on had died as an infant and he had been killed by bandits \200\224hence prophe- cies could not be trusted. This story only increases Oedipus \200\231s worry and he suspects that he murdered Laius but does not yet realize that Laius was his father. A messenger arrives to inform him of the death of the King of Corinth. The messenger also r eveals that Oedipus was adopted. He begins to sus- pect that he is the son of Laius and con tinues to investigate, ignoring the pleas of Jocasta who has already realized the whole tru th. Eventually he \201 nds the shepherd who took him to the household of the King of Cori nth and the full truth is revealed. At this point he hears anguished cries com- ing from th e palace and rushes to his apartments. Oedipus breaks down the door of the royal bedchamber to \201 nd the queen, his wife and mother, has hanged herself. He seizes her dress pin a nd gouges out his eyes so as not to have to look at the atrocity he has unwittingly committ ed. He enters into exile, having failed to avoid the fate laid out for him. 20_Semple_Chap20.indd 833 12/7/2012 4:32:54 PM CHAPTER 20 Psychotherapy 834 Object relations theory In the mid-twentieth century Winnicott, Klein, Fairbairn, and other s devel- oped object relations theory which emphasized the importance of rela- tionships, r ather than drives such as sexuality and aggression, in affecting the mind. This theory desc ribes a model of infant psychological devel- opment, links abnormal early experiences to sy mptoms in later life, and uses this as a basis for interpretation in therapy. Object relati ons theory remains signi \201 cant in modern psychoanalytical practice. Essence Our \200\230sense of self \200\231 and our adult personality are developed as a re sult of the relationships we form in our lives. The earliest, and hence the most important, relationship is that between mother and child. Our early relationships form a template for future relationships, with abnormal early experiences being associated with psychological symptoms and abnormal relationships later in life. Theory The mind is viewed as blank at birth with the newborn unable to distinguish between \200\230myself \200\231 and \200\230everything else \200\231. Then the infant begins to v iew the external world as a series of (initially unconnected) \200\230objects \200\231. Th ese objects may be things (e.g. a toy, a blanket), people (e.g. mother, father), or parts o f people or things (e.g. the mother \200\231s breast, the mother \200\231s face). The infan t creates an internal representation of each object and has relationships with, and feeling s towards, the internal as well as the external objects. There are three primitive emotions (or \200\230affects \200\231) which an infant can dis- play towards each object \200\224attachment, frustration, and rejection. There is a tendenc y for a single affect to become associated with one object. Inevitably even a caring mother will create some feelings of frustration and rejection: mothers comfort their children and provide food and love, but also scold, punish and are sometimes simply unable to meet thei r child \200\231s needs. Consequently the child will view the mother as comprising a number of objects, some of which he views positively and some with hostility. The child will initially deal with this by keeping the \200\230good objects \200\231 (asso - ciated with attachment) separate from the \200\230bad objects \200\231 (those causing fr ustration and rejection) \200\224a phenomenon known as \200\230splitting \200\231. This is the initial primitive defense mechanism \200\224the \200\230paranoid \200\223schizoid pos ition \200\231. As the child develops, this defense becomes increasingly untenable and, in normal development the child will unify the good and bad maternal objects to a single \200 \230mother object \200\231 containing both good and bad \200\224the so-called \200\230depr essive position \200\231. The relationships we form later in life have a strong tendency to echo relationships from e arlier in our development. Interestingly, we can take on either role in these recapitulated relationships. Hence a child, one of whose parental relationships was with an aggressive/a busive father, can take on a \200\230victim \200\231 posture in some later relationships b ut may instead take on the role of the aggressor in others. In therapy The therapist \200\231s neutral stance provides an ideal environ- ment for the r ecapitulation of previous relationships. Most relationships 20_Semple_Chap20.indd 834 12/7/2012 4:32:54 PM OBJECT RELATIONS THEORY 835 are molded by both parties, but in therapy the therapist aims to allow the relationship mod el to be developed by the patient. The subsequent examination of the role and relationship forced onto the therapist (the transference) is a key part of therapy. Most therapies incor porating object relations theory help the patient resolve the pathological qualities of the transference through the experience of the real relationship between the therapist and the patient. Once these relationships are identi \201 ed they can begin to explore with the p atient how the relationship in the consulting room re \202 ects the patient \200\231s expe rience growing up as well as their current life-situations. 