MODULE III

The Psychotherapies (Part 2)

LESSON 1: Behavior Therapy

Things you should accomplish!

1. Discuss the relevance of behavior therapy in the

treatment of psychological disorder.
2. Identify the different methods used in behavior therapy.
3. Evaluate the strengths and weaknesses of behavior
therapies and their appropriateness in the treatment of
psychological disorders.

Pay Attention!

INTRODUCTION TO BEHAVIOR PSYCHOTHERAPY

 Behavior therapy or behavioral psychotherapy is a broad term

referring to clinical psychotherapy that uses techniques derived
from behaviorism which conceptualize psychological disorders as the
result of maladaptive learning, as people are born tabula rasa (blank
slate).

 Behavior therapy is a form of therapy seeks to identify and help

change potentially self-destructive or unhealthy behaviors. It functions
on the idea that all behaviors are learned and that unhealthy behaviors
can be changed. The focus of treatment is often on current problems and
how to change them.

 Those who practice behavior therapy tend to look at specific,

learned behaviors and how the environment influences those behaviors.
Those who practice behavior therapy are called behaviorists, or behavior
analysts. They tend to look for treatment outcomes that are objectively
measurable.
Module III Clinical Psychology (Psy 137)
  Behavior 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.

 Traditional behavior therapy draws from respondent

conditioning and operant conditioning to solve patient’s problems.

 Behavioral psychotherapy is sometimes juxtaposed with

cognitive psychotherapy, while cognitive behavioral therapy integrates
aspects of both approaches.

 Applied behavior analysis (ABA) is the application of behavior

analysis that focuses on assessing how environmental variables influence
learning principles, particularly respondent and operant conditioning, to
identify potential behavior-change procedures, which are frequently used
throughout clinical therapy.

 Cognitive-behavior therapy views cognition and emotions as

preceding overt behavior with treatment plans in psychotherapy to lessen
the issue.

Who can benefit from behavioral therapy?

People most commonly seek behavioral therapy to treat:

 depression
 anxiety
 panic disorders
 anger issues

It can also help treat conditions and disorders such as:

 eating disorders
 post-traumatic stress disorder (PTSD)
 bipolar disorder
 ADHD
 phobias, including social phobias
 obsessive compulsive disorder (OCD)
 self-harm
 substance abuse

This type of therapy can benefit adults and children.

Theoretical Basis
 The behavioral approach to therapy assumes that behavior that is
associated with psychological problems develops through the same

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 processes of learning that affects the development of other
behaviors. Therefore, behaviorists see personality problems in the
way that personality was developed. They do not look at behavior
disorders as something a person has but that it reflects how
learning has influenced certain people to behave in a certain way
in certain situations.
 Behavior therapy is based upon the principles of classical
conditioning developed by Ivan Pavlov and operant conditioning
developed by B.F. Skinner.
 Classical conditioning suggests a response is learned and repeated
through immediate association. Behavioral therapies based on
classical conditioning aim to break the association between
stimulus and undesired response (e.g. phobia, additional etc.).
Originally this type of therapy was known as behavior modification
but, these days, it is usually referred to as applied behavior
analysis.
 Operant conditioning is a method of learning that occurs through
rewards and punishments for behavior. Through operant
conditioning, an individual makes an association between a
particular behavior and a consequence (Skinner, 1938).

METHODS OF BEHAVIOR THERAPY

1. Behavior management
o It is similar to behavior modification. It is a less intensive version
of behavior therapy.
o In behavior modification, the focus is on changing behavior, while in
behavior management the focus is on maintaining order.
o Behavior management skills are of particular importance to
teachers in the educational system. Behavior management include
all of the actions and conscious inactions to enhance the probability
people, individually and in groups, choose behaviors which are
personally fulfilling, productive, and socially acceptable.
o Behavior management is applied at the group level by a classroom
teacher as a form of behavioral engineering to produce high rates
of student work completion and minimize classroom disruption. In
addition, greater focus has been placed on building self-control.

2. Behavior Modification
o Refers to behavior-change procedures.

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 o Based on methodological behaviorism, overt behavior was modified
with presumed consequences, including artificial positive and
negative reinforcement contingencies to increase desirable
behavior, or administering positive and negative punishment
and/or extinction to reduce problematic behavior.

3. Clinical behavior analysis (CBA; also called clinical behavior

analysis or third-generation behavior therapy)
o CBA represents a movement in behavior therapy away from
methodological behaviorism and back toward radical
behaviorism and the use of functional analytic models of verbal
behavior.
o Clinical behavior analysis (CBA) therapies include:
 acceptance and commitment therapy (ACT). This approach
was referred to as comprehensive distancing. Every
practitioner mixes acceptance with a commitment to one's
values. These
ingredients become enmeshed into the treatment in different
ways which leads to ACT being either more on the
mindfulness side or more on the behavior-changing side.
 community reinforcement approach and
family training (CRAFT). Community reinforcement
approach and family training (CRAFT) is a model developed
by Robert Meyer and based on the community reinforcement
approach (CRA) first developed by Nathan Azrin and Hunt.
The model focuses on the use of functional behavioral
assessment to reduce drinking behavior. CRAFT combines
CRA with family therapy.
 functional analytic psychotherapy (FAP). It places a greater
emphasis on the therapeutic context and returns to the use
of in-session reinforcement. The basic FAP analysis utilizes
what is called the clinically relevant behavior (CRB1), which
is the client's presenting problem as presented in-session.
Client in- session actions that improve their CRB1s are
referred to as CRB2s. Client statements, or verbal behavior,
about CRBs are referred to as CRB3s. In general, it supports
the idea that in- session reinforcement of behavior can lead
to behavioral change.
 behavioral activation (BA). Behavioral activation is based on
a matching law model of reinforcement. A recent review of
the research supports the notion that the use of behavioral
activation is clinically important for the treatment of
depression.
o integrative behavioral couples therapy). Integrative
behavioral couples therapy looks to Skinner (1966) for the
difference between contingency shaped and rule-governed
behavior. It couples this analysis with a thorough functional
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 assessment

Module III Clinical Psychology (Psy 137)

 of the couple’s relationship. Recent efforts have used radical
behavioral concepts to interpret a number of clinical
phenomena including forgiveness.

