BEHAVIOR

MODIFICATION

TECHNIQUES

TABLE OF CONTENTS

SYSTEMATIC DESENSITIZATION……………………………………….. 1 RELAXATION TRAINING………………………………………………….. 55 IMPLOSIVE THERAPY AND FLOODING…………….………………….. 83 ASSERTIVE TRAINING………………………………….………………….. 101 AVERSION THERAPY……………………………………………………….. 117 POSITIVE REINFORCEMENT…………………………..………………….. 127 RESPONSE-SHAPING…………………………………….………………….. 150 INTERMITTENT REINFORCEMENT…………………..………………….. 158 EXTINCTION……………………………………………….………………….. 164 MODELING…………………………………………………………………….. 178 TOKEN ECONOMIES…………………………………….………………….. 194 QUIZZES…………………………………………………….………………….. 206 ANSWER KEY…………………………………………………………………. 237 REFERENCES………………………………………………………………….. 244 EVALUATION & SUMMARY OF QUIZZES……………………………….. 251

SYSTEMATIC

DESENSITIZATION

ADIGUE, MARY LOU

BUENASFLORES, MA. FE FERRAN, KIMBERLY G.

GOMEZ, MARA CASSANDRA NACIONAL, CHRISTELLE JAN

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SYSTEMATIC DESENSITIZATION Systematic Desensitization is a procedure for the treatment of phobias originally developed by Joseph Wolpe (1958). Systematic desensitization was originally a treatment for phobias in individuals with generally adequate cognitive functioning and required their organized assistance in implementing the several components of the treatment plan. Since Wolpe’s original publication, systematic desensitization has been successfully used to reduce a wide variety of phobias, and a number of elaborations and variations on the procedure have been developed. Systematic desensitization is when the client is exposed to the anxiety-producing stimulus at a low level, and once no anxiety is present a stronger version of the anxiety-producing stimulus is given. This continues until the individual client no longer feels any anxiety towards the stimulus. There are three main steps in using systematic desensitization. The first step is to teach the client relaxation techniques.

HISTORY (JOSEPH WOLPE’S SHORT BACKGROUND) Joseph Wolpe (20 April 1915 in Johannesburg, South Africa – 4 December 1997 in Los Angeles) was a South African psychiatrist, one of the most influential figures in Behavior Therapy. One of the most influential experiences in Wolpe’s life was when he enlisted in the South African army as a medical officer. Wolpe was entrusted to treat soldiers who were diagnosed with what was then called "war neurosis" but today is known as post-traumatic stress disorder. The mainstream treatment of the time for soldiers was drug therapy. Doctors would use a type of "truth serum" to get soldiers to talk about their experiences. It was believed that by having the soldiers talk about their experiences openly it would effectively cure their neurosis. However, this was not the case. It was this lack of successful treatment outcomes that forced Wolpe, once a dedicated follower of Freud, to question psychoanalytic therapy and search for more effective treatments options. Wolpe is most well-known for his Reciprocal Inhibition techniques, the most heralded being Systematic Desensitization, which revolutionized behavioral therapy. Systematic desensitization is what Wolpe is most famous for. However, he was not the first to happen upon such an idea. Mary Cover Jones had used similar techniques in treating phobias in younger children. But it was Wolpe who coined and perfected it. Wolpe received the idea of relaxation from Edmund Jacobson, modifying his muscle relaxation techniques to take less time. Wolpe’s rationale was that you cannot be both relaxed and anxious at the same time. The second step is for the client and the therapist to create a hierarchy 2 | P a g e of anxieties. The therapist normally has the client make a list of all the things that produce anxiety in all its different forms. Then together, with the therapist, the client makes a hierarchy, starting with what produces the lowest level of anxiety to what produces the most anxiety. Next is to have the client be fully relaxed while imaging the anxiety producing stimulus. Depending on what their reaction is, whether they feel no anxiety or a great amount of anxiety, the stimulus will then be changed to a stronger or weaker one. Systematic desensitization, though successful, has flaws as well. The patient may give misleading hierarchies, have trouble relaxing, or not be able to adequately imagine the scenarios. Despite this possible flaw, it seems to be most successful.

COMPONENTS/STEPS OF SYSTEMATIC DESENSITIZATION Systematic desensitization, as developed by Wolpe, consisted of three primary components. The first was to develop with the individual a hierarchy of anxiety promoting stimuli. The client was asked to imagine a variety of objects and/or situations that induced anxiety, and to rank these in degree of anxiety from one to ten. The therapist worked with the client to develop a list of anxiety provoking stimuli at all levels of the continuum, so that there were only small increments of additional anxiety between each item on the hierarchy. The second component was to teach the client how to relax (a state considered incompatible with anxiety). This was accomplished did by teaching the client to take long deep breaths, and to tighten and relax different muscle groups throughout the body. The third component was the systematic pairing of the relaxation response to the stimuli on the anxiety hierarchy, starting with the lowest level of anxiety. After repeated pairings of the relaxation response with the anxiety response, typically the anxiety was extinguished, and the relaxation procedure was applied to the next item on the anxiety hierarchy. If the anxiety was not eliminated at a particular step, additional stimuli of lesser anxiety level were developed to bridge the gap. This procedure was repeated through all items on the hierarchy, thereby leading to elimination of the phobia. In most cases systematic desensitization was done in an office setting and involved the client imagining objects or situations, but the technique could also be used in real life situations. In general, this procedure was effective in reducing phobias and is an often used treatment option for phobias. The desensitization procedure makes use of the fact that a person’s anxiety response (tensing of muscles, feeling of discomfort, uptightness, etc.,) to the imagined situation resembles his anxiety response to the real situation. So, when you can feel entirely comfortable and relaxed when thinking of your target behavior, your real-life target situation will shortly begin to be

3 | P a g e progressively less anxiety-producing. Experience with patients has proven this method of relaxing while imagining to be quite effective in reducing anxiety. The purpose of the first half of this manual is to teach you precisely how to construct an anxiety hierarchy, learn deep muscle relaxation, and desensitize yourself to the steps in your hierarchy, thereby helping you reduce the anxiety you experience in your target situation. The number of sessions required depends on the severity of the phobia. Usually 4-6 sessions, up to 12 for a severe phobia. The therapy is complete once the agreed therapeutic goals are met (not necessarily when the person’s fears have been completely removed). Exposure can be done in two ways: · In vitro – the client imagines exposure to the phobic stimulus. · In vivo – the client is actually exposed to the phobic stimulus.

APPLICATION OF THE PROGRAM STEP 1: Creating your Anxiety Hierarchy You should attempt to create about 16 or 17 situations at the beginning. Most people tend to discard some items in the sorting process, so you can expect to end up with about 10 to 15 items in your final hierarchy. To aid in sorting the items, write each one on a separate index card. As was mentioned earlier, the situations or scenes in your hierarchy should represent a fairly well-spaced progression of anxiety. The best way to achieve this goal is to first grade the anxiety of each item by assigning it a number on a scale from 0 to 100, where 100 is the highest level of anxiety imaginable and 0 is no anxiety (complete relaxation). Write this number on the back of the index card for the item being graded. At this point, you need not worry about how well- spaced the items are; just give each item the first number grade that “pops into your head.” When each item has an anxiety grade, your next step will be to sort the cards into 5 piles. Each pile will represent a different category of anxiety, as follows:

Pile Anxiety Grade

Low Anxiety 1–19

Medium Low Anxiety 20–39

Medium Anxiety 40–59

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Medium High Anxiety 60–79

High Anxiety 80–100

The goal here is to end up with at least two items in each pile. If this happens, congratulations. If not, you will have to go back and re-evaluate some items or create some new items. When you have finished, combine all the cards into one pile that is ordered from lowest to highest anxiety. This is your personal Fear of Flying anxiety hierarchy. Set the cards aside for one day. It helps to check the accuracy of your ordering by shuffling the cards the next day or so. Without looking at the grades on the back of the cards, re-order them. Then check the grades to see if your second ordering is the same as the first. If not, make some adjustments. You don’t have to waste a lot of time with this; just try to get an order that feels right and that represents a fairly smooth progression from low to high anxiety. The anxiety hierarchy is a list of situations relating to your target behavior to which you react with varying degrees of anxiety. The most disturbing item is placed at the bottom of the list and the least disturbing at the top. In working on the hierarchy, you will begin with the top item on the list (that is, the least disturbing item) and work step by step through the hierarchy to the last item (the one which produces the greatest anxiety affecting your target behavior). Thus, the hierarchy provides a framework for desensitization, through relaxation, of progressively more anxiety-producing situations. CONSTRUCTION OF AN ANXIETY HIERARCHY CAN AID YOU IN THREE WAYS: 1. It helps you verbalize your problem and set it down in terms of concrete situations which you have, or perhaps will, come up against in real life. 2. You will begin to analyze your problem further by breaking it down into situational components which will make it easier for you to see what specific things about the target behavior cause you anxiety; how they are related to anxiety-provoking situations other than your target behavior; and how the problem may be systematically approached. 3. You will place the problem in a form that can be treated by this method. Some people say that merely constructing the anxiety hierarchy has therapeutic value. They have an increased understanding of the problem and a clearer idea of how and why they experience anxiety in certain social situations.

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CONSTRUCTING THE HIERARCHY Constructing a good hierarchy is very important since it provides the framework for approaching the problem. Time and care must be devoted to it. As was stated above, the hierarchy is a list of the situations related to your target behavior which you react to with graded amounts of anxiety. Such a hierarchy is constructed in three steps. 1. Write down as many situations as you can think of in which the problem occurs. If you are nervous with strangers or members of the opposite sex, for instance, write down these specific situations in which you experience difficulty. Write down all you can think of. Your list will include some situations which are worse than others. Some will be very frightening, some hardly frightening at all, and some in between. 2. Make a list of some of the VARIABLES that affect your anxiety level. This can increase your insight into the causes of your anxiety and make it easier to create a good hierarchy. a) Examples of variables affecting the amount of anxiety in presenting a speech to a class: class size; length of speech; amount of preparation; importance of speech; how critical instructor is; length of time before the speech (week before, night before, walking to classroom, being called upon to give speech, etc.); how personal the speech is; degree to which others will disagree with it; etc. b) Other common variables affecting anxiety levels; amount of rejection expected; sex of other person; attractiveness of other person; difficulty of test; etc. c) Look at some of the sample hierarchies and identify variables affecting the amount of anxiety in them. Of course each person is unique, but there are often similarities between hierarchies. 3. Now arrange these items in order from the least upsetting to the most upsetting by thinking about each one and imagining just how bad it would be to be in that situation. 4. Now build your final hierarchy. Most people include about 10-20 items (you may have more) beginning with items so mild that they are practically non-frightening. You might have to invent some very mild items such as having someone say the word girl (for guys who are afraid of girls), or looking at the picture of a professor (for people who are afraid of those with high status), etc. The ten to twenty items should be chosen so as to contain very small jumps in severity from one item to the next, so that when you have finished an

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item you don’t have a very much harder item just in front of you. The final items, of course, should be the most severe items from the original list. This ranked list of anxiety evoking items constitutes the hierarchy that you will use in your treatment. Modifications additions, combining of items, and further breaking-down of items on the hierarchy may be made at any time during the desensitization therapy. Most people=s hierarchies require some modification as desensitization. SAMPLE HIERARCHIES To aid you in constructing your hierarchy, we have included five sample hierarchies below. Studying these hierarchies will give you a good idea of how they are constructed and should help you construct yours. These are, however, samples only to show you the form. You must construct your own hierarchy which applies to your specific case. HIERARCHY #1 Target Behavior: Anxiety when interacting with members of the opposite sex. 1. Being with a member of the opposite sex who is a member of my family. 2. Being with a member of the opposite sex I know very well, who is not a member of my family. 3. Seeing a member of the opposite sex I know fairly well. 4. Smiling at a member of the opposite sex I know fairly well. 5. Talking to a member of the opposite sex I know fairly well. 6. Seeing a member of the opposite sex I know slightly or not at all on campus. 7. Smiling at a member of the opposite sex I know slightly or not at all. 8. Saying hello to a member of the opposite sex I know slightly or not at all. 9. Meeting a very attractive member of the opposite sex for the first time. 10. Talking on the phone a short time with a member of the opposite sex. 11. Talking on the phone a short time with a member of the opposite sex. 12. Talking in person for a short time with a member of the opposite sex. 13. Talking for a long time (e.g., one hour) with a member of the opposite sex. 14. Asking out or being asked out by an attractive member of the opposite sex. 15. Being on a date with a very attractive member of the opposite sex.

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HIERARCHY #2 Target Behavior: Anxiety when interacting with my boss. 1. At home the night before I go to work, thinking about my boss. 2. Driving to work, thinking about my boss. 3. Walking into the building, thinking about my boss. 4. Entering the office or the room where I work. 5. Greeting and talking to those I work with about the boss. 6. Seeing the boss from afar. 7. Passing the boss. 8. Smiling at the boss. 9. Saying hello to the boss and exchanging greetings. 10. Asking the boss a short question about my job. 11. Asking the boss a more detailed question. 12. Listening to the boss give instructions and then performing them. 13. Talking with the boss on a more personal level. 14. Listening to the boss evaluate my work. 15. Talking to and taking an order from the boss when he’s very rushed or brusque-acting. HIERARCHY #3 Target Behavior: Anxiety when interacting with strangers or those I don’t know very well. 1. Seeing a stranger from a distance. 2. Walking through a group of strangers. 3. Seeing a stranger walking towards me. 4. Passing a stranger. 5. Looking at a passing stranger who is also looking at me. 6. Smiling or nodding to a stranger I’ve often passed. 7. Being spoken to be someone who sits near me in class. 8. Talking to a class member I don’t really know about the course material in a small classroom discussion. 9. Being approached by and talking to someone in my class. 10. Being approached by and talking on a more personal level with someone I know slightly. 11. Meeting one stranger.

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12. Meeting two or three strangers. 13. Meeting a group of strangers (5-15). 14. Talking briefly with a stranger I just met. 15. Talking at length with a stranger I just met. 16. Talking briefly with two or three strangers. 17. Talking at length with two or three strangers. 18. Talking briefly with a group of strangers. 19. Talking with a group of strangers I just met. 20. Introducing myself and initiating conversation with strangers. HIERARCHY #4 Target Behavior: Anxiety when interacting with a certain person. 1. Smiling at the person. 2. Saying hello to the person. 3. Asking the person how he is. 4. Asking the person a short, factual question (e.g., about school). 5. Asking the person a more detailed question that takes longer to answer. 6. Telling the person a short experience I had. 7. Asking the person’s opinion on a non-anxiety arousing topic. 8. Telling the person my opinion on a non-anxiety arousing topic. 9. Asking the person two or three questions and responding to his answers. 10. Telling the person something about myself, like my family. 11. Talking back and forth with the person for a long time about a factual topic. 12. Talking back and forth with the person on a more personal level. 13. Approaching the person and beginning a long conversation. HIERARCHY #5 Target Behavior: Fear of speaking up in class. 1. At home, the night before I go to class. 2. Driving to school before the class. 3. Walking to my class. 4. Walking inside the classroom. 5. Looking around at the people in the room.

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6. Walking in and saying hello to someone in the room. 7. Sitting down in the front row. 8. Catching the professor’s eye and smiling. 9. Nodding or agreeing with a comment made in class. 10. Asking the professor a question from the front of the room. 11. Asking the professor a question from the back of the room. 12. Answering a short question from the front of the room. 13. Answering a short question from the back of the room 14. Answering a longer question. 15. Making a comment on a particular point to the class. NOTE: This hierarchy was designed by a student for himself. He was 23 and had never had a date. Within a few months, he had completed his hierarchy in REAL LIFE. A Hierarchy of Interacting With Opposite Sex 1. Being with a member of the opposite sex who is a member of the family. 2. Being with a member of the opposite sex who is not a member of the family 3. Seeing a less attractive member of the opposite sex that I know not so well. 4. Smiling at a less attractive member of the opposite sex that I know not so well. 5. Saying hi or hello to a less attractive member of the opposite sex. 6. Talking to a less attractive member of the opposite sex for a short time. 7. Conversing with a less attractive member of the opposite sex for a long time. 8. Capitalize on free information when conversing with a less attractive member of the opposite sex. 9. Utilizing open-ended questions in a conversation with a member of the opposite sex, who is less attractive. 10. Seeing a moderately attractive member of the opposite sex I know not so well. 11. Smiling at a moderately attractive member of the opposite sex I know not so well. 12. Saying hi or hello to a moderately attractive member of the opposite sex. 13. Talking to a moderately attractive member of the opposite sex for a short time. 14. Listening to a moderately attractive member of the opposite sex for a short time. 15. Conversing with a moderately attractive member of the opposite sex for a long period.

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16. Capitalizing on free information when conversing with a moderately attractive member of the opposite sex. 17. Utilizing open-ended questions when conversing with a moderately attractive member of the opposite sex. 18. Meeting a very attractive member of the opposite sex for the first time. 19. Seeing a very attractive member of the opposite sex that I know not so well. 20. Smiling at a very attractive member of the opposite sex that I know not so well. 21. Saying hi or hello to a very attractive member of the opposite sex that I know not so well. 22. Talking to a very attractive member of the opposite sex that I know not so well. 23. Listening to a very attractive member of the opposite sex that I know that so well. 24. Conversing with a very attractive member of the opposite sex for a short time that I know fairly well. 25. Conversing with a very attractive member of the opposite sex for a long period that I know fairly well. 26. Smiling at each other. 27. Eye-to-eye contact. 28. Asking for initiating activities together: a) Could I walk you out to your car? b) In asking for a phone number, give yours first. c) Asking him or her for a date. d) Asking him or her for a dinner date. 1. Putting your personal feelings forward. a) You have a warm and sensitive nature about you. b) You are a very beautiful person. c) Being close with you sure makes me feel nice inside. d) I would like to get to know you better. e) I am beginning to like you a lot. f) I would like to become a friend with you. 2. Coming to grips with your feelings about him or her for the moment. 3. Opening up and saying what you feel about him or her. 4. Express compliments B feelings about the other person.

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a) I like the way you wear your long beautiful hair. b) You have lovely eyes. 5. Expressing physical B sexual approaches a) Snuggling up close to him or her b) Putting your arm around his or her shoulder c) Touching his or her hands B receiving positive vibes. d) Eye-to-eye contact. e) Touching his or her hair. f) Holding his or her face within your hands. 6. A Kiss a) On the hand. b) On the face. c) On the forehead. d) On the lips. 7. A hug B an embrace. 8. A caress B a total body caress. 9. Being close to one another so as to share and enjoy each other. 10. Non-demand pleasuring of your partner. (When you have constructed your hierarchy, write out each item on a separate index card and number the cards in the proper order. This will give you a convenient reference during the desensitization sessions. Please write your items on one side of the card only, as the other side will be used for record keeping.) At this point, also make 4 positive, very relaxing scenes. (One might be a positive outcome scene related to your hierarchy situation). STEP 2: Deep Muscle Relaxation In order to do this, you must first learn to relax completely, and also learn how to achieve this relaxation at will. The technique which behavior therapists use to relax patients is known as deep muscle relaxation. This technique will help you to achieve a very deep and thorough state of relaxation, enabling you to progress through the desensitization of your hierarchy.

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Before beginning your desensitization sessions, you should spend at least two half-hour sessions or two days, a half hour per day practicing the relaxation technique. In order to receive the full benefit of deep muscle relaxation, you should observe the following guidelines in relaxation training: 1. Spend at least one twenty-minute session, every other day, relaxing and imaging the steps in your hierarchy. 2. Read and imagine acting out the steps in a setting in which you can carry through the full twenty-minute session uninterrupted. 3. It is of the utmost importance that the relaxation training sessions (as well as the desensitization sessions) be carried through without interruption. 4. It is also important that you concentrate completely on each of the relaxation procedures and carry out the exercises as instructed. 5. Both the relaxation training sessions and the desensitization sessions should be carried out in a quiet, semi-darkened room. Sit in a comfortable chair or lie down on a comfortable bed or couch. It is important that you be comfortable and able to concentrate throughout a training session or a desensitization session. 6. In addition to practicing the relaxation exercises during an actual relaxation training session, it is helpful to practice the exercises at other times as well. An excellent time to practice is during the minutes in bed before falling asleep. Many people find that such practice not only increases the rapidity and effectiveness of achieving relaxation during a session but also helps them to fall asleep earlier and to snatch periods of relaxation during the day. When you are able to relax yourself completely in three or four minutes by briefly running through the relaxation exercises, then you are ready to begin your desensitization sessions. Many people need only 2 practice sessions. If you find you need more, stay with them until you feel that you have achieved the ability to relax. STEP 3: The Desensitization Sessions Having constructed an anxiety hierarchy of from ten to twenty items, and having practiced deep muscle relaxation so that you feel you have achieved the capacity to relax at will, you are ready to begin desensitizing yourself to the hierarchy.

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Briefly, an item is desensitized by imagining it in vivid and realistic detail while trying to maintain a state of complete relaxation. The item is repeatedly imagined until you are able to imagine it with feelings of complete relaxation and comfort, i.e., without experiencing any anxiety or tension. When you are able to imagine a given item with complete relaxation, you then move on to the next item and repeat the process: Imagine each item in vivid and realistic detail while remaining relaxed. In this way, you proceed through the hierarchy from less to increasingly more anxiety-provoking items B desensitizing the hierarchy item by item. IMAGINING AN ITEM Each item on your hierarchy describes a situation. For the desensitization to be effective it is extremely important that when you imagine the situation described by an item, the image in your mind be as realistic as possible as if you were actually experiencing the situation. An excellent way to make your image realistic is to imagine the situation very vividly and in complete and minute detail. You should imagine all the accessory details of the situation B all the sights, sounds, and smells that you would be aware of where you actually experiencing the situation. For example, if an item involved your making a date with a member of the opposite sex, you should have an image of the other person his or her facial expressions your gestures, etc. You should notice all the aspects of the other person his or her face, smiles, eye contact, etc. Make the other person seem real and alive. Hear your voices and the words you say and notice your emotions and thoughts, etc. You should imagine all these sensations vividly and make them an integral part of your image of the situation. Or, if an item involves your speaking with a high status professor, you should have a very specific and complete picture of yourself and that person, the clothes he is wearing, the way he is standing his facial expressions, the words that are said between you, and your own reactions and feelings about the conversation. With only a little practice in imagining all the details of a situation, you will soon be able to make your images very realistic. THE COMPLETION OF AN ITEM It is important for you to know when you have completed an item and are ready to move on to the next item on the hierarchy. During your training sessions and practice of deep muscle relaxation, you will learn what it feels like to be completely relaxed and at ease. An item is completed when you can experience the feeling of complete relaxation while vividly imagining the item as you do when you practice deep muscle relaxation without the item in mind. One pitfall in this progress is leaving an item before it is really finished. In order for an item to be completed,

14 | P a g e the degree of relaxation you can attain while imagining it must be total. That means that even if you feel the slightest bit of tension or nervousness, you are not completely desensitized to that item. Stay with the item until you feel absolutely no nervousness, until you feel just as calm as the relaxing exercises. In desensitizing yourself to an item, you first relax completely using what you have learned in the training session. When you are completely relaxed, you then imagine the item vividly. You will soon learn to perceive when tensions and anxiety enter into the imagined scene and interfere with your relaxation. If you feel anxiety while imagining the scene, immediately stop imagining the item and imagine a relaxing scene or just focus on relaxing again. You may then try the scene again or add new items to your hierarchy to fill in any gaps. STEP BY STEP CONDUCT OF A DESENSITIZATION SESSION The number of sessions necessary varies in accordance with many factors. For relatively simple problems, experience has shown that ten to twenty sessions is often sufficient. Occasionally fewer are necessary and sometimes many more. However, it is not wise to set a limit or expectations on the number of sessions you will need to desensitize your hierarchy; just proceed step-by-step through the hierarchy moving on to a new item when you have completed the previous one. In the beginning, when you are working on the low-anxiety provoking items, you may be able to complete several items in a single session. Later, as you reach items which provoke more anxiety it may take more time to desensitize yourself to an item perhaps several sessions to complete a single item. It is an excellent idea to set yourself a regular schedule for the sessions. You will be desensitizing every other day. Since the sessions are only twenty minutes apiece, this should not be a great burden. The setting is basically the same for the sessions as that of the relaxation training sessions: work in a quiet, semi-darkened, private room where you will not be interrupted; sit comfortably on a chair or lie on a bed or couch; work without interruption for the duration of the twenty minutes. DESENSITIZATION SESSION STEPS Each session is conducted in the same basic way, according to the following outline: 1. Sit upright or recline on the chair or couch, making yourself as comfortable as possible.

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2. Have two piles of cards placed conveniently so that you do not have to reach for them. It is best to have the cards immediately before you, on your lap. Memorize the first 3-4 items of each stack of cards. 3. Make sure your cassette recorder is within easy reach and locate the beginning of the relaxation instructions on side 2 of the Self-Desensitization Instructions. Relax yourself completely using what you have learned from the relaxation training. 4. When you feel relaxed, start your desensitization session. Use the following procedure to guide you: a) Each time you imagine an item on your hierarchy, we will call this a trial. Each trial lasts 25 seconds, during which you keep the image as vividly before you as possible while trying to remain completely relaxed. At the end of each trial, take a 15 second rest, during which you should think about your body getting more and more relaxed. (Imagine a positive scene from between each hierarchy scene). b) The session is divided into blocks of three trials. You should stay with a given item until you can imagine it three consecutive times (a block of three trials) with absolutely no tension or anxiety of any kind. If you successfully complete an item at the beginning of your desensitization session, go on and work on another, but don’t desensitize yourself to more than two items per session. Remember to stay with each particular item until you have gotten through a complete block of three trials without any anxiety. c) If you have tried a given item for nine trials (or three blocks) and are still feeling anxiety when you visualize it, then go back to the previous item and complete an anxiety-free block of three trials on that one. Then try the difficult item again. If, after going through this three times, the difficult item still doesn’t yield, this means that the jump is too great between it and the previous item. You should then modify your hierarchy by inserting one or two items between these two. These new items should be less anxiety-provoking than the one which gave you trouble but slightly more anxiety-provoking than the last one you completed. One good way to invent such intermediate items is to consider the situation of the difficult item and then think up ways to make that situation slightly less fearful. If the difficult item appeared very early in the hierarchy, this means that you are starting off with items that are too

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difficult, and that you should begin the hierarchy with a couple of very easy items and then work up very slowly. d) You should begin each session with the last item you completed in the previous session. Thus, if you were working on item #6, for instance, and had not completed it when the session ended, you should start the next session with item #5 and stay with it until you have again imagined it three consecutive times without anxiety. Then go on to #6. e) When you have completed the hierarchy, that is, when you are desensitized to the most difficult item, go back through the entire hierarchy once more just to make sure that you are in fact thoroughly desensitized t each item. On this run-through you should be able to imagine each item on the list three consecutive times without the slightest tension or nervousness. If any item still evokes the slightest bit of anxiety, stay with it until it is completely anxiety-free. You may reach the end of your hierarchy before the end of the four weeks or you may not just work at your own pace. THE TRANSFER OF THERAPEUTIC EFFECTS TO REAL-LIFE SITUATIONS The completion of an item on your hierarchy in desensitization sessions indicated that you are making progress toward the alleviation of your problem. The real test that you are solving the problem, however, is that your ability to imagine a situation without anxiety is followed by an ability to experience the real-life situation without anxiety. For some people, such transfer is almost immediate: some people take longer to achieve the ability to experience the analogous real-life situation without anxiety. The lag may range from a few days to several days or weeks, depending on the person and the particular item. Should you have progressed a good way into your hierarchy without noticing any significant transfer to analogous real-life situations, that is, situations related to your target behavior, it is likely that you are not desensitizing the items completely. This can often be remedied by spending a full session on relaxation between each group of 5 to 8 desensitizing sessions. Then be sure you are completely anxiety-free before leaving one item and proceeding to the next. After you have completed a few items successfully in your hierarchy, begin to follow this important rule: 1. ACTIVELY SEEK OUT those situations which you are about ready for in your hierarchy.

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2. AVOID situations very high on your hierarchy which you are not ready for. 3. If you end up in a situation that has a negative outcome, you may experience a set-back. In that case, just back up a ways in your hierarchy and repeat steps and/or add new steps. PERSISTANCE is THE MOST IMPORTANT DETERMINANT OF ULTIMATE SUCCESS!!! 4. SEEK encouragement and assistance from those who can adequately provide it to you. Having family or friends, or a counselor routing for you can be very helpful. THE SELF-ADMINISTERED SYSTEMATIC DESENSITIZATION PROCEDURE The self-administered systematic desensitization procedure is presented below. It consists of seven steps that are repeated for each item of your anxiety hierarchy.

Step 1. Induce relaxation using your preferred relaxation technique.

Step 2. Read the appropriate item from your hierarchy. (In the first session, this will be the first item in the hierarchy. In all other sessions, this will be the last item from the previous session.)

Step 3. Imagine yourself in the situation for a tolerable time. Note. The length of “a tolerable time” will vary. Be careful of overloading yourself on the first encounter with an item, especially with high anxiety items. Although it might

seem a short time, 10 seconds of imaginary exposure might be all you can tolerate. Slowly increase the amount of time you imagine the situation on subsequent presentations until you can tolerate at least 30 seconds of exposure.

Step 4. Stop imagining the situation and determine the level of anxiety that you are experiencing

(on a 0–100 scale). Re-establish your relaxation again and relax for about 30 seconds.

Step 5. Re-read the description of the situation. Imagine yourself in the scene for a tolerable

time.

Step 6. Stop and again determine your level of anxiety. If you are experiencing any anxiety,

return to Step 2. If you feel no anxiety, go on to Step 7.

Step 7. Move on to the next item of your hierarchy. Repeat the above procedure for this next

item, beginning with Step 1.

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WHAT MAKES SYSTEMATIC DESENSITIZATION AN INTERESTING?  It’s gentler.  It’s less severe.  It could help our public image  It still extinguishes the inappropriate behavior.  It has shown good generalization.  It is easier to implement.  Untrained practitioners and parents are less likely to fail at its implementation.  It utilizes the naturally occurring reinforcement (escape).  It mitigates the effects of the extinction burst.  Reduces likelihood of the (unintended) shaping up of (VR schedules of reinforcement for) inappropriate behaviors. WHAT ARE SOME POTENTIAL PROBLEMS?  Time needed to complete steps  Unsure of effectiveness, generalization, and maintenance as compared with pure extinction  Potentially more labor intensive in program planning and creation (though maybe not)  Still NOT a cookie cutter solution, must be modified for each client GENERAL NOTES FOR A GOOD PROGRAM  Frequency / Intervals that you want the program run  Response definition for a “correct” response  Examples and non-examples of a correct response  Mastery criteria for each step  Method for selecting step to start at  Method for determining if step should be skipped  Method of selecting item to begin with if multiple items need the program (i.e. for food refusal) APPLICABLE TO…  Individuals with Developmental Disabilities In considering using systematic desensitization with individuals with developmental disabilities, modifications to the standard procedure are necessary. The first modification is in developing the hierarchy of anxiety provoking situations. Most individuals with developmental

19 | P a g e disabilities have severely limited ability to assist in this. Therefore the therapist has to generate a hierarchy of anxiety-producing items or situations based upon his/her best estimates of what produces anxiety for the individual. To the extent possible, input should be sought from the individual and other individuals who support the person and have knowledge of the objects and situations that provoke anxiety in the client. The second modification requires using real objects and/or situations to present the anxiety provoking stimuli. Individuals with developmental disabilities are typically unable to imagine anxiety provoking situations with the accuracy and control needed for the procedure to work effectively. The third issue is training the individual in a response that is antagonistic to anxiety. In the cases to be described, the individuals were not able to learn to enter a state of relaxation through long deep breathing or tightening and relaxing of muscle groups, so it was necessary to find another response that was incompatible with anxiety. Use of emotive or competence imagery, which has been successfully used with non-disabled children, is not a choice for the majority of individuals with developmental disabilities as they lack the skills needed for this.  Self-administered RESEARCHES MADE There has been some research to compare the effectiveness of exposure to real situations as opposed to imagined situations. In a review of 24 controlled studies on behavioral treatments (including systematic desensitization) for agoraphobia, Jansson and Oest, (1982) found clinically significant improvements in approximately 60-70% of patients exposed to in vivo stimuli, both following treatment and at six-month follow-up. Patients exposed to indirect stimuli did not do as well. James (1985) reviewed the literature on desensitization treatment of agoraphobia and identified some studies that did not support the superiority of in vivo exposure. He suggested that imaginal and in vivo exposure might be so inextricably confounded that it is not possible to clearly isolate their individual effects. Levin and Gross (1985) examined the role of relaxation in systematic desensitization. They noted that different populations had differences in the ability to generate vivid imagery. Their findings suggested that relaxation helped those with poor imaging ability to produce more vivid imagery, which assisted treatment success. Those with good imaging ability were not particularly assisted by the relaxation component. There is a significant amount of research on use of systematic desensitization with children without developmental disabilities. Kearney and Silverman (1990) used systematic desensitization

20 | P a g e to treat a nine-year-old boy with fears of school. They used both imagined and in vivo stimuli paired with relaxation training, leading to successful treatment in 8 sessions. Palace and Johnston (1989) treated a ten-year-old boy with recurrent nightmares. Using progressive muscle relaxation and systematic desensitization, they reduced his nightmares 68%. They then added training in making coping statements to the therapy, and reduced nightmares to 88%. Lastly, they added guided rehearsal of imagined mastery responses to the dream content, and achieved 100% reduction of nightmares. A study by Slifer, Babbitt and Cataldo (1995) employed a behavioral counterconditioning procedure to reduce the anxiety of five children undergoing invasive medical procedures. This consisted of providing preferred play activities to the children to help them into a relaxed state, and then gradually introducing simulated medical procedures. This practice led to a decrease in behavioral distress measures during the actual medical procedures. The children were also provided differential positive reinforcement contingent on engagement with the preferred activities and on compliance with instructions during the medical procedures. Noeker and Haverkamp (2001) report the successful treatment of a 12-year-old boy with photogenic partial seizures who had developed phobic avoidant behavior toward situations with potential photo stimulation. Their procedure consisted of training relaxation through intense contraction and relaxation of facial and hand muscles, teaching relaxing visual imagery (a lake with a stone thrown into it), and gradual exposure to computer and television screen photo stimulation. The subject was provided buttons to control the brightness and contrast levels of the screen, to regulate the intensity of the photo stimulation and the anxiety it generated. The treatment resulted in complete remission of phobic anxieties. Lazarus described a variation on systematic desensitization that employed competence and emotive imagery (1968) in which the subject imagined himself engaging in activities with competence and success, as a means of reducing anxiety. King, Cranstoun and Josephs (1989) used this procedure to treat nighttime fears in three young children. This consisted of constructing anxiety hierarchies for each child and also identifying for each child a favorite hero character. The therapist developed scripts of the child and the hero working together to overcome the fears of the child. DuHamel, Redd, Johnson, and Vickberg (1999) described an application of this procedure (along with other behavioral procedures) in reducing stress and anxiety in children undergoing cancer treatment. They identified the child’s favorite storybook hero and created a series of stories involving the child and his/her hero. Each story brought the child closer to the feared setting, while

21 | P a g e the hero helped the child to master the situation. In this manner, the child came to associate the phobic or distressing stimuli with positive feelings of self-assertion and pride. Moran and O’Brien (2005) used this procedure in treating an 11-year-old girl with a fear of encountering vomit. They were unsuccessful using physical relaxation with presentation of imagined video and in vivo vomit stimuli. They changed the procedure to have her utilize competence imagery. This consisted of imagining playing her musical instruments, swimming laps in a pool, and practicing yoga postures, all of which were areas of competence for her. Pairing these images to presentation of vomit stimuli led to a successful reduction of anxiety, including in vivo presentations. Research on the treatment of phobias in persons with developmental disabilities is limited. One case study, Jackson and King (1982), described the successful treatment on an autistic girl who had a phobia of flushing the toilet. She was taught to engage in laughter and mirth as a response incompatible with anxiety, and successfully overcame her fear of flushing the toilet. She was also given a positive reinforcement for flushing the toilet. Another study described the treatment of six children with developmental disabilities and sleeping problems (Didden, Curfs, Sikkema, & deMoor, 1998). For one of them, part of the treatment included desensitization to anxiety related to going to bed. THEORIES CLASSICAL CONDITIONING (Also known as Pavlovian or respondent conditioning) is a learning process in which an innate response to a potent stimulus comes to be elicited in response to a previously neutral stimulus; this is achieved by repeated pairings of the neutral stimulus with the potent stimulus. Behavioral Theory of Anxiety In classical conditioning, anxiety is initiated by association of a neutral stimulus with a negative (fear inducing) stimulus while in operant conditioning anxiety is maintained by escape or avoidance in the presence of the feared stimulus. Behavioral Theory of Phobia All of us have phobias. Some of us are scared of the dark, and some of us are scared of enclosed spaces. Some of us fear heights, and some of us are terrified of spiders. Some of us developed these phobias because of an event while some of us developed these phobias because of an association. Phobias are defined as irrational fears, and while this definition is true to a

22 | P a g e degree, there is an understanding of why we are scared of certain things. These understandings fall into two categories: classical conditioning and operant conditioning. Let’s take a look at the very common fear of spiders to explain classical conditioning. If you encounter a spider, there may not be anything inherently scary about the spider itself. Only a small number of spider species are venomous, and really big spiders are usually found in tropical jungles. Your fear of the spider is probably borne from an unfounded fear – perhaps something you watched when you were a child that exaggeratedly depicted dangerous spiders. In fact, the most common phobias develop at an average age of 8 years. Inaccurate as though that was, that thing you watched created the association between spiders and a threat to your life. This is what’s known as classical conditioning. You may also be familiar with the story of Pavlov’s dog, where Ivan Pavlov observed that his dog eventually associated the sound of a bell ringing to the promise of food, whether or not the food was actually present. The other understanding of phobias is operant conditioning. While classical conditioning creates an association between two stimuli, operant conditioning is based on a system of reward and punishment. There are four components to operant conditioning:  Something desirable can be offered  Something desirable can be taken away  Something undesirable can be offered  Something undesirable can be taken away Operant conditioning works on the basis of reinforcing behavior. If you are afraid of something, you will take steps to avoid exposing yourself to it. This is desirable, so you associate the avoidance with feeling good, feeling relieved, and feeling safe. Similarly, if you have to expose yourself to the phobia, you associate that exposure with undesirable feelings (shame, fear, etc.). Your brain seals the association, reinforcing the negative consequences of exposure and deterring you from trying again.

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CASE STUDY BEST PRACTICES FOR TEACHING THOSE AFRAID IN WATER Belinda E. Stillwell California State University, Northridge, USA

The primary purpose of this study is to share what has been found to work well in professional practice based on a series of exploratory scholarly studies as well as information gathered informally from students and through specialized aquatic workshops, conferences and seminars. Research has shown that there is an existing population of at-risk swimmers, and, therefore, it is inevitable that many aquatic professionals will encounter individuals in need of a specialized approach to learning. The concept of systematic desensitization holds great promise and, when refined, can be introduced to educators to augment existing swimming instruction and eventually contribute to the extinction of preventable drowning. Keywords: water, anxiety, fear, phobia, systematic desensitization, at-risk swimmers INTRODUCTION According to the CDC (Center for Disease Control) nine people drown each day in the US and it is the second-leading cause of unintentional injury-related death for children aged 1- 14 (Center for Disease Control, 2007). For every child that dies, five more receive emergency medical care for nonfatal submersion injuries (Center for Disease Control, 2007). In 2008, the US Swimming Foundation commissioned a nationwide research study to be conducted in five metropolitan areas (Chicago, Houston, Memphis, Oakland and Philadelphia) and found that in ethnically-diverse communities the youth drowning rate is two to three times higher than the national average (R. Irwin, Drayer, C. Irwin, Ryan, & Southhall, 2008). Variables found to significantly increase the chances for children 6-11 years of age being a low ability “at-risk” swimmer included living in a home with a level of income that qualifies for free/reduced lunch program, and where a parent fears that the child may drown or be injured while swimming (Irwin et al., 2008). Specifically, 45% of at-risk swimmers indicated that they were afraid of drowning or being injured while swimming (compared to 16% of non-at-risk swimmers), while 46% of parents of at-risk swimmers agreed or strongly agreed that they were afraid that their children would drown or become injured while swimming (compared to only 21% of non- at-risk swimmers) (Irwin et al., 2008). Additionally, 65% of parents of at-risk swimmers were, themselves, at-risk swimmers (Irwin et al., 2008). Hence, it is inevitable that aquatic professionals who teach in a variety of settings will encounter individuals who are considered at-risk swimmers,

24 | P a g e and, for that reason, it is important to establish effective teaching strategies that can best help this specific population. The primary purpose of this article is to share what has been found to work well in professional practice based on a series of exploratory scholarly studies, as well as information gathered informally from students and through specialized aquatic workshops, conferences and seminars. To date, there is little published research on the impact of anxiety and fear on learning swimming skills; consequently, past studies referred to date back as early as 1933. DEFINING ANXIETY AND FEAR Although anxiety and fear often result in some of the same behaviors displayed among individuals (e.g., heart palpitations, chest pains and shortness of breath), there is a difference. Anxiety is defined as a negative mood-state characterized by bodily symptoms of physical tension and apprehension about the future (American Psychiatric Association, 1994; Barlow, 2002). Conversely, fear is an immediate emotional reaction characterized by strong escapist tendencies in response to present danger or life-threatening emergencies and, often, there is a surge in the sympathetic branch of the autonomic nervous system (Barlow, Brown, & Craske, 1994). Therefore, the most noticeable difference between anxiety and fear is that anxiety is thought of as excessive worry and apprehension of future events that appear out of one’s control, whereas, fear is a more immediate response to a true alarm such as an earthquake, severe fire or burglary. Panic is also a part of the discussion when referring to anxiety and fear. A panic attack is a sudden and intense feeling of terror, fear or apprehension, without the presence of actual danger (About.Com., 2010). There are three basic types of panic attacks: (1) spontaneous (uncued); (2) situationally (cued) bound; and (3) situationally predisposed (About.Com., 2010). Spontaneous (uncued) panic attacks come without warning and may happen anywhere at any time. Situationally (cued) bound panic attacks occur when someone is exposed (or anticipating exposure) to a specific situation. For example, a person who fears swimming pools experiences an attack when entering, or thinking about entering, a pool. Finally, situationally predisposed panic attacks may, or may not, arise when an individual is exposed to a specific situation. Likewise, the attack may be delayed. For example, someone who fears open water may or may not have a panic attack in an open water situation or could have a delayed attack after a long period of exposure. Anxiety and fear can lead to panic. Situationally predisposed attacks are important in

25 | P a g e understanding the development of panic disorder, where situationally (cued) bound attacks are more common in the development of specific phobias (e.g., water phobia). A specific phobia is an irrational fear of a specific object or situation that markedly interferes with an individual’s ability to function in daily life (Barlow & Duran, 2002).

STUDY ONE—WHAT THEY SAID The purpose of this study was to document what individuals were afraid of, and why, with regard to the water. Participants included two female college-aged students who participated in a required swimming course as part of a Bachelor’s science degree in physical education. During interviews, these students cited developmental, social, psychological and biological reasons for their anxieties and fears. Developmental contributions refers to certain critical periods when individuals are more or less reactive to a given situation or influence. In 1933, Berlin used questionnaires and interviews with parents and teachers to uncover the causes of fear among his 20 participants. Of the 14 eight- to fourteen- year olds and six twenty-year olds, all participants had experienced an unfortunate event, such as watching or being personally involved in a near-drowning. Similarly, Bentler (1962) found that fear of the water may be a result of prolonged unpleasant water experiences over a number of years or the result of a single traumatic experience. One student recalled this traumatic memory, “I was walking along the side of the pool and I got grabbed by my ankle and I got thrown in. I got thrown into the deep end. I remember just sinking straight down to the bottom— panicking. I think I panicked so much that I began to move a lot and that got me back to the top. Once there, I was able to hold on to the side and get out. And basically from that point I didn’t like going into the water” In 1945, Elliott found that social and cultural contributions, such as the family’s attitude, school pressures from various social groups and the immediate swimming group, had an influence on individuals who were fearful. Hewitt (1947) suggested the following reasons (among others) for the development of fear: (1) imitating those who are afraid; and (2) a sense of insecurity in home situations. A student said this during a formal interview, “…When I saw (my friend) doing that (swimming skill), I personally didn’t tell her that it was making me angry. I wanted to do that (swimming skill) too!… I knew I shouldn’t have done that (compared myself to another person) but I was thinking that we’ve both been here the same amount of class time—I should be at least, at least, that far along”. She added this about peer pressure, “I felt more

26 | P a g e comfortable being under the water than I did above the water, because people couldn’t see me”. Additional social contributions that led to higher levels of anxiety and fear for students included having to pass a swimming course before graduating, ending long-term relationships and quitting a job that they had had throughout school. There is increasing evidence that shows we may inherit a tendency to be tense or uptight (Merikangas & Pine, 2002). And although beyond the scope of this article, anxiety and fear has also been associated with specific brain circuits and neurotransmitter systems (Deakin & Graeff, 1991; Lesch et al., 1996; Maier, 1997). One student came to realize that she had the same ill feelings about the water as her parents and siblings did, “If I look at my family, it’s like none of them like being in the water, really”. In this case, a predisposition to anxiety and fear seemed to be something transmitted from family member to family member. Whiting and Stembridge (1965) hypothesized that a non-swimmer’s personality may contribute to their susceptibility to fear. Researchers divided swimmers into two categories: (1) those that received previous instruction and were still unable to swim; and (2) those who had never received previous instruction. Using the MPI (Maudsley Personality Inventories) for male university swimmers, results from category (1) showed a lower extraversion mean than those in category (2). No significant differences were found in neuroticism scores. In addition, the Junior MPI was used for 11- and 12- year-old boys. Researchers concluded that the non-swimmers in both age groups reported significant levels of introversion and neuroticism. Rather than using personality terms, Speilberger (1983) separated anxiety into two types: trait anxiety and state anxiety. Trait anxiety indicates how a person generally feels all of the time. Conversely, state anxiety refers to how an individual feels at a particular time (e.g., right before swimming class starts). One student experienced both types. She spoke about her sisters and mother, all of who were also afraid of the water. Additionally, she said that her parents rarely took any of their daughters to places where water existed. With regard to her personal feelings about anxiety, “It’s funny because I just don’t relax about anything. I’m always really tense”. Additional frightening things noted by students were the color of water (“bluer” water meant “deeper” water), poor visibility and floating debris (e.g., hair, dirt and trash). At-risk students were also concerned about other classmates (who were not afraid in water). Their primary concern was that a classmate would inadvertently bump into them or unintentionally pull them under the water.

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STUDY TWO—WHAT WORKED The purpose of this study was to record what strategies swimming teachers believed to work well with students who were afraid in water. A 16-question survey was designed to examine participants’ demographic information, background and personal aquatic experiences, professional training, work experiences and teaching strategies they employed. Demographically, a total of 14 teachers (10 females, 4 males) ranging in age from 20-51 years old volunteered to answer questions, six (3 females, 3 males) of the participants also served as swimming coaches. All of the participants were college-educated with ten seeking a Bachelor’s degree in kinesiology. Two had received Master’s degrees and two completed a Ph.D. program. In terms of background and personal aquatic experiences, teachers had rated their swimming and water skills at an advanced or competitive level. When asked about the occurrence of any past personal traumatic water experiences, six teachers responded “Yes”. Fortunately, these events did not have a significant impact on their motivation to pursue their swimming certificates and actively teach and/or coach. Similarly, with regard to experiencing any traumatic experiences while instructing, three had mentioned having to make minor rescues (e.g., assist a student who had slipped off a kickboard or the stairs), whereas three others were involved in more serious scenarios (spinal injury, seizure and cardiac arrest). As with personal traumatic experiences, these distressing work-related situations did not detour them from continuing their teaching and coaching careers. Every teacher had been certified as a WSI (Water Safety Instructor) through the ARC (American Red Cross). Three teachers had additional certifications through the YMCA (Young Men’s Christian Association), the county lifeguard service or a specialized swim school (e.g., Australian Swim School). Regardless of their professional certifications, only three felt that their training had provided the necessary information and practical experience for working with at-risk students. Collectively, this group had 3-37 years of employment experiences under similar conditions. Everyone had taught in diverse settings and interacted with a variety of skill levels, group sizes and ages across the lifespan. Twelve of the teachers felt comfortable teaching at-risk students, while one was uneasy about working with adults and the other felt more confident in her abilities in general as time went on. Before sharing their teaching strategies, participants were asked to talk about what they thought at-risk students struggled with most. The seven most common answers across age groups for all teachers combined were putting their faces in the

28 | P a g e water, being on their backs (supine), going underwater, and traveling into the deep end, trust, confidence and previous traumatic incidences. As expected, many of their strategies focused on these areas. The most frequent strategy mentioned was using an individualized style of teaching. This meant that the majority of the teachers believed in letting students learn at their own pace. It did not include forcing or pushing students to perform, but allowed students to make choices along the way to perform what was most comfortable for them at a particular time. Additionally, most teachers agreed that it was important to break down the skills into manageable pieces that gradually introduced students to the water. Other strategies central to their success included proximity, communication and skill selection. Teachers agreed that it was important to stay physically close to students in the water to help gain their trust and increase their confidence levels. In terms of communication, they felt it was essential to talk with their students about their anxieties and fears, take time to answer all of their questions and provide lots of positive verbal and nonverbal feedback. Lastly, teachers believed that selecting a specific set of skills to learn first helped minimize a student’s anxiety and fear, namely buoyancy (floating), exhaling in the water, gradual submersion, propulsion (arm and leg movements) and safety skills. Honorable mentions included having the at-risk student watch the instructor as they taught a student who was not afraid, establishing a positive relationship with the students outside of class and performing swimming and water skills on land.

STUDY THREE—USING SYSTEMATIC DESENSITIZATION: AN EXPLORATORY CASE STUDY The purpose of this study was to explore the use of systematic desensitization to help individuals overcome their anxiety and fear in water. Systematic desensitization was introduced by Joseph Wolpe in the 1950’s (Rachman, 2000). It is one type of exposure therapy that has been used successfully for over 50 years to treat a variety of anxieties and phobias in the general population (Menzies & Clarke, 1993; Osborn, 1986; Pomerantz, Peterson, Marholin, & Stern, 1977). It is a simple and non-threatening approach that involves two key steps. Step one is to teach relaxation techniques, such as deep breathing, progressive muscle relaxation or positive mental imagery to participants. The second step is to gradually expose individuals to situations they find fearful. This part begins with the individual or group, constructing a fear hierarchy; a list of situations from least fearful to most fearful (Hewitt, 1947). For example, in

29 | P a g e the case of the individual afraid in water, the first five situations (from least to most) may be: (1) looking at a swimming pool from a distance; (2) walking up to the swimming pool; (3) touching the water; (4) wading on the first step; and (5) stepping down to the second step. It should be noted that the individual is first exposed to these situations virtually, perhaps in a quiet room, and then practices them in the “real-life situation”, in this case, the water. The crucial goal for each person is to remain calm while gradually being exposed to the situations listed in their hierarchy. The participant in this study was a young woman who had experienced a brain tumor. Prior to her tumor, she had been a confident swimmer and enjoyed the water. After surgery, her balance, muscular strength and muscular endurance were severely compromised. As a result, she had lost a great deal of her water confidence. With the water being the most appropriate rehabilitative setting for her to regain her functional skills, it also became a place that was feared due to her inability to right herself in the water if she “fell over”. Therefore, her primary goal was to learn how to stand upright and walk to safety if she “fell over” in the pool. She was especially motivated to learn this skill so she would feel safe being in any pool on her own. Her independence was of utmost importance to her. Step one was deciding to incorporate some systematic desensitization practice into her already established adapted aquatic exercise program. Her exercise program was scheduled two times per week for approximately one hour per session for 15 weeks, and depending on how she was feeling on any given day, the systematic desensitization practice could last the entire hour or some portion thereof. Next, although the process recommends learning and practicing a relaxation technique in a setting other than the one that creates fear for the person, this participant believed she could achieve a state of relaxation while back floating (with assistance) in the about 4.5 feet of water; thus, each session began in this position. Finally, the following individual hierarchy was constructed to use as a guide for each practice session: (1) Back floating with assistance (no anxiety—least fearful situation); (2) Back floating unassisted; (3) Back floating unassisted while exhaling out of my nose; (4) Back floating unassisted, exhaling out of my nose while putting my chin to my chest; (5) Back floating unassisted, exhaling out of my nose, putting my chin to my chest while simultaneously bringing my knees to my chest; (6) Back floating unassisted, exhaling out of my nose, putting my chin to my chest while

30 | P a g e simultaneously bringing my knees to my chest and holding myself in a “ball” for at least three seconds (this allowed adequate time for rotation, from a horizontal to vertical position, to occur); (7) Back floating unassisted, exhaling out of my nose, putting my chin to my chest while simultaneously bringing my knees to my chest, holding myself in a “ball” for at least three seconds until I see my feet; (8) Back floating unassisted, exhaling out of my nose, putting my chin to my chest while simultaneously bringing my knees to my chest, holding myself in a “ball” for at least three seconds until I see my feet then placing my feet on the pool bottom; (9) Back floating unassisted, exhaling out of my nose, putting my chin to my chest while simultaneously bringing my knees to my chest, holding myself in a “ball” for at least three seconds until I see my feet, placing my feet on the pool bottom and extending my arms to balance in an upright position; (10) Finding myself alone in the water after “falling down” and landing in a back floating position, exhaling out of my nose, putting my chin to my chest while simultaneously bringing my knees to my chest, holding myself in a “ball” for at least three seconds until I see my feet, placing my feet on the pool bottom, extending my arms to balance in an upright position and walking to safety (overwhelming anxiety—most fearful situation). It should be re-emphasized that the hierarchy began with a situation that did not create any anxiety or fear for the participant. It was established that the participant felt completely comfortable back floating while being supported, and that the next situation only took place if it could be completed without any feelings of anxiety or fear. If not, the participant returned to the previous situation. Responses were monitored closely by routinely asking the participant to rate her levels of anxiety/fear by using the numbers “0” (indicating no anxiety/fear) through “10” (indicating overwhelming anxiety—most fearful situation). Results demonstrated that the participant learned, through the systematic desensitization process, to successfully recover from a back floating position to a standing position and walk slowly to safety (e.g., pool steps or swim bench). A two-year follow-up found the participant, with routine practice, had retained her ability to recover from a back floating position and move carefully to safety.