20_Semple_Chap20.indd 835 12/7/2012 4:32:54 PM CHAPTER 20 Psychotherapy 836 Psychoanalysis 1 Dynamic therapies, including psychoanalysis or psychodynamic psycho- thera py and group analysis are derived from the psychoanalytic principles and practice of Sigmun d Freud and those who have subsequently devel- oped his ideas. Most therapies which concept ualize an unconscious mind affecting our perceptions and actions can be considered part of the school of the dynamic psychotherapies. Rationale Traumatic experiences, particularly those in early life, give rise to psycho- log ical con \202 ict. The greater part of mental activity is unconscious and the conscious mi nd is protected from the experience of this con \202 ict by inbuilt defenses, designed to decrease \200\230unpleasure \200\231 and to diminish anxiety. These defenses are developme ntally appropriate but their continuation into adult life results in either psychological s ymptoms or in a diminished ability for personal growth and ful \201 lment. Con \202 ict c an be examined with regard to the anxiety itself, the defense, or the underlying wish or me mory. The individual \200\231s previous family and personal relationships will have sym- bo lic meaning and be charged with powerful emotions. Representations of these relationships w ill emerge during therapy and provide a route towards understanding and change. How illness is viewed Both mental illness and normal psychological development can be under - stood using psychoanalytic theories. In psychoanalysis overt symptoms are viewed as merel y the external expression of underlying psychic abnormal- ity. Symptoms continue, despite t he suffering they cause to the individual because of what Freud called primary gain. This i s the bene \201 t to the indi- vidual of not having unacceptable ideas in the conscious mi nd. While a typical descriptive assessment of a patient by a psychiatrist may categorize pa tients into groups using diagnostic criteria, a dynamic assessment of a patient uses psycho analytic theory to explore the unique layout of the individual patient \200\231s conscious and unconscious mind. Techniques Psychoanalysis is an intense therapy that usually involves one to \201 ve, 50- min sessions per week possibly for a number of years. Psychoanalysis typically features tra ditional techniques to attempt to interpret uncon- scious content, including the \200\230f undamental rule \200\231 of free association, analysis of the transference/countertransfere nce, the interpretation of dreams, \200\230parapraxes \200\231, and the symbolism of neuro tic symptoms. Therapists of dif- ferent schools will utilize these techniques in slightly d ifferent ways, e.g. by choosing what to interpret and why. The three mainstays of analyst \200\223 analysand interaction are enquiry, clari \201 cation, and interpretation. Free association The patient agrees to reveal everything which comes to mind, no matter how embarrassing or socially unacceptable (i.e. \200\230speaking without self- censorship \200\231). Traditionally the patient is speaking in a reclining position with minimal eye c ontact with the therapist, i.e. \200\230on the couch \200\231. 20_Semple_Chap20.indd 836 12/7/2012 4:32:54 PM PSYCHOANALYSIS 1 837 The therapist assumes a position of neutrality, in which reassurance and directive advice a re withheld. Areas where free association \200\230breaks down \200\231 and areas of resist ance to pursue associative thought may represent dif \201 culties which are important to e xplore. Exploration of transference/countertransference (See Transference reactions b p. 828.) The intense and frequent nature of psychoanalysis often results in a patient forming powerful f eelings towards a therapist, who adopts a stance of neutrality \200\224a blank screen on wh ich the patient can project their internal world. Important repressed aspects of past relat ionships and defense mechanisms used by the patient in current relationships \201 nd expr ession in the transference relationship. Through adopting a mindset called \200\230reverie \200\231 (similar to evenly suspended attention), psychoanalysts, through monitoring their own countertransfer- ence, attempt to avoid ful \201 lling the patient \200\231s unconsci ous expectations that they will act like the