{"id":133,"date":"2023-07-18T12:21:58","date_gmt":"2023-07-18T11:21:58","guid":{"rendered":"https:\/\/handbook.cbt2go.net\/index.php\/behavioral-therapy-diagnostics-problem-analysis\/"},"modified":"2023-08-08T17:42:18","modified_gmt":"2023-08-08T16:42:18","slug":"behavioral-therapy-diagnostics-problem-analysis","status":"publish","type":"page","link":"https:\/\/handbook.cbt2go.net\/index.php\/behavioral-therapy-diagnostics-problem-analysis\/?lang=en","title":{"rendered":"Behavioral therapy diagnostics – problem analysis (Rabenstein)"},"content":{"rendered":"\n

Rafael Rabenstein<\/em><\/p>\n\n

rafael@rabenstein.net<\/p>\n\n

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.<\/p>\n\n

The most important instruments of behavioral therapy diagnostics are the vertical and horizontal behavioral analysis (Fig.: III.3.2.a).<\/p>\n\n

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Figure <\/a>1: Horizontal and vertical behavior analysis<\/p>\n\n

III.3.2.1. Horizontal behavior analysis<\/h4>\n\n

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.<\/p>\n\n

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Figure <\/a>2: Amplifier<\/p>\n\n

III.3.2.1.1. Kanfer<\/h5>\n\n

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]<\/a>), or SORK model (German).<\/p>\n\n

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Figure <\/a>3: SORC model, dynamic self-regulation system Kanfer et al., 1996<\/p>\n\n

This form of the SORK scheme can be interpreted in different ways:<\/p>\n\n

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  1. 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.<\/li>\n\n\n\n
  2. 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.<\/li>\n<\/ol>\n\n

    Both accesses are possible. It is important to provide patients with a procedure that is easy to understand.<\/p>\n\n

    III.3.2.1.2. Bartling<\/h5>\n\n

    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. <\/p>\n\n

    Especially when a problem behavior is due to interpersonal functionalities, the differentiation between internal and external factors is useful.<\/p>\n\n

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    Figure <\/a>4: Behavior sequence according to Bartling (1998)<\/p>\n\n

    III.3.2.1.3. „Chains of behavior“<\/h5>\n\n

    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.<\/p>\n\n

    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)<\/em><\/em><\/p>\n\n

    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.<\/p>\n\n

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    Figure <\/a>5: „Chain behavior analysis“ adapted from Linehan et al., 1996b.<\/p>\n\n

    III.3.2.1.4. Summary<\/h5>\n\n

    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.<\/p>\n\n

    Situation: All internal or external stimuli (as opposed to Kanfer).<\/p>\n\n

    O variable: thoughts, evaluations and interpretations<\/p>\n\n

    Feelings and emotions<\/p>\n\n

    Physiological reactions mainly vegetative symptoms: Palpitations, sweating, etc.<\/p>\n\n

    \u00e0 The O variable refers to the inner processes currently experienced<\/p>\n\n

    Behavior primary visible behavior<\/p>\n\n

    In situation: but also thought compulsions, brooding, worrying, etc.<\/p>\n\n

    Consequences:<\/p>\n\n

    important to distinguish whether consequences are relevant for the person or environment<\/p>\n\n

    Also, whether behavior brings short-term relief and<\/p>\n\n

    may have negative consequences in the long term <\/p>\n\n

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    Figure <\/a>6: Behavioral analysis (adapted from Marx, 2004)<\/p>\n\n

    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.<\/p>\n\n

    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.<\/p>\n\n

    Literature:<\/p>\n\n

    Bartling G, Echelmeyer L, Engberding M (2016). Problem analysis in the psychotherapeutic process: guide for practice. <\/em>6th revised edition, Stuttgart: Kohlhammer Verlag.<\/p>\n\n

    Beck JS (2013). Cognitive therapy practice<\/em>. Weinheim: Beltz.<\/p>\n\n

    Caspar F (2007). Understanding relationships and problems-An introduction to psychotherapeutic plan analysis<\/em>. Huber: Bern.<\/p>\n\n

    Kanfer FH, Reinecker H, Schmelzer D (2012). Self-Management Therapy. A textbook for clinical practice<\/em>. 5th ed. Berlin: Springer.<\/p>\n\n

    III.3.2.2. Vertical behavior analysis<\/h4>\n\n

    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.<\/p>\n\n

    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.<\/p>\n\n

    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.<\/p>\n\n

    III.3.2.2.1 Plan analysis according to Caspar<\/h5>\n\n

    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.<\/p>\n\n

    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.<\/p>\n\n

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    <\/a>Figure <\/a>7: Plan analysis according to Marx (2004)<\/p>\n\n

    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.<\/p>\n\n

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    <\/a>Figure <\/a>8: Plan analysis (adapted from Bartling et al., p.60, 2004)<\/p>\n\n

    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.<\/p>\n\n

    III.3.2.2. cognitive case concept J. Beck<\/h5>\n\n

    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.<\/strong> 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.<\/p>\n\n

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    1. Basic assumptions<\/em> – core beliefs<\/em> – central external and self-schemas<\/em><\/li>\n<\/ol>\n\n

      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.<\/p>\n\n