Pass Your Exam: Know These Essential Counseling Theories

Welcome to the addiction counselor exam review. This presentation is part of the addiction counselor certification training. Go to. Learn more about our specialty Certificates starting at $149. Hi, everybody, and welcome to your review of counseling theories. In this presentation, we're going to be focusing on counseling theories that we typically use with individuals, not feature families. Family counseling is a different video. In this one, we're going to review the most common counseling theories used with individuals and potentially groups and related interventions. We're going to start with my favorite. Cognitive behavioral. The premises of cognitive behavioral are that people respond to their representation of events rather than the events themselves. So, for example, roller coasters. I hate roller coasters. I'm terrified of them. Some people love roller coasters. Now, the event riding a roller coaster is the same for them and for me. We're doing the same exact thing. They happen to find it thrilling. I happen to find it terrifying. So I'm responding to how I perceive the event. Learning is cognitively mediated. So everything we learn influenced by everything we've learned up until then. If a dog comes charging up the fence at you, you know me, I've been raised around dogs. You know, I'm gonna think, oh, my gosh, he's protecting his property. Isn't that sweet? I'm probably gonna talk to him in baby talk and we're gonna become best friends or not. But that's the way it's gonna go. Somebody else who has had a bad experience with a dog may perceive that as threatening and become terrified. So every experience you encounter, your brain goes, okay, have I done anything like that before? And is it safe, unsafe, good, bad, you know, what am I supposed to do here? So you got to remember that everybody's experiences are going to affect how they experience things in the future. Thoughts impact emotional and behavioral reactions. If you take the roller coaster, for example, if I think that riding a roller coaster is. Is, you know, dangerous, that's my thought. It's going to make me feel scared. And my behavioral reaction is to say, oh, no way in the world am I going to ride that. If you have positive thoughts and you say, oh, my gosh, that is so much fun. That is totally safe, and it is a really fun way to get your adrenaline going. Then that person is going to be happy about getting on a roller coaster, maybe even downright excited. They're going to be eager to get on there. They're going to be moving toward the roller coaster. Some types of thoughts can be monitored and modified. If you have a fear of spiders, for example, spiders are Everywhere, just that's the way it is. And if that makes your skin crawl, those types of thoughts that spiders are dangerous and spiders are going to crawl on me and spiders are going to bite me, those things can be addressed and modified. So we want to look at the thoughts that can be addressed. Other types of thoughts that can be modified are what we call irrational or I call them unhelpful thoughts. Like everybody is always against me. That's probably not true. I don't have never met a person yet I have not met a person yet where everybody was always against them. So they were catastrophizing. So we want to change those thoughts and say, a lot of the people in my family don't seem to support me. For example. Now that's more specific. Okay, well, where are the people that do support you? So cognitive behavioral helps people look at a range of cognitive distortions or unhelpful thoughts. And you can google those or you can watch our video on cognitive behavioral techniques to learn more about those. But they address those in order to help people improve their mood, feel more empowered, and behaviorally act differently. Act more assertively and less fearfully and less depressed. Modifying thoughts can help modify emotions and behavioral responses. If you modify your thought about something you're angry about, for example, then you can de escalate your anger and it'll modify whatever your behavioral urges are. Maybe you want to put your fist through the wall. Well, if you're not angry anymore, then you're not going to want to put your fist through the wall. Well, isn't that awesome? Both behavioral and cognitive techniques are useful and can be and probably should be integrated. So the goal is to identify and correct unhelpful cognitions or cognitive distortions by clarifying and challenging unhelpful or inaccurate cognitive skill, which is cognitive schema. Are the way we think about things, our memories, if you will, and increase the client's problem solving abilities. So when you encounter a situation like this that makes you angry, what can you do to de escalate your anger, which will also remove the likelihood that you're going to do something behaviorally that you'll regret. A cognitive behavioral assessment. Well, I'm a cognitive behavioral therapist, so I tend to think these are the easiest to do. Clinical interviews can clarify antecedents and consequences to emotions and behaviors and strategies that have and have not been helpful in the past. What does that mean? It means we want to look at when something has happened that has made you angry. You know, I want to look at what caused you to get angry, then you got angry and what was the result? What are the consequences? What was the result of you getting angry? You know, if you got angry and threw a temper tantrum and got your way, well, then you're likely to get angry and throw your temper tantrum again. If you were angry and threw a temper tantrum and got fired, then you might be less likely to do that in the future. Maybe not. But we want to look at the antecedents, what causes it, and the consequences of emotions and behaviors. And then we also want to look at strategies that the person's used before that have been helpful, because that's where we're going to start. We're not going to reinvent the wheel. They know what's worked for them at least a little bit, and we'll build off of that. But we also want to know what they've done that hasn't worked at all because there is no sense continuing to do something that they don't think is going to work. Inventories and questionnaires are helpful in identifying cognitive distortions. So giving people handouts that say, I believe that all people are against me, and examples of cognitive distortions, for example, people can go through and check those. And you can either use a Likert scale so they don't believe it at all, they believe it a little bit, they believe it a fair amount, or they believe it a whole bunch. So 1, 2, 3, and 4, or a simple yes, no, however you want to do it. But that can help. Instead of having to sit there and go through these different