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DISCUSSION AND CONCLUSION Because many aquatic professionals will encounter at-risk swimmers during their teaching and coaching careers, it is imperative that a humane and systematic approach to working with this particular population be created, tested and shared among organizations, agencies and communities responsible for swimming instruction. The concept of systematic desensitization holds great promise and, when refined, can be introduced to educators to augment existing swimming instruction and eventually contribute to the extinction of preventable drownings. As discovered in Study Two, many teachers were already using similar strategies to assist those afraid in water by individualizing their instruction and breaking skills down into manageable pieces, but also mentioned that they would benefit from additional specialized training. These strategies can be collectively achieved by creating individual or group hierarchies for students and having them practice each situation without experiencing any anxiety, fear or panic. Additionally, as learned in Study One, finding out what frightens an individual or group is equally as informative when it comes to personalizing instruction and constructing hierarchies. Study Three demonstrated the potential effectiveness of systematic desensitization when working with an individual with physical disability. Future studies should continue to expand the systematic desensitization process by adding out-of-the-water components such as practicing physical skills on land as suggested by an instructor in Study Two and, perhaps, including discussion groups, writing assignments or role- playing exercises to compliment in-the-water skill components. Learning to be comfortable in water is crucial to survival, maintenance of health, and enjoyable leisure and recreational experiences.

SYSTEMATIC DESENSITIZATION IN THE TREATMENT OF FEAR OF FLYING

Juan I. Capafóns, Carmen D. Sosa and Pedro Avero University of La Laguna

Systematic desensitization in the treatment of fear of flying. In this work we present the preliminary results for the validation of a systematic desensitization program applied to fear of flying. The program is made up of three phases: the first consists of four sessions in relaxation and imagination training, the second phase has three sessions focusing on

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the elaboration of the phobic stimulus hierarchy (travelling by plane); the third, with a minimum of five and maximum of eight sessions, deals with the application of the systematic desensitization, together with stop thinking. The program was applied to 20 patients (treatment group), while 21 patients made up the waiting-control group. Therapeutic success was assessed by means of self-report scales, clinical interview and the recording of psychophysiological variables in a simulation situation. The results obtained appear to support the validity of the program. Within the field of psychological treatment, few techniques have generated as many studies as systematic desensitization (SD). Today, it is almost impossible to find an unexplored angle with respect to the use of this technique. Nevertheless, a great deal continues to be said and written about it and, although less intensively and extensively, researchers commonly readdress some point or other in order to contribute to debate or make some clarification. It is not our intention here to re-enter the classic controversy about the application of the technique or the theoretical explanations of its effectiveness (type of antagonistic response to use, the basic processes on which the success of the technique is based, etc.), aspects which were excellently reviewed in the early 1970s by Davison and Wilson (Davison and Wilson, 1973; Wilson and Davison, 1971) and by Wilkins (1971). Far removed from this type of discussion, centered on theoretical bases, our concern is to be found within an approach whose fundamental aim is the validation of standardized intervention programs that permit the greatest possible success in the specific treatment of phobias, especially fear of flying. The purpose of this study, therefore, is to offer some preliminary conclusions about the assessment of the therapeutic success of systematic desensitization applied to this type of specific phobia. We consider SD to be a technique that is especially useful in the case of fear of flying, for several reasons: 1. Confrontation-exposure to the phobic stimulus in the case of this phobia is not enough to eradicate the fear reaction. There are patients who have to take an average of 30 to 40 two- or three-hour flights per year, and who do not succeed in eliminating the phobic behavior. SD incorporates the exposure, but impregnated with the sensation of self-efficacy, since the patient exposes him/herself to the phobic stimulus feeling that he/she can control the situation. 2. The fact that the SD technique can be applied in images means that many of the disadvantages involved in in vivo exposition with this type of phobia can be eliminated. 3. SD is a treatment method that increases the feeling of self-control; that is, the therapist

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suggests, guides or helps, but does not represent the nucleus of the treatment. The risk of dependence upon the therapist or of perceiving improvements as being external to the patient are thus minimized in this technique. 4. SD also minimizes the unpleasant effects of exposition. This technique, due to its progressive structure, allows the patient to control the steps he/she must make until fear is overcome. This absence of disturbing elements makes this technique less likely to provoke abandonment of the therapy. SD is thus a treatment method that has not gone unnoticed in this field of application. On the contrary, it is one of the most commonly employed strategies in the few existing studies on the treatment of this type of phobia (Canton, 1974; Howard, Murphy and Clarke, 1983; Sank, 1976; Scrignar, Swanson and Bloom, 1973). In short, SD is already a classic technique, which can contribute greatly to the elimination of phobias. The results of our study help to confirm that SD, in spite of its veteran status –or perhaps because of it– continues to be an effective strategy in the treatment of maladjusted fears. METHOD SAMPLE The sample of this study consists of 41 people with fear of flying: 20 were randomly assigned to the treatment group and 21 to the waiting-control group. The two groups were arranged so as to make them balanced in terms of sex, age, self-reported fear level and analogous psychophysiological measures. Thus, the treatment group was made up of 8 males and 12 females, with a mean age of 29.65 (DT = 6.22); the waiting-control group was made up of 9 males and 12 females, with mean age 34.05 (DT = 9.52). Patients were recruited as a result of a media campaign (radio, press and television) set up by the research team, which informed of personal intervention programs (free of charge) aimed at treating fear of flying. INSTRUMENTS The following instruments were used: a) General Diagnostic Information on Fear of Flying (Capafns, 1991): general anamnestic interview to obtain data about patients’ life history and about aspects related to fear of flying. b) Fear of flying scales: 1. Fear of Flying Scale (Sosa, Capafns, Via and Herrero, 1995), which measures degree of anxiety perceived in relation to different flight situations. 2. Scales of

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Expectations of Danger and Anxiety (Sosa, Capafns, Via and Herrero, 1995): these two measure the frequency of various catastrophic thoughts and the occurrence of different physiological manifestations that may present themselves in the flight situation. c) Videotape of a plane trip (Capafns, Sosa, Herrero and Via, 1993): a video made from a subjective perspective about a trip by plane, which begins with the traveler packing his/her case and ends with the plane touching down at its destination. d) Psychophysiological recording instruments: Cardioback (heart rate measure): muscular tension measure: skin temperature measure MEASURES OF THE DEPENDENT VARIABLES The measures taken in the pre and post-treatment assessments were the following: a) Answers to three questions from the IDG-FV: 1. How afraid of flying would you say you were? (Answers: not at all, a little, very, extremely). 2. Do you travel by plane when there is no alternative way to travel? (Answers: I’m not afraid —I always fly; Yes, but I get a little afraid; Yes, but I get quite afraid; Yes, but I’m terrified; No, never). 3. Whilst flying, have you ever had any of the following symptoms or feelings? This question contains a list of 21 disagreeable effects (sweating, tachycardia, muscular tension, feelings of loss of control, etc.). For each item on the list there are 4 possible answers (No, Sometimes, Many times, Always). b) The three EMV scales: 1. Fear during the flight: this contains 9 elements related to situations that occur from the moment of take-off acceleration to touchdown. 2. Fear of flight preliminaries: this includes 8 situations that are preliminary to the actual flight (going to the airport, obtaining boarding card, etc.). 3. Fear without involvement: this contains 4 elements related to flying in which there is not direct personal involvement (seeing an aeroplane flying, etc.). c) The two EPAV scales: 1. Catastrophic thoughts: 9 elements that contain highly disturbing thoughts (fear of the engines catching fire, fear of a wing falling off, etc.). 2. Physiological anxiety: 10 elements that refer to disagreeable psychophysiological

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manifestations. d) Heart rate, palm temperature and muscular tension during take-off in the simulation. Measures recorded here are divided for each subject by the baseline measures (obtained in the absence of the phobic stimulus). Post-treatment measures were taken after the patient had taken two flights (outward and return journeys of the same trip). The first flight was to take place in the 7 days following the treatment. Psychophysiological recording of heart rate, palm temperature and muscular tension during take-off in the simulation, however, was made before the flight, in order to balance the two groups in terms of the presentation conditions for this test. PROCEDURE All those participating in this study were interviewed individually by members of the research team. In this interview subjects completed the IDG-FV, and in subsequent sessions the rest of the measures were taken using the self-report method. Subjects were later called back for the administration of the psychophysiological assessment in the simulation situation (video-tape), which took place in the university’s Department of Personality, Assessment and Psychological Treatment. These sessions were also individual, carried out in a room of some 5 x 3.5 meters at a temperature of 22.5… C ( +1…C). The subject sat in an armchair 1.8 meters from a television. Once seated, the apparatus for recording psychophysiological responses was behind the subject. Before the viewing of the video there was a habituation session, in which the patient became acquainted with the application conditions of the simulation situation. In the assessment and recording session proper — his/her physiological responses having previously stabilized—, the patients psychophysiological responses were measured for a three-minute period in the absence of the phobic stimulus. The patient then proceeded to watch the video, and was told to feel as involved as possible. At the end of the session, a new interview appointment was made, for presenting the treatment to be followed, (in the case of the treatment group), or for the next assessment session (in the case of waiting-control group subjects). In either case the interval between the first session and the second was approximately eight weeks for all the measures. The treatment was also carried out in the Department, in a room 2.5 x 3.5 meters in size, which contained two seats, a table and a relaxing armchair. Patients had two 1-hour (approx.) sessions per week, as part of a standardized individual desensitization program of minimum 12

36 | P a g e and maximum 15 sessions. In addition to training in techniques of breathing, progressive relaxation and imagination, the treatment combines imagination and in vivo elements, the main differences from the original model being the emphasis on hierarchy —which is elaborated using cardinal and ordinal procedures— and the systematic use of the technique of stop thinking and of brief relaxation, applicable in natural situations where the phobic stimulus is present. RESULTS We shall now proceed to a description of the results obtained from the differential analyses (Student t test intragroup and intergroup) and discriminant analyses (intergroup), of the self-report fear of flying scales —EPAV-A, EPAV-B, EMV—, of the responses to the three interview questions and, finally, of the simulation situation (video). INTRAGROUP ANALYSIS Differential analysis of waiting-control group (before after) Table 1 shows the analyses carried out for the waiting control group in the self-report scales, interview responses and physiological reactions in the simulation. As we can observe, the mere passing of time does not lead to quantitative change in any of the dependent variables considered in this study.

Differential analysis of treatment group (before-after) Table 2 shows the analysis carried out on the treatment group in the “before” and “after” conditions for the same variables. The results suggest that significant changes take place, and in the expected direction, in both the self-reported variables and those of the interview; subjects’ performances in the psychophysiological measures during the simulation also improve significantly. Only in

37 | P a g e the measures of fear without involvement and skin surface temperature are significant differences not found. INTERGROUP ANALYSIS Waiting-control group versus treatment group before therapy As already pointed out in the sample description, the results presented in Table 3 show the homogeneity of the two groups with respect to self-reported fear level and the objective analogous measures before the treatment. Waiting-control group versus treatment group after therapy The results of this comparison confirm the results obtained in the intragroup comparison. Scores are significantly different for each group for practically all variables analyzed, with only two maintaining non-significant differences: fear without involvement and palm temperature.

DISCRIMINANT ANALYSIS In the pre-treatment analysis no discriminant function could be obtained due to the similarity between the groups with respect to the variables. It was thus confirmed that the two groups, considering all the variables together, were homogeneous with respect to fear of flying. In the post-treatment discriminant analysis, with the aim of avoiding artifacts in the results, the eleven dependent variables of the study were excluded. In this second analysis we have taken into consideration two self-reported measures that we feel to be of special relevance in the case of this phobia: fear during the flight (EMV-l) and the avoidance behavior assessed in the IDG-FV (do you travel by plane when there is no alternative way to travel?). As objective measures we considered heart rate and muscular tension during take-off in the simulation situation.

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This analysis can be examined in detail in Table 5. The four variables showed significant changes in the Raos V, and the canonic correlation obtained was 0.85, with the discriminant function attaining a level of significance superior to 0.001. These results, together with the distance between the centroidal groups, mean that the confusion matrix gives 92.7% of correctly classified clients. Only one control group patient presents a profile of scores similar to that of the treatment group, and only two patients of the latter group maintain similar scores in the dependent variables to those of the non-treated patients. In the light of these results, then, we can affirm that psychological treatment by means of desensitization has been capable of producing a clear difference between the two groups, as is clear from the post-treatment assessment. It can be seen that only 10% of the patients with fear of flying do not undergo significant changes with respect to the fear level presented by non-treated patients. Moreover, in a small percentage of those with this phobia (less than 5%) it may subside within a short period of time. CONCLUSIONS Analyzing the results of this study in a global way, we can conclude that the intervention program as outlined presents guarantees for its use in treatment for decreasing or eradicating fear of flying. The three criteria of success used in the differential analysis coincide in showing the lack of improvement in the waiting-control group and, by contrast, the significant development in all respects of the treatment group. The multivariate analysis confirmed the absence of differences between the two groups in the pretest, and showed extremely satisfactory results in the post-treatment test. Using four dependent variables of the eleven available —variables which we consider crucial to be able to speak of therapeutic success— the classification matrix gave us a percentage of patients correctly

39 | P a g e classified superior to 90%. Only 3 patients of the 41 assessed were classified incorrectly, one from the waiting-control group and two from the treatment group. The cases of these three patients allow us to make two important observations. Firstly, the simple passage of time cannot be expected to improve matters: of 21 patients, only one presents a dependent variables profile similar to that of the treatment group. Secondly, the two treatment group patients classified incorrectly represent a warning that this therapeutic technique is not infallible in the field of flight phobia: a 10% failure rate is better than a 20, 30 or 40% rate, but 5% or no failures at all is better than 10%. Meanwhile, these first results do not allow us to affirm that the success of those who most improved is the maximum success possible. In view of all of the above we consider that in future research we must look into both why the therapy was successful and why it failed in certain patients. Some of the precautions taken in the application of the desensitization program presented here may answer, in part, the first question. We consider that certain variables have contributed to the therapeutic success achieved: 1. The training in breathing and relaxation techniques was carried out rigorously, encouraging practice at home and facilitating overlearning. In our opinion, relaxation, sufficiently trained, can fulfil its authentic role as a response incompatible with anxiety. 2. The double filter developed for the elaboration of the hierarchy (cardinal and ordinal) resulted in a smoothly-gradated slope for each patient. We attempted to guarantee a minimum difference of intensity of anxiety between elements, and at the same time to avoid excessively recurrent elements. In this way we succeeded in exposing the majority of the patients to a total of between 25 and 33 elements, a number that probably made possible a suitable level of approach to the phobic stimulus. 3. The inclusion of gradated tasks in real situations provided an exposition in situ, and at the same time reinforced the improvements achieved in the clinical sessions. Furthermore, we feel that the precaution of not beginning these tasks until one third of the imagination situations had been overcome prevented advancing prematurely, before consolidation had been achieved. This absence of failures in the exposure in real life probably encouraged the sensation of self-efficacy in the patients. 4. Introducing the techniques of brief relaxation and stop thinking in the third phase of the program was also considered positive. These tools permit the patient to control physiological responses of activation and maladjusted cognitions that may induce the appearance of alarm

40 | P a g e signals. The perception of physiological and cognitive control foments the effect obtained in the clinical sessions, and confirms to the patient the innocuousness of the phobic stimulus. As regards the case of failure, it is still early to draw any conclusions or make any suggestions. A more in depth study of the success achieved by the patients and an increase in the number of patients treated will provide us with more precise criteria for measuring the level of effectiveness of the technique and for determining which aspects may be responsible for its limitations.

USE OF IN VIVO AND IN VITRO DESENSITIZATION IN THE TREATMENT OF MOUSE PHOBIA: REVIEW AND CASE STUDY

DAVID KRAFT TOM KRAFT* (formerly of Harley Street, London, UK) *Deceased ABSTRACT This is a case study of a 45-year-old woman with severe mouse phobia. She had developed the phobia at the age of 10 and this had been due to the fact that her mother had also been phobic of mice. She sought treatment because her phobia had worsened over the last two years, and the fear of suddenly coming across a mouse had caused an avoidance reaction at work. The treatment was a multi-modal approach combining imaginal exposure in hypnosis with in vivo desensitization, both approaches using a hierarchy of scenarios. The therapist also used props to encourage her to view the mouse as a “friendly” object, as well as pictures of cartoon mice and real mice. Gradually, the woman became desensitized to mice and, after five sessions, having held two dead mice in her hand, made a complete recovery. This improvement was maintained at six- month follow-up. Key words: mouse phobia, in vitro desensitization, in vivo desensitization, imaginal exposure INTRODUCTION Mouse phobia is classified as a specific phobia, animal type in DSM-IV (American Psychiatric Association, 1994) in which the patient often experiences high levels of anxiety and avoidance behavior when (s)he anticipates, or is exposed to, an animal or insect. The literature search for this study focused its attention on the treatment of specific phobias (animal phobia subtype), while some attention was given to the treatment of other specific phobias. Using

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PsychInfo, EMBASE, and Medline from 1960 to the present day, it was revealed that specific phobias have been treated using hypnosis (Schneck,1952;Gustavson & Weight, 1981; Morgan, 2001), psychotherapy (Sperling, 1971), eye movement desensitization and reprocessing (EMDR) (Jongh et al., 1999), group therapy (Öst et al., 1997), virtual reality exposure therapy (VRET) (Carlin et al.,1997 ),cognitive behavioural therapy (CBT) (Muhlberger et al., 2003; Koch et al., 2004), systematic desensitization (Lang et al., 1970), in vivo desensitization (Thyer, 1981; Arntz & Lavy, 1993), a combination of CBT, psychodynamic, and virtual reality treatment (Kahan,2000),and flooding (Baum,1988).It seems that, over the last 50 years, a behavioral approach to treatment has been favored by clinicians; indeed, all the approaches above, with the exception of the psychoanalytic approach, used some form of desensitization—whether imaginal or in reality—during the course of the treatment. Indeed, Choy et al.(2007),in an extensive review, sited nine studies on animal phobics all of which used either systematic desensitization (described as imaginal exposure) or in vivo desensitization. Focusing on the treatment of animal phobics, successful results have been found in the treatment of snake phobia (Rasmussen,1973;Hunt & Fenton,2007),spider phobia (Jong et al.,2000),dog phobia (Thyer,1981;Hoffmann & Odendaal,2001),bird phobia (Scott,1970; Lassen & McConnell,1977),cat phobia (Freeman & Kendrick,1960),insect phobia (Jones & Friman, 1999), and wasp phobia (Brough et al, 1965; Brown et al., 2003).The general term ‘animal phobia’, known as zoophobia, often has a childhood onset (Marks & Gelder,1966), and is twice as common in females (Craske et al., 1996). Patients suffering from a specific phobia (animal subtype) go to lengths to avoid the animal or insect; often they become so fearful of the phobic stimulus that it interferes and restricts day-to-day functioning at work and in social situations. This anxiety can lead to an immediate panic attack—for instance, an outburst of screaming or shouting—or a highly complex and ‘unreasonable’ series of avoidance patterns. For instance, an arachnophobic patient, after a prolonged period of ruminations, might be un-able to look at a magazine due to an uncontrollable, irrational fear of finding a spider on one of the pages; others would avoid going on holiday because of the fear of coming across a spider on the trip. Indeed, adults recognize that the fear, and its associated behavior patterns, are excessive and ‘unreasonable’; a diagnosis of specific phobia, however, should not be given to an individual who is frightened of snakes and who lives in a village whose inhabitants are constantly encountering venomous snakes. Whatever the subtype of the specific phobia—for instance, animal type, natural

42 | P a g e environment type, or situational type— they are all, to a greater or lesser extent, associated with the fear of losing control (Kraft & Kraft, 2004). According to the DSM-IV classification (American Psychiatric Association, 1994), there is an increased risk for family members of developing a specific phobia: in many situations—and particularly in women—offspring develop phobic anxiety as a response to one of the parent’s behavior (Davey et al., 1993; Unnewehr et al., 1998). However, an epidemiological study on genetics, which focused on phobic women (n = 2163), suggested that the aetiology of specific phobias arose from a combination of ‘modest genetic vulnerability’ and traumatic events in childhood (Kendler et al., 1992). Behavior therapy has been shown to be extremely effective in the treatment of anxiety, fears, and phobias (Jongh et al., 1999; Antony & Barlow, 2002). In this approach, the therapist constructs a graded series of anxiety-provoking stimuli and,over a period of time, the patient is gradually introduced to more difficult stimuli. The graded hierarchy (Wolpe, 1958) is presented through imaginal exposure in hypnosis (in vitro systematic desensitization) or through real-life exposure in or outside the consulting room (in vivo systematic desensitization).The worldwide literature indicates that monosymptomatic phobias, where the individual has not suffered significant early life trauma, are particularly responsive to in vivo desensitization—viz., prolonged exposure to the conditioned stimuli in a real-life situation (Öst, 1997). In 1969, Bandura et al. analyzed the efficacy of desensitization on animal phobics. They found that 92% of subjects were able to handle the feared stimulus (the animal) without fear; this compared favorably to the control group which had a 0% success rate. Two important studies (Barrett,1969;Rosen et al.,1976),which focused on the effect of systematic desensitization on subjects with snake phobia, consistently revealed improved subjective anxiety compared to the control condition, although the effects on avoidance behavior were inconclusive. The latter study (Rosen et al., 1976) also reported reduced heart rate response to the feared stimulus. Interestingly, they found that there was no effect on avoidance post- treatment, whereas, in the Barrett study (1969), which compared desensitization with implosive therapies, it was found that 11 out of the 12 subjects in the desensitization group were able to hold or even touch the snake at the post-treatment stage (p < 0.01).This result compared favorably to the control group, where only 1 out of 12 were able to touch the snake after treatment. Barrett (1969) also assessed clinical status using a behavioral approach test (BAT) and found that the gains

43 | P a g e had been maintained: the author stated that the results showed that systematic desensitization had ‘a consistent and continuing effect across subjects and across time’, whereas the results in the implosive therapy group were more variable. In vivo exposure involves patients confronting the phobic stimulus: usually, it is helpful for both patient and therapist to construct a graded hierarchy from the least anxiety-provoking to the most anxiety-provoking. However, in clinical trials, in order to limit confounding results (e.g.Gilroy et al.,2000;Götestam & Hokstad,2002),researchers have used the same graded hierarchy for all subjects. Consistently, in both the Gilroy et al. (2000) trial and the Götestam & Hokstad (2002) trial—both of which assessed the treatment of snake phobics—results showed that there was a greater decrease in subjective anxiety in the in vivo group compared to the control condition. Two studies (Bandura et al.,1969;Egan 1981) compared in vivo exposure to systematic desensitization—the first study (Bandura et al., 1969) assessed the efficacy of desensitization compared with modelling techniques in the treatment of snake phobics, while the second (Egan,1981) looked at the treatment of aquaphobia using either in vivo or in vitro desensitization. Results in both studies showed that in vivo exposure was significantly more effective than systematic desensitization. Rentz et al.(2003),in a study of dog phobics (n = 82),reported that in vivo exposure was not significantly better than imaginal exposure (in hypnosis).Öst et al.(1997) compared in vivo exposure to vicarious exposure: they randomly assigned spider phobics (n = 46) to three forms of treatment—in vivo exposure, direct observational/modelling (where subjects observed someone else receiving treatment),and indirect observation using video exposure. Using Jacobson’s criteria (Jacobson et al., 1984), there were a greater number of responders in the in vivo group (75%) compared to the direct observation group (7%) and the video observation group (31%) (p < 0.0005). In addition, long term follow-ups have reported that, in the treatment of animal pho-bias using in vivo exposure, acute treatment gains have either been maintained or have improved still further over time (Arntz & Lavy,1993;Hellstrom & Öst,1995;Öst,1996;Öst et al., 1997; Götestam & Hokstad, 2002). The literature specifically on the treatment of mouse phobia is scant. Ten Broeke and Jongh (1993) treated a 63-year-old woman with severe mouse phobia. They used in vivo exposure therapy but had not managed to resolve her phobic anxiety. However, they also used EMDR and,

44 | P a g e after one further session, this resulted in a significant reduction in her anxiety: she was able to be in the same room as a mouse while feeling significantly less anxious. Her improvement was maintained at follow-up. In Norway, Götestam and Berntzen (1997) investigated the efficacy of modelling expo- sure in the treatment of three pairs of patients (n = 6).The first pair (Pair I),both females, suffered from mouse phobia and Pairs II and III, both of which had one member of each sex, had spider phobia. In each case, Patient 1 acted as a ‘model’ and Patient 2 acted as the ‘observer’;however,the experimenters made sure that both patients had an equal amount of exposure time. Further, patients were given the choice to participate as either observer or model: of note, the observers were less willing to be exposed to the feared animal. It was, therefore, assumed that more anxiety would be seen in the Patient 2s (the observers). In order to assess whether the individual fulfilled the criteria in DSM-III-R (American Psychiatric Association, 1987) for specific phobia, subjects were given an open interview in which they discussed their levels of anxiety. Götestam and Berntzen (1997) used the visual analogue scale (VAS) first employed by Hayes and Patterson (1921) using a scale of 0–10, 0 denoting no anxiety at all and 10 denoting maximum anxiety. The VAS anxiety was assessed before approaching an open box in which the feared animal was placed. Each subject was asked to close his or her eyes before approaching the box. They were then assessed using a BAT. In the study, patients were informed about the rationale of the treatment—that is to say, each step towards the feared animal would gradually reduce anxiety levels. Gradually the Patient 1s (n = 3) were encouraged to walk closer to the box, and eventually to touch it first with a pen and then with one finger. The experiments modelled this process for each patient. Patient 2s observed this process. Results indicated that, in both patients, there were significant reductions in thoughts and somatic complaints regarding the feared animal post-treatment; however, long term results indicate that the Patient 1s (the models) better maintained their improvement compared with the Patient 2s (the observers).The results found in the treatment session (at the intermediate stage) showed that the improvement for both Patient 1 (the model) and Patient 2 (the observer of the model) was nearly at the same level; in addition, the results for the mouse phobics in Pair I, were exactly the same. Although the long term results for Patient 2s were not as significant when compared with the results for Patient 1s, this paper, to some extent, illustrates the value of the modelling effect in

45 | P a g e therapy and suggests that more research be done in this area. Further, and more importantly, it highlights the importance of gradual in vivo desensitization in treatment. For some years, VRET has been used in the treatment of many types of phobia including height phobia (North et al., 1998; Emmelkamp et al., 2002), flying phobia (Rothbaum et al., 2002), spider phobia (Carlin et al., 1997), and driving phobia (Wald & Taylor, 2000). In this process, individuals are exposed to a computer-generated, virtual reality environment using body tracking devices, high quality computer graphics, as well as seat and pressure sensors. Carlin et al. (1997) treated a 37-year-old female spider phobic using VRET and concluded that, after 12 weekly one- hour sessions, VR graded exposure was successful. In the following case study, the therapist (TK) used a multi-modal approach in the treatment of a mouse phobic. Using the principles of systematic desensitization, he combined imaginal desensitization with in vivo exposure; importantly, it was the attention to detail in the hypnosis that, using all the sensory modalities, helped significantly in the treatment. CASE STUDY Cynthia was a 45-year-old woman who contacted TK for an urgent appointment due to her mouse phobia. In her first consultation, she reported that she had been frightened of mice since the age of 10 and that this had been due to the fact that her mother was phobic; indeed, her mother had been unable to say the words ‘mice’ or ‘mouse’, whereas Cynthia was able to do this. She then explained that her phobic symptoms had worsened over the last two years, and that this was related to the fact that there were a lot of mice at her place of work. She described a recent scenario in which a mouse had appeared immediately in front her and that this had made her feel terrified. In the hypnosis that followed, Cynthia was asked to imagine a special place—past, present, or future—in which she felt comfortable and relaxed, and capable of maximizing her potential. She described in detail that she saw herself in a garden full of grass and that there was also a path which ascended up to heaven. Having established her special place, the therapist asked her to visualize a toy mouse, ‘Mini Mouse’™, in front of her. It was explained to Cynthia that the mouse was a harmless, ‘cuddly toy’ which was soft to the touch—the sort of toy that a child would take to bed in order to provide comfort during the night. Still in hypnosis, but only in imagination, Cynthia was invited to sit near Mini Mouse and even to touch her. She was given two trials and, after each one, she was re-turned to her special place. She was then asked to imagine reading a children’s book about a mouse known as ‘Maximus Mouse’. Again, Cynthia coped very well with

46 | P a g e this task. Then she was asked to imagine reading about a second mouse—‘Angelina Ballerina’. Cynthia had greater difficulty with this mouse because she could imagine Angelina’s tail; however, after two trials, she was able to imagine reading the book without any difficulty. Finally, she was given ‘Mini Mouse’ to touch—it is important to note that this soft toy is much larger than a real mouse, measures between 25cm and 35cm in height, is dressed, and has no tail. After disengagement, Cynthia was invited, again, to touch Mini Mouse and to sit with her in close proximity. Cynthia coped very well with this task and seemed to enjoy the challenge. It was clear, however, that her mouse phobia had caused avoidance behavior: she commented that there were a number of mice on the London Underground and that this had stopped her from using this mode of transport. In the second session, Cynthia reported that they had employed new contractors to get rid of the mice at work: she described in detail how they strategically placed sticky boards on the floor in order to catch them at night. Each morning, Cynthia would feel compelled to ask how many mice had been caught—it was here that her therapist pointed out that she needed to exercise some control over the mice catching. Against that, she described a television program that she had watched last night in which a chosen number of interviewees were required to strike a live rat. However unpleasant the nature of the program, it was important that Cynthia felt able to watch it: she didn’t switch the television off and watched the entire program. In the hypnosis, again she chose as her special place the garden with the path leading upwards towards heaven. In imagination, she was presented with some pictures of real mice and was asked to handle Mini Mouse. After disengagement, TK capitalized on this by asking her to look at pictures of real mice and these were handed to her on separate pieces of paper. At this point, she decided to make two piles: the first pile comprised pictures that she could look at with no difficulty, while the second pile caused her some distress. She was then given two plastic mice to hold, and TK modelled this process. She was able to handle the first plastic mouse because of its unrealistic blue color; however, she was resistant to touching the grey plastic mouse because of its life-like appearance and its tail. She was also given three or four clothed felt mice to touch. In the hypnotherapy during the third session, Cynthia was invited to imagine looking through a selection of books on real mice; she was also handed these books one by one and was given the opportunity to open her eyes and look at some of the pages. Whenever this caused her

47 | P a g e some distress, she was returned to her special place. After the hypnosis, the in vivo therapy consisted of her looking at mice in the same books. Interestingly, and very positively, Cynthia described some of the mice as ‘cute’, whereas others caused her some distress. She pointed out that she least liked the mice which were lighter, and therefore, more realistic in color; she also didn’t particularly enjoy looking at their tails. It is important to note that she hugged Mini Mouse throughout the session. At the end of the consultation, TK pointed out that he had bought a dead mouse and that it had been safely stored in the freezer compartment of his fridge; he said that, at some point, when she was ready, she would be given the chance to have a look at it. It was pointed out to her that, eventually, she should be able to touch a real mouse or, at least be able to cope with it in close proximity. In her fourth session, Cynthia said that she was determined to hold the dead mouse in her hand. She said that she had been open about her therapy at work, and it was obvious that she had been given a tremendous amount of support and encouragement from her work colleagues. They were the same colleagues in her office who had witnessed seeing her vomit into a waste paper basket, screaming blue murder after having seen a dead mouse in the corner of the room. In the hypnosis, having revisited the toy mice, and having opened her eyes to look at the pictures of real mice in the various books, her therapist constructed a subsequent hierarchy of potentially anxiety-provoking stimuli. Now, with her eyes shut, whenever Cynthia showed signs of distress, she was given ego-strengthening and, where appropriate, she was returned to her special place. Throughout this process, Cynthia was given the chance verbally to feedback her thoughts and feelings. She also held Mini Mouse to her chest throughout. The hierarchy was as follows: 1. Approaching the fridge 2. Opening the fridge door 3. Opening the freezer compartment 4. Taking the wrapped, frozen dead mouse out of the freezer 5. Unwrapping the frozen dead mouse 6. Therapist holding the frozen dead mouse in the palm of his hand 7. Holding the frozen dead mouse in the palm of her hand.

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At this point, Cynthia realized that she had to put theory into practice. She crossed herself,in the manner of someone in church, and managed to hold the dead mouse in her hand for several seconds. Cynthia was very pleased with herself.TK also modelled holding the mouse in his hands. At the beginning of the fifth session, Cynthia explained how important it was for her to have held the dead mouse in her hand. As soon as she left the consulting room, at the end of the previous week’s session, she had used her mobile phone to text her work colleagues, and, when she arrived at work, she had a tremendous amount of support from them. She also told her therapist that she had a lot of support from her family. The seven-stage procedure of session four was repeated in the hypnotherapy: Cynthia was able to cope with each task without crossing herself and with only light reservation. After the hypnosis, she was asked to approach the fridge, to open the ice compartment, and to take out the dead mouse. She unwrapped the packaging and then held the mouse in her hand for over a minute. Cynthia was able to do this, although it took some time. Next, having held the mouse, she placed it on the floor and imagined that it was alive; finally, after several minutes, she put the mouse back into the ice compartment. At this point, Cynthia was asked to evaluate her anxiety, providing a number from 0 to 10, 0 representing no anxiety at all and 10 representing extreme terror. She reported that, at the beginning of the therapy, her anxiety with regard to mice was at level 10, whereas now, she would put it at level 4.She also commented that, while some people profess not to be frightened of mice, they would be unlikely to want to hold a dead mouse in their hand. She also pointed out that her mother was terrified of mice and, if a mouse were to appear at home, she would scream and the television would be switched off. Cynthia dis-cussed the relevance of her mother’s phobia to her own levels of anxiety. Towards the end of this important session, Cynthia said that she kept a book on mice in her desk at all times in order to force her to look at the cover. She had also decided that it was important to read about mice, and she did this in her spare time. In the fifth session, her last, Cynthia repeated the seven-stage scenario in hypnosis and managed to hold two dead mice in her hand. Having completed these tasks, she was pleased to report that she was feeling very much better. She commented that she was no longer terrified about the possibility of coming across a mouse at work—dead or alive—and that she felt this problem was not affecting her everyday life. She said that she had been able to go to the shed at the bottom

49 | P a g e of the garden and tip out the contents of a black bag, knowing full well that there could be a mouse inside. She felt that her therapist was there with her telling her that ‘she could do it’. She graded her anxiety with regard to mice at level 2. At the sixth-month follow-up, Cynthia said that, on one occasion, she had been out in the garden, and that she had come across a live mouse. She explained that, in the past, this would have terrified her and would have stopped her going out into the garden; however, in this instance, she had been able to put on her gloves and discard it without any difficulty. She had made a complete recovery from her mouse phobia. COMMENT This study clearly illustrates the importance of using a multi-modal approach in treatment. The patient described in this paper experienced high levels of anxiety and avoidance behavior at work. It has been a frequent finding of the author (DK) that it is important in therapy to begin with the easiest of tasks and to move gradually to more and more difficult scenarios. The ‘playfulness’ of having a toy mouse next to her in the consulting room also augmented the therapy and aided relaxation. As the patient became more confident, she was encouraged in the hypnosis to look at books on mice and, finally, to imagine a situation, using a graded hierarchy, in which she would hold a dead mouse in her hand. She also practiced this final scenario in hypnosis. TK described in great detail this event so that the patient experienced the feared situation using all the sensory modalities. It was immediately apparent that the patient was able to visualize walking towards the mouse, as if she were actually there in the situation. It was important to describe this situation in detail but also to provide her with support: when-ever she became anxious, she was returned to her special place. Kraft and Kraft (2004), reported a case of driving phobia. In this study, the therapist (TK) took considerable care in the hypnotherapy to create a detailed imaginal situation using all the sensory modalities, and it was this verisimilitude, akin to VRET, which helped significantly in the recovery process. However, this is a dual process. In the present study, not only did the therapist provide the patient with detail, but he also asked her for constant feedback, and encouraged her to experience the situation in her own unique way. In order to do this, it is important to provide the patient with the space to create this ‘virtual environment’ in her imagination. Constant feedback is

50 | P a g e a vital component in the treatment of specific phobias as much as it is for situational and environmental phobias. The therapist also modelled holding Mini Mouse and the plastic mice. In this case, he was acting as a ‘mastery model’ (Götestam & Berntzen, 1997) during the tactile augmentation, and this maximized the level of presence achieved. Importantly, modelling also provides patients with space during the therapy and this, in turn, has the effect of reducing avoidance behavior (Götestam & Berntzen, 1997). In addition, she was able to see how comfortable her therapist felt when touching the plastic mice, and this was tremendously important for her during her therapy. Further, she was given constant support and encouragement throughout the process. This encouragement, ‘playfulness’, and support continued post-hypnosis. The patient was encouraged to talk about her feelings, to sort through pictures of mice, and to work towards the final stage which was to touch a dead mouse in the fridge. In order for the desensitization to be successful, it is essential to work towards touching a real animal (Thorndike, 1931; Carlin et al., 1997). She also continued the desensitization work outside the consulting room; indeed, she kept a picture of a mouse in her desk at work and began to read books about mice. Further, she had a great deal of support from her colleagues and this eventually led to a complete recovery of her phobic anxiety.

APPLICATION OF SYSTEMATIC DESENSITIZATION TO THE TREATMENT OF PHOBIAS IN INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES A.W. is a 43-year-old man with autism. He has moderate developmental disabilities and for 12 years has lived in an intensive tenant support home with three other persons with developmental disabilities. He speaks in single words or short phrases that are difficult to understand but he does understand a lot of what is said to him. What he does and doesn’t understand is often difficult to tell. He has difficulties understanding social interactions and why some things are appropriate and others aren’t. He can do a number of tasks but needs a lot of direction. He likes things orderly and he straightens things up around his house. He in not interested in interacting with others much, but over time does develop fondness for staff who help him do things he likes. For about twelve years he has been afraid to get in a car and be driven places. He totally refuses to get in a car, and so this had made it difficult to get him to activities, doctors’

51 | P a g e appointments, etc. Staff have found a doctor within walking distance, and he also has a job that is within walking distance. If attempts are made to pressure him to get in a car, he starts slapping his head severely and retreats into the house and his bedroom. He also has a fear of being closed in rooms, and gets very upset if anyone attempts to close his bedroom or the bathroom door when he is in the room. Her parents report that they did discipline him when he was at home by sending him to his room and holding the door closed. They also reported that his resistance to getting in cars began when he was riding in vans that became more and more crowded with other individuals. Some attempts were made to force him into the van or cars, which only made his resistance increase. Therapy with A.W. began two years ago. Attempts were made to explain the process to him, and then he was asked to take some deep breaths. After complying for several breaths, he refused to do any more, despite repeated attempts. Discussions of alternative responses that would be incompatible with anxiety led to deciding to try using food consumption as a relaxing behavior (food would also be a direct positive reinforcer for the target behavior). In addition, it was decided to hide various toys or interesting objects in the car, to attempt to arouse his curiosity in searching for items in the car and thereby offsetting anxiety he might have. The procedure was for the psychologist to make a weekly home visit to conduct a therapy session, and to train residential staff to do similar sessions on a daily basis. Initially, two small packets of snacks and a pop were hidden in the psychologist’s station wagon. A.W. had no resistance regarding approaching the car and looking in it, as long as he was standing outside it. He would indicate anxiety by making noises, flicking himself with his fingers, or slapping his face if he was more upset. Any time he indicated anxiety, requests were dropped and he was allowed to return to the house if he wanted. By the end of six months whenever the psychologist drove up, he would immediately come out and initiate the process. First he learned to sit in the back tailgate area a few minutes at a time, while eating trail mix. He wasn’t very interested in the non-food items placed in the car, and that was phased out. Within another few months he would open doors on his own and would sit inside the car with his feet in the car (for a while he had sat with his feet out the door) with the door open. Once he was very comfortable getting in the car, the next step was for A.W. to learn to close the car door. Sessions began focusing on asking him to pull the door shut. He was willing to pull the door in within about 8 to 10 inches of being closed, but wouldn’t bring it in more. Efforts

52 | P a g e were made to teach him to move it in and out repeatedly. It was demonstrated to him on the driver’s door how to open it from the inside, and he was shown how to pull the handle to open the door. He continued to resist this step. Then playing some of his favorite music tapes in the car was introduced. He showed a definite positive response to this and began staying in the car longer. As part of this the engine was turned on, and he did not show anxiety over that. Windows were rolled down to attempt to reduce the feeling of being closed in, but that did not change his resistance to closing the door. It was then attempted to drive the car forward slowly, up to 30 feet, with the door open. After a brief initial startle response the first time, he allowed this to happen and was not disturbed as long as the door was open. It was repeatedly explained to him that he if he closed the door he could immediately open it, and that he would be in control of it. It was also explained that if he did close the door it would be possible to drive to a convenience store where he could get a Slurpee, which he really liked. Despite showing interest in a Slurpee, he would not close the door. The psychologist regularly got out of the car and attempted to gently push in on the door without applying strong pressure, and urged A.W. to let it come in more, but he would only allow it to a certain point. After several months of no progress, it was decided to give him a sedative an hour prior to the training sessions. This was done and he did appear sedated, but he still resisted the closing of the car door as much as before, and so the sedative was discontinued after five sessions. After two years of sessions, closing the door remained the barrier to successful treatment of this issue. Right at the point of reviewing alternative options, the therapy was put on hold due to budgetary cutbacks. DISCUSSION The case involved use of a more questionable response to compete with the anxiety of the phobic stimuli. Consuming food or drink may well have a relaxing effect and compete with an anxiety response. However, it was more difficult to systematically pair this response with the anxiety provoking stimuli. Food consumption requires the availability of something to eat or drink, and when the food is consumed the response is not available. In contrast breathing in, or blowing on ones fingers, is a response available at any time in any situation, which appears to be a significant advantage. The procedure in this case may actually have been closer to a traditional shaping process using positive reinforcement than one of systematic desensitization. An additional issue, may be the nature of the resistance to closing the car door. While A.W. did appear anxious

53 | P a g e and upset when attempts were made to close the door, his resistance may also include a control issue that goes back to power struggles with his parents. When added to his general rigidity about changing his patterns of behavior (part of his autism), his resistance to allowing a door to be closed on him may have been more complex than a simple phobic reaction. In A.W.’s case, the identified phobic response was very long standing and well ingrained. This tends to suggest that early treatment of phobias in individuals with developmental disabilities has a better prognosis than treatment of long standing phobias.

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RELAXATION TRAINING

BALANQUIT, JOSHUA HONRADO, HANEYLLETTE RUALES, ABEER SAN JOSE, RIA JOY

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INTRODUCTION People respond to stress by becoming overwhelmed, stressed or a mixture of both. The body’s natural reaction to prepare for “fight or flight” at highly stressful situations is a useful tool when there is true emergency but having it turned on almost all the time can be extremely taxing and unhealthy. One cannot possibly avoid all stress. It is however, possible to counteract its negative effects by learning how to induce the relaxation response, “a state of deep rest that is the polar opposite of the stress response” (helpguide.org, mental stress relief). Relaxation training is any activity or method which helps a person to attain a state of calmness, reduce levels of anxiety, pain or anger. It is also often used as part of a broader anxiety/stress management program which can help to lower blood pressure, decrease muscle tension, slow breathing and heart rates, among other benefits. In addition to these, research shows that increase in focus and energy, combating illness, heightening problem-solving abilities, and boosting motivation and productivity are also included in the positive effects of relaxation techniques thus, when practiced regularly, it leads to the reduction of everyday stress levels and boost feelings of serenity and joy. Stress is the feeling of being under pressure. It is our body’s natural response to stressors such as environmental conditions or stimulus. During stressful events our body activates the fight- or-flight response, and so physiological changes will happen during stress response, your heart rate increases, breathing quickens, muscles tighten, and blood pressure rises. A little bit of pressure/stress is actually beneficial. It can increase alertness, increase productivity, be a motivating force and improve performance. However, to much pressure or prolonged pressure can lead to stress, which is unhealthy for the mind and body. Especially if an individual lacks the coping skill to combat these everyday stressors, he or she can divert it to other ways which in the long term be the cause of acute or chronic stress, anxiety and addiction. Relaxation techniques, helps the person attain the “relax state”. During relaxation, the body and the mind are free from tension and anxiety. In general, relaxation techniques involve refocusing your attention on something calming and increasing awareness of your body which helps improve coping with stress. By practicing relaxation techniques and individual can reduce the bad effects of stress by: slowing heart rate, lowering blood pressure, slowing breathing rate, reducing activity of stress hormones, increasing blood flow to major muscles, reducing muscle

56 | P a g e tension and chronic pain, improving concentration and mood, lowering fatigue, reduce anger and frustration and boosts confidence to handle problems. Aside from helping an individual to manage stress, relaxation technique can also be used for the following: anger management, anxiety attacks, cardiac health, childbirth, depression, general well-being, headache, high blood pressure, preparation for hypnosis, immune system support, insomnia, pain management, relaxation (psychology), stress management, addiction treatment and nightmare disorder. BRIEF HISTORY AND PROPONENTS The promising effects of relaxation techniques began to be known in public during the 1920’s when American physician Edmund Jacobson introduced the Progressive Muscle Relaxation. In 1908, Dr. Jacobson began his physiological investigation at Harvard University. Due to his investigation, he was able to prove the connection between excessive muscular tension and different disorders of the body and psyche. The findings show that tension and exertion shortens the muscular fiber, hence decreases the activity of the central nervous system. Therefore, inducing the body into relax state can be a remedy and preventive/alternative way against psychosomatic disorders. In 1929, after twenty years of research he published the book “Progressive Relaxation” but it only addressed doctors and scientist. In 1939, he published “You Must Relax” which was directed to the public. Herbert Benson, a professor at the medical school at Harvard University, discovered the relaxation response, which is a mechanism of the body that counters the fight-or-flight response, which can be achieved through meditation. The relaxation response reduces the body’s metabolism, heart and breathing rate, blood pressure, muscle tension, and calms brain activity. It increases the immune response, helps attention and decision making, and changes gene activities that are the opposite of those associated stress. In 1975, Herbert Benson and Miriam Z. Klipper published the book “The Relaxation Response”. The book includes instructions in how to incorporate meditation techniques into daily activities the average person could do. BENEFITS OF RELAXATION TECHNIQUES Relaxation techniques provide benefits to individuals who practice these techniques. As for mental health benefits, it lowers anxiety, induce slower and clearer though processes, as shown in EEG, helps reduce stress and its negative effects on the body and improves coping mechanisms. It can also reduce insomnia for those who have sleeping disorders by

57 | P a g e providing alternative way of combating it, hence reducing/being off the use of medication or sleep aids. Relaxation techniques can also reduce the symptoms of chronic diseases, not necessarily get rid of the disease, as these techniques are also taught to cancer and AIDS patients. Physical benefits include normal heart and breathing rate, which help the body have time to rest. This will reduce the extra stress that these things can do to the body if they are over worked. Muscle tension will decrease. Metabolism can also decrease; this is mostly seen in hibernation and sleep and that gives the body extra time to rest and focus on other aspect that it needs to. This could be seen as a good or bad thing, depending on the overall quality of health. People who practice relaxation has said to be able to tolerate pain better both mentally and physical. In regards to the nervous system relaxation techniques practices the body in taking time to catch up in switching between sympathetic and parasympathetic activity of the body. An individual will go from active and alert (sympathetic) to parasympathetic, which is rest and digest. When they are relaxing, it gives the body time to catch up. TECHNIQUES IN RELAXATION TRAINING There are many techniques which can be used by individuals to improve their state of relaxation. Some methods can be performed alone, some needs the help and assistance of others- preferably with trained professionals, other techniques may involve stillness and focus, while some involves activity and movement. It is not difficult to learn the basics of relaxation techniques but it takes daily practice to fully harness its power. Most stress experts recommend setting aside 10 or 20 minutes a day for relaxation therapy, others may recommend 30 minutes to an hour a day. The best way to start and maintain the practice is to set aside a portion of the day to incorporate it. Don’t do it while feeling sleepy, practice when fully awake and alert to get the most out of these techniques. Choose what appeals the most. There is no single technique that is best, consider the specific needs, fitness level and preference. The right relaxation technique is the one which fits the lifestyle and truly resonates with the person. DEEP BREATHING: The key to deep breathing is to breathe deeply from the abdomen, getting as much fresh air as possible in the lungs. Taking deep breaths from the abdomen, rather than shallow breaths from the upper chest, more oxygen is inhaled. The more oxygen the less tense, short of breath, and anxious a person feels.

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THREE BREATHING EXERCISES "Practicing regular, mindful breathing can be calming and energizing and can even help with stress-related health problems ranging from panic attacks to digestive disorders." Andrew Weil, M.D. Since breathing is something we can control and regulate, it is a useful tool for achieving a relaxed and clear state of mind. I recommend three breathing exercises to help relax and reduce stress: The Stimulating Breath, The 4-7-8 Breathing Exercise (also called the Relaxing Breath), and Breath Counting. Try each and see how they affect your stress and anxiety levels. Exercise1: The Stimulating Breath (also called the Bellows Breath) The Stimulating Breath is adapted from a yogic breathing technique. Its aim is to raise vital energy and increase alertness.  Inhale and exhale rapidly through your nose, keeping your mouth closed but relaxed. Your breaths in and out should be equal in duration, but as short as possible. This is a noisy breathing exercise.  Try for three in-and-out breath cycles per second. This produces a quick movement of the diaphragm, suggesting a bellows. Breathe normally after each cycle.  Do not do for more than 15 seconds on your first try. Each time you practice the Stimulating Breath, you can increase your time by five seconds or so, until you reach a full minute. If done properly, you may feel invigorated, comparable to the heightened awareness you feel after a good workout. You should feel the effort at the back of the neck, the diaphragm, the chest and the abdomen. Try this breathing exercise the next time you need an energy boost and feel yourself reaching for a cup of coffee. Exercise2: The 4-7-8 (or Relaxing Breath) Exercise This exercise is utterly simple, takes almost no time, requires no equipment and can be done anywhere. Although you can do the exercise in any position, sit with your back straight while learning the exercise. Place the tip of your tongue against the ridge of tissue just behind your upper front teeth, and keep it there through the entire exercise. You will be exhaling through your mouth around your tongue; try pursing your lips slightly if this seems awkward.  Exhale completely through your mouth, making a whoosh sound.  Close your mouth and inhale quietly through your nose to a mental count of four.

