Rafael Rabenstein
rafael@rabenstein.net
Behavioral therapy, in addition to a disorder-specific approach, is always a personalized, or individualized therapy. The central component of this approach is the behavioral therapy diagnosis, the problem analysis. The findings of this diagnostic process result in a hypothetical and functional model of conditions that serves as both an explanatory and a solution model (see Chapter III.4). This is not a completed procedure, but is adapted, changed, and also leads to the discarding of hypotheses as part of the ongoing therapy.
The most important instruments of behavioral therapy diagnostics are the vertical and horizontal behavioral analysis (Fig.: III.3.2.a).
Figure 1: Horizontal and vertical behavior analysis
III.3.2.1. Horizontal behavior analysis
Horizontal behavior analysis is based on the operant, or instrumental, learning model. A central assumption is that behavior is learned and unlearned through reinforcement and, to a lesser extent, through punishment (Fig. 3.2.1.a). However, motivational aspects represent an essential behavioral control component, see vertical behavioral analysis, chapter III.3.2.2. The two main models of horizontal behavior therapy are presented below.
Figure 2: Amplifier
III.3.2.1.1. Kanfer
An important contribution in the context of problem analysis, both vertical and horizontal, has been made by Kanfer et al. achieved. (Kanfer et al., 1996). His dynamic model of self-regulation is one of the standard models within behavior therapy. Particular attention is paid to organism variables. The O variable is used in the context of vertical behavior analysis, chapter 3.2.2. described in more detail. This is an extension of Skinner’s operant learning model, the SORC(K[1]), or SORK model (German).
Figure 3: SORC model, dynamic self-regulation system Kanfer et al., 1996
This form of the SORK scheme can be interpreted in different ways:
- It is possible to subsume in the O variable all preceding conditions in the form of rules, basic assumptions, i.e. aspects of vertical behavioral analysis, and then describe the reaction in terms of automatic thoughts and emotional responses. Consequence could be behavior like self-harm, substance use, etc. To identify the consequences of problem behavior one would have to perform a chain of behavior analysis.
- A second approach would be to record only immediate responses in the O variable. Like automatic thoughts and emotional, or physical reactions. Reaction would then be a problem behavior like excessive hand washing with washing compulsion. The consequence would be, on the one hand, negative reinforcement – an unpleasant feeling is regulated down. A second consequence but skin damage, loss of work due to prolonged forced behavior.
Both accesses are possible. It is important to provide patients with a procedure that is easy to understand.
III.3.2.1.2. Bartling
Bartling contributes another model for problem analysis. There are many similarities to Kanfer’s model. However, the O variable is described here as Internal Processing and Perceptual Processes. The proportions that will act on these processes in the current event, specify here in the vertical behavior analysis (plan analysis, system rules). It is also guided by the plan analysis of Casper and also Grawe. By describing perception and interpretation, the focus is taken from subjective patterns of evaluation, perception, and experience.
Especially when a problem behavior is due to interpersonal functionalities, the differentiation between internal and external factors is useful.
Figure 4: Behavior sequence according to Bartling (1998)
III.3.2.1.3. “Chains of behavior”
A special form of behavioral analysis is the “behavioral chain analysis”. This approach is especially familiar in the development of skill chains in DBT. The goal is to break down problem behavior into individual sequences and, above all, to work out unclear triggers. Often patients cannot articulate why a crisis such as self-injurious behavior, conflict, or dissociative states has occurred. The start is therefore often the end of a longer lasting crisis, i.e. the problem behavior. It often takes a close look to identify causative triggers. This can be an experienced rejection with associated fears of abandonment or the like, which can also date back longer.
Chain analysis examines the chain of events that lead to ineffective behaviors and the consequences of those behaviors that might make them difficult to change. It will also help you figure out how to fix the damage. (M. Linehan 1996b)
The terminology used depends on the orientation in the therapeutic setting. Whether different emotions such as anger, fear, etc. or “schema modes” are used is secondary here. Subsequently, it is important to find strategies for dealing with the stressful emotions for each link in the chain.
Figure 5: “Chain behavior analysis” adapted from Linehan et al., 1996b.
III.3.2.1.4. Summary
Any model is only good if it helps to understand problems better and it helps to enable change. With this in mind, we recommend making the behavioral analysis (Fig.3.2.1.4.a) as simple as possible so as not to overwhelm patients. At this point, a model is recommended that is broadly a synthesis of Kanfer and Bartling.