4. Contingency management (CM)

o It is the application of the three-term contingency (or operant
conditioning), which uses stimulus control and consequences to
change behavior, and originally derived from the science of applied
behavior analysis (ABA), but it is sometimes implemented from
a cognitive-behavior therapy (CBT) framework as well (such as
in dialectical behavior therapy, or DBT).

o Incentive-based contingency management is well-established when

used as a clinical behavior analysis (CBA) treatment for substance
abuse, which entails that patients' earn money (vouchers) or other
incentives (i.e., prizes) as a reward to reinforce drug abstinence
(and, less often, punishment if they fail to adhere to program rules
and regulations or their treatment plan).

o Based in applied behavior analysis (ABA), contingency

management includes techniques such as choice, shaping,
time-out, making contracts between the therapist and patient.

o Forms of contingency management include:

 Token Economy System. Token economy is a system in which
targeted behaviors are reinforced with tokens (secondary
reinforcers) and later exchanged for rewards (primary
reinforcers). Tokens can be in the form of fake money,
buttons, poker chips, stickers, etc. While the rewards can
range anywhere from snacks to privileges or activities. For
example, teachers use token economy at primary school by
giving young children stickers to reward good behavior.
Token systems have been shown to be successful with
a diverse array of populations including those suffering from
addiction, those with special needs, and those experiencing
delinquency.
The goal of such systems is to gradually thin out and to
help the person begin to access the natural community of
reinforcement (the reinforcement typically received in the
world for performing the behavior).
 Voucher Programs. In voucher-based contingency
management, patients earn vouchers exchangeable for retail
items contingent upon objectively verified abstinence from
recent drug use or compliance with other behavior-change
targets. This particular form of contingency management
was

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 introduced in the early 1990s as a treatment for cocaine
dependence. The approach is the most reliably effective
method for producing cocaine abstinence in controlled
clinical trials.
Contingent vouchers are also used to cease smoking
addictions. One study claims that people with substance use
disorders can receive help with their addiction through the
use of voucher-based treatment for smoking.
 Medication take-home privileges. Is frequently used
in methadone maintenance treatment. Patients are permitted
to "earn" take-home doses of their methadone in exchange
for increasing, decreasing, or ceasing certain behaviors. For
example, a patient may be given one take-home dose per
week after submitting negative drug screens (generally via
urine testing) for three months. (It is worth noting that take
home- doses (or "bottles") are seen as desirable rewards
because they allow patients to come to the clinic less often to
obtain their medication).
 Level systems. Are often employed as a form of contingency
management system. Level systems are designed such that
once one level is achieved, then the person earns all the
privileges for that level and the levels lower than it.

5. Covert conditioning
o Assists people in making improvements in their behavior or inner
experience. The method relies on the person's capacity to
use imagery for purposes such as mental rehearsal. In some
populations, it has been found that an imaginary reward can be as
effective as a real one. Effective covert conditioning is said to rely
upon careful application of behavioral treatment principles such as
a thorough behavioral analysis.
o Some clinicians include the mind's ability to spontaneously
generate imagery that can provide intuitive solutions or even
reprocessing that improves people's typical reactions to situations
or inner material. However, this goes beyond the behavioristic
principles on which covert conditioning is based.

6. Exposure therapy and Response Prevention (ERP)

o It is a technique in behavior therapy to treat anxiety disorders.
Exposure therapy involves exposing the target patient to the
anxiety
source or its context without the intention to cause any danger.
Doing so is thought to help them overcome their anxiety or
distress. Procedurally, it is similar to the fear extinction paradigm
developed studying laboratory rodents. Numerous studies have
demonstrated its effectiveness in the treatment of disorders such
as generalized
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 anxiety disorder, social anxiety disorder, obsessive-compulsive
disorder, PTSD, and specific phobias.
o ERP is predicated on the idea that a therapeutic effect is achieved
as subjects confront their fears, but refrain from engaging in the
escape response or ritual that delays or eliminates distress.
Individuals usually combat this distress through specific behaviors
that include avoidance or rituals.
o However, ERP involves purposefully evoking fear, anxiety, and or
distress in the individual by exposing him/her to the feared
stimulus. The response prevention then involves having the
individual refrain from the ritualistic or otherwise compulsive
behavior that functions to decrease distress. The patient is then
taught to tolerate distress until it fades away on its own, thereby
learning that rituals are not always necessary to decrease distress
or anxiety.
o Exposure therapy is based on the principle of respondent
conditioning often termed Pavlovian extinction. The exposure
therapist identifies the cognitions, emotions and physiological
arousal that accompany a fear-inducing stimulus and then tries to
break the pattern of escape that maintains the fear. This is done by
exposing the patient to progressively stronger fear-inducing
stimuli. Fear is minimized at each of a series of steadily escalating
steps or challenges (a hierarchy), which can be explicit ("static") or
implicit ("dynamic") until the fear is finally gone. The patient is able
to terminate the procedure at any time.
o There are three types of exposure procedures:
 In vivo or "real life." This type exposes the patient to
actual fear-inducing situations. For example, if someone
fears public
speaking, the person may be asked to give a speech to a
small group of people.
 Imaginal. Where patients are asked to imagine a situation
that they are afraid of. This procedure is helpful for people
who need to confront feared thoughts and memories.
 Interoceptive. Which may be used for more specific disorders
such as panic or post-traumatic stress disorder. Patients
confront feared bodily symptoms such as increased heart
rate and shortness of breath.