questions, which takes a long time in the assessment, that can give you an idea about their cognitive style and their thinking style and the distortions that may be contributing to their dysphoria. Self monitoring can help identify the frequency, antecedents and consequences of unhelpful thoughts and or reactions. So once you've identified some of those unhelpful thoughts and, and educated them about cognitive distortions, then give them a sheet so they can monitor themselves each day and keep a log. You know, they can just have a hash mark next to each time they use a particular cognitive distortion. And then they can start looking at how often are these happening, what triggers these types of unhelpful thoughts, and what are the consequences? And generally the consequences are it causes them to get anxious, angry, or depressed, which is why they're in your office. So self monitoring helps people get an idea of how often it's occurring, what causes it, so they can intervene there. And if they can't intervene there, Then they can figure out a different way of responding so they don't have the negative consequence. Data from the assessment helps identify clients problem solving abilities. When things happen, do you emotionally dysregulate? You can't think clearly and you can't problem solve? Or when these things happen, what do you do? How do you handle it? And again, what are the consequences? If you handle it and it has perfectly good consequences, it de escalates the situation. It's a win win, everybody's happy, that's great. But likely the person chooses a problem solving technique that isn't wholly effective and, and it ends up having negative consequences. So then you're going to look at how can you modify that problem solving strategy in order to help them have more success in problem solving. You're going to look at their attributional style. Attributions are where you assign responsibility, so to speak. It can be global or specific. So if somebody's walking down the street and they trip over and they trip, a global assessment or attribution would be that person is so clumsy. A specific attribution would be that person did something right there that was really clumsy. You know, maybe if you watched Miss Congeniality, there were some really good examples in there of where she was very prim and proper and then all of a sudden she would just like fall down somewhere. So you want to look, is it global or stable? When we're looking at attributions, global attributions such as I'm stupid, I'm useless, are going to contribute to people's misery as opposed to specific attributions such as I am not any good at woodworking or at math. Those are specific things that I know are not my strengths. And you know, I'm okay with that because globally I'm a good person and I'm smart. But there are some things that not my strengths, stable or changeable. You know, this thing that you've got going on, if you don't like it, is it stable? Can it be changed at all? If it can, great. If you're clumsy, that's generally considered a stable trait. If you had your shoelaces untied, that's changeable. So when you're walking, like when my son was little, we started getting in the little Velcro shoes because his shoes would always come untied and then he'd trip and you know, but that was changeable. There was something I could do to change it. It wasn't about him, it was about his equipment and it was fixable. And then the final attribution is it internal or external? So going back to the tripping, an internal attribution would be saying that person is clumsy, so. So it's something about them that made them trip. An external attribution would be to say, there must have been a crack in the sidewalk that they tripped over. That's putting the blame somewhere else. Now, too internal or too external can be bad because some things are due to you and some things are due to external forces. But looking at attributions and challenging those and seeing are there negative things that are changeable, external or specific, that you're looking at as global, stable, and internal. And it gives you information, the assessment that is about their underlying belief systems and the cognitive distortions they use, such as, everybody's always against me and I never succeed at anything I do. All of those statements help you start seeing what may be maintaining this person's unhappiness. So what can you do about it? Daily mood and activity monitoring is the place to start because we're going to keep track of it, increase rewarding behaviors, and establish a daily routine. So do things that make yourself happy each day. You know, you need to rest, relax, sharpen the saw, whatever you want to call it. And a daily routine helps keep your circadian rhythm set so you're getting more quality sleep, so your energy levels are more predictable, and you have a sense of mastery over, you know, when you're going to be sleepy, when you're going to be awake, when you're going to be doing whatever. Encourage the person to develop an understanding between the relationship of the relationship between their feelings, thoughts, and behaviors. So start with, you know, when you're depressed, how does it affect the way you think about things that day? And how does it affect the things that you do? Okay, so let's move it, and instead of being a feeling, let's go to thoughts. If you are just being a negative Nelly, you are in a negative mood that day. How does it affect your mood? You know, if your thoughts are negative, how does it affect your mood? And it probably tends to make you more angry and irritable. So you're negative, you're angry and irritable. How does it affect what you do? Then finally move it around to behaviors and say, all right, so you wake up in the morning and you decide, you know what, I'm just not going to get out of bed today. I don't have it in me. And you stay there all day long in the dark watching a Netflix marathon how does that affect your mood? It's probably going to make you feel tired, more depressed, a little bit more helpless and hopeless. There are things that it can contribute to and how does it affect the way you think? You know, does your attitude change throughout the day? Generally, if you have time to sit there and dwell on things, your attitude is going to get a little bit more negative. So, you know, helping people see that if you intervene anywhere on the three pillars, you're going to improve the situation. Use graded tasks to help clients start approaching and addressing seemingly overwhelming problems. Maybe they have social anxiety. Okay. You know, a lot of people do. I have a little bit. You know, I really hate mixers, and I just don't introduce myself to people well, but. So graded tasks would be having people do things that don't make them so nervous. Like when