Mario Di Fiorino Ovidiu Alexinschi Tomasz Maciej Gondek
Mario Di Fiorino Ovidiu Alexinschi Tomasz Maciej Gondek
Exercises of Behavioral Therapy
I’m delighted that cognitive behaviour therapy (CBT) is now offered in many countries in Europe and elsewhere. Despite widespread constraints in resources, CBT is effective for many anxiety, depressive and other disorders without being time-consuming. It can be delivered as guided self-help online with minimal or even no therapist help, as well as in out- and in-patient settings. Improvements tend to persist over long-term follow up.
Emeritus Professor of Psychiatry, Institute of Psychiatry, University of London
past president of European Association for Behavioural and Cognitive Therapy (EABCT)
We like to thank prof Isaac Marks, Emeritus Professor of Psychiatry at the University of London, past president of “European Association for Behavioural and Cognitive Therapy” (EABCT), for all he has done to promote the spreading of the techniques of behavioral therapy, including a variety of lessons and courses held in Viareggio (Italy) and in Iași (Romania) in the last twenty years.
In the light of today’s trends on psychiatric treatment it appears more and more clear that mental health specialists should combine prescribing drugs with psychosocial intervention and/or psychotherapy in order to augment and consolidate the results on long term periods.
In order to allow the greatest number of patients using these treatments, Marks developed a nurse behavioral psychotherapist training program (in relation to which he coined the term “Barefoot therapist”, modeled on Mao Zedong’s term “Barefoot doctor”) through the Internet.
Since the early seventies, Marks paved the way, based on scientific evidence long before the evidence-based medicine became fashionable, for the current behavioral approach to the phobic disorders (particularly agoraphobia). Based on a series of controlled trials he was able to determine that the key ingredient of the patient’s clinical improvement is phobic exposition (real, not the imagination) to the phobic situation. More prolonged and more complete is this exposure (of course within certain limits) greater the improvement.
Through the proposed methodology, the treatment of this category of disorders has achieved important progress, and many people, who suffer from it, can be cured through short behavioral psychotherapy. The behavioral treatments are effective in most cases, which means that they are able to help people suffering because of one of the described problems. Phobias, obsessive-compulsive disorder, post-traumatic stress disorder and sexual dysfunction respond well to this type of treatment, and usually the improvement persists in the years following the end of treatment. When phobias and rituals involving the family and friends, they will give you a hand and work with you as co-therapists.
In order to develop the ability in dealing with behavioral therapy you must already have a full picture of what are the problems that a patient can accuse.
Already in the first few minutes we can get an idea of why the patient seeks help. The problems may be different. The patient may complain of panic and fears, or avoidance.
For example, the patient may say: “My problem is that I have panic attacks”, but if the patient complains to have this disorder, you should know when he comes to panic, whether leaving home or going to the grocery store or being in a crowd (in the case probably a crisis of agoraphobia).
Furthermore it is likely that this patient has no problems with his wife at home, because there are no panic inside the walls of the house, as well as for a patient who claims to be afraid of contamination, it is unlikely to have other types of problems: so you already have a picture of what may be the characteristics of the various issues and consequently also know how to move and what questions to ask to the patient.
They may report an excessive need to wash, to control themselves after using the bathroom, or to feel depressed constantly or only in the workplace. Sometimes patients need time before talking about erection or anorgasmia disorders, it may be that the beginning is part of another specialist: for example, the dermatologist may look first the skin changes due to washing rituals.
Perform a screening to determine to which category your patient belongs, it does not take long, generally within an hour you can have the response. However, there are some patients for whom more time is needed, such as patients who speak slowly and they want you to be aware of every detail, so talking for a long time and not allowing to be stopped and questioned about other arguments. In most cases one hour is sufficient to get an idea, and then proceed to therapy, and especially to help the patient to develop a self-help program.
So the first question to ask to the patient is as follows: “What provokes the problem?”
The patient may respond: “I have a panic attack when I go out alone or when I enter into a crowded store!” or “I constantly have to wash myself, if I touch the floor or the toilet seat, after having counted money”; also the patient may be continuously haunted and repeatedly checks if the front door or the windows are closed before going out or going to sleep, or closed are the gas taps and more.
