Punishment-Based Strategies

  Punishment-based strategies involve exposing clients to an unpleasant consequence after an undesired behavior, with the goal of decreasing the frequency of the undesired behavior. The term aversive conditioning is often used to describe punishment-based techniques. A number of aversive stimuli can be used, including electrical shock or substances that induce a feeling of suffocation or nausea. For example, a drug called disulfiram (Antabuse) is sometimes used to treat alcohol dependence. Within minutes of drinking alcohol, a client taking disulfiram will experience a number of very unpleasant symptoms, including nausea, vomiting, headache, increased heart rate, and shortness of breath. Clients taking disulfiram learn very quickly not to drink alcohol while on the drug.

Other types of aversive conditioning therapy include aversion relief, in which a client learns to stop an aversive stimulus by performing a desired behavior (Emmelkamp & Kamphuis, 2005), and covert sensitization, in which the aversive stimulus occurs in imagination. The latter was designed to be used as a treatment for deviant sexual behavior (Plaud, 2005).

Punishment-based treatments should generally only be considered when other effective alternatives are not available (Wacker, Harding, Berg, Cooper-Brown, & Barretto, 2009). Although punishment-based procedures can be effective for reducing unwanted behaviors in the short term, relapse is common once the aversive consequences are withdrawn. To maximize the likelihood of long-term change, it is often helpful to include other strategies (e.g., strategies for reinforcing desired behaviors).

Cognitive Strategies

  Cognitive strategies assume that distress and unpleasant emotional states (e.g., fear, anxiety, depression, anger) are triggered by negative thoughts, predictions, assumptions, and beliefs. For example, depression is assumed to stem from a consistently negative view of oneself, the future, and the world (Beck, Rush, Shaw, & Emery, 1979). Cognitive therapy addresses several levels of thinking. First is an emphasis on identifying and correcting cognitive errors or distortions, which refer to thinking errors that individuals often engage in when feeling intense anxiety, depression, or upset. Examples include all-or-nothing thinking (i.e., viewing situations in terms of opposite categories, such as flawless vs. defective), jumping to conclusions (i.e., focusing on one aspect of a situation when trying to understand it), and inappropriate blaming (i.e., using hindsight to decide what one should or should not have done; DeRubeis, Webb, Tang, & Beck, 2010). Cognitive therapy also attempts to address more deeply held beliefs, known as core beliefs or schemas. These assumptions can color how an individual views his or her world. Examples include deeply held beliefs that one is incompetent or that others cannot be trusted. Schemas can also take the form of if–then statements, such as “If I am not competent in every way, then I am a complete failure” (DeRubeis et al., 2010, p. 280).

Cognitive therapy is a collaborative process. The therapist and client work together to identify negative thoughts, to evaluate the evidence concerning these thoughts, and to arrive at more realistic ways of viewing oneself and the world. The goal of cognitive therapy is not simply to replace negative thinking with positive thinking, but rather to take an empirical approach to understanding things. Clients are encouraged to think critically, to treat their thoughts as hypotheses rather than as facts, and to examine the evidence that supports and contradicts their negative thinking. Clients are also encouraged to look at events and situations from multiple perspectives and to accept negative feelings rather than trying to actively fight or control them.

The Daily Record of Dysfunctional Thoughts (Beck et al., 1979) provides an opportunity for clients to record their negative automatic thoughts and to challenge their assumptions by considering the evidence. Several variations of this form exist, including Greenberger and Padesky’s (1995) Thought Record and Antony and Norton’s (2009) Anxiety Thought Record (see Figure 4.1 for an example). When completing thought records, clients are encouraged to ask themselves questions such as

  What is the evidence for my belief? What is the evidence against my belief?

Are there other ways of viewing this situation? How might someone else view this situation?

What if my belief were true? How could I cope with that?