MODULE 13 EVIDENCED BASED PRACTICES
Title 450 Chapter 18
Standards and Criteria for Alcohol and Drug Treatment Programs
450:18-1-2. Definitions
"Evidence based practice" means programs or practices that are supported by research methodology and have produced consistently positive patterns of results when replicated within the intent of the published guidance.
Top Five Evidence-Based Practices Rated Most Familiar
Cognitive Behavioral Therapy: 93.8%
Trauma-Focused Cognitive Behavioral Therapy: 65.3%
Reality Therapy: 61.7%
Rational Emotive Therapy: 56.7%
Medication Management: 52.6%
Top Five Evidence-Based Practice Rated Most Used
Cognitive Behavioral Therapy: 81.4%
Trauma-Focused Cognitive Behavioral Therapy: 35.8%
Medication Management: 31.6%
Integrated Treatment for Mental Health and Substance Use: 29.2%
Motivational Interviewing: 27.2%
EVIDENCE BASED PRACTICES
MODALITIES & TECHNIQUES
BEHAVIORAL THERAPY / COGNITIVE BEHAVIORAL THERAPY / TRAUMA FOCUSED CAREDEFINITION
Behavioral therapy, or behavioral modification, is a psychological technique based on the premise that specific, observable, maladaptive, badly adjusted, or self-destructing behaviors can be modified by learning new, more appropriate behaviors to replace them.
ORIGINS
Reward and punishment systems have been used throughout recorded history in an attempt to influence behavior, from child rearing to the criminal justice system. Modern behavioral therapy began in the 1950s with the work of B.F. Skinner and Joseph Wolpe. Wolpe treated his patients who suffered from phobias with a technique he developed called systematic desensitization. Systematic desensitization involved gradually exposing a patient to an anxiety-provoking stimuli until the anxiety response was extinguished, or eliminated. Skinner introduced a behavioral technique he called operant conditioning. Operant conditioning is based on the idea that an individual will choose his behavior based on past experiences of consequences of that behavior. If a behavior was associated with positive reinforcements or rewards in the past, the individual will choose it over behavior associated with punishments.
By the 1970s, behavior therapy enjoyed widespread popularity as a treatment approach. Over the past two decades, the attention of behavioral therapists has focused increasingly on their clients' cognitive processes, and many therapists have begun to use cognitive behavior therapy to change clients' unhealthy behavior by replacing negative or self-defeating thought patterns with more positive ones.
BENEFITS
Behavioral therapy can be a useful treatment tool in an array of mental illnesses and symptoms of mental illness that involve maladaptive behavior, such as sub-stance abuse, aggressive behavior, anger management, eating disorders, phobias, and anxiety disorders. It is also used to treat organic disorders such as incontinence and insomnia by changing the behaviors that might be contributing to these disorders.
Cognitive-behavioral therapy, an offshoot of behavioral therapy that focuses on changing maladaptive behaviors by changing the faulty thinking patterns behind them, is a recommended treatment option for a number of mental disorders, including affective (mood) disorders, personality disorders, social phobia, schizophrenia, obsessive compulsive disorder (OCD), agoraphobia, post-traumatic stress disorder (PTSD), Alzheimer's disease, and attention-deficit hyperactivity disorder (ADHD). It is also frequently used as a tool to deal with chronic pain for patients with illnesses such as rheumatoid arthritis, back problems, and cancer.
Behavioral therapy techniques are sometimes combined with other psychological interventions such as medication. Treatment depends on the individual patient and the severity of symptoms surrounding the behavioral problem.
DESCRIPTION
Behavioral therapy, or behavior modification, is based on the assumption that emotional problems, like any behavior, are learned responses to the environment and can be unlearned. Unlike psychodynamic therapies, it does not focus on uncovering or understanding the un-conscious motivations that may be
behind the maladaptive behavior. In other words, behavioral therapists don't try to find out why their patients behave the way they do, they just teach them to change the behavior.
Initial treatment sessions are typically spent explaining the basic tenets of behavioral therapy to the patient and establishing a positive working relationship between therapist and patient. Behavioral therapy is a collaborative, action-oriented therapy, and as such, it empowers patients by giving them an active role in the treatment process. It also discourages overdependence on the therapist, a situation that may occur in other therapeutic relationships. Treatment is typically administered in an out-patient setting in either a group or individual session. Treatment is relatively short compared to other forms of psychotherapy, usually lasting no longer than 16 weeks or sessions.
There are a number of different techniques used in behavioral therapy to help patients change their behaviors. These include:
- Behavioral homework assignments. The therapist often requests that the patient complete homework assignments between therapy sessions. These may consist of real-life behavioral experiments where patients are encouraged to try new responses to situations discussed in therapy sessions.
