On This Day … 27 September

People (Births)

  • 1913 – Albert Ellis, American psychologist and author (d. 2007).

People (Deaths)

  • 2004 – John E. Mack, American psychiatrist and author (b. 1929).

Albert Ellis

Albert Ellis (27 September 1913 to 24 July 2007) was an American psychologist and psychotherapist who founded Rational Emotive Behaviour Therapy (REBT). He held MA and PhD degrees in clinical psychology from Columbia University, and was certified by the American Board of Professional Psychology (ABPP). He also founded, and was the President of, the New York City-based Albert Ellis Institute. He is generally considered to be one of the originators of the cognitive revolutionary paradigm shift in psychotherapy and an early proponent and developer of cognitive-behavioural therapies.

Based on a 1982 professional survey of US and Canadian psychologists, he was considered the second most influential psychotherapist in history (Carl Rogers ranked first in the survey; Sigmund Freud was ranked third). Psychology Today noted that, “No individual—not even Freud himself—has had a greater impact on modern psychotherapy.”

John E. Mack

John Edward Mack (04 October 1929 to 27 September 2004) was an American psychiatrist, writer, and professor and the head of the department of psychiatry at Harvard Medical School. In 1977, Mack won the Pulitzer Prize for his book A Prince of Our Disorder on T.E. Lawrence.

As the head of psychiatry at Harvard Medical School, Mack’s clinical expertise was in child psychology, adolescent psychology, and the psychology of religion. He was also known as a leading researcher on the psychology of teenage suicide and drug addiction, and he later became a researcher in the psychology of alien abduction experiences.

What is Schema Therapy?

Introduction

Schema therapy was developed by Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies (for example, traditional cognitive behavioural therapy, CBT). Schema therapy is an integrative psychotherapy combining theory and techniques from previously existing therapies, including CBT, psychoanalytic object relations theory, attachment theory, and Gestalt therapy.

Concepts

Four main theoretical concepts in schema therapy are early maladaptive schemas (or simply schemas), coping styles, modes, and basic emotional needs:

  1. In cognitive psychology, a schema is an organised pattern of thought and behaviour. It can also be described as a mental structure of preconceived ideas, a framework representing some aspect of the world, or a system of organizing and perceiving new information. In schema therapy, a schema specifically refers to an early maladaptive schema, defined as a pervasive self-defeating or dysfunctional theme or pattern of memories, emotions, and physical sensations, developed during childhood or adolescence and elaborated throughout one’s lifetime. Often they have the form of a belief about the self or the world. For instance, a person with an Abandonment schema could be hypersensitive (have an “emotional button” or “trigger”) about their perceived value to others, which in turn could make them feel sad and panicky in their interpersonal relationships.
  2. Coping styles are a person’s behavioural responses to schemas. There are three potential coping styles. In “avoidance” the person tries to avoid situations that activate the schema. In “surrender” the person gives into the schema, doesn’t try to fight against it, and changes their behaviour in expectation that the feared outcome is inevitable. In “counterattack”, also called “overcompensation”, the person puts extra work into not allowing the schema’s feared outcome to happen. These maladaptive coping styles (overcompensation, avoidance, or surrender) very often wind up reinforcing the schemas. Continuing the Abandonment example: having imagined a threat of abandonment in a relationship and feeling sad and panicky, a person using an avoidance coping style might then behave in ways to limit the closeness in the relationship to try to protect themselves from being abandoned. The resulting loneliness or even actual loss of the relationship could easily reinforce the person’s Abandonment schema. Another example can be given for the Defectiveness schema: A person using an avoidance coping style might avoid situations that make them feel defective, or might try to numb the feeling with addictions or distractions. A person using a surrender coping style might tolerate unfair criticism without defending themselves. A person using the counterattack/overcompensation coping style might put extra effort into being superhuman.
  3. Modes are mind states that cluster schemas and coping styles into a temporary “way of being” that a person can shift into occasionally or more frequently. For example, a Vulnerable Child mode might be a state of mind encompassing schemas of Abandonment, Defectiveness, Mistrust/Abuse and a coping style of surrendering (to the schemas).
  4. If a patient’s basic emotional needs are not met in childhood, then schemas, coping styles, and modes can develop. Some basic needs that have been identified are: connection, mutuality, reciprocity, flow, and autonomy. For example, a child with unmet needs around connection – perhaps due to parental loss to death, divorce, or addiction – might develop an Abandonment schema.

The goal of schema therapy is to help patients meet their basic emotional needs by helping the patient learn how to:

  • Heal schemas by diminishing the intensity of emotional memories comprising the schema and the intensity of bodily sensations, and by changing the cognitive patterns connected to the schema; and
  • Replace maladaptive coping styles and responses with adaptive patterns of behaviour.

Techniques used in schema therapy including limited reparenting and Gestalt therapy psychodrama techniques such as imagery re-scripting and empty chair dialogues (Refer to techniques in schema therapy, below).

There is a growing literature of outcome studies on schema therapy, where schema therapy has shown impressive results (Refer to outcome studies on schema therapy, below).

Early Maladaptive Schemas

Refer to List of Maladaptive Schemas.

Early maladaptive schemas are self-defeating emotional and cognitive patterns established from childhood and repeated throughout life. They may be made up of emotional memories of past hurt, tragedy, fear, abuse, neglect, unmet safety needs, abandonment, or lack of normal human affection in general. Early maladaptive schemas can also include bodily sensations associated with such emotional memories. Early maladaptive schemas can have different levels of severity and pervasiveness: the more severe the schema, the more intense the negative emotion when the schema is triggered and the longer it lasts; the more pervasive the schema, the greater the number of situations that trigger it.

Schema Domains

Schema domains are five broad categories of unmet needs into which are grouped 18 early maladaptive schemas identified by Young, Klosko & Weishaar (2003):

  • Disconnection/Rejection includes 5 schemas:
    • Abandonment/Instability.
    • Mistrust/Abuse.
    • Emotional Deprivation.
    • Defectiveness/Shame.
    • Social Isolation/Alienation.
  • Impaired Autonomy and/or Performance includes 4 schemas:
    • Dependence/Incompetence.
    • Vulnerability to Harm or Illness.
    • Enmeshment/Undeveloped Self.
    • Failure.
  • Impaired Limits includes 2 schemas:
    • Entitlement/Grandiosity.
    • Insufficient Self-Control and/or Self-Discipline.
  • Other-Directedness includes 3 schemas:
    • Subjugation.
    • Self-Sacrifice.
    • Approval-Seeking/Recognition-Seeking.
  • Over-vigilance/Inhibition includes 4 schemas:
    • Negativity/Pessimism.
    • Emotional Inhibition.
    • Unrelenting Standards/Hypercriticalness.
    • Punitiveness.

Schema Modes

Schema modes are momentary mind states which every human being experiences at one time or another. A schema mode consists of a cluster of schemas and coping styles. Life situations that a person finds disturbing or offensive, or arouse bad memories, are referred to as “triggers” that tend to activate schema modes. In psychologically healthy persons, schema modes are mild, flexible mind states that are easily pacified by the rest of their personality. In patients with personality disorders, schema modes are more severe, rigid mind states that may seem split off from the rest of their personality.

Identified Schema Modes

Young, Klosko & Weishaar (2003) identified 10 schema modes grouped into four categories. The four categories are: Child modes, Dysfunctional Coping modes, Dysfunctional Parent modes, and the Healthy Adult mode. The four Child modes are: Vulnerable Child, Angry Child, Impulsive/Undisciplined Child, and Happy Child. The three Dysfunctional Coping modes are: Compliant Surrenderer, Detached Protector, and Overcompensator. The two Dysfunctional Parent modes are: Punitive Parent and Demanding Parent.

