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Cognitive Behaviour Therapy
Cognitive behaviour therapy (CBT) has a well-elaborated theoretical background and documented standard therapeutic process. However, new specific
theoretical formulations and genuine techniques seem to continually appear.
These new treatment developments in CBT constitute the heart of this book.
Leading researchers and clinicians, who are also well-established experts in
the application of CBT, present the extent of their experience, as well as
appropriate and state-of-the-art treatment techniques for a variety of specific
disorders. Topics covered in this book include:
Management of major depression, suicidal behaviour and bipolar disorder
Treatment of anxiety disorders, such as panic disorder, obsessive compulsive disorder and generalised anxiety disorder
Application of CBT to eating disorders and personality disorders, especially borderline personality disorder
Implementation of CBT with specific populations, for example couples
and families or children and adolescents.
Cognitive Behaviour Therapy: A Guide for the Practising Clinician is a clinical
practice oriented and treatment techniques focused book which allows for
adequate flexibility in order to help the practising clinician become more
competent and efficient in applying cognitive behaviour therapy. It will be
invaluable to clinicians, researchers and mental health practitioners.
Gregoris Simos, MD, PhD, is a cognitive behavioural clinician at the
Aristotelian University of Thessaloniki, Greece. He is on the United
Kingdom Council of Psychotherapy and an accredited Cognitive and
Behavioural Psychotherapist, and is a founding member and current
President of the Greek Association for Cognitive and Behavioural
Psychotherapies. He is also a Founding Fellow of the Academy of Cognitive
Therapy, USA.
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Cognitive Behaviour Therapy
A Guide for the Practising Clinician
Gregoris Simos
First published 2002 by Brunner-Routledge
This edition published 2012 by Routledge
27 Church Road, Hove, East Sussex BN3 2FA
711 Third Avenue, New York, NY 10017, USA
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2002 Gregoris Simos selection and editorial matter; individual chapters, the contributors
Typeset in Times by M Rules, London
Cover design by Terry Foley
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any
form or by any electronic, mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information storage or retrieval system,
without permission in writing from the publishers.
This publication has been produced with paper manufactured to strict environmental standards and
with pulp derived from sustainable forests.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress
ISBN 978-1-58391-105-1 (pbk)
ISBN 978-1-58391-104-4 (hbk)
To all those who were –
and as such, will always be –
my teachers.
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List of figures and tables
About the editor
List of contributors
The cognitive treatment of depression
Cognitive behavioural treatment of suicidal behaviour
Cognitive therapy of bipolar disorder
Cognitive behaviour therapy for panic disorder
Psychosocial treatment for OCD: Combining cognitive
and behavioural treatments
Cognitive behavioural therapy for worry and generalised
anxiety disorder
Cognitive behavioural treatment of eating disorders
Schema-focused therapy for personality disorders
Letting it go: Using cognitive therapy to treat borderline
personality disorder
Techniques and strategies with couples and families
Cognitive behavioural therapy with children and adolescents
Figures and tables
The cognitive model of panic disorder
Cognitive behavioural model of obsessive compulsive
Downward arrow of a man obsessed with accuracy
The pie-chart technique
Downward arrow of a compulsive cleaner/organiser
Levels of cognition
Channels of input in relation to age
Thought record – Part 1
Adaptive responses: Thought record – Part 2
The downward arrow technique
Overview of CBT for OCD
An example of a cumulative odds ratio for a compulsive
Major content areas for cognitive therapy
The effects of semi-starvation from the 1950 Minnesota
Steps in cognitive restructuring
Schema domains
Eriksonian stages associated with schema development
Parallels between Piagetian and borderline characteristics
About the editor
Gregoris Simos graduated from the Medical School of the Aristotelian
University of Thessaloniki, Greece, and was trained in Psychiatry and
Psychotherapy at the 2nd Department of Psychiatry of the same University.
Part of his post-graduate training was conducted at the Institute of
Psychiatry, University of London, where he worked with Professor Isaac M.
Marks (Psychological Treatment Unit), Professor Gerald Russell (Eating
Disorders Clinic) and Dr Michael Crowe (Sexual and Marital Problems
Clinic). Dr Simos also trained at the University of Pennsylvania (Center for
Cognitive Therapy) under the direction of Aaron T. Beck, MD. He earned his
PhD at the Aristotelian University of Thessaloniki, Greece, where he is currently involved in research and teaching.
Dr Simos is regarded as a leading cognitive behavioural clinician in Greece.
He is also on the United Kingdom Council of Psychotherapy, an accredited
Cognitive and Behavioural Psychotherapist, and is a founding member and
current President of the Greek Association for Cognitive and Behavioural
Psychotherapies. He is also a member of the Editorial Board of the Journal
of Anxiety Disorders.
Dr Simos is the editor of the series “Bibliotherapy”, published by Patakis
Publishing Co., and under his supervision has already translated into Greek
Helen Singer-Kaplan’s PE: How to Overcome Premature Ejaculation, David
Burns’ Feeling Good, Aaron T. Beck’s Love is Never Enough, Janet Klosko and
Jeffrey Young’s Reinventing Your Life, and Christopher Fairburn’s
Overcoming Binge Eating, Frank Lamagnere’s Manies, Peurs et Idées Fixes,
Alan Garner’s Conversationally Speaking, Robert Alberti and Michael
Emmon’s Your Perfect Right!, and Judith Beck’s Cognitive Therapy: Basics
and Beyond. He is also a Founding Fellow of the Academy of Cognitive
Therapy, USA.
M. Teresa Blanch, MA
Altabix Mental Health Center, Alacant, Spain.
Thomas D. Borkovec, PhD Department of Psychology, The Pennsylvania
State University, 417 Bruce V. Moore Building, University Park, PA 168023104, USA.
Frank M. Dattilio, PhD ABPP Center for Integrative Psychotherapy, Suite
211-D, 1251 S Cedar Crest Boulevard, Allentown, PA 18103, USA.
Arthur Freeman Department of Psychology, Philadelphia College of
Osteopathic Medicine, 4190 City Avenue, Philadelphia, PA 19131-1693,
David M. Garner, PhD River Centre Clinic, 5465 Main Street, Sylvania, OH
43617, USA.
Aude Henin, PhD Massachusetts General Hospital, Department of
Psychiatry, 50 Staniford Street, Suite 580, Boston, MA 02114, USA.
James Jackson Department of Psychology, Philadelphia College of
Osteopathic Medicine, 4190 City Avenue, Philadelphia, PA 19131-1693,
Philip C. Kendall, PhD, ABPP Temple University, Department of
Psychology, Weiss Hall (265–66), Philadelphia, PA 19122, USA.
Kevin T. Kuehlwein, PsyD University of Pennsylvania, Center for Cognitive
Therapy, Room 754, The Science Center, 3600 Market Street, Philadelphia,
PA 19104-2648, USA.
Peter D. McLean, PhD Department of Psychiatry, UBC Hospital, 2255
Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
Susan B. Morse, PhD Creative Cognitive Therapy Productions, 2118
Central, SE # 46, Albuquerque, NM 87106, USA.
Cory F. Newman, PhD
University of Pennsylvania, Center for Cognitive
Therapy, Room 754, The Science Center, 3600 Market Street, Philadelphia,
PA 19104-2648, USA.
Michelle G. Newman, PhD Department of Psychology, Penn State
University, University Park, PA 16802, USA.
S. Rachman, PhD Department of Psychology, University of British
Columbia, Vancouver, BC, V6T 1Z4, Canada.
Gregoris Simos, MD, PhD Aristotelian University of Thessaloniki,
CMHC/2nd Department of Psychiatry, 15 Komninon Street, 546 24
Thessaloniki, Greece.
Melissa Warman, PhD Temple University, Department of Psychology,
Weiss Hall (265–66), Philadelphia, PA 19122, USA.
Maureen L. Whittal, PhD Anxiety Disorders Unit, UBC Hospital, 2211
Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
Jeffrey E. Young, PhD Cognitive Therapy Center of New York, Suite 530,
120 East 56 Street, New York, NY 10022, USA.
Since its development in the 1960s, cognitive behaviour therapy (CBT) has
already acquired its own solid and individual identity in the field of developmental and clinical psychology. Whereas in 1967 CBT originated through a
rather experimental approach with Aaron T. Beck and colleagues’ efforts to
articulate a comprehensive method of understanding and treating depression,
it has become, along with psychodynamic and behaviour therapy, one of the
three major psychotherapeutic modalities. Dr Beck is second only to Freud in
the number of citations to his work in the psychiatric literature. Cognitive
therapy of depression was nevertheless only the beginning – CBT has already
proven its effectiveness with anxiety disorders including panic disorder, obsessive compulsive disorder and generalised anxiety disorder; CBT has also been
found to be effective in the management of eating disorders, couples and
family problems, personality disorders, substance abuse, bipolar disorder,
along with a number of other disorders. New developments in the use of
CBT include its implementation with children and adolescents, crisis intervention, schizophrenic patients, and inpatient treatment.
A part of the “cognitive revolution” is reflected in the increasing number of
articles, books, and book chapters on CBT in the literature. A search in the
Excerpta Medica/Psychiatry database (EMBASE CD: Psychiatry, Elsevier
Science BV) shows that during 1985–1995, 7891 articles were indexed under
the general term “psychotherapy”, while 4674 articles were indexed under the
terms “behavior therapy” and “cognitive therapy”.
Therefore, why another handbook on CBT? There are several reasons;
however, the most prominent one has to do with the integrative nature of
CBT. CBT fulfils the criteria for a true system of psychotherapy by virtue of
the fact that it provides a comprehensive theory of psychopathology and a
body of knowledge and empirical evidence to demonstrate its effectiveness. It
also retains a certain degree of flexibility in its philosophy and theory, allowing for the accommodation of other modalities. On the treatment
implementation level CBT is continually evolving. Therefore, since no treatment modality has currently been found to be universally and totally effective,
CBT is on the move toward both a self-refinement and self-integration that in
an ever changing way will become even more powerful as a treatment option.
This last aspect of CBT is also reflected in the fact that CBT is considered to
be the most heavily researched form of psychotherapy.
In a survey by Norcross and Prochaska (1988), which examined the most
frequent combinations of theoretical orientations, the majority of clinicians
favoured an integrative approach, with the highest percentage rating cognitive
behaviour therapy as their number one choice.
Although CBT has a well-elaborated theoretical background and documented standard therapeutic process, new specific theoretical formulations
and genuine techniques seem to be continually appearing. These new treatment developments in CBT constitute the heart of this book. Leading
researchers and clinicians, who are also well-established experts in the application of CBT, present the extent of their experience, as well as appropriate
and state-of-the art treatment techniques for a variety of specific disorders.
A final note of appreciation. I really feel indebted to all authors of this
book for the great deal of work they have put into their chapters. Taking
advantage of the saying “all people are equal, but some of them are more
equal than others”, I would like to express additional appreciation to Frank
Dattilio for his always willing, accurate, and valuable guidance throughout
the process of editing this book.
Gregoris Simos, MD, PhD
Norcross, J.C. & Prochaska, J.O. (1988). A study of eclectic (and integrative) views
revisited. Professional Psychology: Research and Practice, 19, 170–174.
Aaron T. Beck
I am delighted to write this introduction to Cognitive Behavior Therapy: A
Guide for the Practicing Clinician. Gregoris Simos trained with me many
years ago and is especially well qualified to have edited this volume. The
chapters in this volume have been prepared by specialists in the various Axis
I and Axis II Disorders and cover the full range of psychological disorders. I
am particularly gratified that various of the authors have worked with me in
the past. This volume is unique in its presentation of guiding principles and
strategies by these experts.
Cognitive Therapy, covered in this volume, draws on a very strong empirical base for its theoretical formulation. The generic cognitive model derived
from the theory has been tailored to the specific characteristics of the Axis I
and Axis II disorders. A large number of outcome studies have supported its
efficacy in the treatment of primarily Axis I disorders.
In addition to the earlier work with the depressive and anxiety disorders,
the most recent controlled outcome studies have indicated cognitive therapy’s efficacy with or without medication in the more intractable and severe
disorders, such as Severe Chronic Depression, Bipolar Disorder, Anorexia
Nervosa, Schizophrenia, Chronic Fatigue Syndromes, and Substance Abuse.
I would especially highlight new cognitive approaches to schizophrenia.
As we enter the new millennium, we ask, ‘How can cognitive therapy best
serve the changing needs of the patients and the payers of health care?’. In
the future, I anticipate the emergence of a broad psychotherapy that will be
refined for the broad range of psychological problems in psychiatric and
medical patients. With changes in the delivery of health care, I expect that
some kind of triage will assign psychotherapists according to their degree of
expertise and specialized skills. In all probability less experienced, less skillful
therapists will treat the simple garden-variety of disorders on a short-term
basis (from three to twelve visits). The more skillful and highly trained therapists will work with the challenging Axis I and Axis II disorders in
longer-term therapy, possibly in combination with drugs. This will include
spacing the visits over a longer period of time than is customary presently
and providing ‘booster’ sessions.
Many therapists will work as members of a team with primary care physicians. The therapist would be responsible for assessing and screening medical
patients for psychiatric problems. Since 40–50 per cent of patients in a family
practice have some degree of depression, these problems will be addressed by
the primary care therapists. They will also be involved in the ‘disease management’ of disorders such as diabetes, hypertension, low back pain, and
I predict that opportunities for well-trained, experienced therapists should
increase. In the future the accreditation of therapists will be based on the
assessment of their competency in dealing with patients, and they either will
or will not be assigned to patients depending upon their ‘non-specific’ psychotherapy skills as well as their more highly specialized skills. I am pleased
that this volume will provide a framework for present and future therapists to
hone their skills.
Aaron T. Beck, M.D.,
University Professor of Psychiatry,
University of Pennsylvania
Chapter 1
The cognitive treatment of
Kevin T. Kuehlwein
Impact of depression
Depression in its various forms (major depression, dysthymia, the depressed
phase of bipolar disorder) is both a highly disabling and disturbingly widespread phenomenon in today’s society. It causes huge suffering and economic
costs to individuals and society because of both its high prevalence and its
undertreatment among most segments of society (National Depressive and
Manic-Depressive Association Consensus Statement on the Undertreatment of
Depression (NDMACS); Hirschfeld et al., 1997). Moreover, although effective
treatments for depression exist, various factors on both the client and professional side prevent people from recognising the signs of depression and then
receiving optimal treatment from qualified professionals. Depressed individuals often feel the stigma attached to problems of “mental illness”. This makes
them reluctant to seek help in the earlier stages of the disorder before certain of
their negative cognitive-affective-behavioural patterns have strengthened.