7. Flooding (sometime referred to as implosion therapy)

o It works by exposing the patient directly to their worst fears. (S)he
is thrown in at the deep end. For example a claustrophobic will be
locked in a closet for 4 hours or an individual with a fear of flying
will be sent up in a light aircraft.
o What flooding aims to do is expose the sufferer to the phobic object
or situation for an extended period of time in a safe and controlled

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 environment. Unlike systematic desensitization which might use in
vitro or virtual exposure, flooding generally involves vivo exposure.
o Fear is a time limited response. At first the person is in a state of
extreme anxiety, perhaps even panic, but eventually exhaustion
sets in and the anxiety level begins to go down.
o Of course normally the person would do everything they can to
avoid such a situation. Now they have no choice but confront their
fears and when the panic subsides and they find they have come to
no harm. The fear (which to a large degree was anticipatory) is
extinguished.
o Prolonged intense exposure eventually creates a new association
between the feared object and something positive (e.g. a sense of
calm and lack of anxiety). It also prevents reinforcement of phobia
through escape or avoidance behaviors.

8. Habit reversal training (HRT)

o It is a "multicomponent behavioral treatment package originally
developed to address a wide variety of repetitive behavior
disorders."
o Behavioral disorders treated with HRT
include tics, trichotillomania, nail biting, thumb sucking, skin
picking, temporomandibular disorder (TMJ), and stuttering.
o It consists of five components: awareness training, competing
response training, contingency management, relaxation training,
and generalization training.

9. Matching law
o It is a quantitative relationship that holds between the relative
rates of response and the relative rates of reinforcement in
concurrent schedules of reinforcement. For example, if two
response alternatives A and B are offered to an organism, the ratio
of response rates to A and B equals the ratio of reinforcements
yielded by each response.
o This law applies fairly well when non-human subjects are exposed
to concurrent variable interval schedules; its applicability in other
situations is less clear, depending on the assumptions made and
the details of the experimental situation. The generality of
applicability of the matching law is subject of current debate.
o The matching law can be applied to situations involving a single
response maintained by a single schedule of reinforcement if one
assumes that alternative responses are always available to an
organism, maintained by uncontrolled "extraneous" reinforcers.
For example, an animal pressing a lever for food might pause for a
drink of water.

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10. Modelling
o It is a method pioneered by Albert Bandura which is used in
certain cognitive-behavioral techniques of psychotherapy whereby
the client learns by imitation alone, without any specific verbal
direction by the therapist.
o It is a general process in which persons serve as models for others,
exhibiting the behavior to be imitated by the others.
o Bandura proposed that four components contribute to behavioral
modeling.
 Attention: The observer must watch and pay attention the
behavior being modeled.
 Retention: The observer must remember the behavior well
enough to recreate it.
 Reproduction: The observer must physically recreate the
actions they observed in step 1.
 Reinforcement: The observer's modeled behavior must be
rewarded.

11. Observational learning

o It is learning that occurs through observing the behavior of others.
It is a form of social learning which takes various forms, based on
various processes.
o In humans, this form of learning seems to not need reinforcement
to occur, but instead, requires a social model such
as a parent, sibling, friend, or teacher with surroundings.
Particularly in childhood, a model is someone of authority or
higher status in an environment.
o The stages of observational learning include exposure to the model,
acquiring the model's behavior and accepting it as one's own.
o Bandura's social cognitive learning theory states that there are
four factors that influence observational learning:
 Attention: Observers cannot learn unless they pay attention
to what's happening around them. This process is influenced
by characteristics of the model, such as how much one likes
or identifies with the model, and by characteristics of the
observer, such as the observer's expectations or level of
emotional arousal.
 Retention/Memory: Observers must not only recognize the
observed behavior but also remember it at some later time.
This process depends on the observer's ability to code or
structure the information in an easily remembered form or to
mentally or physically rehearse the model's actions.
 Initiation/Motor: Observers must be physically and
intellectually capable of producing the act. In many cases,
the observer possesses the necessary responses. But
sometimes,

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 reproducing the model's actions may involve skills the
observer has not yet acquired. It is one thing to carefully
watch a circus juggler, but it is quite another to go home and
repeat those acts.
 Motivation: The observer must have motivation to recreate
the observed behavior.

o Bandura clearly distinguishes between learning and performance.

Unless motivated, a person does not produce learned behavior.
This
motivation can come from external reinforcement, such as the
experimenter's promise of reward in some of Bandura's studies, or
the bribe of a parent.

12. Operant conditioning (also called instrumental conditioning)

o is a type of associative learning process through which the strength
of a behavior is modified by reinforcement or punishment. It is also
a procedure that is used to bring about such learning.
o In operant conditioning, stimuli present when a behavior is
rewarded or punished come to control that behavior. For example,
a child may learn to open a box to get the sweets inside, or learn to
avoid touching a hot stove; in operant terms, the box and the stove
are "discriminative stimuli". Operant behavior is said to be
"voluntary". The responses are under the control of the organism
and are operants. For example, the child may face a choice
between opening the box and petting a puppy.
o In contrast, classical conditioning involves involuntary behavior
based on the pairing of stimuli with biologically significant events.
The responses are under the control of some stimulus because
they are reflexes, automatically elicited by the appropriate stimuli.
For example, sight of sweets may cause a child to salivate, or the
sound of a door slam may signal an angry parent, causing a child
to tremble. Salivation and trembling are not operants; they are not
reinforced by their consequences, and they are not voluntarily
"chosen."

13. Professional practice of behavior analysis

o The professional practice of behavior analysis is the delivery of
interventions to consumers that are guided by the principles of
behaviorism.
o Professional practice seeks maximum precision to change behavior
most effectively in specific instances.
o The professional practice of behavior analysis is a hybrid discipline
with specific influences coming from counseling, psychology,
education, special education, communication disorders, physical
therapy and criminal justice.