I go to the grocery store, I talk to the cashier. When I'm in other situations, I try to get outside of my comfort zone and talk to people I don't know. So I get more comfortable doing that. The next step would be going to, for example, presenting. And that's weird because I really love presenting, but I would do that. So I'm in front of 150 people that I don't know, and then I might go do something else that elicits a little bit more anxiety as I master each level and realize that, hey, I can do this, it's not so bad. Let me try something a little bit more difficult. Not too much more difficult, just a little bit. And sometimes there has to be an envisioning step in between there. So before I go to a chamber of commerce mixer, I need to rehearse it in my mind several times, or maybe more than that, and get to the point where I'm comfortable doing it in my mind. I know how I'm going to act. I know what I'm going to do. I feel confident in my mental rehearsal, and then I can actually go do it in person. So there are great. When they say graded tasks, it's not like graded abc, but it's gradually increasing movement towards those things that are stressful and teach new skills and have clients practice them between sessions. I have clients learn a new skill each week, like the ABC worksheet, Cognitive processing worksheet. We'll try different things, and I'll say, I'll introduce it, we'll try it in session, we'll work through a few examples, and then I'll say, well, why don't you try this during the week and see if it Helps. Obviously, I choose interventions based off of what they have told me their strengths are. So we're building on what they are, what already works for them. Another thing that we do in cognitive behavioral is address automatic thoughts. So the first thing is to teach the concept, what are automatic thoughts? And then you want to elicit the client's thoughts. So help them figure out, you know, when somebody cut you off in traffic and then you got angry, you had a bunch of automatic thoughts in there that led to you having that stress reaction. So what were your thoughts? It was dangerous. I could have been killed. That person was so rude, yada yada. Help them start eliciting and figuring out all those things that they're telling themselves in a millisecond. Label any distortions that you hear or see if you can have them write it down. It's even better. I'll generally write it on a whiteboard as we're talking and then we'll label each cognitive distortion with all or nothing thinking, magnification, personalization, you know, you know your distortions. Identify and challenge and modify maladaptive schemas. So you could have died. Well, that's kind of catastrophic. How likely is it that you would have died? It was unsafe. That's true. So we're changing the thought, we're changing the schema. We're kind of changing the memory of that event to something that was catastrophic and life threatening, to something that was potentially hazardous and unsafe in order to help reduce the anxiety about the situation. And then when the person encounters future situations, they're going to have a lower level of anxiety because we've modified that schema and we're going to develop helpful alternatives when this happens. How can you handle it and how can you prevent it happening in the first place? A, B, C, D and E are, you know, the basics of cognitive behavioral and rational emotive behavioral therapy. The activating event, getting cut off in traffic, the consequences, your emotional and behavioral reactions. But between those is like a little millisecond of automatic beliefs that your brain kind of floods you with to tell you whether you're safe or whether there's a threat. Then you use D and you go back and you dispute those automatic beliefs, looking for cognitive distortions and inaccurate schema or inaccurate representations or memories of how dangerous it was or what happened. And the final step is to evaluate your reaction and the consequences for helpfulness. So if you got cut off in traffic and you decided that you were going to speed up next to the person, you were going to scream at them and flip them off. Did that do any good? Was that going to keep them from cutting you off? Was that really a smart thing to do? And the answer is no in both cases. So you want to evaluate the use of your energy. Was getting upset over this a good use of my energy? Was screaming at somebody over this a good use of my energy? What would have been a better use of my energy? You know, if the person's driving like an idiot, maybe calling local law enforcement to, you know, come check and see if they're dui? That could be. But most of the time it's just not even worth your energy and you need to let it go. Cognitive processing. Another technique where when you have a belief such as, you know, I am going to be alone the rest of my life, you want to ask the person to evaluate whether they're using fact or emotional reasoning. Do they have the facts that are telling them, no doubt objectively, you're going to be alone the rest of your life, or are you using emotions because you feel unlovable and abandoned and lonely? Right now you fear that you're going to be alone for the rest of your life. There's a difference. One's fact, one's purely in emotion. The next step is to identify all of those facts for and against your thought. So what are the facts that you will be alone for the rest of your life? You know, let's look at those. You know, let's look at statistics, let's look at data. You know, let's look at it. And what are the facts that support the notion that you won't be alone for the rest of your life because there's going to be facts on both sides. Help the person figure out if they're looking at the big picture or they're looking at tunnel vision. Sometimes we think that we should have been more responsible. Or, you know, stay with this metaphor of being alone for the. For your whole life. You know, you break up with from one relationship and you say, you know what, I'm going to be alone the rest of my life. But the big picture is you've dated 30 people and you know, 27 of them. You're the one who's broken up with them because you got bored or whatever. You know, it's not necessarily that you're going to be alone for the rest of your life. You've got tunnel vision right now because you hurt and you're focusing on the hurt. The other aspect to look at here is hindsight. You know, hindsight is 20 20. So when you're looking back at a relationship, you know, you might have been able to see the warning signs that it was a bad relationship or something. And when you're looking backwards at it, but when you're in it, you know there's other things going on and other factors contributing to your decision making. So you're going to have a different perspective after