Topic 8: Core Beliefs & Behavioral Exposure {by 10/31}

[Core Beliefs] – Watch MDD-18: Core Beliefs – Modifying 3 – Behavioral Experiment [MDD-18: Early Session Stage – Late Phase on website].  Answer the following (you can be brief): (1) In what ways was this behavioral experiment helpful in providing “evidence” for this client’s new core belief?  (2) What could be another behavioral experiment for this client that could potentially strengthen his new core belief?

 

[Behavioral Exposure] – There is one reading due this week (Volungis – 1 Chapter).  For this discussion, share at least two main thoughts: (1) Why is behavioral exposure very effective for certain disorders/types of distress?  (2) What are some cautions to consider when implementing behavioral exposure interventions?  Your original post should be posted by the beginning of class 10/31.  Have your two replies posted no later than 11/2.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

28 Comments (+add yours?)

  1. Adam Rene
    Oct 29, 2019 @ 16:02:37

    [Core Beliefs]

    1. I felt that this experiment provided Mark with a plethora of evidence for his new core belief. Mark appeared bright and excited in the session as he discussed how his behavioral experiment went. Mark did note the apprehension he experienced and he correctly identified some negative automatic thoughts, but the fact that he committed himself to his plan and had a backup plan in case things did not go how he expected ultimately was very helpful for him. Mark noted in the session that he ‘pushed himself out of his comfort zone’ and that he wouldn’t have been ready for this in previous weeks, which I believe speaks to the importance of establishing an understanding of core beliefs and not jumping to a behavioral experiment too quickly. When Dr. V asks Mark what ‘evidence’ he could think of after he discussed how the date night went, Mark stated that his friends ‘laughed with him’ and that they ‘wanted to do it again.’ Mark also indicated that he was okay with the discussion of future plans not being solidified at that time and that he appreciated how they chose to spend time with him and Melissa. One particular moment that I found interesting was when Mark was discussing how the night was ‘almost perfect’ and he included how he got to the place they planned to meet on time and that he and Melissa didn’t have any issues getting ready to go – and then Mark caught himself and said “Well, I didn’t have any issues getting going…” I felt that this comment in particular was excellent, as Mark caught himself and owned his own role in that situation as compared to previous sessions where Mark was having a lot of difficulty connecting his thoughts -> emotions -> behaviors.

    2. As for a new behavioral experiment for Mark to reinforce his new core belief, maybe Mark could seek to set up a weekly or biweekly lunch with a coworker. If this coworker agrees, it could be some semi-frequent opportunities for Mark to reinforce his likeability and connect with another person more often. It could also be a good opportunity for when this person cancels for Mark to practice some strategies to manage any emotions or thoughts that may arise.

    [Behavioral Exposure]

    1. Behavioral exposure can be a very effective technique for certain disorders and types of distress simply because it focuses on ‘exposure.’ According to Dr. V’s text, exposure literally has the opposite effect of avoidance and the avoidance is often why clients are presenting for therapy. As clients come to face these situations they have avoided, they will experience emotionally or physiologically some anxiety or fear but cognitively they will come to see that the situation is not threatening and create new coping strategies to manage current distress and thus set themselves up for future adaptability. For anxiety, behavioral exposure is a great intervention to use since anxiety is characterized by a worry regarding the future and the distorted thoughts that can come along with it. Just recently, a client I’m working with was looking to apply for a job at a local movie theater. Upon arriving in the parking lot, my client completely froze up and refused to leave my car. As we processed, I found that he had no relaxation techniques established – so I spent the next several weeks leading up to now working with this client on in-the-moment relaxation techniques so that this client can feel comfortable trying the movie theater again and having established strategies for the future.

    2. With regard to behavioral exposure, it is important to know what challenges can occur. According to Dr. V’s text, there are several common challenges ranging from a client’s difficulty assessing anxious and fearful patterns to hesitation regarding in vivo exposure techniques. It would be important to establish with a client early on the differences between anxiety and fear as well as potentially using hierarchy of feared situations for graded exposure to gain an understanding of what is most distressing to the client. Also, as stated during my example above, it would be important not to rush into behavioral exposure before the client has solid understanding of their own core beliefs, automatic thoughts, and that the client has a desire to make changes and modify their own core belief(s).

    Reply

    • Tricia Flores
      Oct 30, 2019 @ 16:30:52

      Adam- I appreciated your example of working with the client to develop coping strategies in the form or relaxation techniques. Identifying that as a skill for him to use to meet his goals was a good plan. With having that skill in his tool box he will hopefully be better able to meet other goals such as applying for a job.

      Reply

    • Kelsey Finnegan
      Oct 30, 2019 @ 20:17:49

      Adam,

      I like your idea for Mark to initiate regular outings with a coworker. This will both provide him with additional positive evidence to reinforce his new core belief, and give him an opportunity to experience rejection from the lens of his new core belief. Ideally, with this new core belief and supporting evidence, Mark will be able to modify his response and cope with any negative emotions that may arise in a more adaptive way.