Module III Clinical Psychology (Psy 137)

14. Systematic desensitization (also known as graduated exposure
therapy)
o Is a type of behavior therapy developed by South African
psychiatrist, Joseph Wolpe. It is used in the field of clinical
psychology to help many people effectively overcome phobias and
other anxiety disorders.
o This therapy aims to remove the fear response of a phobia, and
substitute a relaxation response to the conditional stimulus
gradually using counter conditioning.
o When used by the behavior analysts, it incorporates
counterconditioning principles, such as meditation (a private
behavior/covert conditioning) and breathing (which is a public
behavior/overt conditioning).
o The process of systematic desensitization occurs in three steps.
 First, the patient is taught a deep muscle relaxation technique
and breathing exercises. E.g. control over breathing, muscle
detensioning or meditation. This step is very important
because of reciprocal inhibition, where once response is
inhibited because it is incompatible with another. In the case
of phobias, fears involves tension and tension is
incompatible with relaxation.
 Second, the patient creates a fear hierarchy starting at
stimuli that create the least anxiety (fear) and building up in
stages to the most fear provoking images. The list is crucial
as it provides a structure for the therapy.
 Third, the patient works their way up the fear
hierarchy, starting at the least unpleasant stimuli and
practicing their relaxation technique as they go. When they
feel comfortable with this (they are no longer afraid) they
move on to the next stage in the hierarchy. If the client
becomes upset they can return to an earlier stage and regain
their relaxed state.
The client repeatedly imagines (or is confronted by) this
situation until it fails to evoke any anxiety at all, indicating
that the therapy has been successful. This process is
repeated while working through all of the situations in the
anxiety hierarchy until the most anxiety-provoking.

15. Aversion Therapy

o This process pairs undesirable behavior with some form of aversive
stimulus with the aim of reducing unwanted behavior. For
example, alcoholics enjoy going to pubs and consuming large
amounts of alcohol.
o Aversion therapy involves associating such stimuli and behavior
with a very unpleasant unconditioned stimulus, such as an electric
shock. The client thus learns to associate the undesirable behavior

Module III Clinical Psychology (Psy 137)

 with the electric shock, and a link is formed between the
undesirable behavior and the reflex response to an electric shock.
o In the case of alcoholism, what is often done is to require the client
to take a sip of alcohol while under the effect of a nausea-inducing
drug. Sipping the drink is followed almost at once by vomiting. In
future the smell of alcohol produces a memory of vomiting and
should stop the patient wanting a drink.
o More controversially, aversion therapy has been used to "cure"
homosexuals by electrocuting them if they become aroused to
specific stimuli.

16. Dialectical Behavior Therapy (DBT)

o DBT is a comprehensive, evidence-based treatment program.
o DBT consists of:
 Weekly individual therapy sessions
 Weekly group skills training sessions
 Therapist consultation team meeting
 Telephone support between sessions can also be part of this
program
o Patients learn to cope with stress through improving distress
tolerance, emotional regulation, mindfulness ability and
interpersonal skills.
o DBT has been shown to be effective in treating:
 Borderline Personality Disorder (BDP)
 Depression
 Eating disorders
 Emotion regulation
 Substance abuse disorders
 Suicidal and self-harming thoughts

Wit On!
*Use separate sheet if necessary!

Choose three (3) methods of behavior therapies which you

think are the most effective in the treatment of personality
disorders, phobias and addictions? Provide additional
researches that support your claim.

Module III Clinical Psychology (Psy 137)

 Continue working
on the next activity!

Stop, Think and Evaluate!

Direction: Provide the strengths and weaknesses of the given behavior
therapies. In the last column, provide at least one psychological disorder
or maladjustment to which the given therapy could be helpful/threated
and your reason for thinking so. Additional researches may be necessary.
Use separate sheet if necessary.

BEHAVIOR STRENGTHS WEAKNESSES DISORDER/

THERAPY MALADJUSTMENT

Behavior
Management

Behavior
Modification

Contingency
Management

Flooding

Exposure and
Response
Prevention
Systematic
Desensitization

Aversion
Therapy

Operant
Conditioning

Observational
Learning

Module III Clinical Psychology (Psy 137)

LESSON 2: Cognitive Behavior Therapy

Things you should accomplish!

1. Discuss the importance of Cognition or thoughts in the

display of maladaptive behaviors.
2. Differentiate Cognitive behavioral therapy from
behavioral therapy.
3. Evaluate the appropriateness of the different types of
cognitive-behavioral therapies.
4. Devise a form of art used to cope with the different
emotional encounters.

Pay Attention!

Theoretical Foundation of Cognitive Behavioral Therapy

Cognitive behavioral therapy was invented by a psychiatrist, Aaron

Beck, in the 1960s. He was doing psychoanalysis at the time and
observed that during his analytical sessions, his patients tended to have
an internal dialogue going on in their minds — almost as if they were
talking to themselves. But they would only report a fraction of this kind
of thinking to him.

For example, in a therapy session the client might be thinking to

herself: “He (the therapist) hasn’t said much today. I wonder if he’s
annoyed with me?” These thoughts might make the client feel slightly
anxious or perhaps annoyed. He or she could then respond to this
thought with a further thought: “He’s probably tired, or perhaps I haven’t
been talking about the most important things.” The second thought
might change how the client was feeling.

Beck realized that the link between thoughts and feelings was very
important. He invented the term automatic thoughts to describe
emotion-filled thoughts that might pop up in the mind. Beck found that

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people weren’t always fully aware of such thoughts, but could learn to
identify and report them. If a person was feeling upset in some way, the
thoughts were usually negative and neither realistic nor helpful. Beck
found that identifying these thoughts was the key to the client
understanding and overcoming his or her difficulties.

Beck called it cognitive therapy because of the importance it places

on thinking. It’s now known as cognitive-behavioral therapy (CBT)
because the therapy employs behavioral techniques as well. The balance
between the cognitive and the behavioral elements varies among the
different therapies of this type, but all come under the umbrella term
cognitive behavior therapy. CBT has since undergone successful
scientific trials in many places by different teams, and has been applied
to a wide variety of problems.

CBT is based on a model or theory that it’s not events themselves

that upset us, but the meanings we give them. If our thoughts are too
negative, it can block us seeing things or doing things that don’t fit – that
disconfirm
– what we believe is true. In other words, we continue to hold on to the
same old thoughts and fail to learn anything new.