the fact than you do in the midst of it. So cut yourself some slack, basically. Learn from it, but cut yourself some slack. Another thing to ask them is, are you confusing high probability with low probability? Is there a high probability you're going to be alone the rest of your life? And how long have you gone without being in a relationship? How many people have you dated? Looking at that versus low probability, you know, maybe you're going to be alone for six months or a year or maybe even two years, but how likely is it that you're going to be alone the rest of your life? And look for cognitive distortions when people are talking about their thought that, you know, I'm going to be alone for the rest of my life, you know, that's kind of an extreme statement. You know, you don't know what's going to happen six months from now or six years from now. So let's focus on the present and then start addressing some of the unhelpful thoughts that might be making them feel unlovable or abandoned. Another technique is called the downward arrow. Let's follow it through. You know, you broke up with your boyfriend, so you're alone right now. All right, now what? You know, are you going to start dating again? Okay, if you start dating again, then what happens? You meet somebody and it doesn't work out, you know, you decide you don't like them. Okay, then what happens? You keep dating. Okay, then what happens? And you work through it and follow the behavior all the way through to the end until you figure out what happens at the very end of the story. You can question the evidence, you know, and that's kind of what we did in cognitive processing, decatastrophized. You know, when somebody says, I'm never going to get another job or I'm never going to find somebody to love me again. You know, we want to take the catastrophe out of that, take the never out of it, and look at how likely is it that that will happen. Cognitive rehearsal is something else you can do. And I talked about that a little bit earlier, and that's imagining. You know, if you're getting ready to do something scary or getting ready to Have a tense conversation with somebody. You might want to rehearse how it's going to go in your head a few times before you do it. So you know what you're going to say, you know how you're going to react. Your planned. It's kind of like when football teams practice. You know, they're not doing it cognitively, they're actually on the practice field. But a lot of athletes will actually rehearse in their own mind. You know, quarterback may rehearse the perfect pass. They rehearse what it's going to look like so they're prepared. And it also helps prepare your mind and body. Problem solving skills training always helpful because there's multiple ways to solve any problem. Thought stopping is just what it sounds like. And that's helping people figure out how to quiet that annoying voice in their head that is saying that the sky is going to fall or telling them that they're not good enough. How can they stop that thought? Getting themselves distracted. Telling themselves they're not going to think about it. Singing the ABCs what can they do? And behavioral. You can narrow things. Sometimes things become associated with too much, like eating. You know, people. When I was growing up, we ate all the time. We ate when we were watching tv, we ate when we were on the way home from the grocery store, we ate at dinner time, we ate when we were bored, we ate when we went to the movies, we ate, we ate, we ate. And that didn't develop really good eating habits. So narrowing would be reducing the number of situations when it is quote, okay to eat when you choose to allow yourself to eat. So for example, instead of allowing yourself to eat while you're watching tv, sitting on the couch, say, you know, the only time I'm going to eat is when I'm sitting at the table. So then that means you're not eating in the car, you're not eating when you're sitting on the couch and you're not eating in bed. So that narrows the number of stimuli that tell your brain, hey, it's time to eat. Cue strengthening for positive behaviors. You know, we want to trigger the positive reactions. We want to trigger people to exercise, to eat healthy. So you can put apples and oranges and healthy foods, healthy fruits and stuff in a basket on the counter. That's a cue. People see it, they're like, oh, sounds like looks like something good to eat. And they may eat that instead of foraging for chocolate or something less healthy, you can put your gym bag by the front door to remind you to Go to the gym. You know, there are a lot of different things you can do to prompt yourself to do helpful, healthy behaviors. Finally, self reinforcement and punishment. You know, telling yourself, if I, you know, do this, whatever it is for the entire week, then at the end of the week, I will reward myself by doing whatever. We do that with our kids when they're little. You know, if you get stars, so many stars on your star chart this week, then on Saturday you can pick what movie we watch or whatever it is. But there's reinforcement concept to there indications for cognitive behavioral pretty much anything. Mood disorders, especially depression, anxiety and phobias, fears of failure, rejection and abandonment, eating disorders, and to a certain extent, personality disorders. Now sometimes personality disorders are egosyntonic, so the person doesn't see the problem with the behaviors. So it can be sort of an uphill battle here. But it has been used. The only time you wouldn't use CBT is if somebody has significant cognitive dysfunction, you know, they have a brain injury or something, psychosis or mania, they need to be able to think things through and see consequences. You're probably not going to use a lot of cognitive behavioral with young children either. Really young children, your elementary and middle school, they can make connections. You just have to adjust what you use to meet their cognitive development level. Behavioral models. The premise of behavioral models is that current behaviors are what we focus on. Current behaviors are under stimulus control. That means things that are rewarded happen more frequently. Things that are punished happen less frequently. Bada bing. There's no thought, there's no feeling. It's, you know, stimulus reaction. It rejects the idea that maladaptive behaviors reflect underlying pathology. An elimination of the behavior is the primary goal of treatment. So if you're working with somebody who self injures, you know, the primary goal of a behaviorist, for a behaviorist will be to eliminate self injurious behavior, not to address any underlying intrapsychic conflicts. Those don't exist. So we're going to remove the behavior. Assessment takes the form of a functional analysis. That