Basic Behavioral Principles
Behavior therapy involves the application of the principles of learning and behavior. Classical conditioning is used to explain the acquisition of abnormal behaviors through contingency learning; in PTSD, this might account for the pairing of certain sounds (loud bangs or breaking glass) with arousal and escape or avoidance behavior. Operant conditioning, with its principles of positive reinforcement, negative reinforcement, and punishment accounts for behavior through an analysis of the conditions or consequences that follow it. In PTSD, negative reinforcement might account for maintaining the core symptoms of avoidance, for example. Extinction occurs when a behavior ceases to be reinforced and may be helpful in eliminating particular behaviors by the withholding or preventing of reinforcement. The principles of discrimination, stimulus control, and generalization are important in understanding how particular stimuli elicit particular responses and how these same responses may be generalized across a wider range of stimulus situations or how a particular behavior might be brought adaptively under more appropriate stimulus control. In PTSD, the principle of generalization is illustrated in the phenomenon of reacting to a loud sound as if it is a gunshot or explosion for example. July 4th celebrations can be particularly stressful for combat veterans because of this very principle.
Behavior therapy emphasizes the unlearning of maladaptive or problem behavior and the acquisition of more adaptive and healthy behavior. Therapists attempt this with a number of techniques, including behavior modification, guided imagery, role-playing, self-monitoring, relaxation training, progressive relaxation, behavioral rehearsal, activity scheduling, and exposure techniques. There are a variety of exposure techniques, including imagery-based (e.g., guided imagery and systematic desensitization) versus direct-exposure techniques (e.g., graduated exposure and flooding). Behavior therapy works in many ways but often by removing reinforcement of a negative behavior; reinforcing the practice, occurrence, and utilization of healthy behavior; pairing learning conditions and situations for adaptation or adjustment; or increasing stimulus control and discrimination while reducing negative generalization and increasing positive generalization. Again, at the core of all behavior therapies is learning and unlearning.
Cognitive therapy is built on an information-processing model of psychology, viewing pathology as a consequence of systematic biases in the processing of information. (See Chapter 5 for more detail on cognitive models of PTSD.) In essence, the mediating role of thinking between stimulus and behavior is the critical point of change and alteration in cognitive therapy. Errors in thinking and the processing of information, be it environmental or more internal in nature, are the targets of therapy. Many different concepts and terms are used to characterize and describe thinking and dysfunctional cognitions in cognitive therapy, such as schemas, automatic thoughts, conditional assumptions, mal-adaptive cognitions, and cognitive distortions. Different classes of mental disorders are characterized by a specific type of cognitive errors. For example, depression is characterized by a negative view of self, the world, others, current experience, and the future. Panic Disorder is characterized by a catastrophic interpretation of body and mental experiences. Anxiety Disorders are characterized by thinking that maintains a sense of danger.
Cognitive distortions are systematic errors in thinking and are a central feature of cognitive therapy. Here are some examples of cognitive distortions (Beck & Weishaar, 1989):
Arbitrary inference: drawing a specific conclusion without evidence in the face of contradictory evidence
Selective abstraction: taking details out of context or ignoring pertinent information
Overgeneralization: abstracting a general rule from a few incidents
Magnification and minimization: imbuing more or less significance to a situation or event
Personalization: attributing events to oneself without evidence Dichotomous thinking: categorizing events in either black and white terms
Cognitive therapy is about examining thinking and changing the way one thinks and arrives at conclusions. This is embodied in the process of collaborative empiricism, in which therapist and patient engage in the empirical or experiential testing of the evidence that allegedly supports a patient's cognitive distortions. Socratic dialogue, a specific form of questioning that is designed to promote new learning (Beck & Young, 1985), is used. This is like asking a question to which you already know the answer. Other cognitive therapy techniques include guided discovery, reattribution, redefining, decentering, cognitive restructuring, reframing, hypothesis testing, and homework.
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