PSYCHOLOGICAL COUNS PSYC 3083
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This 118 page Class Notes was uploaded by Javonte Nolan on Tuesday October 13, 2015. The Class Notes belongs to PSYC 3083 at Louisiana State University taught by S. Kunen in Fall. Since its upload, it has received 35 views. For similar materials see /class/222957/psyc-3083-louisiana-state-university in Psychlogy at Louisiana State University.
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Date Created: 10/13/15
Addiction Prevalence In 2008 an estimated 8 or 201 million of persons aged 12 or older were current past month illicit drug users NSDUH 08 Note that the diabetes rate is about 7 Illicit drugs include marijuanahashish cocaine including crack heroin hallucinogens inhalants or prescription medications used nonmedically Age Variations in Addiction Prevalence Rates of current use of illicit drugs in 2009 were higher for young adults aged 18 to 25 212 than for youths aged 12 to 17 100 0o and adults aged 26 or older 63 NSDUH 2009 Among young adults 181 percent used marijuana in the past month 63 percent used prescriptiontype drugs non medically 18 percent used hallucinogens and 14 percent used cocaine Addiction Most common drugs Marijuana was the most commonly used illicit drug 152 million past month users among people 12 and older Illicit use of prescription meds 62 million Cocaine use 19 million Hallucinogens 11 million Meth 731000 Illicit drug use among youth aged 12 to 17 declined from 2002 to 2008 although stable between 2007 to 2008 Alcohol amp Tobacco 23 of persons 12 or older engaged in binge drinking 581 million people Bing drinking for men having 5 or more drinks on the same occasion on at least 1 day in the prior 30 days for women 4 7 of people 12 and older reported heavy drinking 173 million people Heavy drinking is de ned as 5 or more binge drinking episodes in the last month 28 3 age 12 or 71 million are current users of tobacco 24 smoke cigarettes 4 Treatment needs According to the SAMHSA s NSDUH study 2006 almost 10 of those 12 and older 236 million needed treatment for an illicit drug or alcohol abuse problem Only 108 25 million of those who needed treatment received it at a specialty facility Initiation In 2008 an estimated 29 million persons aged 12 or older used an illicit drug for the first time within the past 12 months This averages to almost 8000 initiates per day A majority of these started with marijuana 57 30 started with illicit prescription meds Perceived Risk Prevention programs focus on teaching youth about drug use risks so that they will be less inclined to try drugs Roughly 50 of youth aged 12 to 17 believe that there is great risk in smoking MJ once or twice a week About 50 of youth aged 12 to 17 say that it is easy or very easy for them to get MJ if they wanted it Gender and race differences Past month illicit use age 3 12 NSDUH African Americans 101 White 82 Hispanic 62 Asian 36 age 12 and older Males 99 females 63 Among pregnant women aged 15 to 44 years 51 used illicit drugs in the past month based on data averaged for 2007 and 2008 Substance Abuse in Louisiana FY 09 10 all served Race African American Caucasian Total Gender Male Female 8973 2729 77 row 23 row 43 col 27 col 11823 7267 62 row 38 row 57 col 73 col 20796 9996 68 of tot 32 of tot Total 11702 3 8 of total 19090 62 of total 30792 9 First Drug of Choice for African Americans and Caucasians Served in FY 0910 DR FRE UENCY UG Q of Total Alcohol 9547 310 39 2 10 Her01n other 7119 3 A Opiates Marijuana 6356 206 Cocaine 5053 164 Totals 28075 out of 30792 91 1O Drug Use by Age Group AACA FY 0910 Age Group Frequency Cumulative 10 17 1727 66 66 18 26 6822 221 287 26 45 13564 5163 803 46 65 5086 193 997 66 91 6 100 Totals 26290 100 Referral Source All Served AA amp Caucasian FY 0910 Referral Source Frequency Percent Self Family Friend 9323 354 Criminal Justice 7703 293 other Drug 6362 242 Program Total 23388 889 of 262920 Addiction Costs Substance abuse costs in the US are one halftrillion dollars annually Treatment can help reduce these costs NIDA 2009 Drug addiction treatment is very cost effective Each dollar invested in prevention and treatment can save from 4 to 7 in criminal justice costs Treatment Savings For example the average cost for 1 full year of methadone maintenance treatment is approximately 4700 per patient whereas 1 full year of imprisonment costs approximately 24000 per person If health care and other societal costs are included lost wages lost productivity child protection involvement etc the savings can be up to 12 for each dollar invested Problem Gambling Quiz 1 Approximately patients were seen in Louisiana for problem gambling between fiscal years 04 05 to 09 10 a 4500 b 7500 c 10500 d 13500 2 More men than women were treated for a gambling problem in Louisiana between fiscal years 04 05 to 09 10 a True b False 3 A greater percentage based on population s of AfricanAmericans are treated for gambling problems than Caucasians a True b False Problem Gambling Quiz 4 Gambling is an equal opportunity disorder and shows no significant differences in s across income groups a True b False 5 The s of the total with a gambling dx are about the same for persons in the age groups 25 to 44 and 45 to 64 these are Center for Disease Control age groups a True b False Problem Gambling Gender In scal years 04 05 to 09 10 4462 persons were seen with a gambling diagnosis in Louisiana Quiz question 1 a 0 Gender 1 2497 females out of 55474 females 45 had a gambling dX 2 1965 males out 117973 males 167 had a gambling dX Quiz question 2 is false Problem Gambling Race ALASKA NATIVE 25 AMERICAN INDIAN 27 ASIAN 27 AFRICANAMERICAN 265 they are 32 of Louisiana population so quiz question 3 is false NATIVE HAWAIIAN WHITE OTHER TOTAL INCOME LEVELS ASSOCIATED WITH GAMBLING quiz question 4 is false Monthly Income OF TOTAL lt1000 2085 469 10012000 904 203 2001 3000 609 137 3001 4000 318 72 4001 5000 217 49 5001 10000 260 59 10001 20000 37 8 20001 14 2 Age groups and gambling quiz question 5 is true the s are about the same AGE GROUP OF TOTAL lt15 8 2 15 24 47 25 44 436 45 54 464 65 74 42 75 8 10001 20000 2 Problem Gambling Problem gambling Ludomania is an urge to gamble despite harmful negative consequences or a desire to stop Severe problem gambling may be diagnosed as pathological gambling if 5 of the following criteria are met preoccupation tolerance need to gamble more to get a high withdrawal escape chasing losses lying loss of control illegal acts risks losing 21 Problem Gambling important relationships bailout turns to family for financial help often Although the term gambling addiction is common in the recovery movement it is technically an impulse control disorder and not an addiction Recent studies see Roy 2002 NIAAA show that pathological gambling resembles drug addiction in that gambling stimulates norepinephrine and probably dopamine the same as cocaine and amphetamines 22 Problem Gambling Problem gambling is often associated with SUDS mood anxiety amp personality disorders increased suicide rates especially among the older gamblers those who started gambling early amp those w comorbid mental disorders The prevalence rate is probably less than 1 according to the British Gambling Prevalence Survey 2007 Treatment CBT l2Step programs SSRI s PaXil shown to be somewhat effective Kim et aL2002 23 When is Substance Use A Problem Substance is often taken in larger amounts or over a longer period than intended Persistent desire or unsuccessful efforts to cut down or control substance use A great deal of time is spent in activities necessary to obtain the substance eg visiting multiple doctors or driving long distances use the substance eg chain smoking or recover from its effects Important social occupational or recreational actIVItIes given up or reduced because of substance abuse 24 Problems Difficulty controlling use The individual sometimes use more or for a longer time than intended When drinking or using any drug the intention is just to have a few drinks but the individual can t stop Negative consequences Continued use even though there have been negative consequences legal family health job schooD 25 DS M IV Definition of Dependence Continued substance use despite knowledge of having a persistent or recurrent psychological or physical problem that is caused or exacerbated by use of the substance Dependence leads to clinically significant impairment or distress as manifested by three or more of the following occurring at any time in the same 12 month penod DS M IV Definition of Dependence Tolerance needs more and more to get same effects Withdrawal shakes vomiting Difficulty Controlling Use Neglecting or Postponing activities Spending much time gettingusinghiding drug use Inability to quit Experiences negative consequences and can t stop DSM IV Definition ofiAbus e A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one or more of the following occurring at any time in the same 12 month period Substance Abuse Continued use despite social or interpersonal problems Repeated use resulting in failure to fulfill obligations at work school or home Repeated use