Angry ChildThis is fuelled mainly by feelings of victimisation or bitterness, leading towards negativity, pessimism, jealousy, and rage. While experiencing this schema mode, a patient may have urges to yell, scream, throw/break things, or possibly even injure themselves or harm others. The Angry Child schema mode is enraged, anxious, frustrated, self-doubting, feels unsupported in ideas and vulnerable.
Impulsive ChildThis is the mode where anything goes. Behaviours of the Impulsive Child schema mode may include reckless driving, substance abuse, cutting oneself, suicidal thoughts, gambling, or fits of rage, such as punching a wall when “triggered” or laying blame of circumstantial difficulties upon innocent people. Unsafe sex, rash decisions to run away from a situation without resolution, tantrums perceived by peers as infantile, and so forth are a mere few of the behaviours which a patient in this schema mode might display. Impulsive Child is the rebellious and careless schema mode.
Detached ProtectorThis is based in escape. Patients in Detached Protector schema mode withdraw, dissociate, alienate, or hide in some way. This may be triggered by numerous stress factors or feelings of being overwhelmed. When a patient with insufficient skills is in a situation involving excessive demands, it can trigger a Detached Protector response mode. Stated simply, patients become numb in order to protect themselves from the harm or stress of what they fear is to come, or to protect themselves from fear of the unknown in general.
Abandoned ChildThis is the mode in which a patient may feel defective in some way, thrown aside, unloved, obviously alone, or may be in a “me against the world” mindset. The patient may feel as though peers, friends, family, and even the entire world have abandoned them. Behaviours of patients in Abandoned Child mode may include (but are not limited to) falling into major depression, pessimism, feeling unwanted, feeling unworthy of love, and perceiving personality traits as irredeemable flaws. Rarely, a patient’s self-perceived flaws may be intentionally withheld on the inside; when this occurs, instead of showing one’s true self, the patient may appear to others as “egotistical”, “attention-seeking”, selfish, distant, and may exhibit behaviours unlike their true nature. The patient might create a narcissistic alter-ego/persona in order to escape or hide the insecurity from others. Due to fear of rejection, of feeling disconnected from their true self and poor self-image, these patients, who truly desire companionship/affection, may instead end up pushing others away.
Punitive ParentThis is identified by beliefs of a patient that they should be harshly punished, perhaps due to feeling “defective”, or making a simple mistake. The patient may feel that they should be punished for even existing. Sadness, anger, impatience, and judgement are directed to the patient and from the patient. The Punitive Parent has great difficulty in forgiving themselves even under average circumstances in which anyone could fall short of their standards. The Punitive Parent does not wish to allow for human error or imperfection, thus punishment is what this mode seeks.
Healthy AdultThis is the mode that schema therapy aims to help a patient achieve as the long-lasting state of well-being. The Healthy Adult is comfortable making decisions, is a problem-solver, thinks before acting, is appropriately ambitious, sets limits and boundaries, nurtures self and others, forms healthy relationships, takes on all responsibility, sees things through, and enjoys/partakes in enjoyable adult activities and interests with boundaries enforced, takes care of their physical health, and values themselves. In this schema mode the patient focuses on the present day with hope and strives toward the best tomorrow possible. The Healthy Adult forgives the past, no longer sees themselves as a victim (but as a survivor), and expresses all emotions in ways which are healthy and cause no harm.

Techniques in Schema Therapy

Treatment plans in schema therapy generally encompass three basic classes of techniques: cognitive, experiential, and behavioural (in addition to the basic healing components of the therapeutic relationship). Cognitive strategies expand on standard CBT techniques such as listing pros and cons of a schema, testing the validity of a schema, or conducting a dialogue between the “schema side” and the “healthy side”. Experiential and emotion focused strategies expand on standard Gestalt therapy psychodrama and imagery techniques. Behavioural pattern-breaking strategies expand on standard behaviour therapy techniques, such as role playing an interaction and then assigning the interaction as homework. One of the most central techniques in schema therapy is the use of the therapeutic relationship, specifically through a process called “limited reparenting”.

Specific techniques often used in schema therapy include flash cards with important therapeutic messages, created in session and used by the patient between sessions, and the schema diary – a template or workbook that is filled out by the patient between sessions and that records the patient’s progress in relation to all the theoretical concepts in schema therapy.

Schema Therapy and Psychoanalysis

From an integrative psychotherapy perspective, limited reparenting and the experiential techniques, particularly around changing modes, could be seen as actively changing what psychoanalysis has described as object relations. Historically, mainstream psychoanalysis tended to reject active techniques – such as Fritz Perls’ Gestalt therapy work or Franz Alexander’s “corrective emotional experience” – but contemporary relational psychoanalysis (led by analysts such as Lewis Aron, and building on the ideas of earlier unorthodox analysts such as Sándor Ferenczi) is more open to active techniques. It is notable that in a head to head comparison of a psychoanalytic object relations treatment (Otto F. Kernberg’s transference focused psychotherapy) and schema therapy, the latter has been demonstrated to be more effective in treating Borderline Personality Disorder.

Outcome Studies on Schema Therapy

Schema Therapy vs Transference Focused Psychotherapy Outcomes

Dutch investigators, including Josephine Giesen-Bloo and Arnoud Arntz (the project leader), compared schema therapy (also known as schema focused therapy or SFT) with transference focused psychotherapy (TFP) in the treatment of borderline personality disorder. 86 patients were recruited from four mental health institutes in the Netherlands. Patients in the study received two sessions per week of SFT or TFP for three years. After three years, full recovery was achieved in 45% of the patients in the SFT condition, and in 24% of those receiving TFP. One year later, the percentage fully recovered increased to 52% in the SFT condition and 29% in the TFP condition, with 70% of the patients in the SFT group achieving “clinically significant and relevant improvement”. Moreover, the dropout rate was only 27% for SFT, compared with 50% for TFP.

Patients began to feel and function significantly better after the first year, with improvement occurring more rapidly in the SFT group. There was continuing improvement in subsequent years. Thus investigators concluded that both treatments had positive effects, with schema therapy clearly more successful.

Less Intensive Outpatient, Individual Schema Therapy

Dutch investigators, including Marjon Nadort and Arnoud Arntz, assessed the effectiveness of schema therapy in the treatment of borderline personality disorder when utilised in regular mental health care settings. A total of 62 patients were treated in eight mental health centres located in the Netherlands. The treatment was less intensive along a number of dimensions including a shift from twice weekly to once weekly sessions during the second year. Despite this, there was no lessening of effectiveness with recovery rates that were at least as high and similarly low dropout rates.

Pilot Study of Group Schema Therapy for Borderline Personality Disorder

Investigators Joan Farrell, Ida Shaw and Michael Webber at the Indiana University School of Medicine Centre for BPD Treatment & Research tested the effectiveness of adding an eight-month, 30-session schema therapy group to treatment-as-usual (TAU) for borderline personality disorder (BPD) with 32 patients. The dropout rate was 0% for those patients who received group schema therapy in addition to TAU and 25% for those who received TAU alone. At the end of treatment, 94% of the patients who received group schema therapy in addition to TAU compared to 16% of the patients receiving TAU alone no longer met BPD diagnostic criteria. The schema therapy group treatment led to significant reductions in symptoms and global improvement in functioning. The large positive treatment effects found in the group schema therapy study suggest that the group modality may augment or catalyse the active ingredients of the treatment for BPD patients. As of 2014, a collaborative randomised controlled trial is under way at 14 sites in six countries to further explore this interaction between groups and schema therapy.

Book: An Introduction to Cognitive Behaviour Therapy: Skills and Applications

Book Title:

An Introduction to Cognitive Behaviour Therapy: Skills and Applications.

Author(s): Helen Kennerley, Joan Kirk, and David Westbrook.

Year: 2016.

Edition: Third (3rd).

Publisher: SAGE Publications Ltd.

Type(s): Hardcover, Paperback and Kindle.

