Okay, so a lot of the therapies we talked about last lecture, the insight therapies they kind of fit our stereotype of somebody laying back on a couch and talking and working through issues and perhaps trying to get at underlying psychological problems. the therapies we're going to talk about in this lecture are quite different. They're much more active, and they're much more directly related to the symptoms of the disorder. So, for example, of psychoanalysis, where we assume the symptoms arise from some deeper issue, and we want to get out that deeper issue. Well, in a lot of the, the therapies we're going to talk about now, it will be no, no, let's think about the symptom, and let's think about if we can actually find ways of helping people behave more appropriately. Okay? Now we'll talk about both approaches that are based on conditioning principles itself but then, especially, we'll move into something called Cognitive Behavior Therapy, or CBT. it's in fact a very dominant form of therapy, now largely because of the, the support it has. So, let's do that story. Week 7, Lecture 7. it's entitle Cognitive Behavior Therapy, but again, I want to start by talking about therapies that are based on classical conditioning in general. So we're going to talk about someone based on classical conditioning, someone offering conditioning, and then we'll get to CBT itself. So with respect to classical conditioning it's had a lot of success in helping people whose basic issues have to do with anxiety. And especially things like phobias where somebody has become anxious or phobic with respect to some stimulus that really they shouldn't be fear, feared of, feared of. They shouldn't be worried about. They shouldn't be scared of. So someone for example scared of you know harmless snakes or scared of heights or scared of elevators something like that. The claim is that a lot of these phobias have developed because of classical conditioning that that simulus somehow got associated with something fearful and that association remains. and therefore the idea is while if it was built by association with anxiety, maybe we can break it down by associating it with relaxation. So literally the dominant therapy is something called systematic desensitization and it rests on that notion that we cannot be both anxious and relaxed at the same time. So maybe, the best way of helping someone battle anxiety, is to teach them how to relax. And if they can learn to relax, in what would normally be anxious situations. You cannot be both anxious and relaxed at the same time. So, by learning to relax, you are learning to fight anxiety. Okay, sounds good, right? How do you actually teach someone to relax? Well, the claim is this. You usually go through two steps, and the first step is just relaxation training. So there are a, a number of techniques out there that are what are termed "guided relaxation." And I'm, and I'm sure if you did a bit of searching you could track some of these down. Usually, they work something like the following. You might be asked, somebody might just be speaking to you, and they may tell you to lay down and to relax. And then they would usually begin at your feet and work their way up, whereby we would take every muscle group, let's say the muscles you use to clench your toes, and you would be told clench your toes as hard as you can, clench them, clench them, clench them, feel that, that... Stress. Feel that tightness in all your muscles. Clench them until your muscles hurt, and then, let go, and relax. And as you feel that relaxation come over your toes, think of some, trigger word. Think of some word, or some image, or better yet both. So for me it's always, beach. Think of beach, the word beach, the relaxation of a beach, laying in some nice, sunny, all-inclusive place and really relaxing. Okay. Now, work your way up. Let's take the calf muscles on your leg and tighten those calf muscles, make them as tight, as tight, as tight as you can possibly make them, etc, you get the idea. You work your way up through the body, tightening muscle groups, but then relaxing them and associating that relaxation with some sort of trigger word or trigger image. And eventually as you work through your whole body, a process that sometimes takes 10 or 15 minutes You are, you, you feel like, you know, well cooked spaghetti laying on a bed. You feel completely and utterly relaxed. And you've been associating that feeling with this trigger word the whole time. Again, conditioning of a sort, but now we're conditioning relaxation to be associated with that trigger word. Then we have something called a hierarchy of fears. Let me skip ahead. Let's say your issue is public speaking. Well, you might come up with some hierarchy of things that, like this one doesn't scare you too much. Watching someone else public speak, hmm, not so much. Having others sing happy birthday to me, well that makes me feel a little on the spot, but I just have to sit there and smile, that's not so bad that much. Being asked to give a toast at a small gathering. Well this is a little traumatic, now I am the center of attention and now I have to say something. finding oneself in the position of telling a long story to a group of friends who are listening, so now it's that longer etc. Giving a toast at a formal wedding versus a small gathering, talking about something you know a lot about. And this means public speaking of course versus public speaking about something you know little about. Okay. So, the idea is this is getting more and more and more anxiety provoking. Now, if somebody has learned, imagine a hierarchy like that If somebody has learned to relax and then you create this hierarchy and you say, okay now we are going to just go through this hierarchy. We're going to slowly relax and I'm going to describe one of these situations to you. So, you know, imagine you're inside the theater and you're watching somebody give a public speech, and as you watch think of that word beach and relax, and relax and relax and relax, and the person usually has some way of signaling when they're feeling anxious. If they're