      Reply

    • Katrina Piangerelli
      Oct 30, 2019 @ 21:36:32

      Adam, I think you had some great insight on Mark’s experience with the behavioral experiment. I agree that Mark does seem to appear to be doing better, based on his body language and facial expressions. I think that these observations are really important to make because they show the progress that Mark is making, along with his ability to identify negative automatic thoughts and be engaged in therapy sessions. Your idea for Mark’s next behavioral experiment is similar to mine, although I said that it may be best for him to ask an employee out to lunch once rather than having a standing weekly or biweekly lunch. I think that both of these options are things that Mark has struggled with, and the recent issue with Mark’s coworkers going to lunch without him may cause him difficulty in completing this behavioral experiment. In the behavioral exposure questions, I really liked how you used a personal example from your current job to gain a deeper understanding of the material. I think applying this to your job helps solidify these ideas for you, and also for the reader, as we see the behavioral exposure being applied.

      Reply

    • Paola Gutierrez
      Oct 31, 2019 @ 10:17:25

      Adam — I really appreciate how you incorporate your own professional work and experience with the topics we’re discussing in class. It helps to put another perspective to the CBT skills and techniques we’re learning. I agree that you may have to teach your client relaxation exercises or maybe try to change some maladaptive coping strategies (such as avoidance) for exposure to be most effective. Overall, your post was well written!

      Reply

    • Zacharie Duvarney
      Oct 31, 2019 @ 12:33:09

      Adam,

      Regarding your suggestions for a new behavioral experiment, I like how you suggested that Mark establish a schedule for socializing. I believe people are more likely to execute goals when they commit to them in advance. Furthermore, Mark seems to experience anxiety over logistical concerns involved in making plans. Perhaps having a schedule will assist him in overcoming this anxiety.

      Good work!

      Reply

    • Anthony Mastrocola
      Nov 01, 2019 @ 13:23:20

      Hi Adam,
      You identified an important part of the video in the first response. Mark was certainly weary about participating in the behavioral experiment. You spoke about Mark’s negative automatic thoughts based around his apprehension for asking his coworkers out. I believe what makes this scene so impressive for Mark is how Mark was able to experience negative thoughts and still commit to the plan.

      Reply

  2. Tricia Flores
    Oct 30, 2019 @ 16:26:49

    1. Mark’s behavior experiment provided ample evidence to support his new core belief. Mark stated that the behavior experiment went “it went better than expected,” and “I’m kind of proud of how it went.” Mark’s alternative core belief to being unlikeable he identified as “I’m kind of a likeable guy.” He identified possible evidence that could show his alternate core belief was true including spending more time with colleges and friends, having fun, feeling valued. Evidence to support the alternate core belief included Mark saying “as soon as I asked they said they would love to go,” “they laughed with me,” “they wanted to do it again,” “they liked me,” and “the door is open for us to do it again.” Evidenced identified as reasons why the old core belief was not valid included “they asked to go out again,” “that they spent time with us,” and Mark noted “I felt proud that I put myself out there.” Mark noted “I feel better about myself already” and “I feel that I am making progress.”
    2. Another behavioral experiment that Mark could conduct that could potentially strengthen his new core belief could be asking coworkers out to lunch and then not withdrawing after they say no. Mark could start with making plans with his close co-workers ahead of time and then work towards asking coworkers whom he is not as close with for lunch or coffee. They key would be how to deal with rejections as not rejections against him, but stating no to going out to lunch/coffee. The task would be not to withdraw afterwards and continuing with what he suggested as a plan by himself. The next step would be to develop behavioral experiments to address feelings of worthlessness, especially getting things done at work.
    1. Behavior exposure is effective for certain disorders/types of disorders because it addresses anxiety-related distress. Anxiety is a cognitive and behavioral process that is future oriented. When a person is anxious they have negative automatic thoughts and increased physiological arousal. As a result, the person avoids the distress both cognitively and behaviorally because of the perception that it is a threat. By avoiding the distress, the person has a decrease in anxiety and learns they are safe through negative reinforcement. The short-term relief that is experienced means that they do not learn skills to deal with the distress and continue to use avoidance. Behavior exposure is utilized for this because what is being avoided needs to be confronted to break the avoidance pattern. Beyond the exposure, the negative automatic thoughts may also need to be addressed because the thoughts can start or continue maladaptive behaviors.
    2. Some cautions to consider when implementing behavioral exposure interventions include developing well worded feared situations and alternatives, identifying unhelpful coping strategies that could impede the success, and developing a range of expected anxiety in order to not make it too easy or too difficult. Unhelpful coping strategies include safety behaviors such as superstitious objects or behaviors to get through exposure activities. When safety behaviors aren’t avoided or phased out the person does not truly learn to address their fears independently and break the negatively reinforced behavior pattern.

    Reply

    • Kelsey Finnegan
      Oct 30, 2019 @ 20:10:13

      Tricia,
      I appreciate your suggestions for additional behavioral experiments for Mark. I agree that it would be beneficial for Mark to do a behavioral experiment that involves rejection. This way he can learn how to cope with these rejections, and he will hopefully realize that they are not a reflection of his likability because he now has solid evidence that he is a likable person. Ideally, this will also help break Mark’s tendency to personalize social rejection.