Synopsis:

This bestselling guide to the basic theory, skills and applications of cognitive behaviour therapy is fully updated to reflect recent developments in CBT theory. It includes in-depth material on working with diversity, and new case studies and exercises to help you reflect and explore how theory can be used to develop effective practice.

The Companion Website features over 40 videos illustrating the CBT skills and strategies discussed in the book, including:

  • Measuring CBT’s effectiveness.
  • Socratic method and applications.
  • Physical techniques and behavioural experiments.
  • Applications of CBT to specific client disorders.
  • Using supervision in CBT.

Book: Cognitive Behavioural Therapy – A CBT Guide To Theories & Professional Practice

Book Title:

Cognitive Behavioural Therapy – A CBT Guide To Theories & Professional Practice.

Author(s): Bill Andrews.

Year: 2019.

Edition: First (1st).

Publisher: Independently Published.

Type(s): Paperback and Kindle.

Synopsis:

Here is finally a complete guide on CBT that is for the mental health practitioner as well as the clients. The guide is expansive on CBT with new ideas and suggestions for both clinical and non-professional settings.

The book’s main purpose will help you deliver:

  • Hacks for fast and effective treatments to most mental health issues.
  • A complete professional guide for mental health practitioners of all levels.
  • Detailed explanations and simple strategies anyone can help implement.
  • Effective uses including suggested therapies for most mental health disorders.

A well researched cognitive therapy guide explores powerful tools & suggested therapies, including everything you should know about CBT and it’s effective uses.

Both professional practitioner and even mental health novices can benefit from this power packed guide.

Finally you can deal with disorders in a fast and powerful way and we also include a complete range of important topics most other CBT guides omit like:

  • Changing Maladaptive Thinking.
  • Cognitive Behavioural Assessment Model Explanations.
  • Intervention & Treatment Analysis.
  • The Power of CBT: Removal of Erroneous Thinking.
  • Cognitive Distortion Made Whole.
  • Reducing Emotional Distress with CBT.
  • Modern CBT & the Latest Tools and More!

Book: CBT Toolbox for Children and Adolescents

Book Title:

CBT Toolbox for Children and Adolescents: Over 220 Worksheets & Exercises for Trauma, ADHD, Autism, Anxiety, Depression & Conduct Disorders.

Author(s): Lisa Phifer.

Year: 2017.

Edition: First (1st).

Publisher: PESI Publishing & Media.

Type(s): Spiral-bound, Paperback and Kindle.

Synopsis:

The CBT Toolbox for Children and Adolescents gives you the resources to help the children in your life handle their daily obstacles with ease. Inside this workbook you’ll find hundreds of worksheets, exercises, and activities to help treat:

  • Trauma.
  • ADHD.
  • Autism.
  • Anxiety.
  • Depression.
  • Conduct Disorders.

Written by clinicians and teachers with decades of experience working with kids, these practical and easy-to-use therapy tools are vital to teaching children how to cope with and overcome their deepest struggles. Step-by-step, you’ll see how the best strategies from cognitive behavioural therapy are adapted for children.

What is Cognitive Analytic Therapy?

Introduction

Cognitive analytic therapy (CAT) is a form of psychological therapy initially developed in the United Kingdom by Anthony Ryle.

This time-limited therapy was developed in the context of the UK’s National Health Service (NHS) with the aim of providing effective and affordable psychological treatment which could be realistically provided in a resource constrained public health system. It is distinctive due to its intensive use of reformulation, its integration of cognitive and analytic practice and its collaborative nature, involving the patient very actively in their treatment.

The CAT practitioner aims to work with the patient to identify procedural sequences; chains of events, thoughts, emotions and motivations that explain how a target problem (for example self-harm) is established and maintained. In addition to the procedural sequence model, a second distinguishing feature of CAT is the use of reciprocal roles (RRs). These identify problems as occurring between people and not within the patient. RRs may be set up in early life and then be replayed in later life; for example someone who as a child felt neglected by parents perceived as abandoning might be vulnerable to feelings of abandonment in later life (or indeed neglect themselves).

Background

As the name implies, CAT evolved as an integrative therapy based on ideas from cognitive and analytic therapies. CAT was also influenced in part by George Kelly’s constructivism. Kelly had developed personal construct theory and the repertory grid method, and Kelly’s approach to therapy “offered a model of nonauthoritarian practice” that psychotherapist Anthony Ryle found appealing.

Ryle, a general practitioner and analytically trained psychotherapist, was undertaking research into psychotherapy practice using repertory grids in the 1970s. He found that the themes eventually addressed in analytic work were in fact present in transcripts from the very first sessions. However the slow, exploratory nature of traditional analytic therapy meant that these were not always addressed early and assertively, with the result that therapy, while effective, took a long time to produce results. In a 1979 paper, he proposed a shorter, more active form of therapy which integrated elements from cognitive therapy practice (such as goal setting and Socratic questioning) into analytic practice. This would include explicitly formulating the problems experienced by the patient, and sharing this formulation with the patient to engage them in psychotherapy as a co-operative enterprise.

Subsequently CAT has been influenced by ideas from the work of Soviet psychologist Lev Vygotsky and Russian philosopher Mikhail Bakhtin. From Vygotsky come concepts such as the zone of proximal development (ZPD) and scaffolding. The ZPD implies that new tasks set for the patient (for example, tolerating anxiety about social situations) should extend what they do beyond their current capabilities, but only by a small and achievable amount. Scaffolding involves the therapist providing support for the patient’s efforts to change, but varying this level of support as the patient’s needs change.

Bakhtin provided concepts such as dialogism from which come techniques such as Dialogical Sequence Analysis. This is a structured attempt to identify and visually display sequences of behaviour, thinking, and emotions so that the patient becomes more aware of these and can start to modify them.

In Practice

The model emphasises collaborative work with the client, and focuses on the understanding of the patterns of maladaptive behaviours. The aim of the therapy is to enable the client to recognise these patterns, understand their origins, and subsequently to learn alternative strategies in order to cope better.

The approach is always time-limited, typically taking place over 8-24 weekly sessions (the precise number being agreed at the start of therapy). Sixteen sessions is probably the most common length. In the first quarter of the therapy (the Reformulation phase) the therapist collects all the relevant information, asking the patient about present day problems and also earlier life experiences. At that point the therapist writes a reformulation letter to the client. This letter summarises the therapist’s understanding of the client’s problems. Particular attention is given to understanding the connection between childhood patterns of behaviour and their impact on adult life. The letter is agreed between patient and therapist and forms the basis for the rest of the work.

After the reformulation letter the patient may be asked to complete diaries or rating sheets to record the occurrence of problems and their context. During this period (known as the Recognition phase) patient and therapist construct a diagrammatic formulation to illustrate the unhelpful procedures which maintain problems for the patient. The aim of this phase is to enable the patient to recognise when and how problems occur.

In the second half of the therapy work moves into the Revision phase, where patient and therapist identify and practice “exits” from the procedural diagram established in the previous phase. For example, a problematic procedure might move a patient from feeling angry to taking an overdose. An exit might involve expressing the anger in some way as an alternative to self-injuring behaviour.

At the end of the therapy, patient and therapist each write “goodbye letters” which they exchange, summarising what has been achieved in the therapy and what remains to be done. After the end of the agreed number of weekly sessions, planned follow-up sessions take place to monitor and support the changes that have been made. Typically, a 16-session CAT might be followed up by a single session one month after the end of therapy, and a final one three months later.