Another problem that can arise is that the patient may complain of fatigue often after coming back from work or has discussed with his wife: “I am very tired and I cannot get to bed .” If the patient suffers from anorexia nervosa, he can refer to fear of being too fat, or whether he is incredibly tired, the patient will tell you that he cannot face the day or rather he cannot do what he did before. Our task is to be careful, keeping our eyes open, to be able to assign the case to a specific diagnostic category, although it is true that every patient is a unique, special case. The first question we asked was: “What causes the problem?”; also we can ask: “What mitigates the problem and makes him feel better?”.
In the cases of people affected by contamination phobia or agoraphobia, the answer will be, respectively: “I am fine if they are clean and do not come into contact with anything that could make me think of the dirt” or “I feel better in isolated places”. Instead, if it is a problem of a sexual nature, he will say that it is better if he remains alone. A question that can simplify the task, to have a more precise idea, is to clarify with the patient what to avoid into further crisis.
So before you can proceed with a behavioral therapy you must have had in mind a picture, a list of the problems.
After speaking with the patient in order to determine which are the reasons that give rise to the problem and in what situations you feel better, with him you try to develop and establish the objectives to be reached gradually, little by little, since it is not possible to do everything in a short time. This is the crux, the essence of behavioral therapy, it is an approach to solve the problem in small steps.
An example: talking to a patient suffering from agoraphobia, the goal to be achieved can be to go to the street alone and try to walk 200 meters in about an hour; note that this is a gradual and every day our objective is to be achieved, always and exclusively alone, for 200 meters, away from home for an hour, so that the anxiety will be diminished by 50%. In fact, if this person comes accompanied by someone who has no problem, the problem takes over when it comes out on its own. “Why to stay out for an hour?” Interesting question we can ask ourselves, and the answer is simpler than expected: an hour because it is the time it takes to develop an addiction, a habit to the new situation. Then the patient can get away for an hour to 400 meters alone to get to the nearest store or at the bus stop, get on this and stop after three stops; note the specific nature of the tasks that are required to the patient in cases of anxiety disorders. In summary a goal should be planned through next objective after being able to complete the previous one, however, for at least three consecutive days without feeling too much anxiety. Remember that what we are doing is to ask the patient to develop a self-help program that leads him to develop an ability to deal with the problem. We explain to the patient what he is required to do, that you will have to stay with that fear, for example in the case of agoraphobia, as long as able he is to get used to the new situation.
Even in cases of patients suffering from depression we must explain the principle that underlies the behavioral psychotherapy, to what we should slowly become accustomed, that have to get used to the situation that creates the problem, and it is in that case it must try to do pleasant things to gratify him. We also need to explain to the patient that we have not been subjecting him to a treatment, but we have only been helping him to find the right path he will face when alone; you also have to explain to him that you teach a treatment that will last a lifetime and that will allow him to develop the skills to deal with disturbing situations.
For patients suffering from depression, without a suicidal intentionality we can ask them to list a series of activities that are enjoyable, perhaps involving other people: for example calling a friend and talking to him; after doing so for at least three times, the patient will have to invite this friend to his home for coffee or go out with him for a coffee.
Another example would be to bring the dog to the park and spend time here talking to the owners of other dogs, and so on. After performing these activities these patients, increasingly suffering from depression, can watch TV, take a warm bath, shopping at a grocery, cooking and enjoying a meal, in short words anything that might work for them.
Another question is how to explain to the patient that what matters are his ideas and not the ones of the therapist, what matters is that he develops the ideas and the task of the therapist is to help and assist him.
Finally, we ask the patient to write down everything that happens during the day on a daily diary, bringing the activities they have done as homework assigned by the therapist; also the patient will bring the diary every session, where we will analyze together with the patient to highlight what they have done as homework, we will discuss on the progress achieved, the difficulties encountered, and that in most cases manage to overcome.
The reader may find some examples of this in the case of sessions we will review with the patient’s diary of the planned activities, which have played in different days of the week as homework; we will discuss the progress achieved, the difficulties they may have encountered and have been overcome and we will continue with the patient planning new activities to be performed and then recorded in his diary.
This book mainly concerns the basic elements of behavioral therapy, emphasizing the pragmatic aspect, with less interest in the theory. So it will interest us above all to see what we should do!