      Reply

    • Katrina Piangerelli
      Nov 02, 2019 @ 14:58:52

      Tricia, your description of Mark’s evidence for his new core belief is very helpful. I think that you were able to recognize when Mark shifted to providing evidence to support his new core belief and the positive nature of what Mark explained. You then explain that another behavioral experiment could be asking his coworker out for lunch. This is the same thing I put for what I thought would strengthen Mark’s new core belief as well. I think that this experience would be good for Mark and allow him to either cope with being rejected or provide more evidence for his new core belief. I agree with your description of behavioral exposure and I think that you defined it in a clear and direct way. You also describe why this is more helpful for people who experience anxiety which is similar to my description as well. I think that you identified some great things to implement prior to the intervention of behavioral exposure. This would then set the client up for success and prepare them for the exposure.

      Reply

  3. Kelsey Finnegan
    Oct 30, 2019 @ 19:59:11

    [Core Beliefs]

    (1) This behavioral experiment was helpful in providing evidence for Mark’s new core belief. Mark appeared to be in a significantly better mood during this session, and he was eager to recount the results of the experiment with Dr. V. Mark went out of his comfort zone by asking some acquaintances to go out with him and Melissa, and they eagerly agreed to go. Mark noted that before he was sometimes too nervous to even ask his close friends like George and Jeff out, but now he feels confident asking people he does not know as well to hang out. Fortunately, the outing went well, which generated a lot of evidence to support Mark’s new belief that he is likable. For example, Mark said they laughed, had a good time, and he felt valued. His friends even explicitly said they enjoyed their time with him, and suggested hanging out again in the future. They would not do this if they did not like Mark. Ultimately, Mark felt proud of himself and this experience provided solid evidence to support his new core belief.

    (2) Another good behavioral experiment for Mark would be to ask George to hangout. It seems like George has a tendency to cancel last minute, or already has plans when Mark asks him to hangout. This would provide Mark with the opportunity to draw upon his new core belief to change his behavioral response to rejection. If Mark feels upset and his typical automatic thoughts arise, he can recall his new found evidence for his core belief that he is likable. Mark can remind himself that his friends would not have told him they enjoyed spending time with him if he was an unlikable person. This will help Mark be less likely to withdraw, and do something enjoyable with Melissa instead. Subsequently, Mark will realize that he can handle rejection, and that rejection is not necessarily a reflection of his friend’s feelings towards him. It might also be a good idea for Mark to start a new hobby, class, or volunteer position that would provide him with an opportunity to form new connections with people who have similar interests. This could also potentially help Mark make new friends who he can call when his other friends are unable to spend time with him.

    [Behavioral Exposure]

    (1) Why is behavioral exposure very effective for certain disorders/types of distress? Behavioral exposure techniques are very effective for many anxiety disorders such as OCD, panic disorder, PTSD, and most phobias. When clients are anxious, they have a tendency to avoid whatever is causing their distress because this temporarily reduces their anxiety and brings them emotional relief. This emotional relief negatively reinforces the avoidance behavior, so clients learn to avoid similar stressors in the future. Avoidance is effective at providing short-term relief, but it prevents clients from learning effective coping skills. Therefore, clients will continue to feel anxious when confronted with similar situations because they haven’t had the opportunity to work through them. Behavioral exposure works by confronting these avoided situations, so clients can learn that their anxiety and fear will dissipate with time. Through the process of exposure, clients will develop effective coping skills and modify the negative automatic thoughts that fuel their anxiety. The automatic thoughts that accompany these distressing situations are often what initiates the avoidance behavior, so it is important to work on these prior to exposure. It’s also helpful to implement relaxation techniques such as diaphragmatic breathing and visualization. When initially confronting the feared situation, client’s physiological responses to the fear will increase, but after 20 or 30 minutes the sympathetic nervous system stops working in overdrive and this fear goes away. After several exposures, clients will notice that nothing harmful happened and they will learn to adapt to the feared situation.

    (2) In order to avoid common pitfalls, there are several important considerations to keep in mind when implementing behavioral exposure interventions. First, it is important to properly word feared situations in a manner that is specific, concrete, and measurable. This will help clarify how to complete each step of the exposure hierarchy. It is also imperative that you and the client work together to identify unhelpful coping strategies that may stand in the way of successful exposure activities. These will need to be avoided or phased out during exposures, so clients can learn how to confront the feared situation independently. Otherwise, clients may think that their safety behaviors protected them, when in reality, there was no danger to be protected from in the first place. Additionally, clients may be hesitant to start in vivo exposure techniques, so it is important to start with small, simple steps and review their reasons for doing the exposure.

    Reply

    • Tricia Flores
      Oct 31, 2019 @ 08:42:40

      Kelsey- I agree that paying attention to the safety behaviors and bringing them to the client’s awareness is important. This is one of the new things I learned in this chapter/section. I had heard a great deal exposure therapy through other outlets, but prior to this class had not considered the impact of safety behaviors on exposure therapy. It appears to be an essential component to understanding and implementing the techniques. Previously I had mostly thought about safety behaviors only in terms of OCD.