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 Hold your breath for a count of seven.  Exhale completely through your mouth, making a whoosh sound to a count of eight.  This is one breath. Now inhale again and repeat the cycle three more times for a total of four breaths. Note that you always inhale quietly through your nose and exhale audibly through your mouth. The tip of your tongue stays in position the whole time. Exhalation takes twice as long as inhalation. The absolute time you spend on each phase is not important; the ratio of 4:7:8 is important. If you have trouble holding your breath, speed the exercise up but keep to the ratio of 4:7:8 for the three phases. With practice you can slow it all down and get used to inhaling and exhaling more and more deeply. This exercise is a natural tranquilizer for the nervous system. Unlike tranquilizing drugs, which are often effective when you first take them but then lose their power over time, this exercise is subtle when you first try it but gains in power with repetition and practice. Do it at least twice a day. You cannot do it too frequently. Do not do more than four breaths at one time for the first month of practice. Later, if you wish, you can extend it to eight breaths. If you feel a little lightheaded when you first breathe this way, do not be concerned; it will pass. Once you develop this technique by practicing it every day, it will be a very useful tool that you will always have with you. Use it whenever anything upsetting happens - before you react. Use it whenever you are aware of internal tension. Use it to help you fall asleep. This exercise cannot be recommended too highly. Everyone can benefit from it. *Watch a video of Dr. Weil demonstrating the 4-7-8 Breath. Exercise3: Breath Counting If you want to get a feel for this challenging work, try your hand at breath counting, a deceptively simple technique much used in Zen practice. Sit in a comfortable position with the spine straight and head inclined slightly forward. Gently close your eyes and take a few deep breaths. Then let the breath come naturally without trying to influence it. Ideally it will be quiet and slow, but depth and rhythm may vary.  To begin the exercise, count "one" to yourself as you exhale.  The next time you exhale, count "two," and so on up to "five."  Then begin a new cycle, counting "one" on the next exhalation.

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Never count higher than "five," and count only when you exhale. You will know your attention has wandered when you find yourself up to "eight," "12," even "19." Try to do 10 minutes of this form of meditation. PROGRESSIVE MUSCLE RELAXATION:

This involves a two-step process in which the person systematically tense and relax different muscle groups in the body. With regular practice, progressive muscle relaxation gives an intimate familiarity with what tension—as well as complete relaxation—feels like in different parts of the body. This awareness helps to spot and counteract the first signs of the muscular tension that accompanies stress. And as the body relaxes, so will the mind. Deep breathing can be combined with progressive muscle relaxation for an additional level of relief from stress. HOW TO DO PROGRESSIVE MUSCLE RELAXATION Progressive Muscle Relaxation teaches you how to relax your muscles through a two- step process. First, you systematically tense particular muscle groups in your body, such as your neck and shoulders. Next, you release the tension and notice how your muscles feel when you relax them. This exercise will help you to lower your overall tension and stress levels, and help you relax when you are feeling anxious. It can also help reduce physical problems such as stomachaches and headaches, as well as improve your sleep. People with anxiety difficulties are often so tense throughout the day that they don’t even recognize what being relaxed feels like. Through practice you can learn to distinguish between the feelings of a tensed muscle and a completely relaxed muscle. Then, you can begin to “cue” this relaxed state at the first sign of the muscle tension that accompanies your feelings of anxiety. By tensing and releasing, you learn not only what relaxation feels like, but also to recognize when you are starting to get tense during the day. HELPFUL HINTS:  Set aside about 15 minutes to complete this exercise.  Find a place where you can complete this exercise without being disturbed.  For the first week or two, practice this exercise twice a day until you get the hang of it. The better you become at it, the quicker the relaxation response will “kick in” when you really need it!  You do not need to be feeling anxious when you practice this exercise. In fact, it is better to first practice it when you are calm. That way, it will be easier to do when

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feeling anxious. GETTING READY Find a quiet, comfortable place to sit, then close your eyes and let your body go loose. A reclining armchair is ideal. You can lie down, but this will increase your chances of falling asleep. Although relaxing before bed can improve your sleep, the goal of this exercise is to learn to relax while awake. Wear loose, comfortable clothing, and don’t forget to remove your shoes. Take about five slow, deep breaths before you begin. HOW TO DO IT: THE TENSION-RELAXATION RESPONSE STEP ONE: Tension The first step is applying muscle tension to a specific part of the body. This step is essentially the same regardless of which muscle group you are targeting. First, focus on the target muscle group, for example, your left hand. Next, take a slow, deep breath and squeeze the muscles as hard as you can for about 5 seconds. It is important to really feel the tension in the muscles, which may even cause a bit of discomfort or shaking. In this instance, you would be making a tight fist with your left hand. It is easy to accidentally tense other surrounding muscles (for example, the shoulder or arm), so try to ONLY tense the muscles you are targeting. Isolating muscle groups gets easier with practice.

Be Careful! Take care not to hurt yourself while tensing your muscles. You should never feel intense or shooting pain while completing this exercise. Make the muscle tension deliberate, yet gentle. If you have problems with pulled muscles, broken bones, or any medical issues that would hinder physical activity, consult your doctor first. STEP TWO: Relaxing the Tense Muscles This step involves quickly relaxing the tensed muscles. After about 5 seconds, let all the tightness flow out of the tensed muscles. Exhale as you do this step. You should feel the muscles become loose and limp, as the tension flows out. It is important to very deliberately focus on and notice the difference between the tension and relaxation. This is the most important part of the whole exercise. Note: It can take time to learn to relax the body and notice the difference between tension and relaxation. At first, it can feel uncomfortable to be focusing on your body, but this can become quite enjoyable over time.

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Remain in this relaxed state for about 15 seconds, and then move on to the next muscle group. Repeat the tension-relaxation steps. After completing all of the muscle groups, take some time to enjoy the deep state of relaxation. MINDFULNESS MEDITATION: Meditation refers to a broad variety of practices that includes techniques designed to promote relaxation, build internal energy or life force (qi, ki, prana, etc.) and develop compassion, love, patience, generosity and forgiveness. Mindfulness is the intentional, accepting and non- judgmental focus of one's attention on the emotions, thoughts and sensations occurring in the present moment, which can be trained by meditational practices. Meditation that cultivates mindfulness is particularly effective at reducing stress, anxiety, depression, and other negative emotions. Mindfulness is the quality of being fully engaged in the present moment, without analyzing or otherwise “over-thinking” the experience. It is not equal to zoning out. It takes effort to maintain concentration and to bring it back to the present moment when the mind wanders or the person start to drift off. Mindfulness practice is being employed in psychology to alleviate a variety of mental and physical conditions, such as bringing about reductions in depression symptoms, reducing stress, anxiety, and in the treatment of drug addiction. It has gained worldwide popularity as a distinctive method to handle emotions. Scientifically demonstrated benefits of mindfulness practice include an increase in the body's ability to heal and a shift from a tendency to use the right prefrontal cortex instead of the left prefrontal cortex, associated with a trend away from depression and anxiety, and towards happiness, relaxation, and emotional balance. Some techniques for this include body scan, walking meditation, and mindful eating. Body scan – Body scanning cultivates mindfulness by focusing the attention on various parts of the body. Like progressive muscle relaxation, start with the feet and work it up. However, instead of tensing and relaxing the muscles, simply focus on the way each part of the body feels without labeling the sensations as either “good” or “bad”. Walking meditation – One does not have to be seated or still to meditate. In walking meditation, mindfulness involves being focused on the physicality of each step — the sensation of feet touching the ground, the rhythm of breath while moving, and feeling the wind. Mindful eating – If one has the habit of reaching for food when under stress or gulping meals down in a rush, try eating mindfully. Sit down at the table and focus the full attention on the

63 | P a g e meal (no TV, newspapers, or eating on the run). Eat slowly, taking the time to fully enjoy and concentrate on each bite. STARTING A MEDITATION PRACTICE A quiet environment. Choose a secluded place within the home, office, garden, place of worship, or in the great outdoors where the person can relax without distractions or interruptions. A comfortable position. Get comfortable, but avoid lying down as this may lead to falling asleep. Sit up with the spine straight, either in a chair or on the floor. Try sitting cross-legged or in lotus position. A point of focus. Pick a meaningful word or phrase and repeat it throughout the session. The person may also choose to focus on an object in the surroundings to enhance concentration, or alternately, close the eyes. An observant, non-critical attitude. Don’t worry about distracting thoughts that go through the mind or about how well everything is going. If thoughts intrude during the relaxation session, don’t fight them. Instead, gently turn the attention back to the point of focus. VISUALIZATION: Also known as “guided imagery”, is a variation on traditional meditation that can help relieve stress. When used as a relaxation technique, guided imagery involves imagining a scene in which the person feels at peace, free to let go of all tension and anxiety. This can be done on your own, with a therapist’s help, or using an audio recording. Guided imagery works best if you incorporate as many sensory details as possible. There is no single correct way to use visual imagery for stress relief. However, something similar to the following steps is often recommended:  Find a private calm space and make yourself comfortable.  Take a few slow and deep breaths to center your attention and calm yourself.  Close your eyes.  Imagine yourself in a beautiful location, where everything is as you would ideally have it. Some people visualize a beach, a mountain, a forest, or a being in a favorite room sitting on a favorite chair.  Imagine yourself becoming calm and relaxed. Alternatively, imagine yourself smiling, feeling happy and having a good time.

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 Focus on the different sensory attributes present in your scene so as to make it more vivid in your mind. For instance, if you are imagining the beach, spend some time vividly imagining the warmth of the sun on your skin, the smell of the ocean, seaweed and salt spray, and the sound of the waves, wind and seagulls. The more you can invoke your senses, the more vivid the entire image will become.  Remain within your scene, touring its various sensory aspects for five to ten minutes or until you feel relaxed.  While relaxed, assure yourself that you can return to this place whenever you want or need to relax.  Open your eyes again and then rejoin your world. Guided imagery involves the systematic practice of creating a detailed mental image of an attractive and peaceful setting or environment. Guided imagery can be practiced in isolation, but it is frequently paired with physical relaxation techniques such as progressive muscle relaxation and massage. When guided imagery is paired with physical relaxation techniques, the aim is to associate the sensations of relaxation with the peaceful visual image, so that future practice sessions involving imagery alone will quickly bring back to mind the physical sensations of relaxation. As is the case with many techniques, they involve an element of distraction which serves to redirect people’s attention away from what is stressing them and towards an alternative focus. The techniques are in essence a non-verbal instruction or direct suggestion to the body and unconscious mind to act “as though” the peaceful, safe and beautiful (and thus relaxing) environment were real. Finally, guided imagery can work through the associative process described above, where scenes become a learned cue or trigger that helps recall memories and sensations resulting from past relaxation practice. Imagery techniques can be thought of as a form of guided meditation. As is the case with other forms of meditation, one of the goals and desirable outcomes is to help people learn how to detach themselves from their moment to moment fixation on the contents of their minds, and instead cultivate a relaxed detachment from which it is easy to watch (but not become embedded in) the various sensations and thoughts streaming through the mind. The repetitive practice of imagery techniques can help this meditative learning to occur. The practice of guided imagery is extremely portable, as it relies on nothing more than one’s imagination and concentration abilities which people always have at their disposal (provided they aren’t exhausted). However, like most techniques requiring mental concentration, it is usually

65 | P a g e most successfully practiced without interruption in a setting that is free from distracting stimulation. YOGA: This involves a series of both moving and stationary poses, combined with deep breathing. The physical and mental benefits of yoga provide a natural counterbalance to stress, and strengthen the relaxation response with daily life. Although almost all yoga classes end in a relaxation pose, classes that emphasize slow, steady movement and gentle stretching are best for stress relief. Look for labels like gentle, for stress relief, or for beginners. Since injuries can happen when yoga is practiced incorrectly, it’s best to learn by attending group classes or hiring a private teacher. YOGA FOR STRESS RELIEF Yoga is an excellent stress relief technique. It involves a series of both moving and stationary poses, combined with deep breathing. The physical and mental benefits of yoga provide a natural counterbalance to stress, and strengthen the relaxation response in your daily life. It is also a helpful way in reducing anxiety and stress, yoga can also improve flexibility, strength, balance, and stamina. Practiced regularly, it can also strengthen the relaxation response in your daily life. Since injuries can happen when yoga is practiced incorrectly, it’s best to learn by attending group classes, hiring a private teacher, or at least following video instructions. WHAT TYPE OF YOGA IS BEST FOR STRESS? Although almost all yoga classes end in a relaxation pose, classes that emphasize slow, steady movement and gentle stretching are best for stress relief. Look for labels like gentle, for stress relief, or for beginners. Power yoga, with its intense poses and focus on fitness, is not the best choice. If you’re unsure whether a specific yoga class is appropriate for stress relief, call the studio or ask the teacher. Since injuries can happen when yoga is practiced incorrectly, it’s best to learn by attending group classes or hiring a private teacher. Once you’ve learned the basics, you can practice alone or with others, tailoring your practice as you see fit. Although almost all yoga classes end in a relaxation pose, classes that emphasize slow, steady movement, deep breathing, and gentle stretching are best for stress relief.  Satyananda is a traditional form of yoga. It features gentle poses, deep relaxation, and meditation, making it suitable for beginners as well as anyone primarily looking for stress reduction

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 Hatha yoga is also reasonably gentle way to relieve stress and is suitable for beginners. Alternately, look for labels like gentle, for stress relief, or for beginners when selecting a yoga class.  Power yoga, with its intense poses and focus on fitness, is better suited to those looking for stimulation as well as relaxation. If you’re unsure whether a specific yoga class is appropriate for stress relief, call the studio or ask the teacher. Look for labels like gentle, for stress relief, or for beginners. Power yoga, with its intense poses and focus on fitness, is not the best choice. If you’re unsure whether a specific yoga class is appropriate for stress relief, call the studio or ask the teacher. Since injuries can happen when yoga is practiced incorrectly, it’s best to learn by attending group classes or hiring a private teacher. Once you’ve learned the basics, you can practice alone or with others, tailoring your practice as you see fit. TIPS FOR STARTING YOGA PRACTICE: Consider your fitness level and any medical issues before joining a yoga class. There are many yoga classes for different needs, such as prenatal yoga, yoga for seniors, and adaptive yoga (modified yoga for disabilities). “Hot” or Bikram yoga, which is practiced in a heated environment, might be too much if you are just starting out. Look for a low-pressure environment where you can learn at your own pace. Don’t extend yourself beyond what feels comfortable, and always back off of a pose at the first sign of pain. A good teacher can show you alternate poses for ones that are too challenging for your health or fitness level. TAI CHI: Tai chi is a self-paced, non-competitive series of slow, flowing body movements. These movements emphasize concentration, relaxation, and the conscious circulation of vital energy throughout the body. Though tai chi has its roots in martial arts, today it is primarily practiced as a way of calming the mind, conditioning the body, and reducing stress. As in meditation, tai chi practitioners focus on breathing and keeping attention in the present moment. TAI CHI FOR STRESS RELIEF If you’ve ever seen a group of people in the park slowly moving in synch, you’ve probably witnessed tai chi. Tai chi is a self-paced, non-competitive series of slow, flowing body movements.

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These movements emphasize concentration, relaxation, and the conscious circulation of vital energy throughout the body. Though tai chi has its roots in martial arts, today it is primarily practiced as a way of calming the mind, conditioning the body, and reducing stress. As in meditation, tai chi practitioners focus on their breathing and keeping their attention in the present moment. Tai chi is a safe, low-impact option for people of all ages and levels of fitness, including older adults and those recovering from injuries. Once you’ve learned the moves, you can practice it anywhere, at any time, by yourself, or with others. MAKING TAI CHI WORK FOR YOU  As with yoga, tai chi is best learned in a class or from a private instructor.  Although tai chi is normally very safe and gentle, be sure to discuss any health or mobility concerns with your instructor.  Tai chi classes are often offered in community centers, senior centers, or local community colleges. MASSAGE THERAPY: Massage involves working and acting on the body with pressure – structured, unstructured, stationary, or moving – tension, motion, or vibration, done manually or with mechanical aids. Massage can be applied with the hands, fingers, elbows, knees, forearm, feet, or a massage device. Massage can promote relaxation and well-being can be a recreational activity, and can be sexual in nature. In professional settings massage clients are treated while lying on a massage table, sitting in a massage chair, or lying on a mat on the floor, while in amateur settings a general purpose surface like a bed or floor is more common. The main professionals that provide therapeutic massage are massage therapists, athletic trainers, physical therapists and practitioners of many traditional Chinese and other eastern medicines. Massage therapy is more than relaxing me-time. Studies continue to prove the physical and emotional benefits of even a single massage therapy session. Getting a massage provides deep relaxation, and as the muscles in the body relax so will the overstressed mind. Although self- massage is good for stress relief, getting a massage from a professional massage therapist can be tremendously relaxing and more thorough. The most common type of massage is Swedish massage, a soothing technique specifically designed to relax and energize. Another common type of massage is Shiatsu, also known as acupressure. In Shiatsu massage, therapists use their fingers

68 | P a g e to manipulate the body’s pressure points. Deep tissue and sports massages are more aggressive. They often target specific areas and may leave the person sore for a couple of days, making them less effective for relaxation and stress relief. MASSAGE THERAPY FOR STRESS RELIEF Getting a massage provides deep relaxation, and as the muscles in your body relax, so does your overstressed mind. And you don’t have to visit the spa to enjoy the benefits of massage. There are many simple self-massage techniques you can use to relax and release stress. Self-Massage Techniques

Scalp Soother Place your thumbs behind your ears while spreading your fingers on top of your head. Move your scalp back and forth slightly by making circles with your fingertips for 15-20 seconds.

Easy on the Eyes Close your eyes and place your ring fingers directly under your eyebrows, near the bridge of your nose. Slowly increase the pressure for 5-10 seconds, then gently release. Repeat 2-3 times.

Sinus Pressure Relief Place your fingertips at the bridge of your nose. Slowly slide your fingers down your nose and across the top of your cheekbones to the outside of your eyes.

Shoulder Tension Relief Reach one arm across the front of your body to your opposite shoulder. Using a circular motion, press firmly on the muscle above your shoulder blade. Repeat on the other side.

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CASE STUDY BENEFITS OF HILOT Hilot is a traditional form of massage therapy in the Philippines which is used as an all- around treatment for various types of medical conditions. This therapeutic massage involves the evaluation of the body by assessing the balance of energy or life force within the human body just like any of the other oriental types of massage therapies. Hilot which means healing in Filipino is a great deep tissue therapeutic massage that uses soft and gentle strokes. The therapist usually uses a combination of herbal medicines during the massage therapy along with the special oil extracts from herbs to enhance the healing capability of the therapy. The use of heat is also used on hilot treatment as a way of opening up the body and soothing it to further improve its healing and recovery rate. Heat is known to calm and loosen stiffness within the body which helps greatly during a massage therapy. Herbs are sometimes heated and applied on certain areas of the body for it to absorb the extracts that is believed capable of treating the condition. This type of therapy is used for body relaxation, as a pregnancy massage therapy, skeletal manipulation, for relieving muscle pains, and for treating medical conditions. Total body relaxation is one of the many benefits of hilot. The gentle massage strokes stimulate the body and make it feel relaxed during the massage therapy. The body releases toxins and tensions while the therapist conducts various techniques with his or her hands. The simple touch of the massage therapist creates wonderful effects in the body both physically and mentally. Individuals who are suffering from their stressful lifestyle can benefit from this type of therapy. Hilot is popularly used in the Philippines during the early years as a form of therapy that is also used for the delivery of babies. This therapeutic massage is also used as a pregnancy massage which removes stress, fatigue and muscle pain from the expectant mother. This type of therapy can also be used for post-pregnancy for the quick recovery of the new mother. It aids and conditions the body for it to quickly regain strength, improve immunity and get back to its healthy condition. This type of massage therapy also includes skeletal manipulation as a part of the treatment. The manipulation of the bones is carefully done by the therapist during sessions. Hilot is popular

70 | P a g e in the Philippines as a type of therapy used for aligning bones that are dislocated or injured. Prior to the therapy, the massage therapist examines the injured area of the patient before working on it. During the therapy, heat as well as massage oil is applied on the skin at the area where treatment is required. The massage therapist then begins by applying gentle yet firm strokes to revive the nerves that are usually damaged due to the injury. Regular sessions of this therapy eventually heal and restore the flexibility and mobility of the injured or dislocated bone of the patient. The weakened part of the body is restored to its original healthy physical state.

Meditation: Calming a restless mind AN APPLE A DAY By Tyrone M. Reyes, M.D. | Updated October 19, 2010 - 12:00am

If you learned of one simple activity that has the potential to enhance your well-being, increase your ability to focus and concentrate, and improve your overall quality of life, wouldn’t you be eager to take advantage of it? Well, increasingly, research is providing evidence that meditation enhances memory and learning, decreases feelings of stress and anxiety, improves sleep quality, helps control blood pressure, improves back pain and fatigue, decreases anger, and improves overall well-being. WHAT IS MEDITATION? Meditation has been practised across the world in most cultures for thousands of years. The term describes a variety of techniques that involve quieting the mind and relaxing the body by focusing on an object, word, or sensation and ignoring interrupting thoughts. The concept behind meditation is to train your mind to decrease its restlessness and its tendency to generate many, often negative thoughts. Just as aerobic exercise strengthens your heart, meditation is an exercise to strengthen your mind’s focus. Training involves concentration, relaxation, and task-specific exercises. “All types of meditation involve regular sessions — ideally 20 minutes or more each day — in which you spend uninterrupted time calmly, becoming aware of your thoughts and distancing yourself from those thoughts. You may notice the voice in your head, but you work to detach from it and not react to it, focusing instead on your breathing, a word or brief prayer, or your physical sensations. The process has been aptly described as ‘thinking about not-thinking,’ ” explains Sara W. Lazar, PhD, a neuroscientist at Massachusetts General Hospital who did extensive research on the effects of meditation on the brain.

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An untrained mind’s attention tends to be superficial, often disengaged, and focused on the negative. Such attention increases stress and decreases efficiency and joy in life. Training your mind allows you to deepen your attention, focus on the present moment, and appreciate your situation, rather than worrying about the past or future. Lifestyle Feature ( Article MRec ), pagematch: 1, sectionmatch: BRAIN CHANGES Meditation appears to have a direct influence on the structure and activities of the brain, Dr. Lazar says. Her research, published in the September 23, 2009 online edition of Social Cognitive and Affective Neuroscience, suggests that twice-daily sessions of meditation over an eight-week period can cause physical changes in the brains of people who are chronically stressed. At the outset of the study, brain scans of study participants with chronic stress showed that a region of the brain called the amygdala, which is activated by emotional arousal, appeared denser than in individuals who are not overly stressed. Following eight weeks of meditation, participants reported significantly reduced feelings of stress, and brain scans showed a corresponding decrease in the density of gray matter in the amygdala. In earlier research, Dr. Lazar found evidence that regular meditation causes thickening of the brain’s prefrontal cortex and right anterior insula, regions that are associated with decision- making, attention, memory, and sensory processing. Since these regions of the brain normally thin with age, the findings suggest that meditation may be an effective strategy for slowing the aging process by building up these brain areas and strengthening memory and attention abilities that decline as people age. Meditation also affects the way the brain functions, scientists have found. A study published in the November 15, 2009 issue of the Journal of Alternative and Complementary Medication found significant differences in brain wave activity between people who were engaged in meditation and those who simply rested. Brain waves — short bursts of electrical activity produced by the transmission of signals among groups of neurons — are associated with thinking and other brain activity, and can be measured with electroencephalograph (EEG) testing (refer to diagram) and brain scanning. The researchers found that compared with the resting state, meditation involved more abundant theta waves (associated with relaxed attention and alertness) across all brain regions, and especially in the frontal and temporal-central areas of the brain. Meditation was also associated

72 | P a g e with more abundant alpha waves (an indication of wakeful rest in which the brain relaxes from intentional, goal-oriented tasks) in the posterior brain regions. TYPES OF MEDITATION There are two basic meditative programs to train your mind:  Concentrative meditation. In this type, you sit in a safe, quiet, and comfortable place and focus on a particular thought, word, image, sound, or your breath. To start, make an effort to sustain your attention on your chosen object for a period of time — often five to 15 minutes. An instructor may direct you to simply watch your thoughts when they arrive, as you would watch a TV screen. Early in practice, many extraneous thoughts are likely to come into your mind and may not seem to offer much benefit. Try not to forcibly suppress or obsessively track these thoughts. Gently bring your attention back to the object of your contemplation. As you continue your practice, the tendency of these thoughts to take you away from your primary object of focus will gradually decrease. With continued practice, you’re likely to find it relaxing and pleasing. Some of the common roadblocks toward meditation practice include sleepiness, lethargy, lack of time, and body discomfort. In general, most of these difficulties tend to decrease in intensity over time.  Mindfulness meditation. Mindfulness is staying focused and completely absorbed in the task at hand. It means staying in the moment and pushing away worries about the past and future. This type of meditation is based on developing a state of being mindful, or having an increased awareness and acceptance of living in the present moment. You cultivate an ability to observe your thoughts and emotions, and can let them pass at will without judgment. Training your attention and refining interpretations constitute two essential steps toward cultivating mindfulness. GETTING STARTED Seated-breath-work meditation is a key component of many types of meditation. Start by comfortably sitting on the floor or a straight-backed chair. If you’re using a chair, if possible, don’t lean back. Level your chin and elongate the spine. Meditation with three-part breathing involves the following: 1) Gradually deepen your breathing, allowing your breaths to flow smoothly one into the next.

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2) Begin abdominal breathing by relaxing your stomach and letting your diaphragm move freely. Build on this breathing with mid-chest breathing. Let your rib cage expand out to the sides, bringing additional air into the lungs in the most natural way. 3) Add upper chest breathing to the first two. Let your breath flow all the way up to lift the collarbones. Repeat this three-part breathing process 10 or more times to deeply relax your body. While practicing this breathing method, concentrate on the natural flow of your breath, whether rhythmic or irregular, deep or shallow. Once three-part breathing is established, broaden your focus to include all the sensations of breathing. Then broaden your awareness further to include all your sensations. In this type of meditation, you remain in the present by concentrating on your breath. Resist the temptation to cling to what’s pleasant and push away what’s painful. If your focus drifts, bring your attention back to your breathing to regain focus on the moment. Gradually allow awareness to broaden outward once again. At the end of the session, drop all techniques and stop any attempt to focus your mind. End your session with a prayer or affirmation of thankfulness for your experience, whatever it may have been.

INTRODUCTION OF RELAXATION TECHNIQUES & IMPROVE SELF CONFIDENCE SUMMARY OF HEALTHY SCHOOLS PLUS ACTIONS • Use of PASS to collect data regarding the children’s perception of their Perceived Learning Capability, Self-Regard and Confidence in Learning. • Staff meeting to explain Healthy Schools Plus objectives and demonstrate and discuss how to use the materials correctly. • ‘Relax Kids’ materials purchased and used in conjunction with circle time activities. • Relax Kids activities initially piloted with one Year 6 class and children were consulted after each session. • Staff delivery of the ‘Relax Kids’ sessions monitored by PSHE Coordinator/Healthy Schools Plus Lead.

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• Routines adapted to suit restrictions of space and materials personalized by individual staff to their class. • Staff training in Massage in Schools Program [MISP] • MISP introduced in conjunction with ‘Relax Kids’ but not disseminated to all staff until piloted with one Year 6 class – child and parental anxieties were addressed prior to introduction. Consultation with the children and regular review of pilot carried out • Future plans to introduce the Massage in Schools Program with the younger children in the school first EVIDENCE OF IMPACT • After initially feeling ‘uncomfortable’ with some of the ‘Relax Kids’ materials, as they became used to the structure of the sessions, the children became less self-conscious. • This reflective time has enabled the children to find something positive, no matter how small • Most teachers were supportive and believed that the sessions were effective • Children remind staff if it is a ‘Relax Kids day’ and their responses across the year groups has been extremely positive • Parents noticed children leaving school more relaxed and less negative • SATs proved to be a positive experience for the Year 6 children – many reporting that they enjoyed the challenge and did not find the exams as hard as they expected to. • Feedback from the Year 6 children involved in the piloting of the MISP approach highlighted that it would be more beneficial to start this program with the younger children in the school, where they might feel more comfortable about the massage techniques. The schools have taken on board these comments and adjusted their plans, intending to use this program as a link with the children from the feeder Infant School as well. REFLECTIONS FROM THE SCHOOL The children commented that the discussions leading up to SATs, with the Relax Kids materials, had helped. They believe the reflection time allowed them to talk about their feelings and they realized that the other children were feeling the same. Recent data showed a significant improvement in Self Regard and Confidence in Learning and although it cannot be directly attributed to the ‘Relax Kids’ techniques, it would be a contributing factor to these increases in emotional health and wellbeing for all children.

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THE EFFECTIVENESS OF RELAXATION THERAPY IN THE REDUCTION OF ANXIETY RELATED SYMPTOMS (A CASE STUDY)

Uzma Ali, Ph.D (Corresponding author) Associate Professor Institute of Clinical Psychology, University of Karachi, Pakistan

ABSTRACT The aim of present paper is to highlight the significance of relaxation therapy for the reduction of anxiety related symptoms. This paper is based on a case of a girl who was suffering from fatigue and pain hampering her occupational and social life to certain level. Her problem remained unresolved through previous treatment. In psychological clinic psychological interventions of relaxation therapy were applied which included deep breath, instant vacation, ideal relaxation, visualization etc. IPAT Anxiety and IPAT Depression scale were administered before the start of therapy. Detailed history and psycho diagnostic report indicated that client could be diagnosed as having Anxiety Disorder NOS category according to the criteria of DSM-IV-TR. Subsequent to application of different techniques of relaxation therapy client also learned to do it herself at home. After twelve sessions both scales of anxiety and depression were administered again. Results showed drastic decrease in the level of anxiety and depression. Hence as reported by patient there was also reduction in muscle tension, pain, sleep disturbances and her occupational and social functioning were also restored. Keywords: Relaxation therapy, Tense muscles, Anxiety, Depression occupational, Social functioning Introduction The term behavior is interpreted as covert responding of an individual for example, emotions, and verbalization; whereas when these can be clearly specified it is said to be overt responding. There are several behavioral techniques that have been employed since 1950s. Relaxation therapies, systematic desensitization, self-monitoring, exposure, assertive training, modeling, self-control procedures are its well-known techniques (Rimm, 1979; Rodebaugh et al., 2004; Berstein, Borkovec, &Hazlett, 2000). There are individuals who suffer from anxiety disorders, such as generalized anxiety disorder, panic disorders with or with agoraphobia, and

76 | P a g e acute stress disorder; the symptoms of anxiety revolve around physiological symptoms like palpitation, sweating, muscular tension, pain, and headache. Besides physiological symptoms most of the clients with these disorders report pattern of thinking that shows thoughts and images of social or physical harm or both (Beck et al., 1974). There are some other clients who shared their concerns with diffuse pattern of worry and social failures (Chambless &Gracely, 1989). These clients are best treated with cognitive behavioral therapies (Wright, 2006). A variety of approaches have been used to modify cognitions (Ellis, 1962) and alter state of tension; progressive muscle relaxation (Jacobson, 1938; Wolpe 1973; Berstein et al., 2000) is the one of these approaches. A lot of empirical work (i.e Rimm, 1979;Clark et al., 2003; Conrad &Roth, 2006; Goodwin &Montgomery, 2006; Hoyer et al., 2009) showed that muscle tension is related to anxiety and that an individual will experience comfort and www.ccsenet.org/ijps International Journal of Psychological Studies Vol. 2, No. 2; December 2010 Published by Canadian Center of Science and Education 203 decreased amount of anxiety if tense muscles can be made loose and comfortable. Relaxation is best when used within the context of self – management by the clients. After the therapist has gone through the relaxation protocol two-three times, clients are encouraged to practice on their own, which serve as a mean of coping with stress. Several researchers have worked on the effectiveness of relaxation therapy in the reduction of anxiety. Rokovec et al. (1987) found that cognitive behavior therapy was superior to nondirective plus relaxation therapy in student sample, while Borkovec and Mathews (1988) found that the effects of two treatments were similar at posttest and 12 months follow up with clinical sample. Clients with generalized anxiety disorder frequently show symptoms of depression Chambless and Gillis (1996, p.122) compared three studies of different researchers and found CBT to have greater impact on depression than behavior therapy (Butler et al., 1991); CBT was superior to nondirective therapy but not to applied relaxation (Borkovec &Costello, 1993); further Borkovec et al.(1987) showed that there were no significantly superior CBT effects for depression among treatment completers. Furthermore Arakawa (1997) showed the efficacy of progressive muscle relaxation to reduce nausea, vomiting and anxiety induced by chemotherapy. Somewhat recently Hoyer et al. (2009) investigated the efficacy of worry exposure and applied relaxation therapeutic techniques for the treatment of generalized anxiety disorder, while comparing with control group both were found to be effective. Considering above mentioned literature and applicability of relaxation therapy in psychologically disturbed individuals it is clear that relaxation therapy or cognitive

77 | P a g e behavior therapy plus relaxation are effective treatment methods in the reduction of depression and anxiety disorders. In our culture there is a lack of psychological sophistication in people, they think that symptoms are physiological in nature and only physician can treat it. If there is an absence of medical bases then people visit different types of healers who try to treat patients with conventional medicines. There are very few people who visit clinical psychologist for psychotherapy. However, with the advancement of education; now a day’s people have started visiting clinical psychologist and for psychotherapy. In our culture mostly people don’t express their feelings verbally; they tend to repress them, and when they couldn’t express their wishes or desires in acceptable manner, they learn to express them in physiological symptoms. In the present study researchers want to understand the effectiveness of relaxation therapy for client who has anxiety symptoms that were accompanying depression and she was diagnosed with Anxiety Disorder Not otherwise specified (DSM IV TR, APA, 2000). Ms.X is a 20 years old girl who is a student of MS, in a well reputable institution at Karachi-Pakistan. She belongs to upper middle class family. Her father is working abroad (Middle East) and mother is a housewife. She is a first born and has one sister. She came to Institute of Clinical Psychology, University of Karachi in private practice of the author with the presenting complaints of nervousness, irritability, crying spells, negative thinking, and confused state of mind, uncertainty, guilt feeling, intra- aggression, disturbed sleep and appetite, indecisiveness, pain in legs and sometimes she becomes depressed. Detailed clinical interview revealed that her problem was started when she came to Karachi for her studies. She had been living abroad since her childhood but for her higher education she came to Pakistan since it was very expensive there. She was very close to her mother, but since the time she was living at Karachi (with her paternal grandparents) she felt anxious, lonely, had palpitation and become fearful. She was also worried about her future especially about her male friend with whom she talks on phone. She had some traumatic experiences (sexual) in her childhood as she reported. She did not tell this to her mother. Her parents didn’t have good relations since their marriage. She also felt that her father gave more appreciations to her younger sister while most of the time he criticized her. She was a good student in school. She had very good relations with her friends but somehow she felt fearful. Her sexual desires were sometimes disturbing for her, she wanted to control them but at times she did not succeed. These facts and perception were contributing to her extreme guilt, sadness, laziness and at times her absence from classes. She also took some medications by herself for her sleep problem. The following tests were administered

78 | P a g e for her psychological evaluation, for identifying the problem area, estimation of prognosis and for treatment planning. Intake Card and Case History Sheet of Institute of Clinical Psychology, University of Karachi. Bender Gestalt Test (BG- Pascel, 1951); Human Figure Drawing Test (HFD-Koppitz, 1968; &Gilbet, 1986);Thematic Apperception Test (TAT-Murray,1993) and the Rorschach Inkblot Test(ROR-Exner,2004). In conclusion it appeared that there were some anxieties and depressive feelings that were produced by external sources and due to her internal conflicts. She had intellectual potentials and some meaningful relations to deal with them and appeared less subject to distortion as she was able to perceive things in realistic and conventional way. However she also had extreme introspective tendencies and criticism towards self. Her feelings of inferiority and of being scared were due to her negative self-image; which was developed after facing the traumatic experiences and criticism by others. METHOD 2.1 Participant Current research utilized the case study method (n=1). The characteristics, demographics and other related information are given in introduction. 2.2 Measures 2.2.1 Intake Card and Case History Sheet: Intake Card and Case History Sheet of Clinical Psychology, University of Karachi is comprised of Identifying Information, family history, medical history, school and work history, friendship and other activities. It also focuses on information regarding sleep, orientation, behavior, and affect etc. 2.2.2 IPAT Anxiety Scale: King, Scheier & Cattell (1976) The total scores on anxiety scale contain 40 items. 20 items on the left hand test page are for unrealized, covert anxiety. 20 right hand test page items measures an overt, symptomatic, conscious anxiety .The scores are presented for covert (A) and overt (B) anxiety. This scale measures five components of personality, apprehension, tension, low self-Control, emotional instability and suspicion. Scoring: for each item there are three options A, B, and C, B is always score as 1; whereas A and C are score as 0 or 2 depending upon the question. 2.2.3 IPAT Depression Scale: (Krug & Laughlin, 1976) IPAT Depression scale, measuring depression, has 40 items 20 items on sheet A and 20item on sheet B. the last two items on both of the sheet also evaluate anxiety symptoms. For taking

79 | P a g e depression score, clinician is required to minus the score of item no. 19, 20, 39 and 40. Now only depression score can be calculated this score is called “with correction factor”. For present study depression scores were taken with correction factor. Scoring: for each item there are three options A, B, and C, B is always score as 1; whereas A and C are score as 0 or 2 depending upon the question. THERAPEUTIC INTERVENTION Initially the researcher took permission from the authorities of the Institution and discussed ethical consideration for this research. Then the informed consent was taken from the participant, and anonymity of identifying information was assured. Brief description of the research was also given. Therapy session was planned with the client. It was decided that twice a week sessions would be suitable. First of all therapist conducted a detail Interview, followed by a detailed psychological assessment and then the administration of IPAT Anxiety and IPAT depression Scales. In the initial sessions therapist facilitated the client to pent-up her emotions with the help of emotional catharsis, then the therapist noted the initial subjective evaluation of her symptoms, (like sleep disturbances, nervousness, feeling inferiority, inability to control sexual desires, examination anxiety and of being scared etc.) that may contribute in anxiety and depressive feelings. The client rated them between 0-100% intensity levels, along this cognitive restructuring was also done to change her negative thinking into positive one to decrease her depression. As she was also depressed, application of relaxation in the state of depression was not suitable. After 3-4 sessions depressive symptoms were decreased to some extent. For the reduction of her anxiety symptoms relaxation therapy was applied. Relaxation therapy was consisted of different techniques including deep breathe, simple muscle relaxation, walk, recreational activities, like watching favorite TV programs, talking on telephone with friend, doing household work and reading books. To reduce stress, time management was also done which was also helpful for sleep management and hence reduces laziness and fatigue. After the management of time and sleep, deep breath and simple muscle relaxation were applied by the client herself at home. The whole treatment interventions were consisted of 15 sessions; out of 15 sessions relaxation therapy was applied in 12 sessions. After the completion of 12 sessions IPAT Anxiety and IPAT Depression Scale were administered again to evaluate the symptoms of anxiety and depression. Subjective ratings of above listed problems were also done. To evaluate follow up sessions the therapist called the client and she reported that she is functioning pretty well and also attained A grade in exams,

80 | P a g e however due to her visit to abroad she could not manage to come in follow up sessions, so the overall treatment period was of 8 months. RESULTS Therapeutic outcome of Relaxation therapy showed that relaxation techniques are very effective in the reduction of anxiety and depressive symptoms (Table I-III). THERAPEUTIC OUTCOME Relaxation therapy is used with psychologically disturbed clients in clinical practice. This case study showed its effectiveness (see table I & III) it is indicated that there was a reduction in anxiety related symptoms after applying the relaxation therapy. It included deep breathe, simple muscle relaxation, involving in recreational activities, going on vacations, managing time, and visualization. Client also verbalized the improvement during therapy sessions like “now I am attending university on time, and concentrating more on reading, things have settled now, I plan to sleep early so in morning I don’t feel pain in my legs, feel less lethargic.” She further reported that “now I am concentrating more on my studies and in my exam I did not forget I do most of the paper”. The client’s verbalization and pre-post difference in scores of depression, anxiety and subjective rating of anxiety related symptom showed the association between psychological problems and psychological intervention i.e. cognitive restructuring and relaxation therapies. There was a marked decreased in depression (see Table II). It was further confirmed that (see table III) patient felt improvement in her negative thinking that was related to feeling of inferiority which was dealt with cognitive restructuring as according to Beck (Sharf, 2000) feelings of inferiority and worthlessness is a core belief that lead to depression. After developing positive concept about self the connection between bodily tension and how to relax her was described. Here Relaxation techniques were very helpful in managing her sleep, nervousness, inability to control her desires. Other behavioral activities were a part of relaxation therapies that were applied by the client like she started involving herself in reading books, preparing daily meal, giving tuitions to children so that she become more busy in constructive activities and feel less anxious and depressed and her self-image become positive as she said “I have done it that means if I work hard I can do it”. This further showed that the outcome was clearly due to relaxation therapies that pushed her to constructive and relaxing activities. As Deffenbacher et al. (1988) suggested that preceding cognitive intervention with relaxation made them more acceptable and easier to implement. Relaxation therapy is also useful in developing her perception of home environment as she said

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“now I feel less tension and also give time to mother, now relationships with father are also better, my father gave me time, I also communicated with him, I did not feel afraid.” This change is also attributed to relaxation therapy because whenever she talked with her father she become tense, however after learning relaxation it was easier to communicate with her father as she reported. One of her belief, feelings scared, that was based on catastrophizing cognitive distortion (Sharf, 2000) was also decreased, but it is still present to certain extent that is related to her fear of relapse as she said “I feel sometime fearful if I couldn’t control myself, I am afraid if I lose my control and go back to previous state”. To change this belief cognitive restructuring and relaxation were really helpful, however for this client was suggested to take further sessions. Client’s scores and subjective expression showed that relaxation therapy is very useful and effective in the reduction of anxiety symptoms and problem related to the areas that cause anxiety and depression. Our findings are also supported by the findings of Goodwin and Montgomery (2006); Conrad and Roth (2007) and Jacobson and Heather (2008). CONCLUSION AND FUTURE DIRECTIONS It is concluded that relaxation replaces arousal, the client gains therapeutic outcome that involves a sense of control over disruptive emotional –physiological arousal, which helps her in restoring social occupational functioning. Relaxation therapies are found to be the key factor in the treatment of anxiety disorders. Present study demonstrates the effectiveness of psychological intervention in Pakistani (Asian) culture where people express their feelings in bodily symptoms. Considering the present finding it is strongly recommended that professionals dealing with mental disorders should consider the important of relaxation therapies in their treatment plan to rehabilitate clients’ past functioning and to reintegrate their mental resources through different modalities. To generalize the findings further research should focus on the investigation of effectiveness of relaxation and cognitive behavior therapies with larger samples.

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IMPLOSIVE THERAPY

& FLOODING

ESTAYAN, MAIKO KIMBERLY

GITGANO, ADONIS

LADICA, LENNIE KLARYZ

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ORIGIN AND HISTORY Flooding can be also called as Exposure Therapy or Intensive Exposure Therapy. It was developed by Thomas Stampfl and later on developed another therapy named Implosive Therapy, or Implosion Therapy, with the help of Don Levis on 1967. The key to flooding is the rapid exposure to the conditioned stimulus rather than more spaced presentations. The assumption is that this approach will facilitate the extinction, perhaps because the person becomes too physically exhausted for the conditioned response to occur, perhaps because the response prevention helps break down avoidance responses which do not have the time or opportunity to occur. The underlying theory behind Flooding and Implosive Therapy is that a phobia is a learned fear, and need to be unlearned using exposure to the thing that you fear. DEFINITION FLOODING [FLUD´ING] In behavior therapy, a form of desensitization for the treatment of phobias and related disorders in which the patient is repeatedly exposed to highly distressing stimuli without being able to escape but without danger, until the lack of reinforcement of the anxiety response causes its extinction. In general, the term is used for actual exposure to the stimuli, with implosion used for imagined exposure, but the two terms are sometimes used synonymously to describe either or both types of exposure. IMPLOSIVE THERAPY Implosive therapy (or implosion therapy) is a form of exposure therapy similar to the imaginary/imaginal form of flooding, with which it can be confused. Implosive Therapy is a variation of flooding. It is flooding with these characteristics: (a) all presentations of anxiety situations are done by having the client imagine scenes. (b) The imagined scenes are often ones of exaggerated or impossible situations designed to elicit as much anxiety as possible. (c) The scenes are often based on hypothesized sources of anxiety, some of which are psychodynamic in nature. These hypothesized sources of anxiety center around such things as hostility toward parental figures, rejection, sex, and dynamic concepts like oedipal complex and death wish.

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METHODS OF DELIVERING EXPOSURE THERAPY 1. PATIENT-DIRECTED EXPOSURE. Patient-directed exposure is the simplest variation of exposure treatment. After the patient makes his or her hierarchy list with the therapist, he or she is instructed to move through the situations on the hierarchy at his or her own rate. The patient starts with the lowest anxiety situation on the list, and keeps a journal of his or her experiences. Patient-directed exposure is done on a daily basis until the patient's fears and anxiety have decreased. For example, if a patient is afraid of leaving the house, the first item on the hierarchy might be to stand outside the front door for a certain period of time. After the patient is able to perform this action without feeling anxious, he or she would move to the next item on the hierarchy, which might be walking to the end of the driveway. Treatment would proceed in this way until the patient has completed all the items on the hierarchy. During therapy sessions, the therapist reviews the patient's journal; gives the patient positive feedback for any progress that he or she has made; and discusses any obstacles that the patient encountered during exposures to the feared situation. 2. THERAPIST-ASSISTED EXPOSURE. In this form of exposure treatment, the therapist goes with the patient to the feared location or situation and provides on-the-spot coaching to help the patient manage his or her anxiety. The therapist may challenge the patient to experience the maximum amount of anxiety. In prolonged in vivo exposure, the therapist and patient stay in the situation as long as it takes for the anxiety to decrease. For example, they might remain in a crowded shopping mall for four or more hours. The therapist also explores the patient's thoughts during this exposure so that any irrational ways of thinking can be confronted. 3. GROUP EXPOSURE. In group exposure, self-exposure and practice are combined with group education and discussion of experiences during exposure to feared situations. These sessions may last as long as three hours and include 30 minutes of education, time for individual exposure practice, and 45 minutes of discussion. Group sessions may be scheduled on a daily basis for 10–14 days. EXPOSURE TREATMENT FOR SPECIFIC ANXIETY DISORDERS 1. AGORAPHOBIA. Many research studies have shown that graded exposure treatment is effective for agoraphobia. Long-term studies have shown that improvement can be maintained for as long as

85 | P a g e seven years. Exposure treatment for agoraphobia is best done in vivo, in the actual feared situation, for example entering a packed subway car. Exposure treatment for agoraphobia is likely to be more effective when the patient's spouse or friend is involved, perhaps because of the support a companion can offer the patient during practice sessions. 2. PANIC DISORDER. Exposure treatment is the central component of cognitive-behavioral treatment for panic disorder. Treatment for this disorder involves identifying specific fears within the patient's experience of panic, such as fears of being sick, fears of losing control, and fears of embarrassment. Once these fears are identified, the patient is instructed to expose him or herself to situations in which the fearful thoughts arise (walking away from a safe person or place, for example). The rationale behind this instruction is that enduring the anxiety associated with the situation will accustom the patient to the situation itself, so that over time the anxiety will diminish or disappear. In this way, the patient discovers that the feared consequences do not happen in real life. In some patients, physical symptoms of panic lead to fears about the experience of panic itself. Fears related to the physical symptoms associated with panic can be targeted for treatment by inducing the bodily sensations that mimic those experienced during a panic attack. This technique is called interceptive exposure. The patient is asked to induce the feared sensations in a number of ways. For example, the patient may spin in a revolving chair to induce dizziness or run up the stairs to induce increased heart rate and shortness of breath. The patient is then instructed to notice what the symptoms feel like, and allow them to remain without doing anything to control them. With repeated exposure, the patient learns that the bodily sensations do not signal harm or danger, and therefore need not be feared. The patient is taught such strategies as muscle relaxation and slow breathing to control anxiety before, during, and after the exposure. Interceptive exposure treatment for panic usually begins with practice sessions in the therapist's office. The patient may be instructed to practice at home and then practice in a less "safe" environment, such as the patient's work setting or a nearby park. The next step is the addition of the physical activities that naturally produce the feared symptoms. Situational or in vivo exposure would then be introduced for patients with agoraphobia combined with panic disorder. The patient would be instructed to go back into a situation that he or she has been avoiding, such as an elevator or busy railroad terminal. If the patient develops symptoms of anxiety, he or she is instructed to use the techniques for controlling anxiety that were previously learned.

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The effectiveness of exposure treatment for decreasing panic attacks and avoidance has been well demonstrated. In research studies, 50%–90% of patients experience relief from symptoms. 3. SPECIFIC PHOBIA AND SOCIAL PHOBIA. Graded exposure is used most often to treat specific phobia or simple phobia. In graded exposure, the patient approaches the feared object or situation by degrees. For example, someone afraid of swimming in the ocean might begin with looking at photographs of the ocean, then watch movies of people swimming, then go to the beach and walk along the water's edge, and then work up to a full swim in the ocean. Graded exposure can be done through patient-directed instruction or therapist-assisted exposure. Research studies indicate that most patients respond quickly to graded exposure treatment, and that the benefits of treatment are well maintained. Treatment for social phobia usually combines exposure treatment with cognitive restructuring. This combination seems to help prevent a recurrence of symptoms. In general, studies of exposure treatment for social phobia have shown that it leads to a reduction of symptoms. Since cognitive restructuring is usually combined with exposure, it is unclear which component is responsible for the patients' improvement, but there is some indication that exposure alone may be sufficient. Exposure treatment can be more difficult to arrange for treating social phobia, however, because the patient has less control over social situations, which are unpredictable by their nature and can unexpectedly become more intense and anxiety-provoking. Furthermore, social exchanges usually last only a short time; therefore, they may not provide the length of exposure that the patient needs. 4. OBSESSIVE-COMPULSIVE DISORDER. The most common non-medication treatment for obsessive-compulsive disorder (OCD) is exposure to the feared or anxiety-producing situation plus response prevention (preventing the patient from performing a compulsive behavior, such as hand washing after exposure to something thought to be contaminated). This form of treatment also uses a hierarchy, and begins with the easiest situation and gradually moves to more difficult situations. Research has shown that exposure to contamination situations leads to a decrease in fears of contamination, but does not lead to changes in the compulsive behavior. In a similar fashion, the response prevention component leads to a decrease in compulsive behavior, but does not affect the patient's fears of

87 | P a g e contamination. Since each form of treatment affects different OCD symptoms, a combination of exposure and response prevention is more effective than either modality by itself. Exposure combined with response prevention also appears to be effective for treating OCD in children and adolescents. Prolonged continuous exposure is better than short, interrupted periods of exposure in treating OCD. On average, exposure treatment of OCD requires 90-minute sessions, although the frequency of sessions varies. Some studies have shown good results with 15 daily treatments spread over a period of three weeks. This intensive treatment format may be best suited for cases that are more severe and complex, as in patients suffering from depression as well as OCD. Patients who are less severely affected and are highly motivated may benefit from sessions once or twice a week. Treatment may include both therapist-assisted exposure and self-exposure as homework between sessions. Imaginal exposure may be useful for addressing fears that are hard to include in vivo exposure, such as fears of a loved one's death. Patients usually prefer gradual exposure to the most distressing situation in their hierarchy; however, gradual exposure does not appear to be more effective than flooding or immediate exposure to the situation. 5. POST-TRAUMATIC STRESS DISORDER. Exposure treatment has been used successfully in the therapy of post-traumatic stress disorder (PTSD) resulting from such traumatic experiences as combat, sexual assault, and motor vehicle accidents. Research studies have reported encouraging results for exposure treatment in reducing PTSD or PTSD symptoms in children, adolescents, and adults. Such intrusive symptoms of PTSD as nightmares and flashbacks may be reduced by having the patient relive the emotional aspects of the trauma in a safe therapeutic environment. It may take 10–15 exposure sessions to decrease the negative physical sensations associated with PTSD. These sessions may range from one to two hours in length and may occur once or twice a week. Relaxation techniques are usually included before and after exposure. The exposure may be therapist-assisted or patient-directed. A recent study showed that imaginal exposure and cognitive treatment are equally effective in reducing symptoms associated with chronic or severe PTSD, but that neither brought about complete improvement. In addition, more patients treated with exposure worsened over the course of treatment than patients treated with cognitive approaches. This finding may have been related to the fact that the patients receiving exposure treatment had less frequent sessions with long periods of time between sessions. Some patients diagnosed with PTSD, however, do not seem to

88 | P a g e benefit from exposure therapy. They may have difficulty tolerating exposure, or have difficulty imagining, visualizing, or describing their traumatic experiences. The use of cognitive therapy to help the patient focus on thoughts may be a useful adjunctive treatment, or serve as an alternative to exposure treatment. Many persons who have undergone sexual assault or rape meet DSM-IV-TR criteria for PTSD. They may re-experience the traumatic event, avoid items or places associated with the trauma, and have increased levels of physical arousal. Exposure treatment in these cases involves using either imaginal or in vivo exposure to reduce anxiety and any tendencies to avoid aspects of the situation that produce anxiety (also known as avoidance behavior). Verbal description of the event (imaginal exposure) is critical for recovery, although it usually feels painful and threatening to patients. It is important that the patient's verbal description of the traumatic event, along with the expression of thoughts and feelings related to it, occur as early in the treatment process as possible. It is in the patient's "best long-term interest to experience more discomfort temporarily in order to suffer less in the long run." Prolonged exposure is the most effective non-medical treatment for reducing traumatic memories related to PTSD. It combines flooding with systematic desensitization. The goal is to expose patients using both imaginal and in vivo exposure techniques in order to reduce avoidance behavior and decrease fears. Prolonged exposure may occur over nine to 12 ninety-minute sessions. During the imaginal exposure phase of treatment, the patient is asked to describe the details of the traumatic experience repeatedly, in the present tense. The patient uses the SUDS scale to monitor levels of fear and anxiety. The in vivo component occurs outside the therapist's office; it involves the client exposing himself or herself to cues in the environment that he or she has been avoiding— for example, the place where the motor vehicle accident or rape occurred. The patient is instructed to stay in the fear-producing situation for at least 45 minutes, or until their anxiety levels have gone down significantly on the SUDS rating scale. Often patients will use a coach or someone who will stay with them at the beginning of in vivo practice. The coach's role gradually decreases over time as the patient experiences less anxiety. ADVANTAGES  A major advantage of flooding is that it is much faster than gradual approaches such as desensitization.

