Rafael Rabenstein

rafael@rabenstein.net

There is an increasing number of approaches, models, extensions and partly approaches that want to establish themselves as an independent form of therapy within behavior therapy. However, all have common roots in cognitive psychology and the psychology of learning. However, the aim of this book is a synopsis, a synthesis and simplification with emphasis on the unifying aspects of this questioning. Often, further developments are known phenomena with new names. It is therefore important to take a critical view of this fragmentation and to focus more on what unites us.

Figure 25: Model of personalized, evidence-based and modular psychotherapy.

We follow a similar approach as the modular psychotherapy according to Herpetz et al. (2016). This includes an evidence-based and disorder-specific approach. Likewise, it postulates various functional impairments through neurophysiological correlates. For example, “Theory of Mind” problems in psychosis and borderline personality disorder. These dysfunctions are to be treated therapeutically in a targeted manner. For example, metacognitive training and/or social skills training. In our view, in addition to a disorder-specific approach, a personalized approach should always be chosen after a diagnosis has been made, not as a substitute, but as a complement and integrated into a comprehensive treatment.

Examples of individualized interventions based on functional impairment:

• Problem Solving
• Self-checking procedure
• Emotion modulation/regulation – DBT Skills
• Exposure-based techniques (in sensu, in vivo).
• Cognitive restructuring
• Behavioral experiments
• Metacognitive intervention
• Contingency management
• Mindfulness-based interventions
• PMR
• Imaginative techniques
• Metacognitive training

Figure 26: Horizontal behavior analysis

Horozontal behavior analysis (Figure 23: horizontal behavior analysis): Based on instruemntal or operant learning, the SORK scheme has evolved. In contrast to the Balck box, the O variables, the organism variable is given great importance. Motivational aspects of behavior are an essential part of behavior therapy.

Figure 27: Vertical behavior analysis

Vertical behavior analysis (Figure 27: vertical behavior analysis): Even if one has different models to choose from, an integrative approach is preferred here. In addition to the basic requirements, schemes are presented here independently of the model behind them as the supreme hirachic ordering concept. Whether as primary or secondary emotion or maladaptive schemas. The term that best fits the patient and his problem should be used. Among them, plans or even approach and avoidance goals are cited. Especially if these are conflictual, a detailed discussion is worthwhile. Rules are the executive betsimmungen, i.e. how a plan must/should be implemented.

Automatic thoughts are besides images and self-descriptions also interpretations and partly problematic evaluations (cognitive distortions) especially when patients tend to jump to conclusions it is worthwhile to restructure them by means of cognitive strategies.

Figure 28: Bio-Psycho-Social Condition Model

The Bio-Psycho-Social Condition Model (Figure 28: Bio-Psycho-Social Condition Model) summarizes the findings and hypotheses of the vertical and horizontal behavioral analyses. Pre-existing conditions, or biographical work, is important only to the extent that it is necessary to develop an understanding of the problem, but for many patients it is important and valuable to gain a deeper understanding of their current problems. Often, however, functionality, or the conditions that maintain it, is the most important starting point for therapeutic action. For example, when self-injury, substance use, or other self-harming behaviors serve as maladaptive emotion regulation attempts.

Change vs. stabilization (Figure 29: Behavioral therapy interventions.): In addition to disorder-specific, evidence-based approaches for isolated mental disorders, there are a large number of affected people who have one or more comorbid disorders, have been chronically ill for years, and also have psychosocial impairments. Aspects such as healing are not realistic or superficial goals in these cases. Regardless of prognosis, it is important to adjust therapeutic goals and interventions to the patient’s psychosocial level of functioning.

This is true of any psychotherapy, of course, but especially true for people who experience one or more impairments in their level of functioning.

Figure 29: Behavior therapy interventions

Therefore, a hierarchical approach should always be kept in mind when selecting approaches and, if a disorder-specific and always personalized approach proves to be too burdensome, a lower-threshold approach should be chosen (Figure 29: Hierarchy of therapeutic approaches).

Of course, these levels are not separate and overlap each other. However, it is important to be flexible in adapting the therapeutic process to the patient’s current situation.