resulting in physically hazardous situations Use resulting in legal problems 29 Health Consequences of Addiction Cardiovascular disease Stroke Cancer HIVAIDS Hepatitis B and C Lung disease Obesity Mental disorders co occurring 30 Health Consequences of Addiction Tobacco use causes cancer of the mouth throat blood lungs stomach pancreas kidney bladder and cervix USDHH 2004 Inhalants can damages CNS nerve cells in and can cause death by cardiac arrest SUDs amp mental disorders have a 30 comorbidity rate Mental disorders can precede addiction sometimes addiction can cause mental disorders particularly in individuals with specific vulnerabilities NIDA 2009 Alcohol and driving At least twice as many people die from alcoholism in the US every year as die from motor vehicle accidents JAMA 2004 Alcohol intoxication is associated with 40 50 of traffic fatalities and alcohol is present in nearly 50 of homicides either in the victim or the perpetrator Alcohol and hepatitis are responsible for the majority of liver cirrhosis cases 32 Consequences to others from addiction Beyond the harmful consequences for the addicted individual drug abuse can cause serious health problems for others Three of the more destructive consequences of addiction are Drugs are often te ratogenic for the fetus Can be subtle such as learning deficits more serious such as ADHD or they can be severe such as FAS syndrome disorders and death 33 Consequences of specific drugs NIDA 09 Alcohol impairs 1 frontal cortex executive functions amp personality 2 hippocampus memory and learning 3 cerebellum movement coordination MJ impairs memory motivation learning contributes to a learning disorder can induce psychosis in those who are at risk lnhalants damage the heart kidneys lungs and brain gynacomastia Cocaine interferes with heart lungs digestion can lead to fatal Ml s 34 Consequences to others from addiction Exposure to second hand smoke increases the risk of heart disease by 25 to 30 and lung cancer by 20 to 30 in those who never smoked Surgeon General39s 2006 Report Tobacco use is responsible for 5 million deaths worldwide each year Lancet 2003 SUDs increases risky sexual behaviors and needle sharing Heroine cocaine and meth use account for about 25 of new AIDS cases CDC 2007 35 Consequences Amphetamines including meth amp Ecstasy can cause high body temperature heart problems blood pressure problems and seizures Opioids include heroin Oxycontin morphine and hydrocodone Can severely depress CNS eg BP HR breathing and can lead to death Steroids Two big classes 1 anabolic androgenic steroids based on testosterone 36 Consequences of specific substances NIDA 09 2 Corticosteroids Prednisolone Hydrocortisone Triamcinolone abuse can cause heart disease cancer liver problems depression and T aggression Brain damage can occur when brain cells can die brain cells generally can t be replaced except in the hippocampus and the olfactory bulb or when neuronal dendrites can retract or dissappear 37 Loss and recovery of brain function Next slide shows loss and recovery of brain function after prolonged meth use Images represent dopamine transporter levels in the striatum The striatum is best known for its role in the planning of movement and other executive functions In humans the striatum is activated by stimuli associated with reward but also by aversive unexpected or intense stimuli 38 Dopamine transporter levels RECOVERY DF BRAIN FUNCTIUN WITH PRCIL NEED AESHNENE E a 1 a Hadlilw antral HEW Maser mm Jib um l nhsfiirenca l4 malts n hma 39 Addiction is often a chronic relapsing disease GU MPAHHEUN F HEELAF SIE HATES BEI39WEIENI DRUG ADDIGWDN AND IU THEFI CHHDIMIB ILLMESEES lilii Bi 5 sources 5mm ii iii I g E 3 g 3 1 E a hug V Trypgll Hammiansim Mirna Mdi i n Diabetes 4o McLellan et al Jamgag 205001 Treatment considerations Treatment decisions follow accurate assessment Often use the Addiction Severity Index developed by McClelland Takes about an hour and it reviews history of drug use family legal social economic health issues Results in an addiction rating from 1 to 10 which helps determine level of treatment needed A 10 might suggest the need for detox a 7 for intensive outpatient a 4 outpatient 41 Effective Treatment Principles NIDA Addiction is a complex but treatable disease that affects brain function and behavior No single treatment is appropriate for everyone Need to reduce barriers to access to treatment cost accommodates family treatment model distance child care acceptance transportation medical care and need to make treatment readily available 42 Effective Treatment Principles NIDA Effective treatment attends to multiple needs of the individual not just drug abuse Treatment must be appropriate for age gender ethnicity and culture Treatment needs to be able to engage and retain patients Rule of thumb individuals need at least 30 60 days of treatment to get some benefit from treatment Comorbidities such as anxiety depression amp psychosis need to be addressed 43 Effective Treatment Principles NIDA Treatment does not need to be voluntary to be effective Sanctions or enticements from family employment settings andor the criminal justice system can significantly increase treatment entry retention rates and the ultimate success of drug treatment interventions 44 Components FAMILY SERVICES HEILIEINE I TRANSPDRTATIEIN SERVICES BEHAVIORAL THERAPY AN D BCLINSELINIS CLINICAL AND EASE FINANCIAL MANAGEMENT SERVICES LEGAL S ERVIBES l H ILD CARE SERVICES INTAKE PRDCESSINE ASSESSMENT TREATMENT PLAN PHARMABUTHERAF Y CEINTINLIIME BARE HIVAIDS SERVICES of Com Preh ensitJe Drug 14b use Treatment VCCATICNAL SERVICES MENTAL HEALTH SLISSTANCE UEE SERVICES MUNITEIRING SELFHELFI PEER ELIPPEIRT EREILIPS MEDICAL SERVICES EDUCATICNAL SERVICES Tim ms trmmwm pragmm rcvvide I combinatialn qf therapies and DI Fu r Scrzlims in mm 113 n S qf I39m individual patient Treatment considerations Withdrawal symptoms such as anxiety depression sleeplessness can motivate people to start reusing Some medications can help with withdrawal symptoms For example benzodiazepines Ativan Klonopin Xanax can help with agitation and anxiety Trazodone amp Remeron antidepressants can help with sleep Seroquel antipsychotic amp Clonidine anti seizure meds help w sleep amp hypomania16 Treatment approaches Cognitive Behavioral Therapy Help patients recognize avoid and cope with the situations in which they are most likely to abuse drugs Challenges dysfunctional and irrational beliefs about drugs Behavioral treatment Uses reinforce ment for remaining drug free for attending and participating in counseling sessions or for taking treatment medications as prescribed Use of sanctions can be powerful increase abstinence thru reinf47 Treatment approaches Motivational Interviewing Employs strategies to evoke rapid and internally motivated behavior change to stop drug use and facilitate treatment entry Group Therapy Helps patients by hearing others and discussing problems publically where they can be confronted by other group members for not being straightfonNard or honest 48 Major treatment issue Retention For treatment to be successful patients have to be engaged in treatment and motivated to stay in treatment Barriers to treatment not acknowledging the problem lack of social support not ready for treatment job distance drugs are fun child care responsibilities comorbidities don t like treatment approach medical problems like pain disorders 49 Major treatment issue Women s Needs Research has shown that physical and sexual trauma followed by posttraumatic stress disorder PTSD is more common in drugabusing women than in men seeking treatment Need to address PTSD amp borderline personality issues Other factors that frequently influence the course of treatment for women are pregnancy and child care financial independence and residential stability 50 12 Step selfhelp programs Alcoholics Anonymous AA Narcotics Anonymous NA and Cocaine Anonymous CA all of which are based on the 12 step model can be an effective complements to other treatment methods Most drug addiction treatment programs encourage patients to participate in self help group therapy during and after formal treatment These groups can be particularly helpful during recovery offering additional social support 51 Exercise Exercise is increasingly becoming a component of many treatment programs and has shown efficacy in combination with cognitivebehavioral therapy for promoting smoking cessation and treatment of depression Exercise increases serotonin and possible dopamine positively influencing mood and feelings of selfefficacy 52 Motivational Enhancement Therapy Motivational Enhancement Therapy MET helping individuals resolve ambivalence about engaging in treatment Critical to avoid confrontation and arguing This approach has been used successfully with alcoholics marijuana dependence in combination with CBT The results of MET for treatment of other drugs such as heroin cocaine nicotine are mixed 53 Final Exam FAMILY SYSTEMS 0 Major goals of couple therapy 0 Reduce anger and blaming 0 Increase communication 0 Facilitate problem solving skills BEHAVIORAL approach focus on having couple ID