      Reply

    • Bianca Thomas
      Oct 31, 2019 @ 11:26:07

      Kelsey, Mark did seem to be in a much better mood during the session, and he did appear to be eager to jump right in. I also agree with your suggestion that he ask George to hang out, in order to give him the opportunity to really test his new core belief and to effectively cope with possible rejection.

      Reply

    • Adam Rene
      Oct 31, 2019 @ 13:15:53

      Kelsey –

      Thank you for your post. Seeing similarities amongst our responses was helpful in ensuring that we all comprehended and appraised Mark’s therapy session accurately. In particular, I liked your idea regarding volunteer opportunities. I hadn’t considered this, but this could open up Mark to new environments where he has not previously encountered a situation that has fueled his negative core belief. Engaging in a new setting with new people could provide Mark more unique opportunities to test out his new core belief.

      Reply

  4. Katrina Piangerelli
    Oct 30, 2019 @ 21:35:25

    [Core Beliefs] – Watch MDD-18: Core Beliefs – Modifying 3 – Behavioral Experiment [MDD-18: Early Session Stage – Late Phase on website]. Answer the following (you can be brief):
    (1) In what ways was this behavioral experiment helpful in providing “evidence” for this client’s new core belief?

    The behavioral experiment allowed Mark to try out asking some friends to dinner. Despite these people not being very close to Mark, he asked them to dinner and had a great time with them. This was something that he was initially nervous about, and even brainstormed ways to cope if the night did not go as planned. The behavioral experiment accounted for Mark troubleshooting if the couple canceled or if they were unable to make it at the last minute. Mark expressed feeling valued and said that the couple indicated they would like to have dinner again sometime because they enjoyed themselves. Some more evidence that Mark is likeable is the fact that this couple did say yes in the first place. We have watched Mark transform throughout these videos, and in the most recent video regarding the behavioral experiment, he seemed to be much more comfortable with himself and able to recognize when he had negative automatic thoughts. This behavioral experiment also allowed Mark to push himself in ways that he probably would not have considered in the first few therapy sessions. Evidence for Mark’s new core belief was found as he reflected on how the behavioral experiment went. Mark disclosed that he got along very well with his dinner companions and that they even wanted to meet up again in the near future. This behavioral experiment provided evidence for Mark to recognize that he is likable to some people and is able to spend time and enjoy his time with others.

    (2) What could be another behavioral experiment for this client that could potentially strengthen his new core belief?

    A behavioral experiment that Mark may be able to participate in is potentially asking a coworker to have lunch with him. I think that with the recent event of his co workers having lunch without him, this may be particularly challenging for Mark, but it may also push him in the right direction. I think this challenge after his previous successful behavioral experiment would hopefully give Mark the confidence to be able to ask someone at work if they would like to have lunch with him. It would also be important for Mark to plan some coping skills as well as have a back up plan like he did for his previous behavioral experiment. This will allow him to be prepared if the coworker is not able to have lunch or cancels on Mark.

    [Behavioral Exposure] – There is one reading due this week (Volungis – 1 Chapter). For this discussion, share at least two main thoughts:
    (1) Why is behavioral exposure very effective for certain disorders/types of distress?

    Behavioral exposure is used to help relieve anxiety related distress. Behavioral exposure techniques are rooted in the idea that clients should be exposed to what is causing them to be anxious. This exposure has the opposite effect of avoidance, with the repeated exposure eventually leading to a decrease in distress. Clients begin to learn that this situation is not threatening and also to develop behavioral and coping skills that will help them manage distress in the future. Clients will then face the situations that they have been avoiding and experience the emotional and psychological symptoms triggered from the stimulus. This allows the client to react and then develop new coping strategies to manage their distress in this new situation. Behavioral exposure works particularly well with anxiety because anxiety involves worrying about something in the future and having negatively distorted thoughts about this future event.

    (2) What are some cautions to consider when implementing behavioral exposure interventions?

    Some cautions to consider are the increase in distress, anxiety, and fear that will be associated with the initial exposure, as this is something that the client has been avoiding. There can also be complications with the client assessing situations that may cause anxiety and fear. The client may need assistance in understanding the difference between the two, as outlined in this chapter.

    Reply

    • Paola Gutierrez
      Oct 31, 2019 @ 10:13:51

      Katrina – I agree that asking a coworker out to lunch might be a good next step. I think that having opportunities to strengthen Mark’s new core belief of being a “generally likable” person might help not only encourage him to take initiative in asking friends to meet up, but not take it as harshly if friends turn him down. It also provides an opportunity to strengthen Mark’s coping skills if coworkers turn down an invitation or cancel last minute.