Situation: All internal or external stimuli (as opposed to Kanfer).
O variable: thoughts, evaluations and interpretations
Feelings and emotions
Physiological reactions mainly vegetative symptoms: Palpitations, sweating, etc.
à The O variable refers to the inner processes currently experienced
Behavior primary visible behavior
In situation: but also thought compulsions, brooding, worrying, etc.
Consequences:
important to distinguish whether consequences are relevant for the person or environment
Also, whether behavior brings short-term relief and
may have negative consequences in the long term
Figure 6: Behavioral analysis (adapted from Marx, 2004)
It is often very difficult for patients to differentiate thoughts, feelings and physical reactions at the beginning, often this is also part of the problem. It then requires patience and repeated discussion of the behavior analysis together.
In addition to the diagnostic aspect, behavioral analyses also have a role in self-management or as a self-control strategy. Often, observing a behavior already changes the behavior, or brings relief by distancing oneself from the situation.
Literature:
Bartling G, Echelmeyer L, Engberding M (2016). Problem analysis in the psychotherapeutic process: guide for practice. 6th revised edition, Stuttgart: Kohlhammer Verlag.
Beck JS (2013). Cognitive therapy practice. Weinheim: Beltz.
Caspar F (2007). Understanding relationships and problems-An introduction to psychotherapeutic plan analysis. Huber: Bern.
Kanfer FH, Reinecker H, Schmelzer D (2012). Self-Management Therapy. A textbook for clinical practice. 5th ed. Berlin: Springer.
III.3.2.2. Vertical behavior analysis
In the following chapter, several models of vertical behavior analysis are presented. The only thing in common is the assumption of a hierarchical structure, i.e. different levels of behavior controlling aspects. In the context of cognitive psychology, the term schema or schemas has generally come to mean the highest level of order, These schemas have both emotional and cognitive parts. They can be triggered by a variety of stimuli. Several researchers assume that the activation of these schemata can be mapped as neuronal excitation patterns in the brain; these consist of different areas in the brain that “fire” together.
However, the focus of the different scheme approaches is somewhat different. Young describes 18 maladaptive schemas found primarily in personality disorders; he has been a student of A.T. Beck. Grawe, in turn, assumes that there are several motivational schemas per basic need. These form goals, motives for one’s own actions and experiences. These plans, goals, motives can also come into conflict and thus cause suffering. Greenberg, coming from Gestalt therapy, focuses mainly on the emotional components in his concept of schema.
J. Beck who has further developed her father’s cognitive therapy in turn focuses mainly on the cognitive parts. A.T. Beck also describes the term schema in his work on personality disorders.
III.3.2.2.1 Plan analysis according to Caspar
Plan analysis was originally closer to cognitive therapy, but has since become more closely aligned with Grawe’s motivational schemas. The most important statement is that we humans are guided by different plans we can implement our needs and goals.
There are upper and lower plans and rules how to implement them. Rules are therefore more guidance for action. Here, too, there may still be hierarchical gradations. In addition to conflicting plans, it is also important to develop an understanding of one’s own behaviors, because often these plans and rules lead to little self-care behavior. Originally, they served to meet an environment that was not always validating and open to unbiased need satisfaction. In Figure 7: Plan analysis according to Marx (2004) an example of a plan analysis. Whether the approach is “bottom up” or “bottom down” varies depending on the problem.
Figure 7: Plan analysis according to Marx (2004)
Figure 8: Plan analysis (adapted from Bartling et al., p.60, 2004) shows an adapted plan analysis according to Bartling. Here extended by the level of basic needs. It is worthwhile to teach Grawe’s model as it is usually easy to understand and is now widely used.
Figure 8: Plan analysis (adapted from Bartling et al., p.60, 2004)
Again, it is important not to be too academic in your approach to working with patients, the model is only as good as it serves to provide patients with an understanding of their difficulties.
III.3.2.2. cognitive case concept J. Beck
Judith Beck has continued the work of her father A.T. Beck. The overall concept is described in the chapter: Error! Reference source could not be found. in more detail. Here only the aspects of the case concept in the context of the problem analysis. There is a great deal of commonality throughout with Casper’s original plan analysis. However, the conditional assumptions are described differently than just in plans and rules.