positive and negative behaviors in relationship INTEGRATIVE behavior family systems approach9teaches how to make arguments less hurtful by accepting each others differences no evidence that this is better PSYCHODYNAMIC approaches look for transferences and partner selection based on childhood dynamics Murray Bowen originally trained as a psychoanalyst Saw families as an emotional system balance between togetherness and individuality INTERGENERATIONAL FAMILY SYSTEMS THERAPY o Groundbreaking study with schizophrenics o 1975 Georgetown Family Center 0 View of Human Nature I Human behavior tied to family relationship and the systems that govern these relationship Emotional illness is in all life forms The family operates as an emotional system and system governs family life 0 Core Concepts I Differentiation of self I Triangulation I Nuclear Family Emotional System people choose similarly differentiated spouses Family Projection Process Multigenerational Transmission Process Sibling position Emotional cutoff Societal emotional process 0 Levels of differentiation of self key to emotional family system I Differentiation of self ability to separate oneself from family simultaneously be an individual while maintaining family connection 0 Bowenian triangulation I Third party recruited to reduce anxiety 2 insiders 1 outsider I Therapist works to detriangulate 0 Projection process is similar to psychoanalytic projection concept o Societal emotional process recognizes that pressures from society such as racism disasters lack of employment opportunities can create added anxieties and reduce likelihood of differentiation 0 Genogram work look at family over several generations 0 look for crucial turnint points in family emotional process 0 characteristics of family members 0 evolutional picture of family tools for assessment 0 Conjoint family Virginia Satir self esteem is the basis of family emotional health 0 How she got started young girl with schizophrenia improved satir brought mother into therapy then father then brother until family achieved balance 0 All families have rules I Close families rigid and dysfunctional I Open families clear exchange of info and exibile o Congruence do words match personal feelings o What makes people dysfunctional Lack of emotional honesty and miscommunication or false communication about what is really going on Inconsistencies contradictions and incongruencies are all sensed by developing child learns she cannot trust the spoken message but must always look to underlying message Unclear communication can feel like rejection and lead to negative self esteem o Satir s two kinds of family structures I Hierarchical in Nature Power based on threats and rewards Family seen as needing to be controlled I Organic and Seed Model people seen as innately good People encouraged to develop according to their needs and interests rather than needs of parents Differences valued o 4 common patterns in Conjoint family defenses I Placating avoid a con ict situation by being overly agreeable or giving in to another person Nonassertive passive self effacing Do not feel an inner sense of value and feel helpless without other so do and say what will please them I Blaming sacrifice others to maintain their view of themselves Avoid con ict by increasing stress temporarily and forcing others into a passivedefensive position Over react in an aggressive way to protect against weak personal position or guard against a poor selfconcept Now see what you made me do I Distracter creates distraction to reduce con icts Shifts focus from con ict to something else confrontation avoided and stress temporarily reduced Common distractions psychosomatic illness abrupt changes in topic temper tantrums behavior problems I Rational analyzer avoids con ict by staying on intellectual level Does not become emotional stays detached Strives for complete control over herself Rigid isolated from family 0 Congruenceleveling is healthy communication style that involves relating directly on emotional and intellectual level what family therapists work to achieve 0 Satir s family Roles I Victim I Peace keeper I Stern taskmaster I Disciplinarian I Hardworking caregiver I Troublemaker Satir vs Bowen 0 Bowen encourage one spouse to speak other to listen and comment gets patient out of their normal roles o Bowendifferentiation o Satir has spouses talk to each other 0 Satir emphasizes Carl Whitaker on Experiential Family Therapy a free wheeling intuitive sometimes inconventional approach to unmask pretense create new meaning liberate family members to be themselves 0 Techniques are secondary to the therapeutic relationship 0 Interventions create turmoil and intensify what is going on here and now in the family 0 Key Concepts I Focuses on individual needs of family members I Assumption all family members have a right to be themselves I Needs of family may be suppressing rights of the individual I Goal Authenticity There is no right or wrong way to be 0 Therapist CREATES family turmoil and COACHES family on how to get out of it o 3 phases engagement all powerful involvement dominant parent figure advisor and disentanglement more personal less involved Structural Family Therapy Salvador Minuchin focus is on family interactions in the present avoids past Wants to understand structure of the family 0 Symptoms are byproduct of structural failings structural changes must occur in a family before individual s symptoms can be reduced 0 Techniques are active directive and well thought out Focuses on how when and whom the family members relate 0 Family Structure Invisible set of functional demands or rules that organize the way family members relate to one another 0 Observe family to see the structure O O O O O O O O O I Who says what to whom I In what way I With what result Pathologizing or labeling individuals NOT encouraged Involves direction by the therapist Very action oriented Goal is to change behavior by enactment seeing families enact dysfunction and creation of alternative realities NOT symptom relief learn how to organize family in adaptive way around the symptom DYSFUNCTIONAL FAMILY SYSTEMS I Disengagement overly detached r39igid I Enmeshment very involved individuality difficult to maintain o Example anorexia attempt to gain control in family Bring about structural change by I Modifying family s transactional rules I Developing more appropriate boundaries I Creating more hierarchial structure Intensity often when members of family are stuck Minuchin would increase intensity of the interactions Any means necessary using drama exaggeration amplification telling stories etc Unbalancing therapist sides with a weaker family member to restructure power and give weaker member a voice Complementarity show how family members characteristics complement each other sensitivity and toughness Restatement Their messiness drives me crazy Why do you allow them to drive you crazy They seem to be quite free and creative in how they re living Assumptions and Core Concepts Structural Family Therapy I View of Human Nature 0 Humans must live in social groups to survive Family is the basic social unit Family functions to psychosocially protect its members and to accommodate and transmit the culture Looking at the relationship of a family is different than looking at family members as individuals or as a whole 0 Families are constantly in states of change I Core Concepts 0 Family Structure 0 Family roles and who takes on which roles o How the family interacts with other families 0 Subsystems and Boundaries o Subsystems involve alliances and special relationships 0 Examples spousal parental sibling subsystems o Subsystems are formed according to roles skills and functions and allows the family to carry out its functions 0 Boundaries enable the subsystems to operate efficiently o Enmeshed families discourage autonomy and differentiation 0 Disengaged families interfere with the family s support systems 0 Haley and Cloe Madanes Strategic Family Therapy 0 Haley sees symptom formation as largely unconscious doesn t believe that insight and awareness are necessary for change 0 Techniques I Reassigning designated patient I Power restructuring in family I Paradoxical intervention Core Concepts I Therapist responsibility for developing and carrying out a treatement plan I Symptoms as attempts at communication I Redefining symptoms problemscreatively and innovatively I Brief therapy focused on the presentcreate new conditions I Units I Circularitymultiple events interacted 0 Major relationship issues have to do with COMMUNICATION and POWER 0 Pathological behavior is a metaphorical attempt to communicate that there is a major unsolved problem Symptoms serve a function Solving problems in PRESENT Presenting a problemattempt to communicate 0 Therapy is brief processfocused and solution oriented therapist designs strategy for change 0 Circulari series of moves and countermoves in repeating cycles 0 Paradoxical intervention exaggerate or perfect problematic behavior 0 Reframing reinterpreting problematic behaviors may produce new behaviors that fit the new interpretation 0 Interventions I Approach to problem is to