COGNITIVE-BEHAVIORAL THERAPY (CBT)

 It is one of the most common and popular types of therapy and it is

focused on your thoughts and
beliefs.
 CBT is a short-term, goal-oriented psychotherapy treatment that
takes a hands-on, practical approach to problem-solving.
 Its goal is to change patterns of thinking or behavior that are behind
people’s difficulties, and so change the way they
feel.
 It focuses specifically on the way that these two things influence all
of the things that you do and feel. By looking at these thoughts and
at the problems that are currently being faced, this type of therapy
attempts to change the way that you think.
 The idea is that your thoughts are unhealthy and that by changing
them it will be possible for you to change more than just your
perception, but the way that you interact with the world.
 CBT treatment focuses on shifting thought and behavior patterns
form dysfunctional to
functional.
 CBT works by changing people’s attitudes and their behavior by
focusing on the thoughts, images, beliefs and attitudes that are
held (a person’s cognitive processes) and how these processes
relate to the way a person behaves, as a way of dealing with
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 emotional problems.

Module III Clinical Psychology (Psy 137)

  Cognitive behavioral therapy can be thought of as a combination of
psychotherapy and behavioral therapy.
o Psychotherapy emphasizes the importance of the personal
meaning we place on things and how thinking patterns begin in
childhood. Behavioral therapy pays close attention to the
relationship between our problems, our behavior and our
thoughts. Most psychotherapists who practice CBT personalize
and customize the therapy to the specific needs and personality
of each patient.
 CBT has been shown to perform slightly better at treating co-occurring
depression than behavior therapy.
 It is used to help treat a wide range of issues in a person’s life, from
sleeping difficulties or relationship problems, to drug and alcohol
abuse or anxiety and depression.

Cognitive Behavioral Therapy Strategies

Module III Clinical Psychology (Psy 137)

CBT has been effective in treating the following:

 CBT can also be an effective therapy for the following problems:

o anger management
o child and adolescent problems
o chronic fatigue syndrome
o chronic pain
o depression
o general health problems
o habits, such as facial tics
o mood swings
o obsessive-compulsive disorder
o sexual and relationship problems

The Therapeutic Process

Cognitive-behavioral therapy differs from many other types of

psychotherapies because sessions have a structure, rather than the
person talking freely about whatever comes to mind.

Module III Clinical Psychology (Psy 137)

 At the beginning of the therapy, the client meets the therapist to
describe specific problems and to set goals they want to work towards.
The problems may be troublesome symptoms, such as sleeping badly,
not being able to socialize with friends, or difficulty concentrating on
reading or work. Or they could be life problems, such as being unhappy
at work, having trouble dealing with an adolescent child, or being in an
unhappy marriage.

These problems and goals then become the basis for planning the
content of sessions and discussing how to deal with them. Typically, at
the beginning of a session, the client and therapist will jointly decide on
the main topics they want to work on this week. They will also allow time
for discussing the conclusions from the previous session. And they will
look at the progress made with the homework the client set for him- or
herself last time. At the end of the session, they will plan another
assignment to do outside the sessions.

Doing Homework

Working on homework assignments between sessions, in this way,

is a vital part of the process. What this may involve will vary. For
example, at the start of the therapy, the therapist might ask the client to
keep a diary of any incidents that provoke feelings of anxiety or
depression, so that they can examine thoughts surrounding the incident.
Later on in the therapy, another assignment might consist of
exercises to cope with problem situations of a particular kind.

The importance of structure

The reason for having this structure is that it helps to use the
therapeutic time most efficiently. It also makes sure that important
information isn’t missed out (the results of the homework, for instance)
and that both therapist and client think about new assignments that
naturally follow on from the session.

The therapist takes an active part in structuring the sessions to

begin with. As progress is made, and clients grasp the principles they
find helpful, they take more and more responsibility for the content of
sessions. So by the end, the client feels empowered to continue working
independently.

Group sessions

Cognitive-behavioral therapy is usually a one-to-one therapy. But

it’s also well suited to working in groups, or families, particularly at the

Module III Clinical Psychology (Psy 137)

beginning of therapy. Many people find great benefit from sharing their
difficulties with others who may have similar problems, even though this
may seem daunting at first. The group can also be a source of especially
valuable support and advice, because it comes from people with personal
experience of a problem. Also, by seeing several people at once, service-
providers can offer help to more people at the same time, so people get
help sooner.

Time-frame

An important advantage of cognitive behavioral therapy is that it

tends to be short, taking five to ten months for most emotional problems.
Clients attend one session per week, each session lasting approximately
50 minutes. During this time, the client and therapist are work together
to understand what the problems are and develop new strategies for
tackling them.

CBT introduces patients to a set of principles that they can apply

whenever they need to, and that’ll last them a lifetime.

TYPES OF COGNITIVE BEHAVIORAL THERAPY (CBT)

1. Computerized Cognitive Behavioral Therapy

 Computerized CBT consists of the same strategies and
techniques as face-to-face CBT, but it is delivered via apps or
computers. Also called iCBT, it has been shown to be equally as
effective as face-to-face CBT.

Module III Clinical Psychology (Psy 137)

 2. Virtual Cognitive Behavioral Reality Therapy (VCBRT)
 Provides realistic, computer-based simulations of troublesome
situations.
 The modeling process involves a person being subjected to
watching other individuals who demonstrate behavior 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 behavior that way the
relationship can be seen between the appropriateness of a
certain behavior and situation in which that behavior occurs is
demonstrated.
 With the behavioral rehearsal and homework treatment, a client
gets a desired thoughts and behavior during a therapy session
and then they practice and record that behavior between their
sessions.
 Note that in this type of therapy, the client needs to focus and
take mental notes of the desired behavior and also how the
model person thinks in different scenarios.
 VCBRT deals with fear of heights, fear of flying, and a variety of
other anxiety disorders.
 It has also been applied to help people with substance abuse
problems reduce their responsiveness to certain cues that
trigger their need to use drugs.

3. Cognitive Behavioral Play Therapy

 When it comes to children, play therapy is a great way to help
them with any problems that they may be facing.
 The idea is that children play in different ways and those
different ways will help give a therapist insight into what the
child is going through.
 They may be able to express more difficult situations because
the toys that they play with and how they play with them. Some
of these forms of play therapy are about free expression while
others may be a little more guided.
 No matter what method, however, the child is encouraged to
play and express themselves.