      Reply

  5. Paola Gutierrez
    Oct 31, 2019 @ 10:09:55

    Core Beliefs/Behavior Experiment

    1. The behavioral experiment was designed to provide “evidence” for Mark’s new core belief that he is a generally likeable person. Several facets of this experiment were helpful in reinforcing the new core belief. First, Mark asked out acquaintances as opposed to close friends or coworkers who had a closer relationship with Mark. This decision aligns with the “generally” part of the core belief. The fact that Mark’s invitation was accepted and followed through also strengthens the new core belief. Finally, Mark was evidently pleased and excited that the other couple had fun with Mark and were interested in hanging out again. These other people wouldn’t have made such comments if they hadn’t enjoyed their time with Mark. I think this behavioral experiment also helped to provide evidence for the new core belief because Mark recognized negative automatic thought patterns, such as “what if they don’t value me?” and was able to challenge them through the behavioral experiment.

    2. I noticed that Mark said a few times that the other couple seemed to like “spending time with us” (meaning Mark and Melissa) as opposed to “like spending time with me.” To strengthen the new core belief, I think Mark needs to do more behavioral experiments on his own (without Melissa) because I could see how Mark might say “oh well they didn’t necessarily like spending time with me, they actually enjoyed Melissa’s company more” which would detract from his new core belief. Other behavioral experiments for Mark might include one-on-one outings with friends or coworkers, such as Jeff.

    Behavioral Exposure

    1. Behavioral exposure is especially effective for anxiety-related disorders (i.e., social phobia, PTSD, panic disorder with agoraphobia) and types of distress (such as poor problem-solving or coping skills) because anxiety involves worry about future events. A common theme in anxiety is to avoid the situation or stimulus that provokes anxiety. Exposure involves breaking the avoidance pattern by basically confronting the situation/stimulus that causes anxiety or distress. The behavioral avoidance offers negative reinforcement (reduction of distress) in the short-term, but often creates long-term problems. Exposure works by demonstrating that the fear/anxiety is manageable, will likely reduce after repeated exposure exercises, and that the situation/stimulus is not actually a threat. Clients also learn that they are able to cope with the anxiety and decatastophize the situation.

    2. Some considerations before implementing behavioral exposure is to acknowledge to the client that the initial exposure will likely result in increased anxiety and physiological arousal, but that over time, these reactions will decrease. It is also important to note the client’s maladaptive coping strategies and/or safety behaviors (which should be phased out eventually). Graded exposure/hierarchy of fear and creating measurable and realistic goals for anxiety reduction, is also necessary for the effectiveness of intervention so that client is ready for in vivo exposure of the feared stimulus. Lastly, some disorders (such as panic disorder) may not benefit from initial fear modification (modifying automatic thoughts) in combination with exposure, and may in fact reinforce certain safety behaviors. These are all some factors to be aware of when implementing exposure interventions.

    Reply

    • Bianca Thomas
      Oct 31, 2019 @ 11:23:20

      Paola, your considerations before implementing behavioral exposure were very insightful. I like how you initially started off by mentioning how the initial exposure will likely result in increased anxiety and physiological arousal. I also agree with your statement that the maladaptive coping strategies or safety behaviors should be phased out before attempting.

      I also appreciating your insight on how Mark mentioned that people liked spending time with “us” as opposed to just him, and your suggestion of doing behavioral experiments excluding Melissa first, in order to see how strong the new core belief truly is.

      Reply

    • Zacharie Duvarney
      Oct 31, 2019 @ 12:30:31

      Paola,

      I liked how you broke down Mark’s new core belief and stated which pieces of evidence corresponded with each part. This is something I hadn’t considered doing.

      I also thought you were correct in stating that Mark needs to perform future experiments on his own (without Melissa). Mark has certainly made progress, however, he is still working within his “comfort zone”. I think that it would be constructive for Mark to engage in behavioral experiments that involve new experiences.

      Nice work!

      Reply

  6. Bianca Thomas
    Oct 31, 2019 @ 11:19:10

    Core Beliefs
    1. The behavioral experiment was helpful in providing evidence for Mark’s new core belief that he is actually pretty likeable by showing Mark that people do actually want to spend time with him, and that when he asked his colleagues to go out with him and Melissa, that they would want to be around him. Mark had some initial apprehension before partaking in the behavioral experiment, but he was very pleased that his colleagues had said yes, and even in the event that they said no, he had a coping skill in place to deal with the situation, and still go out and enjoy himself.

    2. I think another behavioral experiment for this client that could potentially strengthen his new core belief is to ask a new colleague who he has not yet become acquainted with, out for lunch or to hang out, in order to show that meeting new people is not as difficult or scary as it seems, and that he is someone people want to know and spend time with.

    Behavioral Exposure
    1. Behavioral exposure is incredibly effective for certain disorders and types of stress because it allows the individual to stop avoiding the sources of distress that they experience, and to discontinue the maladaptive learned coping skills they deemed “safe,” and to replace them with facing the challenge in a sequenced manner to overcome, over time, their fear and discontinue the negative reinforcement. As stated in the textbook, in order to break the avoidance pattern, clients need to be exposed to what makes them anxious.

    2. Some cautions to consider when implementing behavioral exposure interventions include jumping too quickly to high ranking feared situations, pushing the client to perform the behavioral experiment when they aren’t ready, or not adequately teaching the relaxation techniques necessary to cope with feared exposure situations. Another caution includes not working on the automatic thoughts and core beliefs before suggesting to a client to try a behavioral exposure technique.