not we'll say okay, now the scene has changed. Let's imagine you're at a restaurant and you hear the waitresses coming and they're singing Happy Birthday. And you realize at some point they're coming to you. and everyone's going to sit around and look at you and watch happy birthday. But say "beach," "beach" to yourself. Relax, just enjoy it. Relax. So you would walk people through these steps slowly. you'd usually begin by doing it with an imaginary situation. Where somebody is just relaxing. But then you might actually move into the real world. And have them actually engage in these behaviors, learning to use this trigger word to bring themselves down, every time they want. Now, this is by the way, just a very effective tool to have in your back pocket any time. If you can learn to relax, then when you're boss is in your face, saying, you didn't do blah, blah, blah, blah, blah, blah. If you can just relax, listen and respond in a non-emotional way. It looks good. It looks good when it happens with your spouse. It looks good when it happens with your children. It looks good when it happens with your buddies. You know the, the ability to kind of control yourself, literally, and respond to things in an intelectual and a non-reactive way is very powerful. And that's really what systematic desensitization is all about, learning to reign in that fight or flight response. Pull it back, relax, take it easy. This is very helpful for people with phobias like anachrophobia or anything else. It usually takes anywhere from seven to ten sessions of systematic desensitization. And, and usually they are fine. in fact, just about everybody, like 90 plus percent of people that go through systematic desensitization feel less fearful towards whatever it was. and some of them feel completely non-fearful. So it's a very powerful, very effective therapy. There are other therapies based on Operant Condition. Now remembering the distinction, classical conditioning is all about what things are associated with Operant conditioning is all about the consequences of what happens. And one of the things, one of the techniques that's used with operant conditioning is similar to what we've just talked about for systematic desensitization. The idea is if there's a behavior you don't like, can you think of an opposite? Where the two cannot be simultaneously occurring. And maybe rather than punishing the behavior you don't like, you could reward the one you do. And if they cannot coexist then this a way of using reward to get rid of bad things. So, here's my example. I may have mentioned this before. It's one of my favorites. So, image you have a young child in your house. Who likes to run around naked in front of your friends. And as I said early on you think this was funny, everybody laughed, you rewarded him. And now you've created a monster so to speak [LAUGH]. This, this child now every time there's guests out wants to run around naked. Well, what if you said the following. Here's how we're going to change his behavior. First of all, we will not laugh anymore. We will not give him anymore positive attention if he comes out naked. In fact, we will ignore him and pretend he doesn't exist. But, if he comes out wearing clothes, maybe even just shoes, [LAUGH] maybe that's enough. If he comes out wearing just shoes, then we will say, very good, Johnny, I see you have your sneakers on. Your sneakers look so great, blah, blah, blah, blah. And we will reward him for being dressed. and we might want to up the bar on that a little bit to a point where we actually want him to come out fully clothed. but the point being, if you're rewarding him for being fully clothed, then you're getting rid of the naked behavior. But without focusing on the negativity of the naked behavior, you're focusing on the positivity of something opposite, something that cannot coexist, the dressed behavior. So that's called reinforcing of adaptive behavior. Sometimes you can get rid of the maladaptive by reinforcing an adaptive. some people take this notion of reinforcement very directly and they create what are called token economies. This is often done in places like juvenile detention facilities where you really want to foster, I mean the child may be there because of something negative they did but you want to foster positive behavior. And so what you might do is have chips like this And you might say every time you see a child do something good, a, and maybe you give them opportunities. Maybe, you know, there's chores they could do. certain activities maybe around the, the facility. Trimming, hedges, mowing lawns, sweeping floors. Whatever, and if the child chose, chooses to do those things, they get tokens. And they can then cash in those tokens for, you know, various, I don't know, snacks, on, on, on entertainment night, on movie night, whatever. and so you actually, again, a form of reinforcing the behavior you want, but sometimes very directly by giving tokens. and then that's a good way of immediately saying, hey, you just did something good, here you go. so this is a, a, just an explicit method people use when they're trying to modify behavior using operant conditioning. And of course we can also use punishment. This is what police forces usually do. They usually wait for us to do something wrong and then they punish us for doing that wrong thing. We get speeding tickets, we get parking tickets, whatever. It's, it's not always considered the best form of therapy because it really is focused on wrong doing, but in some cases, like you know imagine the police trying to reward somebody every time they did something right. Well, when it comes to things like driving the car, most of us do right things most of the time. So it's a lot easier for the police to focus on those few people who do something wrong and punish them. But it is a form of behavior modification. Okay. Everything so far has been about directly looking at, at the symptom, and trying to find ways using either rewards or associations to, to change the behavior, to change the symptoms. What cognitive behavior therapy adds to this. So the behavior