Evidence Base

CAT has been the subject of a number of research studies published in peer-reviewed journals. These include randomised controlled trials (RCTs) and other kinds of study. The approach is too new for any systematic reviews of RCTs to have been conducted, and therefore is not yet explicitly recommended by name by the UK National Institute for Health and Clinical Excellence (NICE). However NICE has recommended that there should be further research of CAT, for example in borderline personality disorder. A review of CAT research evidence published in 2014 reported that although there were five randomised controlled trials published, research evidence into the approach was dominated by small-scale, practice-based studies. These tended to be with complex and severe clinical groups; 44% of studies reviewed involved personality disorder. A review of CAT looking back over the 30 years to its beginnings contains a meta-analysis of 11 outcome studies of CAT. The overall number of patients treated in the studies was 324 and the average effect size across all studies was 0.83 (95% confidence interval 0.66-1.00). This is a large effect and suggests that CAT is efficacious in treating mental health problems.

Evidence from Randomised Controlled Trials

CAT has been shown to lead to subjective improvement in people with anorexia nervosa. It has also been shown to produce significant improvements in adolescents with a diagnosis of borderline personality disorder. A different trial suggested that CAT for adult patients with personality disorders also showed improvements in symptoms and interpersonal functioning, as against controls who deteriorated on these measures. CAT has also been shown to improve patients’ management of diabetes. An RCT of the use of a CAT-informed assessment for young people who had self-harmed suggested that it was effective in increasing rates of attendance at community follow-up.

Evidence from Other Methodologies

Comparative studies have suggested CAT to be at least as effective as other forms of brief psychotherapy, person-centred therapy and cognitive behavioural therapy, and interpersonal psychotherapy.

Case series and single case studies have also been published describing the use of CAT in:

  • Depression.
  • Dissociative psychosis.
  • The treatment of offenders.
  • Brain injury.
  • Deliberate self-harm.
  • Dissociative identity disorder.
  • Histrionic personality disorder.
  • Panic disorder.
  • Psychological problems in multiple sclerosis.
  • With carers of people with dementia.
  • Morbid jealousy.
  • Borderline personality disorder.
  • Paranoid personality disorder.
  • Survivors of child sexual abuse.

What is Trichotillomania?

Introduction

Trichotillomania (TTM), also known as hair pulling disorder or compulsive hair pulling, is a mental disorder characterised by a long-term urge that results in the pulling out of one’s hair. This occurs to such a degree that hair loss can be seen. A brief positive feeling may occur as hair is removed. Efforts to stop pulling hair typically fail. Hair removal may occur anywhere; however, the head and around the eyes are most common. The hair pulling is to such a degree that it results in distress.

The disorder may run in families. It occurs more commonly in those with obsessive compulsive disorder. Episodes of pulling may be triggered by anxiety. People usually acknowledge that they pull their hair. On examination broken hairs may be seen. Other conditions that may present similarly include body dysmorphic disorder, however in that condition people remove hair to try to improve what they see as a problem in how they look.

Treatment is typically with cognitive behavioural therapy (CBT). The medication clomipramine may also be helpful, as will clipping fingernails. Trichotillomania is estimated to affect one to four percent of people. Trichotillomania most commonly begins in childhood or adolescence. Women are affected about 10 times more often than men. The name was created by François Henri Hallopeau in 1889, from the Greek θριξ/τριχ; thrix (meaning “hair”), along with τίλλειν; tíllein (meaning “to pull”), and μανία; mania (meaning “madness”).

Brief History

Hair pulling was first mentioned by Aristotle in the fourth century B.C., was first described in modern literature in 1885, and the term trichotillomania was coined by the French dermatologist François Henri Hallopeau in 1889.

In 1987, trichotillomania was recognised in the Diagnostic and Statistical Manual of the American Psychiatric Association, third edition-revised (DSM-III-R).

Epidemiology

Although no broad-based population epidemiologic studies had been conducted as of 2009, the lifetime prevalence of trichotillomania is estimated to be between 0.6% and 4.0% of the overall population. With a 1% prevalence rate, 2.5 million people in the US may have trichotillomania at some time during their lifetimes.

Trichotillomania is diagnosed in all age groups; onset is more common during preadolescence and young adulthood, with mean age of onset between 9 and 13 years of age, and a notable peak at 12-13. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female. Among adults, females typically outnumber males by 3 to 1.

“Automatic” pulling occurs in approximately three-quarters of adult patients with trichotillomania.

Signs and Symptoms

Trichotillomania is usually confined to one or two sites, but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, and legs. Some less common areas include the pubic area, underarms, beard, and chest. The classic presentation is the “Friar Tuck” form of vertex and crown alopecia. Children are less likely to pull from areas other than the scalp.

People who suffer from trichotillomania often pull only one hair at a time and these hair-pulling episodes can last for hours at a time. Trichotillomania can go into remission-like states where the individual may not experience the urge to “pull” for days, weeks, months, and even years.

Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape. Individuals with trichotillomania may be secretive or shameful of the hair pulling behaviour.

An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socialising, due to appearance and negative attention they may receive. Some people with trichotillomania wear hats, wigs, false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as “pulling”) whatsoever. This “pulling” often resumes upon leaving this environment. Some individuals with trichotillomania may feel they are the only person with this problem due to low rates of reporting.

For some people, trichotillomania is a mild problem, merely a frustration. But for many, shame and embarrassment about hair pulling causes painful isolation and results in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. Hair pulling can lead to great tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem.

Other medical complications include infection, permanent loss of hair, repetitive stress injury, carpal tunnel syndrome, and gastrointestinal obstruction as a result of trichophagia. In trichophagia, people with trichotillomania also ingest the hair that they pull; in extreme (and rare) cases this can lead to a hair ball (trichobezoar). Rapunzel syndrome, an extreme form of trichobezoar in which the “tail” of the hair ball extends into the intestines, can be fatal if misdiagnosed.

Environment is a large factor which affects hair pulling. Sedentary activities such as being in a relaxed environment are conducive to hair pulling. A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep. An extreme example of automatic trichotillomania is found when some patients have been observed to pull their hair out while asleep. This is called sleep-isolated trichotillomania.

Causes

Anxiety, depression and obsessive-compulsive disorder (OCD) are more frequently encountered in people with trichotillomania. Trichotillomania has a high overlap with post traumatic stress disorder, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hair pulling as addictive or negatively reinforcing, as it is associated with rising tension beforehand and relief afterward. A neurocognitive model – the notion that the basal ganglia plays a role in habit formation and that the frontal lobes are critical for normally suppressing or inhibiting such habits – sees trichotillomania as a habit disorder.

Abnormalities in the caudate nucleus are noted in OCD, but there is no evidence to support that these abnormalities can also be linked to trichotillomania. One study has shown that individuals with trichotillomania have decreased cerebellar volume. These findings suggest some differences between OCD and trichotillomania. There is a lack of structural MRI studies on trichotillomania. In several MRI studies that have been conducted, it has been found that people with trichotillomania have more gray matter in their brains than those who do not suffer from the disorder.

It is likely that multiple genes confer vulnerability to trichotillomania. One study identified mutations in the SLITRK1 gene.

Diagnosis

Patients may be ashamed or actively attempt to disguise their symptoms. This can make diagnosis difficult as symptoms are not always immediately obvious, or have been deliberately hidden to avoid disclosure. If the patient admits to hair pulling, diagnosis is not difficult; if patients deny hair pulling, a differential diagnosis must be pursued. The differential diagnosis will include evaluation for alopecia areata, iron deficiency, hypothyroidism, tinea capitis, traction alopecia, alopecia mucinosa, thallium poisoning, and loose anagen syndrome. In trichotillomania, a hair pull test is negative.

A biopsy can be performed and may be helpful; it reveals traumatised hair follicles with perifollicular haemorrhage, fragmented hair in the dermis, empty follicles, and deformed hair shafts. Multiple catagen hairs are typically seen. An alternative technique to biopsy, particularly for children, is to shave a part of the involved area and observe for regrowth of normal hairs.

Classification

Trichotillomania is defined as a self-induced and recurrent loss of hair. It includes the criterion of an increasing sense of tension before pulling the hair and gratification or relief when pulling the hair. However, some people with trichotillomania do not endorse the inclusion of “rising tension and subsequent pleasure, gratification, or relief” as part of the criteria because many individuals with trichotillomania may not realise they are pulling their hair, and patients presenting for diagnosis may deny the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled.