The roots of Behavioural Therapy
The pioneering researches of Ivan Petrovic Pavlov, who observed the ability to change stably the behavior through conditioning techniques, represent the starting point for the construction of a whole series of practices that aim to cure the pathological behavior.
It’s really fascinating reading today the description of the clinical cases treated by Vladimir Michajlovic Bechterev and by Pierre Janet, who employed exposure in a patient suffering by obsessive-compulsive disorder.
In 1958 Wolpe proposed the Systematic desensitization. If a person was allowed to relax, during gradual exposure to a fearful stimulus, the fear would be “reciprocally inhibited, and he could not experience fear in the same time.”
It was an exposure in Fantasy (Imagination): the first behavioral method to be widely used in phobic patients (Wolpe, 1958).
This technique was an effective, slow and time-consuming treatment.
Also in the perspective of logotherapy, Viktor Frankl (1960) proposed exposure, calling the technique “paradoxical intention”.
The phobic patient is persuaded to stay in the phobic situation until he feels better, and to repeat until this becomes so customary that it holds no more terrors.
The in vivo-exposure at first was called flooding (Stampfl, Levis, 1967). This treatment was found to be more effective than imaginative flooding (Emmelkamp, Wessels, 1975).
The exposure therapist identifies the cognitions, emotions and physiological arousal that accompany a fear-inducing stimulus and then tries to break the pattern of escape that maintains the fear. This is done by exposing the patient to progressively stronger fear-inducing stimuli. Fear is minimized at each of a series of steadily escalating steps or challenges (a hierarchy), which can be explicit (“static”) or implicit (“dynamic”) until the fear has finally gone. The patient is able to terminate the procedure at any time.
The first type of exposure procedures is in vivo or “real life”, in which the patient exposes himself to actual fear-inducing situations.
The second type of exposure is in imagination: the patients is asked to imagine a situation that he is afraid of.
Three Golden Rules for exposure treatment
1) Though anxiety is uncomfortable, it will not harm you, you will not lose control, be crazy or die.
2) Anxiety does eventually reduce.
3) Practice makes perfect.
It is important to stick with the session until the anxiety is reduced, for avoiding the idea that anxiety is harmful.
When you repeat the exposure, the anxiety will decrease further and so when you do exposure.
The therapist explains the rationale of exposure treatment and then has to identify the target of the treatment with the patient.
Obsessive-Compulsive Disorder (OCD) is a disorder characterized by excessive worry, nagging, unpleasant, involuntary but irrepressible (obsessions) and repetitive behaviors and uncontrollable (compulsions) mostly, to reduce the anxiety generated by the thoughts themselves, by which may take the form of actual ritual that the patient performs without being able to dominate his will.
The obsessive thought is not desired by the patient, it has an intrinsic character of unpleasantness and invades the consciousness in an intrusive way, like ivy which is rooted in the mind.
We speak about “psychic parasite” in reference to the obsessions and “psyche of defense” in relation to the rituals put in order to reduce anxiety.
The obsession is seen in a egodystonic way by the patient who tries to oppose to it. Therefore with the term “resistance” we refer to the voluntary effort implemented against the obsessions and compulsions (low resistance levels are correlated with a greater severity of the disorder) while the term “interference” refers to the fact that the pathology interferes in the social operation and work of the subject.
Both the interference and the resistance are two dynamic entities as variable and fluctuating in relation to the patient’s subjective experience and the severity of symptoms of the disorder.
Alongside the concept of Obsessive-Compulsive Disorder, there is the obsessive personality, which is characterized by an extreme need for order, formal perfection and completeness of such principles on which to base its existence in order to escape from the disorder that generates anxiety. There are three essential aspects from a cognitive point of view that characterize the obsessive patient: a great sense of uncertainty, indecision and insecurity. It is a subject extremely scrupulous, ranked, with a great sense of duty.
From a clinical point of view, a simple and effective distinction was proposed by Insel (1985), who identified four key sub-groups, in which patients can be attributed depending on the prevailing symptom manifestations: washer, checker, pure obsessives and primary obsessive slowness.