people from their past as well as using though ts that enter consciousness as information about the patient \200\231s inner world. Examination of dreams Dreams are traditionally viewed as being formed by a mix of daytime m em- ories, nocturnal stimuli, and representations of unconscious desires, which are then di storted by the ego to protect us from conscious knowledge of the content. The actual or \200\230latent \200\231 dream is eventually reconstructed from the \200\230manifest \200 \231 dream, the portions of the dream that patients remember in therapy, by a process of sy mbolization and elaboration which can poten- tially expose the hidden unconscious meanings. Examination of parapraxes A parapraxis is a slip of the tongue, which today is often referr ed to as a \200\230Freudian slip \200\231. They may reveal unconscious desires, thoughts a nd feelings. Examination of symbolism In individual patients, neurotic symptoms may have symbolic meanin g which can be usefully explored. Symbolism may also be analyzed in child psychotherapy whe n observing play and drawings. Interpretation Expression of the therapist \200\231s understanding of the meaning of what i s occurring in therapy. Interpretations commonly include descriptions of defense mechanisms , explanations for current anxiety in the context of underlying desires and making links be tween what is happening in the here-and-now of the transference relationship between patien t and thera- pist and how that connects to their earlier experiences. 20_Semple_Chap20.indd 837 12/7/2012 4:32:55 PM CHAPTER 20 Psychotherapy 838 Psychoanalysis 2 Phases of treatment Assessment and early sessions The analyst will typical ly explain methods of therapy, establish bounda- ries (e.g. about times of sessions), and b egin to produce a psychodynamic formulation of the case. The therapist will assess patient suitability and motivation while exploring potential risk factors. Middle sessions As the patient progresses in psychoanalysis, the therapist, who will typi- cally work with a supervisor (providing a valuable third position view of the case outwith the close relationship between analyst and analysand), identi- \201 es unconscious defens e mechanisms, key con \202 icts, personality structure, patterns of object relations and t ransference/countertransference. Later sessions The therapist may use more interpretive techniques, which may increase anxie ty. Towards the end of therapy, which is in the main mutually negoti- ated, increasing focu s will be placed on the patient \200\231s thoughts, feelings, and attitudes to termination of therapy as loss and abandonment are often key areas in patients \200\231 pathology. Indications and contraindications (See also Assessment for psychotherapy b p. 822.) \200 Commonly chosen by the patient rather than prescribed though this may be due to its lack of availability through the public sector. Not reserved only for speci \201 c mental illness es \200\224those with relatively sound mental health may \201 nd it improves the quality of their lives. Commonly sought by patients where there are anxious or emotional symptoms, such as mild to moderate depressive symptoms, somatic symptoms, dissociative or other neuro tic symptoms Patients with substantial personality dif \201 culties are increasingly seen. May be a good choice for patients who are looking for change, motivated to explore past ex periences, and are emotionally stable and willing to re-experience some emotional challenge s in doing so. Psychoanalysis is not absolutely contraindicated for drug or alcohol depende nce, suicidal thoughts or harmful/violent behaviors, psychotic illness, severe depressive f eatures, limited cognitive ability, but most practitioners would be aware of the potential pitfalls present in each of these classes of patient. \200 Ef \201 cacy and limitations of dynamic therapies Evidence base? Studies have demonstrated bene \201 ts in decreased symptoms, decreased need for medication, as well as long-term a nd enduring improvements in personality-disordered individuals. The volume, validity, and r eliability of the evidence, however, is limited. Some clinicians criticize all dynamic ther apies because they have arisen primarily from theory and clinical observations instead of e vidence-based medicine. This may not re \202 ect 20_Semple_Chap20.indd 838 12/7/2012 4:32:55 PM PSYCHOANALYSIS 2 839 on the inef \201 cacy of psychodynamic therapies as much as it re \202 ects the inherent dif \201 culties in designing research studies. There is a lack of stand- ardization in di agnosis, in method of therapy delivery (as by its very nature it is delivered by individual s to other individuals, both of whom are bewil- deringly complex), problems with gaining su f \201 cient numbers of patients