Trichotillomania may lie on the obsessive-compulsive spectrum, also encompassing OCD, body dysmorphic disorder (BDD), nail biting (onychophagia) and skin picking (dermatillomania), tic disorders and eating disorders. These conditions may share clinical features, genetic contributions, and possibly treatment response; however, differences between trichotillomania and OCD are present in symptoms, neural function and cognitive profile. In the sense that it is associated with irresistible urges to perform unwanted repetitive behaviour, trichotillomania is akin to some of these conditions, and rates of trichotillomania among relatives of OCD patients is higher than expected by chance. However, differences between the disorder and OCD have been noted, including: differing peak ages at onset, rates of comorbidity, gender differences, and neural dysfunction and cognitive profile. When it occurs in early childhood, it can be regarded as a distinct clinical entity.

Because trichotillomania can be present in multiple age groups, it is helpful in terms of prognosis and treatment to approach three distinct subgroups by age: preschool age children, preadolescents to young adults, and adults.

In preschool age children, trichotillomania is considered benign. For these children, hair-pulling is considered either a means of exploration or something done subconsciously, similar to nail-biting and thumb-sucking, and almost never continues into further ages.

The most common age of onset of trichotillomania is between ages 9 and 13. In this age range, trichotillomania is usually chronic, and continues into adulthood. Trichiotillomania that begins in adulthood most commonly arises from underlying psychiatric causes.

Trichotillomania is often not a focused act, but rather hair pulling occurs in a “trance-like” state; hence, trichotillomania is subdivided into “automatic” versus “focused” hair pulling. Children are more often in the automatic, or unconscious, subtype and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hair pulling, including seeking specific types of hairs to pull, pulling until the hair feels “just right”, or pulling in response to a specific sensation. Knowledge of the subtype is helpful in determining treatment strategies.

Treatment

Treatment is based on a person’s age. Most pre-school age children outgrow the condition if it is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including behaviour modification programmes, may be considered; referrals to psychologists or psychiatrists may be considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other mental disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated.

Psychotherapy

Habit reversal training (HRT) has the highest rate of success in treating trichotillomania. HRT has also been shown to be a successful adjunct to medication as a way to treat trichotillomania. With HRT, the individual is trained to learn to recognise their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioural versus pharmacologic treatment, cognitive behavioural therapy (CBT, including HRT) have shown significant improvement over medication alone. It has also proven effective in treating children. Biofeedback, cognitive-behavioural methods, and hypnosis may improve symptoms. Acceptance and commitment therapy (ACT) is also demonstrating promise in trichotillomania treatment. A systematic review from 2012 found tentative evidence for “movement decoupling”.

Medication

The United States Food and Drug Administration (FDA) has not approved any medications for trichotillomania treatment.

Medications can be used to treat trichotillomania. Treatment with clomipramine, a tricyclic antidepressant, was shown in a small double-blind study to improve symptoms, but results of other studies on clomipramine for treating trichotillomania have been inconsistent. Naltrexone may be a viable treatment. Fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) have limited usefulness in treating trichotillomania, and can often have significant side effects. Behavioural therapy has proven more effective when compared to fluoxetine. There is little research on the effectiveness of behavioural therapy combined with medication, and robust evidence from high-quality studies is lacking. Acetylcysteine treatment stemmed from an understanding of glutamate’s role in regulation of impulse control.

Different medications, depending on the individual, may increase hair pulling.

Devices

Technology can be used to augment habit reversal training or behavioural therapy. Several mobile apps exist to help log behaviour and focus on treatment strategies. There are also wearable devices that track the position of a user’s hands. They produce sound or vibrating notifications so that users can track rates of these events over time.

Prognosis

When it occurs in early childhood (before five years of age), the condition is typically self-limiting and intervention is not required. In adults, the onset of trichotillomania may be secondary to underlying psychiatric disturbances, and symptoms are generally more long-term.

Secondary infections may occur due to picking and scratching, but other complications are rare. Individuals with trichotillomania often find that support groups are helpful in living with and overcoming the disorder.

Society and Culture

Support groups and internet sites can provide recommended educational material and help persons with trichotillomania in maintaining a positive attitude and overcoming the fear of being alone with the disorder.

Media

A documentary film exploring trichotillomania, Bad Hair Life, was the 2003 winner of the International Health & Medical Media Award for best film in psychiatry and the winner of the 2004 Superfest Film Festival Merit Award.

Trichster is a 2016 documentary that follows seven individuals living with trichotillomania, as they navigate the complicated emotions surrounding the disorder, and the effect it has on their daily lives.

What is Behaviour Therapy?

Introduction

Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology.

It looks at specific, learned behaviours and how the environment, or other people’s mental states, influences those behaviours, and consists of techniques based on learning theory, such as respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method but it has a wide range of techniques that can be used to treat a person’s psychological problems.

Behavioural psychotherapy is sometimes juxtaposed with cognitive psychotherapy, while cognitive behavioural therapy integrates aspects of both approaches, such as cognitive restructuring, positive reinforcement, habituation (or desensitisation), counterconditioning, and modelling.

Applied behaviour analysis (ABA) is the application of behaviour analysis that focuses on functionally assessing how behaviour is influenced by the observable learning environment and how to change such behaviour through contingency management or exposure therapies, which are used throughout clinical behaviour analysis therapies or other interventions based on the same learning principles.

Cognitive-behavioural therapy views cognition and emotions as preceding overt behaviour and implements treatment plans in psychotherapy to lessen the issue by managing competing thoughts and emotions, often in conjunction with behavioural learning principles.

A 2013 Cochrane review comparing behaviour therapies to psychological therapies found them to be equally effective, although at the time the evidence base that evaluates the benefits and harms of behaviour therapies was felt to be weak.

Brief History

Precursors of certain fundamental aspects of behaviour therapy have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Wolpe and Lazarus wrote,

While the modern behavior therapist deliberately applies principles of learning to this therapeutic operations, empirical behavior therapy is probably as old as civilization – if we consider civilization as having started when man first did things to further the well-being of other men. From the time that this became a feature of human life there must have been occasions when a man complained of his ills to another who advised or persuaded him of a course of action. In a broad sense, this could be called behavior therapy whenever the behavior itself was conceived as the therapeutic agent. Ancient writings contain innumerable behavioral prescriptions that accord with this broad conception of behavior therapy.

The first use of the term behaviour modification appears to have been by Edward Thorndike in 1911. His article Provisional Laws of Acquired Behaviour or Learning makes frequent use of the term “modifying behaviour”. Through early research in the 1940s and the 1950s the term was used by Joseph Wolpe’s research group. The experimental tradition in clinical psychology used it to refer to psycho-therapeutic techniques derived from empirical research. It has since come to refer mainly to techniques for increasing adaptive behaviour through reinforcement and decreasing maladaptive behaviour through extinction or punishment (with emphasis on the former). Two related terms are behaviour therapy and applied behaviour analysis. Since techniques derived from behavioural psychology tend to be the most effective in altering behaviour, most practitioners consider behaviour modification along with behaviour therapy and applied behaviour analysis to be founded in behaviourism. While behaviour modification and applied behaviour analysis typically uses interventions based on the same behavioural principles, many behaviour modifiers who are not applied behaviour analysts tend to use packages of interventions and do not conduct functional assessments before intervening.

Possibly the first occurrence of the term “behaviour therapy” was in a 1953 research project by B.F. Skinner, Ogden Lindsley, Nathan Azrin and Harry C. Solomon. The paper talked about operant conditioning and how it could be used to help improve the functioning of people who were diagnosed with chronic schizophrenia. Early pioneers in behaviour therapy include Joseph Wolpe and Hans Eysenck.