A clinical case of Obsessive-Compulsive Disorder
Here is another peculiar case of Isaac Marks. A patient who had an obsessive-compulsive disorder, dysmorphophobia, was convinced that the body had an abnormal shape and also not normal sizes, with many avoidance situations. The patient has carried out much the self-exposure assignment at his home; gradually he has abandoned his avoiding behavior; with self-exposure he has faced many social tasks, if we can define them so, but his worry about his abnormal body has remained strong: he continued believing to possess an enormous head and to possess body with a funny shape.
At this point Marks has asked to him to carry out what we call “rational role”.
Marks has said: “Go home and imagine to have to defend yourself before the court; I will be the judge, and you will be the accused; we will play this game where I take the role of the one who charges; I charge you of having a ludicrous head and body and you will have to produce evidence in order to show that you are a normal person”.
I would like to emphasize, at this point, that we had already asked him to follow a therapy as prescribed by Beck, and before he had examined these automatic thoughts and he had tried to challenge himself; but he wasn’t able to change anything.
It was at this point that Marks has introduced the role play, the game of taking the roles. He came to us and the therapist pretended to be the judge: “I have seen you entering the court and I have seen that you had some difficulty in introducing your head into the door, the head is so big …”. “No, it’s silly, it’s absurd: look, I can come back and go through the door!”. “No! I’m sure that if you shake your head, you bang into the sides of the door!”. “No, no, no, no”. Gradually the situation became less and less ludicrous and the patient began retrieving sound reasons about the normality of his head; this play lasted only 20 minutes; even the second session lasted 20 minutes.
Here you see how the situation returns to normal after these 20-minute sessions; of course we should not draw conclusions from only one case.
There was a first exposure therapy: we do not know what would have happened if this game of roles had been done before exposure therapy. We treated in this way different patients getting valid hits.
Marks later told this story to a therapist colleague, who was amazed and wanted to test it on a patient, suffering from OCD, regarding the shape of the body.
The colleague returned the following week and told Marks that this method was gorgeous, because the patient’s concern diminished after only one session.
Marks asked what he had done exactly with his patient; the colleague replied that had followed exactly the description of the procedure adopted; Marks realized that he had been misunderstood. Instead of applying this role of rational therapy, the colleague had done the opposite, and that is the game of irrational positions, in which the patient was the accuser and the therapist should instead assume the role of defender.
The anecdote is told to show how difficult it is to guess the effective ingredients of a therapy. We have to perform many control studies, to locate the really functioning mechanism.
Some people believe that the exposure therapy does not heal through habit, but because it changes the concern.
We believe there are many arguments against this theory; exposure changes not only the knowledge, but also the feelings, behavior and physiology. Cognition often changes after that fear has diminished: we call this “cognitive black” phenomenon.
Another reason to believe that exposure usually does not diminish the fear cognitively, is that fear often decreases, despite the catastrophic expectations are confirmed.
Social phobics who are afraid of the hand tremor when holding a glass can really overthrow a little liquid, but when they exercise decreases anxiety and are able to avoid it. And it is interesting to note that patients with Parkinson’s disease despite the obvious tremor rarely develop social phobia. Social phobics who complain about the trembling of the hands when they put their hands on, observe the tremor, and they are afraid. We have reason to believe that the exposure is not effective in a cognitive way; there have been experiments which showed that cognitive therapy can subsequently reduce the fear and thus the social fear.
Let’s think to the neoplastic patients undergoing cancer therapy. Chemotherapy causes vomiting and many of them succeed in developing this condition the nausea, as soon as they see the doctor or the hospital building or parking; nausea and vomiting become a generalized phenomenon. These patients know that is not the hospital, parking, responsible for this phenomenon, but they are subjected to chemotherapy; but knowing this does not allow them to overcome the feeling of nausea. And it is possible to treat them effectively with exposure therapy. We also know that agoraphobic patients believe they have the catastrophic projections; they say only: “I’m afraid” knowing that emotions can change with repetition. To say it a hundred times cancel its meaning, there is no cognitive restructuring.
We take into consideration the modern techniques of treatment, particularly underlining the psychological cure of Obsessive-Compulsive Disorder through exposure and response prevention, that has been demonstrated as the most effective. We like to remind also the computerised behaviour therapy for Obsessive-Compulsive Disorder, which may have an important role in the future.