Instead of simply realising that they may need professional help, depressed
clients often label themselves as “weak” or “failures” (or fear others may do so)
due to their increasing difficulty in handling many aspects of their lives.
Recent studies on the impact of major depression have compared its negative effects to those of other chronic general medical ailments like heart
disease, hypertension, and diabetes (Hays, Wells, Sherbourne, Rogers, &
Spritzer, 1995). The monetary toll alone in the United Kingdom has been
estimated at between £220 million (Jonsson & Bebbington, 1994) and £2500
million per year (including indirect costs) (Kind & Sorenson, 1995). Optimal
treatment, furthermore, does not often occur because many professionals even
in highly industrialised countries are themselves inadequately trained in both
the diagnosis and treatment of depression, from both the psychotherapeutic as
well as pharmacological angles. A few statistics will illustrate these points.
The lifetime risk of major depression in the United States and other
countries has been reported to range from about 5 to 25% in women and
from 2 to 12% in men (Boyd & Weissman, 1981).
Kevin T. Kuehlwein
Of those who are depressed and see a health professional, the vast majority do not even encounter a mental health professional, but instead are
seen only by a primary practice doctor (Hirschfeld et al., 1997).
Because certain physical disorders can involve symptoms similar to those
of depression, many examining physicians do not accurately or promptly
detect depression in the majority of their patients. Therefore, they often
neither treat the concomitant depression nor refer the patient to a competent mental health professional (Hirschfeld et al., 1997).
Costs of actual treatment combined with diminished productivity resulting from major depressive disorder in the United States total
approximately $16 billion in 1980 dollars (Hirschfeld et al., 1997).
People with three or more episodes of major depressive disorder have a
9 in 10 chance of having a relapse into a further episode (Hirschfeld et
al., 1997).
Luckily, Beck’s cognitive therapy (Beck, Rush, Shaw, & Emery, 1979) has
proved highly effective in many studies as a treatment for depression (Hollon
& Beck, 1994). This chapter will focus primarily on the outpatient treatment
of major depression in individual therapy with adults because the research
has concentrated on that population. It is, however, possible to use this
approach with milder types of non-psychotic depression and, with certain
modifications, as an adjunct to pharmacotherapy with bipolar disorder
clients. Indeed, therapists can use cognitive therapy with many clients on
medications to increase their medication compliance. It has also been practised successfully in group formats (Hollon & Shaw, 1979; Freeman, Schrodt,
Gilson, & Ludgate, 1993) and with children, again with certain modifications
(DiGiuseppe, 1993).
Structure of the chapter
In describing an effective cognitive therapy approach to major depression, I
will first define cognitive therapy, speak about the theory of cognitive therapy
as applied to the problems of depression, focusing especially on conceptualisation, detail some techniques to use in assessing and treating depression,
delineate steps in a typical course of treatment, and mention throughout
common mistakes that even more experienced therapists may sometimes
make in treating depressed clients. Finally I will offer suggestions throughout
as to how to avoid many of these errors.
Defining cognitive therapy
Before beginning the discussion of cognitive therapy of depression, however,
I want to emphasise that cognitive therapy is not a collection of useful techniques to be used in isolation. Indeed, Beck maintains that “cognitive therapy
Cognitive treatment of depression
is best viewed as the application of the cognitive model of a particular disorder with the use of a variety of techniques designed to modify the
dysfunctional beliefs and faulty information-processing characteristic of each
disorder” (Beck, 1993, p. 194).
Cognitive conceptualisation of depression
According to Beck’s cognitive specificity hypothesis (Beck et al., 1979)
depressed clients have a different cognitive profile from those with other psychiatric problems, showing primarily themes of loss, defeat, and failure in
their cognitive content. Their spontaneous verbal output typically reveals
many examples of thinking (including metaphors and images) with a systematic negative bias. This is mirrored in clients’ deeper, unspoken
assumptions across many domains of their experience. Beck has especially
called attention to the “negative cognitive triad” in depressed clients: a fairly
unrelenting tendency to view themselves, the future, and their experience
around them almost entirely in negative terms (Beck et al., 1979). Because of
Beck’s focus in the cognitive treatment of depression on identifying, evaluating, and modifying dysfunctional thoughts and deeper beliefs, some careless
readers of his work are under the misapprehension that Beck assigns a causal
role in depression to distorted thinking. When questioned, he has said that he
would no more make that claim than to suggest that hallucinations and delusion cause schizophrenia (Beck et al., 1979). While Beck is careful to avoid
saying with authority what exactly causes depression in the first place, since
research itself has produced no definitive answers, he maintains that the maladaptive worldview of depressive clients helps to maintain most of the
symptoms of depression as well as significantly interfering with their effective
problem-solving of their many real-life problems (Beck et al., 1979). In many
cases, indeed, clients’ lack of effective action or their actually dysfunctional
action flows from their maladaptive and overly rigid ways of viewing their situation. What cognitive therapy first seeks to do, therefore, is help clients to be
more aware of their active ways of making meaning and to discover the
adaptiveness or maladaptiveness of these constructions. This is called “decentering”, described by Safran and Segal (1990) as
a process through which one is able to step outside of one’s immediate
experience, thereby changing the very nature of that experience. This
process allows for the introduction of a gap between the event and one’s
reaction to that event . . . Stepping outside of one’s current experience fosters a recognition that the reality of the moment is not absolute, immutable,
or unalterable, but rather something that is being constructed (p. 117).
Safran and Segal note, however, that mere theoretical awareness of this
process is insufficient to induce necessary change: “For change to take place,
Kevin T. Kuehlwein
however, patients must have more than an intellectual grasp of this notion.
They must have the experience of actually seeing themselves construct
reality” (p. 118).
After clients learn how to do this, their next task is to explore and learn to
utilise other, more adaptive ways of understanding their own experience. As
they practise this skill of disembedding from their dysfunctional constructions they become progressively better able to detect and resolve problems.
It is important for every clinician to develop and share with the client on
some level his or her evolving cognitive conceptualisation of the client. The
conceptualisation has two major parts. The first part is the general conceptualisation of the phenomenon of depression itself. This more generic idea of
the typical characteristics, predisposing factors, as well as the likely cognitive,
affective, behavioural and situational vulnerabilities helps the therapist better
understand many of depression’s common aspects. For example, the therapist
can predict that a client will usually continue to feel bad if she spends a great
deal of time oversleeping, avoiding most activity, and ruminating. The therapist can then educate the client about her own depression and what will
tend to reduce or increase it. Educating the client in this way about the nature
of depression can help her to break out of a sense of emotional helplessness
(for example, “My moods just come over me and there’s nothing I can do,
Doctor.”). This can help to reduce demoralisation in the client and impart an
increasing sense of self-efficacy in her (for example, “If I work to catch and
reduce my all or nothing thinking, I’ll feel better and enjoy things more” or
“If I get up at 8 a.m. and plan my day with some forethought, I can feel satisfied during and at the end of the day”).
The second part is an individualised case formulation for each client to
answer questions like the following: How does this particular client experience depression? What are the most salient features for her? What possible
sociocultural effects might there be that could affect her experience of herself
and depression? How do the symptoms all fit together? Which component
tends to start the negative cycle? What mitigating factors in her depression
can we utilise to help the client break free of her depression? So, although the
above-mentioned similarities exist across many depressed clients, each client
has a depression that is also unique. Historical factors and current situations
as well as the personal construction of meanings will differ for each client.
For this reason, the therapist must develop an evolving, multifactorial conceptualisation of each client. Most clients find it very interesting and
gratifying to explore and collaborate on this. The positive effect, again, of
such activity is often greater self-understanding and greater self-compassion.
This can also lead to an enhanced sense of control and predictability over
their moods, thoughts, and actions. There are several models for developing
such an individualised case formulation. Beck (1995), for example, has a
Cognitive Conceptualisation Diagram (1995, p. 139) that serves as a quick
summary sheet of the most important information gathered over the early
Cognitive treatment of depression
part of therapy. Layden (1997) also has developed a slightly more differentiated one that places increased emphasis on images as well as more positive
beliefs and experiences of the client. Persons (1989, 1993) has written a fulllength book and several chapters solely on the subject of conceptualisation.
She has put forth a rather comprehensive model for understanding the major
components of a client’s problematic patterns. Whatever model the therapist
uses, the basic conceptualisation probably needs to cover at least the following areas:
1 Major current problems (including behavioural, cognitive, affective, and
physiological) the client is experiencing. For example, one might note that
a client is depressed, sad, and nervous; tends to withdraw socially, drink
alcohol every evening, and watch TV at home; tends to experience
headaches and constant fatigue as well as a gnawing pain in her stomach;
tends to blame herself for anything that goes wrong, tells herself that she
really should pull herself up by her bootstraps and snap out of it, calls
herself a loser and failure, and predicts continued misery and isolation
for the rest of her life.
2 A few representative situations in which these problems occur with the
unique behavioural, affective, cognitive, and physiological aspects noted.
For example, a client becomes especially depressed and fatigued and
withdraws from social contact whenever she receives criticism, even if
well-intentioned. She then says to herself, “They must be right. I can’t do
anything right. It’s just like my ex-husband used to say, I am a failure.”
3 Current predisposing events and situations. Example: mounting debt,
death of a loved one, highly stressful job.
4 Any metaphors, similes, images, or dreams the client reports that represent important aspects of the problems under review. Example: a client’s
image of herself wrapped in chains in a cold, dark room and unable to
5 The current cognitive, affective, physiological, and behavioural strategies that seem to represent coping attempts (even if of questionable
utility in the long term). These, sometimes referred to as “compensatory
strategies” (Beck, 1995), are reactions to the underlying negative core
beliefs that cause the client to experience distress. Examples: frequent
blotting out of unpleasant facts via forgetting or substance abuse, being
overly dependent on others, procrastinating, or criticising oneself before
others can.
6 Past predisposing situations (especially those that had a large impact on
the client as a developing child or those later in life that were so disturbing as to shake the very foundations of her meaning-making structures at
the time). Example: the tragic loss of a close friend from a car accident
years ago, which led a client to question the very concept of safety and
trust in the world.
Kevin T. Kuehlwein
7 Past situations of good coping during stress or change. Example: a client
took a year abroad in Portugal as a break from college and managed to
learn Portuguese quickly and to begin a small business at which he was
very successful.
8 Past accomplishments. Example: a client was one of the top students in
his college class. He also was told by a professor whom he respected that
a paper he wrote for a course should be slightly rewritten and published
because it was so creative.
9 Interests and passions. Example: a client is very interested in all kinds of
sports and follows baseball especially avidly. These interests can often be
used by the knowledgeable therapist as a source of useful linking
metaphors to counter dysfunctional beliefs.
10 Past or present people who have had a positive impact on the client.
Example: as a child a client was taken care of by a woman in the neighbourhood after school during a brief period when his mother worked
full-time outside the home. This older much more maternal woman was
very affectionate, empathetic, and understanding of the needs of the
client as a 6-year-old boy. As an adult, this client still associates the smell
of baked goods with fond memories of her (see also above section on
images). Another positive force in his life is his very kind wife, who has
stood by him during periods of great turbulence in their lives.
Therapists will benefit from having a several-page form with these headings to
contain all of this information, so that they have easy accessibility to a client’s
relevant treatment factors all in one place.
Many therapists when they conceptualise their clients have a primarily
problem-focused orientation and thereby risk viewing their clients solely
through the lens of their current relatively poor coping. The advantages of
examining also the more positive effects (past and present) on the client are
that the therapist gains a much fuller understanding of the client in all her
complexity. Gently enquiring about such positive events and resources in the
client’s life can also help the client to gain better access to those memories and
those parts of her experience. The therapist can then use her knowledge of
these more positive forces in the client’s life to build bridges from the past and
current strengths out of her present difficulties and into the more positive
future. It is key when doing this, however, to ensure that the client does not
believe that the therapist is invalidating her view of the world. Instead the
therapist should convey an attitude of trying to provide a needed balance
between the negative and positive aspects of her life.
Note that both positive and negative outcomes early in therapy serve to
inform therapist and client about the accuracy and utility of the evolving
treatment conceptualisation, so that unexpected results (for example a poor
result from an attempted intervention) should lead the therapist to modify her
case conceptualisation and resulting therapy approach.
Cognitive treatment of depression
It is very important to begin therapy with a good, preferably standardised
diagnostic assessment (SCID I & II; Spitzer, Williams, Gibbon, & First, 1990)
of the client and her whole range of presenting problems. This multi-axial
assessment (American Psychiatric Association, 1994) should include specifically targeted diagnostic questions to help the therapist determine what the
duration, quality, and severity of the depression is as well as any accompanying conditions, whether they be comorbid psychiatric disorders, comorbid
physical disorders, or simply environmental situations that may affect (positively or negatively) the depression or the treatment.
It is helpful, for example, to know if the client is also suffering from an
eating disorder or obsessive compulsive disorder since experts recommend
these other Axis I disorders generally be treated first before trying to
approach the major depression (Agency for Health Care Policy and Research
(AHCPR), 1993a, 1993b). If the client is also comorbid for panic disorder,
the therapist must determine which disorder is primary before deciding which
to treat first. When treating a client who meets criteria for substance abuse,
the therapist generally should first focus on getting the client to discontinue
the substance (via a detoxification programme) and then re-evaluate the
client’s condition 1–2 months afterwards. If the client continues to experience
major depressive disorder, then that becomes the focus of treatment. In some
situations, however, it may be advisable to treat the major depressive disorder
earlier (AHCPR, 1993b). A good assessment will also help the therapist
ascertain the last time a client received a medical check-up that would rule out
some of the many organic causes of depression (Cassem, 1988).
Problem assessment
Of course, cognitive therapy strongly focuses on the careful assessment of
problems both before and throughout the treatment. This emphasis ensures
that the therapist fully understands the full scope of the many problems (as
well as their interrelationships) and attends carefully to the changes in symptoms during the course of therapy. If change does not occur or is not in the
desired direction (that is, the client’s symptoms worsen contrary to expectations), therapist and client can then notice this sooner and modify the
treatment approach accordingly. Cognitive therapy focuses on what is going
on in the client’s current experience (versus the distant past) as of primary
importance in alleviating and preventing distress. Therefore, a therapist need
not gather exhaustive information about the past difficulties of a client at the
outset of therapy, although some background information is, of course,
important. The therapist instead gathers a comprehensive problem list of the
major problems across many modalities that a client currently experiences.
For example, the therapist would inquire about work and relationships –
Kevin T. Kuehlwein
relationships with family, friends, partners – and other relevant potential
support mechanisms or stress-related factors. He would also ask the client
about her nutrition, substance use (including caffeine and tobacco), and exercise/activity level. Many therapists overlook these physiological factors, which
can sometimes significantly affect a client’s depression or recovery from
depression. The author has known, for example, several clients for whom
regular exercise was an absolutely integral part of improving their mood
states. In other cases, modifying odd patterns of nutrition seemed to support
more adaptive thinking and action.
