In this article we propose mechanisms that govern the processing of emotional information, particularly those involved in fear reduction. Emotions are viewed as represented by information structures in memory, and anxiety is thought to occur when an information structure that serves as program to escape or avoid danger is activated. Emotional processing is denned as the modification of memory structures that underlie emotions. It is argued that some form of exposure to feared situations is common to many psychotherapies for anxiety, and that confrontation with feared objects or situations is an effective treatment. Physiological activation and habituation within and across exposure sessions are cited as indicators of emotional processing, and variables that influence activation and habituation of fear responses are examined. These variables and the indicators are analyzed to yield an account of what information must be integrated for emotional processing of a fear structure. The elements of such a structure are viewed as cognitive representations of the stimulus characteristic of the fear situation, the individual's responses in it, and aspects of its meaning for the individual. Treatment failures are interpreted with respect to the interference of cognitive defenses, autonomic arousal, mood state, and erroneous ideation with reformation of targeted fear structures. Applications of the concepts advanced here to therapeutic practice and to the broader study of psychopathology are discussed.

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Emotional processing of fear : exposure to corrective information

ions as internal properties of clients rather than as hypothetical constructs of therapists has resulted in considerable confusion about the types of changes effected by different approaches to the modification of behavior. It is widely assumed that behavioral and psychodynamic approaches are concerned with fundamentally different subject matters. The latter methods supposedly treat complexes, repressed impulses, ego strengths and mental apparatuses, the underlying causes of behavior, whereas behavioral approaches are believed to modify only superficial behavior. This apparent difference in subject matter, however, exists primarily in the therapists’ conceptualizations, not in actual practice. Ego strength, to take an example, is a www.freepsychotherapybooks.org 235 hypothetical construct and not an entity within the client. One can neither observe nor modify hypothetical constructs. The person’s behavior— broadly defined to include cognitive, emotional, and motor expressions—is the only class of events that can be altered through psychological procedures, and therefore it is the only meaningful subject matter of psychotherapy. Similarly, stimulus variables are the only events that the therapist can modify to effect behavioral change. Psychotherapy, like any other social influence enterprise, is thus a process in which the therapist arranges stimulus conditions that produce desired behavioral changes in the client. If, for instance, a psychotherapist creates conditions that increase the frequency of the behaviors from which ego strength is inferred, the client will be said to have acquired increased ego strength as a function of treatment. On the other hand, if the frequency of www.freepsychotherapybooks.org 236 ego-strength behaviors has been reduced in the course of psychotherapy, the client has suffered a loss in ego strength. Clearly, ego strength is simply a hypothetical abstraction whose presumed behavioral referents are the only reality the psychotherapist can modify. In the final analysis, social-learning approaches and all other existing forms of treatment modify the same subject matter, namely, behavioral phenomena. Most discussions of change-inducing processes, however, focus on treating the inferences made from behavioral events as though these abstractions existed independently and caused their behavioral referents. Philosophers of science have cautioned against the attribution of causal potency to described properties of behavior. Their warnings have had little impact on personality theorizing. Neither traits nor types, as concepts, have www.freepsychotherapybooks.org 237 any real existence. They are merely words, and words do not exist in the eye of the observer nor in the people observed. A man can not be said to have either a type or a trait, but he can be said to fit either a type or a trait. At present the fit will be inexact, for dimensions of personality have not yet been quantified well enough to permit of accurate measurement. In the case of height, the measurement can be precise, and little confusion results from saying that a man has a certain height. Observation and concept are so closely related that the phrase is not ordinarily understood to mean more than it says, namely, that the extent of a given datum of observation in one direction fits a certain section of an ideal dimension of distance. But if an attempt is made to fit some mode of human conduct to the trait of courage, the looseness of correspondence between behavior and concepts leads to mischievous reification. The concept parts company with behavior, picks up undefined notions in its flight from reality, and finally acquires an independent real existence in its own right, so that when it is said that a man has courage, he will be thought of as the fortunate owner of something considerably www.freepsychotherapybooks.org 238 more significant than a certain pattern of behavior [Pratt, 1939, p. 115]. Similarly, a person who is plagued with “weak ego strength” will be viewed as suffering from something vastly more significant than the behavioral referents from which the construct is inferred. For purposes of further illustration, let us designate behaviors in which