means they look at the behavior. So we'll stick with self injury at this point. And we say, what are the antecedents? What happens that triggers somebody to want to self injure? What are the consequences of self injury? Does the person get a lot of attention when they're doing it? Does it give them a sense of personal control? Does it release endorphins so they get a little bit of a rush because they're feeling depressed? What are the consequences and what are the discriminative stimuli. That means, what are the things in the environment that kind of make it possible for this to happen? In order to do the functional analysis, you can do it through naturalistic observation. And that can be observing in a classroom, going to somebody's house and observing, or even observing a videotape that the parent brings in, for example, self monitoring. You know, obviously, the person can identify. And we do this a lot in dialectical behavior therapy, role playing. So if there's a particular type of situation that triggers behaviors. When my son was little, I wanted to play with him, and he didn't want to play with me. And, you know, I couldn't figure out why. You know, I was trying really hard, and you'll find out in a few minutes what happened. But I talked to his preschool teacher, and I'm like, jessica, you know, he plays with you guys so well, and he just doesn't seem to be interested in playing with me. What am I doing wrong? So she came to the house, and she said, okay, you know, let's sit down and show me what you do. And so I started showing her what I do. And all my playing was more educational playing. It wasn't fantasy cars and stuff. And after about, you know, three minutes, she's like, okay, you can stop right there. I'm like, you got what you needed. She's like, yeah, you're boring. And I said, oh, okay. Well, then. But she had no way of knowing that until she saw how I interacted. Shawn got bored, which isn't a term the behaviorist would use. Shawn was interacting with me, was not being rewarded would be what a behaviorist would say. So I needed to alter the way I interacted with him in order to make it more rewarding. When it was rewarding for him to interact with me, he was more willing to hang out with mom. So role playing is something you can do in the office. If I would have had a family come in with a similar situation, I would have said, sit down and show me. Or if the parent would have come in, I would say, okay, let me be junior, and I'll sit down here, and I'll pretend to be junior, and you show me what you do so I can get an idea. If I can't observe the situation itself, let's reenact it. And then finally, rating scales. Rating scales are great for helping people get a sense of the frequency, intensity, and duration of things, such as, you know, temper tantrums or crying episodes or, you know, anything that is observable and measurable. Behaviorists Use principles, operant conditioning, classical conditioning, and observational learning. We're going to focus mainly on operant conditioning, which means behaviors are increased or decreased through punishment and reinforcement. And you can reinforce things by adding something positive, like giving somebody a token or a hug or taking away something unpleasant. So you can say, if you eat your main course, then you don't have to eat your green beans. You know, that would be rewarding for some. For some kids. So reinforcement is either adding something positive or taking away something unpleasant. Punishment is just the opposite. Punishment is either adding something unpleasant, like having to go out. We would make my son go out and pick up sticks in the yard that had fallen down if he had misbehaved, and he hated to go out in the Florida sun, so that was punishing for him. Or punishment can mean removing something positive, like taking away somebody's iPhone. So there are basically you either punishment means you make it unpleasant some way. Reinforcement means you make it pleasant in some way. Observational learning means that people can also experience reinforcement and punishment for actions by seeing it happen to others. So if they see somebody, you know, throw a chair in school and then get sent to the principal's office, you know, that's a negative consequence. So they're like, well, probably not going to do that. But if they see somebody smoking in the bathroom and getting a lot of positive attention for it from their peers, then they're going to go, oh, well, maybe if I try that, I'll get positive attention. So we learn vicariously by seeing reinforcement and punishment of behaviors in other people as well as experiencing it directly ourselves. Behavioral therapy's goal is to identify the stimuli that prompt the behavior, the reinforcers, things that are maintaining the behavior, and punishments in the environment. What can we do to make this behavior less pleasurable? In order to figure out how to change it, we want to remove the reinforcement and cues for their target behavior. So with alcohol, for example, if people drink, take Antabuse. When they drink, they don't get the sensation of getting buzzed or whatever. So the reinforcement's gone, and the punishment comes in pretty quickly when they get violently ill. So that thought of drinking starts to become less and less pleasurable and less and less frequent. And we want to increase reinforcement and cues for a new behavior. Because you don't want to just eliminate stuff, you want to add stuff. So let's look at why were you drinking? And, you know, if you were drinking because you were stressed, what else could you do to deal with stress besides drinking? If you were drinking because you like the Taste of it. What else can you do to stimulate your taste buds besides drinking? The assessment emphasizes observable, measurable behaviors and patterns. We're not going with thoughts or feelings. We're looking at what happened, what rewarded it, what would punish it. The client and therapist agree on the definition of the problem behavior. So what is it exactly that we're looking at? And baseline data is required. So if you're looking at temper tantrums, the parent or the person is going to go home and keep track of how many temper tantrums they had that week, how long they lasted, and maybe what triggered them. So that'll bring a lot of information back to the therapist. Interventions that can be used include systematic desensitization, which starts with relaxation training. You've got to learn how to relax, and then you work through that anger or anxiety hierarchy. So you first think about something that makes you, you know, your heart start beating really, really fast. That's measurable. And then, you know, if you've got a heart rate monitor, you practice relaxation until you can think about that situation and your heart rate hardly