In general, behaviour therapy is seen as having three distinct points of origin: South Africa (Wolpe’s group), The United States (Skinner), and the United Kingdom (Rachman and Eysenck). Each had its own distinct approach to viewing behaviour problems. Eysenck in particular viewed behaviour problems as an interplay between personality characteristics, environment, and behaviour. Skinner’s group in the United States took more of an operant conditioning focus. The operant focus created a functional approach to assessment and interventions focused on contingency management such as the token economy and behavioural activation. Skinner’s student Ogden Lindsley is credited with forming a movement called precision teaching, which developed a particular type of graphing programme called the standard celeration chart to monitor the progress of clients. Skinner became interested in the individualising of programs for improved learning in those with or without disabilities and worked with Fred S. Keller to develop programmed instruction. Programmed instruction had some clinical success in aphasia rehabilitation. Gerald Patterson used programme instruction to develop his parenting text for children with conduct problems. With age, respondent conditioning appears to slow but operant conditioning remains relatively stable. While the concept had its share of advocates and critics in the west, its introduction in the Asian setting, particularly in India in the early 1970s and its grand success were testament to the famous Indian psychologist H. Narayan Murthy’s enduring commitment to the principles of behavioural therapy and biofeedback.

While many behaviour therapists remain staunchly committed to the basic operant and respondent paradigm, in the second half of the 20th century, many therapists coupled behaviour therapy with the cognitive therapy, of Aaron Beck, Albert Ellis, and Donald Meichenbaum to form cognitive behaviour therapy (CBT). In some areas the cognitive component had an additive effect (for example, evidence suggests that cognitive interventions improve the result of social phobia treatment) but in other areas it did not enhance the treatment, which led to the pursuit of third generation behaviour therapies. Third generation behaviour therapy uses basic principles of operant and respondent psychology but couples them with functional analysis and a clinical formulation/case conceptualisation of verbal behaviour more inline with view of the behaviour analysts. Some research supports these therapies as being more effective in some cases than cognitive therapy, but overall the question is still in need of answers.

Theoretical Basis

The behavioural approach to therapy assumes that behaviour that is associated with psychological problems develops through the same processes of learning that affects the development of other behaviours. Therefore, behaviourists see personality problems in the way that personality was developed. They do not look at behaviour disorders as something a person has, but consider that it reflects how learning has influenced certain people to behave in a certain way in certain situations.

Behaviour therapy is based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. Classical conditioning happens when a neutral stimulus comes right before another stimulus that triggers a reflexive response. The idea is that if the neutral stimulus and whatever other stimulus that triggers a response is paired together often enough that the neutral stimulus will produce the reflexive response. Operant conditioning has to do with rewards and punishments and how they can either strengthen or weaken certain behaviours.

Contingency management programmes are a direct product of research from operant conditioning.

Current Forms

Behavioural therapy based on operant and respondent principles has considerable evidence base to support its usage. This approach remains a vital area of clinical psychology and is often termed clinical behaviour analysis. Behavioural psychotherapy has become increasingly contextual in recent years. Behavioural psychotherapy has developed greater interest in recent years in personality disorders as well as a greater focus on acceptance and complex case conceptualisations.

Functional Analytic Psychotherapy

One current form of behavioural psychotherapy is functional analytic psychotherapy. Functional analytic psychotherapy is a longer duration behaviour therapy. Functional analytic therapy focuses on in-session use of reinforcement and is primarily a relationally-based therapy. As with most of the behavioural psychotherapies, functional analytic psychotherapy is contextual in its origins and nature. and draws heavily on radical behaviourism and functional contextualism.

Functional analytic psychotherapy holds to a process model of research, which makes it unique compared to traditional behaviour therapy and cognitive behavioural therapy.

Functional analytic psychotherapy has a strong research support. Recent functional analytic psychotherapy research efforts are focusing on management of aggressive inpatients.

Assessment

Behaviour therapists complete a functional analysis or a functional assessment that looks at four important areas: stimulus, organism, response and consequences. The stimulus is the condition or environmental trigger that causes behaviour. An organism involves the internal responses of a person, like physiological responses, emotions and cognition. A response is the behaviour that a person exhibits and the consequences are the result of the behaviour. These four things are incorporated into an assessment done by the behaviour therapist.

Most behaviour therapists use objective assessment methods like structured interviews, objective psychological tests or different behavioural rating forms. These types of assessments are used so that the behaviour therapist can determine exactly what a client’s problem may be and establish a baseline for any maladaptive responses that the client may have. By having this baseline, as therapy continues this same measure can be used to check a client’s progress, which can help determine if the therapy is working. Behaviour therapists do not typically ask the why questions but tend to be more focused on the how, when, where and what questions. Tests such as the Rorschach inkblot test or personality tests like the MMPI (Minnesota Multiphasic Personality Inventory) are not commonly used for behavioural assessment because they are based on personality trait theory assuming that a person’s answer to these methods can predict behaviour. Behaviour assessment is more focused on the observations of a persons behaviour in their natural environment.

Behavioural assessment specifically attempts to find out what the environmental and self-imposed variables are. These variables are the things that are allowing a person to maintain their maladaptive feelings, thoughts and behaviours. In a behavioural assessment “person variables” are also considered. These “person variables” come from a person’s social learning history and they affect the way in which the environment affects that person’s behaviour. An example of a person variable would be behavioural competence. Behavioural competence looks at whether a person has the appropriate skills and behaviours that are necessary when performing a specific response to a certain situation or stimuli.

When making a behavioural assessment the behaviour therapist wants to answer two questions:

  1. What are the different factors (environmental or psychological) that are maintaining the maladaptive behaviour; and
  2. What type of behaviour therapy or technique that can help the individual improve most effectively.

The first question involves looking at all aspects of a person, which can be summed up by the acronym BASIC ID. This acronym stands for behaviour, affective responses, sensory reactions, imagery, cognitive processes, interpersonal relationships and drug use.

Clinical Applications

Behaviour therapy based its core interventions on functional analysis. Just a few of the many problems that behaviour therapy have functionally analysed include intimacy in couples relationships, forgiveness in couples, chronic pain, stress-related behaviour problems of being an adult child of a person with an alcohol use disorder, anorexia, chronic distress, substance abuse, depression, anxiety, insomnia and obesity.

Functional analysis has even been applied to problems that therapists commonly encounter like client resistance, partially engaged clients and involuntary clients. Applications to these problems have left clinicians with considerable tools for enhancing therapeutic effectiveness. One way to enhance therapeutic effectiveness is to use positive reinforcement or operant conditioning. Although behaviour therapy is based on the general learning model, it can be applied in a lot of different treatment packages that can be specifically developed to deal with problematic behaviours. Some of the more well known types of treatments are: Relaxation training, systematic desensitisation, virtual reality exposure, exposure and response prevention techniques, social skills training, modelling, behavioural rehearsal and homework, and aversion therapy and punishment.

Relaxation training involves clients learning to lower arousal to reduce their stress by tensing and releasing certain muscle groups throughout their body. Systematic desensitisation is a treatment in which the client slowly substitutes a new learned response for a maladaptive response by moving up a hierarchy of situations involving fear. Systematic desensitisation is based in part on counter conditioning. Counter conditioning is learning new ways to change one response for another and in the case of desensitisation it is substituting that maladaptive behaviour for a more relaxing behaviour. Exposure and response prevention techniques (also known as flooding and response prevention) is the general technique in which a therapist exposes an individual to anxiety-provoking stimuli while keeping them from having any avoidance responses.