persons violate social and legal codes of behavior and frequently engage in assaultive activities as the external expressions of an inferred zoognick. Based on prevailing clinical practices, the zoognick would come to represent an intrapsychically functioning agent. An honorific causative power would be conferred upon this hypothetical zoognick, whereas the observed behavior from which its existence is inferred would be depreciated as superficial behavioral manifestations. Before long, www.freepsychotherapybooks.org 239 psychological tests would be constructed to measure zoognick strength on the basis of which diagnosticians would tautologically attribute clients’ behavior to the action of the underlying zoognick. Proceeding on the assumption that “patient variables are not conceived to be behaviors, but constructs concerning internal constellations” (Wallerstein, 1963), psychotherapeutic goals would be stated in terms of removing the pernicious zoognick. On the other hand, direct modification of the deviant behavior would be considered not only superficial but potentially dangerous, since elimination of the symptomatic expressions might force the zoognick to emerge in equally pernicious substitute forms. A sufficiently charismatic exponent of zoognick theory could undoubtedly develop a sizable following with the same extraordinary conviction in the vital importance and causative potency of www.freepsychotherapybooks.org 240 zoognicks as that shown by adherents of libidinal forces. Oedipal complexes, collective unconsciouses, and self-dynamisms. Finally, humanists would embrace zoognick theory as more befitting the complexities of human beings than those simplistic mechanistic doctrines that stubbornly insist that the zoognick is the deviant behavior rechristened. Most treatment approaches devote remarkably little attention to the selection of objectives; when they are specified (Mahrer, 1967), the intended outcomes generally include a variety of abstract virtues described in socially desirable terms, such as reorganization of the self, restoration of functional effectiveness, development of individuation and self-actualization, establishment of homeostatic equilibrium, where there is id there shall ego be and where superego was there shall conscious ego be, achievement of identity, www.freepsychotherapybooks.org 241 acceptance of self-consciousness, enhancement of ego strength, or the attainment of self-awareness, emotional maturity, and positive mental health. While some of these objectives allude to vaguely defined behavioral characteristics, most refer to nebulous hypothetical states. These abstractions convey little information unless they are further defined in terms of specifically observable behavior. Behavioral Specification of Objectives A meaningfully stated objective has at least two basic characteristics (Mager, 1961). First, it should identify and describe the behaviors considered appropriate to the desired outcomes. The term “behavior” is used in the broad sense to include a complex of observable and potentially measurable activities including motor, cognitive, and physiological classes of responses. www.freepsychotherapybooks.org 242 After the intended goals have been specified in performance, and preferably in measurable terms, decisions can be made about the experiences that are most likely to produce the desired outcomes. For example, the statement, “Increase the person’s self-confidence and self-esteem,” designates a therapeutic intent; but it furnishes little guidance, since it does not reveal the kinds of behaviors the person will exhibit after he has achieved increased self-esteem. Once self-esteem and the behaviors that will be esteem producing for a particular client have been delineated, one can arrange conditions that will create the requisite behaviors and thereby produce the condition of positive selfevaluation. In some instances learning vocational skills may be most relevant to acquiring selfesteem; in some cases developing interpersonal competencies that will secure positive responses from others may be most appropriate; in other www.freepsychotherapybooks.org 243 cases eliminating alienating social behaviors may be required if self-evaluation is to be altered; and finally, in cases where a person is relatively competent socially and vocationally, an increase in self-esteem behavior may require the modification of stringent, self-imposed standards of behavior upon which self-approving and self-deprecatory responses are contingent. Similarly, unless the goals specify the behavior that persons will exhibit when successfully self-actualized, internally integrated, self-accepted, personally reconstructed, homeostatically equilibrated, or emotionally matured, such goals provide little

Principles of behavior modification

Anxiety sensitivity, anxiety frequency and the prediction of fearfulness.

This study evaluated mindfulness-based cognitive therapy (MBCT), a group intervention designed to train recovered recurrently depressed patients to disengage from dysphoria-activated depressogenic thinking that may mediate relapse/recurrence. Recovered recurrently depressed patients (n = 145) were randomized to continue with treatment as usual or, in addition, to receive MBCT. Relapse/recurrence to major depression was assessed over a 60-week study period. For patients with 3 or more previous episodes of depression (77% of the sample), MBCT significantly reduced risk of relapse/recurrence. For patients with only 2 previous episodes, MBCT did not reduce relapse/recurrence. MBCT offers a promising cost-efficient psychological approach to preventing relapse/recurrence in recovered recurrently depressed patients.

/pdf/prevention-of-relapse-recurrence-in-major-depression-by-37o6bjuzs2.pdf

Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy.