Clear descriptions of problems and progress
One of the most common impediments early in therapy is when clients define
their problems and goals too vaguely. It is not at all uncommon to hear
clients come in with the goal of being happy without clarifying questions like
these: “What am I most unhappy about? What about that makes me
unhappy? What would need to change for me to be more happy? When am I
happiest? How do I behave when I am happy? What are the behaviours most
associated with being unhappy?” Having vague goals begets vague therapy:
wandering around from topic to topic without any sense of focus or progress.
As a general rule, if the therapist cannot form a clear picture either of the
problem or its solution then the client needs to clarify it further. Ideally most
goals should be able to be measured in terms of frequency, intensity, and/or
duration. Example: “When I am less depressed (global goal client is likely to
desire), I will be sleeping 8 hours/night 5 nights a week and not getting out of
bed in the middle of the night” (operationalised definition of this goal).
Having clients complete validated symptom checklist scores – such as the
Beck Depression Inventory (Beck, 1978), Beck Anxiety Inventory (Beck,
Epstein, Brown, & Steer, 1988), and the Beck Hopelessness Scale (Beck,
Weissman, Lester, & Trexler, 1974) – that the therapist briefly reviews at the
beginning of each session is another good way to assess ongoing progress.
Symptom relief
Obviously, one of the first things the therapist wants to provide the client with
is symptom relief since most depressed clients come in feeling quite distressed
and will not continue to attend therapy if they do not experience some degree
of amelioration soon. Keying in especially to the cognitive and behavioural
components of a client’s distress, the therapist may within the first session
begin to explore the client’s constructions of her experience and identify possible ways in which she can transcend these by adopting alternative
perspectives. Depressed clients, for example, often come in with a sense of
personal deficiency such as, “I am a failure.” When client and therapist
explore this more deeply, it often reveals a rigidly applied underlying belief,
Cognitive treatment of depression
“If I do not fulfil my responsibilities [often quite difficult when one is
depressed], then I am a failure.” It can often be somewhat helpful for such
clients simply to label this as a strongly held belief rather than a universally
acknowledged truth that everybody unquestioningly believes. By introducing
the idea that problems primarily result from our dysfunctional interpretations
of situations rather than the situations themselves, the therapist can help a
client to frame her problem quite differently as one which has possible solutions rather than being hopelessly insoluble. An example of this follows:
If I’m hearing you right, you’re awfully discouraged about any possible
solutions to your current problems with your daughter. In fact, you’re so
pessimistic that you’re actually on some level saying, “I’m just a bad
mother or she wouldn’t act that way!” How close does that sound? OK.
I’m proposing that we explore how your depression and problems with
your daughter might be linked to how you view the situation. For example, if you view things as hopeless, how might you act? Right, you’ll
probably give up and not even search actively for any solutions. But how
would things be if you act out of a very different belief like “She can
really act up, but she’s basically a good kid; we just need to understand
each other a bit better and I’m sure we’ll come to a better working relationship”? How do you think you’d feel and act if you saw things that
way? Probably more calmly, less blaming of yourself and her and more
likely to look for the possible areas of agreement and solutions. Sure.
That’s a lot of what we’re going to be doing in here: taking a closer look
at how you view things and how there may be other, possibly more adaptive ways you could also see things: new ways that could indeed lead to
better ways of feeling and more helpful ways of acting both with yourself
and others. One idea of cognitive therapy is that we’re often not very
good at problem-solving when we’re most upset, so we want to distrust
our tendency to think in global, pessimistic ways. We know from experience that we rarely make any progress toward solving our goals when we
think that way. So you want to stop and take the following steps when
you’re upset. 1. Identify what’s going through your mind (automatic
thought or image or deeper belief). 2. Evaluate how adaptive or accurate
that is realistically. 3. Modify that if it looks like there would be more
adaptive ways to view the situation. Don’t forget you’ve got a consultant
here to help you do all that, so you’re not alone in any of this. You will
gradually learn how to do this more and more on your own as you recognise the negative cycles earlier and earlier. How does that all sound?
Course of therapy
Early goals for cognitive therapy (the first 1–2 sessions) include the following:
(1) developing a good therapeutic alliance, (2) specifically defining target
Kevin T. Kuehlwein
problems, (3) determining which problems are most important, (4) increasing
hope, (5) clarifying the integral relationship between beliefs, affect, and
behaviour, (6) beginning to socialise the client into the cognitive therapy
model, and (7) emphasising how critical regular homework is to the success
of therapy.
In the middle section of therapy (approximately sessions 2–10) these are the
most important goals: (1) teaching the client about cognitive distortions, (2)
identifying, evaluating, and modifying his/her dysfunctional cognitions, (3)
experiential testing of targeted client beliefs, (4) refining and practising social
skills, including problem-solving strategies.
In later sessions (approximately session 11 to the last) the focus shifts to (1)
eliciting, examining, and modifying deeper cognitive structures (for example,
conditional assumptions and the rigid, dysfunctional core beliefs) and, in
the last few sessions, (2) relapse prevention, including in-depth review of the
most important lessons learned in therapy and prediction of future situations
likely to trigger dysfunctional cognitions, behaviours, and affects as well as
pre-problem-solving of these: developing written plans to suggest likely plans
of action for coping with these types of problems (Wright, 1988).
Therapy according to Beck’s model proceeds inductively. Initially therapist
and client explore concrete, specific time-limited situations in the client’s current life (for example, a disappointing phone call from a friend the previous
night). As they gather more information about typical situations associated
with dysfunctional affect, behaviour, or cognitions (including images and
metaphors), they together build a more differentiated and individualised conceptualisation of how behaviours, situations, emotions, bodily symptoms (for
example, pain), and cognitive content fit together. This enables the client to
develop increasing distance and ability to see her beliefs as beliefs (versus as
truth). After developing some competence at identifying, evaluating, and
modifying situation-specific dysfunctional automatic thoughts (ATs), client
and therapist move on to applying these decentring skills to examine and
modify deeper level beliefs that cut across many situations. Examples here
include what makes people worthwhile or lovable; what constitutes success;
what level of control is necessary in life; how much you can trust others or the
world. It is these deeper level beliefs and assumptions that provide the dysfunctional depressive template for meaning-making for the client across many
situations, so it is critical that therapy involve collaborative reconstruction of
these deeper meanings. Without such reconstruction the client remains very
vulnerable in thematically related areas which therapist and client have not yet
formally examined. Further, the client is then very vulnerable to relapse after
treatment ends, which is a common problem in depression treatment in general (Hollon & Beck, 1994). One of the hallmarks, indeed, of cognitive
therapy is its ability to instil in the client a set of metacognitive skills that
(when practised) provides great protection against future relapse after termination from therapy (Hollon, 1996).
Cognitive treatment of depression
Therapy sessions are frequently packed with a huge amount of information
about both the client’s current and past life and encompassing a wide range
of modalities: behaviours, beliefs, emotions, and physical symptoms. In addition, the therapist can attend not just to the content of what is being said, but
to the process of how it is communicated and the feelings it engenders within
himself. All these data must be sorted through to determine what is most key
to focus on in each session in order to promote cognitive (and ensuing behavioural and affective) change. A good general rule is, “Follow the affect.”
When a therapist pursues those cognitions most closely tied to high affect, he
is more likely to help the client identify, explore, and reconstruct those deeper
meanings most tied to her present and future distress. Alert therapists will
therefore pay especially close attention to a client’s change in body posture,
hesitation at answering a question, eyes beginning to tear up, and the like.
These are prime points at which to ask, “What’s going through your mind just
now?” to elicit the thought/image that is triggering an emotional reaction.
Likewise, a wise cognitive therapist will rapidly sense (by noting the lack of
high affect) when discussion of certain agenda items is peripheral to meaningful change. At this point the therapist will call the client’s attention to this
fact and elicit collaboration to proceed to more critical issues.
Socialisation throughout therapy
Some therapists mistakenly socialise the client into cognitive therapy only
briefly at the onset of therapy. Instead the therapist should promote ongoing
socialisation into cognitive therapy and the cognitive model of depression
throughout the course of therapy. The therapist might introduce the most
important aspects of the cognitive model in a way similar to this:
Cognitive therapy is a modern therapy that is both very interactive and
problem-focused. It’s based on the idea that the ways you interpret situations have a very strong impact on how you feel about and behave in
response to those situations. When somebody is depressed she’s not
always seeing things clearly. Everything has a negative cast to it and certain problem-solving options are hidden from view. Let’s think of an
example. Suppose you thought that nothing could help you with this
depression and you believed that idea 100% – not a doubt in your mind.
What emotion and behaviour would follow from that? Right. You’d feel
hopeless. And where would you be? Not here in therapy, would you?
Now, what would happen to your depression if you didn’t show up for
therapy? Not much, right? See – before even trying therapy to help you
solve your problems, you might have shut the door on problem-solving.
So you want to be more aware of how you’re actively construing situations. It’s important to identify and evaluate especially those thoughts,
assumptions, and beliefs most associated with downturns in mood or
Kevin T. Kuehlwein
with maladaptive behaviours because in many cases there are other more
adaptive and/or accurate ways of viewing the same situation. I want to
emphasise, however, that these cognitions we want to investigate can
occur in many forms, including verbal or visual form. Often when we’re
upset we get quick mental pictures in our minds that are very unhelpful
to us, but we don’t stop to question them. In cognitive therapy you’ll
learn all about how to identify, evaluate, and modify dysfunctional beliefs
and therefore increasingly be able to be your own therapist. We’ll share
with you a great deal of information about depression and help you to
understand how all your feelings, beliefs, behaviours, and bodily symptoms interconnect. We’ll also teach you how to best use this information
to break free of depression. How does that sound?
In addition to introducing the cognitive therapy model in such a fashion, the
therapist may want the client to read one of several pamphlets or books that
explain the model and the treatment further. Helpful examples of these
include the following: Coping with Depression (Beck & Greenberg, 1974), A
Patient’s Guide to Cognitive Therapy (Center for Cognitive Therapy, 1993),
and the sections on client booklets (Fennell, 1989), or The Feeling Good
Handbook (Burns, 1989), a full-length cognitive therapy self-help book.
The author frequently uses Socratic questioning to underscore the important tenet that the client’s own efforts are responsible for her improvements in
mood. When a client comes in feeling better, the therapist could ask a question like the following: “Margaret, you just said that you felt a lot better this
week. How about if we put on the agenda to discuss exactly what it is that
you’re doing differently that accounts for this?” The therapist thus subtly but
unmistakably attributes the positive change to the client’s own efforts whether
they be internal (beliefs) or external (behaviours, which in turn are supported
by internal changes). The client is thereby directed to look for what she might
have done differently that week. Often clients are initially surprised at the
therapist’s attribution of change to their efforts, feeling as they often do helpless to control their moods. The therapist in casting the client’s attention on
her own efforts can thereby help to undermine the client’s perceived helplessness as well as increase belief in the idea that there are discernible reasons for
upswings and downturns in mood.
Structure and agenda setting
To maximise the effectiveness of time and effort, it is essential that the therapist and client structure the therapy sessions. As part of the early
socialisation process the therapist socialises the client into the importance and
process of agenda setting: what constitutes a reasonable agenda and the need
to set priorities of agenda items. Too often therapists begin a session by
asking the overly diffuse, “How are you doing?” For many clients this is
Cognitive treatment of depression
equivalent to asking for a detailed report. It is more efficient for the client to
fill out prior to the session certain symptom checklists – for example, the Beck
Depression Inventory (Beck, 1978), Beck Anxiety Inventory (Beck et al.,
1988), and the Beck Hopelessness Scale (Beck et al., 1974) – so that significant mood shifts can be noted and possibly added to the agenda. The
therapist can then comment on the client’s apparent mood for the week and
elicit the client’s brief response to this.
Too often therapists will ask clients, “What would you like to discuss this
week?” This does not set up a work orientation for the session and, indeed,
may elicit more of a conversational type of discussion. Far better is something like, “Besides bridging from the last session and reviewing the
homework, what problems would you most like us to work on today?” This
latter type of question adds the bridge from the prior to the present session,
indicates that homework will be discussed, and invites the client to present
only those other agenda items which are problems and on which she is willing
to work. This will produce a manageable but useful agenda. Typical agenda
items for a 45–50 minute session would then include bridging from the prior
sessions (including any reactions that the client had about this session), review
of homework, prioritisation and discussion of 1–2 new topics, summarising
the session’s main points, setting the new homework, and eliciting feedback
on the current session.
Indeed, client feedback is an integral part of cognitive therapy. The wise
therapist frequently asks how the client perceives him and the process of
therapy as well as what the client is learning from the session. Questions like,
“What are you learning here?” or “What new idea did you get from the homework?” are good to focus the client toward the development of new, more
adaptive ideas. “How much sense does this make to you?” can also help the
client provide the therapist with needed feedback on better explaining a point
in therapy. It is good to probe for any strongly positive reactions to the therapy so that the therapist can better understand and repeat the approaches
that maximally benefit the client. Likewise, it is key for the therapist to
enquire whether the client has been upset or offended by something in the session so that this can be processed and addressed as soon as possible.
Frequently such early negative feelings and thoughts that clients have toward
the therapy or the therapist can be a boon to the therapy if they are elicited
and examined. The therapist, by his non-defensive, gently inquiring, and
empathic way of attempting to understand and honestly address the client’s
concerns, often allays any worries the client may have of therapy being mechanised or overly cerebral, for example. From the first session onward
therapists need also to elicit and address, where necessary, clients’ expectations about the therapy and the therapist (both positive and negative, realistic
and ideal). Therapists present from the outset a model of cognitive therapy
progress that is not ideal, but is rather realistic in its depiction of progress that
includes occasional small setbacks.
Kevin T. Kuehlwein
Obviously if a client indicates that she has more than incidental suicidal
ideation, then suicidality becomes the top agenda item. This is addressed
more fully in a later section, “Addressing suicidality”.
How much clients outside therapy think about and act on the ideas discussed
in sessions will determine the speed and depth of therapy progress. Several
researchers have found the performance of such in-between session tasks,
“homework”, to be critical to successful outcome of therapy (Persons, Burns,
& Perloff, 1988). It is therefore helpful for therapists to assist their clients in
thinking about the ideas discussed in therapy and provoking new thought by
helping their clients locate good companion texts and providing them with
certain types of handouts or booklets to read and/or fill out. Therapists may
wish to draw up their own handouts specifically tailored to the types of problems most commonly encountered in their own practice. Clients benefit from
having separate brief 1–2 page handouts for topics such as these: types of
cognitive distortions, questions to help them evaluate their possibly dysfunctional thoughts/images, a sheet (for example, the Dysfunctional Thought
Record; see Appendix 1.A, p. 41) with blanks that represents a format for
writing down their thoughts/images associated with distress and more adaptive replies to these thoughts. The author uses also a sheet of quotes from
various sources that are in some sense supportive of the underlying assumptions of cognitive therapy (see Appendix 1.B, p. 44).