is still there, and there's often a notion that you still want to pay a lot of attention to the behavior, and you still want to do what you can to modify it using classical and operating conditioning. But you should also think of the fonts. So specifically If we think about depression for a moment and we imagine negative events happening in a person's life, well, when something negative happens, sorry, there are sometimes rational beliefs about why that negative thing happened. So let's say, you know, I, I was with a group of friends and I just lashed out at somebody negatively, I said something really nasty about them. And then I noticed the rest of my friends looking like they didn't really like what I said or what I did or how I behaved. Maybe I was over the top. So this could be a rational belief, maybe I reacted too strongly and, and this is like sort of healthy, negative emotion. I feel like crap for acting that strongly, but you know, I need to learn. I need to literally modify my behavior, because that was too rude, too sharp. So sometimes, this is what's going on. But the claim is often, we have irrational beliefs that are in the way and that make us over attribute to the wrong sources so some negative event happens you know. Imagine I am at a party and I'm, I'm sitting there and then the, the police come somehow and a bunch of friends get in trouble for doing things, and I think you know what that's because of me. There's something I did, I knew I should't have went to that party that somehow wherever I go bad things happen. it follows me everywhere, that negative event was due to my presence. That's an irrational belief. You know, chances are, unless you actually did something to bring the police to the party it was just chance. You were just there. But some people, and especially people with depression, show a lot of persistent irrational beliefs. They over attribute negative events to their behavior and themselves. That makes them feel really really bad and it reinforces the negative events. So imagine some life event, and you're thinking oh that's because of me, I never do anything right, I'm useless. And that makes you feel sad, terrible, makes you feel tired and whatever, and then you can't concentrate very well. you have poor memory because you're just feeling like crap. you avoid people, you stay in bed, you reduce activities. and every negative life event that happens, if you attribute it to your own worthlessness, then you can keep this cycle going and going and going. And these negative events just add fuel To these thoughts which are connected to behaviors, etcetera. And so the claim is, if we could get in here, if we could somehow get you to realize and properly think about the negative events in your life, then maybe we could break this cycle. And in fact, you know, I'll give you a very simple form for those of you that sometimes feel that depression is sort of nipping at your heels. Here is a very simple thing to do. As you go through your day, especially if you have, you know, some sort of smart phone like this, then as you go through your day, whenever something good happens in your day, write it down, yeah, take a little note of it. Whenever something bad happens, ignore it. Most depressed people overblow the negatives and they underappreciate the positives. So, let the negatives go, take note of all the positives and at the end of the day, look at your cell phone and read yourself the positives, and think about the positives, and think whether any of those happen because of something you did. And if so, take credit for some of the positivity in your life and try as well as you can to let the negativity slide. If you can do that, you can help break the cycle. And cognitive behavior therapy is kind of about that. Teaching people their irrational beliefs. Making them see the irrational beliefs they have. And trying to change those for much more useful cognitions that help them think about the world differently and ultimately you know, do better. A large, insight therapists worried about things like cognitive behavior therapy, and behavior therapy in general. Because again, they had this notion that the symptoms arise from some inner problem. And so, if you just deal with the symptoms there just going to come out in some other way well in fact there's been a lot of scientific evaluation of cognitive behavior therapy and that evaluation suggests that for certain disorders for anxiety disorders and for mood disorders. It seems to work very well. it often can take a while to work. Someone has to learn to think of their cognitive state in a different way. So they have to be trained and, and, and that training can take a while. But when somebody successfully learns how to rethink about things they can have a long term way of dealing with things like depression without the need for drugs or anything like that. And so that's the hope for cognitive behavior therapy. And that hope seems to be borne out by the scientific data. So for certain sorts of disorders it's not going to help a schizophrenic. Its not going to help a psychopath, but for certain kinds of disorders especially mood disorders and anxiety disorders it can be very effective. Alright, so one more of this lecture set, we're going to talk about biological and drug interventions in the last lecture in the series. Have a great day, bye bye. Oh. [LAUGH] Sorry. I forgot about my video links. Oops. here's one on systematic desensitization. Here's a whole YouTube channel on cognitive behavior therapy, so you can get a sent, better sense of that. And this one's a little ten minute strategy aimed especially at mothers, new mothers, who are dealing with depression. Remember that post-partum depression? this shows you a little bit of a therapeutic session where they ultimately give you some strategies for dealing with depression. On the reading side, What is Cognitive Behavior Therapy? And again, Cognitive Behavior Therapy for Depression, a couple of short readings just again to tie this all up. And that's it for your cognitive behaviors therapy I will see you in the next lecture.