Virtual reality therapy provides realistic, computer-based simulations of troublesome situations. The modelling process involves a person being subjected to watching other individuals who demonstrate behaviour that is considered adaptive and that should be adopted by the client. This exposure involves not only the cues of the “model person” as well as the situations of a certain behaviour that way the relationship can be seen between the appropriateness of a certain behaviour and situation in which that behaviour occurs is demonstrated. With the behavioural rehearsal and homework treatment a client gets a desired behaviour during a therapy session and then they practice and record that behaviour between their sessions. Aversion therapy and punishment is a technique in which an aversive (painful or unpleasant) stimulus is used to decrease unwanted behaviours from occurring. It is concerned with two procedures:

  1. The procedures are used to decrease the likelihood of the frequency of a certain behaviour; and
  2. Procedures that will reduce the attractiveness of certain behaviours and the stimuli that elicit them.

The punishment side of aversion therapy is when an aversive stimulus is presented at the same time that a negative stimulus and then they are stopped at the same time when a positive stimulus or response is presented. Examples of the type of negative stimulus or punishment that can be used is shock therapy treatments, aversive drug treatments as well as response cost contingent punishment which involves taking away a reward.

Applied behaviour analysis is using behavioural methods to modify certain behaviours that are seen as being important socially or personally. There are four main characteristics of applied behaviour analysis:

  • First behaviour analysis is focused mainly on overt behaviours in an applied setting.
    • Treatments are developed as a way to alter the relationship between those overt behaviours and their consequences.
  • Another characteristic of applied behaviour analysis is how it (behaviour analysis) goes about evaluating treatment effects.
    • The individual subject is where the focus of study is on, the investigation is centred on the one individual being treated.
  • A third characteristic is that it focuses on what the environment does to cause significant behaviour changes.
  • Finally the last characteristic of applied behaviour analysis is the use of those techniques that stem from operant and classical conditioning such as providing reinforcement, punishment, stimulus control and any other learning principles that may apply.

Social skills training teaches clients skills to access reinforcers and lessen life punishment. Operant conditioning procedures in meta-analysis had the largest effect size for training social skills, followed by modelling, coaching, and social cognitive techniques in that order. Social skills training has some empirical support particularly for schizophrenia. However, with schizophrenia, behavioural programmes have generally lost favour.

Some other techniques that have been used in behaviour therapy are contingency contracting, response costs, token economies, biofeedback, and using shaping and grading task assignments.

Shaping and graded task assignments are used when behaviour that needs to be learned is complex. The complex behaviours that need to be learned are broken down into simpler steps where the person can achieve small things gradually building up to the more complex behaviour. Each step approximates the eventual goal and helps the person to expand their activities in a gradual way. This behaviour is used when a person feels that something in their lives can not be changed and life’s tasks appear to be overwhelming.

Another technique of behaviour therapy involves holding a client or patient accountable of their behaviours in an effort to change them. This is called a contingency contract, which is a formal written contract between two or more people that defines the specific expected behaviours that you wish to change and the rewards and punishments that go along with that behaviour. In order for a contingency contract to be official it needs to have five elements. First it must state what each person will get if they successfully complete the desired behaviour. Secondly those people involved have to monitor the behaviours. Third, if the desired behaviour is not being performed in the way that was agreed upon in the contract the punishments that were defined in the contract must be done. Fourth if the persons involved are complying with the contract they must receive bonuses. The last element involves documenting the compliance and noncompliance while using this treatment in order to give the persons involved consistent feedback about the target behaviour and the provision of reinforcers.

Token economies is a behaviour therapy technique where clients are reinforced with tokens that are considered a type of currency that can be used to purchase desired rewards, like being able to watch television or getting a snack that they want when they perform designated behaviours. Token economies are mainly used in institutional and therapeutic settings. In order for a token economy to be effective there must be consistency in administering the program by the entire staff. Procedures must be clearly defined so that there is no confusion among the clients. Instead of looking for ways to punish the patients or to deny them of rewards, the staff has to reinforce the positive behaviours so that the clients will increase the occurrence of the desired behaviour. Over time the tokens need to be replaced with less tangible rewards such as compliments so that the client will be prepared when they leave the institution and won’t expect to get something every time they perform a desired behaviour.

Closely related to token economies is a technique called response costs. This technique can either be used with or without token economies. Response costs is the punishment side of token economies where there is a loss of a reward or privilege after someone performs an undesirable behaviour. Like token economies this technique is used mainly in institutional and therapeutic settings.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy, habit reversal training, has been found to be highly effective for treating tics.

In Rehabilitation

Currently, there is a greater call for behavioural psychologists to be involved in rehabilitation efforts.

Treatment of Mental Disorders

Two large studies done by the Faculty of Health Sciences at Simon Fraser University indicates that both behaviour therapy and cognitive-behavioural therapy (CBT) are equally effective for OCD. CBT has been shown to perform slightly better at treating co-occurring depression.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy (habit reversal training) has been found to be highly effective for treating tics.

There has been a development towards combining techniques to treat psychiatric disorders. Cognitive interventions are used to enhance the effects of more established behavioural interventions based on operant and classical conditioning. An increased effort has also been placed to address the interpersonal context of behaviour.

Behaviour therapy can be applied to a number of mental disorders and in many cases is more effective for specific disorders as compared to others. Behaviour therapy techniques can be used to deal with any phobias that a person may have. Desensitisation has also been applied to other issues such as dealing with anger, if a person has trouble sleeping and certain speech disorders. Desensitisation does not occur over night, there is a process of treatment. Desensitisation is done on a hierarchy and happens over a number of sessions. The hierarchy goes from situations that make a person less anxious or nervous up to things that are considered to be extreme for the patient.

Modelling has been used in dealing with fears and phobias. Modelling has been used in the treatment of fear of snakes as well as a fear of water.

Aversive therapy techniques have been used to treat sexual deviations as well as alcohol use disorder.

Exposure and prevention procedure techniques can be used to treat people who have anxiety problems as well as any fears or phobias. These procedures have also been used to help people dealing with any anger issues as well as pathological grievers (people who have distressing thoughts about a deceased person).

Virtual reality therapy deals with fear of heights, fear of flying, and a variety of other anxiety disorders. VRT has also been applied to help people with substance abuse problems reduce their responsiveness to certain cues that trigger their need to use drugs.

Shaping and graded task assignments has been used in dealing with suicide and depressed or inhibited individuals. This is used when a patient feel hopeless and they have no way of changing their lives. This hopelessness involves how the person reacts and responds to someone else and certain situations and their perceived powerlessness to change that situation that adds to the hopelessness. For a person with suicidal ideation, it is important to start with small steps. Because that person may perceive everything as being a big step, the smaller you start the easier it will be for the person to master each step. This technique has also been applied to people dealing with agoraphobia, or fear of being in public places or doing something embarrassing.

Contingency contracting has been used to deal with behaviour problems in delinquents and when dealing with on task behaviours in students.

Token economies are used in controlled environments and are found mostly in psychiatric hospitals. They can be used to help patients with different mental illnesses but it doesn’t focus on the treatment of the mental illness but instead on the behavioural aspects of a patient. The response cost technique has been used to address a variety of behaviours such as smoking, overeating, stuttering, and psychotic talk.

Treatment Outcomes

Systematic desensitisation has been shown to successfully treat phobias about heights, driving, insects as well as any anxiety that a person may have. Anxiety can include social anxiety, anxiety about public speaking as well as test anxiety. It has been shown that the use of systematic desensitisation is an effective technique that can be applied to a number of problems that a person may have.

When using modelling procedures this technique is often compared to another behavioural therapy technique. When compared to desensitisation, the modelling technique does appear to be less effective. However it is clear that the greater the interaction between the patient and the subject he is modelling the greater the effectiveness of the treatment.

While undergoing exposure therapy, a person typically needs five sessions to assess the treatment’s effectiveness. After five sessions, exposure treatment has been shown to provide benefit to the patient. However, it is still recommended treatment continue beyond the initial five sessions.