However, an important starting point should always be a personalized, evidence-based approach (except in acute crises), as every patient should receive a proven and effective therapy at least once. Whether as an initial and sufficient starting point or in the course of a longer ongoing process.

Figure 30: Hierarchy of therapeutic starting points

Relationship management in modern behavior therapy has departed from the purely “medical model,” i.e., special attention is paid to the therapeutic relationship. Whether as a basis, facilitator to gain motivation for change and also to bear unpleasant interventions, or as a relationship as an effective factor, in the sense of a corrective experience, or the limited parental care /reparenting. From a scientific point of view, there is currently probably only evidence for the value of therapeutic ambulation. Even though Webbased, E-Mental Health applications also seem to be effective entirely without therapeutic guidance as well.

It is important to choose a flexible relationship design that is oriented to the needs of the patient (Figure 27: Dimensions of the therapeutic relationship). Shift dialectically between the poles of change/confrontation and acceptance/validation. Apply strategies to the therapeutic relationship, but equally use strategies for problem solving. All these dimensions should be used in a complementary/motive way in the relationship.

Figure 31: Dimensions of the therapeutic relationship

Regardless of personal and individual goals, an overarching goal of behavior therapy is to enable people to actively shape their lives and participate in social life. However, these impairments, whether physical or more psychological, while intended to be alleviated or eliminated, should not be the sole (success) criterion for psychotherapy. Social and occupational participation and an opportunity to actively pursue this are essential overarching goals of any therapy. This is done in the sense of “self-management” and “empowerment”, i.e. the empowerment to successfully implement one’s own goals. It is important to consider the socio-cultural context and to pursue these goals in a socially responsible manner.

Central assumptions of modern behavior therapy:

• Man is a social being
• Therapy is help for self-help
• Man is capable of self-direction and self-control
• Behavior is determined by basic needs, which are manifested in goals, values, plans, and motivational schemas.
• People should be empowered for self-regulation and self-control
• In the sense of empowerment, people should be enabled to realize their goals in their social world and to participate in it.
• People should learn to realize their needs and goals in harmony with their social environment – socially related autonomy
• the therapy process is to be understood as dynamic and interactive problem solving
• Transparency is one of the most important foundations of therapeutic action
• Therapy follows the principle of minimal interventions
• Therapy should serve to maximize personal freedom
• principal pluralism

Bartling, G., Echelmeyer, L., Engberding, M. & Krause, R (2004). Problem Analysis in the Therapeutic Process, 5th ed. Stuttgart: Kohlhammer.

Beck AT, Rush AJ, Shaw BF, Emery G (1986). Cognitive therapy for depression. Munich: Urban and Schwarzenberg.

Beck JS (2013). Cognitive therapy practice. Weinheim: Beltz.

Caspar F (1996). Understanding relationships and problems. Bern: Huber.

Caspar F (2008). Motivational relationship management – concept, prerequisites in patients and effects on process and outcomes. In: Hermer M, Röhrle B (Eds.). Handbook of the Therapeutic Relationship, Volume 1. Tübingen: dgvt-Verlag.

D’Zurilla TJ, Nezu AM (2010). Problem-solving therapy. In Dobson KS (ed.). Handbook of Cognitive-behavioral Therapies. Pp. 197-225, New York: Guilford.

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 (1992). Complementary relationship design as a means of establishing a good therapeutic relationship. In: Margraf J, Brengelmann J (eds). The therapist-patient relationship in behavior therapy. Munich: Röttger.

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 (2002). Emotion – focused therapy. Coaching clients work through their feelings. Washington: American Psychological Association.

Herpetz S, Caspar F, Lieb K (eds.), (2016). Psychotherapy: Functional and disorder-oriented approach. Urban & Fischer Publishers/Elsevier GmbH

Kanfer FH, Reinecker H, Schmelzer D (1996). Self-management therapy. Berlin: Springer.

Roediger E (2011). Practice of schema therapy: textbook on basics, indications, communication, procedure. Stuttgart: Schattauer.

Young JE, Klosko JS, Weishaar ME (2008). Schema therapy. Paderborn: Junfermann.