Bibliotherapy – the reading of certain texts concurrent with therapy – is
also excellent homework for most clients to expand on points covered in the
sessions. There are several good books available that describe the cognitive
therapy model in sufficient detail. The Feeling Good Handbook (Burns, 1989)
and Self-Esteem (McKay & Fanning, 1992) are especially good. Clients who
are very judgemental or have impossibly high standards may benefit from The
Spirituality of Imperfection (Kurtz & Ketcham, 1992). A useful guide that can
also give cognitive therapists some assistance in choosing appropriate bibliotherapy for their depressed clients is The Authoritative Guide to Self-Help
Books (Santrock, Minnett, & Campbell, 1994).
Whichever books (or tapes for those clients who may be visually or reading-impaired) the therapist chooses, it is good for the therapist to be familiar
with them so he or she can intelligently answer any questions the client raises.
The author strongly encourages clients whenever possible to buy and mark up
(for example, using a “highlighter” pen for emphasis in certain passages) the
self-help books. In this way clients can really interact with the material in the
book. Clients also find that they deepen their understanding of the cognitive
therapy approach if they explain it to a friend, relative, or partner.
Of course there are many types of tasks in addition to client handouts and
reading that clients can usefully do for homework, many of which appear
Cognitive treatment of depression
later in the sections on behavioural and cognitive techniques. The basic rules
for cognitive therapy homework are these:
It should be collaboratively agreed upon. Although it need not be a
jointly conceived task, both parties should agree that it could further
therapy goals. Often it will help answer a question posed in therapy (for
example, “Am I unable to experience any pleasure whatsoever, as I often
believe?” or “What would happen to my mood if I call and get together
with my old friends again instead of avoiding them?”).
It should be no-lose in its conception. The client should be able to learn
something useful from the task, regardless of whether the outcome was
expected. Sometimes clients’ ATs are fairly accurate, for a variety of reasons, and if a therapist sets up a situation where he clearly believes a
client’s construction of reality is wrong but his (the therapist’s) is right,
that sets up a dynamic in the therapy where each attempts to prove the
other wrong. It also undermines the therapist’s credibility if the client
brings in data to support her AT when the therapist has assured the
client that a different outcome will result from performing the homework.
The homework and its purpose should be clear to both parties. For example, “In order to better understand the connection between your moods
and your activities, what would you think of jotting down what activities
you are currently doing when you find yourself feeling more sad or
depressed this week?” To this end, it is important for both therapist and
client to write down homework tasks.
It should flow logically from the session. Some therapists miss this point,
believing that the client should do for homework something related to an
agenda item for which there was insufficient time in the last session. This
sets a bad precedent and does not help clients amplify their understanding of concepts explored in the session.
It should be reviewed in the next session. Nothing extinguishes the adaptive behaviour of homework completion like the therapist’s behaviour of
omitting discussion of the prior week’s homework. Good therapists will
add it explicitly to the agenda verbally in the beginning of the session and
will typically discuss it before moving on to discuss other topics. “OK,
let’s review how the homework went” is often a good introduction here.
Problems with homework compliance should be put on the agenda.
“Hmm. I notice that you didn’t get around to doing the homework. I’m
wondering what happened there. Let’s put that on the agenda, OK?”
might be a neutral way of exploring the reasons behind homework noncompliance. Again, it is important for the therapist to convey an attitude
of interested enquiry rather than criticism in this arena, which is often
rife with guilt and accompanying ATs on the client’s part. Indeed, many
times discussions on this topic can uncover some important underlying
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attitudes of the client toward authority figures, their own feelings of
inadequacy, and the like. Some clients will go so far as to label themselves
“a bad client” when they admit that they have not done their homework.
Such an idea obviously says much about their dysfunctional beliefs that
can be profitable to examine.
Some other ideas about non-compliance are addressed later in this chapter.
Exploring deeper levels of cognition
As the therapy progresses it is, of course, necessary to explore and help the
client discover, understand, and modify the deeper level beliefs that undergird
dysfunctional affective, behavioural, and cognitive patterns. It is therefore
critical for therapist and client to look for themes across the major ATs,
images, and problematic situations and to add these to the evolving conceptualisation of the client. These deeper level beliefs typically involve such
themes as clients’ ideas of how loveable or acceptable they are to important
others, how much control or responsibility one has or should have for events
that occur (negative or positive), what is required for happiness, how life
should be, and what is meant by competence or success (Safran, Vallis, Segal,
& Shaw, 1986). They also are often linked with clients’ ideas of trust in others
and the world to respond to and provide for their needs. Many times these
beliefs will determine the expected role for them and others in the world. For
example, some depressed clients may believe “Nothing should be difficult. I
shouldn’t have to work at anything.” This would obviously be a dysfunctional belief for a therapy relationship, putting all of the burden on the
therapist to make the client better. When the therapist helps the client discover and examine these deeper beliefs (see also later section on cognitive
techniques), the therapist wants to be careful not to convey explicitly or
implicitly a judgement of the client for holding these beliefs. Indeed, doing so
would only increase the therapist’s countertransference feelings (Newman,
1994). Rather, what is more helpful at this stage is for the therapist to explore
both the historical origins, accuracy and/or ultimate utility of these ideas. The
therapist can, for example, ask Socratic questions such as the following to
help the client step back from these attitudes and examine them and their
effects more critically: “Tell me, what are the advantages of that belief ? What
good things have resulted from your operating out of it? What disadvantages might there be to that belief ? What opportunities have you missed by
holding this belief in all situations? How would you compare these advantages to these disadvantages? When did you first realise that this was a rule for
you? Where did you come up with this guideline? Who else do you know who
operates out of this or a similar belief ? How happy would you say that person
is? Can you see any advantages to modifying this belief slightly, where it
would be to your long-term benefit, for example? What do you think would
Cognitive treatment of depression
happen if you experimented with less rigid beliefs in this area, for example,
‘I’d like things to be easy for me, but probably not everything will be and that
doesn’t have to be catastrophic.’?” These sorts of questions can help clients
pry themselves loose from the grasp of very dysfunctional beliefs that few
people have invited them to explore. Indeed, the therapist encountering such
client beliefs (and any accompanying frustrating countertransference feelings) should realise that many of these dysfunctional beliefs and behaviours
being displayed were at some point at least somewhat adaptive for the client
(Newman, 1994). The problem is that they are now overly rigid and therefore
too absolutely applied and in too many situations in the client’s life for them
to work well.
Note also that in most cases the client may also have countervailing beliefs
of a more reasonable nature. These more adaptive beliefs are typically, however, currently overshadowed by the stronger dysfunctional attitudes triggered
by the client’s depressive mode. An important task for the therapist is to help
the client uncover and appreciate these more adaptive beliefs. The next therapeutic task is coaxing forth such adaptive cognitions and strengthening
them via Socratic questioning about past and current experiences of success
and coping (see also later section on cognitive techniques). An elegant example of such questioning appears in a videotaped therapy session of Beck
working with a depressed woman who experiences a great deal of pain about
her current relationship. One of the things that most depresses her is the
thought that she can never be happy without her husband. Through a series
of related Socratic questions Beck helps her to remember that the time before
she met him was actually better than her current situation, thereby assisting
her to see that this man is clearly not integral to her happiness.
Specific techniques
In doing cognitive therapy with depressed clients the therapist should realise
that there are specific strategies leading to therapeutic improvement, but also
that cognitive therapy is not a collection of disembodied techniques to be
used in random fashion, one after the other. Techniques are only as good as
the conceptualisation from which they spring. A good therapist, for example,
will appreciate the nuances of teaching the Dysfunctional Thought Record
(DTR) to a depressed client who also meets criteria for avoidant personality
disorder. This type of client will typically experience higher sensitivity to
criticism from others (even when unintended) so the therapist must tailor
the teaching of this tool to this individual. This would involve being especially
alert to any signs of the client feeling rejected, criticised, or inadequate during
this process and actively probing for any negative feelings after the exercise.
The following comment and question is an example of how the therapist
might successfully elicit honest feedback about the therapeutic process midsession from a client: “You’ve mentioned that you often feel criticised by
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others. I’m wondering to what extent you felt criticised by anything that’s
happened here today.” Given that certain clients, especially at the beginning
of therapy, would be reluctant to criticise the therapist, he might proceed a bit
further upon getting a denial and ask the client, “How easy or difficult would
it be for you to tell me if you did feel criticised by something I said or did?”
In this way, the therapist would be most likely to elicit and then process any
possible distortions in the therapeutic relationship before they became harder
to manage.
In keeping with a differentiated case conceptualisation the therapist would
likely use different strategies at different stages of therapy. For example, it is
more common to teach techniques such as cognitive distraction earlier on,
when the client is first learning the model. This technique helps to provide
quick, albeit temporary, relief and can illustrate to the client with her own
data that her focus of attention largely determines her mood and behaviour.
Note, however, that this technique does little to explicitly identify, evaluate, or
modify dysfunctional beliefs or behaviours, so it would be a huge mistake to
overuse this particular technique.
Behavioural techniques
Activating the depressed client is of prime importance because of the tendency for the typical client to withdraw from normal activities that could
provide pleasure and then to spend the resulting free time in negative rumination, which further depresses her mood. Behavioural activation techniques
are therefore often most important in the early stages of therapy, especially
with clients who are most depressed. Not engaging in useful or pleasurable
activities robs clients of many opportunities to feel good about themselves
and increases self-blame and dread about the future. These clients therefore
need to become more active in certain specific ways. Chief among these
behavioural techniques are activity planning and scheduling. Both involve
keeping an Activity Chart, a simple weekly form with empty boxes for each
reasonable hour of the day and night. Clients can fill this out prospectively
(especially helpful if they are unsure how to fill their time) or retrospectively,
right after they complete a task (good to track their actual versus reported
behaviours). Additionally, the therapist can ask the client to indicate the level
(0–10) of pleasure (for example, P = 6) or accomplishment (for example, A =
2) beside each activity so the therapist can note and explore any unusual
patterns. Clues to ATs or images that may interfere with a sense of accomplishment or pleasure can often be detected via very low reported levels of
pleasure or accomplishment compared to what one would expect associated
with these activities.
By having the client fill out an Activity Chart retrospectively the therapist
can gather early in therapy more precise information about the client’s typical day. He can, for example, observe the amount of and balance between
Cognitive treatment of depression
leisure/pleasure and task-oriented activities. Patterns that are dysfunctional
(for example, oversleeping, avoidance of necessary tasks) can then be noted
and corrected. In addition, clients will be able to actively experiment with the
possible positive effects on their mood of engaging in certain old and new
activities. This underscores empirical aspects of the cognitive model in the
client’s own mind by using their own data – harder for them to discount – to
evaluate their beliefs. It also gives clients increased confidence in their ability
to display some control over their dysphoria. Given that clients often show
little confidence in their own ability to positively affect their moods – instead
seeing the moods either as random or inevitable – this type of intervention
can be quite powerful. A third reason for this intervention is that it actively
challenges clients’ beliefs about how little they do or can do in other spheres
of their lives since it challenges the more general sense of helplessness. In this
sense all “behavioural” techniques are also cognitive in their desired effects.
They are a means of actively testing beliefs such as “Nothing will make me
feel better,” “I can’t do anything,” or “I’m not accomplishing anything during
the day.” Therefore many techniques are neither purely cognitive or
Reducing helplessness
Many times clients will claim that they can’t or couldn’t do some activity that
was probably in their best interests to perform. Helping clients realise that
they can perform these actions – although not as easily as before – is a key
step in therapy. Therapists can thus ask questions like these, “When you say
you can’t do X, how do you mean that? Are you physically unable to do that?
Able but not very motivated or energetic about it? Or is it just harder to do
than before you were depressed, but you can do it if you push yourself ?”
Often that will help clients realise they are not as helpless as they feel. (This
is often a great opportunity for the therapist to illustrate the cognitive distortion of “emotional reasoning”.) Another question that can help clients is
this: “If you were in bed thinking that you just couldn’t pull yourself up out
of bed and get going with your day and suddenly noticed that the far edge of
the bed were on fire, what would you do?” Typically clients answer that they
would somehow manage to get up and see the difference between true and
perceived helplessness. Discussion of “I can’t” offers a great opportunity to
illustrate the negative effects on emotion/motivation and subsequent behaviour of accepting such dysfunctional assumptions unquestioningly.
Graded task assignment, another behaviourally focused strategy, is used
especially when clients feel overwhelmed by the perceived enormous size of a
certain task. In this technique the client breaks down the task into smaller,
more manageable segments and then focuses on the easier parts of these in
turn, so as to minimise any feelings of being overwhelmed by the entire task.
This not only typically reduces fear in the client, but it also increases a sense
Kevin T. Kuehlwein
of self-efficacy (for example, “I can do this if I only slow things down and
work on each segment in turn”), which can then generalise to other tasks.
Exercise and relaxation
Many clients can greatly benefit not only from these types of behavioural
approaches designed to reduce depressive affect, but also from various types
of physical exercise and relaxation training. Most depressed clients experience
high levels of anxiety as well as depression, due to their negative view of the
future and their low level of confidence in their abilities to handle life challenges. For this reason clients may benefit greatly from learning techniques to
interrupt anxious sequences in their lives. Bourne (1995) offers many such
useful techniques to teach clients. Many clients also report exercise to have
anti-depressant effects as well as to improve their sleep–wake cycle disturbances. As well as helping clients to show themselves that they can do
something when they tend to disbelieve this, exercise actively stimulates the
production in the body of certain natural chemicals that improve a sense of
Cognitive techniques
There are a multitude of cognitive techniques available to therapists, not all
of which can be explained in this chapter. For a more extensive review see
Beck (1995) and McMullin (1986).
Metacognition and empiricism
Therapy is always a collaborative enterprise with the client trained from early
on in therapy to learn and practise skills of metacognition – thinking about
her thinking. Emphasis is on the empirical: what actually happens versus
what the client envisions will happen. In this way the client discovers certain
inconsistencies and maladaptive tendencies in her ongoing construal of the
world. There is no struggle for whose view of a situation – the client’s or the
therapist’s – is correct. Indeed, when therapy is done well, typically therapist
and client co-create meanings that are individually suited to the client’s life.