goes up at all. And then you move to the next step. Let's take spiders. So you're looking at an aquarium full of spiders. You're not touching them, you're completely safe from them, but you're looking at the aquarium. Your heart rate goes up, you practice relaxation, and you get to the point where you can be in the same room with the aquarium. Your heart rate doesn't really go up at all. And the next step is taking the lid off the aquarium so there's a chance that the spider could crawl out. You see where we're going with this? Assertiveness training can be used to combat anxiety because the belief is assertive behaviors are completely counter to anxious behaviors. Anxious behaviors make you make people tend to run, tend to, you know, get nervous, tend to flee. Assertive behaviors are the opposite. Behavioral rehearsal. So practice doing things you know, if you've got to go give a speech, go to wherever it is that you're going to give the speech and practice giving the speech there. Aversion therapy. Make it unpleasant, just like taking ant abuse, for example, makes drinking unpleasant. Flooding. And this flooding needs to be used with great caution. It is the treatment of choice for agoraphobia. But, you know, you need to know what you're doing. It is in vivo exposure with response prevention, which basically means you take somebody and put them in the situation that freaks them out and don't let them leave it. They're stuck there. So they've either got spiders crawling all over them or with agoraphobia, you make somebody go out into public and you don't let them retreat back into their home and help them deal with the feelings and the thoughts that they're having during that extremely stressful period. You can increase behaviors through reinforcement. So if you want your kids to do more chores or, you know, your child to get his homework done before 6 o' clock at night, you can add reinforcement. So if you do that, then you get additional hour of TV time, or you can stay up an hour later. So you can increase behaviors by adding rewards. Shaping means rewarding what we call successive approximations. So if I want my son to keep his room clean, that's, you know, a big step. So the first thing I'm going to say is, you know, in order for your room to pass inspection, you can't have laundry on the floor. You know, we got to. Let's start by working on getting the laundry off the floor. Once he's doing that regularly, I can say, all right, now you've got the whole getting the laundry up, down really well. Now I want you to start making your bed too. Okay, he gets that down. So shaping is rewarding a behavior until it's consistent, and then saying, okay, you don't get the reward anymore until you do that plus something else or until you do that a little bit better. The Premack principle is one of my favorite. It pairs high frequency or high likelihood activities with low likelihood activities or pleasurable activities with less pleasurable activities. So, for example, I fold laundry while I watch tv. I love watching tv, so, you know, it makes it less yucky. When I used to do my calculus homework, I always used to save my M&Ms. For the day until I did my calculus homework. And that's when I could eat my M&Ms. So it made it a little bit more tolerable. Not necessarily the healthiest, but so pairing things that somebody doesn't really want to do something, that's not so bad. A lot of people like to listen to podcasts or watch their favorite television show while they're at the gym. So getting an iPad so they can watch it while they're on the treadmill or whatever. That's the Premack principle response. Cost is having to give away something each time the target behavior occurs. So speeding is the perfect example. You get caught speeding, you have to pay a fine, you have to give away money, and most of us don't like to do that. But you can use it with Other things like nail biting. Each time you bite your nails, you have to put a quarter in the nail biting jar. Each time you say a swear word, you have to put a quarter in the, in the swear jar or whatever it is. And timeout. We all know what timeout is, but we have to use it correctly. If the function of whatever the person's doing is to get quiet time because they're overstimulated, then timeout is probably just going to reward that behavior because they're like, hey, if I do this, I get to go where it's quiet. So we want to determine the function of the behavior. If it's to get attention, then putting somebody in timeout is punishing because they're not getting attention anymore. And they're like, well, this is no fun. If they're doing something out of boredom, then putting them in timeout, which is still boring, probably isn't going to have much of an effect. So you want to figure out what the reinforcer is and give them time out from the reinforcer. So timeouts are not all the same. Behavior therapy contracts, Contingency contracts have an explicit definition of the behavior, such as, Johnny will go to bed by 10pm the behaviors can be monitored. They have to be observable and measurable. So I can look in his room and say, you're asleep or you're in bed or you're not in bed. Sanctions for failure. So there has to be a punishment if you're not in bed by 10 or what happens. And there has to be record keeping with contingency contracts. I also like to put reinforcers in there. So if you do go to bed by 10 o' clock each day this week, then on Saturday you can choose whatever from this list of possible rewards, which takes us to our token economy. You want to define the target behaviors. When I ran the adolescent treatment center, we used a token economy. And the youth had things they had to do every day, from making their bed to participating in their schoolwork, participating in treatment, doing their chores, bathing. There was a list of about 10 things and the counselors would monitor and mark those off. And for each level of completion, we had a 70% level, an 80% level, a 90% level, and 100% level, they would get a different number of points. So at the end of the week that we would tally their points and they could cash those points in in the store and that's where they could buy tokens for video time or snacks or there were a variety of things they could get to reward their behavior. But the token were the points. So we were giving them these tokens. They were able to cash them in at the end of a week. You want to be able to select the reinforcers that are going to work for that person. Video games wouldn't work for me. You know, there are a bunch of other reinforcers that might. So select appropriate reinforcers, monitor the behaviors. Then eventually you're going to have to fade out. Reinforcers where the person's just doing it because it's what they do, not because they're hoping for a token. But