Two cases of Obsessive-Compulsive Disorder, two “washers” with contamination obsessions and ablutomanic ceremonial
We present two cases of OCD, two women with contamination obsessions and ablutomanic ceremonial. Ritualistic washers usually worry and avoid “contaminations”. Obsessional rituals serve to reduce anxiety, but this anxiety reduction has a short life, so the ritual has to be repeated.
The first patient, Enrica, presented some depressive phases, during which surfaced ideas of guilt. During an interview she blamed, about the suicide of a cousin that took place 20 years earlier, She did not understand in time the drama, of not being able to hold her back.
Handwashing is a common ritual.
The actual obsessive symptomatology is traced to about 6 years ago, when she was 29 years old. Enrica repeatedly washes her hands with alcohol, can not refrain from making too frequent bathing to her 8 years old daughter, sometimes wakes up in the middle of the night with the thought of having to clean the house. The patient herself claims to have the “phobia of grease and stink.” It must be said that, paradoxically, since when she was a girl worked as aesthetician and even now, when she is required, “goes into private homes to do a pedicure.”
In some periods in which the rupophobia is more intense, the patient does not cook. So she was invited by the mother-in-law, who lives in the apartment below hers. But when she returns home, the “oiled” perceptions remains. She thinks about clothes, and to an object that has “rubbed” the mother’s-in-law table. She would like to rinse thoroughly also the little girl. Due to possible contamination of the objects, cleans everything very accurately: first with soap and water for three times, then holding hands above, observes the water running away. When this appears to be clear, it starts washing with alcohol.
The ritual aspect stands out for the required atmosphere to this procedure: “If I hear someone, I get distracted and have to continue to restart washing.”
Enrica gets up at night to take the ceremonials. The parents-in-laws heard the noise produced by the movement of furniture, so they are informed.
The patient has felt observed, limited in their freedom. During these years she met crisis in his marriage. She wants to move from her house. When she argues with her husband, even for long periods she takes refuge with her parents. The obsessive compulsive behaviours then appear to recede, although without disappearing.
In the story of the patient is enhanced the coarseness of the mother-in-law, frying potatoes. The grease and the stink rising, reaching the Enrica’s apartment, pervade and permeate everything.
Contacts with “contaminants” leads to prolonged washing.
This patient has had good results with the application of exposure techniques, associated with treatment with chlorimipramine.
The other patient, Anne, has been presented to Marks, many years ago, during a workshop in Viareggio.
At the time she was suffering from OCD with contamination obsessions and ablutomanic rituals for about 6 years.
Even then, the relational world of the p. was limited to the relationship with her husband and son, fifteen years old.
The patient, especially for the exhausting contamination by dirt obsessions and rituals, was not able to keep the house tidy and look after the family. Again, as in the previous, obsessions seem to affect some aspects of her world. Anne spends most of the time stripped, in order to limit the controls and the washes that would invest her clothes, she otherwise needs to mentally break down the movements performed, and then to understand at what point of her body touching something, to be submitted to the ritual.
Despite this, she has tolerated the presence in the house of a guinea pig, the son’s pet , that her husband introduced with the idea of promoting a more natural concern for the dirt.
She was visited by a number of private specialists and has practised the recommended therapies (stabilizers, atypical anti psychotics, antidepressants) with poor effects. The perfusion scan is practised intravenous therapy of chlorimipramine. A few years ago she was treated with phenelzine, an MAOI, with poor results. Anne had no lasting benefit from the application of exposure techniques, and was aided by the use of thought-stopping technique.
The patient was asked to write a list of her obsessions, starting with the recent one.
After an exercise of relaxation, for permitting to focus the cognitive task of thought stop, she was asked to image the action that bothered her. When she turned off the imaginary movements of her body, she was asked to ruminate about 15-30 seconds. Then the therapist made a taps, she was asked to shout “Stop”.
Anne practised the technique outside the clinic every day for two months.
By exposure in vivo, in real life, the patient has to confront cues (objects, words, images, or situations) that trigger obsessive thoughts.
For example, touching water faucets in a public restroom might trigger germ obsessions.
Cues are presented in a hierarchical manner, beginning with the moderately distress-provoking ones and progressing to more distressing cues, the disastrous consequences that they fear will happen if they do not perform the rituals.
Imaginal exposure may be proposed when the feared consequences cannot and should not be created in reality.
For example, the obsession of contracting a sexually transmitted disease because he did not wash their hands sufficiently after using a public bathroom.