first identify the feedback loops that maintain behaviors I ID the frames rules that support the interactions I Change the rules 0 Not all symptoms are the result of system variables sometimes individual simply has problems that preceded entrance into the family 0 O BEHAVIOR THERAPY Learning a relatively permanent change in behavior or behavior potential due to experience Behaviorism research on learning has been in uenced by this approach to psychology that emphasizes the study of observable behavior and the role of the environment as determinant of behavior Conditioning association between environmental stimuli and responses to organisms responses al primitive re exive responses that are learned elicited 0 Classic I Definition the process by which a previously neutral stimulus acquires the capacity to elicit a response through association with a stimulus that already elicits a similar or related respons eg Pavlov s dogs Principles Fear Higherorder conditioning a form of learning in which a previously neutral stimulus which has now gained reinforcing qualities can condition a second previously neutral stimulus paper money amp paystub Stimulus generalization stimuli similar to conditioned stimulus elicit similar response child learns to respect police officer in uniform now respects fireman in uniform Stimulus discrimination learn to inhibit responses to similar stimuli Dog comes to owner s whistle but not the neighbors Response generalization emit range of similar responses to one stiumuls at partyparty behaviors Extinction a nonreinforced response results in the weakening and eventual disappearance of the response In CLASSICAL CONDITIONING extinction occurs when the conditioned stimulus is no longer paired with the unconditioned stiumuls Habituation repeated exposure results in no response usually it is an orienting response without reinforcement that decreases vs extinction Unconditioned stimulus elicits unconditioned response Unconditioned response response that is automatically produced Conditioned stimulus initially neutral stimulus that comes to elicit a conditioned response after being paired with an unconditioned stimulus Conditioned response response elicited by a conditioned stimulus occurs after the CS is associated with the US Usually similar to UR 0 Watson amp Raynor o Conditioned Little Albert I Paired neutral stimulus white rats with unconditioned stimulus loud noise I Within days his fear had extended to furry objects I Counter conditioning the process of pairing a conditioned stiumuls with a stimulus that elicits a response that is incompatible with an unwanted conditioned response 0 OPERANT CONDITIONING voluntary behaviors are learned emitted 0 Instrumental learning 0 Definition the process by which a response becomes more of less likely to occur depending on its consequences 0 Thorndike s Law of Effect Behavior that is followed by a satisfying state of affairs is likely to be repeated 0 Reinforcement a stimuls that follows a response strengthens the response or increases the probability of the response I Primag reinforcers inherently reinforcing and typically satisfy a physiological need I Secondag reinforcers stimuli that have acquired reinforcing properties through associations with other reinforcers I Positive reinforcement when a consequence that follows a response makes the response more likely to occur I Negative reinforcement when a response is followed by the avoidance or removal of a stimulus that makes the response more likely to occur 0 Skinner s Box 0 Punishment the process by which a stimulus weakens or reduces the probability of the response that it follows I Prima punisher something that is inherently punishing such as eclectic shock I Seconda punisher a stimulus that has acquired punishing properties through an association with other punishers giving birth painful pregnant woman causes emotional distress I Positive punishers something unpleasant occurs after a behavior I Negative punisher something pleasant is removed after a behavior I Problems with punishment 0 Punishment administered inappropriately Recipient responds with anxiety fear or rage Effectiveness often temporary Most behavior hard to punish immediately Punishment conveys little information 0 Action intended to punish may instead reinforce scolding may by misinterpreted as attention 0 Behavior of punisher may be copied Behavior management 0 The application of operant conditioning techniques to I Teach new responses I Reduce or eliminate maladaptive or problematic behavior 0 Begins with thorough functional behavior assessment Exposure therapies use the principles of o Extinction 0 Prevention of escape or avoidance o Reciprocal inhibition Systematic desensitization 1 graduated exposure originally called reciprocal inhibition a behavioral treatment for phobias fears and anxieties based on CLASSICAL conditioning Based on the pairing of an anxiety provoking stimulus with a relaxation response using fear hierarchy o JOSEPH WOLPE developed systematic desensitization o Flooding massive exposure to fear stimulus with no escape eventually fears extinguish I Wolpe locked a girl with car phobia in a car and drove her around for hours freaked out at first eventually got over the phobia o Punishment or aversion therapies force someone to smoke til they get sick 0 Covert sensitization imagined punishmentprobably very powerful in real life Operant approaches to skills training theory is that problems and disorders are based on the lack of trainable skills Social skills problems are either learned abnormal behaviors or represent deficits Behavioral management techniques include o Extinction Time out Restitution Response cost 000 Precursor to modern CBT is Bandura and Social Learning Theory argued that many behaviors are situationally specific and based on expectations Selfefficacy an individual s belief in his or her belief to manage bahviors or situations predicts ability to quit smoking 0 low selfefficacy is associated with I negative selfevaluation I a focus on failures and problems rather than on successes I quitting prematurely I SUDs I Depression and anxiety disorders Model performs behavior Observer learns it General thinking problems 0 extreme idealistic table in notes General Thinking Problems I Extreme 0 Consistently negative 0 Catastrophic o Unscientific o Pollyannaish I Idealistic o Demanding o Obsessive 0 Comfort Seeking o Overly broad CBT assumes that there is a belief hierarchy which starts with core beliefs or assumptions that are the most stable and least accessible cognitions to voluntary thoughts which are the least stable but most acceptable cognitions Levels of thought 0 O O 0 Core beliefs I am not lovable Assumptions there is no true justic Strategies I need to always be on alert for injustices Automatic thoughts and images People are always unfair with me CBT often creates HW assignments called behavioral experiments Thoughts lead to feelings feelings lead to behaviors BECK believes that role playing can help individuals THINKING cognitive ERRORS O O O 0000 000 Magnify negative and minimize positive Over generalize Make negative global attributions about the self If you fail at one thingyour whole life is a failure Polarization black and white world dichotomizing Personalization Catastrophizing Emotional reasoning believing that your negative feelings re ect the way a situation really is Fortune telling anticipating events will turn out badly Labeling one behavior defines whole person Mental Filter I We all have them but this distortion refers to specific situations where we ignore either positive or negatives to one issue Mind reading believing that we know what a person is thinking based solely on behavior Personalization assuming that a person is at fault for some negative event 0 Should Statements statements that begin with should or must are often punishing demands we make on ourselves Albert Ellis REBT 0 Challenges irrational beliefts Ellis thinks irrational beliefs lead to failures that lead to shame 0 One cannot live wout others BECK identified three stages of CBT 0 Initial stage build relationship educate patients about relatinship between thoughts and feelings Define problem giving some initial relief through problem solving Therapist ACTIVE in this stage Middle stage getting patient to ID and challenge automatic thoughts Underlying schemas core beliefs can be examined Patient learns to assume core responsibility for identifying problems and solutions Later stage client able to use cognitive therapy to solve own problems without therapist Learns to deal with setbacks Inoculation or relapse prevention occurs at this stage may include occasional booster sessions 0 O ADDICTION In 2008 8 of people 12 were current illicit drug users diabetes only 7 For young adults 182521 1217 year olds10 26 years and older 63 181 of young adults have used marijuana in the past month 63 used prescriptions nonmedically 18 used hallucinogens 14 cocaine 10 of those 12 and older needed treatment for an illicit drug or alcohol abuse problem Illicit drug use 0 African Americans101 Whites82 O o Hispanic62 o Asian36 I Males99Females63 Alcohol amp