- Contingency contracting. In conjunction with the patient, the therapist outlines a written or verbal contract of desired behaviors for the patient. The contract may have certain positive reinforcements (rewards) associated with appropriate behaviors and negative reinforcements (punishments) associated with maladaptive behavior.
- Modeling. This is where the patient learns a new behavior through observation.
- Rehearsed behavior. The therapist and patient engage in role-playing exercises in which the therapist acts out appropriate behaviors or responses to situations.
- Skills training techniques. The patient undergoes an education program to learn social, parenting, or other relevant life skills.
- Conditioning. The therapist uses reinforcement to encourage a particular behavior. For example, a child with ADHD may get a gold star every time he stays focused on tasks and accomplishes certain daily chores. The gold star reinforces and increases the desired behavior by identifying it with something positive. Reinforcement can also be used to extinguish unwanted behaviors by imposing negative consequences (this is also called punishment and response).
- Systematic desensitization. Patients are gradually exposed to a situation they fear, either in a role-playing situation or in reality. The therapist will employ relaxation techniques to help them cope with their fear reaction and eventually eliminate the anxiety altogether. For example, a patient in treatment for agoraphobia, a fear of open or public places, will relax and then picture herself on the sidewalk outside of her house. In her next session, she may relax herself and then imagine a visit to a crowded shopping mall. The imagery gets progressively more intense until eventually, the therapist and patient approach the anxiety-producing situation in real life by visiting a mall. By repeatedly pairing a desired response (relaxation) with a fear-producing situation (open, public spaces), the patient gradually becomes desensitized to the old response of fear and learns to react with feelings of relaxation.
- Flooding. Flooding is an accelerated version of systematic desensitization, in which the patient is exposed directly to the anxiety-provoking situation that he fears most (either through mental visualization or real life contact) in an effort to extinguish the fear response.
- Progressive relaxation. As the name implies, progressive relaxation involves complete relaxation of the muscle groups of the body and calm and even breathing until the body is completely tension free. It is used by behavioral therapists both as a relaxation exercise to relieve anxiety and stress, and as a method of preparing the patient for systematic desensitization. Progressive relaxation is performed by first tensing and then relaxing the muscles of the body, one group at a time. The therapist may suggest that the patient use one of many available instructional relaxation tapes for practicing this technique at home.
Additional treatment techniques that may be employed with cognitive-behavioral therapy include:
- Cognitive rehearsal. The patient imagines a difficult situation, and the therapist guides him through the step-by-step process of facing and successfully dealing with it. The patient then works on practicing, or rehearsing, these steps mentally. Ideally, when the situation arises in real life, the patient will draw on the rehearsed behavior to address it.
- Journal therapy. Patients are asked to keep a detailed diary recounting their thoughts, feelings, and actions when specific situations arise. The journal helps to make the patient aware of his or her maladaptive thoughts and to show their consequences on behavior. In later stages of therapy, it may serve to demonstrate and reinforce positive behavior.
- Validity testing. Patients are asked to test the validity of the automatic thoughts and schemas they encounter. The therapist may ask the patient to defend or produce evidence that a schema is true. If the patient is unable to meet the challenge, the faulty nature of that schema is exposed.
- Biofeedback. Biofeedback is a patient-guided treatment that is also associated with behavioral therapy. Biofeedback teaches an individual to control muscle tension, pain, body temperature, brain waves, and other bodily functions and processes through relaxation, visualization, and other techniques. In some cases, positive reinforcements are used to reward patients who generate the correct biofeedback response during treatment. The name biofeedback refers to the biological signals that are fed back to the patient in order for the patient to develop techniques of controlling them.
Patients may seek therapy independently, or be referred for treatment by a primary physician, psychologist, psychiatrist, or other healthcare professional. Because the patient and therapist work closely together to achieve specific therapeutic objectives, it is important that their working relationship be comfortable and that their treatment goals are compatible. Prior to beginning treatment, the patient and therapist should meet for a consultation session, or mutual interview. The consultation gives the therapist the opportunity to make an initial assessment (a detailed behavioral analysis of the particular incidents which lead up to and ensue after a specific unwanted behavior) of the patient and recommend a course of treatment and goals for therapy. It also gives the patient an opportunity to find out important details about the therapist's approach to treatment, professional credentials, and any other relevant issues important to them.
In some managed-care clinical settings, an intake interview or evaluation is required before a patient begins therapy. The intake interview is used to evaluate the patient and assign him or her to a therapist. It may be conducted by a psychiatric nurse, counselor, or social worker.
PRECAUTIONS
Behavioral therapy may not be suitable for some patients. Those who don't have a specific behavioral issue they wish to address and whose goals for therapy are to gain insight into the past may be better served by psychodynamic therapy. Patients must also be willing to take a very active role in the treatment process.
Behavioral therapy may also be inappropriate for cognitively-impaired individuals (e.g., patients with organic brain disease or a traumatic brain injury) depending on their level of functioning.