and controls for statistical analyzes to be viable, and d etermining how improvement is measured as even Freud regarded the task as converting \200 \230neurotic misery into ordinary unhappiness \200\231. Psychodynamic researchers also stre ss the point that much of psychoanalysis is process- and not out- come-orientated. Nonethel ess, the future may bring more of an evidence base to support dynamic therapies, both alone and in combination with psychotropic medications. Studies may also show more support for t he theories behind psychodynamic therapies. There is already experimental psychological res earch to support that mental activity can be unconscious, such as studies that show initiat ion of action by pre-frontal cortex begins before \200\230consciousness \200\231 in the fr ontal areas is involved. Possible harm? While dynamic therapies do not have the biological side-effects of psychi- a tric medications, they are not free of risk. These therapies aid in increas- ing the insigh t of the patient, which may involve the removal of defense mechanisms that play a protectiv e role, and therefore must be done with caution, especially with patients whose \200\230ps ychic scaffolding \200\231 is integral to their managing day to day life. The risks and ben e \201 ts of such phenomena are a subject of study and controversy, although most dynamic therapists would agree that patient readiness determines when to explore painful experience s in therapy. Training Involves education in psychoanalytic history, theory and practice, exten- sive sup ervised case work, and personal psychoanalysis for the therapists themselves. Many major Br itish and Irish cities have a local psychoanalytic institute that may offer formal psychoan alytic training to those with doc- toral or master \200\231s degrees in mental health and 2 yrs of clinical experience. Training usually consists of a 5yr postgraduate curriculum spec i \201 cally in psychoanalysis. For doctors, this training would typically be completed af ter completion of a basic specialist psychiatric training. Most institutes also offer super vision and classes for therapists who are interested in dynamic psychotherapy, but have not chosen the 5yr psychoanalytic program. 20_Semple_Chap20.indd 839 12/7/2012 4:32:55 PM CHAPTER 20 Psychotherapy 840 Psychodynamic psychotherapy Psychodynamic psychotherapy is an intervention where the concep ts of symptom development are based on those of psychoanalysis, but the methods of therapy are adjusted for a reduced frequency of sessions and decreased number of total sessions. Su pporters of this type of therapy state that some of the insights and opportunity for change and growth available from long-term psychoanalysis can be achieved in a shorter time and t hat introducing directive elements and focus on particular topics does not reduce overall e ffectiveness. Rationale and How illness is viewed As for psychoanalysis (b p. 836). Techniques \200 Psychodynamic psychotherapy is modi \201 ed from psychoanalysis in that it often involves active therapy, where the therapist may say more in an attempt to allow therapy to be more structured. It can vary in length depending on both the therapist and the needs of the pati ent. It may be signi \201 cantly more brief than psychoanalysis, often lasting 6mths or 1y r with the termination date decided at the outset. Shorter treatments (of around 16 session s) may be placed under the heading of \200\230brief psychodynamic psychotherapy \200\231. The frequency may be 1 \200\2232 sessions a week. The therapist usually develops a working psychodynamic formulation early on which is then referred to throughout the therapy. b p. 8 36), Methods employed are similar to those of psychoanalysis ( but with therapist \200\223p atient eye contact (i.e. both sitting on chairs rather than the patient lying on a couch) a nd more verbal interaction from the therapist. Both transference and countertransference gi ve the therapist valuable information about the nature of past relationships (b p. 837). Th e therapist will help the patient to explore symptom precipitants and associated early trau ma and avoidance. The therapist may guide therapy by use of interpretation at an earlier po int than in psychoanalysis. In the case of patients with more severe mental illness, such a s psychosis, or in acute crisis or decompensation, these techniques are sometimes further m odi \201 ed to be less focused on improving insight, and instead, the emphasis is more sup portive, particularly focusing on encouraging the expression of emotions. This can be combi ned with drug treatment. Phases of treatment Initial assessment Diagnosis, including consideration of appropriatenes s of this method of therapy in this patient. Consideration of appropriate use of medication . Early sessions Identi \201 cation of main problems, goals, and issues. Limited comments fr om therapist. Usually there is positive transference due to expectation of 20_Semple_Chap20.indd 840 12/7/2012 4:32:55 PM PSYCHODYNAMIC PSYCHOTHERAPY 841 \200\230magical \200\231 change. Identi \201 cation of main defenses, coping styles, and ability to accept and work with interpretations. Middle sessions Exploring present emotions and emotions evoked by past experiences. Explora tion of transference, countertransference, and resistance in discus- sion with supervisor. Closing sessions Exploring anticipation of termination. Arrangements for aftercare. Indications and contraindications See Assessment for psychotherapy b p. 822 and Ef \201 ca cy and limitations of dynamic therapies b p. 838. \200 Indications and contraindications are similar to those of psychoanalysis b p. 838. Particul ar emphasis on the ability and motivation to form a collaborative relationship with a thera pist. Training Similar to training for psychoanalysis, including education in psychoanalytic hist ory, theory and practice, supervised case work, and personal psycho- analysis. Local psycho analytic institutes may offer courses varying in length and required time commitment. 20_Semple_Chap20.indd 841 12/7/2012 4:32:55 PM CHAPTER 20 Psychotherapy 842 Group psychotherapy Group psychotherapy is a form of treatment in which selected individual s are brought together under the guidance of a therapist with the goals of reducing distres s and symptoms, increasing coping, or improving relation- ships. Group methods were \201 rst developed in the early twentieth century following observations of bene \201 cial grou p effects with TB patients. Like individual psychotherapy, the term group psychotherapy enc ompasses a range of modalities, settings, and techniques. Groups may be homogeneous or heterogeneous (e.g. in terms of diag- nosis, age, gender), and may vary as to the frequency and duration of meetings, the degree of therapist involvement , and whether they are time- limited or ongoing. The basic tasks of the therapist include m aking deci- sions about these factors, preparing and assessing patients for the therapy, fo rmulating goals for therapy, and building and maintaining a therapeutic environment that pr omotes group interaction. Yalom1 described a set of therapeutic factors common to many types of group: instillation o f hope, universality, imparting information, altru- ism, corrective recapitulation of the p rimary family group, development of socializing techniques, imitation of adaptive behavior, interpersonal learning, group cohesion, catharsis, and existential factors. Indications and contraindications Group therapy generally requires that members: \200 \200 \200 Are able to tolerate the task of interacting in a group. Have problem areas that are compat ible with the goals of the group. Are consciously motivated for change. While most patients may bene \201 t from some form of group therapy, exclu- sion criteria include: \200 Inability to comply with the group norms for acceptable behavior (e.g. assaults on other pa tients or therapist). Inability to tolerate the group setting (e.g. paranoid ideas). Severe incompatibility with one or more group members (which may only be discernible after member s have joined the group). \200 Types of group therapy Supportive groups Features \200 Focus on promoting and strengthening adaptive defenses, giving advice, providing encouragem ent. Goals include re-establishing and/or maintaining function, improving coping. 20_Semple_Chap20.indd 842 12/7/2012 4:32:55 PM GROUP PSYCHOTHERAPY 843 Indications May be useful in psychotic disorders, anxiety disorders, and in a self-help con text. Problem-focused cognitive \200\223behavioral groups Features \200 Useful where the goal is modi \201 cation of dysfunctional thoughts, feelings, and behavio rs, such as in anxiety, depressive, and eating disorders. Focus is on psychoeducation, mutu al support, and group examination of strategies for change within a CBT framework, rather t han on the nature of interpersonal interactions between members. Therapist takes an active and central role. Peers may be experts at identifying resistance and rationalization for av oiding change in other group members. \200 Indications Can include anxiety or anger management, assertiveness training, acute or chron ic depression, alcohol or drug dependence. Psychodynamic groups, including group analysis Features \200 \200 The individual is viewed as embedded in a social network or \200\230matrix \200\231. Membe rs \200\231 interactions with each other and the therapist re \202 ect their interactions with others outside the group (i.e. the interpersonal dif \201 culties which have brought them to therapy). An