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 Flooding can be seen as quite a good technique as the patient who is undergoing the treatment becomes increasingly more anxious until their anxiety peaks and they realize that they cannot actually get more anxious and therefore, the anxiety lessens and they realize that their fear was irrational, therefore curing them of their fear. DISADVANTAGES  A major disadvantage is that often it will increase the strength of the anxiety rather than extinguish it.  It causes a lot of unnecessary stress to the patient which can be damaging and leave them with other psychological problems especially if they decide to drop out of the treatment which many of them do.  It does not protect the participants and this is the main reason why many believe that it is unethical.

CASE STUDY Since early 2003, researchers have been implementing the ‘Nakivale Camp Mental Health Project’ in Uganda. In the framework of this project, besides adult therapy, they also offer a child- friendly version of Narrative Exposure Therapy (NET). One of the key questions that they aim to investigate is whether or not NET can be applied with equal success to children, as to adults (Neuner et al., 2002, 2004); and if so, from what age onwards. Current scientific knowledge holds that narrative requires abilities which are not well developed in early childhood, and does not sufficiently take into account the cognitive framework and the emotional needs of a small child. In general, the capacity for autobiographical memory develops with age. Although infants and young children process and retain information (Bauer 1996), events occurring before the age of 2- 3 years cannot be recalled in narrative form. But on the other hand, due to the presence of threat, traumatic events are usually remembered, even in early childhood, and the memories can be remarkably accurate (Koss, Tromp &Tharan 1995). In very young children (age 2-5 years), who cannot perfectly express themselves in coherent narratives but remember fragments, their memory nevertheless was shown to be accurate and correct (Jones &Krugman 1986; Terr 1988; Howe, Courage & Peterson 1994; Peterson 1996), even when the traumatic event took place a long time ago (Widom& Shepard 1996; Widom& Morris 1997; Wagenaar&Groeneweg 1990). Misperception and forgetting significant aspects of the experienced violence and horror are

90 | P a g e however also common. However, treatment with memory recovery techniques that involve remembering and talking about the traumatic event and its aftermath, was found to improve memory in older children (Goenjian 1997). The researchers developed KIDNET as a child-friendly exposure treatment for children and adolescents with PTSD. Since children often need more help which involves play and visual instruction to elaborate their experiences, we use theatre and illustrative material, such as the ‘life- line exercise’ during NET treatment sessions (Schauer et al., 2003). A rope is used to represent the child’s lifeline. Flowers are used to mark positive experiences along the lifeline, while stones are used to mark negative and traumatic experiences. The child clients re-construct their own lifelines at the beginning of therapy and produce a painting of it. They are encouraged to name the events for which an item is placed, i.e. ‘when we had to leave home’, ‘death of uncle’, and the therapist writes down the headline. In subsequent sessions the therapist is able to use the painting repeatedly for illustrative purposes. At the end of therapy children are encouraged to unwind some of the unused section of the rope, to shed some light on future hopes and fears in their imagination. The life-line exercise is especially important for the first NET sessions with a child. It helps to ‘break the ice’ quickly and employs creative media, which allows the child’s life story to unfold in a playful manner. In fact this simple technique works so well, that we have also been able to use it successfully with adults from many different cultures, especially when it is difficult for a patient to reconstruct a clear chronological order of events in life. RESULTS OF KIDNET Finding ways to effectively reduce, as well as prevent, the psychological suffering of victims of war, especially children, is an important challenge for scientists and aid organizations alike, and indeed remains an ethical obligation. In the presented case study KIDNET has again proven a successful approach for the treatment of traumatized child survivors. We maintain that the tradition of joint psychological and testimony approaches, chronicling major events of the entire lifetime - good or bad - may offer opportunities to remedy mental suffering and to provide adequate assistance to children in need. The results of this case study indicate that it is possible that well-established knowledge about the efficacy of exposure techniques for the treatment of PTSD (Foa, 2000; Neuner et al., 2004) may be transferred to child refugee populations, even when living in unsafe conditions. In contrast to a variety of other cognitive behavioral approaches, KIDNET is shorter (usually not more than six sessions are applied) and the procedure is more

91 | P a g e pragmatic and might be easier to learn for therapists without a psychosocial education. This makes the method especially appropriate as one tool in community based approaches in war and disaster areas. A strict evaluation of community-based interventions will have to show what additional interventions, such as support of the family system, are beneficial or necessary within a complex community-based framework.

Table 1: Mohamed’s (one of the children who received KIDNET) pre- and post-test PDS item scores indicate frequency rating of symptoms: 0 means “not at all or only once in the last month”, 1 means “2 to 4 times in the last month”; 2 means “5 to 16 times in the last month”, 3 means “almost always”.

A note of caution, however, seems necessary. In the case of adults, as we already know, inadequate treatment can do more harm than good. Exposing the patient too briefly to traumatic memories, not allowing complete habituation to aroused emotional reactions (i.e., learning that these memories are not frightful) and insufficient reconstruction of the major traumatic events will not end the suffering, and may even increase anxiety and lead to even greater disappointment and depression. ‘Conspiracy’ between therapist and patient, the tacit agreement not to narrate and thus expose patient and therapist to the major traumatic events in imagination, is another common risk, whereby avoidance ensures that only the most negligible events are elaborated in great detail. More

92 | P a g e research must follow, focusing on significant numbers of refugee children treated with KIDNET. Our next focus will also be on the success of the application of treatment by trained local refugee therapists. Further, more insight must be gained in how parents, caretakers, teachers and other significant adults can be actively involved in the recovery processes of children, individually and at a community level. In addition, the applicability and efficacy of KIDNET for even more different groups of especially vulnerable populations (e.g. orphans, former child soldiers) has to be established. Furthermore, knowledge must be established on how co-morbid disorders and somatic complaints can be taken care of in a comprehensive KIDNET for traumatized and displaced children. More collected narratives of child survivors, chronicling child rights violations, must reach institutions, governments and international bodies in order to inform the general public on the consequences of modern warfare on millions of children, and its implications for the future of war-torn countries and regions.

Virtual Reality Exposure Therapy for PTSD Vietnam Veterans: A Case Study Barbara Olasov Rothbaum, Larry Hodges, Renato Alarcon, David Ready, Fran Shahar, Ken Graap, Jarrel Pair, Philip Hebert, Dave Gotz, Brian Wills, and; David Baltzell Virtual reality (VR) integrates real-time computer graphics, body tracking devices, visual displays, and other sensory input devices to immerse a participant in a computer-generated virtual environment that changes in a natural way with head and body motion. VR exposure (VRE) is proposed as an alternative to typical imaginal exposure treatment for Vietnam combat veterans with posttraumatic stress disorder (PTSD). This report presents the results of the first Vietnam combat veteran with PTSD to have been treated with VRE. The patient was exposed to two virtual environments, a virtual Huey helicopter flying over a virtual Vietnam and a clearing surrounded by jungle. The patient experienced a 34% decrease on clinician-rated PTSD and a 45% decrease on self-rated PTSD. Treatment gains were maintained at 6-month follow-up. Posttraumatic stress disorder (PTSD) is one of the most disabling psychopathological conditions affecting the veteran population. Weiss et al. (1992) estimated 830,000 veterans suffered from chronic combat-related PTSD. Exposure treatments for PTSD involve repeated reliving of the trauma with the aim of facilitating its processing, a mechanism presumably impaired in victims with chronic PTSD (Foa, Steketee, & Rothbaum, 1989). Three controlled studies demonstrated statistically significant yet relatively small effects utilizing imaginal exposure (IE)

93 | P a g e for reducing PTSD and related pathology in male Vietnam veterans (Boudewyns & Hyer, 1990; Cooper & Clum, 1989; Keane, Fairbank, Caddell, & Zimering, 1989). One of the most common complaints of Vietnam Veterans with PTSD is a strong emotional response to the sound of helicopters. The American Lake VAMC PTSD program used "helicopter ride therapy" for several years as a regular part of their treatment (Fontana, Rosenheck, & Spencer, 1993). More than 400 Vietnam veteran patients had the opportunity to ride in Huey helicopters as part of their treatment. The authors reported that this type of exposure treatment was very helpful to their patients, although no data was reported. However, it is not practical to use actual Huey helicopters for the thousands of veterans with PTSD, and the benefits of standard imaginal exposure in this population are modest, at best. Therefore, virtual reality exposure (VRE) therapy is proposed as a new medium of exposure therapy for veterans with PTSD. Advantages of VRE include conducting exposure therapy without leaving the therapist's office, exactly controlling exposure stimuli, and exposing the patient to less risk of harm or embarrassment. In a controlled treatment study of acrophobia, VRE significantly reduced fear and avoidance of heights and improved attitudes toward heights (Rothbaum et al., 1995a). Repeated exposures to virtual foot bridges, outdoor balconies, and a glass elevator that ascended 50 floors produced physical symptoms of anxiety including sweating, butterflies, heart palpitations, shaking, weakness in the knees, tightness in the chest, and tension (Hodges et al., 1995). Case studies of VRE have demonstrated reduced fears of heights (Rothbaum, Hodges, Kooper, Opdyke, & Williford, 1995b), flying (Rothbaum, Hodges, Watson, Kessler, & Opdyke, 1996), and spiders (Carlin, Hoffman, & Weghorst, 1996). What distinguishes virtual reality from a mere multimedia system or an interactive computer graphics display is a sense of presence. A sense of presence is also essential to conducting exposure therapy. As mentioned before, exposure therapy is aimed at facilitating emotional processing (Foa & Kozak, 1986). For this to occur, it has been proposed that the fear structure must be activated and modified. Exposure therapy is historically effective at activating the fear structure via confrontation with the feared stimuli, which elicits the fearful responses. The processes of habituation and extinction, in which the feared stimuli cease to elicit anxiety, aid modification of the fear structure, making it meaning less threatening. Any method capable of activating the fear structure and modifying it would be predicted to improve symptoms of anxiety. Thus, VRE has been proposed to aid the emotional processing of fears (Rothbaum et al., 1995).

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In summary, no therapeutic approach has proven to be consistently effective in the management of combat-related PTSD. Behavioral therapies with an exposure element have proven more effective than most other types of treatment (Van Etten & Taylor, in press), but a significant number of patients do not seem to benefit from them, possibly due to difficulties imagining, visualizing or describing their traumatic experiences. An uncontrolled treatment development study is currently underway to evaluate the therapeutic effectiveness of VRE for Vietnam veterans with combat-related PTSD. The present report is a case study of the first patient to complete this treatment. METHOD PARTICIPANT The subject of this report is a middle class, married, 50-year-old, Caucasian male, who served as a helicopter pilot in Vietnam approximately 26 years prior to this study. He met DSM- IV (APA, 1994) criteria for current PTSD, current major depressive disorder (recurrent, with melancholic features), and past alcohol abuse. He had recently completed a group based treatment at the Atlanta VAMC and yet still suffered with significant PTSD and depressive symptoms which were being managed with medication including Prozac (40 mg), Buspar (20 mg) and Doxipin (150 mg). He had never received exposure therapy prior to the current study. He was unemployed and was receiving 100% VA disability compensation. PROCEDURE Informed consent was obtained and a preliminary screening interview conducted at Emory University. A pre-treatment evaluation was conducted by an independent assessor who reviewed the inclusion (currently meet PTSD diagnostic criteria, manageable suicidal ideation) and exclusion criteria (current substance abuse, mania, suicidal intent, unstable mediation in 3 months) and explained the procedures of the project in detail and scheduled the initial treatment session. APPARATUS During VRE the patient wore a Virtual Research V6 head mounted display equipped with a Polhemus InsideTrak position tracker and high-quality headphones. This head mounted display contains two mini television screens, one in front of each eye, and ear phones over each ear. The head mounted display is worn on the head with T-straps holding it on the head, with a cable connected to the computer. Computer graphics images and spatial audio consistent with the orientation and position of the patient's head were computed in real time as the patient experienced

95 | P a g e and explored each environment. All environments were immersive, i.e., the patient experienced only the computer-generated audio and visual stimuli while "real-world" stimuli were shut out. Therapist communications were via a microphone connected to the headphones. During the helicopter virtual environment, the patient sat in a "Thunder Seat," that included an integrated woofer under the seat which allowed the vibrations from the helicopter to be experienced. For the clearing environment, the patient stood on a raised (eight inches) platform (3.5 ft x 3.5 ft) surrounded by hand-rails. The patient "walked" in the environment by pushing a button on a hand- held joystick. Audio, headtracking, and real-time graphics were computed on a PC with a 233 MHZ Intel Pentium II Processor, 64 MB of ram, and an Evans & Sutherland 3D graphics card. The Virtual Vietnam software and environment models were custom-built at Georgia Tech and Virtually Better, Inc. using the Simple Virtual Environment (SVE) tools. TREATMENT Treatment was delivered in fourteen, 90-min individual sessions conducted twice weekly over 7 weeks. Session 1 was devoted to information gathering, explaining the therapy from an emotional processing viewpoint, teaching a brief breathing relaxation method, and familiarizing the patient with the virtual reality equipment using a neutral environment. During sessions 2 and 3 the participant was exposed to the two virtual environments (VEs). In the virtual jungle clearing, the audio effects included recordings of jungle sounds (i.e., crickets), gunfire, helicopters, mine explosions, and men yelling "Move out! Move out!" which could be increased in intensity. Visual effects included muzzle flashes from the jungle, helicopters flying overhead, landing and taking off, and fog. In the virtual helicopter, audio effects included the sound of the rotors, gunfire, bombs, B52s, engine sounds, radio chatter, and men yelling "Move out! Move out!" Visual effects included the interior of a Huey helicopter in which the backs of the pilot's and copilot's heads with patches were visible, instruments, controls, as well as the view out of the helicopter side door. This view included aerial shots of other helicopters flying past, clouds, and the terrain below which included rice paddies, jungle, and a river. Sessions four and five exposed the patient to these VEs plus triggered memories. The patient was asked to describe in detail memories triggered by the VEs and to repeat those several times to allow habituation. The content of these triggered memories was controlled by the patient. Sessions 6-14 were spent exposing the patient to the VEs plus imaginal exposure to his most traumatic memories. His most traumatic memories were determined prior to treatment and were prompted by the therapist. As in standard imaginal exposure for PTSD

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(e.g., Foa, Rothbaum, Riggs, & Murdock, 1991), the patient was asked to recount these memories in the present tense repeatedly until his anxiety decreased. In contrast to standard imaginal exposure, the patient was asked to keep his eyes open, and the therapist attempted to match in virtual reality what the patient was describing as closely as possible, for example, landing and taking off the helicopter when the patient described these activities and gunfire at appropriate times. Self-rating of Subjective Units of Discomfort (SUDS) from 0 to 100 were elicited from the patient every 5 min during exposure. The therapist simultaneously viewed on a video monitor all of the VEs with which the patient was interacting and therefore was able to comment appropriately and encouraged continued exposure until anxiety habituated. At the end of the session's exposure, practice with the breathing exercise was completed. The patient and therapist discussed the session and the patient's reactions. All treatment sessions were videotaped for supervision by the first author. INSTRUMENTS The following clinician-rated and self-report measures of PTSD were incorporated: Clinician-administered PTSD Scale (CAPS; Blake et al., 1996); Combat Exposure Scale (CES; Foy, Sipprelle, Rueger, & Carroll, 1984); Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 1995); Impact of Events Scale (IES; Horowitz, Wilner, & Alvarez, 1979); Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961); and State-Trait Anger Expression Inventory (STAXI; Spielberger, Jacobs, Russell, & Crane, 1983; Spielberger, 1996). Full assessments were conducted at pretreatment and posttreatment. A brief midtreatment assessment included only the IES and BDI. The patient was informed that the result of the assessments would not become part of his VA hospital file to try to avoid the confound of improvement in symptoms and loss of compensation. The patient was informed of the payment schedule in which he was to receive $10 for completing the posttreatment assessment, $20 for completing the three month follow-up, and $30 for completing the six month follow-up, for a total of $60. In addition, this patient was reimbursed $7 per session for travel to treatment sessions. RESULTS Results from pretreatment to posttreatment on individual measures and the percentage decrease from pre-treatment to the other assessment points can be found in Table 1. As can be seen, scores on all measures decreased from preto posttreatment and gains were generally

97 | P a g e maintained at follow-up. No statistical analyses were incorporated since this was a single subject. Instead, each measure is discussed in terms of clinical significance and references are made, where data exists, to studies with information on these measures in similar populations. In this vein, the patient's pretreatment CAPS Total score of 64 falls into the "severe" range (60-79, Weathers, 1998) and his posttreatment CAPS Total score of 42 falls into the "moderate/threshold" range (40-59) indicating a decrease in clinical severity, although obviously still suffering from some PTSD symptoms. His follow-up scores remain in this range. In two samples of Vietnam veterans with PTSD, their IES scores for a specific Vietnam incident was 25 (Pitman, Orr, Forgue, Altman, de Jong, & Herz, 1990; Pitman, Orr, Forgue, de Jong, & Claiborn, 1987). The current patient's pretreatment IES Total score of 33 is more than one standard deviation higher than this group and his posttreatment total score of 18 is greater than 1 SD lower, indicating a meaningful over two standard deviation move following therapy. His 6-month follow-up total IES score of 0 indicates a complete absence of intrusive and avoidance symptoms related to the traumatic incident rated (see Discussion). His Beck Depression Inventory pretreatment score of 37 as well as his posttreatment score of 30 indicate severe depression according to the cutoffs recommended by Beck (Steer & Beck, 1988). His BDI 6-month follow-up score of 21 falls into the moderate depression range, indicating a decrease in severity of depression over time although a continuation of meaningful symptoms. The pretreatment STAXI State anger score of 27 is within 1 SD of the pretreatment mean of 30.1 of a group of "severely angry Vietnam war veterans suffering from combat-related PTSD" (p. 184, Chemtob, Novaco, Hamada, & Gross, 1997), and the post treatment STAXI State anger score of 10 is more than 1 SD below the posttreatment mean of 19.5 for the treated veterans in the Chemtob, Novaco, Hamada, and Gross (1997) study indicating a meaningful shift in state anger.

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DISCUSSION This case study of the first known Vietnam veteran to undergo virtual reality exposure therapy lends support to the idea that this new medium of exposure therapy may hold promise. The results indicate that PTSD scores decreased following treatment. Depression, anger, and substance abuse do not appear to be adversely affected by the treatment, as has sometimes been the case with exposure therapy for Vietnam veterans (Pitman et al., 1991). It is interesting to note that the patient's midtreatment IES intrusion score increased and avoidance score decreased. The patient was informed prior to treatment that symptoms may increase temporarily during exposure therapy and to try not to avoid trauma-related thoughts or cues during this time. The midtreatment increases on the IES Intrusion scale indicate that, in fact, his intrusive symptoms did increase as predicted. The mid-treatment decreases on the IES Avoidance scale indicate that he was following instructions not to avoid. Had only pre- and posttreatment IES scores been gathered, this information would have been missed. The six month follow-up IES score of 0 obviously indicates no intrusion or avoidance related to the trauma rated, which, at first glance, is hard to believe. Instructions for the IES refer the patient to a specific incident and to complete the symptoms as they relate to that incident and

99 | P a g e were followed exactly. Therefore, the patient was asked to rate event-related intrusion and avoidance to his single most traumatic event ("LZ Brown" in his case) rather than his entire combat service in Vietnam. This explains how his six month IES could be 0 whereas he was still symptomatic when rated by the clinician on the CAPS, rating his PTSD symptoms related to his entire service in Vietnam. When completing the IES at the six month assessment, he commented that he hadn't thought of LZ Brown in quite some time, but that it was no longer as distressing to him and therefore he had not been making any particular efforts to avoid thinking about it. This was the patient's most traumatic memory identified at pretreatment and was the focus of the majority of treatment sessions incorporating imaginal exposure. Obvious limitations to the generalizability of these results center on the fact that this is just one subject and just one component of treatment. The parent study is ongoing and continuing to treat more patients, which will lend more information. Regarding the scope of treatment, VRE therapy is proposed as a component of a comprehensive treatment program. It is generally accepted that this population requires a comprehensive treatment program (Foy et al., 1998) rather than just PTSD focused treatment. This therapy has the advantages of allowing veterans to virtually reexperience aspects of Vietnam in a controllable manner that allows for habituation. The patient appeared to become immersed in the virtual environment. This was a very "typical" Vietnam combat veteran with PTSD participating in the VA system: he met current criteria for PTSD and major depression and past substance abuse of alcohol. He was currently on several medications. He was on 100% disability for his PTSD. He was quick to anger and slow to trust, yet unhappy with his current life and verbally expressing motivation to change and to try almost anything that might help. His marriage was in distress, and he had problems in most other areas of his life. He was very weary of this treatment and admitted to not wanting to attend sessions at times. Yet, this treatment appears to have helped, even if modestly. This report is quite limited in its scope, with just one participant, but it is suggestive that imaginal exposure while immersed in Vietnam audio and visual stimuli may be an effective component of a comprehensive treatment package for Vietnam veterans with PTSD and is worthy of further study.

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ASSERTIVE

TRAINING

ENECILLO, JESSICA GABRIEL, ELLYN JOY MIGUEL, NATALIE ZUÑIGA, KELLY MARGARETH

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INTRODUCTION Assertiveness is a skill regularly referred to in social and communication skills training. Often wrongly confused with aggression, assertive individuals aim to be neither passive nor aggressive in their interactions with other people. Although everyone acts in passive and aggressive ways from time to time, such ways of responding often result from a lack of self-confidence and, therefore, are inappropriate expressions of what such people really need to say. Non-assertiveness may be seen as the use of inefficient communication skills, whereas assertiveness is considered a balanced response, being neither passive nor aggressive. This examines the rights and responsibilities of assertive behavior and aims to show how assertiveness can benefit people. WHAT IS ASSERTIVENESS? Assertiveness is not only about standing up for yourself, but also about respecting the opinions and needs of others. When we communicate assertively, we are not only clear about our opinions and wishes, but we are also open to others. The Concise Oxford Dictionary defines assertiveness as: “Forthright, positive, insistence on the recognition of one's rights” In other words: Assertiveness means standing up for your personal rights - expressing thoughts, feelings and beliefs in direct, honest and appropriate ways. It is important to note also that: By being assertive we should always respect the thoughts, feelings and beliefs of other people. Those who behave assertively always respect the thoughts, feelings and beliefs of other people as well as their own. Assertiveness means being able to express feelings, wishes, wants and desires appropriately and is an important personal and interpersonal skill. Assertiveness can help you to express yourself in a clear, open and reasonable way, without undermining your own or others’ rights in all your interactions with other people, whether at home or at work, with employers, customers or colleagues.

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Assertiveness enables individuals to act in their own best interests, to stand up for themselves without undue anxiety, to express honest feelings comfortably and to express personal rights without denying the rights of others. CHARACTERISTICS OF ASSERTIVE PERSON  They feel free to express their feelings, thoughts, and desires.  They are “also able to initiate and maintain comfortable relationships with other people”.  They know their rights.  They have control over their anger, This does not mean that they repress this feeling; it means that they control anger and talk about it in a reasoning manner.  “Assertive people…are willing to compromise with others, rather than always wanting their own way…and tend to have good self-esteem”.  :Assertive people enter friendships from an “I count my needs. I count your needs’ position”. TYPES OF ASSERTIVENESS  PASSIVE BEHAVIOR - The person who behaves non-assertively in a situation does not assert his/her basic rights, instead he/she allows others to infringe upon them. - The basic message of a passive communicator: “My feelings don’t matter – only yours do. My thoughts aren’t important – yours are the only ones worth listening to. I’m nothing – you’re superior”. - The goal of a passive communication is to appease others and to avoid conflict at any cost. - Body language: No eye contact, soft, whiny or muffled voice, cringing/or physically making yourself seem small (hang-dog posture), use of nervous or childish gestures.  ASSERTIVE BEHAVIOR - The person who behaves assertively in a situation asserts his/her basic rights. He/she takes responsibility for them whilst recognizing and respecting to other person’s basic rights. - The basic message of an aggressive communicator: “This is what I think – you’re stupid for believing differently. This is what I feel – your feelings don’t count”.

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- The goal of aggressive communication is domination, and winning, forcing the other person to lose. Winning is ensured by humiliating, degrading, belittling, or overpowering other people so that they become weaker or less able to express and defend their needs and rights. - Body language: Invasive/angry staring – eye contact, loud voice, invasion of personal body space, use of aggressive gestures (pointing finger), stiff, “muscled up” posture, towering over others.  AGGRESIVE BEHAVIOR - The person who behaves aggressively in a situation asserts his/her basic rights at the expense of the other person’s rights. He/she does not respect that other person has rights. - The basic message of an assertive communicator: “This is what I think. This is what I feel. This is how I see the situation.” - The goal of an assertive communication is to get and give respect, to ask for fair play and to leave room for compromise when the rights and needs of two people conflict. - Body language: Direct, but non-threatening eye contact, calm voice, respectful of personal body space, use of illustrative gestures and an erect, but relaxed posture. ASSERTIVE BEHAVIOUR INCLUDES:  Being open in expressing wishes, thoughts and feelings and encouraging others to do likewise.  Listening to the views of others and responding appropriately, whether in agreement eith those views or not.  Accepting responsibilities and being able to delegate to others.  Regularly expressing appreciation of others for what they have done are or are doing.  Being able to admit mistakes and apologize.  Maintaining self-control.  Behaving as an equal to others. WHY PEOPLE ARE NOT ASSERTIVE? There are many reasons why people may act and respond in a non-assertive way and this examines some of the most common. When people are not assertive they can suffer from a loss of confidence and self-esteem, which is more likely to make them less assertive in the future. It is therefore important to break

104 | P a g e the cycle and learn to be more assertive, whilst at the same time respecting the views and opinions of other people. We all have a right to express our feelings, values and opinions.  LOW SELF-ESTEEM AND SELF-CONFIDENCE Feelings of low self-esteem or self-worth often lead to individuals dealing with other people in a passive way. By not asserting their rights, expressing their feelings or stating clearly what they want, those with low self-esteem or self-confidence may invite others to treat them in the same way. Low self-esteem is reinforced in a vicious circle of passive response and reduced self-confidence.  ROLES Certain roles are associated with non-assertive behavior, for example low status work roles or the traditional role of women. Stereotypically, women are seen as passive, while men are expected to be more aggressive. There can be great pressure on people to conform to the roles that are placed upon them. You may be less likely to be assertive to your boss at work than you would be to a colleague or co-worker who you considered to be at an equal or lower level than you in the organization.  PAST EXPERIENCE Many people learn to respond in a non-assertive way through experience or through modeling their behavior on that of parents or other role models. Learnt behavior can be difficult to unlearn and the help of a counselor may be needed.  STRESS When people are stressed they often feel like they have little or no control over the events their lives. People who are stressed or anxious can often resort to passive or aggressive behavior when expressing their thoughts and feelings. This is likely to increase the feelings of stress and potentially make others feel stressed or anxious as a result.  PERSONALITY TRAITS Some people believe they are either passive or aggressive by nature, in other words that they were born with certain traits and that there is little they can do to change their form of response. This is very nearly always an incorrect assumption since everybody can learn to be more assertive even if their natural tendencies are passive or aggressive.

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CRITICISM All of us have been criticized at some point in our lives. Being able to accept criticism assertively is one of the most important tasks we face on our journey to maturity. The word criticism comes from an Ancient Greek word describing a person who offers reasoned judgement or analysis, value judgement, interpretation or observation. So to accept criticism maturely we need to be able to accept feedback in the form of analysis, observation or interpretation from other people about our behavior. TYPES OF CRITICISM Constructive criticism is designed to provide genuine feedback in a helpful and non- threatening way in order that the person being criticized may learn and grow in some way. The feedback is typically valid, that is, it is a true criticism. For example, “I really liked the way you wrote your report; I think it could be even better if you focused more on improving your spelling”. Destructive criticism is criticism that is either not valid or true or criticism that if valid is delivered in an extremely unhelpful way. It is often given by someone without much thought or can be designed to embarrass or hurt. For example, “This report is atrocious, your spelling is appalling”. HOW DO YOU RESPOND TO CRITICISM Some of the common non-assertive ways of responding to criticism are: • Becoming confused • Retaliating with anger and blame • Becoming defensive • Shutting down • Acting silly • Withdrawing • Ignoring it and hurting inside • Running away • Internalizing anger and stewing over it ASSERTIVE TRAINING All of us should insist on being treated fairly; we have to stand up for our rights without violating the rights of others. This means tactfully, justly, and effectively experiencing our preferences, needs opinions and feelings. Psychologist call that being “assertive”, as distinguished from being unassertive (weak, passive, compliant, self-sacrificing) or aggressive (self-centered, inconsiderate, hostile, arrogantly demanding). Because some people want to be “nice” and “not cause trouble” they “suffer in silence”, “turn the other cheek”, and assume nothing can be done to change their situation or “it is our cross

106 | P a g e to bear”. The rest of us appreciate pleasant, accommodating people but whenever a “nice” person permits a greedy, dominant person to take advantage of him/her, the passive person is not only cheating him/herself but also reinforcing unfair, self-centered behavior in the aggressive person. That’s how chauvinist is created. HISTORY OF ASSERTIVE TRAINING During the second half of the 20th century, assertiveness was increasingly singled out as a behavioral skill taught by many personal development experts, behavior therapists, and cognitive behavioral therapists. Assertiveness is often linked to self-esteem. The term and concept was popularized to the general public by books such as Your Perfect Right: A Guide to Assertive Behavior (1970) by Robert E. Alberti, and When I Say No, I Feel Guilty: How To Cope Using the Skills of Systematic Assertiveness Therapy (1975) by Manuel J. Smith. Joseph Wolpe originally explored the use of assertiveness as a means of "reciprocal inhibition" of anxiety, in his 1958 book on treating neurosis; and it has since been commonly employed as an intervention in behavior therapy. Assertiveness Training ("AT") was introduced by Andrew Salter (1961) and popularized by Joseph Wolpe Wolpe's belief was that a person could not be both assertive and anxious at the same time, and thus being assertive would inhibit anxiety. USES OF ASSERTIVE TRAINING Learning to communicate in a clear and honest fashion usually improves relationships within one's life. Women in particular have often been taught to hide their real feelings and preferences, and to try to get their way by manipulation or other indirect means. Specific areas of intervention and change in assertiveness training include conflict resolution, realistic goal- setting, and stress management. In addition to emotional and psychological benefits, taking a more active approach to self-determination has been shown to have positive outcomes in many personal choices related to health, including being assertive in risky sexual situations; abstaining from using drugs or alcohol; and assuming responsibility for self-care if one has a chronic illness like diabetes or cancer. Assertive training is also use in anxiety reduction and control, anger reduction and control, and redirection of this energy, increase in self-esteem, awareness of self and others in interpersonal situations, awareness of social and cultural rules of behavior, increased awareness of personal rights.

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HOW TO BE ASSERTIVE?  Be honest and direct about your feeling, needs, beliefs  Express yourself firmly and directly to specific individuals  Be reasonable in your requests  State your viewpoint without being hesitant or apologetic  Be honest when giving or receiving feedbacks  Learn to say “No” to unreasonable expectations  Paraphrase what others have stated to you TECHNIQUES OF ASSERTIVENESS  BROKENRECORD TECHNIQUE This technique consists of simply repeating your requests or your refusals every time you are met with resistance, The term comes from vinyl records, the surface of which when scratched would lead the needle of a record player to loop over the same few seconds of the recording indefinitely. Example: “Yes, I know it's important, but I don't want to go...Sorry, but I don't want to go...I realize what it means to you, but I don't want to go.” “It's too expensive...I know it's good value, but it's too expensive...I know about finance deals, but it's too expensive.” A disadvantage with this technique is that when resistance continues, your requests may lose power every time you have to repeat them. If the requests are repeated too often, it can backfire on the authority of your words. In these cases, it is necessary to have some sanctions on hand.  FOGGING Fogging is a way to accept criticism without letting it bring you down. Just imagine you're like the fog. When someone throws a stone at you, you accept it and you envelop the stone in your fog without throwing the stone back at the other person. Fogging is so termed because the individual acts like a 'wall of fog' into which arguments are thrown, but not returned. There are three (3) types of Fogging: 1. AGREE IN TRUTH Criticism: “You haven’t got a job, you’re completely unproductive.”

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Assertive Response: “Yes it’s true, I don’t have a job.” 2. AGREE IN PROBABILITY Criticism: “If you don’t floss your teeth, you’ll get gum disease and be sorry for the rest of your life.” Assertive Response: “You’re right, I may get gum disease.” 3. AGREE IN PRINCIPLE Criticism: “That’s the wrong tool for that job. A chisel like that will slip and mess up the wood. You ought to have a gauge instead.” Assertive Response: “You’re right; if the chisel slips it will really mess up the wood.”  NEGATIVE ASSERTION Acceptance of your errors and faults (without having to apologize) by strongly and sympathetically agreeing with hostile or constructive criticism of your negative qualities. Criticism: “Your desk is very messy. You are very disorganized.” Assertive response: “Yes, it’s true, I am not very tidy.”  POSITIVE INQUIRY Positive inquiry is a simple technique for handling positive comments such as praise and compliments. People often struggle with responding to praise and compliments, especially those with lower self-esteem as they may feel inadequate or that the positive comments are not justified. It is important to give positive feedback to others when appropriate but also to react appropriately to positive feedback that you receive. Positive inquiry is used to find out more details about the compliment or praise given, and agree with it: Example: Sender: “You made an excellent meal tonight, it was delicious!” Receiver: “Thanks. Yes, it was good. What did you like about it in particular?” This is different from a passive response that may have been: "It was no effort" or "It was just a standard recipe"  NEGATIVE INQUIRY The opposite of positive inquiry is negative inquiry. Negative inquiry is a way to respond to more negative exchanges such as receiving criticism.

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Dealing with criticism can be difficult, remember that any criticism received is just somebody's opinion. Negative inquiry is used to find out more about critical comments and is a good alternative to more aggressive or angry responses to criticism. Example: Sender: “That meal was practically inedible, I can't remember the last time I ate something so awful” Receiver: “It wasn't the best, exactly what didn’t you like about it?” This is different from an aggressive response that may have been: "How dare you, I spent all afternoon preparing that meal" or "Well that's the last time I cook for you"  “I” STATEMENTS This can be used to voice one’s feelings and wishes from a personal position without expressing a judgment about the other person or blaming one’s feelings on them. - Describe the behavior “When you do this…” - Express your feelings “I feel…” - Empathize “I understand why you…” - Negotiate a change “I want you to…” - Indicate consequences “If you do/don’t, I will…”  DELICATE ART OF SAYING “NO” WHY IS IT DIFFICULT TO SAY NO?  They may feel hurt or rejected  They may not like me anymore  They may never ask again  They would say “yes” to me (and so I will feel guilty if I refuse them)  I feel sorry for them - When saying no, be direct, concise and to the point - Offer reasons for refusal, but don’t get carried away with numerous excuses - Make answer short and don’t give long explanation - Be honest direct and firm - Remember you are saying “no” to that particular request not rejecting the person.

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- If the request takes you unawares or you have not sufficient time to think when asked, you can always say, “I will let you know” in order to give yourself time to think about what you want to say. - Take responsibility for saying no- do not blame other person for asking you. - Ask for more information if you need it in order to decide whether you want to say “yes” or “no”. WHY IS IT DIFFICULT TO SAY YES?  I don’t deserve it  They might not really mean it  I am not really sure that is what I want  I don’t have enough information  DESO TECHNIQUE DESO or Describe, Express, Specify and Outcome script. These four steps can be used when learning to make an assertive request. DESCRIBE – before making a request define the situation. Helpful description- Assertive person: “It’s been a long time since we went out for dinner together.” Unhelpful description- Passive/Aggressive: “Why don’t you ever take me out to dinner anymore?” EXPRESS Assertive: “I miss you…” Passive/Aggressive: “You don’t love me anymore.” SPECIFY – indicate what you would like to happen Assertive: “I would like to go out on a Sunday.” Passive/Aggressive: “I don’t suppose you’re free on Saturday, either…” OUTCOME – describe the outcome you want to achieve if the other persons went along with your requests. Assertive: “It would be a great chance for us to catch up and spend some time together.” Passive/Aggressive: “Like always, you’re letting me down.”

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RISKS OF USING ASSERTIVE TRAINING There are minimal risks associated with assertiveness training. Personal relationships may be affected if those around the participant have difficulty accepting the changes in their friend or family member. This risk, however, is no greater than that associated with any other life change. Another potential risk is that of overcompensating in the early stages of training by being too aggressive. With appropriate feedback, participants can usually learn to modify and improve their responses. People who are very shy or self-conscious, or who were harshly treated as children, may also experience anxiety during the training as they work toward speaking up and otherwise changing their behaviors. The anxiety may be uncomfortable, but should decrease as the person becomes more comfortable with the techniques and receives encouragement from others in the program. The major problem for assertion training involves negative evaluations of assertive people by others. Confusion between assertion and aggression. Problem involves transfer of training, the difficulty experienced by trainees in generalizing assertive from the training context to real-life situations. Finally some of the difficulties in applying assertion training outside the training context may be due to intuitive training procedures that are inadequately based in research. Here are some helpful and assertive thoughts to challenge any unhelpful thoughts you may have. Remember you can also use Thought Diaries and Behavioral Experiments to help you come up with more helpful and assertive thoughts. • If there is something wrong with what I’ve done it doesn’t mean anything about me as a person. I need to separate the behavior from me. • What can I learn from this criticism? Most criticism is probably based, at least in part, on some truths. Criticism may appear negative. But, through criticism we have the opportunity to learn and improve from their suggestions. Always ask yourself “What can I learn?” • I have the right to let someone know if their behavior has hurt, irritated or upset me. • Giving direct feedback can be loving and helpful. See if you can think of any other assertive thoughts about being criticized. If you identified your own unhelpful thoughts see if you can identify more helpful thoughts to challenge these.

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______There are also skills to learn when giving criticism so that the person is more receptive to what you are saying. You have a right to request a change in someone’s behavior if it hurts, upsets or irritates you in some way. Remember that requesting change doesn’t mean that the person will change. However, if you push your resentment down and don’t express it, it could cause further problems with the relationship. Giving direct feedback to others about their behavior can be both loving and helpful. This feedback can be negative or positive. It shows you value the other person and your relationship with them. Try and follow the guidelines below when giving constructive criticism. 1. Time and place. Make sure you choose a good time and place. If you are giving constructive criticism about something that has led to you having a strong emotional reaction wait until you are away from the situation that is bothering you and have calmed down before criticizing. Don’t wait until the next time the situation occurs to confront the behavior. 2. Describe the behavior you are criticizing rather than labelling the person. For example: “You made a mistake in the report” rather than: “What are you, an idiot?” 3. Describe your feelings (using “I” statements) without blaming the other person. For example: “I feel angry when...” rather than: “You make me angry”. 4. Ask for a specific change. If you just make a complaint without giving alternative suggestions you don’t give the person any help in knowing how to change the behavior. For example rather than saying: “I can’t stand your loud music” you might say: “I find the loud music really disturbing could you please turn it down after 8.00pm?” 5. Specify both the positive consequences if the person does meet your request for change and negative consequences if they don’t make the changes. 6. Be realistic in the changes you are suggesting and the consequences if they do not. Do not make empty threats. For example you wouldn’t say: “I will kill you if you don’t turn the music down”. 7. Ask the other person how they feel about what you have just said. Being assertive is about having an equal interaction. Be careful this doesn’t end us as an exchange of criticisms. 8. Try

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and end on a positive note. If appropriate add a positive statement of your feelings towards the other person. ACTUAL PRACTICE OF ASSERTIVE TRAINING WORKSHOPS:  James* had a boss who frequently undermined him and showed him no respect, whom he struggled to deal with. After attending an assertiveness workshop, he learned he did have the right and the technique to assertively say No to his boss at key times at work.  Elly* came from a culture where it was considered impolite to refuse your family in any way. However certain members of her family frequently invaded her space and her rights on one too many occasions and left her on the edge of a breakdown. Attending the workshop helped her to understand that there were particular times when she did have the right to challenge their authority, especially when it was threatening her own mental health. She learned how to stand up to some of their more extreme demands. ASSERTIVENESS COACHING:  Roger* was finding the relationship with his grown-up student daughter increasingly fraught since his divorce and marriage to his second wife: “She was trying to manipulate me with guilt over the divorce and demanding money to prove I loved her enough”. Through assertiveness coaching he gained a better understanding of the situation, the techniques and confidence to set appropriate limits with her, and ultimately established a better relationship with her.  Reema* worked as a P/A for a highly successful executive in a multinational company. She was compensated well but as a result had been putting up with her boss’s overbearing attitude and controlling behavior at work more than she should have done. She had always found it difficult to stand up to him because she was afraid of losing her job. Assertiveness coaching helped her consolidate the belief that despite his being her boss, she did have the right to ask for and make clear what she wanted, and could do so without appearing to be unreasonable. With this understanding clear in her mind, she was able to take back some control within the relationship, assert what she needed, thus considerably reducing her stress.  Fiona* was the only female in a male-dominated senior management team but had a comfortable working relationship with her boss. However she felt that another male

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colleague always appeared to be undermining her, making patronizing comments and seizing any opportunity to show her up. Through assertiveness coaching she began to appreciate the stress this man was under in terms of his own performance and how he could have been fearful of the position she held. She also began to realise that some of her own behavior was actually passive-aggressive and how that might be perceived by someone in his position. This realization lead her to be more direct in her communication with him and she found in response that he became more respectful in his treatment of her and their working relationship improved significantly.

CASE STUDIES Case Study #1: Make promises and keep them Katie Torpey is a filmmaker and screenwriter. Assertive executives and insistent dealmakers dominate the industry she works in. Katie was successful, making several movies and television episodes, but she often held back in meetings, rarely saying what was on her mind. Instead she said what she thought others wanted to hear. “I was a people pleaser. I didn’t want to piss anyone off or hurt anyone’s feelings,” she says. When Katie pitched work to producers they often lowballed her. “I was getting work, but I was not getting what I was worth.” She blames no one but herself. “I would take what they offered because I was afraid to demand my asking price,” she says. She was worried the project would fall through or they’d find another director. It became clear to Katie that this was hindering her career. To change, she made a promise to herself: if she left a situation without saying what she really wanted, she would have to remedy it within 24 hours. For example, when she walked away from a meeting without telling her boss that a product wasn’t actually ready, she forced herself to contact him within 24 hours to fess up. This practice paid off. After cleaning up several of her messes, she realized it was much easier to be assertive from the outset. “Living a life where you speak what you think and feel is so much more freeing than holding everything in,” she says. This has changed her career for the better. “People respect me. I still have the same abilities but I now have more confidence. People know that I won’t take a job unless my heart’s in it and I’m paid well,” she says. And if producers ask her to take a lower price, she stands up for herself, saying, “I will do an excellent job for you, but you have to pay me my asking price.”

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Case Study #2: Put yourself out there Jigar Zander was working as an attorney at a law firm, and hated his job so he hired a personal coach to help him find a new profession. He soon, however, realized that the problem wasn’t his field; it was his firm. His coach encouraged him to build his network and secure enough clients to quit his job and start his own law practice. But Jigar was shy and uncomfortable reaching out to people he didn’t know. “I was someone who really held back,” he says. So Jigar started small. He made a commitment to talk about his budding law practice with one or two people each day. This proved to be harder than he thought. “I didn’t want my current employer to find out, so I had to be especially careful,” he says. And he struggled at the networking events he attended three or four times a week. But he didn’t want to fall down on his pledge so he soon found himself talking to strangers on the subway or in a restaurant. “I once talked to a doctor who was an entrepreneur himself and he gave me some great advice,” he says. “I had some amazing conversations.” This all gave him the confidence he needed to leave the firm. “When you’re not assertive, you settle for things and I had a high tolerance for being in places where I was unhappy,” he says. Now he feels like a very different person. “Anyone who knows me now is shocked to find out that I was shy. But it’s not always easy. I still have to remind myself to get out there,” he says.

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AVERSION

THERAPY

ANDRADE, KAY CELINE

BORRERO, DAISY

CAGOMOC, JAYVIE

GARCIA, PRINCESS GRACE

SOUSA, NICOLEI KATRINA

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AVERSION THERAPY As with other behavior therapies, aversion therapy is a treatment grounded in learning theory—one of its basic principles being that all behavior is learned and that undesirable behaviors can be unlearned under the right circumstances. Aversion therapy is an application of the branch of learning theory called classical conditioning. Within this model of learning, an undesirable behavior, such as a deviant sexual act, is matched with an unpleasant (aversive) stimulus. The unpleasant feelings or sensations become associated with that behavior, and the behavior will decrease in frequency or stop altogether. A conditioned aversion is a learned dislike or negative emotional response to some stimulus (Psychology: A Modular Approach to Mind and Behavior). Aversion therapy differs from those types of behavior therapy based on principles of operant conditioning. In operant therapy, the aversive stimulus, usually called punishment, is presented after the behavior rather than together with it. This is rather different to the preceding therapies because aversion therapy attempts to condition an aversion to a stimulus event which the individual is inappropriately attracted. (Complete Psychology, 2014)

CLASSICAL CONDITIONING Classical conditioning occurs when a conditioned stimulus is paired with an unconditioned stimulus. Usually, the conditioned stimulus (CS) is a neutral stimulus (e.g., the sound of a tuning fork), the unconditioned stimulus (US) is biologically potent (e.g., the taste of food) and the unconditioned response (UR) to the unconditioned stimulus is an unlearned reflex response (e.g., salivation). After pairing is repeated (some learning may occur already after only one pairing), the organism exhibits a conditioned response (CR) to the conditioned stimulus when the conditioned stimulus is presented alone. The conditioned response is usually similar to the unconditioned response (see below), but unlike the unconditioned response, it must be acquired through experience and is relatively impermanent.

(UCS) Emetic Drug Vomiting (UCR)

(NS) Alcohol

+ (UCS) Emetic Drug Vomiting (UCR)

(CS) Alcohol Vomiting (CR)

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USES  Aversion therapy can be used with alcoholics.  Alcohol is paired with an emetic drug (a drug which causes nausea and vomiting).  Over time the alcoholic associates alcohol with being sick and does not want to drink alcohol anymore.  Other drinks such as soft drinks are given without the drug so that the person is not conditioned to feel sick to all drinks.  Aversion therapy can be used with paedophiles.  Paedophiles can give themselves a self-administered electric shock every time they look at a child or a picture of a child.  Smoking  Gambling  Violence or anger issues IN ADDICTIONS The major use of aversion therapy is currently for the treatment of addiction to alcohol and other drugs. This form of treatment has been in continuous operation since 1932. The treatment is discussed in the Principles of Addiction Medicine, Chapter 8, published by the American Society of Addiction Medicine in 2003. Aversion therapy is also used in the self-help community to treat minor behavioral issues with the aid of an elastic band, the user or patient would snap the elastic band on his/her wrist while an undesirable thought/behavior presents itself. The results of Antabuse combined with behavioral marital therapy for treating alcoholism was popular and well-regarded in the 80s and 90s, though the results were mainly ascribed to the behavioral therapy provided. Traditional aversion therapy, which employed either chemical aversion or electrical aversion has now, since 1967, typically been replaced by aversion in the imagination, a technique which is known as covert sensitization. Kraft & Kraft assessed the value of covert sensitization in six case studies—a fingernail biter, a cannabis smoker, an obese lady, a cigarette smoker, an individual with a chocolate addiction, and an alcoholic. The study found that covert sensitization was effective in all six individual cases. All the participants in the study eliminated their undesirable behavior and this

119 | P a g e effect held in a longitudinal follow-up. I n contrast, Okulitch and Marlatt found that a cohort of 30 alcoholics and 30 social drinkers subjected to aversive therapy via electric shock did worse than an untreated control group at the 15 month follow up period. TWO TYPES OF AVERSION THERAPY  OVERT SENSITIZATION It is a type of aversion therapy that produces unpleasant consequences for undesirable behavior. For example if an individual consumes alcohol while on Antabuse therapy, symptoms of severe nausea, vomiting, dyspnoea, palpitation and headache. Instead of euphoria feeling normally experienced from the alcohol, the individual receives a punishment that is intended to extinguish the unacceptable behavior.  COVERT SENSITIZATION It relies on the individual produce symptoms rather than on medication. The technique is under clients control and can be used whenever and whenever it is required. The individual learns through mental imagery to visualize nauseating scenes and even to induce a mild feeling of nausea. It is most effective when paired with relaxation exercises that are performed instead of the undesirable behavior. PROCEDURES AND EXAMPLES  CASE EXAMPLE #1 : What would a treatment protocol look like for a relatively well-adjusted patient specifically requesting aversion therapy on an outpatient basis to reduce or eliminate problem gambling behavior? The therapist begins by asking the patient to keep a behavioral diary. The therapist uses this information both to understand the seriousness of the problem and as a baseline to measure whether or not change is occurring during the course of treatment. Because electric shock is easy to use and is acceptable to the patient, the therapist chooses it as the aversive stimulus. The patient has no medical problems that would preclude the use of this stimulus. He or she fully understands the procedure and consents to treatment. The treatment is conducted on an outpatient basis with the therapist administering the shocks on a daily basis for the first week in the office, gradually tapering to once a week over a month. Sessions last about an hour. A small, battery-powered electrical device is used. The electrodes are placed on the patient's wrist. The patient is asked to preselect a level of shock that is uncomfortable but not too painful. This shock is then briefly and repeatedly paired with stimuli (such as slides of the race track, betting sheets, written descriptions

120 | P a g e of gambling) that the patient has chosen for their association with his or her problem gambling. The timing, duration, and intensity of the shock are carefully planned by the therapist to assure that the patient experiences a discomfort level that is aversive and that the conditioning effect occurs. After the first or second week of treatment, the patient is provided with a portable shocking device to use on a daily basis for practice at home to supplement office treatment. The therapist calls the patient at home to monitor compliance as well as progress between office sessions. The conditioning effect occurs; the discomfort from the electric shock becomes associated with the gambling behavior, the patient reports loss of desire and stops gambling. Booster sessions in the therapist's office are scheduled once a month for six months. A minor relapse is dealt with through an extra office visit. The patient is asked to administer his or her own booster sessions on an intermittent basis at home and to call in the future if needed.  Case example #2 : What would the treatment protocol look like for an alcohol-dependent patient with an extensive treatment history including multiple prior life-threatening relapses? The patient who is motivated to change but has not experienced success in the past may be considered a candidate for aversion therapy as part of a comprehensive inpatient treatment program. The treating therapist assesses the extent of the patient's problem, including drinking history, prior treatments and response, physical health, and present drinking pattern. Patients who are physically addicted to alcohol and currently drinking may experience severe withdrawal symptoms and may have to undergo detoxification before treatment starts. When the detoxification is completed, the patient is assessed for aversion therapy. The therapist's first decision is what type of noxious stimulus to use, whether electrical stimulation or an emetic (a medication that causes vomiting). In this case, when the patient's problem is considered treatment-resistant and a medically-monitored inpatient setting is available, an emetic may be preferable to electric shock as the aversive stimulus. There is some research evidence that chemical aversants lead to at least short-term avoidance of alcohol in some patients. An emetic is "biologically appropriate" for the patient in that it affects him or her in the same organ systems that excessive alcohol use does. The procedure is fully explained to the patient, who gives informed consent.