- Basic assumptions – core beliefs – central external and self-schemas
In addition to central assumptions about oneself and the environment, these are also basic assumptions such as “I am bad”, “I am to blame”, etc., but of course also positive self-attributions, “I am a good person”, etc.
- Conditional assumptions
- Axioms: These are absolutely correctly recognized principles. Principles of how a rule can be achieved or not achieved.
- Attitudes: It is the evaluation on the basic assumption: “It is terrible to be bad”.
- Rules: Similar to the compensatory strategies, this is the instruction to avoid this basic assumption, or to bypass it
- Compensatory strategy(s) – Coping styles
Especially higher-level strategies to “escape” the basic assumption to compensate or avoid it. There is a great deal of overlap here with coping modes and conditional schemas in Young’s
- Automatic thoughts
All images, thoughts, intrusive thoughts, evaluations and interpretations in a situation
- Feelings
Often difficult for patients, thoughts, feelings and bodily sensations are often mixed; here it often takes some time to perceive and learn to name the thoughts.
In Figure 9 Example of a Cognitive Case Concept, an example of a case concept is given:
Figure 9 Example of a cognitive case concept
Young and other proponents of 3rd wave, mindfulness-based disorders also come originally from cognitive therapy.
Literature:
Beck AT (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.
Beck JS (2013). Cognitive therapy practice. Weinheim: Beltz.
Young JE, Klosko JS, Weishaar ME (2008). Schema therapy. Paderborn: Junfermann.
III.3.2.2.3. Schemes
The term schema comes from cognitive psychology and the description of perceptual, information processing and memory processes. This was coined by researchers such as Bartlett (1932) and Piaget (1936). They are part of implicit memory, so they are not consciously recalled. There is no single definition, schemas are described as knowledge structures, categories, scripts, representations or similar. What is common is that it is a class of certain environmental events, action schemata, perceptual schemata, motivational schemata. When a schema is activated, schema-consistent information is more likely to be perceived than schema-consistent information.
Piaget (Piaget, 1967) describes schema as follows:
- Scheme: way of handling environmental conditions.
- Schema is understood here as a typical way of man to handle certain classes of environmental facts. Such a schema exists as a cognitive schema, which is expressed in certain action schemata – e.g. the schema of throwing, tapping, multiplying and the like.
- Schemata turn objects of different kinds into objects of the same kind (e.g., those that can be thrown, knocked with, multiplied, etc.), thus cognitively facilitating interaction with the environment.
Piaget assumes 2 processes for the change and shaping of schemata, both of which serve the adaptation to environmental conditions:
- Assimilation: adaptation of empirical values to existing schemata
- Accommodation: adaptation of schemata, trigger of accommodation: imbalance / cognitive conflict
A.T. Beck (Beck, 1976) defines schemes as follows:
- Every situation consists of an abundance of stimuli. The individual selectively pays attention to certain stimuli, combines them into a pattern, and forms a concept of the situation
- There is a tendency to respond consistently to similar event types
- Relatively stable cognitive patterns account for the uniformity with which certain classes of situations are interpreted.
- Certain circumstances activate a scheme appropriate for these circumstances
- Activated schemata directly determine how a person reacts
- There are prevailing ideosyncratic schemata which lead to disturbances of reality and consequently to systematic errors in the thinking of the depressive à negative interpretations cannot be recognized as “erroneous
Behavior therapy has increasingly, after the cognitive turn, addressed the emotional/motivational aspects of human behavior. This has led to another concept of schema that emphasizes mainly emotional components. Schemas are seen as patterns of perception, experience that are directly related to basic psychological needs. So as blueprints, plans, programs that are automatically activated when needs are activated. They include all experiences and adaptations to the way and possibilities to fulfill these needs. However, if frustrating experiences are associated with them, these schemata can lead to being maladaptive in the here and now.
Starting, for example, from the basic need for attachment, a feeling of love, affection, joy is triggered. If the child now learns this feeling is answered by his parents through physical closeness, attention and the like, this feeling will also be accompanied by a pleasant expectation in the future. However, if this need is regularly or irregularly frustrated, a feeling of fear (in the case of experiences of violence) or loneliness (in the case of neglect) will be learned along with the feeling of affection and then be “pave”, i.e. “written”, into the schema.
Schemata can also be seen as neuronal excitation patterns that are currently triggered for a certain type of situation, but they also include experiences or are part of them.