individual \200\231s range of relationship styles derives from early e xperience (e.g. the position they tended to take up within the family, at school, etc.). Ex amination of interactions between group members and with the therapist aims to increase pat ients \200\231 understanding of this repeating repertoire of contact with people, and to ch ange dysfunctional patterns. Techniques include close examination of transference, counter- transference, resistance, and unconscious con \202 ict. Goal is lasting change through mo di \201 cation of personality factors. Indications See Psychoanalysis b p. 838. Activity groups Generally helpful for patients wit h intellectual impairment, or severe and persistent mental illness. Examples include art, m usic, computing, exercise, and social activity groups. Can foster social skills and adaptiv e behaviors. Helpful for psychosocial and vocational rehabilitation. Self-help groups Strictly speaking, not a form of group therapy, though may have bene \201 - cial therapeutic effects. Groups tend to be organized around a speci \201 c problem, ha ve strong peer support and group cohesion, and be led from within the group. Examples inclu de Alcoholics Anonymous, Narcotics Anonymous, Gamblers Anonymous, Overeaters Anonymous. 1 Yalom ID (1995) The theory and practice of group psychotherapy, 4th edn. New York: Basic Books. 20_Semple_Chap20.indd 843 12/7/2012 4:32:55 PM CHAPTER 20 Psychotherapy 844 Basic learning theory Behavioral psychology is a method for understanding the development o f knowledge and behaviors in organisms. In an individual organism these are shaped by envir onmental in \202 uences and can change as a result of experience. Learning theory concerns the testing of methods to pro- duce behavioral adaptation through changing environmental i n \202 uences. The two basic learning processes are classical (Pavlovian) conditioning \200\224 involuntary behaviors which become associated with stimuli, and operant (Skinneria n) conditioning \200\224learning to obtain reward and avoid punishment related to voluntary behaviors. Although most abnormal mental pro- cesses and mental illnesses are not amenable to understanding purely in terms of conditioning, understanding of learning theory is help ful in con- ceptualizing the development and maintenance of abnormal mental pro- cesses and provides a rationale for behavioral and cognitive behavioral treatment approaches. Classical conditioning In his initial experiment, Pavlov presented a dog with food which pr o- duced the response of salivation. Here the food is the unconditioned stimulus (US) and t he salivation is the unconditioned response (UR). A neutral stimulus such as a bell ringing is not associated with any uncondi- tioned response. However, if a bell is rung immediatel y before the food is presented, after a number of repetitions the dog will salivate in resp onse to the bell alone. Now the bell is a conditioned stimulus (CS) producing a conditioned response (CR), the salivation. Acquisition The development of the association between the UR and the US produ- cing a CR. In animal experiments this can take between 3 and 15 pairings. Where there is suf \201 cie nt emotional involvement, acquisition can occur with as few as one pairing. Extinction The loss of the association between the CR and the CS. Occurs when the CS is rep eatedly not followed by the US. Generalization The phenomenon where similar stimuli to the initial CS produce the response. The subject then demonstrates the conditioned response (CR) to these similar stimuli (e.g. to a buzzer as well as a bell). Higher-order conditioning Process in which conditioned trials cause the subject to demonstr ate the CR to new stimuli by pairing them with the CS (e.g. where the dog has been conditio ned to salivate to a bell, pairing the bell with a light stimulus so the dog becomes condit ioned to salivate to the light). Spontaneous recovery During extinction trials, following a rest period, the conditioned res ponse (CR) often brie \202 y reappears. Habituation The subject becomes accustomed to and less responsive to a stimulus after repea ted exposure. 