Ritual prevention means the patient has to abstain from the ritualizing that they believe prevents the feared disaster or reduces the distress produced by the obsession (eg, washing hands after touching the floor and fearing contracting a disease).
By practicing ritual prevention the patient learns that the anxiety and distress decrease without ritualizing and that the feared consequences do not happen.
The therapist discuss the patient’s experience during or after exposure and response prevention, and how this experience confirms or disconfirms the patient’s expectation.
“You touched the floor and you did not wash your hands for about 1 hour. Is your level of distress as high as in the beginning of the exposure? How strong are your urges to wash? Are they as strong as you expected?”
These sessions can be
conducted either once a week, twice a week, or daily in an intensive treatment
program, depending on symptom severity.
 Marks, I.M. et al. (2004). Saving clinicians’ time by delegating routine aspects of therapy to a computer: a randomized controlled trial in phobia/panic disorder. Cambridge University Press. Psychological Medicine, 2004, 34, 9–18.
 Isaac Marks: Foreword at the Italian edition of the “Scritti psichiatrici” (Psychiatric Writings) of Ivan Petrovic Pavlov , Psichiatria e Territorio, 2004.
 Vladimir Michajlovic Bechterev “Le Perversioni dal punto di vista della riflessologia” (The Perversions from the Reflexology point of view Italian edition Edited by Andrea Di Fiorino Psichiatria e Territorio, (Die Perversitäten und Inversitäten vom Standpunkt der Reflexologie. Vol 68, Num 1, pagg 100-213, December 1923, Publisher Dietrich Steinkopff, Darmstadt., Über die Perversion und die Abweichungen des Geschlechtstriebes vom reflexologischen Standpunkt aus. Psychologie und Medizin, pagg 197-253, Ferdinand Enke, Stuttgart, 1927).
 Presenting to the patient, for a maximum of one minute, phobic stimuli (in vivo or in imagination) graduated from least to most anxiety-provoking, in conjunction with an intense relaxation of the subject in order to get one that in Wolpe intentions should have been a reciprocal inhibition between the state of relaxation and anxiety and so resulting in a reduction of the latter.
 Marks, Isaac Meyer (1981). Cure and care of neuroses: theory and practice of behavioral psychotherapy. New York: Wiley
 De Silva, P.; Rachman, S. (1981). “Is exposure a necessary condition for fear-reduction?”.Behav Res Ther. 19 (3): 227–32.
 So the obsession is characterized by the awareness (Einsicht) of the absurdity of the disorder and its strangerness for its personality (egodystonia) (Westphal). Binswanger has observed that there may be fluctuations in this awareness. But also about the dystonia, Ey detects elements of ambiguity. The obsessive does not always live obsessions as extraneous but as an own tendency to conflict. He wrote about a “dark satisfaction” of a “desire to force and restrain” a “compulsive gambling”, whereby he rejected what draws and committing himself to what he fears.
 The case has been presented by Isaac Marks also in Viareggio, in September, 2000
 Recently there has been a significant growth of interest in the methods of treatment that can reduce the intervention of the therapist as much as possible. In this regard, an increasingly used technique is the one that includes the use of computers with two different methodologies (Tumur, 2007).
The first was developed by Marks et al. (1998) and named BT STEPS (i.e. “walk” or “steps” of behavioral therapy). It has nine “steps”: the first four explain to the patient how to conduct therapy sessions and exposure and response prevention, while the other five steps teach the subject how to perform self-treatment using exposure and prevention of answer. Various studies (Nakagawa et al., 2000; Greist et al., 2002) have evaluated the effectiveness of the program, noting that patients who progressed beyond the assessment phase and led at least two sessions of exposure and prevention of obtained response have significant improvement symptoms, comparable to those obtainable with a therapy conducted personally by a therapist (Nakagawa et al., 2000; Greist et al., 2002).
The second mode of use of the computer is to provide a vicarious exposure through an interactive program in which subjects with OCD are attending interactive scenes on screen, guided by the subject, in which they could get their hands virtually dirty several times and always more (Kirkby et al., 2000), without then subsequently washing them. Regarding the gradual approach, generally the literature supports that non gradual procedures, in which all the rituals are eliminated from the beginning, are the most effective (Foa et al., 1992).