    Reply

  7. Olivia L Corfey
    Oct 31, 2019 @ 12:04:20

    Core Beliefs

    1. By walking through how behavioral experiment went with the client and identifying reasons for the new core belief and against the old core belief, it helps to solidify the new core belief. Mark provided many examples of evidence for his new core belief. Mark stated he was proud of himself for putting himself out there even thought he was a little hesitant. Mark said he felt as though they enjoyed having him around and genuinely enjoyed his company. These positive thoughts and feelings helped to solidify the new core belief while finding little evidence to support his old core belief. The behavioral experiment provided a way for mark to confront his feared situation rejection. Although mark was prepared for this scenario with coping skills, thankfully his friends said yes to outing and stated they would want to get together soon. As Mark knew the dates were not set in stone, he knew the doors were open. Mark’s perception upon of the lack of set dates indicates the his belief in his new core belief.

    2. Another area Mark could use a behavioral experiment is at his workplace. Scheduling a weekly lunch outing with a co-worker or multiple co-workers may be another way to strengthen his new core belief of being likable. If Mark is able to feel generally likable in his home environment as well as work environment, this will strengthen this will continue to strengthen his new core belief.

    Behavioral Exposure

    1. Many disorders include avoidance behaviors, from agoraphobia, to GAD. Avoidance behaviors are typically negative reinforcements that strengthen the behavior through removing or avoiding the believed negative outcome. As avoidance behaviors may seem to provide comfort in the short term, these behavior perpetuate continued distress. The individual is unable to learn how to cope with their source of distress. The fear of negative outcomes it sometimes based upon the result of previous outcomes. Therefore, the safety behaviors reassure the perceived negative outcome will be avoided. Behavioral exposures impede on the comforts of avoidance behaviors by stopping the negative reinforcement pattern of avoidance. Behavioral exposures involve client’s confronting their perceived fearful situation or event and learning how to adapt and cope with the situation and immediate increased distress. As avoidance behaviors may form a habitual pattern of short-term comfort, behavioral exposures are very effective with ending the negative cycle of avoidance.

    2. As avoidance behaviors are typically strongly reinforced, there are some challenges to consider when varying out behavioral exposure techniques. Clients may have difficulty identifying the anxious and fearful patterns. The clinician may want to focus on avoidance behavior patterns that are in response to a particular situation or event. Identifying their physiological arousal may provide a path to the client’s anxious thoughts, as physiological arousal is a response to the thought. Clients may also experience hesitancy toward relaxation techniques or vivo exposure techniques. Relaxation techniques are an important coping skill that help lower levels of distress. Relaying the effectiveness of relaxation techniques may help clients become more open to practicing the techniques. As clients are also hesitant to start in vivo exposure techniques, it is important to begin with small steps. It is also important to remind hesitant clients of their previous progress with the relaxation techniques and modifying anxious thoughts. This reminder may motivate the clients to confront their feared situations.

    Reply

    • Adam Rene
      Oct 31, 2019 @ 13:11:26

      Olivia –

      Thank you for your post. I found many similarities amongst our answers in the core belief section regarding our perceptions of evidence for Mark’s core belief as well as a similar behavioral experiment for Mark. I appreciated what you included regarding avoidance behaviors, I hadn’t considered that explicitly in my reading on behavioral exposure. This was helpful for me.

      Reply

    • Anthony Mastrocola
      Nov 01, 2019 @ 13:34:20

      Hi Olivia,

      I really liked your alternative method of reinforcing Mark’s new core belief. I haven’t thought of creating a weekly schedule of going out with coworkers. Possibly, if Mark normalizes going out with coworkers, it may become so natural that he won’t think twice about whether or not he is liked among his peers.

      Reply

  8. Zacharie Duvarney
    Oct 31, 2019 @ 12:25:55

    Core Beliefs

    1.

    Through examination of the therapy session, it is evident that Mark has accumulated evidence for his new core belief: “I am generally likable”. First, it is important to note that Mark experienced several negative automatic thoughts prior to his behavioral experiment. Despite this, he was able to identify and cope with these thoughts, ultimately allowing him to participate in the behavioral experiment despite his reservations.

    Mark’s “dinner date” when better than expected. According to Mark, everyone enjoyed themselves. Conversation flowed naturally and did not center around work. Furthermore, everyone told Mark they enjoyed themselves. The explicit mention that everyone had a good time is good evidence that Mark’s new core belief is accurate. In general, Mark’s positive experience was constructive in that it provided several pieces of evidence for his new core belief. This is apparent in how Mark presented himself in therapy. His mood appeared much better relative to previous sessions, and he was excited to discuss how his dinner plans went. This shift in mood is a good indication that not only does Mark buy into his new core belief, but that his symptoms of depression are beginning to improve due to his modified core belief.

    2.