that's way down the line. The humanistic perspective. So we're switching gears now. We did cognitive behavioral, which focused on the cognitive. Then we went to straight up behavioral, which only looked at observable, measurable, external behaviors. Now we're moving over to a whole different school of thought called humanistic. The premise of humanistic is to understand a person, one must understand his or her subjective experience. So remember I said we can go through the same thing and interpret it differently. Like riding a roller coaster. Well, to understand why somebody really loves riding roller coasters, I have to try to understand their experience because my experience is different. Emphasis on the uniqueness and wholeness of the individual. Because each person is unique and all of their characteristics combined create who they are. A belief in the person's inherent ability for growth and self determination. If they're provided a good environment, they will grow and prosper. Therapy involves authentic collaborative interactions and rejection of traditional assessment techniques and diagnostic labels. The self is a conceptual gestalt composition of perceptions of I, who am I? And the relationship of who I am with the world and values attached to those perceptions. So you know, I know who I am, and if I think I am adequate and lovable and I think those values are important, then I'm going to feel pretty darn good. If I think I am inadequate and incompetent or untrustworthy or whatever, you know, how I view myself, then I'm going to look at is this a good thing or a bad thing? And I'm going to value whether I'm a good person or a bad person based on that. To grow, the person must remain unified and organized. Disorganization occurs when there's incongruence between the self and the experience. So, for example, the person believes I'm lovable for who I am. You know, they're going along great and then all of a sudden things change. And the parents are like, no, no, you are only lovable if you make me proud. Those are the conditions of worth. I don't love you for who you are. I love you for what you do. And then that kind of shakes the person's world because they're like, no, no, I'm lovable for who I am. And the parents are sending the message, no, you're lovable if you do what I want you to do. And it creates sort of a schism or disorganization. Therapeutic goals are to help the client achieve congruence between self and experience by providing an authentic atmosphere with unconditional positive regard. So this atmosphere says, you are an awesome person, you are a good person. Now, sometimes you may make poor choices, but. But you are a good person. And that removes the blocks and empowers people to grow. Assessment is pretty minimal in Person Centered. It examines the difference between who the client is and who the client perceives herself to be. So if I am, for example, really successful at what I do and whatever, but I perceive myself to be inadequate, you know, then that's something we're going to work on in counseling, is to fix that gap. And it also believes that the client is the expert on themselves. So we're not going to start offering a whole lot of opinions. Techniques include unconditional positive regard, accepting the person for who they are as a good person, providing accurate empathy. You know, really connecting with the client, being genuine and congruent, you know, admitting how you feel. You know, if you feel frustrated, saying, you know what? I'm feeling frustrated right now. I'm wondering how you're feeling. So being, you know, transparent, basically, and avoiding interpretation, manipulation, probing, or advice giving. Gestalt therapy is another humanistic therapy. And the premise it's based on are that people tend to seek closure, and people's gestalts reflect their current needs, so things they're doing reflect their current needs. Behavior represents a whole that is greater than the sum of its parts. So behavior is, you know, just what we're seeing, but it is a representation of something much greater. There was one video with Fritz Pearls, and I can't remember the woman's name. I should. I saw it enough times, but she was shaking her. Shaking her foot. And Pearl said, tell me what your foot is trying to communicate. Because that behavior was what was observable, but what was underneath it was anxiety and frustration and fear that, you know, he wouldn't be able to help her or whatever. So that behavior was just kind of the tip of the iceberg. Behaviors have to be understood in context. So shaking your foot may mean that you're nervous or you're frustrated, or it could mean that you're cold or a variety or your foot's asleep. You know when your foot's asleep, you may shake it to try to get it to wake up. A focus on the here and now is needed to increase self awareness and help clients live in the now. We can't change the past, we can't forecast the future. So let's look at what's going on with you now and improve the present moment. It believes that the self is the creative, forward moving aspects of the person and the self image is the part that imposes external demands. So the self is who you are and this wonderful forward moving person, the self image is that idea you have of who you should be and that can place external demands that say you are not good enough unless historical information and Gestalt therapy is only relevant to the extent that it's impacting the present. So we look at, you know, if you have unfinished business with your, in your family of origin and it impacts your current ability to trust in relationships, we're going to look at it in terms of that, but we're not going to start dealing with, with all that stuff in your past. We're dealing with how your past experiences made you who you are right now and are impacting your present. Problems are believed in Gestalt therapy to arise from abandonment of the self for the self image. So instead of being true to yourself and thinking, I'm good, gosh darn it, saying I'm going to be who everybody else thinks I should be, who society says I need to be, which creates a lack of authenticity. A lot of times problems stem from disruption of the boundary between self and the external environment, resulting in failure to meet personal needs. So when you're doing what everybody else wants you to do or what you think you should do, sometimes you neglect what you actually really need. And that causes problems and emotional distress. Boundary issues in Gestalt therapy are seen as reactions to problems or problems. Interjection means that people accept things from the environment without understanding or questioning. So since I'm a female, then I should get married, I should have children, I should do this, I should do that. You know, these cultural mores that are