4. Art Therapy
 This type of therapy requires counselling skills in facilitating
creative processes as well as psychology.
 Therapist can use visual art, dance, music, poetry, etc.
 It can be applied with individuals, couples, families and groups.
 This therapy is based on the theory that internal conflicts and
unconscious thoughts that are responsible to one’s
abnormalities
can be projected through the use of art. As a product of this

Module III Clinical Psychology (Psy 137)

 projection, the therapist then, interprets and gives meaning to
behavioral cues surrounding the client while performing the art.
 Art therapist use the creative process to help clients:
o Decrease anxiety
o Delve into their thoughts and feelings
o Foster self-esteem
o Improve social skills
o Manage addictions
o Promote self-awareness
o Reduce stress
o Regulate thoughts and behavior
o Resolve internal conflicts

5. Hypnotherapy
 Hypnotherapy is guided hypnosis performed by a clinical
hypnotherapist.
 Therapist use mental imagery and suggestion to help clients
resolve issues and change negative thoughts and habits, or help
them explore their unconscious in a safe environment.
 Hypnotherapy is used as an adjunct therapy, along with other
forms of therapy or medical treatment.
 Hypnotherapy has been shown to be effective in treating:

Module III Clinical Psychology (Psy 137)

 o Anxiety
o Dementia
o Learning disorder
o Interpersonal problems
o Negative thoughts and habits
o Pain management
o Phobias
o Substance abuse, including tobacco
o Sexual dysfunction
o Sleep problems and disorders
o Stress management

It’s time to work!

Direction: Compare and contrast behavioral therapies and cognitive
behavioral therapies. Use separate sheets if necessary.

Behavioral Therapy Cognitive-Behavioral

Therapy

Strengths

Weaknesses

Focus

Disorders treated

Module III Clinical Psychology (Psy 137)

 Continue working
on the next activity!

Wit ON!
Direction: Provide your answer on the following questions. Use separate
sheet if necessary!

1. Which among the cognitive-behavioral therapies is more effective in

the treatment of:
a. anxiety disorder
b. depression
c. substance-use addiction
d. sleep disorders and problems
e. personality problems?

Explain the how such therapy work on the above abnormalities.

2. In a form of ART, illustrate your state of being (just how you feel) upon
random encounter of the following:
a. a family member who is a breath away from death;
b. former loved one with someone else in the same park you used
to stroll in;
c. failing a major exam where you most expect to pass; and
d. affronting phobia/ fear in the middle of a celebration.

Module III Clinical Psychology (Psy 137)

LESSON 3: Rational Emotive Behavior Therapy

Things you should accomplish!

1. Explain the relevance of REBT in many aspect of our

daily lives.
2. Evaluate the differences among behavioral, cognitive
and rational emotive behavior therapy.
3. Describe how rationality and emotion play hand in
hand in one’s display of behavior.

Pay Attention!

RATIONAL EMOTIVE BEHVAIOR THERAPY

 A form of psychotherapy founded by Albert Ellis which is a
combination of cognitive, emotive and behavioral therapies.
 REBT holds that virtually all serious emotional problems directly
stem form magical, empirically unvalidatable thinking.
 If disturbance-creating ideas are vigorously disputed by
logical/empirical thinking, they can be eliminated or minimized
and
will ultimately cease to reoccur.

Rational Emotive Theory of Personality

 Philosophical viewpoints as well as attention to biological and social
factors have influenced the development of rational emotive
behavior’s theory of personality. Ellis’s A-B-C model is the basis of
his personality theory.
 Responsible hedonism, humanism, unconditional self-acceptance
(USA) and rationality are philosophical ideas that can be seen in
REBT’s approach to psychotherapy.
o Hedonism is a philosophical term referring to the concept of
seeking pleasure and avoiding pain. In REBT, responsible
hedonism refers to maintaining pleasure over the long-term
by avoiding short-term pleasures that may lead to pain, such
as alcohol or cocaine.

Module III Clinical Psychology (Psy 137)

 o Humanism: A philosophy or value system in which human
interests and dignity are valued and that takes an
individualist, critical and secular as opposed to a religious or
spiritual perspective.
o Unconditional Self-Acceptance (USA): Individuals have worth.
They should accept that they make mistakes and that some
of their assets and qualities are stronger than others.
Individuals’ acts or performances should be criticized, not
their personal worth.
o Rationality: Thinking, feeling, and acting in ways that will
help individuals attain their goals. This is in contrast to
irrationality in which thinking, feeling and acting are self-
defeating and interfere with goal attainment.

Factors Basic to REBT Theory of Personality

 Ellis recognized that individuals’ personality development and their
emotional disturbances were not independent of biological and
social aspects.
 Ellis believes that individuals have a biological tendency to severely
disturb themselves and to prolong their emotional dysfunctioning.
 One reason that Ellis uses such powerful and direct therapeutic
techniques is his view of the strength in which individuals hold
irrational beliefs. Some of this is due to biological factors. Social
factors refer to the effect of interpersonal relationships on beliefs
about self. Criticism from others contributes to negative self-
beliefs. Likewise, caring too much about what others think of you
can negatively affect your own beliefs about yourself.
 Irrational belief: Unreasonable views or convictions that produce
emotional and behavioral problems.
 Being vulnerable to emotional disturbance for both social and
biological reasons is a core view of Ellis. Although individuals
desire to be successful and happy, many irrational beliefs interfere
with these goals.

A-B-C Theory of Personality

 The A-B-C model refers to what happens when an activating event
(A) leads to emotional and behavioral consequences (C).
 The emotional and behavioral consequences are not caused by (A)
the activating event but by the individual’s belief system (B).
 Irrational beliefs occur when the activating event (A) is an
unpleasant one.
 Irrational beliefs (B) can then partly cause difficult emotional and
behavioral consequences (C).

Module III Clinical Psychology (Psy 137)

 o A – ACTIVATING EVENT
o B – BELIEF SYSTEM
o C – CONSEQUENCES

A-B-C Premise
 Ellis believes that it is not the activating event (A) that causes
positive or negative emotional and behavioral consequences (C),
but rather it is that they interpret these events unrealistically
and therefore have irrational belief system (B) that helps cause
the consequences (C). The “real” cause of upsets is themselves and
not what happens to them.