    Mark may have benefited from attempting to socialize with people he has no prior relationship with. While this certainly would be anxiety provoking, it may also prevent Mark from internalizing a failed attempt (given he has no real connection with the person he is attempting to talk to). This type of experiment could be easily implemented. Mark could go to a restaurant or bar and strike up conversation with other patrons who are not involved with another conversation. Mark could also attend a public event he is interested in (assuming there is one) and attempt to converse with the attendants. Attending an event would be advantageous, as there would be a common interest shared by the people attending, making initiating conversation easier. Examples include conventions, concerts, event nights at restaurants and bars, farmer’s markets, sporting events, etc.

    Behavioral Exposure

    1.

    Efficacy studies have demonstrated that behavioral exposure in effective in treating anxiety disorders as well as depression. Anxiety disorders are characterized by fear and apprehension about future events. Often, fear responses are physiological in nature, followed by cognitive and behavioral responses (Volungis, 2019). Due to the unpleasant nature of fear responses and subsequent negative automatic thoughts, clients often seek immediate relief from the anxiety provoking situation. Typically, this is done by avoiding or fleeing from the anxiety-provoking stimulus. Therefore, negative reinforcement (removal of the unwanted stimulus) perpetuates the client’s maladaptive behavior.

    Behavioral activation (or exposure) is effective at treating anxiety because it breaks the cycle of avoidance and reinforcement. In order for clients to overcome their anxiety, they must directly confront (through exposure) the stimulus that causes their distress. Eventually, clients will understand that their fear response in disproportionate to the actual danger of the perceived threat. Of course, this process is unpleasant and typically takes time. Thus, clients will develop coping mechanisms and behavioral strategies that are equipped to deal with their anxiety. In order to complete exposure, they will have to learn to manage their distress before they overcome their anxieties of a cognitive level. All in all, exposure works because it breaks the cycle of negative reinforcement, helps clients develop coping skills, and ultimately allows them to overcome their anxiety on a cognitive level.

    2.

    As with all interventions, it is important not to rush the client into something they are not adequately prepared for. For example, one technique involved with exposure is flooding, which involves exposing the client to a considerable amount of distress. Not all clients can handle this on a cognitive level, so it is important to exercise caution when working with flooding.

    It is equally important to set realistic goals for the client. Major depression has profound effects on people’s motivation, so setting realistic goals is especially important when working with people who are depressed. Setting goals that are too high can have an adverse effect on the therapeutic process. If the client internalizes failures to complete behavioral exposure tasks, they may even drop out of therapy.

    Reply

    • Kara Rene
      Oct 31, 2019 @ 20:58:45

      Zacharie-

      I appreciate that you pointed out that Mark had several automatic thoughts before he went into the behavioral experiment. I had not focused on this, so I missed appreciating how far he has come in participating in things that cause negative thoughts to surface despite those negative thoughts. I also appreciated your point that Mark’s general presentation seemed to change as a result of believing his new core belief.

      I also appreciated your point about setting realistic goals for clients. I think that this is important especially in helping client set realistic goals for themselves. It is important that the goal selected for behavioral exposure is attainable so that clients achieve success.

      Reply

  9. Anthony Mastrocola
    Oct 31, 2019 @ 12:26:04

    (1) In what ways was this behavioral experiment helpful in providing “evidence” for this client’s new core belief? 

    This behavioral experiment was a positive experience for Mark. Mark was able to share an event that includes him and Melissa going out with two other couples. The process of asking the other couples out, as well as going out provided evidence that suggests to Mark that he is likeable, as opposed to his old core belief of being unlovable. The first part about this scene that stood out to me was Mark’s plan for how he was ready to cope with any distressing information. To Mark’s surprise, everything went perfectly fine. Mark’s coworkers all agreed to going out, and they had a great time. Mark also mentioned that by the end of the night, his friend even said that they should all go out again. All of this detail proves that Mark is likeable. If the coworkers didn’t like Mark, they would not have gone out, the night would not have gone as well, and they wouldn’t have said that they should make plans to go out again.

    (2) What could be another behavioral experiment for this client that could potentially strengthen his new core belief?

    Now that Mark at least partly believes that he is likeable, I would like for him to analyze the other relationships in his life. For example, I would like Mark to list out why he thinks Melissa likes him. Although it is pretty clear that Melissa likes Mark, it could be helpful for Mark to consider all of the evidence that suggests that she values him. The same thing could be done to analyze Mark’s relationship with his parents that displays why they would be proud of him. A basic list of past evidence that suggests why people like Mark seems to be enough to dispute any notions of him being overall unlikeable.

    (1) Why is behavioral exposure very effective for certain disorders/types of distress? 