To this end, one of the common cognitive therapy approaches involves
creatively juxtaposing certain aspects of clients’ experience so as to provide
optimum disequilibrium and perturbation of knowledge structures. For
example, one might help a client who believes she has always been a failure to
explore whether everybody would agree that she had failed at everything and
search for examples of exceptions, where even the client herself admits to at
least partial success in some arenas.
One of the most important yet often hardest tasks for depressed clients
when they first come in for therapy is to identify their automatic thoughts and
Cognitive treatment of depression
images. This is not surprising, since the nature of ATs is to be so automatic
that they at first appear only peripherally in one’s awareness and are gone too
quickly to adequately explore them, their adaptiveness, or their accuracy.
For this reason it is crucial for therapists to educate clients about the type and
nature of ATs early on in therapy. Sometimes the therapist can jot down
obvious ATs of the client that emerge spontaneously within the first session
and share these with the client as examples. It is often helpful for a therapist
to offer some examples that he has heard from other clients in their depressed
phase of treatment. For example:
It’s very common when clients first come in to have the following sorts of
thoughts running through their heads, although at first they are not
wholly aware of these: “Oh, god, this is such an effort. Here I have to tell
my story to a complete stranger. He’s probably not even going to be able
to help. What on earth am I doing wasting my money on this? I might as
well give up.” I wonder if you’ve had any of those or similar ones while
you were thinking about coming here for help?
Therapists should further provide clients with clues as to when they are most
likely to find ATs and images: typically when they have just experienced a
negative shift in mood. Sometimes clients find this easier to detect via a
change in a physical symptom (for example, tension in the stomach or sighing). A therapist could present it to clients in a way similar to this:
Remember when you sighed loudly earlier in the session and I asked
you, “What’s going through your mind right now?” Well, I was able to tell
that an AT or image just went through your mind at that time because of
your sigh. When our mood changes there are often physical markers for
dysfunctional thoughts and images. This includes things like sighing,
tensing certain muscles of the body, headaches, stomach upset, changes
in breathing, sweating, and the like. So when you notice yourself suddenly feeling more upset or tense, what’s usually happening inside you?
Right, you’re probably believing some sort of dysfunctional
thought/image. So what’s the all-important question to ask yourself at
that time? Good – “What’s going through my mind?” How about if we
practise that sequence just for a moment now to really drive that point
home? Let’s do the “OMIGOD!” response: take a sharp intake of breath
as you think, “Omigod, what’s happening to me now!” THEN you notice
this reaction and say, “Wow, I must have just had an AT/image. What was
going through my mind just then?” Good! Now, how likely are you to
remember that the next time you get upset? Excellent. Of course, nobody
catches all their ATs and you don’t have to. It’s just important to be able
to catch some of them, especially when you’re most upset. And writing
them down helps you and I examine them more closely. In this way you
Kevin T. Kuehlwein
can better understand how they might be maladaptive for you. You can
also see how there are other ways to understand the situation that are
going to work much better for you in terms of solving the problems
you’re facing. How does that sound?
Socratic questioning
Socratic questioning is, of course, a primary in-session cognitive technique.
Here the therapist opens up a client’s way of viewing herself and/or the world
by means of guided discovery involving primarily open-ended questioning
(Overholser, 1993a, 1993b). This series of questions explore the personal
meanings attached to certain phenomena and the relationships between different parts of the client’s experience. The author has found that many
cognitive therapists are somewhat confused by the term “Socratic questioning”
and so has devised a sheet by which to instruct therapists (see Appendix 1.C,
p. 45). The most important Socratic questions for clients to memorise are the
ones printed at the bottom of the example DTR (see Appendix 1.A, p. 43):
What’s the evidence for and against my AT/image? What are other ways of
looking at this situation? What’s the worst that could happen in this situation
and could I survive it? What’s the most likely to happen? What’s the effect of
my believing my AT? What constructive action could I take to make things
better? Therapists also use Socratic questioning in performing the downward
arrow exercise to determine the underlying meaning to the client of prior ATs
if they were true (for example, What would it mean if I did fail the test? What
would this mean?, etc.) (Burns, 1980; see also Figures 5.2 and 5.4).
The dysfunctional thought record (DTR)
One of the prime tools for therapists and clients to have at their disposal is the
DTR. This sheet enables clients to more easily dissect their problematic experiences and examine how adaptive and/or accurate certain examples of their
thinking are. An example of this filled in with actual responses from a client
is found in Appendix 1.A (p. 41). Note that the more common, useful Socratic
questions are found at the bottom of the page to help the client formulate
more adaptive responses. A therapist might introduce the DTR to the client
I have a form here which helps us tease apart the different parts of distressing situations you encounter. By clarifying these different aspects –
emotions, thoughts, the situation itself – we can see more easily how
your current way of interpreting situations contributes to your distress.
We can also help you see the same situation more objectively and adaptively. This way you can explore other ways of interpreting the situation
Cognitive treatment of depression
that are not so painful or disruptive for you. By practising these new ways
of looking at things (including yourself and your own behaviour) there’s
a very good chance that you’ll feel a great deal better. How about if we
take a look at it now?
Some of the snags that can occur in teaching the DTR to clients are detailed
next. The author has found that clients especially tend to make these mistakes:
Putting interpretations of the situation (which really belong in the AT
column) in the Situation column. For example, “Steve arrives late to the
party, as always.” Correct would be: Situation: “Steve arrives 15 minutes
late to the party.” AT: “He always arrives late.”).
Not understanding the difference between thoughts/images and feelings.
This is especially common when the client uses the phrase, “I feel
that . . .” followed by an interpretation of the situation rather than following the “feel” word with an actual emotion word as in, “I feel sad.” It
can help to provide the client with a visual list of one-word feelings at
these points. Usually saying something like the following can help clarify
these points in the client’s mind: “OK, you thought that you were a bad
parent. We’ll put that belief in the AT column. And how did that thought
make you feel? Embarrassed, annoyed, guilty, pleased, sad?”
Occasionally clients will also put words really indicative of interpretations in the emotion column. For example, a client may put “rejected” in
the emotion column, but this really implies an action by someone else.
The emotion accompanying this perceived rejection (“sad” or “lonely”)
would go in the emotion column, whereas the “rejection” would go in the
AT column.
Misunderstanding the exact intention of the reasonable adaptive
response (RAR) column. In many cases I have seen clients write something in that column that does help them feel better temporarily, but is
irrelevant to the AT or image that is causing them to feel distressed.
Example: A client had written as her AT, “I have no friends.” She
believed this strongly and it made her sad. For her response she had
written, “Well, at least my mom loves me.” This did briefly improve her
mood. It did not, however, directly address either the original AT or any
assumptions underlying this (for example, If I currently have no friends,
I never will. If I currently have no friends, it means I’m deeply flawed. If
I currently have no friends, it must be all my fault. I am unlovable). For
this reason it was a poor response to her AT and led only to very temporary relief rather than helping her to view herself and the world more
accurately and adaptively. Only this deeper type of cognitive reorientation would likely lead to lasting change.
Kevin T. Kuehlwein
In addition, therapists sometimes make the mistake of teaching the DTR to
a client all at once and thus overwhelming the client. Instead, it is often a
better idea for the therapist and client together to partially fill out the DTR
with the client’s own example, simply inserting data in the first three columns
and leaving the RAR column blank, since this is the hardest column to complete. The RAR column can be addressed in the next session after the client
has better understood the structure of the sheet.
Repetition of nascent positive beliefs
Whenever a client comes up with an at least moderately persuasive functional belief that represents an alternative to a more depressive belief the
therapist seeks to reinforce this nascent cognition by repetition in the client’s
mind. Many clients are persuaded by their old negative beliefs largely because
they or others have incessantly repeated these or related cognitions. Joseph
Goebbels, Hitler’s Minister of Propaganda, is said to have claimed, “If you
repeat a lie often enough, the people will believe it.” Therefore clients typically
need to self-consciously support new, somewhat weaker beliefs that are more
functional via similar repetition. Coping cards represent one such way. In this
approach a client transcribes onto 3 inch by 5 inch cards (preferably coloured
for added emphasis) new more adaptive beliefs she seeks to strengthen. She
then carries them with her, reading them many times during the day. She
may also want to post them in prominent places at home or work where she
would read them often. She could augment the effectiveness of this technique by actively searching for examples of the new belief (for example, “I am
at least as competent as most people”) in her daily life and writing these
down with sufficient details that will help her recall them later. Indeed, she
can amass weekly examples of such new beliefs on a running list (for example, an adequacy log) so that the impact of these may accrete over time and
provide a persuasive antidote to lingering fears of the truth of the old belief.
Revising core beliefs
As the therapy progresses, deeper, more central beliefs will surface. Sometimes
a client may successfully address these by using the DTR. More often, however, other methods may need to be used. One of these is a sheet similar to
Revising Core Beliefs (see Appendix 1.D, p. 47). This tool measures the
strength of old, dysfunctional beliefs as well as newer, more functional ones.
Its most important use, however, is in eliciting so-called evidence that the
client has maladaptively used to support dysfunctional deeper beliefs (for
example, I am worthless) currently or in the past. The therapist and client
write in the first column data allegedly supporting the negative core belief (for
example, I was given away at birth by my birth mother). The second column
examines this often poor quality “evidence” and attempts to undermine it by
Cognitive treatment of depression
exploring other plausible explanations for the same data (for example, She
couldn’t care for me and wanted me to have a better chance in a better family
situation. She likely felt a lot of conflicts about the adoption). The final
column attempts to elicit several various data that are supportive of the new
core belief that conflicts with the old core belief (for example, I have several
good friends who treat me well and am dating a good man who shows me
respect and care). Finally, the bottom portion serves as a place for the client
to fill in possible activities she could engage in during the next week that
would lead to further experiences supporting the new core belief. This sheet
is typically begun in-session and the client is sent home to continue it after
entering several examples in each column. Completing several such sheets on
each of the client’s major negative core beliefs over time often greatly reduces
the client’s belief in damaging cognitions and builds up confidence in the
more adaptive core beliefs. As above, clients should ideally strengthen these
new beliefs by carrying written copies of them around on coping cards that
they refer to several times per day.
Rational–emotional role plays
Frequently clients will complain that they know the new adaptive beliefs are
accurate, but that the old beliefs still feel more accurate. They may phrase the
idea somewhat differently: “I don’t believe it in my gut yet.” The
rational–emotional role play is often the ideal cognitive intervention for such
clients. This experience (largely imported from gestalt therapy) distils the
two sides of internal struggle and pits them against each other in a very
evocative (and thus memorable) way. The client begins by identifying two
opposing beliefs, one emotionally persuasive and maladaptive and the other
at least somewhat intellectually persuasive and more desirable. The client
then occupies another chair facing her original one and speaks to her now
absent self to convince herself that the old core belief (for example, “I’m
incompetent”) is correct. The therapist actively encourages the client to verbalise literally all the data used over the years to support her old core belief.
In this way both therapist and client can ascertain which data need to be
reframed in more positive ways. In the next phase the client returns to her
original chair and – with prompting and/or modelling, if necessary – rebuts
the alleged evidence previously offered by her more critical side. The therapist
encourages the client vehemently and firmly to challenge the relevance of
such data and instead develops other, more plausible and balanced interpretations of these same data. Once the therapist is satisfied that the client has
explored this second side fully, he checks for a reduction in belief level in the
old core belief and in the accompanying distress. If it does not occur, the exercise may be repeated. Again, the client writes down key points emerging from
this role play so that she may review and repeat these to herself over the next
few weeks as a way of strengthening them.
Kevin T. Kuehlwein
A certain subset of depressed clients temporarily benefit from cognitive
restructuring, but derail this almost reflexively by an opposing, negative AT
that counters the more adaptive thought. It is as if the client had said, “OK,
that [new belief] may be technically true, but it doesn’t count because . . .”
Clearly the client at this point is having a secondary, disqualifying AT that
needs to be addressed and evaluated. Point–counterpoint is a technique that
has been successfully employed to parry these latter types of thoughts. In this
technique the client draws a vertical line down the middle of a sheet of paper,
labelling one column ATs and RARs. She then writes her first AT and in the
next column a good RAR that specifically examines and modifies this AT.
Moving back to the first column, she enters the disqualifying AT that makes
her doubt or minimise the prior RAR, but she does not stop there. Instead
she continues to evaluate and modify this AT by developing and writing a
RAR to counter this, repeating this process as long as necessary. The only
rule is that the client must end in the RAR column. The client therefore
never lets her minimising AT stand without challenge. In this fashion the
client can gradually wear down any resistance she may have to accepting her
more reasonable responses by repetition and not shying away from a fair
examination of the supposed evidence that disqualifies the original RAR.
This can also be done out loud in an evocative role play whereby the client
rotates between chairs (see also the similar rational–emotional role play exercise described in the preceding section) as she states her objections to the
RAR and then calmly answers these in turn.
Depressed clients often suffer from a paucity of healthy imagination. By that
I mean that it is hard for them to see themselves, the world around them, and
the future with any fullness and clarity. Instead they see a very stereotypically
reduced image of things, all phenomena basically having a negative cast.
This biased perception naturally makes it harder to emerge fully from the
chrysalis of depression for it forestalls much adaptive action, emotion, and
thought. It is for this reason that helping clients to visualise better (i.e., more
accurately and adaptively) can be an important part of helping them move
out of depression. Many therapists make the mistake of not probing adequately for automatic thoughts that occur in imagined form, but this is often
a large mistake. One of the peculiar things about having images is that these
internal pictures can seem especially convincing to clients because they have
in some sense actually seen their fears being realised or have gone back in time
when a terrible real event from the past occurred and are reliving it, if only for
an instant. Although these cinematic realities occur only within the client’s
own head, they can still be powerful impediments to feeling, thinking, and
Cognitive treatment of depression
acting more adaptively. Frequently when clients report dysfunctional images
the best way for them to counter these is by replacing them with a more
accurate and/or adaptive mental image, rather than with a simple, one-dimensional verbal reasonable adaptive response.
Layden (Layden, Newman, Freeman, & Morse, 1993) has written of the
integral part of visualisation in assisting clients out of distress. As part of a
process designed to help clients move toward their future goals, she recommends therapists work with clients to actively foster positive, attainable
images of their not-too-distant future (for example, six months to several
years from the present), thus building an evolving, adaptive mental representation of one’s future toward which to strive during the course of therapy.
This not only helps clients to rehearse more salubrious mental scenarios, it
often lifts depressed affect as clients experience a momentary escape into a
more positive future. The sparks of hope that are nurtured at home as clients
practise seeing in ever-increasing and multi-sensorial detail key aspects of
their future life can provide some of the warming growth toward realising (in
both senses of the word) these more positive potential future outcomes.