Disturbances about Disturbances

- According to Ellis, it is bad enough that individuals have irrational
beliefs, but they turn these beliefs into new activating events which
cause new irrational beliefs.
- Ellis refers to this as disturbances about disturbances.
- Thus, if an individual does not get a job promotion that he wants,
he may say to himself, “I feel terrible and hopeless,” and feels
depressed.
- This consequence can then turn into a new activating event, and
the individual can say, “This is really awful that I’m so depressed
and hopeless.”
- Now a new consequence is even greater than the original
consequence.
- For Ellis, words such as “have to” and “must” are consequences
that lead to more irrational beliefs.

Rational Emotive Behavior Theory of Psychotherapy

 The A-B-C theory of personality affects the way REBT therapists
determine goals for their clients, assess their clients, and select
therapeutic techniques. Disputing irrational beliefs is a most
important therapeutic intervention.

Goals of Therapy
 A general goal of REBT is to help clients minimize emotional
disturbances, decrease self-defeating behaviors, and become
happier.
 If individuals can think rationally and have fewer irrational beliefs,
Ellis believes they will live happier lives.
 REBT teaches clients how to deal with negative feelings such as
sorrow, regret, frustration, depression, and anxiety.
 all client problems are viewed from the perspective of the
contribution of their irrational beliefs.

Module III Clinical Psychology (Psy 137)

Assessment
o REBT therapists try to assess which thoughts and behaviors create
problems for their clients.
o They may listen for themes that repeat themselves.
o Identifying activating events (A), rational and irrational beliefs (B),
and emotional and behavioral consequences (C) is the most basic
form of assessment in REBT.
o This assessment continues in each session and is not limited to the
first few sessions.

Counselor-Client Relationship
 Rational-emotive therapists do not believe a warm relationship
between counselee and counselor is a necessary or a sufficient
condition for effective personality change.
 REBT therapists fully accept clients as fallible humans without
necessarily giving personal warmth.
 To keep clients from becoming unduly dependent, REBT therapists
deliberately use hardheaded methods of convincing clients that
they had damned well better resort to more self-discipline.

The A-B-C-D-E Therapeutic Approach

 The therapeutic interventions referred to by D are three parts of
disputation. When irrational beliefs are disputed, the client will
experience E, a new effect. In essences, the client will have a logical
philosophy that allows her to challenge her own irrational beliefs.
 A (Activating Event)
o Therapists often divide activating events into two parts:
a. what happened and
b. what the patient perceived happened.
o Typically, therapists focus only on a few activating events at
a time.
o Sometimes previous consequences (C) become activating
events.
 C (Consequences)
o Sometimes it is difficult for therapists to distinguish between
consequences and beliefs.
o Consequences tend to be feelings such as “I feel so stressed
out.”
o Feelings cannot be disputed, but beliefs that bring about
feelings can.
o Changing beliefs (B) can alter consequences (C).
 B (Beliefs)
o Irrational or self-defeating beliefs, rather than self-helping
beliefs, are the focus of therapy.
o Changing irrational beliefs can change consequences.

Module III Clinical Psychology (Psy 137)

  D (Disputing)
o Disputing irrational beliefs is the major therapeutic technique
in REBT.
o Disputing is often done in three parts.
 1. Detecting – the client and therapist detect the
irrational beliefs that underlie activating events.
 2. Discriminating – the therapist and client
discriminate irrational from rational beliefs.
 3. Accepting 1 and 2, knowing that insight does not
automatically change people, and working hard to
effect
change.
 E (Effect)
o Developing an effective philosophy in which irrational beliefs
have been replaced by rational beliefs is the product of
successful REBT.

Insight
 Three types of insight develop form REBT that can lead to
behavioral
change.
 1. Acknowledging that disturbances largely come from
irrational beliefs not from the past.
 2. Learning how one has reindoctrinated oneself with
irrational beliefs from the past.
 3. Accepting 1 and 2, knowing that insight does not
automatically change people, and working hard to
effect
change.
 Ellis believes that when clients have achieved all three types of
insight, “elegant” change takes place. Clients have thus made
changes and know why they have made the changes.

Cognitive Approaches Used

o Coping self-statements
o Cost-benefit
analysis
o Psychoeducational methods
o Teaching others
o Problem solving

Emotive Techniques Used

o Imagery
o Role-playing
o Shame-attacking exercises
Module III Clinical Psychology (Psy 137)
 o Forceful self-statements
o Forceful self-dialogue

Module III Clinical Psychology (Psy 137)

Behavioral Techniques Used
o Activity Homework
o Reinforcements & penalties
o Skill Training

Wit On!
*Use separate sheet if necessary!

Explain how rationality and irrationality (faulty beliefs)

contributes to maladaptive behaviors.

Illustrate the role of emotion or EQ in the therapeutic process of

client suffering from a psychological disorder.

Module III Clinical Psychology (Psy 137)

LESSON 4: Existential Therapy

Things you should accomplish!

1. Assess the relevance and importance of existential

therapy in one’s life.
2. Explain how existential therapy could be of help in the
treatment of today’s many psychological disorders.

Pay Attention!

EXISTENTIAL THERAPY
 It is a form of psychotherapy based on the model of human nature
and experience developed by the existential tradition of European
philosophy.
 Rollo May was a key figure in the development of existential
psychology.
 It focuses on concepts that are universally applicable to human
existence including death, freedom, responsibility, and the
meaning of life.
 Instead of regarding human experiences such as anxiety,
alienation and depression as implying the presence of
mental illness, existential psychotherapy sees these experiences
as natural stages in a normal process of human development and
maturation.
 In facilitating this process of development and maturation,
existential psychotherapy involves a philosophical exploration of an
individual's experiences stressing the individual's freedom and
responsibility to facilitate a higher degree of meaning and well-
being in his or her life.