Tobacco o 23 of persons 12 or older engaged in binge drinking 0 7 of people 12 or older reported heavy drinking 5 or more binge episodes in the past month 0 27 age 12 and older are current users oftobacco Substance abuse costs in the US are one halftrillion dollars annually Treatment can help reduce these Each dollar invested in prevention and treatment can save from four to seven dollars in criminal justices costs Gambling 0 Approximately 4500 patients were seen in LA for problem gambling between 0410 0 More females than males were treated for gambling problem in LA O O O O 0 OOO Whites then African Americans are most treated for gambling in LA Caucasians71 The greater the monthly income the more likely individual is to have a gambling problem Age affects gambling I 1524very low I 2564 becomes and stays much higher I 65drops again problem gambling ludomania an urge to gamble despite harmful negative consequences or a desire to stop Severe problem gambling has been diagnosed as pathological gambling if 5 of the following are met 1 preoccupation 2 tolerance 3 withdrawal 4 escape 5 chasing losses 6 lying 7 loss of control 8 illegal acts 9 risks losing Recent studies show that gambling resembles drug addiction Prevelance rate lt 17 Treatment I GET I 12Step Programs I SSRIs DSMIV Definition of DEPENDENCE continued substance use despite knowledge of having a persistent or recurrent psychological problem that is caused or exacerbated by use of the substance Dependence leads to clinically significant impairment or distress as manifested by 3 or more of the following occurring at any time in the same 12 month period 0 O O O O O O Tolerance Withdrawal Difficulty controlling use Neglecting or postponing activities Spending much time getting using hiding drug use Inability to quit Experiences negative consequences and can t stop DSMIV Definition of ABUSE a maladaptive pattern on substance use leading to clinically significant impairment or distress as manifested by one or more of the following in the same 12 month period 0 O O 0 Continued use despite social or interpersonal problems Repeated use resulting in failure to fulfill obligations at work school or home Repeated use resulting in physically hazardous situations Use resulting in legal problems Treatment Approaches 0 Principles I Addiction is a complex but treatable disease that affects brain function and behavior I No single treatment is appropriate for everyone I Need to reduce barriers to access to treatment cost accommodate family treatment model distance child care acceptance transportations medical care and need to make treatment readily available I Effective treatment attends to multiple needs of the individual notjust drug abuse I Treatment must be appropriate for age gender ethnicity and culture I Treatment needs to be able to engage and retain patients Rule of thumb individuals need at least 3060 days of treatment to get some benefit from treatment I Comorbidities such as anxiety depression and psychosis need to be addressed I Treament does not need to be voluntary to be effective Cognitive Behavior Therapy Helps patients recognize avoid and cope with the situations in which they are most likely to abuse drugs Challenges dysfunctional and irrational beliefs about drugs Behavioral Treatment uses positive reinforcement for remaining drug free attending and participating in counseling sessions or for taking treatment medications as prescribed Use of sanctions can be powerful negative reinforcement Motivational Interviewing employs strategies to evoke rapit and internally motivated behavior change to stop drug use and facilitate treatment entry Group therapy Helps patients by hearing others and discussing problems publically where they can be confronted by other group members for not being straightforward or honest Motivational Enhancement therapy helping individuals resolve ambivalence about engaging in treatment HEALTH amp MEDICINE 0 Best treatment Is usually combo of therapy and meds 0 Development of Psychopharmacological Approaches 0 000000 1 1869 chloral hydrate introduced as treatment for melancholia and mania 2 1917 malaria toxin used to treat mental symptoms of syphilis 3 1948 lithium used to treat mania 4 1954 Thorazine used to treat schizophrenia 5 1963 Valium introduced as a treatment for anxiety 6 1950s tricyclic antidepressants developed 7 1987 Prozac SSRI introduced 0 Antidepressants O Tricyclics or TCAs older cheaper often work on treatment resistant depressions I Can treat OCD ADHD enuresis pain o Monoamine oxidase inhibitors MAOIs older rarely used Have to avoid foods containing tyramine which can elevate blood pressure some meats and cheeses o SSRIs Selective Serotonin reuptake inhibitors includes Zoloft Paxil Prozac Celexa Lexapro Luvox Many minor side effects including dry mouth dizziness sexual inhibition sometimes weight a1n SSNRI s selective serotoninnonepinephrine reuptake inhibitors Include Trazodonedesyrel Premeronmirtazapine cymbalta wellbutrin Anxiol ics these medications deal with anxiety but SSRIs are now preferred because of less abuse potential Benzodiazapines Valium Xanax Ativan and Klonopin Can also use these to help patients with alcohol withdrawal Antipsychotics used to control hallucinations delusions paranoia extreme agitation and aggression 0 First generation haldol prolixin tardive dyskinesia and Thorazine and Mallaril 0 Second generation Zyprexa and Clozaril Help reduc negative symptoms of psychosis 0 third generation Risperdal Seroquel Geodon and Abilify Fewer side effects Compliance Issues 0 Lack of compliance costs the US health system over 100 billion dollars annually and results in 100000 deaths and one million hospitalizations yearly Poor compliance found in every medical field Noncompliance can lead to erroneous beliefs that medications are not effective and may cause physicians and psychologists to switch to less effective meds Ways to be noncompliant I Failure to buy medicines Failure to start therapy Delay in starting theray Intentional unintentional skipping of doses Increasing doses per day Changing intervals between doses Prematurely stopping medication Prescription bottle top study Munchausen Syndrome factitious disorder Person pretends to be sick or actually causes sickness or injury to fufill deep emotional needs 0 OO O PSYC 3083 Final Quick view Chapter 9 Cognitive Approaches Counselor Roles REBT Ellis active teacher uses homework does not center on therapeutic relationship Cognitive Therapy Beck leads rather than confronts stresses need for therapist exibility and interpersonal skills relationship has trust and respect but client is not equal to counselor uses homework Stress Inoculation Meichenbaum collaborative relationship attempts to inoculate a person by going through a stress rehearsal S19 Constructivist Cognitive Behavioral Treatment therapeutic alliance therapist educates client Eye Movement Desensitization Reprocessing Shapiro requires advanced therapeutic skills 5 Quick Facts REBT Ellis lrrational 0 Current thoughts play a major role in emotionalpsychological disturbances 0 People are both rational and irrational with a tendency to be irrational o Counselor does not center on therapeutic relationship active uses homework 0 Uses ABC method A eventactivator B beliefs thoughts cognitions about event C consequences of A and B emotional upset or negative behavior After ABC D disputing irrational beliefs and E develop effectiverational philosophy of life 0 Has no formal assessment 0 Irrational beliefs either 1 ego disturbances 0r 2 discomfort disturbances 0 Goals negotiated between pt and t no emphasis on past change irrational beliefs 0 Couple s dissatisfaction vs couple s disturbance o Musturbating someone must do something Wife must get ready for me to be happy Cognitive Therapy Beck Dysfunctional 0 Goal is to modify thinking that leads to problem behaviors and feelings o Counselor leads with trust and respect 0 Linear equation Schemas Automatic Thoughts Interpretations EmotionalBehavioral Problems 0 Discussed cognitive triad schema of chronically depressed person9 pro les 9 systematic bias in processing information 0 Uses modes discharge amp modify thinking distortions Overgen Labeling etc 0 Uses primal modes phobia example o Jeffry Young continues With schema therapy 4 constructs early maladaptive schemas schema domains coping styles and schema modes 0 Uses Socratic dialogue 9 collaborative empiricism 9guide clients 0 Three stages Initial t 9active educates client Middle t9adviser pt identi es problems and creates hw Later treatment ends when client doesn t need therapist recommends booster sessions Stress Inoculation Meichenbaum o Focused on selftalk 3 stages C 1 39 Skills 39 quot39 quot quot 1 11 Eye Movement Desensitization Reprocessing Shapiro o Requires advanced therapeutic skills for therapist Problem solving therapy 0 Method 1 problem de nition and formation 2 generation of alternatives 3 decision making 4 solution implementation Cognitive Therapies criticized for 0 Not taking into account affects of racism sexism and discrimination o Therapist imposes values on client 0 Approaches are superficial 0 Doesn t deal