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During a ten-day hospitalization, the patient may receive aversion therapy sessions every other day as part of a comprehensive treatment program. During the treatment sessions, the patient is given an emetic intravenously under close medical supervision and with the help of staff assistants who understand and accept the theory. Within a few minutes following administration, the patient reports beginning to feel sick. To associate the emetic with the sight, smell and taste of alcohol, the patient is then asked to take a sip of the alcoholic beverage of his or her choice without swallowing. This process is repeated over a period of 30–60 minutes as nausea and vomiting occur. As the unpleasant effects of the emetic drug become associated with the alcoholic beverage, the patient begins to lose desire for drinking. Aversion therapy in an inpatient program is usually embedded within a comprehensive treatment curriculum that includes group therapy and such support groups as AA, couples/family counseling, social skills training , stress management, instruction in problem solving and conflict resolution, health education and other behavioral change and maintenance strategies. Discharge planning includes an intensive outpatient program that may include aversive booster sessions administered over a period of six to twelve months, or over the patient's lifetime.  Case example #3: A follow-up study was conducted at approximately one year post-treatment of a group of clients treated at a commercial stop smoking program (Schick Smoking Centers). A sample of 327 clients was contacted from the total number of 832 clients treated in the year 1985. These clients were selected in a random systematic fashion and were contacted by telephone using a structured interview. The treatment program employed five days of aversive counter-conditioning (faradic and “quick Puff”) for various smoking behaviors. It also included an educational and counseling component during the initial counter-conditioning phase and a six week support phase with weekly support groups and one counter-conditioning reinforcement treatment in the second week. The clients were contacted a mean of 13.7 months after completion of treatment. The majority (55.7%) of the clients were male. Fifty-two percent of all clients achieved their goal of total abstinence from cigarettes since “graduation” from the program. The factor most predictive of success or failure was whether or not the client returned to a home containing a smoker. Of those returning to a non-smoking home, 61.4% of the men and 60.2% of the women were successful. Of those who returned to a smoking household, 70.2% returned to smoking. This study demonstrates that the treatment, process appears to be free of complications and is associated with successful

122 | P a g e outcomes in the majority of clients. Further improvement in outcome might result from simultaneous Treatment of all household smokers. Briefly, the program consists of three phases termed “countdown phase,” “counter-conditioning phase,” and “support phase.”

TREATMENT PREPARATION, AFTERCARE, RISKS, NORMAL RESULTS AND ABNORMAL RESULTS

PREPARATION Depending upon his/her customary practice, a therapist administering aversion therapy may establish a behavioral contract defining the treatment, objectives, expected outcome, and what will be required of the patient. The patient may be asked to keep a behavioral diary to establish a baseline measure of the behavior targeted for change. The patient undergoing this type of treatment should have enough information beforehand to give full consent for the procedure. Patients with medical problems or who are otherwise vulnerable to potentially damaging physical side effects of the more intense aversive stimuli should consult their primary care doctor first. AFTERCARE Patients completing the initial phase of aversion therapy are often asked by the therapist to return periodically over the following six to twelve months or longer for booster sessions to prevent relapse. RISKS Patients with cardiac, pulmonary, or gastrointestinal problems may experience a worsening of their symptoms, depending upon the characteristics and strength of the aversive stimuli. Some therapists have reported that patients undergoing aversion therapy, especially treatment that uses powerful chemical or pharmacological aversive stimuli, have become negative and aggressive. NORMAL RESULTS Depending upon the objectives established at the beginning of treatment, patients successfully completing a course of aversion therapy can expect to see a reduction or cessation of the undesirable behavior. If they practice relapse prevention techniques, they can expect to maintain the improvement.

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ABNORMAL RESULTS Some clinicians have reported that patients undergoing aversive treatment utilizing electric shocks have experienced increased anxiety and anxiety-related symptoms that may interfere with the conditioning process as well as lead to decreased acceptance of the treatment. As indicated above, a few clinicians have reported a worrisome increase in hostility among patients receiving aversion therapy, especially those undergoing treatment using chemical aversants. Although aversion therapy has some adherents, lack of rigorous outcome studies demonstrating its effectiveness, along with the ethical objections mentioned earlier, have generated numerous opponents among clinicians as well as the general public. These opponents point out that less intrusive alternative treatments, such as covert sensitization, are available. PRECAUTIONS A variety of aversive stimuli have been used as part of this approach, including chemical and pharmacological stimulants as well as electric shock. Foul odors, nasty tastes, and loud noises have been employed as aversive stimuli somewhat less frequently. The chemicals and medications generate very unpleasant and often physically painful responses. This type of aversive stimulation may be risky for persons with heart or lung problems because of the possibility of making the medical conditions worse. Patients with these conditions should be cleared by their doctor first. Often, however, the more intrusive aversive stimuli are administered within inpatient settings under medical supervision. An uncomfortable but safe level of electric (sometimes called faradic) shock is often preferred to chemical and pharmacological aversants because of the risks that these substances involve. In addition to the health precautions mentioned above, there are ethical concerns surrounding the use of aversive stimuli. There are additional problems with patient acceptance and negative public perception of procedures utilizing aversants. Aversion treatment that makes use of powerful substances customarily (and intentionally) causes extremely uncomfortable consequences, including nausea and vomiting. These effects may lead to poor compliance with treatment, high dropout rates, potentially hostile and aggressive patients, and public relations problems. Social critics and members of the general public alike often consider this type of treatment punitive and morally objectionable. Although the scenes were exaggerated, the disturbing parts of the Stanley Kubrick film A Clockwork Orange that depicted the use of aversion

124 | P a g e therapy to reform the criminal protagonist, provide a powerful example of society's perception of this treatment. Parents and other advocates for the mentally retarded and developmentally disabled have been particularly vocal in their condemnation of behavior therapy that uses aversive procedures in general. Aversive procedures are used within a variety of behavior modification strategies and that term is sometimes confused with the more specific technique of aversion therapy. Aversive procedures are usually based on an operant conditioning model that involves punishment. Advocates for special patient populations believe that all aversive procedures are punitive, coercive, and use unnecessary amounts of control and manipulation to modify behavior. They call for therapists to stop using aversive stimuli, noting that positive, non-aversive, behavioral-change strategies are available. These strategies are at least as, if not more, effective than aversive procedures. One of the major criticisms of aversion therapy is that it lacks rigorous scientific evidence demonstrating its effectiveness. Ethical issues over the use of punishments in therapy are also a major point of concern. Practitioners have found that in some cases, aversion therapy can increase anxiety that actually interferes with the treatment process. In other instances, some patients have also experienced anger and hostility during therapy. In some instances, serious injuries and even fatalities have occurred during the course of aversion therapy. Historically, when homosexuality was considered a mental illness, gay individuals were subjected to forms of aversion therapy to try to alter their sexual preferences and behaviors. Depression, anxiety, and suicide have been linked to some cases of aversion therapy. The use of aversion therapy to "treat" homosexuality was declared dangerous by the American Psychological Association (APA) in 1994. In 2006, ethical codes were established by both the APA and the American Psychiatric Association. Today, using aversion therapy in an attempt alter homosexual behavior is considered a violation of professional conduct. CRITICAL EVALUATION Apart from ethical considerations, there are two other issues relating to the use of aversion therapy.

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First, it is not very clear how the shocks or drugs have their effects. It may be that they make the previously attractive stimulus (e.g. sight/smell/taste of alcohol) aversive, or it may be that they inhibit (i.e. reduce) the behavior of drinking. Second, there are doubts about the long-term effectiveness of aversion therapy. It can have dramatic effects in the therapist’s office. However, it is often much less effective in the outside world, where no nausea-inducing drug has been taken and it is obvious that no shocks will be given. Also, relapse rates are very high – the success of the therapy depends of whether the patient can avoid the stimulus they have been conditioned against.

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POSITIVE

REINFORCEMENT

BALAONG, MARIFLOR JARINA, JAYMAR

MEJARITO, POLYGEM VILLAR, APRIL GRACE

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HISTORY Operant conditioning was coined by behaviorist B.F. Skinner. As a behaviorist, Skinner believed that it was not really necessary to look at internal thoughts and motivations in order to explain behavior. Instead, he suggested, one should look only at the external, observable causes of human behavior. Through the first part of the 20th-century, behaviorism had become a major force within psychology. However, it was the ideas of John B. Watson that dominated early on. Watson focused on the principles of classical conditioning, once famously suggesting that he could take any person regardless of their background and train them to be anything he chose. Where the early behaviorists had focused their interests on associative learning, Skinner was more interested in how the consequences of people's actions influenced their behavior. Skinner used the term operant to refer to any "active behavior that operates upon the environment to generate consequences" (1953). In other words, Skinner's theory explained how a person acquires the range of learned behaviors he/she exhibits each and every day. His theory was heavily influenced by the work of psychologist Edward Thorndike, who had proposed what he called the Law of Effect. According to this principle, actions that are followed by desirable outcomes are more likely to be repeated while those followed by undesirable outcomes are less likely to be repeated. Skinner distinguished between two different types of behaviors: respondent behaviors and operant behaviors. Respondent behaviors are those that occur automatically and reflexively, such as pulling your hand back from a hot stove or jerking your leg when the doctor taps on your knee. You don't have to learn these behaviors, they simply occur automatically and involuntarily. Operant behavior, on the other hand, are those under our conscious control. Some may occur spontaneously and others purposely, but it is the consequences of these actions that then influence whether or not they occur again in the future. People’s actions on the environment and the consequences of those action make up an important part of the learning process. While classical conditioning could account for respondent behaviors, Skinner realized that it could not account for a great deal of learning. Instead, Skinner suggested that operant conditioning held far more importance. Skinner had often invented many different devices during his boyhood and he put these skills to work during his studies on operant conditioning. He created a device known as an operant

128 | P a g e conditioning chamber, most often referred to today as a Skinner box. The chamber was essentially a box that could hold a small animal such as a rat or pigeon. The box also contained a bar or key that the animal could press in order to receive a reward. In order to track responses, Skinner also developed a device known as a cumulative recorder. The device recorded responses as a upward movement of a line so that response rates could be read by looking at the slope of the line. REINFORCEMENT - a term used in operant conditioning to refer to anything that increases the likelihood that a response will occur. *Note: Reinforcement is defined by the effect that it has on behavior - it increases or strengthens the behavior. For example: Reinforcement might involve presenting praise (the reinforcer) immediately after a child puts away her toys (the response). By reinforcing the desired behavior with praise, the girl will be more likely to perform the same actions again. 2 MAJOR CATEGORIES OF REINFORCEMENT  PRIMARY REINFORCEMENT, sometimes referred to as unconditional reinforcement - occurs naturally and does not require learning in order to work. Primary reinforcers often have an evolutionary basis in that they aid in the survival of the species. Examples of primary reinforcers include food, air, sleep, water and sex. Genetics and experience may also play a role in how reinforcing such things are. For example, while one person might find a certain type of food very rewarding, another person may not like that food at all.  SECONDARY REINFORCEMENT, also known as conditioned reinforcement - involves stimuli that have become rewarding by being paired with another reinforcing stimulus. For example, when training a dog, praise and treats might be used as primary reinforcers. The sound of a clicker can be associated with the praise and treats until the sound of the clicker itself begins to work as a secondary reinforcer. In operant conditioning, there are two different types of reinforcement: POSITIVE REINFORCEMENT - involves the addition of something to increase a response, such as giving a bit of candy to a child after she cleans up her room. NEGATIVE REINFORCEMENT - involves removing something in order to increase a response, such as canceling a quiz if students turn in all of their homework for the week. By removing the

129 | P a g e aversive stimulus (the quiz), the teacher hopes to increase the occurrence of the desired behavior (completing all homework). POSITIVE REINFORCEMENT Positive reinforcement involves the addition of a reinforcing stimulus following a behavior that makes it more likely that the behavior will occur again in the future. When a favorable outcome, event, or reward occurs after an action, that particular response or behavior will be strengthened. One of the easiest ways to remember positive reinforcement is to think of it as something being added. Positive reinforcement occurs when a desirable event or stimulus is presented as a consequence of a behavior and the behavior increases. A positive reinforcer is a stimulus event for which the animal will work in order to acquire it. DIFFERENT TYPES OF POSITIVE REINFORCERS There are many different types of reinforcers that can be used to increase behaviors, but it is important to note that the type of reinforcer used depends upon the individual and the situation.  Natural reinforcers - are those that occur directly as a result of the behavior. For example, a girl studies hard, pays attention in class, and does her homework. As a result, she gets excellent grades.  Token reinforcers - are points or tokens that are awarded for performing certain actions. These tokens can then be exchanged for something of value. * Social reinforcers involve expressing approval of a behavior, such as a teacher, parent, or employer saying or writing "Good job" or "Excellent work."  Tangible reinforcers involve the presentation of an actual, physical reward such as candy, treats, toys, money, and other desired objects. While these types of rewards can be powerfully motivating, they should be used sparingly and with caution. WHEN IS POSITIVE REINFORCEMENT MOST EFFECTIVE? When used correctly, positive reinforcement can be very effective. According to a behavioral guidelines checklist published by Utah State University, positive reinforcement is most effective when it occurs immediately after the behavior. The guidelines also recommend the reinforcement should be presented enthusiastically and should occur frequently.

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The shorter the amount of time between a behavior and the presentation of positive reinforcement, the stronger the connection will be. If a long period of time elapses between the behavior and the reinforcement, the weaker the connection will be. It also becomes more likely that an intervening behavior might accidentally be reinforced. In addition to the type of reinforcement used, the presentation schedule can also play a role in the strength of the response. NEGATIVE REINFORCEMENT Negative reinforcement is a term described by B. F. Skinner in his theory of operant conditioning. In negative reinforcement, a response or behavior is strengthened by stopping, removing, or avoiding a negative outcome or aversive stimulus. Aversive stimuli tend to involve some type of discomfort, either physical or psychological. Behaviors are negatively reinforced when they allow you to escape from aversive stimuli that are already present or allow you to completely avoid the aversive stimuli before they happen. One of the best ways to remember negative reinforcement is to think of it as something being subtracted from the situation. Negative reinforcement occurs when the rate of a behavior increases because an aversive event or stimulus is removed or prevented from happening. A negative reinforcer is a stimulus event for which an organism will work in order to terminate, to escape from, to postpone its occurrence. NEGATIVE REINFORCEMENT VERSUS PUNISHMENT One mistake that people often make is confusing negative reinforcement with punishment. Remember, however, that negative reinforcement involves the removal of a negative condition in order to strengthen a behavior. Punishment, on the other hand, involves either presenting or taking away a stimulus in order to weaken a behavior. According to Wolfgang (2001), negative reinforcement should be used sparingly in classroom settings, while positive reinforcement should be emphasized. While negative reinforcement can produce immediate results, he suggests that it is best suited for short-term use. The type of reinforcement used is important, but the frequency and schedule used also plays a major role in the strength of the response.

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Punishment is a process by which a consequence immediately follows a behavior which decreases the future frequency of that behavior. Like reinforcement, a stimulus can be added or removed. 2 TYPES OF PUNISHMENT:  POSITIVE PUNISHMENT – works by presenting a negative consequence after an indesired behavior is exhibited, making the behavior less likely to happen in the future.  NEGATIVE PUNISHMENT – happens when a certain desired stimulus is removed after a particular undesired behavior is exhibited, resulting in the behavior happening less often in the future. THE STRENGTH OF THE RESPONSE How and when reinforcement is delivered can affect the overall strength of a response. This strength is measured by the persistence, frequency, duration and accuracy of the response after reinforcement is halted. In situations when the presentation of reinforcement is controlled, such as during training, the timing of when a reinforcer is presented can be manipulated. During the early stages of learning, continuous reinforcement is often used. This schedule involves reinforcing a response each and every time it occurs. SCHEDULES OF REINFORCEMENT Schedules of reinforcement are important components of the learning process. When and how often we reinforce a behavior can have a dramatic impact on the strength and rate of the response. 1. CONTINUOUS REINFORCEMENT In continuous reinforcement, the desired behavior is reinforced every single time it occurs. This schedule is best used during the initial stages of learning in order to create a strong association between the behavior and the response. Once the response if firmly attached, reinforcement is usually switched to a partial reinforcement schedule. 2. PARTIAL REINFORCEMENT In partial reinforcement, the response is reinforced only part of the time. Learned behaviors are acquired more slowly with partial reinforcement, but the response is more resistant to extinction. There are four schedules of partial reinforcement:

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 FIXED-RATIO SCHEDULES - are those where a response is reinforced only after a specified number of responses. This schedule produces a high, steady rate of responding with only a brief pause after the delivery of the reinforcer. An example of a fixed-ratio schedule would be delivering a food pellet to a rat after it presses a bar five times.  VARIABLE-RATIO SCHEDULES - occur when a response is reinforced after an unpredictable number of responses. This schedule creates a high steady rate of responding. Gambling and lottery games are good examples of a reward based on a variable ratio schedule. In a lab setting, this might involved delivering food pellets to a rat after one bar press, again after four bar presses, and a third pellet after two bar presses.  FIXED-INTERVAL SCHEDULES - are those where the first response is rewarded only after a specified amount of time has elapsed. This schedule causes high amounts of responding near the end of the interval, but much slower responding immediately after the delivery of the reinforcer. An example of this in a lab setting would be reinforcing a rat with a lab pellet for the first bar press after a 30 second interval has elapsed.  VARIABLE-INTERVAL SCHEDULES - occur when a response is rewarded after an unpredictable amount of time has passed. This schedule produces a slow, steady rate of response. An example of this would be delivering a food pellet to a rat after the first bar press following a one minute interval, another pellet for the first response following a five minute interval, and a third food pellet for the first response following a three minute interval. APPLICATION OF POSITIVE AND NEGATIVE REINFORCEMENT POSITIVE REINFORCEMENT: Positive reinforcement works by presenting a motivating/reinforcing stimulus to the person after the desired behavior is exhibited, making the behavior more likely to happen in the future. The following are some examples of positive reinforcement: o A mother gives her son praise (positive stimulus) for doing homework (behavior). o A father gives his daughter candy (positive stimulus) for cleaning up toys (behavior). o Whenever a rat presses a button, it gets a treat. If the rat starts pressing the button more often, the treat serves to positively reinforce this behavior.

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o A father gives candy to his daughter when she picks up her toys. If the frequency of picking up the toys increases, the candy is a positive reinforcer (to reinforce the behavior of cleaning up). o A company enacts a rewards program in which employees earn prizes dependent on the number of items sold. The prizes the employees receive are the positive reinforcement as they increase sales. o After you execute a turn during a skiing lesson, your instructor shouts out, "Great job!" o At work, you exceed this month's sales quota so your boss gives you a bonus. o For your psychology class, you watch a video about the human brain and write a paper about what you learned. Your instructor gives you 20 extra credit points for your work. NEGATIVE REINFORCEMENT: Negative reinforcement occurs when a certain stimulus (usually an aversive stimulus) is removed after a particular behavior is exhibited. The likelihood of the particular behavior occurring again in the future is increased because of removing/avoiding the negative consequence. The following are some examples of negative reinforcement: o Bob does the dishes (behavior) in order to avoid his mother nagging (negative stimulus). o Natalie can get up from the dinner table (negative stimulus) when she eats 2 bites of her broccoli (behavior). o A child cleans his or her room, and this behavior is followed by the parent stopping "nagging" or asking the child repeatedly to do so. Here, the nagging serves to negatively reinforce the behavior of cleaning because the child wants to remove that aversive stimulus of nagging. o A person puts ointment on a bug bite to soothe an itch. If the ointment works, the person will likely increase the usage of the ointment because it resulted in removing the itch, which is the negative reinforcer. o A company has a policy that if an employee completes their assigned work by Friday, they can have Saturday off. Working Saturday is the negative reinforcer, the employee’s productivity will be increased as they avoid experiencing the negative reinforcer. o Before heading out for a day at the beach, you slather on sunscreen (the behavior) in order to avoid getting sunburned (removal of the aversive stimulus).

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o You decide to clean up your mess in the kitchen (the behavior) in order to avoid getting in a fight with your roommate (removal of the aversive stimulus). o On Monday morning, you leave the house early (the behavior) in order to avoid getting stuck in traffic and being late for class (removal of an aversive stimulus). o At dinner time, a child pouts and refuses to each the vegetables on her plate. Her parents quickly take the offending veggies away. Since the behavior (pouting) led to the removal of the aversive stimulus (the veggies). KEYS TO REMEMBER: When thinking about reinforcement, always remember that the end result is to try to increase the behavior, whereas punishment procedures are used to decrease behavior. For positive reinforcement, think of it as adding something positive in order to increase a response. For negative

reinforcement, think of it as taking something negative away in order to increase a response. 1. We reinforce behaviors, not people. 2. We need to be clear about which behavior(s) will receive reinforcement. 3. The most effective reinforcement systems are those that are individualized to the learner 4. Reinforcement is not something someone likes, rather it is simply something which increases the likelihood that the behavior will occur again in the future.

CASE STUDIES CASE # 1 (CREATED BY BUFFY ANN NELSON, LAST MODIFIED BY KARIN L HOUSELL ON SEP 15, 2013) The Broadcast & Media (BM) department of the Olympic Games is one of the most important functions in the Organizing Committee. They are responsible for bringing the Olympics to the World through their ever important and well-known clients. Foreigners, with multiple Games experience, are hired to manage the local hires and share their wealth of knowledge throughout their teams. The Sochi 2014 Broadcast & Media team is comprised of 9 Venue Broadcast Managers (VBM) who are assigned one competition venue each. Jack was hired to manage this team. He is from Canada and this is his 13th Games and his 4th Olympics. Jack has noticed a motivation problem within his team and a lack of overall morale. One problem is that they are continuously late to work. In Russia, the typical work day is 10:00am - 7:00pm. In Games, it is not uncommon to work outside these office hours. Jack has been lenient

135 | P a g e with his team. If he knows someone worked late the night before, he hasn't said anything to them if they come in at 10:15 or 10:30. Now, his team has started to take advantage of this and are not coming in until 11:00 or 12:00. They also take multiple smoke and coffee breaks per day, as well as extended lunches every day. What can he do to motivate them to come in on time again and to increase their productivity? Another problem Jack is having is the team's inability to produce quality work. They also fail to communicate effectively and respectfully with their clients. In order to be successful in Broadcast & Media, it is crucial to build relationships with the clients. The VBMs are not turning in reports, they are missing mandatory meetings, and they are ignoring their clients. How can Jack motivate his team and overcome the cultural differences? He knows that utilizing reinforcement is the right choice; he just needs to devise a plan. APPLYING THE THEORY: There are multiple ways Jack could utilize the tools of reinforcement theory to keep his workers on task, improve their behaviors, and increase productivity. Before Jack can implement any of the reinforcement theories, he will need to engage in a meeting with all staff regarding their normal working hours. He will formally outline that the normal working hours in the office are Monday- Friday, 10:00am-7:00pm. Employees are expected to be at work on time and leave at the appropriate time, every day. If they have a personal matter, or for any other reason are unable to be at work during this time, notification is required prior to the delay. Notifications can be made via text message, email or by phone call. It should also be understood that, as Venue Broadcast Mangers, employee's normal duties will require longer working hours, outside of the “normal working hours”. This point is not to excuse anyone from these extra duties as a VBM. It is to clarify the minimum working hours each person is expected to keep. This meeting will also clarify

136 | P a g e what is expected of each VBM while they are at work. Mandatory meetings are in fact mandatory and it is expected that each employee attend. They will do this without needing to be reminded or told where to be. It is the individual's responsibility to manage his/her schedule. Reports are due on the date requested. No exceptions. Communication with clients is mandatory. Response time for clients will be within 24 hours. Ignoring clients is unacceptable and will not be tolerated. After the meeting, Jack will write a memo detailing everything that was discussed in detail. APPLICATION OF POSITIVE REINFORCEMENT TO THE CASE: Jack has many options when it comes to positive reinforcement. These options are:  Jack will select an employee of the month. This person will display exemplary behaviors including arriving to work on time, attending all mandatory meetings and turning in all required reports. This should help to increase wanted behavior by adding something pleasant.  Each time an employee arrives on time to work or makes a new contact with a client, they will receive a ticket. Jack will hold a raffle each Wednesday. This raffle will include prizes such as bonuses, gift cards, and employee merchandise.  Jack will start rewarding with verbal affirmation. Besides regularly telling them they are doing a great job, he will make random public announcements regarding a job well done. This rewards positive behavior and encourages continued productive behavior.  Parking and traffic is always a concern around the office. Jack can reserve a special area to park for only the employees that arrive to work on time. Once the work day starts, the arm is closed. By rewarding their timely arrival, the annoyance of the constant fight for a parking spot is removed, and people may be more apt to get to work on time. Whatever reward system is instilled at BM, the progress should be monitored to track the effectiveness of the system. What may work to motivate some employees also may not work to motivate all employees. The reward; especially if monetary; needs to be contingent upon adhering to the employee standards. Either the employee obeys the new standards fully and gets the reward or the employee does not obey them fully and in return gets no reward. APPLICATION OF NEGATIVE REINFORCEMENT TO THE CASE: In order to address the issue of the employees not showing up to work on time, Jack has a couple of options:

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 Jack can implement a clock-in/clock-out system. Each time the employee arrives to the office, they clock-in, each time they leave for a break, or at the end of the day, they clock- out. Once their behavior is more reliable, and they are arriving on time and working productively, this system can be removed.  A mandatory Friday night meeting is held every week. Each employee that arrives to work on time every day that week will be excused from the meeting. When addressing the professionalism issues in the workplace, Jack has a couple of options to increase productivity and effectiveness:  Anytime Jack hears from a client that they were not contacted within the 24 hour time frame, he will have a meeting with the VBM and formally document the infraction. Having an infraction on their record will affect their performance evaluation and ultimately their end of Games bonus. If the employees perform the desired behavior, they will not receive these infractions or have the previous ones removed from their record.  "Non-awards." It recognizes the employees who performed the worst. The employee is awarded a trophy that must be displayed. The employee has five days after getting the award to fix the problem and then the trophy will be taken away. If not, they have to display it for all to see until the next month. However, if employees are performing to standards then no one is awarded this embarrassing trophy. APPLICATION OF PUNISHMENT TO THE CASE: In this case, the problem seems to be the lack of discipline and the abuse of time management, among other things, so clear and firm guidelines for undesirable behavior and its consequences should help improve the situation. First and foremost, Jack should hold a meeting with his team and clearly state his expectations as well as explicitly warn them that unproductive behaviors are unacceptable and will be punished. Second, he should list all of the unacceptable behaviors and inform everybody of the corresponding punishments.Furthermore, Jack should administer the discussed punishments in a timely manner and without exceptions. Finally, Jack should track and document all negative occurrences that affect the productivity. It is a helpful legal tool as well as the employee evaluation tool. Specific positive and negative punishments Jack can use:  making the employees stay later if they were tardy;

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 cut out all unnecessary breaks;  if the employees are late too many times, the more severe measures can be used, such as pay cuts, an unpaid day off, or even discontinuing employment;  if the employees are rude to clients, they would have to apologize personally or write a paper detailing why they were wrong and what they can do in the future to avoid offending clients. SUMMARY : The application of the reinforcement theory of motivation is known as organizational behavior modification (OB Mod) (PSU WC, L3, p. 7). OB Mod is based on the work of B.F. Skinner who theorized that an individual's behavior will give insight into their needs. This theory has been used in the workplace to help interpret an individuals needs based on their behavior. Skinner stated that if an employee performed poorly at work, either the employee did not find the work personally. gratifying or the individual was not being appropriately rewarded for their work (Duff, 2013). Organizations have many ways to reinforce behavior such as bonuses, time off, disciplinary actions, and even threat of suspension or termination. Under OB Mod an organization will team reinforcement with constant feedback. Reinforcement can be positive or negative however, Duff (2013) states that positive reinforcement promotes a positive behavior change better than the other methods of negative reinforcement, punishment, and extinction. The most important aspect to remember with OB Mod is that the positive reinforcement is paired with constant feedback. Keeping in mind OB Mod, Jack could still use the example of rewarding his staff for not being tardy as discussed under positive reinforcement. The difference here would be that he would have to pair that reward with feedback. Jack could offer a "lottery drawing" for those with no tardies where an individual would be pulled for a bonus, a nice watch, or maybe a special parking space. Along with this reward he would continually encourage people for coming in on time so that the associates understand that he recognizes their change in behavior. Jack's original method of dealing with his employee's undesired behavior was to use extinction. Jack ignored the unproductive behavior of his employees thinking that, with time, the employees would correct their behavior. This method, unfortunately, did not work for Jack. Ignoring the undesirable behavior just worsened the problem. Jack knew that he would have to

139 | P a g e look beyond extinction in order to correct these undesirable behaviors. He should have realized that using reinforcement would improve the work climate of his team tremendously.

CASE # 2 (CREATED BY BRIAN FRANCIS REDMOND, JUN 24, 2012) Initially, an Altoona, PA branch manager of Sears, Roebuck and Co., held a meeting for all employees of his branch to explain the importance of opening new credit card accounts. He focused only on how the company benefits from store credit, and he expressed that he wanted to be the number one store for credit card applications. Credit card applications went up slightly after the meeting, but soon went down to the normal low. The manager held another meeting for all employees to once again discuss this issue. This time he directed his attention away from the company benefits and focused on the employees. The boss announced a revised job description at this meeting. He developed a new set of questions employees had to ask every customer: “Do you have a Sears credit card with us... Would you like to open a Sears credit card today to save ten dollars off of your purchase?” By offering customers ten dollars off on their current purchase, he thought credit card applications would go up. He began offering all employees an extra two dollars on their pay check for each credit card application. The employees still received two dollars even if the customer was declined credit. In order to receive two dollars per application, the employees had to have five applications per month. Without at least five, the employees would get paid nothing. Every ninety days, the applications would be counted, and the person with the highest amount would be recognized by having his/her picture hung on the bulletin board in the staff lounge; his/her name was announced at the morning meetings, and he/she received a twenty five dollar Sears gift card. On the other hand, if an employee did not receive five applications each month for ninety days, the employee was required to complete training to help raise his/her credit card applications. Employee’s credit card applications were evaluated every ninety days. If in the next ninety days no improvement was made, the employee was suspended for three days. If an employee's credit card applications were below standard for another ninety days, he/she was terminated. Employees were given adequate time and training to improve their credit card applications. The manager was successful at raising the rate of credit card applications once he used reinforcement. Credit card application rates soared, and the store became the number one store for credit card applications in the state of Pennsylvania. The outcomes from using reinforcement were great. The manager was

140 | P a g e happier with all of his employees, and the employees were happy because they were making extra money. RESOLVING THE ISSUE THROUGH REINFORCEMENT THEORY The main issue in this case is that credit card applications were low and the managerial issue was that there was low employee motivation to promote the credit card applications. Store credit cards are important to retailers like Sears. There are over one hundred million active store credit cards in the U.S. (Spurgin 1998, Lee & Kwon 2002). This Sears’ manager wanted his piece of that pie because store credit card programs increase sales (Chakravorti 2000, Lee & Kwon 2002). The manager presented the need for more credit card applications to his employees. The employees first increased the amount of new store credit cards but the increase soon became extinct and new motivations were needed. The manager's issue was how to motivate his employees to bring in more credit card applications. To resolve this issue several aspects of reinforcement theory were used. “Stimuli are the variables that elicit a behavioral response or conditions leading up to the behavior. Responses are the behaviors or activities that are performed. The consequences are the results of behavior.” (Redmond, 2010) In this case, the manager needed to create some external stimuli to encourage the desired response from the employees and customers: more credit card applications being offered and completed. The consequences of this stimulus would hopefully be an increase in credit card applications and satisfied employees. The Law of Effect is an important concept related to the reinforcement theory. “A fundamental principle of reinforcement theory is called the law of effect, which simply states that people engage in behavior that have pleasant outcomes and avoid behavior that has unpleasant outcomes”. (Thorndike, 1913) In this case, customers were offered the ability to save $10 on their purchase which is a positive outcome. Employees were given a monetary reward for every credit application they turned in which is also a positive outcome. The following two methods of delivery from the reinforcement theory were used in this case: 1. POSITIVE REINFORCEMENT Positive Reinforcement is any consequence of behavior that strengthens the probability of the future occurrence of that behavior, given that the reinforcer is available upon demonstration of the desired behavior (Whyte, 113). Management chooses to employ both money and praise as

141 | P a g e reinforcement. According to Whyte, although money is a very common tangible reinforcer of work behavior, much has been said about other tangible and intangible reinforcers, such as verbal praise and social reinforcement from peers (Whyte, 113). At the second employee meeting, the manager offered customers ten dollars off of their purchase for applying to open a Sear’s credit card. In addition, employees were offered $2 additional pay to be added to their paycheck for each application that was filled out. A stipulation was set, that they must have at least 5 applications in per month to qualify for the monetary bonus. To introduce other tangible and intangible forms of praise, the person with the highest amount of credit card applications had his/her picture hung from the bulletin board in the staff lounge, and their name announced at meetings. An additional monetary reward was also given out in the form of a $25 Sears gift card. The positive reinforcement here also was a way to motivate the employees. The manager giving the extra money as a reward, allowed the employees to become eager in wanting to benefit from asking a question, "would you like to sign up for a Sears card today?". Although not every employee was motivated by the reward, the manager then had to implement a punishment to motivate the others that were not trying to get customers signed up for a Sears card. The motivation here was tied to the Need Theory by Maslow "Safety" which allowed for security of their employment with the Altoona, Sears store if they processed the required amount of credit card applications. 2. POSITIVE PUNISHMENT Punishment is the second class of consequences which operates to control behavior. Unlike positive reinforcement, punishment is a change in the environment which weakens the probability of future occurrence of the behavior. Disciplinary action associated with the occurrence of certain work behaviors is punishment, since the behavior will often decrease in frequency when followed by it (Schneier, 1974). The manager of Altoona Sears choose to implement positive punishment along with positive reinforcement. Positive punishment applies unpleasant stimulus with the end result of decreasing the frequency of undesirable behavior (Redmond, 2010). If an employee did not receive five applications each month during a ninety-day interval, he/she had to undergo additional sales training. If no improvement was shown during the consecutive ninety-day interval, the employee was suspended. In another ninety-days time, if the employee's credit card sales were below standard, then his/her job was terminated.

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Another vital component of the operant model on which research pertinent to work organizations has been conducted is the schedule of reinforcement. Reinforcement can be dispensed on a continuous or variable schedule. In the work setting the fixed interval is typically used, where every appropriate behavior is followed by reinforcement (Schneier, 1974). An important part of the effectiveness of the system was the set interval of time the employees were evaluated in. At the Altoona Sears, applications were counted and evaluations were conducted every ninety-days. Employees had ample time and notice to adjust their behavior accordingly. They could expect an assessment of the number of individual credit card applications they completed, and then anticipate either reward or punishment along a set, fixed interval schedule. ANALYSIS Application of the Reinforcement Theory concepts and the steps of the Behavior Modification Model for Reinforcement (2006), worked to successfully increase credit card applications and employee motivation in this case study. By using Behavior Modification Model concepts, the Altoona Sears was able to become number one in credit card applications. Step 1 of the model says to specify the desired behavior as objectively as possible. Application of step one is evidenced by the two meetings that management held to address the issue of low credit card applications. Initially, he stated how important credit card applications were to the company. He then stated his desire to be the store with the most credit card applications. After the meeting, credit card applications went up slightly, but soon after were back down to the normal low. This shows a flawed reward system was in place which resulted in low employee motivation to solicit credit card applications, so he started over. This flawed system can be directly related to extinction, as the manager failed to recognize the employee's desirable behavior (raising credit card applications) with any tangible reward system that the employees would find motivating. This example of extinction can be tied into the law of effect, as their initial raising of credit card applications did nothing to elicit a pleasant outcome for the employees; therefore their extra efforts were abandoned. Steve Kerr, former chief learning officer believes, defining performance and making your definition operational is the starting point. Anything you would like your staff to do can be done and rewarded, as well as measured, if there is an operational definition to make goals and priorities actionable (Schacter, 2009).

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During the next meeting, the manager showed the goal orientation of the company by clearly stating the importance and benefit of opening new credit card accounts. This time he directed his attention away from the company benefits and focused on the employees. The goal was to ask each customer to open a Sears credit card account; an employee would receive a $2 bonus per application provided they achieved at least 5 applications a month. Step 2 of the model, measured the incidence of desired behavior by fixed interval schedule. By setting the fixed interval schedule of ninety days to count the applications for compliance with the new system, the manager was able to observe the employees, and gather evidence in order to accurately apply reward or punishment. Step 3 of the model, behavioral consequences are then provided that reinforce desired behavior. Here we see how implementing the reinforcement theory resolved the issues. Positive reinforcement increased the frequency of desired behavior by presenting the employees with a monetary bonus, recognition, and gift card rewards. Positive punishment was used for those employees that were unable to meet the requirements of the new system. The undesired behavior was addressed and reduced by introducing new stimuli in the form of extra training, suspension, or termination. Only a few employees fell below the five applications per month minimum, and they successfully completed the extra training. After completing training, employee’s credit card applications rose to above the minimum. Suspension and termination never had to be used since training was always an effective way to correct employee’s poor credit card applications. In this case, the fixed interval schedule successfully gave the staff a timeline to be consistent with. Step 4 of the model, determining the effectiveness of the program by systematically assessing behavioral change, is shown in the increase of credit card applications at the Altoona Sears. End results show techniques were effective. The Altoona store was successful at achieving their goal and became number one in credit card applications in the State of Pennsylvania, after employing methods of the Reinforcement Theory.

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CASE # 3 (CREATED BY RICHAEL FRANCIS C. MANGIBIN, ATENEO DE MANILA UNIVERSITY) B.F. SKINNER’S POSITIVE REINFORCEMENT IN TUTOR -TUTEE RELATIONSHIP BUILDING This paper aims to give an explanation to the process in building a relationship between a tutor and a tutee. This paper also aims to prove that the process is an application of B.F. Skinner’s Operant Conditioning Theory with a specification to the concept of Reinforcement. The successin the building of such relationship will give way to a tutee’s development that goes beyond the academic. STATEMENT OF THE PROBLEM The research, by the end of this conducted, must be able to give plausible answers to thefollowing issues: (1) How can a tutor figure out a way to assess the behavior of the tutee thatwould maximize his full potential both academically and personally?; (2) How is Skinner‟s Positive Reinforcement concept a key element in the process of building of a relationship between a tutor and a tutee?; and (3) What strategies and techniques can a tutor do to build amore personal relationship with his tutee in the process of learning simultaneously? SCOPES AND LIMITATIONS OF THE STUDY THEORETICAL FRAMEWORK Although this study will be in use of Skinner’s Operant Conditioning Theory, the researcher only aims to focus to the theory’s concept of Reinforcement, or more specifically, Positive Reinforcement, which is a stimulus, as a consequence of a response, in an increased probability that the response will reoccur in the future (Reynolds, 1968, p. 9). Also, since the theory of Skinner deals with more behavioral and psychological approach, the researcher will aim this in the context of education, more specifically through a one-on-one tutorial setting with a child that had been handled by a tutor. METHODOLOGY AND ELICITATION OF DATA This study will focus more on a one-on-one,tutorial teaching environment instead of a classroom setting; with this, the research will only have one object – a former tutee – who was taught by the researcher, who is also a tutor. Thetutorial sessions lasted for ten days, two hours in a day, in a tutorial center in U.P, Village,Quezon City. The tutee, during the time of the tutorials sessions, was an incoming 1st grade student and was six years old. The focus of this study is the tutee’s English lessons and his development throughout the 10-day program. The tutorial center

145 | P a g e provided the tutor with a program specified for his needs including worksheets, exercises and homework to be done duringand at home after every tutorial session. After each tutorial session, the tutor is tasked tocompose a short progress report, in a form of a journal, of the tutee‟s performance for the day – with his marked and observed development and the improvement needed. The journal progressreports will be the basis of the researcher in this study to chart the progress of the tutee and thedevelopment of the relationship with the tutor. The tutor will go over the progress reports anddiscuss the development of the tutee; combined with observations made during the tutorialsessions, the researcher will establish DISCUSSION OF DATA In the study conducted by Andrew Olney, Arthur Graesser, and Natalie Person (2010), they began their introduction by saying that “the empirical evidence that one-to-one humantutoring is extremely effective compared to classroom environment is well known. Theeffectiveness of one- to-one tutoring raises the question of what makes tutoring so powerful” (p. 181). The study is a good response to this statement – that building a good relationship between atutor and a tutee. Tutors are on hand to provide not only answers to students but moral andemotional support and to ferret out exactly what areas the student needs help in (Rabow, Chin,Fahimian, p. 31, 1999). In this study, such is true – based on the progress reports – that toestablish a connection, a tutor must be a good observer, particularly at the outset of tutoring(Rabow, Chin, Fahimian, p. 33, 1999). The following data are based on the empirical evidencedone by the tutor onto the tutee. Each progress report represents a key element to create a morestrategic approach to the tutee as the program goes along.On the first day of the tutorial sessions, the student seemed very reluctant. According tothe student report written by the tutor: “Day # 1: Josh today was very reluctant although this is probably due to the factthat it was our first meeting. He still needs to further be familiarized with the English Alphabet.” This only goes to show that the first meeting is always the hardest, and most awkward. However, from here does a tutor able to evaluate the tutee to plan the correct strategy in maximizing the learning experience of the tutee. Initially, the tutee was soft-spoken and very shy; he is also not good at socializing with new people and surroundings and going into the lesson proper, is notable to even recognize with the basic elements of the English alphabet – sounds, chronology, andsymbol. The tutor made use of flash cards that were provided the next day; the flash cardsshowed the letter, and a picture of an object that begins in that letter.

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“Day # 2: Very good improvements for today. He is more familiar with the alphabet and the sounds of the letters. He was less reluctant today, which improved his performance.” Slowly, the tutor always reminded the tutee to use the song whenever there is a difficulty inrecognizing the letter if they are presented at random. The following are the progress reportswritten by the tutor in the coming days: “Day # 3: [The student] showed improvement today with English however there lies room for improvement especially with reading and recognizing letter soundsand words where they are used. Reinforcement is highly advised.” “Day # 4: Josh seemed less enthusiastic today and was distracted. He's having ahard time reading because of his unfamiliarity with letter sounds.” “Day # 5: Josh still need improvement due to his reluctance; he is usually distracted and seems indifferent.” As was reflected in the reports, there is another factor that prevents the tutee from his improvement – it is this “distraction” that was affecting the student. The tutor handled the tuteemore openly by stating that if the performance is good, the tutee will be getting a break after an hour from now on as a form of award for his good deed and hard work. This led to the student’s further motivation in dealing with his work. “Day # 6: Josh, still, was less reluctant, during our session – the least reluctant hecan be so far. He still needs to practice his letter sounds, though, as he can barelyread words. However, visual recognition is of problem whatsoever and is devisedto be of help to sound recognition. Alphabet memorization is improving.” A struggle still occurs for the student however, he was able to open up more and be the leastreluctant he is. Though there is a struggle with word recognition and reading, His visual recognition skills and alphabet memorization showed improvements. Such improvements are theresult of his motivation knowing a rest or a break is coming up if the performance was good. The coming more days were getting smoother as they pass. The tutee was opening up more and sharing his personality a lot more to the tutor than how much was done in the previous sessions; with this, the tutor would talk to the tutee more casually and eventually, the hesitation of the tutee diminished slowly. In terms of the learning of the letters, whenever asked of a particular letter at random, the tutee would automatically respond by singing or reciting the alphabet song orally until the letter asked is spoken. Slowly the tutee was able to learn the sounds of the letters one by one and identify them slowly even without the reinforced singing of the song.

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“Day # 7: There lies slight improvement with Josh, yet, his reading skills and recognizing letter sounds definitely need more reinforcement and practice. His performance with visual aids are remarkable; however, without them, he tends to get confused and oftentimes confounded.” “Day # 8: Though lesser than before, Josh still seems shy and reluctant to work. However, there is an improvement in his memory-retention skills and his ability torecognize words of pictures. Despite these improvement, though, he still needslacks comprehension with his ability to recognize letter sounds making it difficultfor him to read a word without visual aids.” “Day # 9: Big improvement for Josh today. He seems to be more familiar with letter despite it being taught in Filipino. More reinforcement is still needed though.” There was a big leap in the improvement of the tutee – both in the academic performance and thecharacter building; by the end of the series of tutorial sessions, the student was able to identifymore accurately letter sounds and their symbols and the singing came in automatically wheneverthere is confusion with the letters especially to the ones that sound similarly (e.g. L, M, and N).The tutee also was more outgoing and cheerful as compared to his introverted traits during thefirst day. As reflected in the progress reports, there was a big improvement – although the studentstill needs more reinforcement with the topics, a good amount of development lies present. CONCLUSIONS AND RECOMMENDATIONS The role of positive reinforcement, as established by Skinner, in the building of the relationship between a tutor and a tutee lies in the adjustment and the adaptation of the tutor’s approach to the tutee; also, positive reinforcement manifests on the establishment of certain rules of the tutor during the tutorial sessions. These led to the change in the pattern of the tutee’s behavior. Commonly, established rules and adapted behavior refer to “short cut” methods or mnemonics that the tutor teacher the tutee to make learning more efficient and convenient – the establishment of the relationship follows through the way the tutee opens up to the tutor andeventually acquires skills and characteristics that have been hindered, if not totally absent, beforethe tutorial program began.The presence of a positive reinforcer – the awarding of a break after a good performance – led to the increase in the motivated performance of the student; another reinforcer would be thesinging of the alphabet song that led to the increased usage whenever confounded with therandom asking of a certain letter in the alphabet. Both reinforcers led to the building of therelationship between the tutor and the tutee – the eradication of the reluctance and the presenceof the outgoing and cheerful personality – that led to the eventual performance

148 | P a g e development ofthe tutee. Such situation goes to show that Reinforcement, as defined by Skinner in this Operant Conditioning Theory – is an essential factor in the building of the relationship between a tutorand a tutee as this relationship is the initial step to fully maximize the tutee’s full potential. In this study, as was reflected by the progress reports and the explanation of the processes done throughout the tutorial sessions, the application of reinforcers played a major role in thedevelopment of the tutee; in this way, it can be concluded that Skinner’s Reinforcement is an effective key in the building of the tutor-tutee relationship and in doing so, the development ofthe tutee follows.The study is a good case where the focus deviates from the common classroom setting ofteaching. Abundance of the tutorial and one-on-one teaching methods are slowly increasing andyet not much study to this approach of teaching are conducted nor developed. This study can serve as a good contribution to the few studies made in the past so as to it being a stepping-stoneinto dealing with this method of study. Therefore, the researcher recommends further study interms of various theories where such situations can be applied to or even a comparative study between theories; another would be an age- varied study where a theory be applied to tutee of different stages where their effects can be compared and contrasted. Also, further researches can make third party observations of other one- on-one tutorial and with a longer tutorial program, as well a quantitative response from the tutee - such as scores from worksheets, exams, and etc. – to make the empirical evidence more plausible and accountable. All of these recommendations fall onto the eventual development of good tutoring techniques to make the learning process of a tutee more dynamic and effective.

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RESPONSE/BEHAVIOR

- SHAPING

ACUÑA, AIRA VHENYCE A.

BARBUCO, DIANNE MAE B.

GALAPON, BIANCA PATRICIA V.

SUMAGAYSAY, YVON P.

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INTRODUCTION SHAPING, or behavior shaping, is a variant of operant conditioning. Instead of waiting for a subject to exhibit a desired behavior, any behavior leading to the target behavior is rewarded. For example, B. F. Skinner (1904-1990) discovered that, in order to train a rat to push a lever, any movement in the direction of the lever had to be rewarded, until finally, the rat was trained to push a lever. Once the target behavior is reached, however, no other behavior is rewarded. In other words, the subject behavior is shaped, or models, into the desired form. Although rejected by many orientations within the field of psychology, behavioral techniques, particularly shaping, are widely used as therapeutic tools for the treatment of various disorders, especially those affecting verbal behavior. For example, behavior shaping has been used to treat selective, or elective, autism, a condition manifested by an otherwise normal child's refusal to speak in school. Therapists have also relied on behavior shaping in treating cases of severe autism in children. While autistic children respond to such stimulus objects as toys and musical instruments, it is difficult to elicit speech from them. However, researchers have noted that behavior shaping is more effective when speech attempts are reinforced than when speech production is expected. When unsuccessful efforts to produce speech are rewarded, the child feels inspired to make great effort, which may lead to actual speech. Shaping also known as successive approximation, refers to the reinforcement of behaviors that approximate or come close to the desired new behavior. Research has found that this technique works well for phobias and anxiety related disorders. Also Shaping is commonly used to train animals, such as dogs, to perform difficult tasks;

SUCCESSIVE APPROXIMATIONS The successive approximations reinforced are increasingly accurate approximations of a response desired by a trainer. As training progresses the trainer stops reinforcing the less accurate approximations. For example, in training a rat to press a lever, the following successive approximations might be reinforced: 1. Simply turning toward the lever will be reinforced. 2. Only stepping toward the lever will be reinforced. 3. Only moving to within a specified distance from the lever will be reinforced. 4. Only touching the lever with any part of the body, such as the nose, will be reinforced.

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5. Only touching the lever with a specified paw will be reinforced. 6. Only depressing the lever partially with the specified paw will be reinforced. 7. Only depressing the lever completely with the specified paw will be reinforced. The culmination of the process is that the strength of the response (measured here as the frequency of lever-pressing) increases. In the beginning, there is little probability that the rat would depress the lever, the only possibility being that it would depress the lever by accident. Through training the rat can be brought to depress the lever frequently. Successive approximation should not be confused with feedback processes; a s feedback refers to numerous types of consequences. Notably, consequences can also include punishment, while shaping instead relies on the positive reinforcement. Shaping is used when you want the student to engage in a certain desirable behavior that is, at present, infrequently or never displayed by him/her. If you were to wait for the student to show this behavior so that you could reward him/her, you might wait a very long time. Shaping allows you to build this desired behavior in steps and reward those behaviors that come progressively closer to the one you have selected as the final goal. As the student masters each sub step, you require that he/she move to the next increment in order to receive an award or reinforcement.

HOW TO USE SHAPING 1. Identify a desired behavior for this student. Determine the final goal. 2. Identify the student's present level of performance in displaying the desired behavior. 3. List the steps that will eventually take the student from his/her present level of performance to the final desired behavior. These levels of skill should be progressively demanding. 4. Tell the student that he/she must accomplish step 1 to receive the reward. 5. Once the student has mastered a specific behavior, require that he/she demonstrate the next stage of behavior in order to receive a reward. Example: For example, John never does his math homework. You would like to have him complete his homework on a daily basis. You realize that if you wait for him to complete his homework before you reinforce him in some way, you may never (or infrequently) have the opportunity to administer a positive consequence. Therefore, you decide to break down the desired behavior into sub steps that are progressively more demanding. These steps might be:

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1. John will write his name at the top of the worksheet. 2. John will complete one problem of his choice. 3. John will complete five problems of his choice. 4. John will complete either all the odd numbered problems or all the even numbered problems. 5. John will complete all problems except one. 6. John will complete all problems. As John masters each step, you will tell him that he must now move on to the next objective to receive a reward. If the jump between two steps is too difficult, then you must break down the steps further into smaller increments. While recognizing the effectiveness of behavior shaping in the laboratory and in therapy, experts, particularly psychologists who do not subscribe to behaviorism, have questioned the long- term validity of induced behavior change. For example, researchers have noted that people have a tendency to revert to old behavior patterns, particularly when the new behavior is not rewarded anymore. In many cases, as Alfie Kohn has written, behavior-shaping techniques used in school, instead of motivating a child to succeed, actually create nothing more than a craving for further rewards. RESEARCHES MADE  Cuvo, A. J., Reagan, A., Ackerlund, J., Huckfeldt, R., & Kelly, C. (2010). Training Children with Autism Spectrum Disorders to Be Compliant with a Physical Exam. Research in Autism Spectrum Disorders, 4(2), 168-185. Four students with autism and two with PDD were trained to be compliant during a medical examination using a package of interventions including shaping of behaviors, preference assessment, contact desensitization, fading in aversive stimuli, video priming, prompting, verbal instructions, DRO and escape extinction. All children with ASD increased their compliance to mastery levels and this was maintained through follow-up probes.  Esch, B. E., Carr, J. E., & Michael, J. (2005). Evaluating stimulus-stimulus pairing and direct reinforcement in the establishment of an echoic repertoire of children diagnosed with autism. Analysis of Verbal Behavior, 21, 43-58. Three experiments were conducted to evaluate stimulus- stimulus pairing and direct reinforcement in establishing an echoic repertoire for three children (Ages 6 & 8) with autism. One intervention, Experiment 3, demonstrated that shaping increased vowel frequency for one participant.  Hupp, S.D.A., & Reitman, D. (2000). Parent-assisted modification of pivotal social skills for a child diagnosed with PDD: A clinical replication. Journal of Positive Behavior Interventions, 2, 183-

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187. Two parents were instructed in implementing a token reinforcement and shaping program designed to improve the social behavior of their 8-year-old son diagnosed with PDD. Results showed positive response generalization by targeting one pivotal behavior. THEORY Operant conditioning (also, “instrumental conditioning”) is a learning process in which behavior is sensitive to, or controlled by its consequences. For example, a child may learn to open a box to get the candy inside, or learn to avoid touching a hot stove. In contrast, classical conditioning causes a stimulus to signal a positive or negative consequence; the resulting behavior does not produce the consequence. For example, a the sight of a colorful wrapper comes to signal "candy", causing a child to salivate, or the sound of a door slam comes to signal an angry parent, causing a child to tremble. The study of animal learning in the 20th century was dominated by the analysis of these two sorts of learning, and they are still at the core of behavior analysis.