Visualisation is also useful in combating those often potent ATs that occur
in the form of images. The most effective challenge to an imaginal AT is usually a different, more balanced and realistic image, so the therapist encourages
the client with a distressing image to transform it to a more realistic one and
ensures that she has successfully done so by checking to see how much the
client’s distress level reduces at the end of the exercise. Readers especially
interested in the application of imagery to cognitive therapy should also see
Edwards (1989).
Continuum method
In working with depressed clients therapists often encounter a great deal of all
or nothing thinking, itself one of the main cognitive distortions that help to
maintain a client’s depression. It is therefore important to be able to counter
this distortion by means of the continuum method. In this case, the therapist
elicits a key example of all/nothing thinking (that is, one that causes the client
a great deal of distress instead of one that is more peripheral) and explores
with the client the construct in question by means of Socratic questioning. A
reconstructed example (based on a real client of the author) follows:
Th: What problems should we work on today, Linda?
L: I don’t know. I just feel awful today. I am such a bad mother. I am really
Th: Wow. You sure sound and look as if you feel pretty awful. Just slow
down a little and tell me what happened to make you so ashamed and
feel like such a bad mother.
L: I completely screwed up last week and ruined my daughter’s birthday.
Kevin T. Kuehlwein
Th: Hmm. Can you tell me what you mean by “completely screwed up”?
L: I just completely forgot about it! Can you imagine: forgetting your own
daughter’s birthday! God! What kind of mother does that?
Th: That does sound upsetting. Can we explore the specifics of this, though,
Linda? I want to make sure I understand everything so I can help you
answer that very question you just posed. Let me draw something here
so we can look at this more closely [goes to whiteboard and draws a
long continuum, with one side marked GOOD (0% bad) and the other
marked BAD (100% bad)]. Now where would you put yourself on this
scale from 0 to 100 with 0 being the best mother in the world and 100
being the worst mother in the world?
L: 90%.
Th: OK. And what makes you say 90%?
L: Because it’s a really terrible thing to forget a child’s birthday.
Th: You’re right in the sense that children’s birthdays are pretty important
to them. Let’s get a sense of where you’d put some other mothers on
this scale first before we look more at that. Let’s think of somebody
who’s really a terrible mother – somebody right at the end of this. What
would she do as far as parenting?
L: Well I guess she’d be mean to them a lot, yell at them, probably not
clothe them very well and generally criticise them all the time.
Th: So that would be 100 on this scale? That’s the worst that you can think of?
L: Yeah, I guess.
Th: Well, that sounds mean in some ways, but I wonder if you’ve heard of
an even worse mother? What about if a mother were to not only criticise
her kids all the time, but actually physically sexually abuse them, sell
them into slavery, kill them, or who actually takes pleasure in their suffering? Where would that type of mother go on the scale?
L: Oh, my god! That would definitely be a 100.
Th: OK. Yeah, that does sound worse than what you came up with, doesn’t
it? So, if that person would be 100, where do you belong on this scale?
Still at 90 or have you moved up or down?
L: Well, I guess what I did wasn’t that close to somebody who really abuses
their children like that.
Th: What makes you say that? How is what you do different?
L: Well, I’m not hurting her on purpose.
Th: Excellent point. What was Suzie’s actual reaction to everything, by the
way? We didn’t find out how she actually felt about things.
L: She had a great time. She was running around in that new outfit I got
her and was having fun playing a party game with her friends from the
Th: That’s interesting. So although you’re a supposedly bad mother, it
doesn’t seem as if your awful mothering produced any negative effects
in the person you supposedly offended. What do you make of that?
Cognitive treatment of depression
I guess I never thought of that. But isn’t it still a terrible thing to forget
your child’s birthday?
Linda, I’m struck with how you keep using the term “forget” as if you
completely forgot and only remembered 4 weeks later and then chose to
do nothing to rectify your error. Let’s investigate that question you just
put to me by going back to this continuum: How terrible is forgetting a
child’s birthday in the overall scheme of things?
It’s bad, but I guess it’s not so bad.
OK and – getting back to the bad mother part – if you were a really bad
mother – completely bad – what would we expect your reaction to be to
forgetting your daughter’s birthday?
Hmm. [thinking] I guess if I were a really awful mom I wouldn’t care at
all if I forgot it because it wouldn’t mean anything to me. If I were a
really terrible mom, I’d probably make fun of her just like any other day.
Right. Now, how close was that to what you actually did when, like
most of us humans, you forgot something that you didn’t want to forget?
Well, I guess it wasn’t very close. I did try to make up for what I did.
OK and how much does that count: that you didn’t intentionally forget
or try to hurt her, you’d already bought her gifts, you made sure she had
a good time as soon as you remembered, and that she didn’t feel hurt at
all? How do those stack up against your having initially forgotten her
I guess those are really more important.
Seems so, doesn’t it. What we’re doing is looking at the larger picture,
seeing your action in context. But we also want to take a look at this to see
if there’s a pattern here. How often do you condemn yourself so quickly
and completely with issues like this and minimise positive things you do?
Pretty often, I guess.
And what do you suppose is the cumulative effect of that over time?
It probably makes me feel bad a lot.
Yeah, that would be my guess. What do you think would be the effect
over time of your realising that you’re human, too, and therefore entitled to make the occasional harmless mistake?
I guess I’d probably like myself better. [brightening]
I think you really would. So let’s look to see if that happens and let’s be
careful about those cognitive distortions we uncovered [circles them on
a sheet he hands to client]: all or nothing thinking, labelling, disqualifying the positive, OK?
OK [smiling].
Behavioural experiment
This refers to the prospective gathering of data by the client to investigate a
belief she has verbalised (for example, no one will say hello to me today even
Kevin T. Kuehlwein
if I say hello to them). Client and therapist together specify clearly the idea to
be tested and determine criteria that would indicate evidence for and against
this theory. Next they determine a scenario in which the client could impartially test the theory and the client goes out and collects data in response to
her prescribed action (for example, saying hello warmly and smiling to 10
people in varying situations). The data are then recorded and discussed at the
next meeting. Many times the client’s predictions are incorrect, which is often
surprising for the client. This exercise can provide useful support for other,
more adaptive beliefs. The surprise experienced by the client often punctuates
and intensifies the new learning. When the data do support her theory, therapist and client try to determine what circumstances (for example, the client’s
own actions) might have contributed to this. Problem-solving approaches to
develop a new approach to the situation are then explored.
Completing the feedback loop
Another helpful cognitive intervention is what the author refers to as completing the feedback loop. It is quite intriguing to notice how often our clients
(and indeed, we, ourselves) engage in the following dysfunctional and illogical pattern: (1) having an idea about something (for example, I’ll do terribly
on my exam); (2) encountering a situation in which the client could test this
(for example, actually sitting for an exam); (3) having the situation turn out
differently than expected (for example, passing or doing well on the exam)
and then not using this discrepant and important information to go back and
correct our faulty beliefs. Many times clients continue this process with the
same dysfunctional belief numerous times as if for the first time. It is as
though the contradictory data simply vanish. Part of the reason this disappearance of data occurs is that the depressed client does not have a readily
accessible more positive template (for example, “I am competent at many
things”) in which to fit more positive experiences (McKay & Fanning, 1991).
Therefore contradictory information either is forgotten quickly or is simply
not stored in any permanent form at all. Good therapists therefore know the
importance of keeping clients’ attention focused on personal outcomes that
run counter to their dysfunctional beliefs. Observant readers will note how
this is almost a naturalistic post-hoc behavioural experiment.
Practical problem-solving
Clients need to know very clearly that cognitive therapy acknowledges that
there are real problems in their lives; it is not all in the way they look at
things. At the same time cognitive therapy posits that many of depressed
clients’ typical cognitions (for example, “There’s nothing I can do” or “I’m
not smart enough” or “This is too overwhelming!”) significantly interfere
with or even exacerbate the solution of these problems. Such beliefs not only
Cognitive treatment of depression
interfere with solving current problems, but also shroud their past successes
in darkness so that the client cannot see them clearly and draw inspiration
and encouragement from them. So cognitive therapy naturally focuses first on
removing this extra layer of impediments to the problem-solving process and
then moves on to generating possible solutions. It does this by treating the
beliefs again as theories that need to be examined and tested. The therapist
then teaches the client the following steps: identify the problem with precision, devise a range of possible solutions (without judging or censoring any),
evaluate the different possible solutions in terms of their strengths, select a
solution, implement this, and judge its effectiveness in solving the problem.
The process may be repeated if the first solution does not yield the desired
results. The problem-solving model is explained in more detail elsewhere
(D’Zurilla, 1986).
Addressing suicidality
It is critical to address suicidal thoughts, feelings, and behaviours with
depressed individuals. Depression is very demoralising and the hopelessness
that derives from the pervasive negative views of self, future, and ongoing
experience can predispose a client to consider drastic measures (including
suicide) to stop their suffering. For this reason it is paramount to enquire regularly about thoughts of self-harm and hopelessness, the latter of which has
been linked to increased suicidal risk (Beck, Steer, Kovacs, & Garrison, 1985).
Asking at the beginning of each session either verbally or on pre-session
forms (for example, the BHS and BDI) can help to elicit such thoughts and
feelings. Questions 2 and 9 on the BDI are the most highly associated with
suicidality, number 2 even more so than number 9 because it taps a client’s
hopelessness. Likewise a score of 9 or higher on the BHS alerts the therapist
to increased risk of suicidal action. Because of the acute nature of suicidality, it must always be the highest priority on the agenda when suicidal
thoughts are anything more than fleeting.
A common mistake some clinicians make at this stage is to try to elicit from
the client or present reasons to the client why suicide is not a good option. It
is important to realise, however, that the client, already struggling with a
great deal of pain, may consider this approach to be further invalidation of
her pain and problems. Rarely has a client quickly jumped to the idea that
suicide is a good option. Rather most clients arrive at this option only after
many other attempts to solve their problems. It is therefore very important for
the clinician dealing with a suicidal client to elicit the client’s reasons both for
and against this drastic option. This ensures that both of the client’s important perspectives are heard and understood.
After exploring the reasons for suicide the therapist can have a better
understanding of how best to elicit and/or provide alternative methods for
reaching the functional goals underlying the option of suicide (typically
Kevin T. Kuehlwein
cessation of pain). By eliciting these goals the therapist can empathise with
the client while at the same time offering an alternative perspective on how
appropriate the suicide option is for achieving them. Recall that persons who
are depressed often suffer from a narrow imagination. Therefore, their problem-solving skills are currently depressed as well (see earlier section on this).
Eliciting goals and exploring options in terms of problem-solving can therefore help a client feel empowered and as if somebody really understands the
depths of their misery. Eliciting and listing on paper numerous positive reasons for living (for example, I want to see my son graduate from college or I
don’t want to hurt my family) can also help tip the scales of doubt toward
living (Beck et al., 1979; Ellis & Newman, 1996). Many clients who suffer
from chronic suicidality (and, indeed, their therapists) may benefit from reading and working through the exercises in the Ellis and Newman (1996) book,
which takes a cognitive therapy approach to the issue of suicidality. This
subject has been only cursorily explored here because it is discussed in full
detail in Freeman and Jackson (Chapter 2, this volume).
Nurturing the therapeutic relationship
Some therapists have underappreciated the importance of the therapeutic
relationship. Yet it is crucial to the success of cognitive therapy for the therapist to carefully nurture the therapy alliance and pay attention to any
ruptures within this. Careful management of situations where the client is disappointed in the therapy, the therapist, or the client’s own role in the therapy
often leads to resolutions of impasses, including enhancement of the therapeutic relationship and even therapeutic breakthroughs. One of the best ways
to assess the strength of the therapeutic relationship is also the simplest:
simply asking clients in an open way about their reactions to the session or
the therapy as a whole so far. In training therapists the author has found that
many therapists too often ask feedback questions in ways that are ironically
less likely to elicit what the client truly feels and thinks. They do this by framing the questions in all or nothing fashion: “Was the session helpful today?”,
for example, at the end of the session. When a therapist who has been friendly
asks such a question, it can be especially hard for the average client honestly
to admit when it largely has not been. The therapist here also models the
wrong type of thinking (all or nothing) for the client. Many times there are a
variety of feelings and thoughts the client has about the therapy, not all of
them completely positive. Yet, if the therapist presents the feedback in a
yes/no fashion, many clients are unlikely to step out of this framework and
provide this more mixed feedback. For this reason the author suggests that
the therapist ask as many questions during the therapy in the form of openended or continuum-like questions: “Tell me what you got out of today’s
session.” or “To what extent did you feel heard or understood today?” “What
do you like best about therapy?” “What do like least?” “What things would
Cognitive treatment of depression
you change about how we work if you could?” Notice how these latter questions encourage much greater thought and require more in the way of a reply
from the client. Note also how a vague answer to the former question can
provide key feedback for the therapist to revise his approach to the client so
as to increase client retention in the future. As with other aspects of the therapy the therapist must use his conceptualisation to structure the relationship
with each client. This helps him to ensure that his interventions flow from his
best understanding of what the client needs to participate optimally in the
therapy process.
One must be careful not to repeat patterns with clients that helped predispose them to being depressed in the first place. Beware, for example, of doing
too much of the therapy work for a client who presents with a helpless core
belief. In spite of how obvious this sounds when written down, it is surprising how often therapists slip into this pattern in their desire to help clients
escape their suffering more quickly. It is, however, a trap to do too much of
the work for a client who is capable of doing it herself. Rather this pattern
needs to be explored in a sensitive, supportive way with such clients.
Client non-compliance
The author cannot credibly maintain that most depressed cognitive therapy
clients delight in all aspects of the therapeutic process and perform their recommended homework tasks with relish. The nature of depression as well as
characteristics of therapy militate against this. While certain aspects of cognitive therapy (collaboration and presentation of rationales for interventions)
probably help decrease non-compliance tendencies, there are still many times
in therapy when clients do not comply. With these clients the author recommends stepping back from the problem and seeking to understand – true to
the concept of conceptualisation – the nature of the problem.
When the client is reluctant to perform a particular task that seems important in the therapist’s mind for progress in therapy, it is always good to ask
questions of the client to better understand what the obstacle is. The client’s
first stated reasons may not necessarily always be the most accurate ones.
Good questions here in the example of the client not writing thoughts down
could include the following: “How close did you get to completing the assignment? Did you go so far as to take out the sheet and a pen? What thoughts
went through your mind as you thought about doing the assignment? How
helpful did you believe writing down your thoughts would be? What did you
think would happen if you did write down your thoughts?” In this way the
therapist could distinguish social embarrassment ATs (for example, My
neighbour might see it when she comes in for coffee and I’d be embarrassed)
from hopeless ATs (Nothing’s going to help, so why should I bother?). Each
of these suggests a different response from the therapist. A good additional
resource for the therapist here is the Possible Reasons for Not Doing
Kevin T. Kuehlwein
Homework Assignments Sheet (Beck et al., 1979). This sheet can help therapist and client understand the myriad interfering cognitions that may impede
therapy progress. These cognitions can then be examined more carefully as a
way of weakening their grip on the client so that the client can at least experiment with doing the avoided assignment to see what actual result occurs.