Background Current and comprehensive information on the epidemiology of DSM-IV 12-month and lifetime drug use disorders in the United States has not been available. Objectives To present detailed information on drug abuse and dependence prevalence, correlates, and comorbidity with other Axis I and II disorders. Design, Setting, and Participants Face-to-face interviews using the Alcohol Use Disorder and Associated Disabilities Interview Schedule of the National Institute on Alcohol Abuse and Alcoholism in a large representative sample of US adults (N = 43 093). Main Outcome Measures Twelve-month and lifetime prevalence of drug abuse and dependence and the associated correlates, treatment rates, disability, and comorbidity with other Axis I and II disorders. Results Prevalences of 12-month and lifetime drug abuse (1.4% and 7.7%, respectively) exceeded rates of drug dependence (0.6% and 2.6%, respectively). Rates of abuse and dependence were generally greater among men, Native Americans, respondents aged 18 to 44 years, those of lower socioeconomic status, those residing in the West, and those who were never married or widowed, separated, or divorced (all P Conclusions Most individuals with drug use disorders have never been treated, and treatment disparities exist among those at high risk, despite substantial disability and comorbidity. Comorbidity of drug use disorders with other substance use disorders and antisocial personality disorder, as well as dependence with mood disorders and generalized anxiety disorder, appears to be due in part to unique factors underlying each pair of these disorders studied. The persistence of low treatment rates despite the availability of effective treatments indicates the need for vigorous educational efforts for the public and professionals.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/482282/yoa60081_566_576.pdf

Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Alcohol Abuse and Dependence in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions

Background Recognition of the additional social handicaps and distress that people with mental illnesses experience as a result of prejudice.

Aims To determine opinions of the British adult population concerning those with mental illnesses as baseline data for a campaign to combat stigmatisation.

Method Survey of adults ( n =1737 interviewed ; 65% response) regarding seven types of common mental disorders. Responses evaluated concerned eight specified perceptions.

Results Respondents commonly perceived people with schizophrenia, alcoholism and drug addiction as unpredictable and dangerous. The two latter conditions were also viewed as self-inflicted. People with any of the seven disorders were perceived as hard to talk with. Opinions about effects of treatment and prognosis suggested reasonable knowledge. About half the respondents reported knowing someone with a mental illness.

Conclusions Negative opinions indiscriminately overemphasise social handicaps that can accompany mental disorders. They contribute to social isolation, distress and difficulties in employment faced by sufferers. A campaign against stigma should take account of the differences in opinions about the seven disorders studied.

/pdf/stigmatisation-of-people-with-mental-illnesses-4waatbfbt6.pdf

Stigmatisation of people with mental illnesses.

Recent studies have shown that cognitive therapy is an effective treatment for panic disorder. However, little is known about how cognitive therapy compares with other psychological and pharmacological treatments. To investigate this question 64 panic disorder patients were initially assigned to cognitive therapy, applied relaxation, imipramine (mean 233 mg/day), or a 3-month wait followed by allocation to treatment. During treatment patients had up to 12 sessions in the first 3 months and up to three booster sessions in the next 3 months. Imipramine was gradually withdrawn after 6 months. Each treatment included self-exposure homework assignments. Cognitive therapy and applied relaxation sessions lasted one hour. Imipramine sessions lasted 25 minutes. Assessments were before treatment/wait and at 3, 6, and 15 months. Comparisons with waiting-list showed all three treatments were effective. Comparisons between treatments showed that at 3 months cognitive therapy was superior to both applied relaxation and imipramine on most measures. At 6 months cognitive therapy did not differ from imipramine and both were superior to applied relaxation on several measures. Between 6 and 15 months a number of imipramine patients relapsed. At 15 months cognitive therapy was again superior to both applied relaxation and imipramine but on fewer measures than at 3 months. Cognitive measures taken at the end of treatment were significant predictors of outcome at follow-up.

A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder.

http://www.personal.kent.edu/%7Edfresco/CBT_Readings/Wells_et_al_(1995)_BT.pdf

Social Phobia: The Role of In-Situation Safety Behaviors in Maintaining Anxiety and Negative Beliefs