CASE STUDY CASE STUDY 1 Rich was an 8-year-old boy with autistic disorder who was receiving treatment at a psychiatric inpatient unit for children with developmental disabilities. He had been admitted to the unit due to problem behavior at school and home. His language and cognitive abilities were estimated to be at an age equivalent of 4.5 years. When he was 1.5 years old, Rich first demonstrated intense fear reactions to animatronic objects (electronic animated figures) such as a dancing Elmo doll, blinking Halloween decorations, and life- sized Santa Claus replicas. Upon seeing such stimuli he would scream, try to flee, and hit any person attempting to block his escape. At the time of hospital admission, Rich’s parents were unable to take him into stores or visit other community locations where these objects were present. The unit psychologist at the hospital gave Rich a diagnosis of specific phobia (300.29) (American Psychiatric Association, 1994). PROCEDURE BASELINE (THREE SESSIONS) Several of Rich’s preferred objects (tools, catalogs, and magazines) were placed beside the animatronic figures. Preference was determined by staff that interacted with Rich on the inpatient unit. The therapist presented the probe assessment requests in each session. If Rich complied, the

154 | P a g e therapist praised him and permitted access to the preferred objects. If Rich said ‘‘no’’ to the request or walked away, the therapist simply waited until the next probe request. Rich was allowed to leave the room at any time; if he exited, the therapist terminated the session. INTERVENTION (15 SESSIONS) In the first two intervention sessions, Rich had uninterrupted access to the preferred objects, which were placed at the distance criterion located 6 m from the figures. Starting with the third session, the distance criterion was advanced in a five step graduated sequence that required Rich to remain 5 m (Step 1), 4 m (Step 2), 3 m (Step), 2 m (Step 4), and 1 m (Step 5; terminal criterion) from the figures. He continued to have access to the preferred objects at each of these session- specific distance criteria. Steps were changed when Rich remained at the specified distance criterion in 90% of more of recording intervals during two consecutive sessions. If he attempted to move the preferred objects away from the specified distance criterion, the therapist replaced them and reminded him to stay at the location. As in baseline sessions, the therapist presented probe assessment requests and did not prevent him from leaving the room. Unlike baseline sessions, the preferred objects were not placed beside the animated figures during probe assessments. The final session of the study occurred 2 days before Rich was discharged from the hospital. At this time, we advised his mother to bring him to stores and events that contained animatronic figures. Three months after intervention, she reported that he occasionally protested these situations but tolerated the stimuli without escape. This outcome supports the external validity of intervention. Acknowledging the scarcity of behavior-analytic assessment and intervention in inpatient child psychiatry, our results suggest that hospital based treatment of a clinical disorder such as specific phobia can be evaluated rapidly and produce a positive outcome. The study also supports contact desensitization without escape prevention as an effective fear-reduction intervention for children who have developmental disabilities.

CASE STUDY 2 Khuffy is a 2 year old dog learning how to carry a basket. His master used response shaping in developing his new trick. His master prepared a list of hierarchy to which Khuffy will be rewarded as he accomplish each stage. Hierarchy towards desired behavior 1. Simply turning toward the basket will be reinforced.

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2. Staying in front of the basket will be reinforced. 3. Picking something out of the basket will be reinforced. 4. Biting the handle of the basket will be reinforced. 5. Picking up the basket and staying in place will be reinforced. 6. Picking up the basket and carry it around will be reinforced. Each time khuffy accomplished each stage, his master gave him his favorite treat (meat jerky). After 2 weeks, khuffy learned how to carry a basket.

CASE STUDY 3 A 1962 article, a study conducted using two emotionally disturbed boys in a residential treatment center (whose behavior was monitored by the instructor of their English class) exhibits classic cases of shaping used as part of an educational therapy program (Zimmerman and Zimmerman). The first case study was 11 years old and appeared to be of normal intelligence. Whenever he was chosen to spell a word that had previously been studied in class sessions, he would pause and simply utter letters unrelated to the word he was asked to spell. After a considerable period of time had passed and after receiving added attention from the instructor, the boy would finally correctly spell the word. With each subsequent session, the student began to take longer and longer to spell the word and demanded more attention. To eliminate this behavior pattern, the instructor gradually decreased the amount of attention he gave the boy during each session until finally there was an extinction of the behavior. After that, attention was only given after the desired behavior was achieved or some approximation of it.

CASE STUDY 4 Shaping has also been used to decrease aggressive behavior in hyperactive children as an alternative to drug and medical management therapies. Hamblin and Buckholdt (as cited in Prout, 1977) focused on children who were reported to be the most severe behavior problems in a local school system in their 1967 study. The teachers were told to conduct their classroom instructions normally as observers watched. The observational reports showed the teachers were rewarding the aggressive behavior with attention and social reinforcement. A token system was introduced and was structured to the needs of the classroom. Each hyperactive child received a token after each successive step toward decreasing aggression was achieved. As hypothesized, the token exchange

156 | P a g e system reduced the amount of hyperactive and destructive behavior in the classroom. There was an increase in attention level and class cooperation. Although the reward system had to be reconstructed for several of the students, it still proved to be successful in eliminating problem behavior and encouraging appropriate behaviors.

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INTERMITTENT

REINFORCEMENT

AMIGO, ALFRED BABOR, PATRICK DAVE GURAN, TANYA PIGAO, FLORENTINO REFANI, MAYAM REMAE

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INTERMITTENT REINFORCEMENT  Intermittent reinforcement is when rules, rewards or personal boundaries are handed out or enforced inconsistently and occasionally. This usually encourages another person to keep pushing until they get what they want from you without changing their own behavior. By using this type of reinforcement, we tend to teach and mold our subject on what we want them to be. They will learn the things we wanted them to learn and they will do the things we them to do without asking for a reward or incentives and at the same time keeping their attitude in line. SCHEDULES OF REINFORCEMENT  The kinds of reinforcers that we receive occur in different patterns and frequencies.  Sometimes we receive reinforcement after every response, but more typically only a proportion of our responses are reinforced.  These patterns or schedules of reinforcement have strong and predictable effects on learning, extinction and performance. CONTINUOUS REINFORCEMENT SCHEDULE  Every time the desired behavior is done, there is a pleasant consequence.  Every response is reinforced  A schedule of reinforcement in which every occurrence of the instrumental response (desired response) is followed by the reinforcer Lab Example: Each time a rat presses a bar it gets food. Real World Example: Each time a person puts 1 peso in a candy machine and presses the button he receives a candy bar. PARTIAL OR INTERMITTENT REINFORCEMENT  Refers to conditions in which only some responses are followed by reinforcement Can be categorized into:  Ratio Schedules – a certain percentage of the subject’s responses are reinforced.  Interval Schedules – a certain amount of time must elapse between reinforcements, regardless of how many responses might occur during that interval. Both types of partial schedules can be further subdivided into:  Fixed Schedule – the reinforcement always occurs after a fixed no. of responses or after a fixed time interval

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 Variables Schedule – the required no. of responses or the time interval varies at random around an average. This figure shows how all these partial reinforcement categories combine to produce four different reinforcement schedules

INTERVAL RATIO ( a certain amount of time (only a certain proportion of between reinforcements) responses reinforced)

FIXED FIXED – RATIO FIXED - INTERVAL

VARIABLE VARIABLE – RATIO VARIABLE – INTERVAL

SIMPLE SCHEDULES FIXED RATIO (FR)  schedules deliver reinforcement after every nth response. Lab Example: FR5”= rat’s bar pressing behavior is reinforced with food after every 5 bar presses in a skinners box. Real World Example: FR10”= car dealer gets a 10,000 pesos in every 10 cars sold on the lot. VARIABLE RATIO SCHEDULE (VR)  reinforced on average every nth response, but not always on the nth response. Lab Example: VR4”= first pellet deliver on 2 bar presses, second pellet delivered on 6 bar presses, third pellet delivered on 4 bar presses (2+6+4=12 ; 12/3=4 bar presses to receive pellet. Real World Example: slot-machines (because, though the probability of hitting the jackpot is constant, the number of lever presses to hit the jackpot is variable).

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FIXED INTERVAL (FI)  reinforced after n amount of time. Lab Example: FI15”= rat’s bar pressing behavior is reinforced for the first bar press after 15 seconds passes since the last reinforcement. Real World Example: washing machine cycle VARIABLE INTERVAL (VI)  reinforced on an average of n amount of time, but not always exactly n amount of time. Lab Example: VI10”= a rats bar pressing behavior is reinforced for the first bar press after an average of 10 seconds passes since the last reinforcement. Real World Example: going fishing OTHER SIMPLE SCHEDULES INCLUDES: DIFFERENTIAL REINFORCEMENT OF INCOMPATIBLE BEHAVIOR (DRIB)  This is used to reduce a frequent behavior without punishing it by reinforcing an incompatible response. DIFFERENTIAL REINFORCEMENT OF OTHER BEHAVIOR (DROB) –  Also known as omission training procedures, an instrumental conditioning procedure in which a positive reinforcer is periodically delivered only if the participant does something other than the target response. DIFFERENTIAL REINFORCEMENT OF LOW RESPONSE RATE (DRL)  This is used to encourage low rates of responding. It is like an interval schedule, except that premature responses reset the time required between behavior. Lab Example: DRL10” = a rat is reinforced for the first response after 10 seconds, but if the rat responds earlier than 10 seconds from that premature response without another response before bar pressing will lead to reinforcement. DIFFERENTIAL REINFORCEMENT OF HIGH RESPONSE RATE (DRH)  This is used to encourage low rates of responding. It is like an interval schedule, except that premature responses reset the time required between behaviour. Lab Example: DRH10”/15 responses = a rat must press a bar 15 times within 10 seconds to get reinforced. FIXED TIME (FT)  Provides reinforcement at a fixed time since the last reinforcement, irrespective of whether the subject has responded or not. In other words. It is a non- contingent schedule. VARIABLE TIME (VT)  Provides reinforcement at an average variable time since last reinforcement, regardless of whether the subject has responded or not.

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EFFECTS OF DIFFERENT TYPES OF SIMPLE SCHEDULE Intermittent reinforcement is rare and unpredictable Fixed Ratio Variable Ratio Fixed Interval Variable Interval activity slows after high rate of activity increases as Steady activity reinforcer and then responding, greatest deadline nears, can results, good resistace picks up activity of all cause fast extinction to extinction schedules; responding rate is high and stable

Organisms whose schedules of reinforcement are “thinned” (that is, requiring more responses or a greater wait before reinforcement) may experience “ratio strain” if thinned too quickly. This produces behavior similar to that seen during extinction. Ratio Strain is the disruption of responding that occurs when a fixed ratio response requirement is increased too rapidly. Ration Run is high and steady rate of responding that completes ration requirement. It is only higher ratio requirement causes longer post-reinforcement pauses to occur. Partial Reinforcement schedules are more resistant to extinction than continuous reinforcement schedules.

CASE STUDY FIXED RATIO - Giving a child candy every time she picks up her toys - Getting paid after each car gets sold - Students may be given a prize after reading ten books FIXED INTERVAL - Doing my job and receiving my paycheck monthly (last day of month) - The daily mail – I receive my mail at roughly the same time each day - A course where there are exams every three weeks (studying right before the exam and then stopping until the next round)

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VARIABLE INTERVAL - Unpredictable – reinforcement occurs after random amount of time - Checking your phone for text messages – you do not know when you will be rewarded with a message, but continue to check until you do - A parent attending to the cries of a child. Parents will not typically attend to the child each time it cries, but will leave he or she to fuss for a period before attending VARIABLE RATIO - The classic winning the jackpot in the slot machine after changing number of times playing it - Playing poker – I do not win every time, but must play in oder to have a chance - Buying lottery tickets and winning occasionally

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EXTINCTION

GOB, CARLA JANE E. LUMBA, KRISLINE MAE OLIVA, XYZA DENISE VALDEZ, IANNE MAE E.

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INTRODUCTION WHAT IS EXTINCTION? Extinction is a behavior modification technique that is used to reduce and eventually eliminate undesirable behavior. The process of extinction involves the removal of the “reinforcer” that is responsible for maintaining the undesirable behavior. Extinction is present in both classical and operant conditioning. In classical conditioning, extinction happens when a conditioned stimulus is no longer paired with an unconditioned stimulus. The best example is the classic research of Ivan Pavlov, wherein a dog was conditioned to salivate to the sound of a bell, but when the bell is presented repeatedly without the representation of food, the response of the dog to salivate will eventually become extinct. In operant conditioning, extinction occur if the trained behavior is no longer reinforced or if the reinforcement is no longer effective or rewarding. This procedure can be used to decrease the occurrence of undesirable behaviors like swearing, tantrums, whining, and aggressive, self-injurious behavior. HISTORY In B.F. Skinner’s autobiography, it is noted how he accidentally discovered the extinction of an operant response due to the malfunction of his laboratory equipment. "My first extinction curve showed up by accident. A rat was pressing the lever in an experiment on satiation when the pellet dispenser jammed. I was not there at all time, and when I returned I found a beautiful curve. The rat had gone pressing although no pellets were received. The change was more orderly than extinction of a salivary reflex in Pavlov's setting, and I was terribly excited. It was a Friday afternoon and there was no one in the laboratory who I could tell. All that weekend i crossed streets with particular care and avoided all unnecessary risks to protect my discovery from loss through my accidental death. When the extinction of a response has occurred, the discriminative stimulus is then known as an extinction stimulus (S-delta). When an S-delta is present, the reinforcing consequence which characteristically follows a behavior that does not occur. This is the opposite of a discriminative stimulus which is a signal that reinforcement will occur. For instance, in an operant chamber, if food pellets are only delivered when a response is emitted in the presence of a green light, the green light is a discriminative stimulus. If when a red light is present, food will not be delivered, then the red light is an extinction stimulus (food here is used as an example of a reinforcer).

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THEORIES The dominant account of extinction involves associative models. However, there is debate over whether extinction involves simply "unlearning" the unconditional stimulus (US) - conditional stimulus (CS) association or alternatively, a "new learning" of an inhibitory association. A third account concerns non-associative mechanisms such as habituation, modulation and response fatigue. Myers and Davis laboratory work with fear extinction in rodents has suggested that multiple mechanisms may be at work depending on the timing and circumstances in which the extinction occurs. Given the competing views and difficult observations for the various accounts researchers have turned to investigations at the cellular level (most often in rodents) to tease apart the specific brain mechanisms of extinction, in particular the role of the brain structures (amygdala, hippocampus, the prefontal cortex), and specific neurotransmitter systems. A recent study in rodents by Amano, Unal, and Pare published in Nature neuroscience found that extinction is correlated with synaptic inhibition in the fear output of neurons of the central amygdala that project to the periaqueductal gray that controls freezing behavior. They infer that inhibition derives from the ventromedial prefrontal cortex and suggest promising targets at the cellular level for new treatments of anxiety. OPERANT CONDITIONING In the operant conditioning paradigm, extinction refers to the process of no longer providing the reinforcement that has been maintaining a behavior. Operant extinction differ from forgetting in that the latter refers to a decrease in the strength of a behavior over time when it has not been emitted. For example, a child who climbs under his desk, a response which has been reinforced by attention, is subsequently ignored until the attention-seeking behavior no longer occurs. GOALS OF EXTINCTION Extinction procedures are combined with reinforcement procedures so that learners develop more appropriate skills in place of challenging or problematic behaviors that prevent the occurrence of more acceptable, purposeful behaviors. They can be used with other intervention strategies, including functional communication training, differential reinforcement, non- contingent reinforcement, and/or response interruption/redirection. Examples of specific skills that were the focus of extinction interventions in the evidence-based studies include:

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- functional communication (Kelley, Lerman, & Van Camp, 2002);

- self-injurious behaviors (Kahng, Iwata, & Lewin, 2002; Matson & Santino, 2008);

- sleep problems (Weiskop, Matthews, & Richdale, 2001); and

- eliminating challenging behavior during classroom instruction (O'Reilly et al., 2007). WHO CAN USE EXTINCTION? Extinction procedures can be developed and used by a variety of adults who have been appropriately trained, including parents, teachers, special educators, therapists, and paraprofessionals. However, it is critical that the adult be familiar with the learner so that a plan for addressing an extinction burst is created should the unwanted behavior increase in intensity or frequency. WHEN SHOULD EXTINCTION BE USED AS A BEHAVIORAL PROCEDURE? These are questions to ask before deciding to use extinction to reduce or stop a behavior: 1. Can the behavior be tolerated temporarily based on its description and how often it occurs? 2. Can it be tolerated if it increases? 3. Will others imitate the behavior? 4. Have reinforcers been identified? Reinforcers are those people, items or activities that produce a positive effect on behavior and increase a desired behavior or decrease an undesirable behavior. 5. Can these reinforcers be withheld? 6. Have alternative behaviors been identified as ones that would receive reinforcement? The use of the Motivational Assessment Scale (Durand, V.M) can be very helpful in determining why an individual may be engaging in a behavior and if extinction is truly the most effective way in dealing with it. This scale helps individuals look at a behavior and determine if the behavior is occurring because of sensory issues, communication difficulties, avoidance behaviors or attention seeking. PROBLEMS AND CONSIDERATIONS WITH EXTINCTION: Delayed reaction: once a procedure has been put into place (such as ignoring a person whenever they start to tantrum) it may take considerable time to see a reduction in the tantrum.

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This is called "resistance to extinction" and is especially noticeable when a behavior that has gone on for quite some time is suddenly not given attention, or ignored. Increased rate: The saying "It’s going to get a lot worse before it gets better" describes this well. When an extinction program plan is put into effect, parents and teachers should expect to see an increase in the tantrums, hitting, or other behavior that is being ignored. Typically, when parents and teachers decide to ignore the behavior, the individual begins to increase the intensity and length of the behavior that used to get attention. Now, he must try harder to get attention. If the parent or teacher eventually do give attention, the behavior may remain at the increased level of intensity. This is known as an "extinction burst." It is critical that once parents and teachers decide to ignore a behavior to extinguish it, that they truly continue ignoring it, in spite of the stepped-up response of the individual. Controlling attention: Saying "I’m ignoring you. I'm not paying any attention to you" in actuality is giving attention. It takes practice to truly ignore and helps to have something else to focus on, such as attending to someone who is doing something positive, focusing eyes and body on something else, or physically moving away. Extinction-induced aggression: "You think you’re ignoring me? Watch this!" A pattern of escalation and aggression often occurs early in the extinction program. Where the individual had previously yelled and cried until he received the desired goal, he now kicks it up a notch and adds slamming the door, pounding on the floor and maybe even hitting the adult. Spontaneous recovery: After a behavior has seemingly been extinguished or stopped for a time, the teacher or parent may be surprised to see the child or individual repeating the behavior they thought was gone. In essence, the child is really checking to see if the same rule applies after a period of time, or in a new environment. "Hmmm-at home I know if I throw myself on the floor and cry, I don’t get my ice cream treat, but I wonder if that will work in the grocery store?" It is critical that teachers and parents keep the same rule in effect if they wish to keep the behavior from starting up again. The child will quickly learn to resort to tantrums again if he gets a response to them. If he is ignored in the new setting just as he was at home, he will learn that the same rule applies. Imitation or reinforcement by others: Because most people are involved in living and learning situations in which other people are around them, they are influenced by those people in those situations. In the classroom, an individual may continue a behavior because his classmates

168 | P a g e laugh each time he burps, even though the teacher ignores it. At home, the child may continue to tantrum because a sibling attends to him while the parents ignore him. When an extinction procedure is put into place, it is important to consider who else will be in contact with the individual and how they will influence the individual. In the classroom, the teacher may attend to students who are "on task" and reinforce them for positive behavior, while ignoring the student who is burping. At home, parents may guide the sibling to another activity and interact with him while the child who is tantruming is ignored. Limited generalization: this means that the behavior that is being ignored in one classroom may occur more often when the child goes to another classroom where the teacher does not ignore the behaviors all the time. It does not automatically generalize to all settings and situations. ADVANTAGES AND DISADVANTAGES OF USING EXTINCTION

Advantages of extinction Disadvantages of extinction

 It may produce a long-term  Initially, the undesired behavior is likely to increase effect  Delayed reaction or resistance to extinction

 It may be relatively simple  Follow-through of the procedure requires (provided consistency and consistency and persistence by all involved with the individual. persistency are a given)  The time involved in the procedure requires a  It should eliminate a non- commitment. desired behavior  The individual may become aggressive in an  It is considered a relatively attempt to obtain attention. non-aversive procedure  The schedule of reinforcement may determine how long it will take to extinguish a behavior.

PROCEDURE 1. IDENTIFY THE PROBLEM BEHAVIOR In identifying the problem behavior of the client the psychologist or therapist should focus on the following questions:  What the problem behavior looks like? (topography)  How often the problem behavior occurs? (frequency)  How intense the problem behavior is? (intensity)  Where the problem behavior occurs? (location)

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 How long the problem behavior lasts? (duration) 2. COLLECT BASELINE DATA The psychologist/therapist should collect data for an ample period of time while focusing on the topography, frequency, duration, location, and intensity of the problem behavior. 3. DETERMINE THE FUNCTION OF THE PROBLEM BEHAVIOR Before implementing an intervention plan, the psychologist/therapist use observation methods to determine the purpose of the problem behavior, these are the following:  A-B-C DATA (ANTECEDENT, BEHAVIOR, CONSEQUENCE) - When determining the purpose of the behavior, the psychologist must identify what happens before the behavior (antecedent) and what happens immediately after the behavior occurs (consequence). For example, a teacher gives a direction to a student to line up with the class to go outside (antecedent), the student has a tantrum (behavior), and the teacher allows the student to remain inside to calm down (consequence).  ANECDOTAL OBSERVATION - Directly observed occurrences that are clearly and concisely written in a non-judgmental manner in the past tense. This is a factual account of a single incident answering the questions who, what, where, when and how of the incident occurred.  FUNCTIONAL ANALYSIS – Splits the functions of a behavior into four main categories: a. Attention - An extremely powerful reinforcer for behavior. Example: A child in a supermarket calls her ‘mom’ for no considerable reason and thus ignored by her mother. The child continues to call her mother’s attention, and the mother eventually turns around and angrily says ‘WHAT?’ regardless of the nature of the response, the child has learned that repeatedly saying ‘mom’ is an effective means of garnering attention when an initial attempt has failed. b. Escape/Avoidance – People avoid situations that makes them anxious or distressed whenever possible and learn behaviors that are effective in avoiding such situations.

Example: A child realizes they have not completed their homework for school the next day. She learned from previous experience that attending school without her homework will result in an embarrassing and unpleasant interaction with her teacher. Therefore the child pretends to be ill and her parents allowed her not to go

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to school the next day. The child has successful avoided a negative situation and is likely to therefore repeat this behavior to avoid future situations. c. Self-stimulation or sensory reinforcement - Any behavior which is designed to stimulate the person. This could be applied to actions which alleviate boredom. Example: You are so immensely bored that you have been through the TV channels a number of times and cannot see a show you want to watch, however as a result of being so bored you switch the channel to Spongebob Squarepants. Watching Spongebob Squarepants may not be your first choice, but it occupies your brain just enough so that you stop changing channels and feel less bored. In the future you will be more likely to watch said show when feeling the symptoms of boredom. d. Tangible Rewards - When a person receives something ‘tangible’ that they want after behavior occurs, the chance of that behavior occurring again increases. Example: A child is asked to clean the car by his parents and told that if he cleans the car, he will receive an additional pocket money. 4. CREATING AN INTERVENTION PLAN Psychologists should prepare a list of the possible responses of the client to the intervention and determine the appropriate responses they will give. When designing the implementation plan, it's also important to consider the level of actual control the psychologist/therapist have over the behaviors and the environment, as well as what additional interventions and support will be required to teach the client specific skills to replace the problem behaviors. Also, if a problem behavior serves more than one function, extinction procedures for each function are required.

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5. IMPLEMENTING THE INTERVENTION PLAN In implementing the intervention plan the psychologist/therapist waits for the behavior to occur and respond by using the following methods:  Planned ignoring - Literally involves no verbal, physical, and eye contact, and no emotional reaction during or following an attention maintained problem behavior. While this strategy may be difficult to implement initially or for extended periods of time, consistency is crucial but sometimes complete planned ignoring is impossible.  Denied access - Removing reinforcing items or activities. The psychologist/therapist should arrange the client’s environment so that access to these specific items and activities are not readily available. Always bear in mind to consider less physical methods to restrict access to these items or activities.

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 Escape extinction - Preventing client from avoiding or escaping a undesirable task or situation (e.g., not sending a student home for disruptive behavior when the student wants to leave school)  Sensory extinction - Preventing sensory feedback that is reinforcing an interfering behavior (e.g., consistently blocking a student from turning a classroom light switch on and off repeatedly for visual self-stimulation). The next step is to ensure that all people who interact with the client are consistent in withholding these reinforcements. When extinction is first used, there is often an immediate increase in the frequency of the problem behavior this is known as extinction burst. This initial increase usually means that the reinforcers that maintained the problem behavior were successfully identified and withheld. Therefore, extinction burst may be an indication that the extinction procedure will be effective. However, it is critical that the psychologist/therapist be aware of this possible initial response increase (either in frequency or intensity) and should be prepared to continue withholding the reinforcing consequences on a consistent basis otherwise the client will never learn how to use an alternative behavior successfully. During the extinction process the client can also engage in novel behaviors, these are responses the client have not been engaged previously and these are typically emotional and aggressive behavior. For example, if an extinction procedure was implemented for Jane’s screaming and shouting she may engage in the novel emotional behavior of crying, something she had never done before in an attempt to get her teacher to go away. A feature of extinction that is important to the behavioral practitioner is spontaneous recovery. After a behavior has been extinguished, it might recur even though it has not been reinforced for some time. The behavior could recur when the individual is in a situation similar to the one in which the behavior was originally reinforced. For example, a teacher in a classroom may have successfully decreased a student's tantrums using a planned ignoring extinction program. However, after three weeks of no tantrums, the student exhibits an intense meltdown that looks very similar to pre-extinction tantrums. Spontaneous recovery is usually brief and limited as long as the extinction procedure remains in effect. 6. Collect Outcome Data The psychologist/therapist measures again the topography, frequency, intensity, location, and duration of the problem behavior following the extinction intervention. Then comparisons are

173 | P a g e made between the outcome data and the baseline data to determine the effectiveness of the intervention. 7. Review the Intervention Plan If the client continues to exhibit the problem behavior, the intervention plan needs to be modified. Then the psychologist make follow-up observations to determine if the problem behavior has been eliminated. It’s also important to consider if new problem behaviors have developed in place of the original problem behavior.

CASE STUDIES 1. Leighton is a thirteen-year-old middle school student diagnosed with autism spectrum disorder. She is very verbal and is taught within a general education setting all of the time. Leighton enjoys going to school and math is her favorite class. Lately, her teacher has noticed that when it is time to work independently, Leighton makes several mistakes on her worksheets and raises her hand for help. As a consequence, the paraprofessional or teacher comes over to offer prompts, cues, and encouragement. Only after the time- consuming help and attention, however, does Leighton correctly solve the math problem. Both the teacher and paraprofessional are certain that Leighton knows how to complete the math problems, and after conducting an FBA, it seems that their instruction, attentive reactions, and encouragement are positive reinforcement for the incorrect responses. After a meeting, the team decided to place the Leighton's incorrect math responses on extinction from staff attention. The team outlined the steps beforehand on how to implement extinction and what consequences to provide contingent on the target behavior occurring (i.e., Leighton independently completing the math problems without mistakes). It was also decided that slight modifications would initially be made to Leighton's worksheets, such as reducing the number of problems and only having content that Leighton knew how to do from prior observations. As Leighton's independent work improved, the number and complexity of problems would be increased. The next time that Leighton was instructed to work on her math sheet, she glanced at the teacher and raised her hand for assistance. With the extinction plan in effect, the teacher ignored Leighton's request and continued working at her desk. Leighton then looked over at the paraprofessional to gain her attention and similarly, the paraprofessional

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remained seated scoring worksheets. Leighton then made several verbal statements to try to gain a response from either adult, such as saying, "I can't do math," or "I can't remember how." Leighton then marked her paper and put her head down on the desk occasionally sighing or grunting, while both adults continued to ignore her behavior. While her behavior slightly intensified (i.e., extinction burst), no serious escalations occurred and the teacher and paraprofessional both felt comfortable in continuing with the extinction procedure. However, had Leighton demonstrated a more aggressive or disruptive behavior in response to the extinction, such as throwing her chair or hitting her head, the team would have met immediately to develop an extinction burst safety plan. Options might have included adding more modifications to Leighton's' worksheet, introducing additional intervention procedures (e.g., self-management, differential reinforcement), using pull-out time to have Leighton work independently, but in a more controlled environment and then bringing her back into the classroom. However, these additional steps were not necessary. After 15 minutes of not working, Leighton picked up her pencil and began to independently complete her math sheet. The teacher then walked around the class and stopped at Leighton's desk to praise her for working so nicely and correctly solving all the problems. Encouragement and praise continued to be delivered contingent upon Leighton completing the work by herself. After one month of this procedure, incorrect math responses declined to approximately zero per class session and modifications to Leighton's worksheets were no longer necessary.

2. In a parent training group, Carla’s mother, Juanita, told the social worker that almost every time she told 5-year-old Carla to put her toys away, Carla screamed. The baseline duration of Carla’s screaming averaged 5.5 minutes per episode. Juanita would attempt to placate Carla by promising to buy her new clothes and by putting the toys away herself. The social worker suspected that Juanita was positively reinforcing Carla’s screaming by putting the toys away and promising to buy Carla new clothes. She showed Juanita how to use extinction to decrease Carla’s screaming. The procedure involved withholding the positive reinforcers for Carla’s screaming. The social worker instructed Juanita to stop making promises, stop putting away the toys, and walk away from Carla when she screamed about putting away her toys. She told Juanita that Carla’s screaming might get worse before it

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got better but that if she held firm, Carla’s screaming would gradually decrease. Juanita carried out these instructions and the duration of Carla’s screaming gradually decreased, after an increase on the second day of extinction. By the sixth day of the extinction intervention, Carla no longer screamed when told to put her toys away. The social worker also instructed Juanita to praise Carla and give her tangible reinforcers, such as gum or cookies, when she put her toys away. Juanita followed these instructions, and Carla began putting her toys away more frequently.

3. Bella and Cliff were older adults with memory impairment in a group conducted at a senior center. In social situations, they often asked questions and made comments that were unrelated to the topic being discussed. For example, when several group members were discussing a recent film, Cliff asked the person speaking if he was going grocery shopping that afternoon. The baseline rate of Bella’s speaking on topic was zero. In addition, Bella and Cliff were frequently observed talking continuously for 5 minutes or more without pausing for responses from others. These speech patterns resulted in their being ridiculed and excluded from conversations held by other group members. The social worker devised a conversational exercise for the six members of a group in which Bella and Cliff participated. The social worker began the exercise by making a statement and then asking each of the group members to add a statement to her introduction. Each new statement was required to bear logical connection to the preceding statement. For example, the social worker began speaking about how to cook dinner for oneself. At first, Bella and Cliff both added inappropriate statements, such as “You should see my grandson. He is so smart,” or “You know, when I was selling cars in New York I always was the top salesman of the month.” On these occasions, they were stopped by the social worker or group members, who asked them to make appropriate statements and complimented or praised them for doing so. Group members prompted Bella and Cliff, offering hints and suggestions for correct statements. As they practiced this exercise on subsequent occasions, both Bella and Cliff made fewer inappropriate remarks and increasingly more appropriate ones. The rate of Bella’s speaking on topic increased to five times per group meeting after six group sessions. The frequency of Bella’s and Cliff’s appropriate remarks during conversations

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outside the group was also observed to increase. Staff members and relatives reinforced Bella’s and Cliff’s appropriate speech.

4. At bedtime 3-year-old Jordy whined for more television time, and his father usually gave in. Jordy’s bedtime got later and later, and it became difficult to wake him in the morning. Jordy’s parents tried to get him to bed earlier, but Jordy always got his way. To extinguish Jordy’s whining, his father was instructed to turn off the TV at the same time every night, to tell Jordy there would be no more TV that evening, and to ignore his whining. At first, Jordy’s whining increased in intensity (volume), frequency, and duration, and he threw his toys on the floor. Jordy’s father continued to turn off the TV at Jordy’s bedtime each night, and Jordy’s whining began to decrease in frequency, duration, and intensity. On the seventh night, when his father turned off the TV, Jordy went immediately to his room and prepared for bed. Jordy’s father continued this procedure successfully for 2 weeks, and Jordy stopped whining at bedtime. One evening the following week, Jordy’s mother turned off the TV at his bedtime. Jordy whined, but the TV remained off. This incident of spontaneous recovery of Jordy’s whining was handled effectively—that is, Jordy’s mother reinstated the extinction procedure. In anticipation of the possible spontaneous recovery of Jordy’s whining, Jordy’s parents were instructed to remain firm in turning off the TV at bedtime. They were also told to inform anyone else who would be responsible for turning off the TV at Jordy’s bedtime to ignore his whining should it occur. In implementing the extinction procedure, we identify all individuals who have control over the availability or delivery of positive reinforcement for the target behavior in the person’s environment. These individuals are instructed to follow the extinction procedure consistently. In Jordy’s situation, both his mother and father, as well as babysitters and relatives, were instructed to turn off the TV and leave it off at the designated time so that Jordy’s whining would not be positively reinforced. During the course of extinction, Jordy’s parents were instructed to positively reinforce Jordy’s appropriate behaviors at bedtime. Such behaviors included picking out his clothes for the next day, asking for a story, kissing his parents good night, and saying good night to his parents.

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MODELING

BATOMALAQUE, VERGEL

ERLANDEZ, CATHERINE NALDA, JOHN MARK

SAILOG, JUVY ANN SAMALA, NICKY JONN

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HISTORY WHAT IS SOCIAL LEARNING THEORY? The social learning theory proposed by Albert Bandura has become perhaps the most influential theory of learning and development. While rooted in many of the basic concepts of traditional learning theory, Bandura believed that direct reinforcement could not account for all types of learning. While the behavioral theories of learning suggested that all learning was the result of associations formed by conditioning, reinforcement, and punishment, Bandura's social learning theory proposed that learning can also occur simply by observing the actions of others. His theory added a social element, arguing that people can learn new information and behaviors by watching other people. Known as observational learning (or modeling), this type of learning can be used to explain a wide variety of behaviors. Bandura explained: "Learning would be exceedingly laborious, not to mention hazardous, if people had to rely solely on the effects of their own actions to inform them what to do. Fortunately, most human behavior is learned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action." -Albert Bandura, Social Learning Theory, 1977 BASIC SOCIAL LEARNING CONCEPTS There are three core concepts at the heart of social learning theory. First is the idea that people can learn through observation. Next is the notion that internal mental states are an essential part of this process. Finally, this theory recognizes that just because something has been learned, it does not mean that it will result in a change in behavior. 1. People can learn through observation. OBSERVATIONAL LEARNING In his famous Bobo doll experiment, Bandura demonstrated that children learn and imitate behaviors they have observed in other people. The children in Bandura’s studies observed an adult acting violently toward a Bobo doll. When the children were later allowed to play in a room with the Bobo doll, they began to imitate the aggressive actions they had previously observed. Bandura identified three basic models of observational learning:

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A LIVE MODEL, which involves an actual individual demonstrating or acting out a behavior. A VERBAL INSTRUCTIONAL MODEL, which involves descriptions and explanations of a behavior. A SYMBOLIC MODEL, which involves real or fictional characters displaying behaviors in books, films, television programs, or online media. 2. Mental states are important to learning. INTRINSIC REINFORCEMENT Bandura noted that external, environmental reinforcement was not the only factor to influence learning and behavior. He described intrinsic reinforcement as a form of internal reward, such as pride, satisfaction, and a sense of accomplishment. This emphasis on internal thoughts and cognitions helps connect learning theories to cognitive developmental theories. While many textbooks place social learning theory with behavioral theories, Bandura himself describes his approach as a 'social cognitive theory.' 3. Learning does not necessarily lead to a change in behavior. While behaviorists believed that learning led to a permanent change in behavior, observational learning demonstrates that people can learn new information without demonstrating new behaviors. FINAL THOUGHTS In addition to influencing other psychologists, Bandura's social learning theory has had important implication in the field of education. Today, both teachers and parents recognize the importance of modeling appropriate behaviors. Other classroom strategies such as encouraging children and building self-efficacy are also rooted in social learning theory. MODELING AND OBSERVATIONAL LEARNING Classical and operant conditioning have dominated learning theory and research. A third type of learning, referred to as modeling or observational learning, also has been important in the development of behavioral research. Observational learning occurs when an individual observes another person (referred to as a model) engage in a particular behavior. The observer sees the model perform the behavior but does not engage in overt responses or receive any consequences. The observer learns the behavior merely by watching a model.

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We have observed modeling effects during decades of research with animals and humans, in addition to examples readily available in child rearing and other everyday experiences. More recent research has brought to light special cells in the brain (mirror neurons) that are activated when we observe someone else engaged in an activity. When we see someone performing an action or experiencing an emotion, our brain is activated in same areas as if we ourselves are performing the behavior or experiencing the emotion. To clarify modeling effects, it is important to distinguish learning from performance. By observing a model, the observer learns the responses or behaviors. It is assumed that this is accomplished through mental representation or cognitive processes (e.g., thoughts, images) that code the observed sequence of behaviors (Bandura, 1977). No overt behavior is required on the part of the recipient of a modeling experience to learn. However, whether a learned response is actually performed may depend on the consequences of the response or on the incentives associated with the response. The importance of response consequences in dictating performance was demonstrated in a classic laboratory study of modeling (Bandura, 1965). Children observed a film in which an adult modeled aggressive responses (hitting and kicking a large doll). For some children, the models’ aggression was rewarded; for others, it was punished; and for still others, it was met with no consequences. When the children were given the opportunity to perform the aggressive responses, those who had observed the aggression punished displayed less aggression than did those who had observed the aggression rewarded or ignored. To determine whether all of the children had learned the aggressive responses, an incentive was given to them for performing those responses. With the incentives, all three groups performed the aggressive responses equally .Apparently, all of the groups had learned the aggressive responses, but the consequences to the model (on the film) and the observer (the incentive given to the children) determined whether those responses would be performed. Observational learning is an ongoing and ever-present process. Of course, we do not necessarily learn or even notice many of the behaviors around us and consequently much of what we observe is not learned or not learned very well. The extent to which modeling stimuli influence learning and performance also depends on other factors, such as the similarity of the model to the observer; the prestige, status, and expertise of the model; and the number of models observed. As a general rule, imitation of a model by an observer is greater when the model is similar to the

181 | P a g e observer, more prestigious, and higher in status and expertise than the observer, and when several models perform the same behavior. Different types of prompts are often combined. For example, in one study the goal was to develop imitation among children with Autism. Teaching children to imitate is very useful for teaching a broad range of other skills (language, communication, social behavior). Modeling was used by having a trainer model a facial expression; if the child was not paying attention, a verbal prompt was added (“Do this”).” The goal was to have the child imitate the facial expression. When the child did, praise was added to reinforce imitation. This example is important to convey prompts in context. And in operant conditioning modeling is an effective way to get behaviors to occur, while reinforcement maintains the behavior after it occurs. For example, the gradual approach of hierarchies and shaping is often useful. In acquiring new social skills the client may be exposed to models that behave in gradual approximations to the final complex behaviors. Or in reducing a fear the client may be exposed to models that gradually approach the feared object. DEFINITION MODELING, which is also called observational learning or imitation, is a behaviorally based procedure that involves the use of live or symbolic models to demonstrate a particular behavior, thought, or attitude that a client may want to acquire or change. Modeling is sometimes called vicarious learning, because the client need not actually perform the behavior in order to learn it. A person’s behavior often changes merely as a result of observing the behavior and behavior consequences of someone else. A teenager may adopt some of the dress and mannerisms of his socially successful peers. A new employee in an organization may best learn his job by observing an older employee. Behavior change that results from the observation of the behavior of another is called modeling (Bandura, 1969). It is also called observation learning, imitation, vicarious learning, and social learning. What is “observed” is the: o behavior of the model o the consequences of this behavior o verbal cues and instructions of the model.

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One can acquire intricate response patterns merely by observing the performances of appropriate models; emotional responses can be conditioned observationally by witnessing the affective reactions of others undergoing painful or pleasurable experiences; fearful and avoidant behavior can be extinguished vicariously through observation of modeled approach behavior toward feared objects without any adverse consequences accruing to the performer; inhibitions can be induced by witnessing the behavior of others punished; and finally, the expression of well- learned responses can be enhanced and socially regulated through the actions of influential models. MODELING PRINCIPLE: To teach a child new ways of behaving, allow him to observe a prestigeful person performing the desired behavior. PURPOSE Modeling therapy is based on social learning theory. This theory emphasizes the importance of learning from observing and imitating role models, and learning about rewards and punishments that follow behavior. The technique has been used to eliminate unwanted behaviors, reduce excessive fears, facilitate learning of social behaviors, and many more. Modeling may be used either to strengthen or to weaken previously learned behaviors. Modeling has been used effectively to treat individuals with anxiety disorders, post- traumatic stress disorder , specific phobias , obsessive-compulsive disorder , eating disorders, attention-deficit/hyperactivity disorder ,and conduct disorder . It has also been used successfully in helping individuals acquire such social skills as public speaking or assertiveness. The effectiveness of modeling has led to its use in behavioral treatment of persons with substance abuse disorders, who frequently lack important behavioral skills. These persons may lack assertiveness, including the ability to say "no"; in addition, they may have thought patterns that make them more susceptible to substance abuse. Modeling when used alone has been shown to be effective for short-term learning. It is, however, insufficient for long-lasting behavior change if the target behavior does not produce rewards that sustain it. Modeling works well when it is combined with role-play and reinforcement. These three components are used in a sequence of modeling, role-play, and reinforcement. Role- play is defined as practice or behavioral rehearsal of a skill to be used later in real-life situations. Reinforcement is defined as rewarding the model's performance or the client's performance of the newly acquired skill in practice or in real-life situations.

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Several factors increase the effectiveness of modeling therapy in changing behaviors. Modeling effects have been shown to be more powerful when: o The model is highly skilled in enacting the behavior; is likable or admirable; is friendly; is the same sex and age; and is rewarded immediately for the performance of the particular behavior. o The target behavior is clearly demonstrated with very few unnecessary details; is presented from the least to the most difficult level of behavior; and several different models are used to perform the same behavior(s). WHAT DETERMINES WHETHER WE WILL IMITATE THE BEHAVIOR OF A MODEL? The more influential model is often a person who is significant to the observer. Thus children often model after parents, students model teachers, and clients model therapists (which many therapists interpret as improvement). Or the model may be a purposed expert, celebrity, or simply someone who is effective at doing or achieving what the observer wishes. Often the model is someone similar to the observer so that the consequences of the model’s behavior are seen as relevant to what may happen to the observer for acting similarly. The model may also be presented on film or television, be a real person or fictional character, or be a character in a book or cartoon. Thus modeling arises in a wide range/of situations from watching people to reading a book. This gives modeling a broad field of importance and application, but also makes its exact nature and boundaries a little hazy. The influence of the mass media, such as movies and television, gives modeling particular social importance. Although someone may model many behaviors from one model, as a girl may model her mother, it is common for the observer to take diverse combinations of behaviors from different models, often abstracting basic strategies of responding (such as being more cooperative with teachers or being less aggressive socially) rather than specific behaviors. The effects of modeling are also often transient and easily changed. For if the new modeled behavior is not useful (e.g., reinforcing) to the person, it will be altered or abandoned. This is why modeling and operant procedures often fit together well. We are all continually involved in these types of processes, picking up behaviors and strategies from various models, trying out different behaviors, and keeping those that currently “work” for us.

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Modeling is very prevalent, it is a key part of many behavior change programs, but there is no theoretical agreement on how it works. An operant analysis of modeling might be based on the person being reinforced for imitating others’ behavior. But such an approach is sometimes strained to account for the initial acquisition of novel responses, acquisition when there is no overt response to be reinforced, and situations in which there is no apparent reinforcement or the reinforcement is delayed for a long time. Bandura (e.g., 1 971a) argues for a social learning theory approach to modeling. Here modeling is seen as providing information that the person acquires as symbolic representations of the modeled event. Bandura suggests four processes are involved: attentional processes, retention processes, motor reproduction processes, and incentive or motivational processes. ATTENTIONAL PROCESSES regulate the sensory input and perception of the modeled event. Included here are attributes of the model that attract attention and incentives (e.g., possible reinforcement) to attend to the event. RETENTION PROCESSES refer to coding processes by which the observed event is translated into a guide for future performance. Note that what is stored is not simply what was observed, but a coded representation, perhaps abstracting information from several events or sources. Retention processes also include rehearsal of the experiences within the symbolic system. Retention may be facilitated by having the client or model summarize or describe what happened and/or have the client practice the modeled behavior. MOTOR REPRODUCTION PROCESSES refer to the integration of various constituent acts into new response patterns. INCENTIVE OR MOTIVATIONAL PROCESSES determine whether observationally acquired responses will be performed. According to Bandura, the role of reinforcement and incentives is to facilitate attention to the modeled event and encourage rehearsal and translation into overt behavior. Thus it is often desirable to have the model receive reinforcement for his behaviors or have the model the one who controls the reinforcement the observer may receive. GUIDELINES FOR USING MODELING The following are some general guidelines for the effective use of modeling. It may not be possible to follow all of them in every situation, but the more that are followed, the more effective the modeling is likely to be.

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1. Select models who are friends or peers of the learner and who are seen by the learner as competent individuals with status or prestige. 2. Use more than one model. 3. The complexity of the modeled behavior should be suitable for the behavioral level of the learner. 4. Combine rules with modeling. 5. Have the learner watch the model perform the behavior and receive reinforcement (preferably by natural reinforcers). 6. Design the training so that correct imitation of the modeled behavior will lead to a natural reinforce for the learner. If this is not possible, arrange for reinforcement for correct imitation of the modeled behavior. 7. If the behavior is quite complex, then the modeling episode should be sequenced from very easy to more difficult approximations for the learner. 8. To enhance stimulus generalization, the modeling scenes should be as realistic as possible. 9. Use fading as necessary so that stimuli other than the model can take control over the desired behavior. DESCRIPTION TYPES OF MODELING Therapy begins with an assessment of the client's presenting problems. The assessment usually covers several areas of life, including developmental history (the client's family background, education, employment, social relationships); past traumatic experiences; medical and psychiatric history; and an outline of the client's goals. The client works with the therapist to list specific treatment goals; to determine the target behaviors to be learned or changed; and to develop a clear picture of what the behaviors will look like. The therapist then explains the rationale and concepts of the treatment. He or she also considers any negative consequences that may arise as the client makes changes in his or her behavior. The client then observes the model enacting the desired behavior. Some models may demonstrate poor or inadequate behaviors as well as those that are effective. This contrast helps the client to identify ineffective behaviors as well as desired ones. Modeling can be done in several different ways, including live modeling, symbolic modeling, participant modeling, or covert modeling.

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LIVE MODELING refers to watching a real person, usually the therapist, perform the desired behavior the client has chosen to learn. For example, the therapist might model good telephone manners for a client who wants a job in a field that requires frequent telephone contact with customers. SYMBOLIC MODELING includes filmed or videotaped models demonstrating the desired behavior. Other examples of symbolic models include photographs, picture books, and plays. A common example of symbolic modeling is a book for children about going to the hospital, intended to reduce a child's anxiety about hospitals and operations. With child clients, cartoon figures or puppets can be used as the models. Self-modeling is another form of symbolic modeling in which clients are videotaped performing the target behavior. The video is than replayed and clients can observe their behaviors and how they appear to others. For example, public speaking is one of the most common feared situations in the general adult population. A law student who is afraid of having to present arguments in a courtroom might be videotaped speaking to classmates who are role-playing the judge and members of the jury. The student can then review the videotape and work on his or her speech problems or other aspects of the performance that he or she would like to change. PARTICIPANT MODELING, the therapist models anxiety-evoking behaviors for the client, and then prompts the client to engage in the behavior. The client first watches as the therapist approaches the feared object, and then approaches the object in steps or stages with the therapist's encouragement and support. This type of modeling is often used in the treatment of specific phobias. For example, a person who is afraid of dogs might be asked to watch the therapist touch or pet a dog, or perhaps accompany the therapist on a brief walk with a dog. Then, with the therapist's encouragement, the client might begin by touching or holding a stuffed dog, then watching a live dog from a distance, then perhaps walking a small dog on a leash, and eventually by degrees touching and petting a live dog. COVERT MODELING, clients are asked to use their imagination, visualizing a particular behavior as the therapist describes the imaginary situation in detail. For example, a child may be asked to imagine one of his or her favorite cartoon characters interacting appropriately with other characters. An adult client is asked to imagine an admired person in his or her life performing a behavior that the client wishes to learn. For example, a person may greatly admire his or her mother for the way she handled the challenges of coming to the United States from another country. If the

187 | P a g e client is worried about the challenge of a new situation (changing careers, having their first child, etc.), the therapist may ask him or her to imagine how their mother would approach the new situation, and then imagine themselves acting with her courage and wisdom. Models in any of these forms may be presented as either a coping or a mastery model. The coping model is shown as initially fearful or incompetent and then is shown as gradually becoming comfortable and competent performing the feared behavior. A coping model might show a small child who is afraid of swimming in the ocean, for example. The little boy or girl watches smaller children having fun playing in the waves along the edge of the shore. Gradually the child moves closer and closer to the water and finally follows a child his or her age into the surf. The mastery model shows no fear and is competent from the beginning of the demonstration. Coping models are considered more appropriate for reducing fear because they look more like the client, who will probably make mistakes and have some setbacks when trying the new behavior. Having the model speak his or her thoughts aloud is more effective than having a model who does not verbalize. As the models speak, they show the client how to think through a particular problem or situation. A common example of this type of modeling is sports or cooking instruction. A golf or tennis pro who is trying to teach a beginner how to hold and swing the club or racquet will often talk as they demonstrate the correct stance and body movements. Similarly, a master chef will often talk to students in a cooking class while he or she is cutting up the ingredients for a dish, preparing a sauce, kneading dough, or doing other necessary tasks. The model's talking while performing an action also engages the client's sense of hearing, taste, or smell as well as sight. Multisensory involvement enhances the client's learning. ROLE-PLAYING Role-playing is a technique that allows the client opportunities to imitate the modeled behaviors, which strengthens what has been learned. Role-play can be defined as practice or behavior rehearsal; it allows the client to receive feedback about the practice as well as encouraging the use of the newly learned skill in real-life situations. For example, a group of people who are trying to learn social skills might practice the skills needed for a job interview or for dealing with a minor problem (returning a defective item to a store, asking someone for directions, etc.). Role-play can also be used for modeling, in that the therapist may role-play certain situations with clients. During practice, the therapist frequently coaches, prompts, and shapes the client's

188 | P a g e enactment of the behavior so that the rehearsals can come increasingly close to the desired behavior. Feedback and social reinforcement of the client's performance in the practice phase is an important motivator for behavior change. Feedback may take the form of praise, approval, or encouragement; or it may be corrective, with concrete suggestions for improving the performance. Suggestions are followed by additional practice. Such tangible reinforcements as money, food, candy, or tokens have been used with young children and chronic psychiatric patients. The therapist may teach the client how to use self-reinforcement; that is, using self-praise after performing the desired behavior. The purpose of reinforcement is to shift the client's performance concerns from external evaluation by others to internal evaluation of their own efforts. MODELING IN GROUP SETTINGS Modeling has been shown to be effective in such group programs as social skills training and assertiveness training as well as in individual therapy. The general approach to both social skills training and assertiveness training is the incorporation of the modeling, role-play, and reinforcement sequence. After assessment of each group member's presenting problem, each member is asked to keep a diary of what happened when the situation occurred during the week. Group members develop goals for dealing with their individual situations, and each person determines how he or she can meet these goals. Modeling is done with either the therapist or other group members role-playing how to deal effectively with a particular problem situation. LENGTH OF TREATMENT While modeling therapy is a relatively short-term approach to behavioral change, some therapeutic techniques take longer than others. Imagery, for example, requires more sessions than in vivo (real-life) treatments. In vivo work that takes place outside the therapist's office would require longer time periods for each session. Other considerations include the nature of the client's problem; the client's willingness to do homework; the client's financial resources; and the presence and extent of the client's support network. The therapist's length of experience and personal style also affect the length of therapy. There are, however, guidelines of treatment length for some disorders. Treatment of obsessive-compulsive disorder may require five weekly sessions for approximately three weeks, with weekly follow-up sessions for several months. Depressive disorders may require three to six months, with the client experiencing short-term relief after three to four weeks of treatment.

