28.8 Behavior Therapy
881
Table 28.8-2
Daily Monitoring of Rituals
Each day, record the amount of time spent doing rituals in the morning, afternoon, and evening.
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Morning
2 hrs
1.5 hrs
Afternoon
3 hrs
2 hrs
Evening
1.5 hrs
3 hrs
Once a day, record the following details about an episode of rituals:
Day
Time Situation
Feelings Thoughts (Obsessions)
Type of Ritual
Feelings After Rituals
Saturday 8 a.m.
Finished
breakfast
Afraid
Scared
Worried
Shouldn’t have thrown away my
napkin
Might have left something under
my plate
What if I lost something important?
Checking through trash
Looking under plate
Staring to see if I lost
something
Better
For now, I think I have
not lost anything
Sunday 2 p.m.
At the store;
signed a
check
Worried
Anxious
Did I sign my name correctly?
Did I write the correct amount?
What if I give them the check
and it is wrong?
Staring at the check
Tracing the lines I wrote
Standing there
Anxious because
I couldn’t finish
checking
(Courtesy of M. A. Stanley, Ph.D., and D. C. Beidel, Ph.D.)
to bring hoarded items from home and to discard all unnecessary
items during the therapy session. At first, this created tremendous
anxiety, but over time, Phillip was able to throw things away with
less fear of losing something important. He also developed the abil-
ity to conduct self-directed exposure at home. Other exposure ses-
sions involved writing letters and mailing them without checking,
reading passages from magazines and books only once, and sorting
through junk mail to make quick decisions about what to save or
discard. As Phillip was able to take on more responsibility for home-
based exposure, session frequency decreased to two times per week,
and then to once per week. After 3 months of treatment, Phillip’s
scores on the YBOCS (Yale-Brown Obsessive-Compulsive Scale)
and BDI (Beck Depression Inventory) had decreased to 20 and 19,
respectively, demonstrating significant improvement in obsessive-
compulsive symptoms and depression. His SPAI (Social Phobia and
Anxiety Inventory) score, however, remained relatively unchanged,
suggesting that he was still experiencing significant social anxiety.
Next, while Phillip worked on maintaining the gains he had
made following ERP, he and his therapist conducted some role plays
to evaluate his social skills. It was apparent that Phillip had extreme
difficulty with initiating and maintaining conversations. His eye con-
tact also was quite poor in social interactions. Thus, the therapist
devised a plan for teaching and practicing new skills, which also
involved additional exposure to Phillip’s core fears as he was asked
to resume contact with old friends and identify activities where he
could meet new people. He practiced new behaviors first in session
with his therapist and then developed a hierarchy of feared social
situations in which he could practice his new behaviors. These prac-
tice exercises also involved a form of exposure as Phillip was asked
to make social contact, which produced fears of negative evaluation.
After another 3 months of treatment focused on social skills training
(and associated exposure), Phillip’s scores on the YBOCS and BDI
had decreased further (YBOCS
=
15; BDI
=
13), and his SPAI score
had decreased to 100. Phillip had gone back to school to take one
class, he was spending small amounts of time with old friends, and
he was volunteering a few hours each week at his church. (Courtesy
of M. A. Stanley, Ph.D., and D. C. Beidel, Ph.D.)
Aversion Therapy
When a noxious stimulus (punishment) is presented immediately
after a specific behavioral response, theoretically, the response
is eventually inhibited and extinguished. Many types of nox-
ious stimuli are used: electric shocks, substances that induce
vomiting, corporal punishment, and social disapproval. The
negative stimulus is paired with the behavior, which is thereby
suppressed. The unwanted behavior may disappear after a series
of such sequences. Aversion therapy has been used for alco-
hol abuse, paraphilias, and other behaviors with impulsive or
compulsive qualities, but this therapy is controversial for many
reasons. For example, punishment does not always lead to the
expected decreased response and can sometimes be positively
reinforcing. Aversion therapy has been used with good effect in
some cultures in the treatment of opioid addicts (Fig. 28.8-1).
Eye Movement Desensitization
and Reprocessing
Saccadic eye movements are rapid oscillations of the eyes that
occur when a person tracks an object that is moved back and
forth across the line of vision. A few studies have demonstrated
that inducing saccades while a person is imagining or thinking
about an anxiety-producing event can yield a positive thought or
image that results in decreased anxiety. Eye movement desensi-
tization and reprocessing has been used in posttraumatic stress
disorders and phobias.
Positive Reinforcement
When a behavioral response is followed by a generally reward-
ing event, such as food, avoidance of pain, or praise, it tends
to be strengthened and to occur more frequently than before
the reward. This principle has been applied in a variety of
situations. On inpatient hospital wards, patients with mental