Existential Theory

The theory of existential psychology is based on philosophy

(inspired by the writings of Martin Buber, Martin Heidegger, Karl
Jaspers, Søren Kierkegaard, Friedrich Nietzsche and Jean-Paul Sartre).
It aims to help people examine issues of personal meaning, offering
perspective on the

Module III Clinical Psychology (Psy 137)

human condition. It has been argued that our whole society is
experiencing an existential crisis.

Assumptions of Existential Psychology

Each individual is seen as being unique, being born alone and

dying alone. Each of us has our own personal meaning and purpose for
living. It is important to be self-aware, living fully in the here-and-now.
People have free choice – in other words, they can choose what they
become. This freedom can create feelings of fear, because with freedom
comes choice and responsibility, and the possibility of making a poor
choice.

Principles of Existential Psychology

Rollo May talked of ‘wish’ (being in touch with what you really want)
and ‘will’ (organizing yourself so as to achieve your goals).

He classified people as being neo-puritan (all will and no love –

meaning they are highly self-disciplined but do not really know what they
want, so becoming perfectionist but empty); infantile (all wish and no will
– full of dreams and desires but lacking the self-discipline to make these
happen, so becoming dependent and conformist); or (most desirably)
creative (where wish and will are balanced).

Stages of Development

May saw people as passing through a number of developmental

stages, which sometimes (but not always) relate to chronological age:
o innocence – the infant stage, during which the person is pre-
moral (i.e., neither bad nor good)
o rebellion – the childhood/adolescent stage, when the person
wants freedom but does not accept the accompanying
responsibility
o ordinariness – the adult stage, at which the person finds
responsibility over-demanding, and so seeks refuge in
conformity and tradition
o creativity – the congruent adult, who faces anxiety with
courage

Life circumstances or developmental changes can bring up

existential crises, even if they were successfully resolved earlier in life.

Module III Clinical Psychology (Psy 137)

The Therapeutic Process

Existential therapy supports clients to find meaning in life, even

when it is very challenging. This is achieved by focusing on owning
feelings, desires and actions; making connections to past events;
integrating the felt experience into key relationships; and using the
learning to transform continuously into a new person.

The purpose of existential therapy is to confront the anxieties of

daily living and create meaning from and connectedness to lived
experiences (Binswanger, 1958; Bugental, 1978; May, 1996b; Yalom,
1980).

The personal responsibility of existential therapists is to

understand their clients’ anxieties and experiences and to guide them
through their struggles (May, 1996b). However, this responsibility has
become lost in a culture that is shrouded by a veil of quick fixes, patch-
me-ups, and “gimmicks” (May, 1996b). According to Rollo May,
existential psychology strives to understand human beings in their world
and the capacities they bring to therapy.

Essentially, therapists guide clients to become larger in their use of

their capacities and aid them to discover newer approaches for engaging
life problems (May, Angel, & Ellenberger, 1958). And that the goal of the
therapy is the autonomy of the client.

Specialist techniques in existential therapy include:

a. encouraging the client to search for the positive in a situation
(known as ‘reframing’),
b. to do what they are afraid might happen in order to regain
control
(‘paradoxical intention’), and
c. to redirect their focus from the maladaptive to the healthy
(‘dereflection’).

Anxiety in Existential Therapy

Existential therapy looks at how fear and anxiety make our lives
both safer (acting as signals of problems, helping us recognize and cope
with them) and poorer (through evading responsibility, avoiding making
choices, and busying ourselves rather than facing the realities of human
life).

Anxiety is divided into neurotic anxiety (which is not helpful) and

existential anxiety (which makes us aware of important issues and helps

Module III Clinical Psychology (Psy 137)

us navigate through life). While existential anxiety cannot be tolerated all
the time, occasional bouts of it are useful.

Pros and Cons of Existential Therapy

Contemporary developments have made existential therapy more

flexible and easier to use. For example, it has been adapted to briefer
systems of intervention. The modality provides a theoretical framework
from which to be eclectic, is conducive to collaboration with the client to
find a unique way of working together, and is emotionally powerful and
fulfilling for the client.

On the down side, existential therapy can be dense, complex and

difficult to master, especially as there is very little guidance for the
practitioner. You can be an existentialist but you cannot do
existentialism: it is less about technique than about your own personal
stance.

Try doing this!

Direction: Indicate the answer for the following questions. Further

readings and research may be necessary to answer the questions. Use
separate sheets if necessary.

1. Make an essay regarding the given case below:

How would FIND MEANING if you're given only 24 hours to live?

How do you see yourself preparing for your death? In what way you
would be able to say that you live a very meaningful life?

(To be placed in a long bond paper)

- justified
- create your own title
- minimum of 2 pages.
- submission (TBD)

2. How can finding meaning and taking responsibility serve as a helping

hand in the treatment of psychological disorders?

Module III Clinical Psychology (Psy 137)

 MODULE SUMMARY

In module III, you have learned about the other leading

Psychotherapies and its relevance to one’s psychological well-being.

There are four lessons in module III. Lesson 1 consists of

behavioral therapy and its different types.

Lesson 2 deals with Cognitive-behavioral therapy, therapeutic

process, techniques used and different types.

Lesson 3 is the Rational Emotive Behavioral therapy, goals, role of

the therapy, techniques and therapeutic process.

Lastly, lesson 4 pertains to Existential therapy, its theoretical

background, therapeutic technique, conditions, process and outcomes.

Each of these has its own strengths and weaknesses. Its use
depends largely on the appropriateness of the therapy, nature of the
client, and the therapist.

Congratulations! You have just studied Module III. now you are
ready to evaluate how much you have benefited from your reading by
answering the summative test. Good Luck!!!

 SUMMATIVE TEST

1. Which among the psychotherapies presented is you think most

effective in handling depression and anxiety brought about by the
covid-19 pandemic? Why? Provide a substantial and logical
explanation about your chosen psychotherapy and how it would
specifically be of help with the world’s on-going battle against
covid-
19. Use separate sheet if necessary.

2. Come up with a Venn diagram or any form of art presenting the

similarities and differences of the behavior therapy, cognitive-
behavioral therapy, rational emotive behavioral therapy and
existential therapy.

Module III Clinical Psychology (Psy 137)