Schuch (Schuch, 2000) describes schemes as follows:
In cognitive therapy, following Piaget, cognitive schemas are defined as relatively stable, conscious or unconscious basic assumptions that control information processing and behavior. They are goal- and action-oriented, accompanied by emotions, and lead to characteristic cognitions. In many cases, they arise at early ages through the child’s interactions with relevant caregivers. Schemas provide an important contribution to the development of psychopathological abnormalities. Thus, dysfunctional schemas lead to false basic assumptions regarding relevant areas of self and life, and thus to inadequate patterns of processing and behavior. However, schemas can also conflict with each other if contradictory ones are activated at the same time.
In the following, the most important representatives of schema-therapeutic approaches to behavior therapy are discussed:
III.3.2.2.3.1. Schema therapy – Young
Young describes the term scheme as:
- A broad, comprehensive theme or pattern,
- that consists of memories, emotions, cognitions and bodily sensations,
- that relate to the person himself and his contacts with other people,
- a pattern that originated in childhood or adolescence,
- became more pronounced in the course of further life and
- is strongly dysfunctional.
According to this definition, a person’s behavior is not a component of the schema itself; rather, according to Young, dysfunctional behaviors develop in response to a schema. Consequently, behaviors are driven by schemas, but are not a part of them
Figure 10: Overview of schemes according to Young
In Figure 10: Overview of Young’s schemes, Young’s schemes are listed. These are particularly useful for patients to discuss their relationship patterns and relationship models. Compensatory strategies for dealing with loaded basic assumptions are also easy to teach. Many patients easily find themselves here. Especially in the case of unclear motives, one quickly arrives at initial hypotheses here. A detailed description of schema therapy can be found in Error! Reference source could not be found.
III. 3.2.2.3.2. Emotion-focused therapy Greenberg/Lammers
Another model that is easy to convey is provided by Lammers, who uses Greenberg’s emotion-focused therapy as a model. Figure 11: Emotional schemas according to Greendberg/Lammers (Lammers, 2011) shows the model. This model is a good explanatory model when few feelings are maladaptive in situations, for example, fear instead of affection; anger instead of vulnerability.
Figure 11: Emotional schemata according to Greendberg/Lammers (Lammers, 2011)
It can be used as an alternative for Young’s modes, especially when few modes are involved and in cases of patients who tend to dislike a “virtual” fragmentation of their personality.
III. 3.2.2.3.3. Neuropsychotherapy – Grawe
In Grawe’s model, motivational schemas are the most important. These are the means developed during life to satisfy basic needs. He distinguishes between approach goals and avoidance goals/schemes Avoidance schemas are primarily intended to protect against injury, while approach schemas point the way to satisfying needs. Also emphasized are the neurophysiological connections to neuronal excitation patterns. That is, different areas of the brain that fire together are also interrelated and contain different parts, memories, feelings, thoughts, expectations, context, etc..
Figure 12: Schemes Grawe (Graw, 2004)
This model is particularly helpful when patients’ plans and goals are in conflict. For example, the desire for autonomy (would be in Grawe’s model a mixture of self-esteem enhancement, pleasure gain and orientation?) which is balanced by the need for attachment, or need for orientation and control. Here as an approach schema attachment and autonomy, but also avoidance schema, because autonomy also involves the risk of failure, or to get interpersonal problems with attachment figures.
Likewise, the information provided by the model is a good and essential basis for complementary or motivational relationship building.
III.3.2.3. Summary
There are several models of vertical behavior analysis. Depending on the theoretical background, there are different designations and focuses. What they all have in common is the assumption that we humans are guided or controlled by our needs and motives. The realization of needs is determined by blueprints, programs or plans based on experience. Whereby the closer to the needs these schemes are the implied part is larger and less conscious. Plans and rules are more differentiated and cognitively accessible expressions of these needs. All of these models are based on foundations of cognitive psychology and work by Piaget and Bartlett. The theoretical focus of schemas according to Young and Greenberg is primarily the automated emotional components that condition human behavior. Beck also speaks of central schemata of self and other.
Grawe and also Casper also assume in their models basic needs and hierarchical plans for satisfying them.
For an overview, or summary, of the various models within behavior therapy, please refer to Figure 13: Overview Hierarchical Models of Motivational Aspects of Behavior.
