1. Cognitive Behaviour Therapy (CBT) Gerhard Ohrband - ULIM University, Moldova 6th lecture Aversion training

2. Course Structure 1. Introduction: What is CBT? What are differences and similarities with other therapy schools? 2. Diagnostics in CBT 3. Classification of Psychological Disorders (ICD- 10, DSM-IV), Clinical Psychology (Etiology, prevalence, comorbidity and symptoms) 4. Etiological concepts in CBT: learning theories (classical and operant conditioning, vicarious learning, Mowrer’s Two-factor theory) 5. Systematic desensitization: in-vivo exposure and imaginatory 6. Aversion training: overt and covert

3. Course Structure 7. Response prevention: treating obsessive-compulsive disorder (OCD) 8. Social skills training: anger management, assertiveness training 9. Rational-emotive Therapy (RET) 10. Beck’s Cognitive Therapy for depression 11. Marital and Sex Therapy 12. Trauma Therapy: Expressive writing, work with affirmations, visualizations; working with victims of crimes, accidents and other difficult life-events 13. Relaxation techniques: yoga, meditation, Alexander technique, Feldenkrais 14. CBT at school: helping children with autism, hyperactivity, social phobia, social adjustment problems, learning difficulties and antisocial behaviour. 15. CBT in treating addiction and substance abuse

4. Content Aversion training Overt vs. covert aversion training Disorders indicated for aversion training Practical exercises

5. Aversion training Causing a negative reaction to a neutral stimulus by pairing it with an aversive stimulus (UCS) Attempt to establish an unpleasant response (such as a feeling of fear or disgust) to the object that produces the undesired behaviour

6. Example A person with a fetish for woman’s shoes might be given electrical shocks while viewing colour slides of women’s shoes.

7. Indication Aversive therapy has also been used to treat Drinking Smoking Transvestism Exhibitionism Overeating

8. Discussion Moderately effective (Marshall et. al., 1991) Because the method involves pain or nausea, the client’s participation must be voluntary Should be employed only if other approaches fail or are impractical

9. Ethical issues What to do when the individual is so severely impaired that they are unable to give informed consent to a particular therapeutic procedure?

10. Carr and Lovaas (1983) Aversive methods involving stimuli such as electric shock should be used as the last resort. They should be used only when the patient’s behaviour poses a serious threat to their own well-being and after the following methods have been employed unsuccessfully: 1. Reinforcing other behaviours 2. Attempting to extinguish the maladaptive behaviours 3. Temporarily removing the patient from the environment that reinforces the maladaptive behaviours (time-out) 4. Trying to arrange for the patient to perform behaviours that are incompatible with the maladaptive ones Preference of covert sensitisation

11. Overt vs. covert aversion training Overt sensitisation: actual punishment through electric shocks, unpleasant smells, public shaming etc. Covert sensitisation: imaginative punishment through visualization of negative consequences

12. Disorders indicated for aversion training Bulimia Aggressive personality disorder Exhibitionism What else would you imagine?

13. Case study: exhibitionism Mark, 35 years, is an exhibitionist. He starts masturbating at home in the evening. Before having an orgasm he leaves home for the urban park where he exposes his genitals before lone women. Upon the scared reactions he experiences orgasm.

14. Case study: Group work Design treatment for Mark using overt and covert aversion training Which negative consequences could Mark elaborate upon exposing his genitals?

15. Discussion Points What could be possible explanations if an aversion training does not work? How do you consider this treatment from ethical viewpoints? Which disorders would be easier, harder to treat with aversion training? Are there culture, person variables which influence the effectiveness of the therapy?

16. Literature Carr, E.G. and Lovaas, O.J.C. (1983). Contingent electric shock as a treatment for severe behavior problems. In S. Axelrod and J. Apsche (Eds.), The effect of punishment on human behavior. New York: Academic Press. Marshall, W.L., Eccles, A. and Barbaree, H.E. (1991). The treatment of exhibitionists: A focus on sexual deviance versus cognitive and relationship features. Behaviour Research and Therapy, 29, 129-136.