Virtual reality therapy (VRT) has shown to be effective for a fear of heights. It has also been shown to help with the treatment of a variety of anxiety disorders. Due to the costs associated with VRT, therapists are still awaiting results of controlled trials investigating VRT, to assess which applications demonstrate the best results.

For those with suicidal ideation, treatment depends on how severe the person’s depression and sense of hopelessness is. If these things are severe, the person’s response to completing small steps will not be of importance to them, because they don’t consider the success an accomplishment. Generally, in those not suffering from severe depression or fear, this technique has been successful, as completion of simpler activities builds their confidences and allows them to progress to more complex situations.

Contingency contracts have been seen to be effective in changing any undesired behaviours of individuals. It has been seen to be effective in treating behaviour problems in delinquents regardless of the specific characteristics of the contract.

Token economies have been shown to be effective when treating patients in psychiatric wards who had chronic schizophrenia. The results showed that the contingent tokens were controlling the behaviour of the patients.

Response costs has been shown to work in suppressing a variety of behaviours such as smoking, overeating or stuttering with a diverse group of clinical populations ranging from sociopaths to school children. These behaviours that have been suppressed using this technique often do not recover when the punishment contingency is withdrawn. Also undesirable side effects that are usually seen with punishment are not typically found when using the response cost technique.

Third Generation

The third-generation behaviour therapy movement has been called clinical behaviour analysis because it represents a movement away from cognitivism and back toward radical behaviourism and other forms of behaviourism, in particular functional analysis and behavioural models of verbal behaviour. This area includes acceptance and commitment therapy (ACT), cognitive behavioural analysis system of psychotherapy (CBASP), behavioural activation (BA), dialectical behavioural therapy, functional analytic psychotherapy (FAP), integrative behavioural couples therapy, metacognitive therapy and metacognitive training. These approaches are squarely within the applied behaviour analysis tradition of behaviour therapy.

ACT may be the most well-researched of all the third-generation behaviour therapy models. It is based on relational frame theory. Other authors object to the term “third generation” or “third wave” and incorporate many of the “third wave” therapeutic techniques under the general umbrella term of modern cognitive behavioural therapies.

Functional analytic psychotherapy is based on a functional analysis of the therapeutic relationship. It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement. In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component. Behavioural activation is based on a matching model of reinforcement. A recent review of the research, supports the notion that the use of behavioural activation is clinically important for the treatment of depression.

Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1969) for the difference between contingency-shaped and rule-governed behaviour. It couples this analysis with a thorough functional assessment of the couple’s relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness.

Organisations

Many organisations exist for behaviour therapists around the world. In the United States, the American Psychological Association’s Division 25 is the division for behaviour analysis. The Association for Contextual Behaviour Therapy is another professional organisation. ACBS is home to many clinicians with specific interest in third generation behaviour therapy. Doctoral-level behaviour analysts who are psychologists belong to American Psychological Association’s division 25 – Behaviour analysis. APA offers a diploma in behavioural psychology.

The Association for Behavioural and Cognitive Therapies (formerly the Association for the Advancement of Behaviour Therapy) is for those with a more cognitive orientation. The ABCT also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis. In addition, the Association for Behavioural an Cognitive Therapies has a special interest group on addictions.

Characteristics

By nature, behavioural therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behaviour ultimately has), probabilistic (viewing behaviour as statistically predictable), monistic (rejecting mind–body dualism and treating the person as a unit), and relational (analysing bidirectional interactions).

Behavioural therapy develops, adds and provides behavioural intervention strategies and programs for clients, and training to people who care to facilitate successful lives in the communities.

Training

Recent efforts in behavioural psychotherapy have focused on the supervision process. A key point of behavioural models of supervision is that the supervisory process parallels the behavioural psychotherapy.

Methods

  • Behaviour management.
  • Behaviour modification.
  • Clinical behaviour analysis.
  • Contingency management.
  • Covert conditioning.
  • Decoupling.
  • Exposure and response prevention.
  • Flooding.
  • Habit reversal training.
  • Matching law.
  • Modelling.
  • Observational learning.
  • Operant conditioning.
  • Professional practice of behaviour analysis.
  • Respondent conditioning.
  • Stimulus control.
  • Systematic desensitisation.

Reference

Skinner, B.F. (1969). Contingencies of Reinforcement: A Theoretical Analysis. New York: Meredith Corporation.

Book: The PTSD Workbook

Book Title:

The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms.

Author(s): Mary Beth Williams and Soili Poijula.

Year: 2016.

Edition: Third (3rd).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

Post-traumatic stress disorder (PTSD) is an extremely debilitating condition that can occur after exposure to a terrifying event. But whether you are a veteran of war, a victim of domestic violence or sexual violence, or have been involved in a natural disaster, crime, car accident, or accident in the workplace, your symptoms may be getting in the way of you living your life.

PTSD can often cause you to relive your traumatic experience in the form of flashbacks, memories, nightmares, and frightening thoughts. This is especially true when you are exposed to events or objects that remind you of your trauma. Left untreated, PTSD can lead to emotional numbness, insomnia, addiction, anxiety, depression, and even suicide. So, how can you start to heal and get your life back?

In The PTSD Workbook, Third Edition, psychologists and trauma experts Mary Beth Williams and Soili Poijula outline techniques and interventions used by PTSD experts from around the world to conquer distressing trauma-related symptoms. In this fully revised and updated workbook, you’ll learn how to move past the trauma you’ve experienced and manage symptoms such as insomnia, anxiety, and flashbacks.

Based in cognitive behavioural therapy (CBT), this book is extremely accessible and easy-to-use, offering evidence-based therapy at a low cost. This new edition features chapters focusing on veterans with PTSD, the link between cortisol and adrenaline and its role in PTSD and overall mental health, and the mind-body component of PTSD. Clinicians will also find important updates reflecting the new DSM-V definition of PTSD.

This book is designed to give you the emotional resilience you need to get your life back together after a traumatic event.

What is Melancholic Depression?

Introduction

Melancholic depression, or depression with melancholic features, is a DSM-IV and DSM-5 subtype of clinical depression.

Refer to Melancholia.

Signs and Symptoms

Requiring at least one of the following symptoms:

  • Anhedonia (the inability to find pleasure in positive things).
  • Lack of mood reactivity (i.e. mood does not improve in response to positive events).

And at least three of the following:

  • Depression that is subjectively different from grief or loss.
  • Severe weight loss or loss of appetite.
  • Psychomotor agitation or retardation.
  • Early morning awakening.
  • Guilt that is excessive.
  • Worse mood in the morning.

Melancholic features apply to an episode of depression that occurs as part of either major depressive disorder or bipolar disorder I or II.

Causes

The causes of melancholic-type major depressive disorder are believed to be mostly biological factors; some may have inherited the disorder from their parents. Sometimes stressful situations can trigger episodes of melancholic depression, though this is a contributing cause rather than a necessary or sufficient cause. People with psychotic symptoms are also thought to be more susceptible to this disorder. It is frequent in old age and often unnoticed by some physicians who perceive the symptoms to be a part of dementia. Major depressive disorder, melancholic or otherwise, is a separate condition that can be comorbid with dementia in the elderly.

Treatment

Melancholic depression is often considered to be a biologically based and particularly severe form of depression. Treatment involves antidepressants, electroconvulsive therapy, or other empirically supported treatments such as cognitive behavioural therapy and interpersonal therapy for depression. A 2008 analysis of a large study of patients with unipolar major depression found a rate of 23.5% for melancholic features. It was the first form of depression extensively studied, and many of the early symptom checklists for depression reflect this.

Incidence

The incidence of melancholic depression has been found to increase when the temperature and/or sunlight are low. According to the DSM-IV, the “melancholic features” specifier may be applied to the following only:

  • Major depressive episode, single episode.
  • Major depressive episode, recurrent episode.
  • Bipolar I disorder, most recent episode depressed.
  • Bipolar II disorder, most recent episode depressed.