Figure 13: Overview Hierarchical Models of Motivational Aspects of Behavior
In Figure 14: Integrative Model of Vertical Behavioral Analysis, a summary of the different models can be seen. The hierarchy is to be understood as an aid to order, without any claim to general validity. At the top level are the basic needs, here according to Grawe, or Eppstein (2000). However, the need for autonomy is not explicitly mentioned, but it is also a central need.
Figure 14: Integrative model of vertical behavior analysis
The need for attachment, in particular, has been frustrated in many patients and therefore plays a central role. Derived from this, the first 5 schemes according to Young (1996) are particularly appropriate
Emotional deprivation
Abandonment
Inadequacy/shame
Mistrust/abuse
Social isolation
to describe relational conflicts, frustrating relationships, and other repetitive maladaptive patterns of perception and behavior. Basic assumptions are often an equally valid alternative, depending on the patient. Synonymously, the term rules of life or survival rules can also make sense. However, the overlap with rules and plans is fluid
Plans and rules are also used synonymously. However, plans are more in the sense of an imperative “Be popular”, “Avoid being hurt” and rules are more of an instruction/instruction for action. “In order not to get hurt, you have to put your own needs aside”.
Whether feelings or thoughts arise first as a result of a stimulus, or at the same time, is not superficially decisive. It is important that one’s own patterns of perception and interpretation have an influence on feelings, as well as automatic thoughts. However, feelings that cannot be explicitly explained can also trigger thoughts (“what is happening here”), e.g.: Panic disorder
Figure 15: Horizontal and vertical behavior analysis
The key is to select a model (Figure 15: Horizontal and Vertical Behavioral Analysis) that fits the patient. The presence of multiple modes according to Young may be relieving for patients with an emotionally unstable personality (especially of the borderline type), but may be more disconcerting for someone with a high level of functioning. Similarly, terminology such as schemas, whether according to Young, Grawe, or Greenberg are often too abstract to help patients understand their problems. Therefore, always the model with the best fit and as simple as possible and as complex as necessary.
Literature:
Bartlett FC (1932). Remembering. Cambridge: Cambridge University Press.
Beck AT (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.
Beck, J.S. (2013). Cognitive therapy practice. Weinheim: Beltz.
Caspar F (1996). Understanding relationships and problems. Bern: Huber.
Caspar, F. (2007). Understanding relationships and problems – An introduction to psychotherapeutic plan analysis. Bern: Huber.
Epstein, S. (1990). Cognitive-experiental self-theory. In L.A. Pervin (Ed.), Handbook of personality: Theory and research (pp. 165-192). New York: Guilford.
Grawe K, Caspar F (1984) Plan analysis as a concept and instrument for psychotherapy research. In: Baumann U (ed.). Psychotherapy research. Macro and micro perspectives. Göttingen: Hogrefe.
Grawe, K. (2000). Psychological therapy. Göttingen: Hogrefe
Greenberg L (2011). Emotion-focused therapy. Munich: Ernst Reinhard Verlag.
Kanfer FH, Reinecker H, Schmelzer D (1996). Self-management therapy. Berlin: Springer.
Lammers CH (2011). Emotion-focused psychotherapy: foundations, strategies, and techniques. Stuttgart: Schattauer
Parfy E, Schuch B, Lenz G (2016). Behavior therapy: Modern approaches to theory and practice, 2nd edition. Vienna: Facultas/UTB.
Piaget J (1936). The origin of intelligence in children. New York: International Universities Press. (Engl.: The Awakening of Intelligence in the Child. Stuttgart: Klett-Cotta, 1975.)
Piaget J (1967). Biologie et connaissance. Edition Gallimard. (Engl.: Biology and Cognition. Frankfurt am Main: Fischer, 1992.)
Roediger, E. (2011). Practice of schema therapy: Textbook on basics, indications, communication, procedure. Stuttgart: Schattauer.
Schuch B. (2000) Schemata, cognitive. In: Stumm G., Pritz A. (eds) Dictionary of Psychotherapy. Springer, Vienna
Young, J.E., Klosko, J.S., Weishaar, M.E. (2008). Schema therapy. Paderborn: Junfermann.
[1] The (K) refers to the contingency, i.e. the occurrence and probability of amplifiers. So, is a behavior intermittently/irregularly or constantly amplified. R stands for Response and C for Consequence.
