Kaplan & Sadock’s Pocket Handbook of Clinical Psychiatry

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Psychotherapies

to avoid having the patient develop overdependence on a therapist, and the pa tient’s intellectual insight and emotional experiences in the transference. These emotional experiences become corrective as a result of the interpretation. Short-term anxiety-provoking psychotherapy (Harvard University—Sifneos) Treatment can be divided into four major phases: patient-therapist encounter, early therapy, height of treatment, and evidence of change and termination. The final phase of the therapy emphasizes the tangible demonstration of change in the patient’s behavior outside therapy, evidence that adaptive patterns of behavior are being used, and initiation of talk about terminating the treatment. Behavior Therapy Behavior therapy focuses on overt and observable behavior and uses various con ditioning techniques derived from learning theory to directly modify the patient’s behavior. This therapy is directed exclusively toward symptomatic improvement, without addressing psychodynamic causation. Behavior therapy is based on the principles of learning theory, including operant and classical conditioning. Op erant conditioning is based on the premise that behavior is shaped by its conse quences: If behavior is positively reinforced, it will increase; if it is punished, it will decrease; if it elicits no response, it will be extinguished. Classical condi tioning is based on the premise that behavior is shaped by being coupled with or uncoupled from anxiety-provoking stimuli. Just as Ivan Pavlov’s dogs were conditioned to salivate at the sound of a bell once it had become associated with the appearance of a meal, a person can be conditioned to feel fear in neutral sit uations that have come to be associated with anxiety. Uncouple the anxiety from the situation, and the avoidant and anxious behavior will decrease. Behavior therapy is believed to be most effective for clearly delineated, cir cumscribed maladaptive behaviors (eg, phobias, compulsions, overeating, ciga rette smoking, stuttering, and sexual dysfunctions). In the treatment of conditions that can be strongly affected by psychological factors (eg, hypertension, asthma, pain, and insomnia), behavioral techniques can be used to induce relaxation and decrease aggravating stresses ( Table 29-2 ). There are several behavior therapy techniques. Token economy A form of positive reinforcement used with inpatients who are rewarded with various tokens for performing desired behaviors (eg, dressing in street clothes or attending group therapy). This methodology has been used to treat schizophre nia, especially in hospital settings. The tokens can be exchanged for a variety of positive reinforcers, such as food, television time, or a weekend pass. Aversion therapy A form of conditioning that involves the repeated coupling of an unpleasant or painful stimulus, such as an electric shock, with an undesirable behavior. In a less controversial form of aversion therapy, the patient couples imagine something

Psychotherapies

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