20_Semple_Chap20.indd 844 12/7/2012 4:32:55 PM BASIC LEARNING THEORY 845 Note: for emotional disorders the response is usually an emotion rather than a behavior. Fo r example, an initial encounter with a large, barking dog which bites the individual can pr oduce the CR of fear to the general- ized CS of seeing a dog. The affected individual may t hen avoid all contact with dogs and so avoid the unpleasant CR. However, because there is n o occasion when the CS of seeing a dog is not paired with the CR of fear, there is no oppor tunity for extinction to take place. Techniques based on classical conditioning concepts \200 (b p. 848): presentation of situations more Systematic desensitization similar to the CS are paired with relaxation techniques, in orde r to eventually break the association between the CS and the CR. Frequently used in the tre atment of phobic anxiety disorders. (b p. 848): presentation of full CS without the possibi lity of Flooding withdrawal from the situation. The initial unpleasant experience of the CR gradually diminishes, and the patient learns that they can survive exposure to the feared situation without coming to harm. Operant conditioning The experimental techniques and rules of operant conditioning were dev eloped by Thorndike and Skinner. The basic principles of operant conditioning are that if a response to a stimulus produces positive conse- quences for the individual it will tend to be repeated, while if it is followed by negative consequences it will tend not to be repea ted. In the original experiments rats were placed in a box containing a lever which, when p ressed, delivered a pellet of food. Eventually the rat would press the lever and be rewarde d. The rat would then press the lever with increasing frequency. (Note that operant conditi oning doesn \200\231t rely on insight on the part of the rat.) Acquisition The linkage of the response (pressing the lever) with the rein- forcer (receivi ng the food). Reinforcement Can be positive (behavior is followed by a desirable outcome) or negative (be havior is followed by removal of an aversive stimulus). Can occur after every response (con tinuous reinforcement) or only after some responses (partial reinforcement). Behaviors cond itioned by partial reinforcement extinguish at a much slower rate than those conditioned by continuous reinforcement. Punishment In positive punishment an operant response is followed by the presentation of an aversive stimulus in an attempt to decrease the likelihood of a behav- iour occurring in t he future. In negative punishment an operant response is followed by the removal of an aver sive stimulus. Shaping Used to produce a complex behavior which is not in the organism \200\231s initial r epertoire. Initially, component parts of the desired behavior are rewarded, then reward is limited to behavior which approximates the 20_Semple_Chap20.indd 845 12/7/2012 4:32:55 PM CHAPTER 20 Psychotherapy 846 desired result. As appropriate behavior appears it is only rewarded if it is \200\230in th e right direction \200\231 and further reward is contingent upon continued advancement unti l the organism is only rewarded once the entire behavior is performed. Extinction Occurs over time when the response is no longer followed by the reinforcer. Tech niques based on operant conditioning concepts (b p. 848) \200 \200 Behavior modi \201 cation. Aversion therapy. 20_Semple_Chap20.indd 846 12/7/2012 4:32:56 PM This page intentionally left blank CHAPTER 20 Psychotherapy 848 Behavior therapy Techniques based on learning theory are used in order to extinguish mal- a daptive behaviors and substitute more adaptive ones. Systematic desensitization Holds as a central tenet the principle of reciprocal inhibition (i.e. anxi- ety and relaxation cannot coexist). Systematic graded exposure to the source of anxiety is coupled with the use of relaxation techniques (the \200\230desensitization \200\231 component). Effective for simple phobias, but less so for other phobic/anxiety dis orders (e.g. agoraphobia). Process in a typical case is as follows: \200 \200 Patient identi \201 es the speci \201 c fear (e.g. cats). Patient and therapist develop a hierarchy of situations listing the most anxiety-provoking situation at the top (e.g. stro king a cat on one \200\231s knee > touching a cat > having a cat in the room > looking at p ictures of cats > thinking about cats). Patient is instructed in relaxation technique. Pati ent experiences the lowest item on the hierarchy while practicing the relaxation technique and remains exposed to the item until the anxiety has diminished. The process is repeated u ntil the item no longer produces anxiety. The next item in the hierarchy is tackled in simi lar fashion. \200 \200 Flooding/implosive therapy High levels of anxiety cannot be maintained for long periods, an d a pro- cess of \200\230exhaustion \200\231 occurs. By exposing the patient to the phobic object and preventing the usual escape or avoidance, there is extinction of the usual (mal adaptive) anxiety response. This may be done in vivo ( \202 ooding) or in imagination (imp losion). Behavior modi \201 cation Based on operant conditioning. Behavior may be shaped towards th e desired \201 nal modi \201 cation through the rewarding of small, achievable inter- me diate steps. This can be utilized in behavioral disturbance in children and patients with l earning disability. Other forms of behavioral modi- \201 