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General anxiety disorder may also take several months of weekly sessions. The length of treatment depends on the ability to define and assess the target behaviors. Clients may meet with the therapist several times a week at the beginning of treatment; then weekly for several months; then monthly for follow-up sessions that may become fewer in number or spaced more widely until therapy is terminated. NORMAL RESULTS Modeling or observational learning is effective as a method of learning such behaviors as self-assertion, self-disclosure, helping others, empathic behaviors, moral judgment, and many other interpersonal skills. Modeling is also effective in eliminating or reducing such undesirable behaviors as uncontrolled aggression, smoking, weight problems, and single phobias. The expected outcome is that clients will be able to use their new behaviors outside the treatment setting in real-life situations. This result is called transfer of training, generalization, or maintenance. Homework is the most frequently used technique for transfer of training. Homework may represent a contractual agreement between the therapist and the client in which the client gives a report on his or her progress at each meeting. To ensure that generalization occurs and that clients will use their new skills, several "transfer enhancers" are used to increase the likelihood of successful transfer of training. Transfer enhancers include:  Giving clients appropriate rationales and concepts, rules, or strategies for using skills properly.  Giving clients ample opportunity to practice new skills correctly and successfully.  Making the treatment setting as much like the real-life situation as possible.  Giving clients opportunities to practice their new skills in a variety of physical and interpersonal settings.  Giving clients adequate external social reinforcement and encouraging internal self- reinforcement as they use their skills successfully in real life Examples  An infant learns to make and understand facial expressions  A child learns to chew  After witnessing an older sibling being punished for taking a cookie without asking, the younger child does not take cookies without permission

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 A newer employee avoids being late to work after seeing a co-worker fired for being late  A child learns to walk  A child learns how to play a game while watching others  A child shows that she has learned the basic steps of cooking a meal by doing so at a play kitchen in her classroom  A child learns a science concept by demonstration from the teacher  After watching her mother, a young girl shows she has learned how to hold a baby by walking around with the baby in her arms the correct way  An inexperienced salesperson is successful at a sales meeting after observing the behaviors and statements of other salespeople  A child shows observational learning of how to drive a car by making appropriate motions after seeing a parent driving  A young boy swings a baseball bat without being explicitly taught how to do it after attending a baseball game  A young girl watches a basketball game, then shoots hoops without being explicitly taught how to do so  Without previous experience, a child puts on roller skates and skates without being taught.  A student learns not to cheat by watching another student be punished for cheating  A girl sees another child fall on ice in front of her so she avoids stepping on the ice  A person moves to a new climate and learns how to properly remove snow from his car after watching others  A tenant sees a neighbor evicted for late rent payment and as a result consistently pays her rent on time  A new customer in a store learns the process for lining up and checking out by watching other customers  A woman in a clothing store learns the procedure for trying on clothes by watching others  A man in a coffee shop learns where to find cream and sugar by watching other coffee drinkers locate that area  A new car salesperson learns how to approach potential customers by watching others  A girl learns how to mow her own lawn by watching neighbors mowing their lawns

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CASE STUDY 1. O’Connor (1969) used modeling to overcome severe social withdrawal in some nursery schoolchildren. The children were shown a film depicting increasingly more active, positive, social interactions among children. The narrative soundtrack emphasized the appropriate behavior of the models. Viewing this film increased the observers’ social interaction to a level equal to other children. In a later variation of this study, O’Connor (1972) compared the effects of seeing the modeling film or a control film coupled with the presence or absence of later social reinforcement for social interaction. He found that modeling by itself was faster than social reinforcement by itself and the behavior changes following modeling, with or without reinforcement, were more stable than the changes following just social reinforcement. This suggests that adding reinforcement did not significantly change the effects due to modeling alone. But perhaps there was a ceiling effect: there was little more room for improvement following modeling.

2. Altruistic behavior can also be enhanced by modeling. If children are exposed to models who show altruistic behavior, such as giving or helping, the children will often imitate this type of behavior (Bryan & London, 1970). Bryan and Test (1967) have reported a number of naturalistic studies of altruism with adults. In one study an undergraduate female was stationed beside a control car with a flat tire so that she was conspicuous to passing traffic. In the model condition another car, located one-quarter mile down the road, had a girl watching a male changing a flat tire. In the no-model condition there was only the control car. Significantly more people (mostly men) stopped their cars to help the control girl in the model condition than in the no-model condition.

3. Exposing people to scenes of violence would increase the observers’ tendency to act violently. This seems to be the case as supported by studies by researchers such as Berkowitz (1971) and Bandura. For example, in one experiment (Bandura et al., 1961) some nursery school children watched an adult model be aggressive toward a large, inflated plastic doll; others watched the same model act non-aggressively toward the doll; and others had no exposure to models. After being mildly frustrated, the children were given access to the doll. The children who had seen the aggressive model imitated many of the model’s aggressive behaviors; the other children showed significantly less aggressive behavior. Observation of the news over the last few years shows how

192 | P a g e types of violent acts occur in clusters: mass killings, burning slums, campus riots, skyjackings, and political kidnappings. Although there are many reasons for these different acts, the time and way in which they occur suggest that exposure to models may be important in the occurrence of these events.

4. One study compared children who had seen a lot of television and resulting violence with children who had seen much less (Cline et al., 1973). The children who had seen a lot were significantly less autonomically and used by a violent film. Perhaps exposure to violence has a desensitization effect so that one becomes less aroused by violence. This may be one factor in the development of some people’s apathy to violence and the need for more violence to be exciting. There is the famous case of the girl in New York who was assaulted, raped, and murdered over a period of one half hour while more than 40 people were aware of her distress. Yet no one came to her aid directly or indirectly, such as calling the police.

5. Similar modeling effects have been observed with suicides. After a suicide has been publicized in a newspaper, there is a rise in the suicide rate in the area the paper serves. The more publicity devoted to the suicide story, the larger the rise in suicides (Phillips, 1974).

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TOKEN

ECONOMY

BINAYUG, GIDEON RIEL

DACARA, KATRINA FRANCISCO, GHENELYN

GASPAR, DIANA MARIE SORIANO, KARLMARX VLADIMIR

VELASCO, JUSTIN

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INTRODUCTION A token economy is a system of behavior modification based on the systematic reinforcement of target behavior. The reinforcers are symbols or "tokens" that can be exchanged for other reinforcers. A token economy is based on the principles of operant conditioning and can be situated within applied behavior analysis (behaviorism). In applied settings token economies are used with children and adults; however, they have been successfully modeled with pigeons in lab settings. HISTORY 1960s – Teodoro Ayllon, Nathan Azrin and Leonard Krasner were important pioneers in these early years. 1961 – the very first token economy bearing that name was founded by Ayllon and Azrin at Anna State Hospital in Illinois. 1970s – the token economies came to a peak and became widespread. 1980s – despite this success, token economies declined from the 1980s on, due to a variety of problems and criticisms. BASIC REQUIREMENTS  TOKENS Tokens must be used as reinforcers to be effective. A token is an object or symbol that can be exchanged for material reinforcers, services, or privileges (back-up reinforcers). In applied settings, a wide range of tokens have been used: coins, checkmarks, images of small suns, points on a counter. These symbols and objects are comparably worthless outside of the patient-clinician relationship, but their value lies in the fact that they can be exchanged for other things. Technically speaking, tokens are not primary reinforcers, but secondary or learned reinforcers. Examples:

Coins Chips Stickers or Stamps

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 BACK-UP REINFORCERS Tokens have no intrinsic value, but can be exchanged for other valued reinforcing events: back-up reinforcers. It can be a Material reinforcers like sweets, toys, money (although money holds value outside of the patient-clinician relationship); Services like breakfast in bed, having your room cleaned, activities and ; Privileges like passes for leaving the building or area, permission to use the phone or gadgets, attending concerts. Back-up reinforcers are chosen in function of the individual or group for which the token economy is set up, or depending upon the possibilities available to the staff. Prior to starting the staff decides how many tokens have to be paid for each back-up reinforcer. Often, price lists are exposed or given to the clients. Some back-up reinforcers can be bought anytime, for other exchange times are limited (e.g. opening times of a token shop).  SPECIFIED TARGET BEHAVIORS There is a broad range of possible target behaviors: self-care, attending activities, academic behavior, disruptive behavior. A token economy is more than just using exchangeable tokens. For a token economy to work, criteria have to be specified and clear. A staff member giving tokens to a client just because he judges he is behaving positively, is not part of a token economy because it is not done in a systematic way. Sometimes client manuals have specifications how many tokens can be earned by each target behavior. Forinstance, if making the bed is a target behavior, staff and clients have to know how a well-made bed looks like: do the sheets have to be put under the mattress, cushion on top? However, often these specifications are hard to make: behavior such as eating politely and positive cooperation are hard to specify. While planning how many tokens can be earned by each target behavior some factors have to be considered: on the one hand clients should be able to earn a minimal amount of tokens for a minimal effort, and on the other hand clients should not earn too much too soon, making more effort useless. Sometimes the possibility of punishment by token loss is included, technically called 'response cost': disruptive behavior can be fined with the loss of tokens. This also should be clearly specified before the application starts. Clients can be involved in the specifying of the contingencies.

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FEATURES OF TOKEN ECONOMY  SOCIAL REINFORCEMENT Token reinforcement is essential, but is always accompanied by social reinforcement. Tokens are intended to make reinforcement explicit and immediate, and to strengthen behavior, but in the end social reinforcement should be sufficient to maintain what’s been learned.  SHAPING All principles of operant learning are applied within a token economy. Shaping implies clients aren’t expected to do everything perfectly at once; behavior can be acquired in steps. Initially clients can be reinforced for behavior that approaches the target. If the target behavior is keeping attention during a 30 minutes session, clients can initially already get (perhaps smaller) reinforcement for 5 minutes of attention.  IMMEDIACY OF REINFORCEMENT Reinforcement will greater influence behavior if given shortly after the response is emitted. The longer people have to wait for a reward, the less effect and the less they will learn. This is the principle of delay discounting. Immediate token reinforcement can bridge later reinforcement.  LEARNING TO PLAN AHEAD AND SAVE EARNINGS Sometimes clients can earn larger rewards like the permission to spend a weekend at home, going to a movie, or having a class excursion. When such rewards would be given at once for one instance of a target behavior, the scarce resources would soon be depleted and consequently the incentives would be lost. One advantage of tokens is they can be used to divide larger rewards into parts: clients can save tokens to buy more expensive rewards later. This implies they shouldn’t immediately spend all earned tokens on attractive smaller rewards, and instead learn to plan ahead. This way they can acquire self-control.  INDIVIDUAL AND GROUP CONTINGENCIES Mostly token economies are designed for groups. The system is running for a whole ward or class. Within this group contingency specific individual goals and reinforcers can be added. Though sometimes a token economy is designed for only one specific individual.  CONSISTENT APPLICATION The power of a token economy largely depends on the consistency of its application. To achieve this thorough staff training is essential. Some token economies failed exactly on this point.[5] Token economies imply rights and duties for clients as well as for staff. When, according

197 | P a g e to the system, a client deserves tokens, he should get them, even when a staff member judges he doesn’t deserve them because he has been impolite the day before. Family education and involvement is very important. They can support the system or they can undermine it, for instance by secretly giving undeserved rewards.  LEVELED SYSTEM Often token economies are leveled programs. Clients can pass through different levels until they reach the highest level. At that point behaviors are performed without token reinforcement. Higher levels require more complex behaviors. The incentive to progress from one level to the next is the availability of increasingly desirable reinforcers. TOKEN ECONOMY GUIDE (1) The first step in creating a token economy comprises an assessment period. In the assessment period, trained observers count the number of times maladaptive behaviors occur during a set time frame. (Kazdin, 2001). (2) Select behaviors to change. Target behaviors are determined by the type of individuals with whom you are working, by the short-range and long-range objectives you wish to accomplish, and by specific behavioral problems you are encountering that interfere with such objectives. (Kazdin, 2001) (3) Select primary and secondary reinforcers (Kazdin, 2001). Primary reinforcers are naturally reinforcing. A person does not need to learn that they are reinforcing because they satisfy some basic need, such as hunger, thirst, safety, etc. (4) Dispensing Reinforcers. Consider the general method of dispensing with the reinforcers, such as a store, treasure chest, and a method of recording purchases. (5) Selecting the type of token. Poker chips, marks on a chart on the wall or in notebooks, stars pasted in booklets. Tokens should be attractive, lightweight, portable, durable, easy to handle, and not easily counterfeited. Children will also need a way to store their tokens, such as in a box or bag. (6) Assign point values to the specific target behaviors (Kazdin, 2001). It is a good idea to break down complex tasks into more easily defined parts and assign a value for each of these parts. So, in cases where students can partially complete a task, they can be rewarded for their success.

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(7) Select helpful participants. Who will help with the token economy? Teacher's aides, paraprofessionals, members of the token economy itself? Consider how the helping behavior will be reinforced. (8) Ensure immediate success (Mather & Goldstein, 2008). Set the behavioral criteria at a level that students are initially likely to succeed. We want them to get the reinforcers to show them that appropriate behavior will be rewarded. Gradually the set criteria can become more stringent as a way of increasing more desirable behaviors and reducing the inappropriate ones. (9)Change rewards to maintain interest. Often students will habituate to the rewards given so it is incumbent upon the educator to make sure that they don’t become bored with the same reinforcers over and over again. (10) Decide on specific implementation procedures ADVANTAGES AND DISADVANTAGES OF TOKEN ECONOMY ADVANTAGES:  Most students respond to a good token economy class.  Behaviors can be awarded immediately.  Rewards are the same for all members of the group.  Individuals can learn skills related to planning for the future.  Use of punishment (response cost) is less restrictive than other forms of punishment. DISADVANTAGES:  Consistency  It can get expensive  Unintentionally neglect rights of patients if staff members are inadequately trained  Effort in extensive staff training  Some find it time-consuming and impractical  Undesirable back-up reinforcers  Ineffective reinforcement schedule

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DIFFERENCE FROM OTHER THERAPIES:  Goal is to increase desirable behavior and decrease undesirable behavior with the use of tokens.  Often used in institutional settings (psychiatric hospitals and correctional facilities) wherein aggressive or unpredictable behavior is common.  Can also be used in special education, regular education, colleges, various types of group homes , military divisions, nursing homes, addiction treatment programs, occupational settings, family homes.  Can be used individually or by group.

CASE STUDY CASE STUDY NO. 1 “TOKEN ECONOMY PROGRAM: MAX” Max is a 15-year-old boy with autism spectrum disorder (ASD), who is also educated on basic general education setting. Recently, Max has problems in focusing on his math seatworks. Too often than not, he stares on outside the windows or the pictures in the classroom. Mr. Brown his math teacher, seeing this problem, approaches the resource teacher, Ms. Kelly. After hearing this, Ms. Kelly knew that he could use the token economy program. Before setting up the program, Ms. Kelly wanted to establish a base line. She collected the baseline data over the four consecutive days. In her data, Max was prompted 15 times within 5 minutes in doing his individual work. Next, Ms. Kelly identifies potential reinforcers by having Max select desirable items on a reinforcer menu. The identified items (e.g., extra time on the computer, skipped homework assignment, listen to music) will be placed in the “store.” Max will be able to “purchase” these items once he has acquired enough tokens. After the reinforces have been identified, Ms. Kelly establishes the token economy program. She does this by identifying the “token” and by setting up the system in which to exchange the token. Ms. Kelly also decides that Max will carry the “bank”, where he will put his money, with him. Ms. Kelly also established the “store”, where he can exchange his tokens for the given items in the menu. She plans on letting Max to purchase at the store every other day,

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Monday, Wednesday and Friday. But after a while, she makes it a long time before he can buy again. Just before Ms. Kelly and Mr. Brown implement the token economy program, they sit down with Max and describe how the system will work. They tell him that he needs to finish his seatwork without Mr. Brown’s help. Ms. Kelly explains that Mr. Brown will set a timer on his watch for 2 minutes. If Max does his work and does not look out window or at the pictures in the classroom during this time, Mr. Brown will give him a token to put in his special wallet. Ms. Kelly also explains that Max will be able to come to the “store” in her office to buy things on Mondays, Wednesdays, and Fridays. As they explain the system to Max, they also give him a card that outlines all the rules for receiving tokens (see below). I will do my work without Mr. Brown’s help for 2 minutes. Classroom Rules 1. I will do my work during math class. 2. I will not look out the window or look at the pictures in the classroom while I am doing my work. 3. When the timer beeps, I will get a token. The next day, as Mr. Browns hands out the math seatwork. He reminded Max the rules and as such, he placed the card in Max’s stable so he wouldn’t forget it. When Mr. Brown hands out the seatwork assignment, he briefly pauses at Max’s desk and says, “Remember the rules, Max,” while pointing to the card on his desk. Mr. Brown then sets his watch timer for two minutes. Max starts working on his assignment, but is looking out the window after about one minute. Mr. Brown walks over to Max’s desk and points to the rules again and says, “Remember the rules, Max. Finish your work.” Mr. Brown then sets his watch timer again. This time, Max stays on task for two minutes. When the timer rings, Mr. Brown immediately gives him a token and says, “You did your work by yourself, Max. Now here’s your token.” Mr. Brown repeats this process during the remainder of individual seatwork time. After class, Max walks with Ms. Kelly to the resource room and “buys” an item off the menu. When she was setting up the menu, Ms. Kelly made sure to include a variety of reinforcers at different prices. This way, there are lower-priced items that Max can purchase immediately to keep him motivated and to help him understand how the token economy program works. As Max increases his time on task and is able to complete seatwork independently, Ms. Kelly will periodically

201 | P a g e adjust the prices to maintain Max’s motivation. Strategies will also be implemented to fade the use of tokens.

CASE STUDY NO. 2 BEFORE THE INTERVENTION: “Tommy”, age 14, is oppositional to his parents. He says “no”, yells, and does not listen when his parents ask him to do anything. For example, when being asked to turn down the TV, Tommy says no. When asked to clean his room or take out the trash for his chores, Tommy says no. Even when asked to sit at the table to eat meals, Tommy says “no”. Tommy’s parents feel Tommy has control of the house, as he will not listen to their requests. The parents usually end up yelling at Tommy as a result of hisrefusal of requests and combativeness. Tommy’s parents feel frustrated and feel like they have a poor relationship with their son. They feel like Tommy’s behaviors will continue to get worse and think it is time to address these problem behaviors. THE INTERVENTION: Our goal is to implement a reward system that will help decrease/change Tommy’s problem behavior.Tommy’s problem behaviors need to first be identified. Step One. Identify problem behavior. Parents should observe the child’s behavior and decide what the problem behavior is. In Tommy’s case, the problem behavior was his refusal and oppositional yelling when being asked to complete/do a request by his parents. Once the behavior is determined, parents should observe what actions are occurring prior or before the problem behaviors. This is known as the antecedent to the behavior. In Tommy’s case, he was always doing what he wanted to do, like playing video games, watching TV, playing outdoors or riding his bike. The parents determined the antecedent to Tommy’s poor behavior was the parents interrupting Tommy’s own set plans. Parents should then observe how the child and parents react to the problembehavior(s). This is known as the consequence of the behavior. Tommy and his parents would end up yelling at each other, resulting in the original request being completed by the parents and Tommy continuing what he wanted to do. Through identifying the antecedent, behavior, and consequence (or A-B-C), parents can better understand the problem behavior to develop a point/reward system to encourage positive behaviors. Throughout the A-B-C process, Tommy’s parents realized they were demanding Tommy to complete his chores, turn off the TV, et cetra before asking him nicely. They also realized they never sat down andtalked calmly with Tommy

202 | P a g e about his behaviors, asking Tommy how he felt, or addressing his chores and rules. Tommy’s parents then did just that and talked to Tommy. Step Two and Three. Discuss with the child their feelings regarding their behavio rs and set structure and rules.In the discussion, the parents talked about the rules and chores of the house. Tommy reported he did not think he had to listen. At this point, Tommy and his parents began yelling. This is a time when a time-out should take place. Regain composure– stay calm and most importantly do not push the subject. Attempt to talk again in a few days. Tommy and his parents started talking a few days later. Validate or address how the child feels. Parents should also address their feelings as well. Parents should firmly set the rules. Tommy had chores to complete. When they were not completed, his parents stated they would take away TV, playing, and video game time. Step Four and Five. Identify point/reward system and discuss the system with the child. After discussing rules and setting structure, discuss the point/reward system. Tommy’s parents know he loves video games. Previously Tommy’s parents decided that for every time Tommy followed a direction/rule, like turning off the TV or video game when asked, going to bed on time, coming to the table to eat, that he would receive a point. Parents should start lower with the amount of points it will take to receive an award, as they should continually set a gradual positive behavior progress. For every fifteen points Tommy earned from having good behavior, he could choose to be rewarded with two minutes extra video game time or to put $1 towards a new video game. Tommy understood when he did not listen points would be taken away, as well as his regular privileges. After having one month of good behaviors, with enough “money” in the bank, Tommy could be eligible to get a new video game. Step Six, Seven, and Eight. Monitor and model behavior, keep structure, and reinforce desired behaviors. Tommy’s progress would be kept on the family refrigerator for him to view his own progress. Parents should model the behaviors they want to see in their child, for the child to see what the parents expect of them. Even if the child’s behaviors are not appearing to improve, parents need to keep the structure of the point system and follow their set rules. AFTER THE INTERVENTION: Tommy’s oppositional behaviors have decreased. The process was not a quick and simple fix. Tommy and his parents were not able to sit down and discuss the intervention process in one day. Throughout the process, Tommy did not agree with his parents, for example, when setting

203 | P a g e rules. At other times, the parents did not agree with Tommy’s reasoning. Tommy understood for every time he had good behavior he received a point. At first, Tommy was compliant with his parent’s requests as he wanted more TV and game time and wanted a new video game. Tommy reached fifteen points and traded it for two minutes extra video game time. But soon, Tommy got tiredof listening as he was not receiving what he wanted immediately. Tommy’s behaviors began decreasing. Tommy’s parents did not like seeing Tommy’s problem behaviors returning. They continued to model the behavior they wanted to see and follow the rules they previously set. They also continued to take points away when Tommy did not listen, and added points when he did listen; they kept structure. Tommy was able to view his progress on the refrigerator. He saw thateven though he would have bad days, he was still working towards his goals of more TV time and a new video game. Tommy realized points he received each day added up quickly. Tommy’s parents continually gave him praise and attention for his good behaviors, which Tommy liked. They had more open communication, with arguments at times, but soon their relationship began improving. Each week that passed, Tommy began to notice it was easier for him to follow rules and listen to his parents. As Tommy’s behaviors improved, the reward system needed to be modified to keep Tommy moving towards the goal of positive behaviors. By the end of the third month, Tommy and his parents were discussing new possible rewards for every 25 points he earned.

CASE STUDY NO. 3 BEFORE THE INTERVENTION “Ben”, age 16 is a person who is quite addicted to online games that comes to the point that he uses all of his allowance. Resulting to frustration of his parent and feeling of detachment to their child. They decided no to address these problematic behavior. THE INTERVENTION Goal! To implement a reward system that will help decrease/change problematic behavior! Step one: Identify Problem Behavior A-B-C Process: through this, we can better understand the problem behavior to develop a plan.

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Step two and three: Discuss Feeling regarding to the behavior and set structures and rules. Step four and five: Identify point/reward system and discuss the system. Step six, seven and eight: Monitor and model behavior, keep structure and reinforce desired behavior. AFTER THE INTERVENTION Ben’s problematic behaviors have decreased. The process was not a quick and simple fix. As Ben’s behavior improved, the reward system needed to be modified to keep Ben moving towards the goal of positive behavior.

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QUIZZES

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SYSTEMATIC DESENSITIZATION QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. MULTIPLE CHOICE Write the letter of your answer before the number. 1. Systematic Desensitization is a procedure for the treatment of ______. a) Depression c) Phobia b) Borderline d) Schizophrenia 2. Who developed the Systematic Desensitization? a) Josef Wolpe c) Josepph Wolppe b) Joseph Wolf d) Joseph Wolpe 3. Systematic desensitization is when the client is exposed to the anxiety-producing stimulus at a low level, and once ______is given. a) no anxiety is present at a stronger version of the anxiety-producing stimulus b) anxiety is present at a stronger version of the anxiety-producing stimulus c) no anxiety is present at a lower version of the anxiety-producing stimulus d) anxiety is absent at a stronger version of the anxiety-producing stimulus 4. ______the client imagines exposure to the phobic stimulus. a) Vivo c) Vitro b) In Vitro d) In Vivo 5. ______is a list of the situations related to your target behavior which you react to with graded amounts. a) Anxiety Hierarchy c) Hierarchy of Love b) Hierarchy of Needs d) Hierarchy 6. The technique which behavior therapists use to relax patients is known as ______. a) Deep Relaxation c) Relaxation b) Muscle Relaxation d) Deep Muscle Relaxation 7. An item is desensitized by imagining it in ______while trying to maintain a state of complete relaxation. a) with feelings of complete relaxation and comfort b) realistic detail c) vivid and realistic detail d) without experiencing any anxiety or tension 8. What are the theories that became the foundation of Systematic Desensitization? a) Classical Conditioning and Operant Conditioning b) Social Learning Theory c) Psychoanalytic Theory d) Trait Theory

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9. ______is a type of anxiety disorder, usually defined as a persistent fear of an object or situation in which the sufferer commits to great lengths in avoiding, typically disproportional to the actual danger posed, often being recognized as irrational. a) Phobia c) Social Anxiety b) Trauma d) Panic Disorder 10. This therapy aims to remove the fear response of a phobia, and substitute a relaxation response to the conditional stimulus gradually using counter conditioning. a) Systematic Desentization c) Systematic Dezenzitization b) Systematic Desensitization d) Systematic Desenzitization

II. MATCHING TYPE Match the following anxiety to its corresponding level. 1. Thinking about calling dentist’s office to set up an appointment a. 100 2. Looking at television or magazine advertisements depicting people in a b. 50 dentist’s chair. 3. Looking at the bright yellow c. 20 reminder postcard on the refrigerator and thinking about dental d. 40 appointment. 4. Listening to a family member talk e. 90 about her last dental visit. 5. Sitting in dentist’s waiting room. 6. Driving to dentist’s office for f. 60 appointment. 7. Lying back in dental chair, eyes g. 80 closed as dentist examines teeth. 8. Lying in dental chair, watching h. 70 dental technician unwrap sterilized dental tools. i. 30 9. Holding mouth open, eyes closed, listening to the sound of the dental j. 10 drill as a cavity ise repaired. 10. Holding mouth open in preparation for an oral injection.

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III. TRUE OR FALSE Write T if the sentence is true and X if false in the blank. 1. Systematic desensitization was not originally a treatment for phobias in individuals with generally adequate cognitive functioning and required their organized assistance in implementing the several components of the treatment plan. 2. Joseph Wolpe was a South African psychiatrist, one of the most influential figures in Behavior Therapy. 3. Joseph Wolpe was the first one to come up the idea of Systematic Desensitization. 4. Construction of anxiety hierarchy can help you verbalize your problem and set it down in terms of concrete situations which you have, or perhaps will, come up against in real life. 5. In vivo is the client imagines exposure to the phobic stimulus while In vitro is the client is actually exposed to the phobic stimulus. 6. An excellent way to make your image realistic is to imagine the situation very vividly and incomplete and not in detail. 7. In desensitizing yourself to an item, you first relax completely using what you have learned in the training session. 8. The setting of the relaxation training sessions should be: work in a quiet, semi- darkened, private room where you will not be interrupted; sit comfortably on a chair or lie on a bed or couch; work without interruption for the duration of the twenty minutes. 9. The desensitization procedure makes use of the fact that a person’s anxiety response (tensing of muscles, feeling of discomfort, uptightness, etc.,) to the imagined situation resembles his anxiety response to the real situation. 10. The therapist are not working with the client to develop a list of anxiety provoking stimuli at all levels of the continuum.

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RELAXATION TRAINING QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. MULTIPLE CHOICE : Encircle the letter of the correct answer. 1) Any activity or method which helps a person attain a state of calmness, reduce stress levels and is often used as part of a broader anxiety management program. a. Systematic desensitization b. Behavior modification c. Relaxation training 2) The feeling of being under pressure. a. Anxiety c. Stress b. Burn-out 3) Due to his psychological investigation at Harvard University, he was able to prove the connection between excessive muscular tension and different disorders of the body and psyche. a. Dr. Edmund Jacobson c. Professor Edwin b. Dr. Edward Jacobson Jacobson 4) He discovered the relaxation response, which is a mechanism of the body that counters the fight-or-flight response, which can be achieved through meditation. a. Herbert Benson c. Edwin Muirden b. Miriam Z. Klipper 5) The “Bellows Breath” is adapted from a yogic breathing technique. What is it more commonly called? a. Mindful breathing c. Stimulating breath b. 4-7-8 breathing exercise 6) This breathing exercise is a natural tranquilizer for the nervous system. a. Breath counting c. 4-7-8 breathing b. Stimulating breath exercise 7) This involves a two-step process in which the person systematically tense and relax different muscle groups in the body. a. Progressive muscle b. Mindful meditation relaxation c. Breath counting 8) This refers to a broad variety of practices that includes techniques designed to promote relaxation, build internal energy or life force and develop compassion and forgiveness. a. Mindfulness b. Mindfulness meditation c. Meditation 9) This cultivates mindfulness by focusing the attention on various parts of the body. a. Deep breathing c. Body scan b. Mindfulness meditation

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10) This relaxation technique involves imagining a scene in which a person feels at peace; can be done on your own, with a therapist’s help, or with an audio recording. a. Walking meditation c. Visualization b. Yoga 11) This involves a series of both moving and stationary poses, combined with deep breathing. a. Tai Chi c. Yoga b. Qui Gong 12) With its intense poses and focus, this type of yoga is not the best choice for beginners. a. Power yoga c. Satyananda b. Intense yoga 13) A type of yoga which is a reasonably gentle way to relieve stress and is suitable for beginners. a. Satyananda c. Power yoga b. Hatha yoga 14) This type of yoga features gentle poses, deep relaxation, and meditation, making it suitable for beginners. a. Satyananda c. Power yoga b. Hatha yoga 15) This is a type of yoga which is practiced in a heated environment. a. Satyananda c. Bikram yoga b. Tantric yoga 16) A self-paced, non-competitive series of slow, flowing body movements. a. Yoga c. Qui Gong b. Tai Chi 17) Involves working and acting on the body with pressure, tension, motion, or vibration, done manually or with mechanical aids. a. Tai Chi c. Progressive muscle b. Massage relaxation 18) Also known as Shiatsu. a. Hatha yoga c. Deep tissue massage b. Acupressure 19) A more aggressive type of massage often targeting specific areas and may leave the person sore for a couple of days. a. Pressure massage c. Deep tissue massage b. Acupressure 20) A self-massage technique where you slowly slide your fingers down your nose and across the top of your cheekbones to the outside of your eyes. a. Easy on the eyes c. Sinus pressure relief b. Power massage

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II. FILL IN THE BLANKS : Choose from the pool of words/phrases/digits below. 1) ______is a state of deep rest that is the polar opposite of the stress response. 2) By practicing ______, an individual can reduce the bad effects of stress by slowing heart rate, lowering blood pressure, reducing activity of stress hormones, etc., 3) In 1929, after twenty years of research, Dr. Jacobson published the book ______but it only addressed doctors and scientists. 4) Most stress experts recommended setting aside _____ or _____ minutes a day for relaxation therapy, others may recommend 30 minutes to an hour a day. 5) The key to deep breathing is to ______getting as much air as possible in the lungs. 6) In 4-7-8 exercise, you always exhale through your ______and inhale through your ______. 7) People with ______are often so tense throughout the day that they don’t even recognize what being relaxed feels like. 8) ______is the intentional, accepting and non-judgmental focus of one’s attention on the emotions, thoughts and sensations occurring in the present moment. 9) In ______, focusing on the different sensory attributes present in your scene is important so as to make it more vivid in your mind. 10) The physical and mental benefits of yoga provide a natural ______to stress, and strengthen the relaxation response with daily life.

RING FINGERS SWEDISH MASSAGE BREATHING 10,15 FITNESS LEVEL COUNTERBALANCE

RELAXATION RESPONSE 15, 25 FINGERS RELAXATION TECHNIQUES ANXIETY DIFFICULTIES

BREATHE DEEPLY FROM THE ABDOMEN MINDFULNESS MOUTH-NOSE GUIDED IMAGERY 4-7-8

BREATHING PROGRESSIVE RELAXATION PHYSICAL RELAXATION TECHNIQUES THERAPISTS

III. TRUE OR FALSE: At the end of each sentence, write the word RELAX if the statement is correct and STRESS if it states otherwise. 1) Stress is our body’s natural reaction to stressors such as environmental conditions or stimulus. 2) During relaxation, only the body is free from tension and anxiety. 3) The relaxation response reduces the body’s metabolism, heart and breathing rate, blood pressure, muscle tension, and calms brain activity.

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4) During relaxation, an individual will go from active and alert (parasympathetic) to sympathetic, which is rest and digest. 5) It takes daily practice to fully harness the power of relaxation techniques. 6) Do not practice relaxation techniques while feeling sleepy, practice when fully awake and alert to get the most out of it. 7) Taking deep breathes from the upper chest, rather than from the abdomen promotes more oxygen inhaled. 8) In progressive muscle relaxation, first, you systematically tense particular muscle groups in your body such as your neck and shoulders. 9) There is no single correct way to use guided imagery for stress relief. 10) As with yoga, tai chi is best learned in a class or from a private instructor.

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IMPLOSIVE THERAPY & FLOODING QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. TRUE OR FALSE 1. In vivo exposure: When using this type of exposure, a person is exposed to real-life objects and scenarios. 2. Flooding is an effective way of treating arachnophobia. 3. Personality disorders are one of the mental health issues that can be treated with flooding therapy. 4. A major disadvantage of flooding is that it is much faster than gradual approaches such as desensitization. 5. On the process of Flooding and Implosive Therapy, the client also identifies the level of his/her anxiety before and after the therapy. 6. A phobia is an unreasoning fear to a dangerous thing or situation. 7. Flooding is much better than Systematic Desensitization since it is a faster treatment. 8. On the process of the Flooding and Implosive Therapy, the client is under the state of relaxation. 9. In Flooding and Implosive Therapy, the client is bombarded by anxiety that came from his/her fears. 10. In this therapy, the clients are forced to undergo the process even without their consent. II. FILL IN THE BLANKS 1. Avoidance provides ______but ultimately maintains the fear and patterns of avoidance. 2. Implosive therapy is a form of ______similar to the imaginary/imaginal form of flooding, with which it can be confused. 3. Flooding was developed by ______. (Full name) 4. The imagined scenes are often ones of ______situations designed to elicit as much anxiety as possible. 5. Flooding does not protect the participants and this is the main reason why many believe that it is ______. 6. Implosive Therapy can also be called as ______. III. MULTIPLE CHOICE 1. Flooding a form of ______in which the patient is repeatedly exposed to highly distressing stimuli without being able to escape but without danger. a. Exposure therapy c. Relaxation Technique b. Desensitization d. Disaster

2. It is designed to reduce the irrational feelings a person has assigned to an object or situation by safely exposing him or her to various aspects of that fear. a. Exposure Therapy c. Phobia b. Implosive Therapy d. Desensitization

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3. In Implosive therapy, all presentations of anxiety situations are done by having the client ______. a. Relax as he is being exposed to highly distressing stimuli b. Stay in a room with the distressing stimuli c. Imagine scenes d. Find ways to avoid the distressing stimuli

4. Other term for Flooding Therapy. a. Exposure therapy c. Relaxation Technique b. Desensitization d. Disaster

5. Which of the following cannot be treated with Flooding Therapy? a. Panic Attacks c. Acute stress b. Social Anxiety d. Schizophrenia

6. Implosive Therapy was developed by? a. Thomas Levis & James Stampfl c. Thomas Stampfl & Don Levis b. Thomas Stampfl & Carl Levis d. Sam Stampfl & James Levis

7. The Flooding and Implosive Therapy is anchored to? a. Classical Conditioning c. Cognitivism b. Humanistic Psychology d. Operant Conditioning

8. Phobia is a ______. a. Unlearned fear c. Learned fear b. Unconscious fear d. None of the above

9. Implosive therapy was developed on the year of ______. a. 1964 c. 1967 b. 1965 d. 1968

10. Which of the following is not a disadvantage of Flooding therapy? a. It often increases the strength of the anxiety rather than extinguish it. b. It increases the anxiety level of the client until their anxiety reaches its peak. c. It causes a lot of unnecessary stress to the patient which can be damaging physically and emotionally. d. It does not protect the participants from harm.

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ASSERTIVE TRAINING QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. MULTIPLE CHOICES Directions: ENCIRCLE the letter of the correct answer. 1. Which of the following characteristics is not synonymous to assertiveness? A. Being forthright C. being directly honest B. Being positive D. being sarcastic

2. The following are the factors that affect an individual’s behavior towards being assertive, except for one. A. Gender Roles/Roles C. Past Experiences B. Personality Traits D. Civil Status

3. Factor that makes an individual not to be assertive, especially when they feel anxious or unstable with their thoughts and feelings. A. Personality Traits C. Low Self-Esteem/Low Self-Confidence B. Stress D. Roles

4. Many people learned to respond in a non-assertive way through modeling or through experiences A. Stress C. Personality Traits B. Roles D. Past Experiences

5. A person who behaves in a situation that asserts his/her basic rights at the expense of other people’s basic rights. A. Submissive C. Assertive B. Passive D. Aggressive

6. Which of the following is a characteristic of an Aggressive individual? A. Being boastful C. dependent B. Permission seeker D. compulsive

7. Which of the following is not a characteristic of a Passive individual? A. Weak C. compliant B. Hostile D. self-sacrificing

8. A way to accept criticisms without letting it to bring you down. A. Broken Record Technique C. Fogging B. Negative Assertion D. DESO Technique

9. Acceptance of you errors and faults without having to apologize. A. Positive Assertion C. Negative Assertion B. Fogging D. Broken Record Technique

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10. The following are characteristics of an Assertive individual except for one. A. Uses statements that are brief and direct to the point B. Knows the distinction between fact and opinion C. Always puts-down self D. Recognizes and respects the rights of others

II. FILL IN THE BLANKS Directions: Choose the best answer on the set of words below. Write it on the space provided for. 11. During the second half of the ______century assertiveness was increasingly singled out as a behavioral skill. 12. Assertiveness is often linked to ______. 13. ______was introduced by Andrew Salter 14. Joseph Wolpe originally explored the use of Assertiveness as a means of ______of anxiety. 15. Being ______would inhibit anxiety. 16. Assertive Training is also used in ______, and anger reduction and control. 17. Learning to ______in a clear and honest way usually improves relationships within one’s life. 18. ______believes that a person could not be both assertive and anxious at the same time. 19. & 20. The terms and concepts was popularized to the general public by books such as, Your Perfect Right: A Guide to Assertive Behavior published in the year ______by ______.

*Manuel J. Smith * diabetes or cancer *18th *social awareness * Assertive Training *submissive *anxiety reduction and control *1970 *anxiety inhibition *systematic desensitization * self-care * Negative Assertion *1961 * Carl Jung *communicate *passive *20th * assertive therapy * 1975 * self-awareness * reciprocal inhibition * Robert E. Alberti *talk *speak *Joseph Wolpe *1958 * 19th *Andrew Salter *assertive *Aversion Therapy *self-esteem

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III. MATCHING TYPE Direction: Match the appropriate answer from column B in the questions in column A. Write your answer on the space provided for. A B ______21. “You’re right, I may get gum disease.” A. Specify ______22. Listen attentively to other people. B. Describe, Specify, ______23. Indicate what you would like to happen. Express, Outcome ______24. Describe what it is that you want to achieve. C. Agree in Probability ______25. DESO Technique D. Negative Inquiry ______26. Acceptance of error and faults without having to E. Broken Record Technique apologize. ______27. Be honest direct and firm. F. Assertive Training ______28. Used to find out more about critical comments G. Outcome and is a good alternative to more aggressive or angry responses H. Assertive Body Language to criticism I. Positive Inquiry ______29. A simple technique for handling positive J. Art of saying “no” comments such as praises. K. Negative Assertion ______30. When the other person repeats their request to L. Personality Traits you, simply repeat

IV. TRUE OR FALSE. Directions: In the space provided for, write TRUE if the statement is correct and FALSE if it is wrong.

______31. Broken record technique is a verbal response that is firm and clear, and conveys a message that you mean what you say. ______32. Agree in Truth, Agree in Principle, and Agree in Probability are the three (3) types of Broken Record Technique. ______33. By being assertive we should not respect the thoughts, feelings and beliefs of others. ______34. Being Assertive means that what an individual wishes are automatically granted. ______35. Aggressiveness enables individuals to act on their own best interests to stand-up for themselves without undue anxiety. ______36. Fogging is a way to accept criticism without letting it bring you down. ______37. Maintaining eye contact is an example of an assertive body language. ______38. Positive Inquiry is used to find more details about the compliments or praises given. ______39. People who are very shy or self-conscious, or who were harshly treated as children may experience anxiety during the training. ______40. The anxiety may be uncomfortable, but should increase as the person goes through the techniques of the training program.

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AVERSION THERAPY QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. MULTIPLE CHOICE: Encircle the letter of your answer. 1. A form of behavior therapy in which an aversive (causing a strong feeling of dislike or disgust) stimulus is paired with a/an ______in order to reduce or eliminate that behavior. C a. Unconditioned response c. Undesirable behavior b. Conditioned stimulus d. Emetic drug

2. Patients completing the____ phase of aversion therapy are often asked by the therapist to return periodically over the following six to twelve months or longer for booster sessions to prevent relapse. A a. Initial c. Final b. Middle d. None of the above 3. The use of aversion therapy to "treat" homosexuality was declared dangerous by the American Psychological Association (APA) in ______

a. 1994 c. 1995 b. 1995 d. 1997

4. There are doubts about the long-term effectiveness of aversion therapy. It can have dramatic effects in the therapist’s office. However, it is often much less effective in the outside world, where no nausea-inducing drug has been taken and it is obvious that shocks will be given.

a. First statement is wrong, second statement is correct b. First statement is correct, second statement is wrong c. Both statements are correct d. Both statements are wrong 5. Advocates for special patient populations believe that all aversive procedures are punitive, coercive, and use unnecessary amounts of control and manipulation to modify behavior. They call for therapists to stop using aversive stimuli, noting that positive, non-aversive, behavioural-change strategies are available. a. First statement is wrong, second statement is correct b. First statement is correct, second statement is wrong c. Both statements are correct d. Both statements are wrong

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II. TRUE OR FALSE: Write TRUE if the statement is correct and FALSE if the statement is wrong.

1. Patients with medical problem should not consent their primary doctor first before going aversive treatment. 2. Therapist should inform the client what is required in aversive therapy. 3. Patients completing the initial phase of aversion therapy are often asked to return periodically over the following 6 to 12 months for booster sessions to prevent lapse. 4. Patients with cardiac, pulmonary or gastro intestinal problems may not experience a worse symptom. 5. Patient who practice relapse prevention techniques may not expect to maintain treatment. 6. Relapse is a return to an addictive life style. 7. Aversive therapy is not applicable for paedophiles. 8. Other drinks such as soft drinks are given without the drug so that the person is not conditioned to feel sick to all drinks. 9. In Covert sensitization, the individual learns through mental imagery to visualize non- aversive scenes and even to induce a mild feeling of nausea. 10. The major use of aversion therapy is currently for the treatment of eating disorders and autism.

III. IDENTIFICATION: Fill in the blanks with the correct answer.

1. An alcohol dependent patient may experience _____ before undergoing aversion therapy. 2. The therapist's ______decision is what type of noxious stimulus to use, whether electrical stimulation or an emetic 3. Detoxification must be done ______the therapy. 4. How long does the hospitalization take? 5. Is the treatment conducted every day? If not, when it is conducted? 6. Aversion therapy is based on what principle? 7. A strong feeling of dislike. 8. It occurs when a conditioned stimulus is paired with an unconditioned stimulus 9. Today, using aversion therapy in an attempt alter ______behavior is considered a violation of professional conduct. 10. One of the major criticisms of aversion therapy is that it lacks rigorous ______demonstrating its effectiveness

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IV. ENUMERATION: Give issues or problems that can be treated with Aversion therapy

1. 2. 3. 4. 5.

V. MATCHING TYPE:

_____1. Emetic Drug A. Classical conditioning _____2. Aversion therapy B. a drug that causes nausea and vomiting _____3. Covert sensitization C. mental imagery/ imagine scenes _____4. Overt sensitization D. a strong feeling of dislike _____5. Aversive E. exposure to undesired stimulus _____6. Aversive stimulus F. unlearned reflex _____7. Unconditioned reflex response G. relapse rates _____8. Very high H. punishment _____9.Conditioned aversion I. dislike or negative emotional response _____10. self-help community J. minor behavioral issues

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POSITIVE REINFORCEMENT QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. MULTIPLE CHOICES: Encircle and write the letter of the correct answer in the space provided. 1. Who is the proponent of Operant Conditioning? a. B.F Skinner c. Edward Thorndike b. John Watson d. none of the above 2. According to this principle, actions that are followed out by desirable outcomes are more likely to be repeated while those followed by undesirable outcomes are less likely to be repeated a. Law of Effect c. Law of Affect b. Law of Principle d. Law of Outcomes 3. You don’t have to learn these behaviors, they simply occur automatically and involuntarily. a. Operant Behavior c. Respondent Behavior b. Positive Respondents d. Natural Respondents 4. The device that Skinner developed is to track and record responses as upward movement of line so that the response rates could be read by looking at the slope of the line a. Cumulative Recorder c. Skinner’s Box b. Recorder Device d. Tracking Device 5. At what century that behaviorism had become a major force within psychology? a. 18th c. 20th b. 19th d. 21st 6. Tangible reinforcers involve the presentation of an actual, physical reward. Which of the following is not an example of this? a. candy and toys c. gadgets b. money d. job promotion 7. Who is the psychologist that focused on the principles of classical conditioning, famously suggesting that s/he could take any person regardless of their background and train them to be anything he chose? a. Mary Cover Jones c. John Watson b. B.F. Skinner d. Ivan Pavlov

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8. What is measured by the persistence, frequency, duration and accuracy of the response after reinforcement is halted? a. Extinction c. Evaluation b. Strength of response d. Schedule 9. This schedule is best used during the initial stages of learning in order to create a strong association between the behavior and the response. a. Continual Reinforcement c. Fixed-Partial Reinforcement b. Partial Reinforcement d. Continous Reinforcement 10. Which schedule is best use when a response is rewarded after an unpredictable amount of time has passed. This schedule produces a slow, steady rate of response. a. Variable-interval schedules c. Variable-ratio schedules b. Fixed-interval schedules d. Fixed-ratio schedules

II. MATCHING TYPE: Find the match words from the box, then write the appropriate letter that corresponds to the statements. Write the answers on CAPITAL letters on the space provided. ______11. Negative reinforcement is used to avoid a. Positive Punishment or remove this negative outcome. b. Secondary Reinforcement ______12. A stimulus event for which an organism c. Punishment will work in order to terminate, to escape from, to d. Positive Reinforcement postpone its occurrence. e. Negative Reinforcer ______13. It involves either presenting or taking f. Negative Punishment away a stimulus in order to weaken a behavior. g. Primary Reinforcement ______14. Presenting a negative consequence after h. Reinforcement an indesired behavior is exhibited. i. Negative Reinforcement ______15. It happens when a certain desired j. Aversive Stimulus stimulus is removed after a particular undesired behavior is exhibited. ______16. A term used in operant conditioning to refer to anything that increases the likelihood that a response will occur.

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______17. Sometimes referred to as unconditional reinforcement - occurs naturally and does not require learning in order to work ______18. Also known as conditioned reinforcement - involves stimuli that have become rewarding by being paired with another reinforcing stimulus ______19. Involves removing something in order to increase a response ______20. Involves the addition of a reinforcing stimulus following a behavior that makes it more likely that the behavior will occur again in the future.

III. IDENTIFICATION: Identify the right words that corresponds to the statements below. ______21. This schedule involves reinforcing a response each and every time it occurs ______22. The response is reinforced only part of the time ______23. Occur when a response is reinforced after an unpredictable number of responses. This schedule creates a high steady rate of responding. ______24. This is where the first response is rewarded only after a specified amount of time has elapsed ______25. This occur when a response is rewarded after an unpredictable amount of time has passed. ______26. Refers to reinforcers that occur directly as a result of the behavior. ______27. Are points or tokens that are awarded for performing certain actions. ______28. Involve expressing approval of a behavior, such as a teacher, parent, or employer saying or writing "Good job" or "Excellent work." ______29. Involve the presentation of an actual, physical reward. ______30. Implies absence of reinforcements. In other words, it implies lowering the probability of undesired behavior by removing reward for that kind of behavior.

IV. TRUE OR FALSE: Write T if the answer is TRUE and F if FALSE. ______31. Like reinforcement, a stimulus can be added or removed in punishment. ______32. Negative reinforcement can produce immediate results, that is best suited for long-term use. ______33. Punishment is a process by which a consequence immediately follows a behavior which increases the future frequency of that behavior.

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______34. Negative reinforcement occurs when the rate of a behavior decreases because an aversive event or stimulus is removed or prevented from happening. ______35. One of the best ways to remember negative reinforcement is to think of it as something being subtracted from the situation. ______36. Positive reinforcement is done when your instructor shouts out, "Great job!” after you execute a turn during a skiing lesson. ______37. In partial reinforcement, the response is reinforced only part of the time. ______38. In continuous reinforcement, the desired behavior is reinforced every single time it occurs. ______39. When and how often we reinforce a behavior have no impact on the strength and rate of the response. ______40. We reinforce behaviors, not people.

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RESPONSE-SHAPING QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. IDENTIFICATION. Write the correct answer before each number. ______1. It us a variant of operant conditioning. Instead of waiting for a subject to exhibit a desired behavior, any behavior leading to the target behavior is rewarded. ______2. He is the proponent of Operant Conditioning. ______3. Behavioral techniques are widely used as therapeutic tools for treatment of ___. ______4. Other name for Behavior/Response Shaping. ______5. In order to go through behavior shaping, the trainer must make a list of ______to be reinforced. ______6. It refers to numerous types of consequences.

II. FILL IN THE BLANKS. Select from the group of words below the appropriate word for the blanks. A. Successive approximation should 1.) ______confused with 2.) ______processes; as feedback refers to numerous types of 3.) ______. Notably, consequences can also include 4.) ______, while shaping instead relies on the 5.) ______. Feedback not be punishment consequences positive reinforcement reward. B. The 1.) ______of the process is that the 2.) ______of the 3.) ______(measured here as the frequency of lever-pressing) 4.) ______. In the beginning, there is 5.) ______probability that the 6.) ______would depress the lever, the only 7.) ______being that it would depress the lever by 8.) ______through 9.) ______the rat can be brought to depress the lever 10.) ______. Frequently response possibility rat culmination strength accident depress increases little training shaping. III. SEQUENCING. Put a number before each letter corresponding to the correct order of the statements below.