with emotions Cognitive therapies 0 Useful in manage care effective with depression anxiety social phobia marriage 0 Use analogies metaphors and a list of negative feeling words for kids 0 Equal in eff quot to p 39 p39 meds for J J 39 bulimia amp anxiety 0 CBT meds superior to either Chapter 11 Family Systems Approaches Counselor Roles Conjoint Therapy Humanistic Experiential Therapy b00k Satir therapist is both a facilitator and a real person power comes from emotional connection with people active and gives direction change agen Structural Family Therapy Minuchin therapist takes on leadership role Transgenerational Theory Bowen therapist acts as a coach or consultant is respectful to all members and helps family and members become more differentiated He maintains an objective stance and avoids becoming triangulated Strategic Family Therapy Haleytherapist must take on the role of director or authority figure and develop strategies to intervene Therapist consultant expert stage directorchange is therapist s responsibility Experiential Family Therapy Whitaker Highly involved therapist model must be transparent take risks gets involved Quick Facts Conjoint TherapySatir o Satir humanist every human being has innate worth all individualsfamily have potential to grow and ourish Founding member of Mental Research Institute MRI in 1959 Therapist facilitator and real person powers come from emotional connection with family change agent Cornerstone Conceptualization of individual growth and development Primary triad mother father child 9 VERY important Viewed any symptom or problem as blocked growth for person and family Selfesteem is basis of family emotional health no formal diagnosis Rules overt 0r covert need to clarify rules 4 Defensive Communication Patterns Placating Blamer Distracter Rational Analyzer therapy wants CONGRUENCELEVELING 00 000000 0 2 family structures Threatandreward and Seed model 0 3 process stages Contact Chaos Integration 0 Famous for use of affect touch humor family sculpting I statements Structural Family Therapy Minuchin 0 Family structure is basis for family therapy 0 Focuses on present therapist techniques are active and directive t leader 0 Symptoms are a by product of structural failings O O Therapist goal is to change behavior by enactment and creation of alternative realities Therapist can use intensity enactment unbalancing to get reaction Overall goals are structure of family and creation of effective family hierarchy with parents in charge Subsystems boundaries Boundaries Too permeable Enmeshed Too rigid Disengaged Strategic Family Therapy Haley 0 Symptoms are seen as attempts at adaptation and communication sees them as largely unconscious o Therapist director or authority figure whom develops strategies to intervene o Focuses on solving problems in present brief processfocuses solutionoriented 0 Goal is to remedy problem behavior assessment is important 0 Circularity 0 Uses directives and paradoxical interventions Transgenerational Family Therapy Bowen 0 Families are an emotional system center balance between togetherness and individuality 0 Key is the levels of differentiation of self 0 Therapist coach or consultant 0 Differentiation is the foundation of this therapy 0 Genogram technique 0 O A way of diagramming several typically three generations of family relationships Different symbols represent different kinds of relationships and characteristics Promotes discussions about the people and relationships in the different generations Helps clients see patterns of enmeshment emotional cutoff 0 Insight helps promote differentiation 0 Triangulation Societal Emotional Process Experiential Family Therapy Whitaker 0 Aims to unmask pretense create new meaning liberate members to be themselves 0 Goal authenticity o Therapist should create family turmoil and coach family how to get out of it Stage of Change People change voluntarily only when 0 They Become interested in or concernedabout the need for change 0 They Become convinced that the changeis in their best interests or will bene t them more than cost them 0 They Organize a plan of action that they are committed to implementing 0 They take the actions that are necessary to make the change and sustain the change Stages of Change 0 Precontemplation o Contemplation reward analysis and decision making 0 Preparation commitment to take action 0 Action 0 Maintenance Set backs 0 Regression represents movement backward through the stages 0 Slips are brief returns to the prior behavior thatrepresent failures of action or the action plan 0 Relapse is a return to reengagement in the previous behavior to a signi cant degree after initial success 0 After returning to the prior status quo behavior individuals reenters preaction stages at precontemplation contemplation or preparation and may feel like a failure and discouraged about her ability to change Intervention Strategies 0 SEQUENTIAL 7 start with initial symptom or situation and try to resolve that and work way down 0 KEY AREA OR LEVEL 7 Find problem or area where you have the most leverage or client is most motivated o MULTI LEVEL OR MULTI PROBLEM 7Work back and forth across the context identifying and addressing client stage and processes of change for each separate problem Chapter 14 Psychopharmacological Approaches Therapist consultant referral agent toward medication do not prescribe medication 0 Compliance 0 Lack of compliance costs the US health system over 100 billion annually 0 Lack of compliance results in 100000 deaths amp one million hospitalizationsyearly Poor compliance found in every medicalfield including diabetes SUDS HTNschizophrenia HIV etc 0 0 Non compliance can lead to erroneousbeliefs that medications are not effective and may cause physician or psychologistto switch to less effective meds 0 Research indicates that the use of psychotropic medications should be accompanied by counseling Anxiolytics These medications deal with anxiety But SSRI s are actually now the preferred anxiolytic because they are effective and have less abuse potential Benzodiazepines include Valium Xanax AtivanampKlonopin Can also use these to help patients with alcohol withdrawal Antipsychotics 7 used to control hallucinations delusions paranoia extreme agitation and aggression 0 First generation antipsychotics Haldol Prolixin more movement side effects 7 TardiveDyskinesia Thorazine Mellaril less potent side effects Reduce DA 0 Second generation antipsychotics ZyprexaampClozaril Help reduce negative symptoms of psychosis absence of what should be there 0 Third generation Risperdal Seroquel Geodon and Abilify Fewer side effects Less TardiveDyskinesia Bipolar Disorder Treated with the mood stabilizer Lithium Also use anticonvulsants such as Depakote Tegretol Larnictal ampTrileptal which increase GABA gamma aminobutryic acid in the brain GABA is related to seizures and works on inhibitory synapses ADHD Treated with stimulants such as amphetamines 7 Concerta Adderal Dexedrine Focalin Dexedrine Strattera NE reuptake antagonist No evidence that this leads to later substance abuse Generally welltolerated ADHD is probably not diagnosed enough in adults Chapter 14 Psychopharmacological Biological Approaches Counselors face several issues regarding psychopharmacological medications Are these medications indicated for certain quotbiologicallyquot based mental illnesses What is the counselor39s role How should a counselor respond to widespread use of these medications by their clients A biological point of view tends to View the human brain as ultimately understandable in scienti c terms Therefore emotional and psychological problems can ultimately be treatable with medication The use of psychoactive medications is based on the assumption that many psychiatric and psychological problems are a result of chemical imbalances in the brain There are hundreds of neurotransmitters but scientists have focused on four that are involved in mood and emotion regulation and are central to psychiatric and psychological disorders dopamine norepinephrine serotonin and GABA Counselors are most likely to encounter a number of different classes of medications including antidepressants antianxiety medications antipsychotics mood stabilizers and stimulants These medications have numerous side effects and these side effects affect different people in different ways Classes of Medication Antidepressants 5 classes of antidepressants differ from which brain chemical they target 1 Tricyclic antidepressants TCAs Pamelor Elavil Tofranil used to treat pain noctural enuresis OCD ADHD and depression Take several weeks to be effective in depression Quick in treating nocturnal enuresis Side effects dry mouth dizziness weight gain 2 Monoamine oxidase inhibitors MAOIs only prescribed when other antidepressants have failed oldest class Have to eliminate foods that contain tyramine 3 Selective Serotonin Reuptake Inhibitors SSRIs Prozac Celexa Zoloft PaXil increase only serotonin in the brain 4 SNRIs work on both serotonin receptors and norepinephirine receptors 5 NRIs block norepinephrine receptors Another medical treatment for depression is electroconvulsive therapy