Since non-compliance does not occur in a vacuum but is the product of an
interpersonal situation, the therapist also should explore the extent to which
his attitudes and actions play a role in any non-compliance. Keep in mind also
that any non-compliance can inform the therapist’s conceptualisation of the
client (Newman, 1994).
Relapse prevention
Toward the end of therapy when clients have successfully reduced their deeper
negative patterns of belief, affect, and behaviour, the therapist’s attention
turns to reinforcing the patterns of client change. In this last phase of treatment the therapist and client review client gains and seek to identify future
problem scenarios so that the client does not leave therapy falsely believing
herself to be invulnerable. Rather, the therapist inculcates in the client a belief
that she now has a set of effective tools to use across the problem areas of her
life as well as a high degree of competence in applying and knowing when to
apply these tools. For this reason the last few sessions involve the therapist
and client revisiting earlier deeper dysfunctional beliefs and situations so as to
assess how confident the client would be in facing related situations evoking
such types of thinking in her. Client and therapist list scenarios most likely to
lead to a resurgence of depression and develop brief plans for dealing with
these based on therapy successes. Clients can be taught to visualise in session
such trigger situations occurring, becoming initially upset, and then applying
the most relevant coping skills (for example, their most effective new, adaptive
beliefs) so as to reduce their distress. More depth on this topic is offered in
Beck (1995).
External adjuncts to therapy: self-help groups and
computer resources
Recently clients have increasing access to a plethora of quasi-therapy groups
and resources outside the confines of therapy, most of which are descendants of 12-Step fellowships like Alcoholics Anonymous. Many of these can
be excellent adjuncts to therapy because clients often reinforce their knowledge of themselves and the impact of their dysfunctional belief systems. Such
clients may also interact with others who share issues with them and thereby
learn from them how to cope successfully with common problems and issues.
Because fellow group members often suffer or have suffered from depression
(which the therapist may or may not have done), clients exposed to such
Cognitive treatment of depression
people may more likely integrate certain new perspectives from therapy. The
author recommends strongly that clients who attend such groups periodically
share information about what is occurring in them and what their reactions
are to such discussions. In this way therapist and client can take optimum
advantage of opportunities to reinforce messages that will ultimately be helpful to the client or opportunities to clarify points of difference.
Cyberspace offers other potentially useful resources to those with computers and modems. Although not all resources are equally helpful, therapists
should be aware of them and their potential impact (positive and/or negative)
on clients. Clients may, for example, participate directly in on-line discussion
groups run by people struggling with similar problems. They may also be
strongly affected by information promulgated by groups and persons who are
a “virtual” presence on the Internet, computer bulletin boards, or on-line
service companies (for example, America OnLine). There are now support and
advocacy groups for mental health concerns that discuss knowledgeably such
subjects as treatment options, efficacy of certain treatments (psychotherapy,
pharmacotherapy, as well as other, less well-established approaches). There
are also forums that take place in cyberspace at regularly scheduled times,
where a sense of community may build differently than in a newsgroup section where people talk and respond in more piecemeal fashion. Many of
these groups never meet face-to-face. Rather they are more “virtual” communities in that they consist of people connected via computers and modems,
but it would be a mistake to underestimate the importance or potential of
such groups in providing support and knowledge to depressed individuals.
Ideally, such groups and individuals provide accurate information about therapy modalities and medications, but in today’s world there are unfortunately
no assurances and misinformation can also spread quickly in this fashion.
Therefore the author recommends that therapists with clients likely to have
access to these resources should clarify the range of what is available and give
clients a sense both of what dangers and benefits exist on-line. In general
clients receive more consistent and accurate information from well-established
groups without a particular bias to them (for example, pharmaceutical companies who may push all pharmacological options above psychotherapeutic
ones). A good first site to direct clients to is the American Psychological
Association homepage (http://www.apa.org on the World Wide Web). If
clients do use Internet or other on-line resources, the therapist should
strongly encourage them to discuss their experiences, so that the therapist can
be aware of other possible influences (both helpful and unhelpful) on a
client’s progress during therapy.
Concluding thoughts and recommendations
The ideas presented here have given a summary of some useful approaches
within the powerful cognitive model to utilise with depressed clients.
Kevin T. Kuehlwein
However, given that clients often come in to therapy after weeks, months, or
years of suffering depression, it is important to recall that many clients’
entrenched negative patterns can crowd out more adaptive patterns. It is
therefore sometimes difficult for them to maintain positive, alternative perspectives on their situations. For this reason therapists frequently find that
they need to provide the client with concrete reinforcement of the client’s own
new ways of thinking, feeling, and behaving. Some common ways to accomplish this are as follows: audiotaping each session and encouraging the client
to listen to the session later, when they may be better able to hear and consolidate the many messages communicated within the earlier session. Another
good approach is for the client to take written notes during the session and to
review these later. Given that most of the content of a therapy session is forgotten later, these methods can greatly help clients to recall and then integrate
important learning from therapy in their daily life. In general, the more clients
think about the therapy outside, the greater the likelihood that they will be
modifying their thinking, behaviour, and feelings. Therapists should also help
clients to visually represent both old problematic patterns and newer, more
functional ones. The author uses a “whiteboard” and coloured erasable markers to demonstrate graphically certain points during the session. Clients then
copy these down on paper so that they will have a copy to refer to later.
Relationships between certain phenomena within the client’s life are often
easier to understand when they are represented graphically or are at least
greatly aided by additional graphical representation (see Appendix 1.E, p. 48).
Utilisation of these approaches can assist the therapist in strengthening the
newer patterns elicited and explored in the sessions so that durable change
from therapy can occur.
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Briefly jot down a few
details about what you were
doing (including stream of
thought), where you were,
and/or who you were with
when you felt your mood
drop. Example: Sitting
home alone thinking
about test tomorrow.
Use a word or two to
describe your FEELINGS
at the time (e.g., sad,
embarrassed, angry).
Then rate how strongly
you felt these emotions
(5% [very little] to 100%
[the most I have ever felt
this emotion]). Put low,
medium, or high if unsure.
Automatic thought/image:
Put down here what was going
through your mind when you
felt upset.Try to capture it in
the same words or images that
you hear or see, even if they
sound extreme or even silly to
you.Then rate how strongly you
believe the thought or image
(5% [not much at all] to 100%
[I completely believe it]). Or
just put low, medium, high if
it’s hard to quantify.
Reasonable adaptive response:
Take a step back from your thought/
image and the situation (using the
questions at the bottom of the sheet)
and try to evaluate your thought/
image in terms of how accurate and/or
helpful it is for you to look at things in
only this way. (You may also want to
see if you can recognise any types of
“cognitive distortions” that may be
lurking in the AT/image.) Now go
back to the % in the last column. If it
has changed (up or down), then cross
out the old %age and put in the new
%age behind it. Do the same for the
NOTE: If you don’t have this sheet with you at the time, jot down enough details about it on some piece of paper so you can fill out
this sheet later more completely.
Take note of when your mood drops (typically a sign that some sort of dysfunctional thought/image is being triggered and believed).
When you feel the distress, write down the following: a brief description of the situation you’re in, your emotions, the thoughts/images
that accompany the emotions, and then see what alternative responses you can generate to your thoughts/images and/or the
Cognitive treatment of depression
Appendix 1.A. Sample completed Dysfunctional
Thought Record
Had a conversation with
my mother about my
father. She described
him as self-absorbed,
unable to have a
conversation and
(Additional later emotion:
Relief 40%)
(20% later)
(20% later)
I’m going to end up like my
father: self-absorbed, few
friends, isolated, depressed
(20% later)
Disqualifying the positive:
I am overlooking the fact that I have
positive qualities:
1) I admit that I have a problem with
self-esteem and I’m getting help.
2) I’ve made major progress in my
relationship with my daughter. 80%
3) I am less shy than I used to be. 75%
4) I have more confidence than I
used to. 65%
5) I am much less anxious than I was
X years ago. 90%
6) I have friends that I can be honest
with: husband, B., C. [to some
extent], R., & W. 65%
7) I am depressed less often and
with less severity than before. 90%
All or nothing:
If I’m not like my mother it doesn’t
follow that I am like my father. I can
be unique, not a copy of either or
both. 75%
Just because I’m similar to him in
some ways, doesn’t mean I am
totally like him. 75%
Fortune telling: How do I know
that? 60%
Kevin T. Kuehlwein
Appendix 1.A. Cont.
Questions: 1a. What’s the evidence for and against my AT/image? 1b. How persuasive would this evidence be to others? 2a.What’s
another way of looking at the situation or the evidence? 2b. If a friend were in this situation and had this thought, what would I say
to him/her? 3a.What’s the worst that could happen here? 3b.What’s the best? 3c.What’s the most reasonable to expect? 4.What
constructive action could I take to improve my situation? 5a. What’s the effect (on my mood or behaviour) of believing the AT/image,
especially when I don’t yet know if it’s true? 5b.What’s the effect of modifying my thinking?
Cognitive treatment of depression
Appendix 1.A. Cont.
Kevin T. Kuehlwein
Appendix 1.B. Some interesting quotes relevant
to therapy
Theodore N. Vail:
Real difficulties can be overcome; it is only the imaginary ones that are
Norman Vincent Peale:
Change your thoughts and you change your world.
It’s never too late to have a happy childhood.
To be wronged is nothing unless you continue to remember it.
Oscar Wilde:
To become the spectator of one’s own life is to escape the suffering of life.
Bertrand Russell:
Fear is the main source of superstition, and one of the main sources of
cruelty. To conquer fear is the beginning of wisdom.
Aristotle could have avoided the mistake of thinking that women have
fewer teeth than men by the simple device of asking Mrs Aristotle to open
her mouth.
Viktor Frankl:
Everything can be taken from a man but one thing: the last of the human
freedoms – to choose one’s attitude in any given set of circumstances, to
choose one’s own way.
Neil Postman and Charles Weingartner:
Knowledge is produced in response to questions. And new knowledge
results from the asking of new questions: quite often new questions about
old questions.
He who has begun has half done. Dare to be wise: begin!
Dale Carnegie:
Remember happiness doesn’t depend upon who you are or what you have;
it depends solely upon what you think.
It is not because things are difficult that we do not dare: it is because we do
not dare that they are difficult.
Cognitive treatment of depression
Appendix 1.C. Examples of socratic questioning
Situation: A client comes in feeling like a bad mother because of yelling at her
misbehaving child.
Socratic questions to consider asking her (note: you would not ask these all
at once):
1. What makes you think you’re a bad mother? What signs are there that
you’re a good mother?
2. How strongly do you believe this idea, “I’m a bad mother,” now?
3. On a scale of 0–100%, with 100% being the worst mother you could
imagine, where would you fall? Where would other people put you on
this scale? Why might they rate you differently?
4. How often would you say you act as a 100% bad mother?
5. How often do you yell at your kids?
6. Whom would you consider to be a good mother?
7. Would you say that [that person] has never yelled at her kids?
8. What would a good mother do after she’d yelled at her kids and felt bad
about it?
9. In terms of becoming a better mother, how helpful is it to you to criticise yourself at this level of harshness when you do something wrong?
10. What’s the effect on your parenting of your criticising yourself so
strongly for something almost all parents do at one time or another?
What’s the effect on your mood?
11. If you truly don’t want to yell at your children in the future, what are
some things you could work on in therapy? What are some other behaviours you could try when you get angry with them?
12. What were you feeling before you yelled at your kids?
13. What do you think would happen to your parenting skills if you worked
on ways of reducing those self-critical thoughts and feelings that lead
you to be more easily irritated in the first place?
14. Besides viewing yourself as a 100% totally bad mother, what’s another
way you could look at what happened?
Notice what sorts of information this exercise can help you to
a) gather about a client’s belief system
b) impart to her new information to help her think differently about herself
and her problem
c) orient the client to thinking in more problem-solving ways
Note also how the above questions mostly generate open-ended (non-yes/no)
responses that flesh out the client’s ideas about herself and the way the world
is or should be.
Kevin T. Kuehlwein
Here are examples of Non-Socratic questions/comments in the same situation.
(Note how much less useful they are in terms of helping the client to think
differently or gather new information.)
Why are you being so hard on yourself ?
What’s the big deal about yelling at your kids? Almost everyone does it.
Didn’t your parents ever yell at you?
I’m sure your kids will get over it. It doesn’t seem so bad to me.
You’re basically a great mother; don’t you remember what you told me
you did for your kids the other day?
Alternative views of this evidence
Evidence supporting NCB
Actions I could take this week to increase my confidence in my NCB: ___________________________________________________________
Evidence seeming to support OCB
Incident linked to highest: _________________________________
Highest this week: _____%
Incident linked to lowest: ________________________________
Strength of belief now: _____% Lowest this week: _____%
New core belief (NCB): ______________________________________________________________
Incident linked to highest: _________________________________
Highest this week: _____%
Incident linked to lowest: ________________________________
Strength of belief now: _____% Lowest this week: _____%
Old core belief (OCB): ______________________________________________________________
Cognitive treatment of depression
Appendix 1.D. Revising core beliefs
Bob (friend)
walks by without
saying hello
Bob (friend)
walks by without
saying hello
mild concern,
Sad, hurt
That’s strange. He
didn’t acknowledge
me like he usually
does. I wonder
what’s up
He’s ignoring me.
He must be mad
at me.
(No physiological
Call him up later
just to check in and
mention casually
that I saw him but
he didn’t seem to
see me
Pain in the pit of
my stomach. Later:
I don’t return his
phone call for
several days to
“punish” him
Advantage: I don’t feel
lousy because of faulty
“mind reading”. I find
out immediately whether
there is something wrong
with him or whether he’s
upset with me so I can
then decide what I want to
do and I don’t have to
worry about this
Disadvantage: I put
distance between him
and me. I don’t explore
what’s going on with him
if there is a problem with
our relationship
Kevin T. Kuehlwein
Appendix 1.E. Old and newer patterns graphically
Chapter 2
Cognitive behavioural
treatment of suicidal
Arthur Freeman and James Jackson
Suicide, parasuicide, or self-injurious behaviour are situations of crisis for
patients, therapists, and the significant others of both. Whether the actions
leading to potential self-destruction or self-harm are active acts (ingesting
poison, shooting oneself), threatening (collecting pills, cutting in non-lethal
ways) or passive acts (not taking required medication), all have the potential
for danger. Because they can all lead to or hasten one’s demise, any and all
self-damaging behaviours must be addressed in as expeditious a manner as
Even the most experienced therapist reacts with an adrenaline surge of
fear when it becomes clear that a patient has placed a time limit on life or
safety. Given the severity of the consequence of the self-injurious or suicidal
behaviour, it is essential for the therapist to have an understanding of the
causes, assessment, process, and treatment of suicidal ideation, actions, or of
self-injurious and parasuicidal behaviour. The nature of the problem requires
that effective problem-solving be initiated immediately, and that follow-up
treatment be initiated to minimise the relapse and return of the suicidal
thoughts and actions and the subsequent danger.