COGNITIVE-BEHAVIOR THERAPY AND THE DIALOGUE OF SCIENCE The Science and Practice of Cognitive Behaviour Therapy D. M. Clark & C. G. Fairburn (Eds.), Oxford, England: Oxford University Press, 1997,437 pp. $47.50 (paperback). D. M. Clark and C. G. Fairburn have edited an extensive and well-documented text that attempts to scientifically ground the practice of cognitive-behavior therapy (CBT). As someone who holds to postmodern leanings, my interaction with this text gave rise to many questions, cautions, and feelings. First, all the contributors to the text succeeded in relating CBT to the scientific method. Second, Clark and Fairburn constructed a text that offered a solid theoretical base for CBT and documented application of the theory to specific clinical problems and disorders. Third, the language of therapy, medicine, pharmacology, and the scientific method led me to question where I might place this book among the many voices vying for attention in the postmodern world. I experienced this book as an important contribution to the modernist postmodernist dialogue. Science and Practice of Cognitive Behaviour Therapy is organized into two parts. The first section comprises five chapters that deal with theory and other general considerations while the second section addresses cognitive-behavior conceptualizations and therapeutic approaches to specific disorders. I will focus primarily on the first section and somewhat touch on the second. As D. M. Clark's preface indicates, the book seeks to link experimental science with the practice of CBT. Part I of the text, entitled "General Considerations," deals with issues that are primarily theoretical in nature. In chapter 1, S. Rachman traces the evolution of CBT. He outlines a historical process that begins with origins of behavior therapy, proceeds to the rise of cognitive therapy, and concludes with a merging of the two. In line with the spirit of the scientific method, Rachman discusses the importance of the empirical tradition within behavioral therapy that was also embraced by cognitive therapy. Rachman envisions a historical, developmental process in which "cognitive therapy [now] provides the content for behavior therapy." Moreover, Rachman offers D. M. Clark's theory of panic disorder as an example of a scientifically viable theory that contains both parsimony and comprehensive explanatory powers of the data pertaining to panic disorder. He concludes the chapter with a discussion of "future trends" and "growth points" where he envisions the need for cognitive reanalyses of specific disorders, linking CBT with neuroscience and a cognitive conceptualization of a wider degree of medical-psychological problems. In the second chapter, M. Gelder explores the scientific foundations for CBT. Gelder structures his chapter around three major areas: (1) the character of key cognitions in psychiatric disorders, (2) predictions concerning the roles of these cognitions, and (3) studies of the factors that maintain cognitions. Gelder believes that for CBT to continually develop, studies must be grounded in clinical as well as normal populations. True to the scientific method, Gelder argues for a move away from broader models of CBT and for a more focused approach based on clinical observations and abnormalities of cognition. Studies of psychopathology from a cognitive perspective would lean on the areas of cognitive science involving thinking, attention, memory, visual imagery, worry, and metacognition. In chapter 3, A. Mathews discusses the role of information-processing in cognition and emotion. In terms of science, Mathews views the information processing model as an important tool because it provides a framework for generating hypotheses and experimental methods for testing them. Mathews delineates the assumptions of the information-processing model, and then goes on to discuss biases in information processing (encoding, interpretation, and memory) as they relate to psychological disorders. …

Science and practice of cognitive behaviour therapy

A population survey before the start of the Changing Minds campaign showed that negative opinions about people with mental illnesses were widely held, and that opinions about different disorders differed in important ways. We repeated the survey 5 years later, when the campaign had ended. Interviews were again conducted with a representative population sample (1725 interviews; response rate 65%), enquiring about demographic variables, about eight opinions concerning seven common mental disorders, and whether the respondents knew anyone with one of these mental disorders. The pattern of response in this second survey resembled that in the first. However, there were significant changes. Though often small, apart from reported opinions concerning treatment and outcome, they were all reductions in the percentages of stigmatizing opinions. Seventy seven percent of respondents reported knowing someone with one of the seven disorders. Those who did so in respect of severe depression or panic and phobias were less likely to have stigmatizing opinions about people with the corresponding disorder, but the same did not apply to the other disorders. The greatest proportion of negative opinions was in the 16-19 year age group, and respondents with higher education were less likely than the rest to express such views. We conclude that stigmatizing opinions are frequent in the community but the various disorders are not stigmatized in the same way. Campaigns to reduce stigma should take account of these differences, and of the need to address young people.

Stigmatization of people with mental illnesses: a follow-up study within the Changing Minds campaign of the Royal College of Psychiatrists RESEARCH REPORT

Michael Gelder

Papers

Stigmatisation of people with mental illnesses.

A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder.

Social Phobia: The Role of In-Situation Safety Behaviors in Maintaining Anxiety and Negative Beliefs

Science and practice of cognitive behaviour therapy

Stigmatization of people with mental illnesses: a follow-up study within the Changing Minds campaign of the Royal College of Psychiatrists RESEARCH REPORT