procedure in which electric currents are passed through the brain deliberately triggering a brief seizureThis seems to cause changes in brain chemistry that alleviates symptoms of depression Antianxiety Medications anxiolytics commonly called tranquilizers prescribed for anxiety disorders and panic attacks work quickly and can be addictive Benzodiazepines help with anxiety depression and muscle relaxation Valium Xanex Antipsychotics used to decrease symptoms such as auditory hallucinations paranoia extreme agitation and aggression side effects are weight gain diabetes and sedation two general categories 0 First generation older divided into high potency HaIdol and low potency Thorazine Side effects are sedation movement disorders inner restlessness and decreased cog Ability 0 Second generation newer Atypicals improve positive symptoms of psychosis reduce negative symptoms Mood stabilizers used for bipolar disorder two classes 0 Lithium naturally occurring salt treatment for mania side effects nausea vomiting headache rash tremors lithium toxicity slurred speech 0 Anticonvulsants stabilize neuron membranes and increase GABA side effects weight gain drowsiness halmful to fetus Stimulants increase attention decrease hyperactivity and decrease impulsivity by stimulating frontal lobes o Methylphenidate and amphetamines are most common 0 Headaches and decreased appetite 9 side effects Counselors are often involved in a triadic relationship with their client and their client s medical prescriber The dynamics of these relationships are important and can affect counseling Anxiolytics These medications deal with anxiety But SSRI s are actually now the preferred anxiolytic because they are effective and have less abuse potential Benzodiazepines include Valium Xanax AtivanampKlonopin Can also use these to help patients with alcohol withdrawal Antipsychotics 7 used to control hallucinations delusions paranoia extreme agitation and aggression 0 First generation antipsychotics Haldol Prolixin more movement side effects 7 TardiveDyskinesia Thorazme Mellanl less potent side effects Reduce DA mr a i arii symptoms ofpsychosis absence ofwhat should be Lhae 0 Third genaation Risperdai3emquei Geodon and Ability Fewaside effects Less TardiveDyskinesia BipolarDisorder uch asDepako e a Treated with the mood stabilizer LtLhtum Also use anticonvulsants A Tegetol Lamictal ampTnlepta1which increase GABA e gamma its a a synapses ADIED dd mi T dri39n enough in adults Methadone o i i i o and eliminates the need and urge to use haoin o Methadone is a safe medication for longrter m use 0 more than 10 years of chronic treatment nor does It imp air reasoning or er ormance 0 av f Two Medications for Opioid Dependence receptor and antagonist actions at other opioid receptors Suboxone contains buprenorphine as well as the opioid antagonist naloxone emergency tx of overdoses combined to deter crushing 8 intravenous injection Causes significant wdrawal symptoms if injected A Counselors may be called upon to recommend evaluation for medication for their clients or to discuss medications with clients who ask about them as a treatment option They may also recognize side effects that may or may not be known by the client or prescriber Referrals for medication evaluation are tricky and are strongly in uenced by the counselor39s attitudes The process itself is difficult because clients may take it as a negative opinion that they are quotcrazyquot or the client may perceive a referral as a recommendation by the counselor when if fact it is just a referral for evaluation When a client is on a medication or being evaluated communication with the medical doctor or prescriber is crucial This may require persistence and creativity on the part of the counselor since doctors are notoriously difficult to reach Written communication and even emails if a reasonable level of confidentiality is possible may be helpful Also ongoing relationships between counselors and medical personnel are very useful Compliance 0 Lack of compliance costs the US health system over 100 billion annually Lack of compliance results in 100000 deaths amp one million hospitalizationsyearly Poor compliance found in every medicalfield including diabetes SUDS HTNschizophrenia HIV etc Non compliance can lead to erroneousbeliefs that medications are not effective and may cause physician or psychologistto switch to less effective meds O O O Multicultural issues make referral and the use of psychotropic medications even more complex Different cultures may perceive the use of medications in different ways and the expense of medications may be a very big factor for clients of limited means Psychotropic medications that provide quick relief fit well in a managed care model although abuse at the expense of counseling is a distinct possibility Although there are con icting results considerable research indicates that the use of psychotropic medications should be accompanied by counseling Controversy abounds in this area Some believe that we are an overmedicated society and that psychotropic medications are overprescribed others believe that arguments against these medications prevent clients from a treatment that can prevent pain and suffering Chapter 8 Behavior therapy Watson s Extreme Environmentalism Give me a dozen healthy infants well formed and my own special world to bring them up in and I ll guarantee to take any one at random and train him to be any type of specialist I might select doctor lawyer artist merchantchief and yes beggarman and thief regardless of his talents penchants tendencies abilities vocations and race of his ancestors John Broadus Watson 1928 Defining Learning Behaviorism amp Conditioning Learning A relatively permanent change in behavior or behavior potential due to experience Behaviorism Research on learning has been influenced by this approach to psychology that emphasizes the study of observable behavior and the role of the environment as a determinant of behavior Conditioning the association between environmental stimuli and responses to the organism s responses 3 2 Types of Conditioning Classical Operant Primitive Voluntary reflexive behaviors are responses are Iearned learned emitted elicited Classical Conditioning The process by which a previously neutral stimulus acquires the capacity to elicit a response through association with a stimulus that already elicits a similar or relatsd response Pavlov amp conditioned salivation of dogs 53H E114 E A nap Einm midht EA 0 3 mg in manna 1mm mirm gt20 aan 9 JJ 2 TE er 33 A w wmm A New Reflexes from Old Unconditioned unlearned Unconditioned stimulus US Stimulus that elicits an unconditioned response Unconditioned response UR Response that is automatically produced A neutral stimulus is then regularly paired with an unconditioned stimulus Neutral stimulus R l r a Y a re av h 3 7 ts llom ld Conditioned stimulus CS An initially neutral stimulus that comes to elicit a conditioned response after being paired with an unconditioned stimulus Conditioned response CR A response that is elicited by the conditioned stimulus Occurs after the CS is associated with the US ls usually similar to UR 9 Principles of Classical Conditioning Higher order conditioning A form of learning in which a previously neutral stimulus which has now gained reinforcing qualities can condition a second previously neutral stimulus Paper money is previously neutral but made meaningful through association with primary reinforcers A paystub may gain reinforcing qualities because of its association with paper money Stimulus generalization stimuli similar to conditioned stimulus elicit similar response Child learns to respect a police officer in uniform now respects reman in uniform 10 Principles of Classical Conditioning Stimulus discrimination learn to inhibit responses to similar stimuli A dog will come to his owner s whistle but not to a similar whistle of a neighbor Response generalization emit range of similar responses to one stimulus eg at a party we emit party behaviors Extinction a non reinforced response results in the weakening amp eventual disappearance of the response In classical conditioning extinction occurs when the conditioned stimulus is no longer paired with the unconditioned stimulus 11 Principles of Classical Conditioning Habituation repeated exposure results in no response usually it is an orienting response wo reinforcement that decreases vsex nc on Spontaneous recovery After a period of time has elapsed following extinction there may be a burst of responses of the old behavior indicating that the organism has not forgotten or unlearned the behavior Resistance to extinction The longer the resistance to extinction the more powerful the learning D O 3 U 2 E in q 0 U D E D 7c gtm Extinction trials CS presented alone bl What is learned in classical conditioning For classical conditioning to be most effective the stimulus to be conditioned should precede the unconditioned stimulus FonNard conditioning We learn that the first event stimulus predicts the second Backward conditioning the CS follows the U08 not as effective We can learn fear through association Watson and Raynor