Because of the brief nature of behavioral therapy, relapse has been reported in some patient populations. However, follow-up sessions can frequently put patients back on track to recovery.
RESEARCH & GENERAL ACCEPTANCE
The use of behavioral modification techniques to treat an array of mental health problems have been extensively described and studied in medical literature. There may be some debate among mental health professionals as to whether behavioral therapy should be considered a first line treatment for some mental illnesses, and to what degree other treatments such as medication should be employed as an adjunct, or complementary, therapy. However, the general consensus seems to be that behavioral therapy techniques can be a powerful treatment tool for helping patients change undesirable behaviors.
TRAINING & CERTIFICATION
Behavioral therapists are typically psychologists (Ph.D., Psy.D., Ed.D., or M.A. degree), clinical social workers (M.S.W., D.S.W., or L.S.W. degree), counselors (M.A. or M.S. degree), or psychiatrists (M.D. with specialization in psychiatry). Other healthcare providers may suggest brief behavioral interventions, but more extensive treatment should be left to individuals who are trained in behavioral therapy techniques.
BOOKS
Mills, John. Control: A History of Behavioral Psychology. New York: New York University Press, 1998.
PERIODICALS
Gelder, M."The Future of Behavior Therapy." Journal of Psychotherapy Practice. 6, no. 4 (Fall 1997):285-93.
ORGANIZATIONS
The National Association of Cognitive-Behavioral Therapists. P.O. Box 2195, Weirton, WV 26062. (800) 853–1135.
Paula Ford-Martin
COGNITIVE-BEHAVIORAL THERAPY... is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do.
Cognitive-behavioral therapy does not exist as a distinct therapeutic technique. The term "cognitive-behavioral therapy (CBT)" is a very general term for a classification of therapies with similarities. There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.
However, most cognitive-behavioral therapies have the following characteristics:
1. CBT is based on the Cognitive Model of Emotional Response.
Cognitive-behavioral therapy is based on the idea that our thoughts cause our feelings and
behaviors, not external things, like people, situations, and events. The benefit of this fact is that we
can change the way we think tofeel / act better even if the situation does not change.
2. CBT is Briefer and Time-Limited.
Cognitive-behavioral therapy is considered among the most rapid in terms of results obtained. The
average number of sessions clients receive (across all types of problems and approaches to CBT) is
only 16. Other forms of therapy,like psychoanalysis, can take years. What enables CBT to be
briefer is its highly instructive nature and the fact that it makes use of homework assignments. CBT
is time-limited in that we help clients understand at the very beginning of the therapy process that
there will be a point when the formal therapy will end. The ending of the formal therapy is a
decision made by the therapist and client. Therefore, CBT is not an open-ended, never-ending
process.
3. A sound therapeutic relationship is necessary for effective therapy, but not the focus.
Some forms of therapy assume that the main reason people get better in therapy is because of the
positive relationship between the therapist and client. Cognitive-behavioral therapists believe it is
important to have a good, trusting relationship, but that is not enough. CBT therapists believe that
the clients change because they learn how to think differently and they act on that learning.
Therefore, CBT therapists focus on teaching rational self-counseling skills.
4. CBT is a collaborative effort between the therapist and the client.
Cognitive-behavioral therapists seek to learn what their clients want out of life (their goals) and then
help their clients achieve those goals. The therapist's role is to listen, teach, and encourage, while
the client's roles is to express concerns,learn, and implement that learning.
5. CBT is based on aspects of stoic philosophy.
Not all approaches to CBT emphasize stoicism. Rational Emotive Behavior Therapy, Rational
Behavior Therapy, and Rational Living Therapy emphasize aspects of stoicism. Beck's Cognitive
Therapy is not based on stoicism.
Cognitive-behavioral therapy does not tell people how they should feel. However, most people
seeking therapy do not want to feel they way they have been feeling. The approaches that emphasize
stoicism teach the benefits of feeling, at worst, calm when confronted with undesirable situations.
They also emphasize the fact that we have our undesirable situations whether we are upset about
them or not. If we are upset about our problems, we have two problems -- the problem, and our
upset about it. Most people want to have the fewest number of problems possible. So when we
learn how to more calmly accept a personal problem, not only do we feel better, but we usually put
ourselves in a better position to make use of our intelligence, knowledge, energy, and resources to
resolve the problem.
6. CBT uses the Socratic Method.
Cognitive-behavioral therapists want to gain a very good understanding of their clients' concerns.
That's why they often ask questions.They also encourage their clients to ask questions of
themselves, like, "How do I really know that those people are laughing at me?" "Could they be
laughing about something else?"
7. CBT is structured and directive.
Cognitive-behavioral therapists have a specific agenda for each session.Specific techniques /
concepts are taught during each session. CBT focuses on the client's goals. We do not tell our