kind of programmed into us. Introjection means I take those in, I don't question them. I'm just like, this is what I do. I don't say is this what I want? I'm looking at the self image. At that point, projection is disowning aspects of the self and putting them on other people. So if a person tends to be grumpy all the time, and they're like, they look at everybody else and they're like, everybody is so negative all the time. They're projecting that grumpiness onto other people. In 12 step recovery, a lot of times we say the things that you dislike most, other people are often a reflection of what you dislike most in yourself. Retroflexion is doing to the self what you want to do to others. So if you want to abandon them, you know, you're tired, they're stuff, and you just want them to go away. Instead of abandoning them, you may abandon yourself. If you get angry at them and you want to lash out, you may lash out internally at yourself. And finally, confluence is intolerance of differences between self and others, which leads to feelings of guilt and resentment. So, you know, all of these boundary issues can be issues that are handled in gestalt therapy. Techniques that are used include directed awareness, which is being aware of yourself in the here and now. Kind of like mindfulness. What are you doing and what does it mean? No questions are allowed, which prevents intellectualizing. So instead of Pearl saying, what is your foot trying to communicate? He said, tell me what your foot is communicating. There was no question in there. It was a statement. Tell me what it is. Use eye language so you're owning stuff and assume responsibility, saying, I take responsibility for how I react in this situation. The empty chair technique can be really useful for dealing with issues with other people or for behavioral rehearsal. You know, pretend your boss is sitting in that chair and you're going to ask for a raise. Tell me how it would go. Or, you know, you have a lot of stuff that you need. You feel like you need to say to your mother, pretend she's in that chair and go for it. Tell her what you need to tell her. Role reversal is another technique where you take on the Persona. The client takes on the Persona of the other person. So in the last example, maybe you have a lot of resentment towards your mother. So role reversal, you would take your mother's perspective and you would act as if you were your mother and try to get into her head to understand her perspective a little bit. Role rehearsal is just what it sounds like, Envisioning what you're going to do and rehearsing it. And gestalt also works with dream work, which we're not going to get into a lot here. But, you know, that's one of the few techniques that still does do a fair amount of dream work. And finally, psychodynamic therapy rests on the premises that internal conflicts and their relation to the problem are central themes of treatment. So we want to look at, you know, you're depressed or whatever this is, this is the problem. What internal conflicts are causing that? Psychopathology develops especially from early childhood experiences. So psychodynamic therapists believe things happened in childhood and they're continuing to negatively impact you today. That's what's causing problems. Internal representations of experiences are organized around interpersonal relations. So psychodynamic is very interpersonally focused. So when we look back at experiences and we look at current experiences, we're looking at the relationships between people and maybe, you know, how does this person remind you of your mother? How have you recreated your family of origin? Life issues and dynamics will re emerge in the context of the therapeutic relationship as transference and countertransference. So we figure that people have a relatively ingrained way of responding, so they're going to act in therapy the way they act in the outside world, so to speak, so we can start addressing some of those issues. Distress is often marked by defense mechanisms and behavior is influenced by unconscious thought. And once vulnerable or painful feelings are processed, the defense mechanisms tend to reduce or resolve. So you know, you have this distress, which is why somebody's coming to treatment. Well, a lot of that distress is caused by defense mechanisms because you're sitting there going, I'm not going to deal with it, I'm not going to deal with it, I don't feel it. And underneath you're just like, it's like acid, it's burning. So once you deal with these underlying conflicts, you don't need the defense mechanisms to avoid dealing with it because it's not there anymore. There's peace, so to speak. Interventions in psychodynamic therapy Use of free association is a major method for exploration of internal conflicts and problems. So it's a lot less directive. There's a focus on interpretations of transference, defense mechanisms, current symptoms, and the working through of these present problems. There's a lot of interpretation in psychodynamic therapy. Clients often review emotions, thoughts, early life experiences and beliefs in order to gain insight into their lives and their present day problems. They can see why they react this way to this situation because of what happened back then. And then they can choose how they're going to react henceforth, forevermore. But first they need to understand how they got to this place. Psychodynamic therapy encourages clients to trust that insight about how their past is impacting their present is critically important. For success in therapy. So they have to be willing to buy into that whole stuff from the past is impacting the present. In psychodynamic therapy, the therapist will examine acts of the self towards others. You know, how do you interact toward other people? Do you trust them? Do you let them in? Do you have zero boundaries? What are your expectations about others? Reactions, the present and that'll help me learn a little bit about what may have happened in the past. Acts of others toward the person so how do people respond to you? And acts of the self toward the self? How do you act towards yourself? Are you demeaning and hateful towards yourself or do you care for yourself? Cognitive behavioral approaches address the connection between unhelpful thoughts and feelings and behaviors. The focus is often on changing thoughts or behaviors, and the feelings tend to improve. Behavioral interventions focus only on observable, measurable behaviors. Thoughts and feelings are irrelevant. So behavioral is just what what can you see? Humanistic therapists focus on helping people live as authentic, integrated whole organisms. And that includes person centered as well as gestalt therapy and psychodynamic therapies. Focus on how the past is influencing the person's present behaviors.