conditioned Little Albert to be afraid of white rats by pairing the neutral stimulus rats with a unconditioned stimulus loud noise Within days Albert was not only afraid of the rats his fear had generalized to other furry objects Neutral stimulus lolnlearning Counterconditioning The process of pairing a conditioned stimulus with a stimulus that elicits a response that is incompatible with an unwanted conditioned response Another child s fear of rabbits was removed by pairing the stimulus that elicited fear with a stimulus that elicited happiness Classical conditioning in forensics Man claimed that he lost tone perception in an industrial accident and he sued the company for a large sum of money Clever because he did not claim he lost heanng Insurance company hired a psychologist who classically conditioned a Galvanic Skin Response GSR to middle C on the piano Each time he played middle C to the patient a slight electric current was applied to the skin 9 GSR Classical conditioning in forensics Ifthe man truly did not have tone perception then each note further below and above middle C should sound just like middle C eg no stimulus discrimination If we plotted the GSR curve on a graph for someone with normal tone perception the highest GSR would be at middle C and each note further away higher or lower on the scale would elicit a progressive smaller GSR producing an inverted V curve Without tone perception the curve would be flat His curve Inverted V 18 Operant Conditioning Also called instrumental learning The process by which a response becomes more or less likely to occur depending on its consequences Thorndike s Law of Effect Behavior that is followed by a satisfying state of affairs is likely to be repeated Reinforcement vs Punishment The Sk mgr X 20 A neutral consequence neither increases nor decreases the probability that the response will recur Reinforcement strengthens the response or makes it more likely to recur Punishment weakens a response or makes it less likely to recur Reinforcement Reinforcement A stimulus that follows a response strengthens the response or increases the probability of the response Primary reinforcers are inherently reinforcing and typically satisfy a physiological need Secondary reinforcers are stimuli that have acquired reinforcing properties through associations with other reinforcers 22 Types of Reinforcement Positive reinforcement when a consequence that follows a response makes the response more likely to occur Negative reinforcement when a response is followed by the avoidance or removal of a stimulus that makes the response more likely to occur A Positive reinforcer Good grade Behavior 39 Studying x A My Negative reinforcer Nagging ceases lszv Result Studying increases 23 Punishment The process by which a stimulus weakens or reduces the probability of the response that it follows Primary punisher Something that is inherently punishing such as electric shock Secondary punisher A stimulus that has acquired punishing properties through an association with other punishers giving birth was painful seeing a pregnant woman causes emotional distress 24 Types of Punishers Positive punisher When something unpleasant occurs i i e f after a behavior friends Negative punisher l I I i i 3 de When something ecreases pleasant is removed after a behavior punishment Loss of time with friends 25 Use of punishment in medicine Infant with uncontrollable vomiting Physicians unable to control with medications Psychologist used punishment to treat the vomiting Each time the infant began vomiting the psychologist applied a shock to the infants leg to punish the vomiting and eventually the vomiting stopped 26 Problems with punishment People often administer punishment inappropriately eg for their convenience too much too little too inconsistently The recipient responds with anxiety fear or rage The effectiveness is often temporary Most misbehavior is hard to punish immediately Punishment conveys little information An action intended to punish may instead be reinforcing sending a child home from school The behavior of the punisher may be copied 27 Schedules of Reinforcement Continuous A particular response is always reinforced Use when establishing a new behavior Intermittent Partial A particular response is sometimes but not always reinforced Fixedratio variableratio fixed interval and variableinterval VR maintains behavior at the highest levels 28 SCHEDULES OF REINFORCEMENT Extinction Intermittent Continuous Interval Fixed Variable Fixed Variable 29 Cumulative Fixed Ratio Cumulative Number of Responses 140 120 100 80 60 40 20 Post reinforcement pauses Reinforcers Time 30 Shaping To teach complex behaviors may need to reinforce successive approximations of a desired response Break responses down into constituents Goal is to make acquisition of each step easy with few failures For example training social skills reducing shyness teaching children motor skills 31 Behavior Management The application of operant conditioning techniques to teach new responses reduce or eliminate maladaptive or problematic behavior Begin with a thorough functional behavioral assessment which is an analysis of the contingencies maintaining the behavior 32 Extrinsic and Intrinsic Reinforcers Extrinsic reinforcers Reinforcers that are not inherently related to the activity being reinforced Others admire one s loss of weight Intrinsic reinforcers Reinforcers that are inherently related to the activity being reinforced Feeling stronger and looking better after exercusmg Extrinsic reinforcers may undermine intrinsic reinforcers 33 Social Learning Social cognitive theory emphasizes that behavior is learned and maintained through observation and imitation of others through positive consequences and cognitive processes such as plans expectations and beliefs Observational learning involves learning new responses by observing the behavior of model rather than through direct experience Model performs the behavior Observer learns the behavior 34 Behavioral Therapies Acquisition of phobias easy to explain through classical conditioning Example Pt has a car accident that produces a phobia of cars The pt has learned to pair the pain associated with injuries obtained in a car accident with cars and now fears cars The fear is classically conditioned Now pt avoids cars so the pt never gets a chance to have fear extinguished so the fear is negatively reinforced 35 Behavioral Therapies Not everyone is equally conditionable Depends on CNS genetics learning history expectations and preparedness Stress inoculation can reduce occurrence of phobias and other neurotic reactions Behavior therapists AABT rely heavily on the science of learning theory and are concerned with the individual s learning history BT s argue that trust and understanding is important to the therapeutic relationship 36 Exposure Therapies Exposure therapies use the principles of a Extinction b Prevention of escape or avoidance c Reciprocal inhibition Systematic desensitization graduated exposure originally called reciprocal inhibition is a behavioral treatment for phobias fears and anxieties based on classical conditioning Based on the pairing of an anxiety provoking stimulus with a relaxation response using fear hierarchy Exposure Therapies Systematic Desensitization SD was developed by Joseph Wolpe MD Based on classical and operant conditioning principles Begins with training relaxation amp cognitive skills that counter fear amp anxiety responses May involve meditation or progressive relaxation amp cognitive reframingreappraisal Irrational fearsconsequences are discussed The basic idea is that one cannot be both fearful and relaxed at the same time 38 Exposure Therapies Pt amp therapist create a hierarchy of fears regarding planes Lowest fear 1 picture of a plane highest fear 10 riding on a plane Pt trained in progressive or deep relaxation techniques and learns appropriate selftalk Pt starts holding a picture of a plane while relaxing and talking rationally about planes Then exposed to the next level in the hierarchy which may be holding a model plan and practices relaxation and rational thinking Eventually gets on plane in vivo exposure vs in vitro imaginal 39 Exposure Therapies Eye movement desensitization and reprocessing EMDR was developed by Francine Shapiro to deal with PTSDlike emotional problems Shapiro argued that EMDR eye movements left and right while working on issues helps to neurologically reprocess traumatic memories Others argue that EMDR is simply exposure or desensitization therapy As effective as CBT SSRI s and exposure therapy for PTSD in some studies 40 Exposure Therapies Flooding massive exposure to fear stimulus with no escape eventually fears extinguish Wolpe 1973 locked a girl with a car phobia in a car and drove her around for hours She was hysterical at first but eventually her fears were extinguished no negative reinforcement could occur and she lost her phobia of cars Punishment or aversion therapy Force someone to smoke until he gets sick Covert sensitization imagined punishment probably very powerful in real life 41
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