A. ______a.) Tell the client that he/she must accomplish step 1 to receive the reward. ______b.) Once the client has mastered a specific behavior, require that he/she demonstrate the next stage of behavior in order to receive a reward. ______c.) Identify a desired behavior for the client. ______d.) List the steps that will eventually take the client from his/her present level of performance to the final desired behavior. These levels of skill should be progressively demanding. ______e.) Identify the client's present level of performance in displaying the desired behavior. ______f.) Determine the final goal.

B. ______a.) John will complete all problems except one. ______b.) John will complete five problems of his choice.

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______c.) John will write his name at the top of the worksheet. ______d.) John will complete all problems. ______e.) John will complete either all the odd numbered problems or all the even numbered problems. ______f.) John will complete one problem of his choice.

C. ______a.) Only depressing the lever partially with the specified paw will be reinforced. ______b.) Only touching the lever with only part of the body, such as the nose, will be reinforced. ______c.) Simply touching toward the lever will be reinforced. ______d.) Only depressing the lever completely with the specified paw will be reinforced. ______e.) Only stepping toward the lever will be reinforced. ______f.) Only moving within a specified distance from the lever will be reinforced. ______g.) Only touching the lever with a specified paw will be reinforced.

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INTERMITTENT REINFORCEMENT QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. MULTIPLE CHOICE: Encircle the letter of the correct answer. 1. A simple schedule where in the activity slows after reinforce and then picks up. a. Fixed Ratio b. Variable Ratio c. Fixed Interval d. Variable Interval 2. A simple schedule where there is a high rate of responding, greatest activity of all schedules. a. Fixed Ratio b. Variable Ratio c. Fixed Interval d. Reinforcement 3. A simple schedule where activity increases as deadline nears and can cause fast extinction a. Variable Ratio b. Fixed Ratio c. Variable Interval d. Fixed Interval 4. A simple schedule where the effect is having a steady activity results and there is a good resistance to extinction. a. Variable Interval b. Fixed Ratio c. Fixed interval d. Variable Ratio 5. Every response is reinforced a. Intermittent Reinforcement c. Positive Reinforcement b. Partial Reinforcement d. Continuous Reinforcement 6. This is used to reduce a frequent behavior without punishing it by reinforcing an incompatible response. a. Differential Reinforcement of incompatible behavior b. Differential reinforcement of other behavior c. Differential reinforcement of Low Response Rate d. Differential reinforcement of High Response Rate 7. Also known as omission training procedures, an instrumental conditioning procedure in which a positive reinforcer is periodically delivered only if the participant does something other than the target response. a. Differential Reinforcement of incompatible behavior b. Differential reinforcement of other behavior c. Differential reinforcement of Low Response Rate d. Differential reinforcement of High Response Rate 8. This is used to encourage low rates of responding. It is like an interval schedule, except that premature responses reset the time required between behaviors. a. Differential Reinforcement of incompatible behavior b. Differential reinforcement of other behavior c. Differential reinforcement of Low Response Rate d. Differential reinforcement of High Response Rate 9. This is used to encourage low rates of responding. It is like an interval schedule, except that premature responses reset the time required between behavior. a. Differential Reinforcement of incompatible behavior b. Differential reinforcement of other behavior c. Differential reinforcement of Low Response Rate d. Differential reinforcement of High Response Rate 10. Fixed Ratio: a. Washing machine cycle c. Waiting for a jeep

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b. Slot machine d. Every 10 cars sold gets 10000 pesos 11. Variable Ratio Schedule: a. Washing machine cycle c. Waiting for a jeep b. Slot machine d. Every 10 cars sold gets 10000 pesos 12. Fixed Interval: a. Washing machine cycle c. Waiting for a jeep b. Slot machine d. Every 10 cars sold gets 10000 pesos 13. Variable Interval a. Washing machine cycle c. Waiting for a jeep b. Slot machine d. Every 10 cars sold gets 10000 pesos 14. Intermittent Reinforcement is when ______, ______or personal boundaries are handed out or enforced inconsistently and occasionally. a. Attitude, Instructions c. Goals, purpose b. Rules, rewards d. Behavior, reinforcement 15. This usually encourages another person to keep pushing until they get what they want from you without ______their own ______. a. changing, behavior c. continuous, intermittent b. Reinforcement, reward d. fixed, ratio

II. TRUE OR FALSE 1. Fixed interval is the schedules deliver reinforcement after every nth response. 2. Fixed raio is reinforced after n amount of time. 3. Variable ratio schedule is reinforced on average every nth response, but not always on the nth response. 4. Variable interval is reinforced on an average of n amount of time, but not always exactly n amount of time. 5. Variable Time Provides reinforcement at an average variable time since last reinforcement, regardless of whether the subject has responded or not. 6. Fixed Time Provides reinforcement at a fixed time since the last reinforcement, irrespective of whether the subject has responded or not. In other words. It is a non-contingent schedule. 7. Differential reinforcement of High Response Rate is used to encourage low rates of responding. It is like an interval schedule, except that premature responses reset the time required between behaviors. 8. Differential reinforcement of Low Response Rate is used to encourage low rates of responding. It is like an interval schedule, except that premature responses reset the time required between behaviors. 9. Intermittent reinforcement is all about rewarding the subject. 10. Continuous reinforcement is the same with intermittent reinforcement; except for that intermittent is used to reward the subject for finishing a task very well.

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11. Ratio Strain is the disruption of responding that occurs when a fixed ratio response requirement is increased rapidly. 12. Ratio run is high and steady rate of responding that completes reaction requirement. 13. Partial reinforcement schedules are more resistant to extinction than continuous reinforcement schedules. 14. Extinction is when a behavior increases because it is no longer reinforced. 15. Both types of partial schedules can be further subdivided into Fixed schedule and Variable schedule.

III. IDENTIFICATION

Differential Reinforcement of incompatible behavior Ratio schedules Differential reinforcement of other behavior Partial Reinforcement Differential reinforcement of Low Response Rate Fixed Interval Differential reinforcement of High Response Rate Schedules of reinforcement Rare Interval schedules Continuous reinforcement Unpredictable 1 – 2. Intermittent Reinforcement is ______and ______. 3. ______a schedule of reinforcement in which every occurrence of the instrumental response is followed by the reinforcer. 4. ______reinforcement after n amount of time. 5. The patterns or ______have strong and predictable effects on learning, extinction and performance. 6. This is used to encourage low rates of responding. ______7. Other term for Intermittent Reinforcement. ______8. Also known as omission training. ______9. – 10. Intermittent Reinforcement can be categorized into: ______and ______

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EXTINCTION QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. TRUE OR FALSE: Write TRUE if the statement is correct otherwise write FALSE. (2 pts. each) 1. Extinction is a behavior modification technique that is used to reduce and eventually eliminate undesirable behavior. 2. Extinction is present in classical conditioning only. 3. It is noted in Ivan Pavlov’s autobiography how he accidentally discovered the extinction of an operant response due to the malfunction of his laboratory equipment. 4. It may produce a long term effect is one of the advantages of extinction. 5. Extinction procedures can be developed and used with children with Autism Spectrum Disorder (ASD).

II. FILL IN THE BLANKS. (2 pts. each) 1. The process of extinction involves the removal of the ______that is responsible for maintaining the undesirable behavior. 2. In classical conditioning, extinction happens when a conditioned stimulus is no longer______with an unconditioned stimulus. 3. Extinction can be used to ______the occurrence of undesirable behaviors like swearing, tantrums, whining, and aggressive, self-injurious behavior. 4. In the______paradigm, extinction refers to the process of no longer providing the reinforcement that has been maintaining the behavior. 5. One of the disadvantages of the extinction is that the individual may become______in an attempt to obtain attention.

III. IDENTIFICATION: Identify what the problem and consideration with extinction is being described in each statement. 1. This is called the “resistance to extinction” and is especially noticeable when a behavior that has gone on for quite some time is suddenly not given attention, or ignored. 2. This means that the behavior that is being ignored in one classroom may occur more often when the child goes to another classroom where the teacher does not ignore the behaviors all the time. 3. When an extinction procedure is put into place, it is important to consider who else will be in contact with the individual and how they will influence the individual.

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4. When an extinction program plan is put into effect, parents and teachers should expect to see an increase in the tantrums, hitting, or other behavior that is being ignored. 5. The child is really checking to see if the same rule applies after a period of time, or in a new environment; if he is ignored in the new setting just as he was at home, he will learn that the same rule applies.

IV. ENUMERATION: 1. Give the procedures in conducting extinction. (7 pts.) 2. Give 2 advantages of extinction (2 pts.) 3. Give 3 disadvantages of extinction. (3 pts.) 4. Give three things or questions to consider in identifying the problem behavior. (3 pts.)

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MODELING QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. IDENTIFICATION Write the correct answer on the space provided before the number. You can choose your answer on the choices provided. 1. Is a behaviorally based procedure that involves the use of live or symbolic models to demonstrate a particular behavior, thought, or attitude that a client may want to acquire or change. 2. This behavior modification approach is also called ______or imitation. 3. He is the one who run the Bobo Doll Experiment. 4. Behavior change that results from the observation of the behavior of another is called what? 5. What is “______” is the behavior of the model, the consequences of this behavior, and verbal cues and instructions of the model. 6. What theory does this therapy is based from? 7.- 8. Modeling may be used either to ______or to ______previously learned behaviors. 9. Is defined as rewarding the model's performance or the client's performance of the newly acquired skill in practice or in real-life situations. 10. Is defined as practice or behavioral rehearsal of a skill to be used later in real-life situations. 11. Regulates the sensory input and perception of the modeled event. 12. Refer to coding processes by which the observed event is translated into a guide for future performance. 13. Refer to the integration of various constituent acts into new response patterns. 14. Determine whether observationally acquired responses will be performed. 15. Includes filmed or videotaped models demonstrating the desired behavior. 16. Refers to watching a real person, usually the therapist, perform the desired behavior the client has chosen to learn. 17. The therapist models anxiety-evoking behaviors for the client, and then prompts the client to engage in the behavior. 18. Clients are asked to use their imagination, visualizing a particular behavior as the therapist describes the imaginary situation in detail. 19. – 20. ______and ______of the client's performance in the practice phase is an important motivator for behavior change. CHOICES: Model Observational Learning Modeling Social Learning Theory Modeling Strengthen, Weaken Albert Ellis Weaken, Strengthen Albert Bandura Role Play

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Punishment Live Modeling Reinforcement Covert Modeling Retention Processes Symbolic Modeling Motor Reproduction Processes Participant Modeling Attentional Processes Feedback Incentive or Motivational Processes Social Reinforcement II. TRUE OR FALSE Write True if the statement is correct, and write False if the statement is incorrect. 1. When Modeling is used alone, it shows to be effective in terms of short term learning. 2. The person who is likely significant to the observer, becomes the more influential model. 3. Modeling do not work well when it is combined with role-play and reinforcement. 4. The influence of the mass media, such as movies and television, gives modeling an insignificant social importance. 5. The therapist's length of experience and personal style also affect the length of therapy. 6. Modeling is also effective in eliminating or reducing such undesirable behaviors as uncontrolled aggression, smoking, weight problems, and single phobias. 7. Modeling has been shown to be ineffective in such group programs as social skills training and assertiveness training. 8. Having the model speak his or her thoughts aloud is less effective than having a model who does not verbalize. 9. Therapy begins with an assessment of the client's presenting problems 10. Modeling is sometimes called vicarious learning, because the client need not actually perform the behavior in order to learn it. III. ENUMERATION 1-8 Give the 4 types of Modeling with a short description. (2pts. Each) 9-10 Give at least 2 factors that increase the effectiveness of Modeling Therapy in changing behavior.

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TOKEN ECONOMY QUIZ

NAME: ______COURSE, Yr&Sec:______DATE:______I. IDENTIFICATION: Write the correct answer in the space provided.

______1. It refers to an object or symbol to be used in exchange for material reinforces like services or privileges. ______2. It implies clients aren't expected to do everything perfectly at once: behavior can be acquired in steps. ______3. A reinforcement will greater influence behavior if given shortly after the response is emitted. ______4. Although token have no intrinsic value, it can be exchange for other valued reinforcing events. ______5. This implies they should not immediately spend all earned tokens on attractive smaller rewards, and instead learn to plan ahead. ______6. The power of a token economy largely depends on the consistency of its application. ______7.This refers to clients can pass through different levels until they reach the highest level. ______8. It is a system of behavior modification based on the systematic reinforcement of target behavior. ______9. Token economy is a system of behavior modification based on the principles of. ______10. Although tokens are used to award and strengthen certain behavior, this is also sufficient to maintain what's been learned. ______11- 12. Token Economy is often applied to ____ wherein each individual are given a “token” or other fake form of currency exchanged for “good things in life” as a reward for___ that are trying to be taught to the patient. ______13- 15 In____ the very first token economy bearing that name was founded by____ at _____ in Illinois.

II. TRUE OR FALSE: Write ECONOMY if the statement is true. TOKEN if the statement is false.

______1. Tokens are primary reinforcers, not secondary or learned reinforcers. ______2. Tokens have no intrinsic value, but can be exchanged for other valued reinforcing events. ______3. Tokens like symbols and objects are comparably worthless outside of the patient-clinician relationship. ______4. Response cost: disruptive behavior can be fined with the loss of tokens.

______5. Principle of delay discounting implies that the longer people have to wait for a reward, the less effect and the less they will learn.

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______6. Back-up reinforcer can be material things, services and priviledges. ______7. For a token economy to work, criteria have to be specified and clear. ______8. Shaping implies clients are expected to do everything perfectly at once. ______9. Reinforcement will greater influence behavior if given days after the response is emitted. ______10. In assigning token values one factor to be considered is clients should be able to earn a minimal amount of tokens for a minimal effort, and on the other hand clients should not earn too much too soon, making more effort useless.

III. ENUMERATION: 1-3 Give the 3 basic requirements in conducting Token Economy 4-5 Advantages of Token Economy 6-7 Disadvantages of Token Economy 8-10 Give 3 “tokens” that can be used in Token Economy

IV. Explain the difference of token economy compared to other Behavior Modification Training.

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ANSWER

KEY

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SYSTEMATIC DESENSITIZATION ANSWER KEY MULTIPLE CHOICE MATCHING TYPE TRUE OR FALSE 1. C. 1. J 1. X 2. D. 2. C. 2. T 3. A. 3. D. 3. X 4. B. 4. I. 4. T 5. A. 5. F. 5. X 6. D. 6. B. 6. X 7. C. 7. G. 7. T 8. A. 8. H. 8. T 9. A. 9. E. 9. T 10. B. 10. A. 10. X

RELAXATION TRAINING ANSWER KEY TEST I TEST II TEST III 1. C 1. Relaxation Response 1. RELAX 2. C 2. Relaxation Techniques 2. STRESS 3. A 3. Progressive Relaxation 3. RELAX 4. A 4.10, 15 4. STRESS 5. C 5. Breathe Deeply From the 5. RELAX 6. C Abdomen 6. RELAX 7. A 6. Mouth-Nose 7. STRESS 8. C 7. Anxiety Difficulties 8. RELAX 9. C 8. Mindfulness 9. RELAX 10. C 9. Guided Imagery 10. STRESS 11. C 10. Counterbalance 11. RELAX 12. B 11. Tenses & Relaxes 12. STRESS 13. B 12. Diaphragmatic Breathing 13. STRESS 14. B 15. B

IMPLOSIVE THERAPY & FLOODING ANSWER KEY TRUE OR FALSE 10. F FILL IN THE BLANKS 1. F 11. F 1. Temporary Relief 2. T 12. T 2. Exposure Therapy 3. F 13. T 3. Thomas Stampfl 4. F 14. T 4. Exaggerated/Impossible 5. T 15. T Situations 6. F 5. Unethical 7. T 6. Implosion Therapy 8. F 7. Pathological 9. T 8. Distress

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9. 20-25 3. C 7. D MULTIPLE CHOICE 4. A 8. C 1. B 5. D 9. C 2. A 6. C 10. C

ASSERTIVE TRAINING ANSWER KEY TEST I 15. Assertive 28. D. Negative Inquiry 1. D. Being sarcastic 16. Anxiety reduction and 29. I. Positive Inquiry 2. D. Civil status control 30. E. Broken Record 3. B. Stress 17. Communicate Technique 4. D. Past experiences 18. Joseph Wolpe TEST IV 5. D. Aggressive 19. 1975 31. TRUE 6. A. being boastful 20. Robert E. Alberti 32. FALSE 7. B. Hostile TEST III 33. FALSE 8. C. Fogging 21. C. Agree in Possibility 34. FALSE 9. C. Negative Assertion 22. H. Assertive Body 35. FALSE 10. C. Always puts-down Language 36. TRUE self 23. A. Specify 37. TRUE TEST II 24. G. Outcome 38. TRUE 11. 20th century 25. B. Describe, Specify, 39. TRUE 12. Self-esteem Express, Outcome 40. FALSE 13. Assertive Training 26. K. Negative Assertion 14. Reciprocal Inhibition 27. J. Art of saying “no”

AVERSION THERAPY ANSWER KEY I. MULTIPLE CHOICE 10. False IV. ENUMERATION 1. C III. IDENTIFICATION  Addiction 2. A 1. severe withdrawal  Alcoholism 3. A symptoms  Gambling 4. B 2. first  Eating disorder 5. C 3. before  Autism 4. ten days II. TRUE OR FALSE  Pedophiles 5. No. Every other day 1. False  Anger/Violence 6. Classical 2. True  Smoking Conditioning 3. True 7. Aversive 4. False 8. Classical 5. False Conditioning 6. True 9. homosexual 7. False 10. scientific evidence 8. False

9. True

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V. MATCHING TYPE 4. E 8. G 1. B 5. D 9. I 2. A 6. H 10. J 3. C 7. F

POSITIVE REINFORCEMENT ANSWER KEY TEST I 14. A.Positive Punishment 28. Social Reinforcers 1.a 15. F.Negative Punishment 29. Tangible 2. a 16. H.Reinforcement 30. Extinction 3. c 17. G.Primary Reinforcement TEST IV 4. a 18. B.Secondary Reinforcement 31. T 5. c 19. I.Negative Reinforcement 32. F 6. d 20. D.Positive Reinforcement 33. F 7. c TEST III 34. F 8. b 21. Continuous Reinforcement 35. T 9. d 22. Partial Reinforcement 36. T 10. a 23. Variable- ratio schedules 37. T TEST II 24. Fixed- interval schedules 38. T 11. J.Aversive Stimulus 25. Variable- interval schedules 39. F 12. E.Negative Reinforcer 26. Natural Reinforcers 40. T 13. C.Punishment 27. Token Reinforcers

RESPONSE-SHAPING ANSWER KEY IDENTIFICATION B. e=2 1. Behavior Shaping 1. Culmination f=6 2. B. F. Skinner 2. Strength B. 3. Verbal Disorders 3. Response a=5 4. Successive 4. Increase b=3 Approximation 5. Little c=1 5. Approximations 6. Rat d=6 6. Feedback 7. Possibility e=4 FILL IN THE BLANKS 8. Accident f=2 A. 9. Training C. 1. not be 10. Frequently a=6 2. Feedback SEQUENCING b=4 3. Consequences A. c=1 4. Punishment a=4 d=7 5. Positive Reinforcement b=5 e=2 c=1 f=3 d=3 g=5

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INTERMITTENT REINFORCEMENT ANSWER KEY MULTIPLE CHOICE: TRUE OR FALSE IDENTIFICATION 1. A 1. FALSE 1. Rare 2. B 2. FALSE 2. Unpredictable 3. D 3. TRUE 3. Continuous 4. A 4. TRUE reinforcement 5. D 5. TRUE 4. Fixed interval 6. A 6. TRUE 5. Schedules of 7. B 7. FALSE reinforcement 8. C 8. FALSE 6. Differential 9. D 9. FALSE Reinforcement of High 10. D 10. TRUE Response Rate 11. B 11. TRUE 7. Partial reinforcement 12. A 12. TRUE 8. Differential 13. C 13. TRUE Reinforcement of other 14 & 15. B 14. FALSE behavior 15. TRUE 9. Ratio schedules 10. Interval schedules

EXTINCTION ANSWER KEY I. TRUE/FALSE II. FILL IN THE BLANKS III. IDENTIFICATION 1. True 1. Reinforcer 1. Delayed Reaction 2. False 2. Paired 2. Limited Generalization 3. False 3. Decrease 3. Imitation or Reinforcement by 4. True 4. Operant Conditioning others 5. True 5. Aggressive 4. Increased Rate 5. Spontaneous Recovery

IV. ENUMERATION 1. Procedures in conducting extinction.  Identify the problem behavior.  Collect baseline data  Determine the function of the behavior  Creating an intervention plan  Implementing the intervention plan  Collect outcome data  Review the intervention plan 2. Advantages of extinction  It may produce a long-term effect  It may be relatively simple (provided consistency and persistency are a given)  It should eliminate a non-desired behavior  It is considered a relatively non-aversive procedure 3. Give 3 disadvantages of extinction.  Initially, the undesired behavior is likely to increase  Delayed reaction or resistance to extinction

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 Follow-through of the procedure requires consistency and persistence by all involved with the individual.  The time involved in the procedure requires a commitment.  The individual may become aggressive in an attempt to obtain attention.  The schedule of reinforcement may determine how long it will take to extinguish a behavior. 4. Give three things or questions to consider in identifying the problem behavior  What the problem behavior looks like? (topography)  How often the problem behavior occurs? (frequency)  How intense the problem behavior is? (intensity)  Where the problem behavior occurs? (location)  How long the problem behavior lasts? (duration)

MODELING ANSWER KEY IDENTIFICATION 16. Live modeling 1. Modeling 17. Participant modeling 2. Observational learning 18. Covert modeling 3. Albert Bandura 19. Feedback 4. Modeling 20. Social reinforcement 5. Observed TRUE OR FALSE 6. Social Learning Theory 1. True 7. Strengthen 2. True 8. Weaken 3. False 9. Reinforcement 4. False 10. Role play 5. True 11. Attentional Processes 6. True 12. Retention Processes 7. False 13. Motor Reproduction Processes 8. False 14. Incentive or Motivational Processes 9. True 15. Symbolic modeling 10. True ENUMERATION FOR 1-8: Live Modeling - Definition in number 16 Covert Modeling - Definition in number 18 Participant Modeling - Definition in number 17 Symbolic Modeling - Definition in number 15 FOR 9-10: Any of the four Attentional Processes, Retention Processes, Motor Reproduction Processes, Incentive or Motivational Processes

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TOKEN ECONOMY ANSWER KEY IDENTIFICATION 13-15. 1961, Ayllon and Azrin, Anna State 1. Token Hospital 2. Shaping TRUE OR FALSE 3. Immediacy of reinforcement 1. TOKEN 4. Back-up reinforcers 2. ECONOMY 5. Learning to plan ahead and save earnings 3. ECONOMY 6. Consistent application 4. ECONOMY 7. Leveled system 5. ECONOMY 8. Token economy 6. ECONOMY 9. Operant Conditioning 7. ECONOMY 10. Social reinforcement 8.TOKEN 11-12. Groups, good behavior 9.TOKEN 10. ECONOMY ENUMERATION 1.Token 2. Back-up Reinforcers 3. Specified target behaviors 4- 5. Any of the following  Most students respond to a good token economy class.  Behaviors can be awarded immediately.  Rewards are the same for all members of the group.  Individuals can learn skills related to planning for the future.  Use of punishment (response cost) is less restrictive than other forms of punishment. 6-7. any of the following:  Consistency  It can get expensive  Unintentionally neglect rights of patients if staff members are inadequately trained  Effort in extensive staff training  Some find it time-consuming and impractical  Undesirable back-up reinforcers  Ineffective reinforcement schedule 8-10. coins, checkmarks, images of small suns, points on a counter, stamps, chips

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REFERENCES

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REFERENCES: SYSTEMATIC DESENSITIZATION PDF

Juan I. Capafóns, C. D. (1998). SYSTEMATIC DESENSITIZATION IN THE TREATMENT OF FEAR OF FLYING. Retrieved from http://www.psychologyinspain.com/content/full/1998/2bis.htm KRAFT, D., & KRAFT, T. (n.d.). USE OF IN VIVO AND IN VITRO DESENSITIZATION IN THE TREATMENT OF MOUSE PHOBIA: REVIEW AND CASE STUDY. Retrieved from http://londonhypnotherapyuk.com/publications/mouse-phobia-paper-published- version.pdf Sara White PhD, B.-D., & Kari Sachs, M. (n.d.). Retrieved from http://www.nsmha.org/news/SOCI_2011/DesensitizationHO.pdf

WEB SITES http://web.csulb.edu/~tstevens/Desensit.htm http://thenadd.org/modal/bulletins/v9n3a2~.htm http://www.guidetopsychology.com/sysden.htm http://www.psychologyinspain.com/content/reprints/1998/2.pdf https://en.wikipedia.org/wiki/Systematic_desensitization http://www.futuresofpalmbeach.com/co-occurring-disorders-overview/phobias/classical-operant- conditioning/ http://www.simplypsychology.org/Systematic-Desensitisation.html

REFERENCES: RELAXATION TRAINING BOOKS Ali, Uzma Ph. D. The Effectiveness of Relaxation Therapy in the Reduction of Anxiety Related Symptoms (A Case Study). Canadian Center of Science and Education, 2010. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision. Washington D.C., 2013. Altman, Neil. et al,. Relational Child Psychotherapy. Other Press, New York, 2002. Fadem, Barbara, and Edward Monaco III. Brain and Behavior. Lippinicott William & Wilkins, a Wolters Kluwer Business, 2008.

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Izenberg, Neil, and Steven Dowshen. Human Diseases and Conditions: Behavioral Health. Charles Scribner’s Son, 2001. Kneisl, Carol Ren, Holy Skodol Wilson, and Eileen Trigoboff. Contemporary Psychiatric Mental Health Nursing. Pearson Education Inc., Upper Saddle River, New Jersey, 2004. Parker, Jackie. Introduction of Relaxation Techniques & Improve Self Confidence. Southwest Devon, 2011. Pervin, Lawrence and Oliver John. Personality: Theory and Research. John Wiley and Sons Inc., 2001. Slavit, Michael. Improving Relaxation and Control of Anxiety TI 024-Thematic. The Clearinghouse, The University of Texas, Austin, 2002. Zumpe, Doris and Richard Michael. Notes on the Elements of Behavioral Science. Kluwer Academic/Plenum Publishers, New York, 2001.

WEBSITES www.ezinearticles.com/benefits-of-hilot www.helpguide.org/mental/stress_relief_meditation_yoga_relaxation.htm# www.philstar.com/health-and-family/621751/meditation-calming-restless-mind www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/relaxation-technique/art- 20045368 www.mentalhelp.net/articles/visualization-and-guided-imagery-techniques-for-stress-reduction/

REFERENCES: IMPLOSIVE THERAPY & FLOODING BOOKS Mikulas, William.Behavior Modification, Pensacola, Florida, USA. Alarcon, Renato, et al. (June 30, 2005) Virtual Reality Exposure Therapy for PTSD Vietnam Veterans: A Case Study, Journal of Traumatic Stress, Volume 12, (Issue 2), pages 263–271.

WEBSITE Psychologist World http://www.psychologistworld.com/behavior/flooding.php

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REFERENCES: ASSERTIVE TRAINING PDF When I say No I Feel Guilty by Manuel Smith (PDF) Self-Assertion Skills by Linda A. MacNeilage (PDF) Overcoming Destructive Beliefs, Feelings, and Behaviors: New Directions for Rational Emotive Therapy by Ralph Ellies (PDF)

WEBSITES https://en.wikipedia.org/wiki/Assertiveness#Techniques http://www.minddisorders.com/A-Br/Assertiveness-training.html http://www.skillsyouneed.com/ps/assertiveness3.html http://www.inkysmudge.com.au/eSimulation/resources/BROKEN_RECORD_TECHNIQUE.pdf http://changingminds.org/techniques/resisting/broken_record.htm http://www.slideshare.net/mohammedsbahi/handling-difficult-situations-by-assertiveness- techniques https://www.youtube.com/watch?v=1QPVWvkBnhI

REFERENCES: AVERSION THERAPY BOOKS Psychology: A Modular Approach to Mind and Behavior, 2005, Dennis Coon

Complete Psychology, 2014, Graham Davey, Christopher Sterling, Andy Field

WEBSITES http://www.minddisorders.com/A-Br/Aversion-therapy.html#ixzz3k2ZyrfuC https://aslessonupdates.files.wordpress.com/.../aversion-therapy-ppt.pptx http://psychology.about.com/od/typesofpsychotherapy/f/aversion-therapy.htm https://en.wikipedia.org/wiki/Classical_conditioning

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REFERENCES: POSITIVE REINFORCEMENT WEBSITES http://www.psychologyabout.com http://www.bcotb.com http://www.wikipedia.com http://www.maineautismconference.org/ https://wikispaces.psu.edu/display/PSYCH484/Reinforcement+Case+Study https://wikispaces.psu.edu/display/PSYCH484/Fall+2013-+Reinforcement+Case+Study http://www.academia.edu/6168723/The_Application_of_B.F._Skinners_Model_for_Positive_Re inforcement_in_Building_Tutor-Tutee_Relationships

REFERENCES: RESPONSE-SHAPING WEBSITES http://www.behavioradvisor.com/Shaping.html http://psychology.jrank.org/pages/581/Shaping.html http://www.txautism.net/uploads/target/Shaping.pdf https://en.wikipedia.org/wiki/Operant_conditioning https://www.boundless.com/psychology/textbooks/boundless-psychology-textbook/learning- 7/operant-conditioning-47/shaping-198-12733/ http://www.scribd.com/doc/23342323/Shaping-as-a-Behavior-Modification-Technique#scribd

REFERENCES: INTERMITTENT REINFORCEMENT BOOKS PSYCHOLOGY: The Frontiers of Behavior, Third Edition By Ronald E. Smith, Irwin G. Sarason and Barbara R. Sarason Behavior Modification: What It Is and How To Do It, Tenth Edition By Garry Martin, Joseph J. Pear WEBSITES https://en.m.wikipedia.org/wiki/Reinforcement

248 | P a g e http://cyborganthropology.com/Intermittent_Reinforcement https://psychlopedia.wikispaces.com/intermittentreinforcement

REFERENCES: EXTINCTION BOOKS Miltenberger, R. (2012). Behavior modification, principles and procedures. (5th ed., pp. 8799). Wadsworth Publishing Company. VanElzakker, M. B., Dahlgren, M. K., Davis, F. C., Dubois, S. & Shin, L. M. (2014). From Pavlov to PTSD: The extinction of conditioned fear in rodents, humans, and anxiety disorders. Neurobiology of Learning and Memory 113: 3–18. doi:10.1016/j.nlm.2013.11.014 Myers & Davis (2007) Mechanisms of Fear Extinction. Molecular Psychiatry, 12, 120–150. Amano T, Unal CT, Paré D. (2010). Synaptic correlates of fear extinction in the amygdala. Nature Neuroscience 13: 489–494 doi:10.1038/nn.2499 Vargas, Julie S. (2013). Behavior Analysis for effective Teaching. New York: Routledge.p. 52. B.F. Skinner (1979). The Shaping of a Behaviorist: Part Two of an Autobiography, p.95 Kelley,M. E., Lerman,D. C., & Van Camp,C.M. (2002). The effects of competing reinforcement schedules on the acquisition of functional communication. Journal of Applied Behavior Analysis, 35, 59–63. Lerman, D. C., & Iwata, B. A. (1996). Developing a technology for the use of operant extinction in clinical settings: An examination of basic and applied research. Journal of Applied Behavior Analysis, 29, 345–382.

WEBSITES http://www.educateautism.com/applied-behaviour-analysis/extinction-procedure-aba.html http://psychology.about.com/od/eindex/g/extinction.html http://www2.ohlone.edu/people/mmcdowell/ecs300/anecdotalobservationhandout.pdf http://www.clinpsy.org.uk/wiki/article/functional-analysis

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REFERENCES: MODELING BOOKS Behavior Modification in Applied Settings: Seventh Edition Behavior Modification: What It Is and How To Do It, Tenth Edition Garry Martin, Joseph J. Pear

WEBSITES http://uwf.edu/wmikulas/Webpage/behavior/chaptereight.htm http://uwf.edu/wmikulas/Webpage/behavior/chaptereight.htm http://www.minddisorders.com/Kau-Nu/Modeling.html http://psychology.about.com/od/developmentalpsychology/a/sociallearning.htm http://examples.yourdictionary.com/examples-of-observational-learning.html

REFERENCES: TOKEN ECONOMY BOOK

T. Ayllon & N.H. Azrin : The Token Economy: a motivational system for therapy and rehabilitation. New York: Appleton-Century-Crofts, 1968

WEBSITES https://en.wikipedia.org/wiki/Token_economy http://www.educateautism.com/token-economy.html

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EVALUATION

& SUMMARY

OF QUIZZES

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EVALUATION: SYSTEMATIC DESENSITIZATION

CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100%

EVALUATION AS A GROUP

STUDENTS

1 2 3 4 5 6 7 8 9

KNOWLEDGE 24% 24% 24% 20% 25% 23% 25% 23% 24%

PRESENTATION 21% 21% 20% 23% 25% 20% 20% 20% 20%

RESOURCEFULNESS 20% 20% 20% 25% 25% 23% 20% 23% 24%

OVER-ALL IMPACT 23% 23% 23% 24% 25% 20% 25% 22% 22%

TOTAL 88% 88% 87% 92% 100% 86% 90% 88% 90%

AVERAGE 89.89%

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EVALUATION: RELAXATION TRAINING CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100%

SUMMARY OF CLASS EVALUATION BALANQUIT, HONRADO, RUALES, SAN JOSE,

JOSHUA HANEYLLETTE ABEER RIA JOY ACUÑA 100 100 100 100 ADIGUE 100 100 100 100 ANDRADE 98 100 100 100 BATOMALAQUE 95 95 95 95 BALAONG 89 92 100 94 BARBUCO 100 100 100 100 BINAYUG 98 99 99 99 BUENASFLORES 95 100 100 100 BORRERO 100 100 100 100 DACARA 89 93 88 91 ESTAYAN 86 88 87 92 ENECILLO 80 92 80 92 ERLANDEZ 91 98 96 96 FERRAN 90 90 90 90 FRANCISCO 90 90 90 90 GABRIEL 93 95 95 95 GALAPON 96 96 96 96 GARCIA 95 96 96 96 GITGANO 100 100 100 100 GOB 85 90 85 90 GOMEZ 100 100 100 100 GURAN 93 95 95 95 JARINA 95 100 100 98 LADICA 98 98 97 98

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LUMBA 93 97 97 96 MEJARITO 100 100 100 100 MIGUEL 90 95 95 95 NACIONAL 95 95 95 95 NALDA 95 95 95 95 OLIVA 85 89 89 89 PIGAO 92 100 99 100 REFANI 97 99 99 99 SAILOG 80 80 85 85 SAMALA 100 100 100 100 SUMAGAYSAY 95 95 95 95 VALDEZ 100 100 100 100 VELASCO 100 100 100 100 VILLAR 93 93 93 93 ZUÑIGA 96 96 96 96 TOTAL: 3,667 3,744 3,727 3,746 AVERAGE: 94.03% 96% 95.56% 96.05%

RELAXATION TECHNIQUE QUIZ SCORES

NAME SCORE 1. ACUÑA, AIRA VHENYCE 34 2. ADIGUE, MARY LOU 29 3. AMIGO, ALFRED 27 4. ANDRADE, KAY CELINE 34 5. BABOR, PATRICK DAVE 30 6. BATOMALAQUE, VERGEL 28 7. BALAONG, MARIFLOR 30 8. BALANQUIT, JOSHUA REPORTER 9. BARBUCO, DIANNE MAE 30 10. BINAYUG, GIDEON RIEL 29 11. BUENASFLORES, MA.FE 29 12. BORRERO, DAISY 32 13. CAGOMOC, JAYVIE 33 14. DACARA, KATRINA 33 15. ESTAYAN, MAIKO 24 16. ENECILLO, JESSICA 35 17. ERLANDEZ, CATHERINE 34

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18. FERRAN, KIMBERLY 28 19. FRANCISCO, GHENELYN 36 20. GABRIEL, ELLYN JOY 30 21. GALAPON, BIANCA PATRICIA 31 22. GARCIA, PRINCESS GRACE 36 23. GASPAR, DIANA MARIE 33 24. GITGANO, ADONIS 36 25. GOB, CARLA JANE 33 26. GOMEZ, MARA CASSANDRA 35 27. GURAN, TANYA 26 28. HONRADO, HANEYLETTE REPORTER 29. JARINA, JAYMAR 37 30. LADICA, LENNIE KLARYZ 33 31. LUMBA, KRISLINE MAE 35 32. MEJARITO, POLYJEM 31 33. MIGUEL, NATALIE 36 34. NACIONAL, CHRISTELLE JAN 36 35. NALDA, JOHN MARK 29 36. OLIVA, XYZA DENNISE 28 37. PIGAO, FLORENTINO III 30 38. REFANI, MARYAM REMAE 34 39. RUALES, ABEER REPORTER 40. SAILOG, JUVY ANN 34 41. SAMALA, NICKY JOHN 24 42. SAN JOSE, RIA JOY REPORTER 43. SORIANO, KARLMARX VLADIMIR 31 44. SOUSA, NICOLEI KATRINA 35 45. SUMAGAYSAY, YVON PIA 30 46. VALDEZ, IANNE MAE 31 47. VELASCO, JUSTIN 36 48. VILLAR, APRIL GRACE 39 49. ZUÑIGA, KELLY MARGARETH 38

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EVALUATION: IMPLOSIVE THERAPY & FLOODING CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100%

NAME OF REPORTERS NAME Estayan, Ladica, Gitagano, Maiko Kimberly Lennie Klaryz Adonis 1 Acuna, Aira 98 98 97 2 Adigue, Mary Lou 100 100 100 3 Amigo, Alfred 100 100 100 4 Balaong, Mariflor 100 100 100 5 Barbuco, Dianne Mae 100 100 100 6 Binayug, Gideon 100 100 100 7 Buenasflores, Ma. Fe 100 100 100 8 Cagomoc, Jayvie 100 100 100 9 Dacara, Katrina 97 99 98 10 Enecillo, Jessica 96 96 92 11 Erlandez, Catherine 99 99 97 12 Ferran, Kimberly 90 90 90 13 Francisco, Ghenelyn 88 88 88 14 Garcia, Princess Grace 100 100 100 15 Gaspar, Diana Marie 93 93 93 16 Gob, Carla Jane 94 94 94 17 Gomez, Mara Cassandra 100 100 96 18 Guran, Tanya 100 100 99 19 Honrado, Haneyllette 96 96 96 20 Jarina, Jaymar 100 100 100 21 Mejarito, Poly Jem 100 100 100 22 Nacional, Christelle Jan 95 95 95 23 Nalda, John Mark 95 95 95 24 Oliva, Xyza 98 98 98 25 Pigao, Inno 97 99 97 26 Refani, Maryam 95 95 90 27 Ruales, Abeer 100 100 100 28 Sailog, Juvy 100 100 100

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29 Samala, Nicky 99 99 99 30 San Jose, Ria Joy 100 100 100 31 Soriano, Karl Marx 100 100 100 32 Sousa, Nicolei Katrina 85 85 90 33 Sumagaysay, Yvon 95 95 95 34 Valdez, Ianne Mae 95 95 95 35 Villar, April 95 95 95 36 * No name * 100 100 100 AVERAGE 97.22% 97.33% 96.92%

IMPLOSIVE THERAPY & FLOODING QUIZ SCORES NAME SCORES ESTAYAN REPORTER FRANCISCO 36 PIGAO 35 BALANQUIT 29 ROWALES 32 GITGANO REPORTER ACUÑA 26 JARINA 27 AMIGO 24 VILLAR 28 GALAPON 24 GOB 26 ERLANDEZ 29 NACIONAL 30 BORRERO 32 GASPAR 28 BARBUCO 24 GABRIEL 30 BINAYUG 26

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HONRADO 33 VALDEZ 23 CAGOMOC 31 ENECILLO 32 MEJARITO 23 NALDA 23 VELASCO 36 SAILOG 28 DACARA 32 ANDRADE 34 ZUNIGA 32 FERRAN 29 LUMBA 30 LADICA REPORTER BALAONG 28 GOMEZ 26 BUENASFLORES 28 ADIGUE 23 REFANI 34 MIGUEL 31 SAMALA 27 SOUSA 28 BABOR 26 GARCIA 32 SAN JOSE 31 BATOMALAQUE 27 SORIANO 26 OLIVA 28 SUMAGAYSAY 34

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EVALUATION: ASSERTIVE TRAINING CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100% NAME ENECILLO GABRIEL MIGUEL ZUÑIGA ACUÑA 95 95 95 96 ADIGUE 90 89 89 91 AMIGO 95 95 97 100 ANDRADE 90 90 90 90 BABOR 98 96 97 98 BALANQUIT 99 99 97 98 BALAONG 90 90 90 90 BARBUCO 95 90 90 90 BATOMALAQUE 93 90 95 95 BINAYUG 95 92 95 92 BORRERO 91 95 95 95 BUENASFLORES 95 90 95 95 CAGOMOC 99 100 100 100 DACARA 100 99 99 99 ERLANDEZ 95 100 100 100 ESTAYAN 95 93 98 90 FERRAN 93 90 98 90 FRANCISCO 96 94 93 93 GALAPON 95 97 96 96 GARCIA 97 94 94 95 GASPAR 98 96 96 97 GITGANO 97 98 98 98 GOB 97 97 97 97 GOMEZ 91 100 100 100 GURAN 97 92 85 95 HONRADO 95 97 97 97 JARINA 98 95 95 95 LADICA 99 98 99 100 LUMBA 99 94 96 95 MEJARITO 98 99 99 99 NACIONAL 100 98 100 100 NALDA 100 100 100 100 OLIVA 100 100 100 100

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PIGAO 100 100 100 100 REFANI 91 91 93 93 RUALES 90 90 90 90 SAILOG 90 90 90 90 SAMALA 94 93 95 94 SAN JOSE 94 94 94 94 SORIANO 98 98 99 98 SOUSA 91 91 91 91 SUMAGAYSAY 92 94 96 95 VALDEZ 94 95 95 95 VELASCO 94 93 94 94 VILLAR 96 96 97 96 AVERAGE: 95.29% 94.82% 95.53% 95.47%

ASSERTIVE TRAINING QUIZ SCORES

NAME SCORE (40 ITEMS) ACUÑA, AIRA 33 ADIGUE, MARY LOU 35 AMIGO, ALFRED 39 ANDRADE, KAY CELINE 35 BABOR, DAVE 39 BALANQUIT, JOSHUA 37 BALAONG, MARIFLOR 33 BARBUCO, DIANNE 28 BATOMALAQUE, VERGEL 36 BINAYUG, GIDEON 30 BORRERO, DAISY 36 BUENASFLORES, MA. FE 28 CAGOMOC, JAYVIE 34 DACARA, KATRINA 36 ERLANDEZ, CATHERINE 33 ESTAYAN, MAIKO KIMBERLY 34

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FERRAN, KIMBERLY 35 FRANCISCO, GHENELYN 35 GALAPON, BIANCA 32 GARCIA, PRINCESS GRACE 33 GASPAR, DIANA 36 GITGANO, ADONIS 38 GOB, CARLA JANE 33 GOMEZ, MARA CASSANDRA 31 GURAN, TANYA 25 HONRADO, HANEYLETTE 39 JARINA, JAYMAR 35 LADICA, LENNIE KLARISSE 25 LUMBA, KRISLINE MAY 25 MEJARITO, POLYJEM 24 NACIONAL, CHRISTELLE JAN 32 NALDA, JOHN MARK 31 OLIVA, XYZA DENNISE 36 PIGAO, FLORENTINO III 34 REFANI, MARYAM REMAE 37 RUALES, ABEER 37 SAILOG, JUVY 35 SAMALA, NICKY JOHN 33 SAN JOSE, RIA JOY 39 SORIANO, KARLMARX VLADIMIR 39 SOUSA, NICOLEI KATRINA 35 SUMAGAYSAY, YVONNE 35 VALDEZ, IANNA MAE 32 VELASCO, JUSTIN 33 VILLAR, APRIL GRACE 33

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EVALUATION: AVERSION THERAPY CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100%

ANDRADE BORRERO CAGOMOC GARCIA SOUSA

98 98 100 98 97 97 90 88 92 92 96 91 92 92 92 100 95 95 97 100 95 95 93 95 90 95 92 97 95 91 80 80 95 80 80 94 93 95 95 92 95 93 80 95 92 95 94 93 94 94 100 100 94 100 100 100 100 100 100 100 99 99 100 98 98 97 97 96 97 97 100 100 97 100 100 97 97 100 95 96 96 97 95 97 97 90 94 94 98 94 95 95 85 96 85 95 95 95 95 95 93 93 95 95 95 93 100 93

Ave: 96% Ave: 95% Ave: 94% Ave: 96% Ave: 94%

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EVALUATION: POSITIVE REINFORCEMENT CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100%

Sailog Nacional Estayan Galapon Acuna Gob Erlandez Valdez MEJARITO 89 98 94 100 100 100 98 100 JARINA 90 98 97 100 100 100 98 100 VILLAR 90 98 94 100 100 100 98 100 BALAONG 90 98 99 100 100 100 98 100

Ferran Refani Ruales Andrade Gaspar Cagomoc Lumba Gomez MEJARITO 93 93 100 95 92 96 86 92 JARINA 95 95 100 95 92 98 90 94 VILLAR 95 94 100 95 92 96 86 93 BALAONG 95 97 100 95 92 98 91 94

Barbuco Buenasflores Pigao Binayug Dacara Babor Guran Ladica MEJARITO 99 94 96 100 89 97 94 97 JARINA 100 95 96 100 90 99 94 100 VILLAR 99 95 97 100 87 98 94 98 BALAONG 100 95 100 100 95 98 95 100

Soriano Enecillo Amigo Honrado Balanquit Adigue AVERAGE MEJARITO 100 97 100 90 97 90 95.53% JARINA 100 99 100 99 97 100 97.03% VILLAR 100 98 100 93 97 94 96.03% BALAONG 100 98 100 99 97 100 97.50%

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EVALUATION: RESPONSE SHAPING CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100% ACUÑA, BARBUCO, GALAPON, SUMAGAYSAY, EVALUATOR AIRA DIANNE BIANCA YVON Binayug, Gideon 100 100 100 100 Buenasflores, 94 96 96 96 Mafe Adigue, Malou 94 97 94 95 Balanquit, 96 96 96 96 Joshua Honardo, Haney 93 96 95 95 Cagomoc, Jayvie 96 96 96 96 Valdez, Ianne 100 100 100 100 Sailog, Juvy 100 100 100 100 Villar, April 100 100 100 100 Gob, Carla 100 100 100 100 Gomez, Mara 93 94 93 93 Balaong, 100 100 100 100 Mariflor Gaspar, Diana 92 92 92 92 Pigao, Florentino 96 96 97 97 III Andrade, Kay 95 95 95 95 Celine Jarina, Jaymar 95 96 97 98 Estayan, Maiko 95 95 96 97 Ruales, Abeer 100 100 100 100 Nacional, 96 95 95 96 Christelle Dacara, Katrina 90 90 90 90 Amigo, Alfred 100 100 100 Enecillo, Jessica 96 97 98 Soriano, 100 100 100 Vladimir

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Guran, Tanya 94 94 94 94 Lumba, Krisline 91 91 92 92 Erlandez, 94 94 94 94 Catherine Ladica, Lennie 92 91 91 91 Babor, Patrick 96 97 99 98 Ferran, 95 95 95 95 Kimberly Refani, Maryam 94 94 94 95

AVERAGE: 95.95% 96.23% 95.96% 96.43%

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EVALUATION: INTERMITTENT REINFORCEMENT CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100%

AMIGO BABOR GURAN PIGAO REFANI ACUNA 95 95 95 95 95 ADIGUE 97 98 98 98 99 BARBUCO 100 100 97 98 100 BATOMALAQUE 93 94 95 93 95 BINAYUG 92 91 91 92 92 BORRERO 100 100 100 100 100 BUENASFLORES 91 92 93 92 93 CAGOMOC 97 97 97 97 97 ENECILLO 96 96 92 83 90 ERLANDEZ 96 96 96 96 96 FERRAN 95 95 95 95 95 GALAPON 95 95 95 95 95 GARCIA 95 95 95 95 95 GASPAR 95 95 95 95 95 GITGANO 88 91 95 86 89 GOB 96 95 95 95 96 GOMEZ 82 83 83 82 87 JARINA 94 98 93 95 99 LADICA 99 99 99 99 99 MEJARITO 97 98 97 98 97 RUALES 100 100 100 100 100 SAN JOSE 84 88 91 80 86 SORIANO 96 96 92 83 90 SUMAGAYSAY 93 94 95 93 95

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SAILOG 89 89 90 90 90 SAMALA 99 99 99 99 99 VALDEZ 93 94 95 93 95 VELASCO 95 95 95 95 95 VILLAR 93 93 95 93 95 90 92 92 92 98 AVERAGE 94.17% 94.77% 94.67% 93.23% 94.9%

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EVALUATION: EXTINCTION CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100% GOB, CARLA LUMBA, VALDEZ, OLIVA,

JANE KRISLINE IANNE XYZA Acuña 100 99 100 A Adigue 94 94 94 B Amigo 94 94 94 S Balaong 98 90 98 E Babor 98 98 98 N Barbuco 100 100 100 T Binayug 94 94 94 Balanquit 98 98 98 Borrero 100 100 100 Buenasflores 98 99 98 Cagomoc 96 96 96 Enecillo 94 93 93 Erlandez 95 96 94 Ferran 95 95 95 Gitgano 96 96 98 Gaspar 93 93 93 Guran 92 92 92 Honrado 96 95 94 Jarina 94 95 92 Ladica 91 92 91 Mejarito 100 100 100 Nalda 100 100 100 Pigao 97 97 96 Refani 97 97 96 Ruales 93 93 93 Samala 99 99 99 San Jose 97 97 96 Soriano 99 98 98 Sailog 95 89 95 Sumagaysay 100 95 100 Velasco 96 96 96 AVERAGE 96.42% 95.81% 96.16%

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EVALUATION: MODELING CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100% SAILOG, SAMALA, NALDA, BATOMALAQUE, ERLANDEZ, JUVY NICKY JOHN VERGEL CATHERINE ANN JONN MARK Justin 97 97 97 97 97 Inno 97 95 96 95 95 Maryam 97 96 96 96 96 Diana 94 93 93 93 93 Carla 95 93 95 90 91 Ria 96 96 96 96 96 Mara 88 88 88 88 88 Haney 92 93 92 94 94 Tanya 90 90 90 90 90 Jessica 96 93 96 95 96 Lennie 90 90 90 90 90 Krisline 92 90 92 92 90 Marylou 95 95 96 95 95 Jaymar 93 99 99 93 93 Mariafe 98 99 99 97 98 Abeer 93 89 89 89 89 Polyjem 100 100 100 100 100 Dianne 100 100 100 100 100 Adonis 94 92 96 98 93 Jayvie 96 96 96 96 96 Daisy 100 100 100 100 100 Alfred 90 88 88 94 90 Vladimir 100 96 99 100 95 Gideon 92 90 92 93 91 Joshua 98 98 98 98 98 Patrick 98 98 98 98 98 Maj 98 95 98 95 90

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April 100 95 100 98 95 Yvon 100 95 100 98 95 Ianne 95 90 95 95.10% 94.21% Aira 100 98 100 Bianca 100 98 100 95.75% 94.53% 95.75%

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EVALUATION: TOKEN ECONOMY CRITERIA: KNOWLEDGE - 25% PRESENTATION - 25% RESOURCEFULNESS - 25% OVER-ALL IMPACT - 25% TOTAL - 100%

GASPAR DACARA VELASCO FRANCISCO SORIANO BINAYUG 97 98 98 97 98 97 98 98 98 98 98 98 90 90 90 90 90 90 96 98 97 94 95 94 95 95 95 95 95 95 97 98 98 97 97 97 96 97 97 95 95 95 95 96 95 95 95 95 98 98 98 98 98 98 98 98 98 98 99 96 100 100 100 100 100 100 95 96 95 95 95 95 92 93 92 91 93 92 93 94 93 93 94 94 96 96 96 96 96 96 95 96 94 95 96 95 97 98 97 96 97 96 93 93 93 97 93 93 99 100 100 98 99 98 100 100 100 100 100 100 100 100 100 100 100 100 96 100 98 96 100 96 100 100 100 99 99 99 99 99 99 99 99 99 AVERAGE 96.46% 97.13% 96.71% 96.33% 96.71% 96.17%

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