cation include the more explicit use of secondary reinforcement, such as \200\230token economy \200\231, in which socially desirable/acceptable behaviors are rewarded with tokens that can be exchanged for other ma terial items or privileges, or \200\230star charts \200\231 where children \200\231s good behavior is rewarded when a certain level is achieved. May also be used for less voluntary actions such as childhood nocturnal enuresis. Aversion therapy and covert sensitization The use of negative reinforcement (the unpleasant consequence of a par- ticular behavior) to inhibit the usual maladaptive behavioral respon se (extinction). True \200\230aversion \200\231 therapy (e.g. previously used to treat sex ual deviancy) is not used today; however, covert techniques (e.g. the use of antabuse in al cohol dependency) can be (at least partially) effective. 20_Semple_Chap20.indd 848 12/7/2012 4:32:56 PM This page intentionally left blank CHAPTER 20 Psychotherapy 850 Cognitive behavioral therapy 1 The theory and method of cognitive behavior therapy (CBT) we re developed by Aaron Beck and outlined in a series of papers published in the 1960s.1 CBT development was prompted by the observation that patients referred for psychotherapy often held ingrained, negatively skewed assumptions of themselves, their future, and their enviro nment. Treatment is based on the idea that disorder is caused not by life events, but by th e view the patient takes of events. It is a short-term, collaborative therapy, focused on c urrent problems, whose goals are symptom relief and the development of new skills to sustai n recovery. Rationale A person \200\231s emotions, thoughts, behaviors, physiological sensations and th eir external environment all exist together in equilibrium. Altering any component of this system will bring about change in the others. While pathological emotions may not be direct ly amenable to change, the unhelpful cognitions and behaviors associated with these emotion s may be examined and modi \201 ed, leading to change in the underlying emotion. CBT aims to \200\230change how you feel by changing the way you think \200\231.2 The cognitive mode l is a guide for therapy, not a comprehensive model of illness causation, and precludes nei ther neurochemical or other factors as important in symptom development, nor the use of pha rmacological treatments. How illness is viewed In some personality types and in mental illness there are errors in t he evaluation and processing of information (i.e. cognitive distortions). These distortions relate to the self, the world, and the future (Beck \200\231s cognitive triad) and origina te from the child \200\231s early learning and experience of the world around him. Cognitiv e errors are associated with unpleasant emo- tions and maladaptive behavior. An example of this vicious circle is: an event (friend doesn \200\231t call when she said s he would) l negative automatic thought ( \200\230friend doesn \200\231t like me because she thinks I \200\231m a loser \200\231) l emotional response (sadness) l mal- adaptive behavi or l (avoiding friend l self-isolation l worsening of low mood) = pathology (depression). I n CBT with this patient, the therapist would facilitate their recognition of the faulty cog nitive appraisal (cognitive error) and then teach skills to address it \200\224see Box 20.2 and Box 20.3. Modes of delivery CBT can be delivered on an individual basis, in groups, or as self-help v ia books or computer programs (including online). As such it is a cost- effective treatment with evidence of good ef \201 cacy. It is worth stressing that CBT is at its most effecti ve when delivered \200\230by the book \200\231, following established protocols. Sessions by trainees are therefore often taped to ensure adherence to a standard regimen. 20_Semple_Chap20.indd 850 12/7/2012 4:32:56 PM COGNITIVE behavioral THERAPY 1 851 Box 20.2 Cognitions Cognitions are appraisals of events. They may be elicited by asking the patient about thoug hts, ideas, or images in their head. CBT describes three types of thoughts or beliefs: \200 Automatic thoughts are involuntary and appear plausible, but may be distorted, e.g. \200 \230my friend phoned to cancel meeting me tomorrow \200\224she must not like me any more. \200\231 Underlying assumptions fundamental beliefs and shaped by experience, e.g. \200 \230I can \200\231t enjoy myself unless I \200\231m with other people. \200\231 Schemas or core beliefs about themselves and the world around them, e.g. a neglected child believing \200\230I am unlovable. \200\231 are the most super \201 cial and accessible. They are a person \200\231s \200\230rules \200\231 for behaving, based on are a person \200\231s most fundamental beliefs Box 20.3 Common types of cognitive error \200 