    Behavioral exposure is particularly beneficial for individuals who experience anxiety in various situations. Anxiety and fear work together to cause great distress centered around the unknown. Anxiety appears in the form of anticipation for the worst case scenario, and fear is the in-the-moment response to a threatening situation. Maladaptive responses to threatening situations may involve escape, and later avoidance. These responses may provide short-term relief and decrease in anxiety, but doesn’t solve anything. The anxiety and negative automatic thoughts are reinforced and intensified when similar situations occur in the future. Behavioral exposure is especially beneficial for reversing the effects of escape/avoidance behaviors. Exposure initially elicits intense anxiety, which will eventually decrease. Exposure begins to change negative automatic thoughts to be more realistic (e.g. “Maybe I will be OK; I think I can do this presentation”). Through this process, individuals can directly address the sources of their anxiety and negative automatic thoughts. Behavioral exposure is beneficial for anxiety, because instead of worrying about what may happen, the individual gets a first-hand experience of what does happen. Engaging in behavioral exposure provides the opportunity to learn what the outcome would be. Through this process, coping strategies can be considered. In the future, the client and counselor can work together to make a plan for how the client will respond to triggering events. It can be comforting for the client to have a plan previously established to treat anxiety and overall distress. In the future, when the client experiences distress, he or she can refer to the plan for how to cope.

    (2) What are some cautions to consider when implementing behavioral exposure interventions?

    When implementing behavioral exposure techniques, it is important to consider if the client is ready for exposure. Some clients may experience such intense anxiety that they cannot participate in behavioral exposure. If these clients were to try behavioral exposure, the anxiety may be so intense that experience is unsuccessful. As a result, negative automatic thoughts and core beliefs may be reinforced, and the client will believe they really cannot be helped. The counselor should consider what the client typically does to cope with distress. Some behaviors are adaptive, and the counselor should promote these behaviors for the client. However, some of the behaviors will likely be maladaptive, furthering the distress. Essentially, the counselor should be careful to consider what the client does that is beneficial and not beneficial for treating their anxiety.

    Reply

    • Kara Rene
      Oct 31, 2019 @ 20:59:24

      Anthony,

      You raised a good point about considering whether the client is ready for behavioral exposure. It is important that behavioral exposure involves realistic tasks so that the client can experience success and build evidence against their automatic thoughts- rather than building evidence for them, which could happen when behavioral experiments fail! Your point about considering the client’s existing coping mechanisms is valuable, too- if the client is still using especially maladaptive coping skills it may not be advisable to intentionally place them in stressful situations!

      Reply

  10. Kara Rene
    Oct 31, 2019 @ 14:47:10

    Core Beliefs
    1. This behavioral experiment provided a lot of valuable evidence for Mark’s new core belief that he is generally likeable. I enjoyed how he was able to identify not only external sources of evidence but also internal sources. Mark mentioned that when he asked his friends to go on the triple date, they were excited and said yes. This in and of itself also indicates the progress that Mark has made- he was able to follow through with asking his friends out, despite acknowledging his concerns about the outcome, especially when considering the fact that these were not his close friends, but acquaintances that may have been less likely to say yes. Additionally, Mark reflected that his friends laughed with him and said they had a good time and that they would like to go out with him and Melissa again. More importantly, I think, is the fact that Mark was able to identify that he enjoyed the time and that he felt valued both during and following the triple date! This shows that the new belief is starting to take root, especially because Mark did not “pick apart” the date afterwards, searching for evidence that he was actually unliked, but instead held unquestioningly to the feeling that he is valued.

    2. I think that a valuable next step for Mark would be to ask a friend or two to hang out with him without Melissa present. I would want to be sure that Mark is able to complete this exercise and have a positive experience on his own, without the support of Melissa, as she cannot always be available to support him. I think that this would also be valuable because it would eliminate the likelihood of him possibly attributing the event going well because Melissa was likable, rather than because he was likable. To be fair, it does not appear as though Mark is struggling with thinking in this way particularly, but I think it would be a good experience all the same.

    Behavioral Exposure
    1. Research has shown that behavioral exposure is extremely effective, particularly for a variety of anxiety disorders including panic disorder, PTSD, phobias, OCD, and agoraphobia. Behavioral exposure is so effective because it interrupts the avoidance behaviors that are typically common in anxiety disorders. These avoidance behaviors provide short-term relief to the client, which ends up creating a pattern of negative reinforcement that keeps the client from confronting or getting through the source of anxious feelings, resulting in them continuing to feel afraid, anxious, and unable to master the anxiety-causing event. Behavioral exposure interrupts this process be helping clients identify anxiety-causing events and take steps to encounter those events while not using avoidance behaviors. Success in this process increases client’s self-efficacy in their ability not only to get through the feared event, but also to manage anxiety.

    2. It is important to take many aspects into consideration before beginning the process of behavioral exposure with a client, as you will want to set the client up with the best chance to experience success in the exposure process. First, consider what feared event to begin with. Feared events high on the hierarchy should not be attempted first; rather, it is more effective to begin exposure experiments with situations lower on the hierarchy. Next, the clinician and client must ensure that the client has adequate coping skills to utilize during exposure, bother to maximize success and to minimize the use of safety behaviors. The clinician must also consider whether to start with or use imaginal or in vivo exposure. In vivo exposure is more effective, but it may be necessary to start with imaginal exposure to build client confidence in being able to get through the event first. Additionally, it is important to consider what types of in vivo exposure are possible, particularly when the clinician feels it would be best for them to be present for the exposure (this is typically best, especially ea

    Reply

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Adam M. Volungis, PhD, LMHC

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