical component of CBT for social phobia and the addition of cognitive
restructuring to exposure does not appear to improve treatment outcomes.
Pathological fear structures of obsessive compulsive disorder (OCD):
- Are commonly characterized by exaggerated or unrealistic estimates of threat and the belief that
compulsions are the only way to reduce obsessional anxiety.
- Exposure and ritual prevention, combining confrontation and abstinence from rituals, is considered to
be a front line treatment for OCD.
- The combination of imaginal and in vivo exposure also appears to enhance long-term outcome
compared to in vivo exposure alone.
In posttraumatic stress disorder (PTSD):
Psychological problems are based on faulty or unhelpful ways of thinking (cognitive), and on learned patterns of
unhelpful behavior (behavioral).
Behaviorsm: all behaviors are learned through conditioned interaction with the environment, focuses on the
observable.
- Classical conditioning → reflexive/associative/passive learning (involuntary behaviors) (UCS = dog
bite→ UCR - frightened, CS = sight of dog → CR = frightened).
- Operant conditioning → active learning based on consequences of voluntary behavior, through
reinforcements and punishments. Behavior that is reinforced tends to be repeated, no reinforcement =
weakened
Cognitivism: mental (unobservable) processes play a role in learning (does acknowledge the role of behavioral
processes).
Beliefs/thoughts are central and lead to certain behavior
Exposure: breaking through the typical pattern of avoidance, all about facing your irrational fears.
Anxiety in behavioral terms (two-process/factor model):
The fear is acquired by classical conditioning - the fear is maintained by operant conditioning. Avoidance is very
successful and reinforced, it takes away the negative feeling of fear.
→ therapy must not only promote extinction through confrontations with feared object, but also eliminate
avoidances that would prohibit extinction from occurring.
Anxiety in cognitive terms → set of erroneous beliefs about stimuli and resources. Avoidance is the
consequence of these erroneous beliefs. Avoidance + safety behaviors: no disconfirmation of beliefs.
Exposure therapy: repeated and systematic approach toward fear provoking stimuli in the absence of the
expected aversive outcomes.
Habituation based exposure:
Exposure is effective when: break the association between trigger (CS) and expected catastrophe (USC) and fear
(CR) = correct the fear structure to a non/correct fear structure.
- The fear structure has to be activated during the exposure. New information, incompatible with old
info, must be introduced in fear structure.
Correction of fear structure (emotional processing) is indicated by habituation.
Habituation: fear reduction during sessions and over course therapy.
Problems with this model:
- Habituation is not a reliable predictor of long-term treatment outcomes
- Successful outcomes occur despite lack of habituation
- Exposure is used to control anxiety, implicit messaging that anxiety is dangerous → future anxiety
symptoms interpreted as sign of danger/relapse.
Inhibitory learning theory
→ effective exposure therapy = form new, competing non-fear structure, not overriding current fear structure.
After exposure the fear and non-fear structure compete for retrieval. Do exposure in a variety of contexts, so the
non-fear structure will win more often and strengthen.
- Focus on cognitive learning, make it concrete and testable, learn that you can tolerate anxiety.
Behavioral Activation (BA) = breaking through the cycle of inactivity and withdrawal (typical for people with
depression).
,→ the structured scheduling of specific activities for the client to complete in their daily life that functions to
increase contact with positive reinforcement. Desirable things: meaning, connection. accomplishments.
Therapists hould help the client find which activities are related to better mood.
Lewinsohn → the essence of depression is inactivity (low rate of positive behavior), inactivity leads to less
opportunities to experience positive reinforcement (increasing depressed mood). To break through this cycle:
focus on increasing pleasant activities.
Component analysis study of CBT:
- Facilitative strategies (BA)
- Behavioral activation strategies (BA)
- Automatic thoughts strategies (CT)
- Core belief strategies (CT)
→ no difference in effectiveness of full CT package or only facilitative strategies and BA strategies. More
interest in BA.
BA’s Model of Psychopathology:
Depression often starts when there are changes in the environment (big life events) which leads to less positive
opportunities in their lives.
In this model, there is a focus on the cycle and not on the cause because this is a BA approach and not a
cognitive approach.
The ultimate focus on increasing positively reinforced behavior rather than decreasing negatively reinforced
behavior highlights that BA is a constructive therapy, fundamentally concerned with helping clients create rich,
meaningful lives, not simply reducing symptoms or eliminating problem behavior.
Possible reasons for loss of reinforcers:
- Lost due to environmental losses
- Lack of skills to obtain reinforcers
- Mismatch between individual and environment (extravert vs. introvert)
- Genetics and learned differences
BA’s model of treatment:
Goals of BA:
1. Increase engagement in adaptive activities (which often are those associated with the experience of
pleasure or mastery);
2. Decrease engagement in activities that maintain depression or increase risk for depression;
3. Solve problems that limit access to reward.
, In psycho-education it is important to mention:
- Vicious cycle that can develop between depressed mood, withdrawal and worsened mood.
- Suggest activation as a tool to break this cycle and support problem solving
- Emphasize an outside-in approach: act according to plan or goal rather than a feeling of internal state.
BA as a treatment includes monitoring of behavior → which activities associated with highest and which with
lowest mood.
Primary goal: schedule specific activities for the client to engage in to experience positive reinforcement.
Grading tasks:
- Assign simple to more complex tasks in a stepwise fashion
- Design assignments so that early success is guaranteed
Obstacles? → Problem Solving Skills, imaginary rehearsal.
Emotional Processing Theory (EPT): a framework for understanding anxiety disorders and the mechanisms
underlying exposure therapy. This theory specifies two conditions necessary for therapeutic fear reduction:
1. The fear structure must be activated for it to be available for modification.
2. New information that is incompatible with the pathological elements of the fear structure must be
available and incorporated into the pathological memory structure.
→ exposure
Lang’s bioinformation model: the fear network is a program for escaping or avoiding danger that includes
representations of feared stimuli, responses and the meaning of stimuli and responses.
In vivo exposure is currently considered the treatment of choice to treat specific phobias:
- Erroneous information regarding the feared object or situation.
- The exposure is designed to involve confrontation with the feared stimulus to activate the fear structure
and disconfirm negative expectations of harm.
- The large treatment gains following exposure treatments for specific phobias tend to be maintained or
improved over time.
In panic disorder:
- The fear structure is characterised by erroneous beliefs regarding bodily sensations which are perceived
as indicators of catastrophes.
- Exposure is designed to have individuals directly confront feared bodily sensations through
interoceptive exposure and situations that generate these sensations through in vivo exposure.
- The exposure procedures must eliminate safety signals (no medical team on sight).
The fear structure in social anxiety disorder is characterized by misconceptions regarding social interactions:
- Uses role-playing with confederates, which includes video and confederate feedback to help illustrate
to patients how they objectively appear to others and how others perceive them in social interactions. E
- Exposure appears to be a critical component of CBT for social phobia and the addition of cognitive
restructuring to exposure does not appear to improve treatment outcomes.
Pathological fear structures of obsessive compulsive disorder (OCD):
- Are commonly characterized by exaggerated or unrealistic estimates of threat and the belief that
compulsions are the only way to reduce obsessional anxiety.
- Exposure and ritual prevention, combining confrontation and abstinence from rituals, is considered to
be a front line treatment for OCD.
- The combination of imaginal and in vivo exposure also appears to enhance long-term outcome
compared to in vivo exposure alone.
In posttraumatic stress disorder (PTSD):