One of the foremost treatment models for the treatment of suicidality is
cognitive therapy (CT) (Freeman & Reinecke, 1993; Beck, Rush, Shaw, &
Emery, 1979b; Freeman, Pretzer, Fleming, & Simon, 1990; Freeman & White,
1989). By definition, cognitive therapy is a short-term active, directive, collaborative, solution-oriented, psychoeducational, and dynamic model of
psychotherapy originally developed for the treatment of depression, and is
ideally suited for the treatment of the hopelessness and suicidality related to
depression. Understanding the problems of the suicidal individual in terms of
the individual’s idiosyncratic and negative beliefs about self (I’m no good),
the world (“It” is unfair) and the future (“It” will never change), helps to
organise the treatment and lend structure to therapy. Hopelessness, the third
leg of what Beck termed the “cognitive triad” (Beck et al., 1979b), is a key
part of the suicidal thinking. Clinically, it is useful to view a suicide attempt
as an indication that an individual is hopeless and sees few or no options
available to effect a desired change. A diverse set of therapeutic strategies and
Arthur Freeman and James Jackson
techniques have been derived from this theory which have proved useful in
providing a future focus for suicidal patients thereby increasing a sense of
hope. Secondly, several techniques will be described that have the effect of
helping patients in developing alternative solutions for their difficulties.
Myths and realities
A substantial portion of the clinical lore developed about suicide is based on
clinical lore rooted in untested theories and/or limited understandings of
theoretical and clinical concepts. Basing clinical decisions on clinical mythology rather than clinical psychology may likely result in either an over- or
underassessment of lethality, over- or underestimation of risk, difficulty in
conceptualising the problem, and, most seriously of all, difficulty in planning
treatment and the consequent implementation of effective treatment strategies. Some of the mistaken beliefs about suicide commonly held by clinicians
include the following.
1. Suicide is a cry for help In viewing a suicide attempt as a cry for help, one
may underestimate the severity of the patient’s plight. Given the strong relationship between hopelessness and suicide (Beck, Steer, Kovacs, & Garrison,
1985), suicidality is most likely an indication that the patient believes he or she
is far beyond help rather than the suicidal behaviour being a “cry for help”.
2. Talking about suicide reduces the risk This idea is based on the belief that
talking about an impulse will somehow deplete its energy. A number of studies suggest that from 60% to 80% of persons who committed suicide have
talked about it beforehand (Pokorny, 1960). Talking about suicide can
increase, decrease or have no effect on the likelihood of suicide depending on
the content of the discussion, context of the discussion, participants to the
discussion and the patient’s reaction to all of the above.
3. Suicidal “gestures” are not to be taken seriously The patient who makes a
suicide attempt and immediately calls for help, who “attempts suicide” using
a non-lethal method, or who carefully times the attempt so as to be discovered before substantial damage occurs, may be seeking some effect other
than death. However, despite the apparent ambivalence or manipulative
intent, there are at least two good reasons not to simply dismiss the act as a
“gesture”. First the patient may miscalculate the rescue potential making
rescue impossible. Second, if the “gesture” does not achieve the desired
response and the significant others or therapist do not actively intervene, the
patient may initiate more extreme “gestures”.
4. Suicide risk can be determined from demographic factors While suicide rates
may vary with criteria such as sex, age, social support etc., an over-reliance on
Cognitive behavioural treatment of suicidal behaviour
such assessment criteria will lead to overestimation of risk with some patients
and underestimation with others.
5. Suicide runs in families Although the data from twin studies have been
examined and concordance rates for completed suicides are higher for
monozygotic than dizygotic twins (Juel-Nielson & Videbeck, 1970; Tsuang,
1977), none of these studies managed to investigate monozygotic twins reared
apart. Although tentative evidence exists that genetics play a small role in suicide, no methodologically sound study has adequately demonstrated the
connection. Child abuse (Rogers & Luenes, 1979), early loss of parents (Stein,
Levy, & Glassberg, 1974), and modelling of suicidal behaviour by significant
others (Garfinkel, Froese, & Hood, 1982) all appear to place the patient at
greater risk.
6. Talking openly about suicide may suggest it to the patient Novice therapists
are often reluctant to address directly the topic of suicide out of fear of
“putting the idea in the patient’s head” or of making the idea more acceptable
if he or she is already thinking about it. Significant clinical experience shows
that explicit discussions of suicide in therapy make it possible to address the
issues directly and more likely reduce the suicidal risk.
7. Patients are more likely to make suicide attempts as they get less depressed
This notion is largely false and directed toward a specific group of individuals with severe depression. Vegetatively depressed patients normally lack
the energy to plan and carry out a suicide attempt. With a lessening of the
depression and increase in energy, he or she may then make a suicide attempt
if suicidality persists while the depression lifts. However, the more typical
depressed individual does not become more suicidal as his or her depression
lifts. Increasing hopefulness will reduce suicidality as problems are overcome.
8. Holidays are a time of increased suicide risk Quite simply, no evidence
exists to substantiate the popular notion that higher rates of suicide, hospitalisation, or depression occur at holiday time (Christensen, 1984; Lester &
Beck, 1975). Moreover, data suggest that the suicide rate and rate of attempts
is greater in the spring (Rogot, Fabsitz, & Feinleib, 1976).
9. If the patient was serious about suicide he or she would not bring it up in
therapy A high proportion of persons who go on to commit suicide do,
either directly or indirectly, communicate their intent to significant others
(Robins, Gassner, Wilkinson, & Kayes, 1959). While evasiveness in talking
about suicide is a bad sign, willingness to talk openly about suicide does not
necessarily mean that the risk of suicide is low.
Arthur Freeman and James Jackson
10. If someone is serious about suicide you cannot really stop them Measures
to permanently prevent a determined patient from committing suicide do
not exist. However, this does not mean that the therapist is helpless when confronted with a seriously suicidal patient. Since episodes of serious suicidality
are usually time limited, simply delaying the attempt may allow time for the
immediate crisis to pass. If the patient who seriously intends to take his or her
own life begins to believe that he or she has more or better options, the press
and stress of wanting to die will be reduced.
11. Medication can stop suicidal behaviour In an attempt to limit the suicidal behaviour, many non-medical therapists will react to suicidality by
immediately referring the patient to a psychiatrist for antidepressant medication. Since most antidepressants require from one to three weeks before
they have a substantial antidepressant effect, the use of medication may be
too late to bring about an immediate reduction in suicidality. Moreover, tricyclic antidepressants can be quite lethal in overdose and may provide a
convenient means for suicide. Antidepressant medication can be useful, but it
is neither necessary nor sufficient in the treatment of suicidality.
12. Suicidal patients must be hospitalised Related to the medication myth is
the notion that the suicidal patient must be immediately hospitalised. It is
obvious that hospitalisation will be required if the therapist is not able to
intervene effectively on an outpatient basis enough to eliminate the immediate danger to the person. If hospitalisation is the therapist’s primary response
to suicidality and other less drastic and dramatic interventions are not tried
first, patients will often become more hopeless. However, if there is concern
for the individual’s ability for self-control, there is no active support system,
or poor impulse control, a hospital environment may be a good choice in that
the patient can be placed under careful observation.
Another aspect must also be entertained. If the patient has a good support
system, taking them out of that system may remove a powerful deterrent to
the suicidal behaviour.
13. Patients with well-developed plans or methods are more likely to make an
attempt Although patients with well-formulated plans or the means at hand
present far greater risk of suicide, the absence of a plan does not eliminate the
risk of an attempt. Patients with poor impulse control are at particular risk at
any point because they lack the internal controls necessary to avoid selfdestructive action.
14. Patients have a right to take their own lives The case has been made that
no one has the right to interfere with an individual’s existential freedom to
live or die. However, it has been our experience that few patients select suicide
as a free choice but rather feel compelled to attempt suicide by virtue of their
Cognitive behavioural treatment of suicidal behaviour
perception that no other options are available to them. Thinking that they
have no freedom at all, they are governed by dysfunctional thoughts that
dictate the single option of death. The goal of therapy is to enhance the
patient’s free will, not restrict freedom of choice.
Clinical assessment
An immediate and complete clinical assessment of suicide risk is important
both as a part of the initial evaluation for therapy and throughout the therapy whenever indications of possible suicidality appear. The therapist must
take any indications of suicide seriously and evaluate them carefully.
Detecting early signs of escalating suicidality can require considerable sensitivity on the part of the therapist to subtle distinctions in meaning. The
statement “I would like to die” may, for one patient, mean that while death is
attractive as an escape from problems, he or she has no intention of hastening his or her demise. For another patient, the same statement may indicate
that he or she intends to take active steps towards suicide or even has started
implementing a plan. Even the most sensitive clinician cannot safely assume
that he or she fully understands the meaning of suicidal ideation without
asking the patient directly about the beliefs, actions, and thoughts.
Similar care must be utilised for assessment of subtle behaviours that
reflect suicidal ideation or intent. The patient who updates his or her will,
begins completing unfinished details of life, or is giving away possessions
may well be in the process of implementing a suicide plan and merits evaluation. Similarly, expressions of increasing hopelessness or vague comments
such as, “If I’m still around next month, I’ll . . .” can be important warning
signs. Early detection may allow for intervention before a crisis arises.
In assessing suicidality, obtaining an understanding of the patient’s view of
his or her options is critical. The patient who sees few or no options is at far
greater risk than the patient who maintains that options, although limited or
undesirable, exist. In making a clinical assessment of suicidality, the clinician
must be aware of his or her cognitions so that information is not lost or
never sought in an attempt to gain a modicum of comfort. The therapist
who is discomforted by the idea of discussing suicide may be collaborating
actively with the patient’s suicide attempt.
Other factors to consider in assessing the potentially suicidal patient
include: Has the patient made previous attempts? When was the last attempt?
How frequent have the attempts been? What were the circumstances of the
attempts? Is there a family history of suicide? Have either parents or grandparents made suicide attempts? Have these attempts been successful?
A number of tools are available to aid clinicians in the assessment of suicidality. The Beck Depression Inventory, Second Edition, a 21-item
self-report measure of depression (BDI-II, Beck, 1996) can offer the clinician
a measure of the patient’s general level of depression by using the total BDI
Arthur Freeman and James Jackson
score. The clinician can also assess the specific areas of depression by examining the specific items endorsed by the patient. Of particular importance are
the patient’s responses to item 2 (hopelessness) and item 9 (suicidality).
The Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1975) directly
assesses the hopelessness component of depression. Inasmuch as the cognitive model sees hopelessness as the prime ingredient in suicide, such direct
assessment is essential. By evaluating both the overall score and changes in
the score over time and conducting a content analysis, the therapist can
develop a conceptualisation of the problems that are fuelling the patient’s suicidal thinking as specific themes will emerge from the scale.
The Scale of Suicidal Ideation (SSI; Beck, Kovacs, & Weissman, 1979a)
provides a useful framework for assessing factors including the patient’s
thought, his or her intentions regarding suicide, and any plan the patient has
formed. This measure can be used in two ways. First, it can be used as part of
a structured interview with the clinician asking the necessary questions to
obtain the information sought by each item. Questions in each area are asked
in the same manner with the therapist asking for elaboration on any item that
appears to be important. Since suicidality is not a trait, it is best assessed at
different times and situations throughout the therapy. The SSI can also be
used as a self-report measure with the patient indicating in a forced choice
manner which response best fits their situation and thinking.
It is important to distinguish between thoughts of suicide, suicidal intent,
and potential lethality of a chosen method in assessing suicidality because the
three can be quite independent of each other. The clinician should be particularly aware of the potential lethality of a number of suicidal behaviours and
not underestimate any of them. For example, the ingestion of any quantity of
drugs with the intention of dying must be viewed as a lethal attempt, even if
the ingested drug has a wide margin of safety and low lethality.
Suicidal thoughts can take the form of obsessions which the patient may
find distressing or repugnant rather than appealing. Careful assessment may
reveal that in spite of the presence of suicidal thoughts, the patient may have
no intention of committing suicide.
Use of a non-lethal method in a suicide attempt may create the impression
that the attempt was manipulative and not serious, but it is important to
assess the patient’s intent rather than jumping to conclusions. For example: A
24-year-old woman despondent over a lost love made all the plans to die of
asphyxiation. She closed her kitchen window tightly and stuffed kitchen
towels around the kitchen door to make it airtight. She then turned on the
oven and put her head in the oven so she could breathe deeply of the gas. Her
oven, however, was electric and all she did was singe her hair.
Although the attempt may seem comic, her intent was most serious. The
good news was that her attempt failed. However, it is clear that this woman
had very poor problem-solving strategies which is certainly the bad news in
this case because her problem-solving deficits leave her vulnerable to later
Cognitive behavioural treatment of suicidal behaviour
attempts. In addition, her impulse control was flawed which is another poor
prognostic indicator. Without effective intervention, this patient might well
have learned from her experience and have chosen a more lethal method for
her next attempt.
Similarly, an action which is intended as a suicide gesture rather than being
taken without the intention of dying can still be fatal if the patient miscalculates. It is important to take so-called “manipulative” suicide attempts
seriously, not only because they can prove fatal despite the intent, but also
because there is no guarantee that “serious” attempts will not follow. For
example, a 28-year-old man was seen for therapy subsequent to a near-lethal
suicide experience. We have not used the term “attempt” inasmuch as the man
stated that he did not plan to die, but only to “frighten and inform my wife of
my pain”. He had taken several pills from a bottle in the medicine cabinet. He
did not check what the pills were, thinking them to be his wife’s diet pills.
They were, in fact, a common medication that in combination with the antihistamine that he regularly took for his allergies put him into respiratory
difficulty. Fortunately, he was able to call for emergency help. When his wife
came home for dinner she found him gasping for air on the floor while emergency medical technicians worked on him and later transported him to a
hospital emergency room.
Vulnerability factors
Factors that result in lowering an individual’s ability to cope with stress are
known as vulnerability factors. A vulnerability factor has the effect of
decreasing the threshold so that events that were previously ignored or never
noticed now shout loudly for attention. The vulnerability factors also serve to
make the individual more sensitive to internal and external stimuli that may
affect the suicidal thoughts and actions.
A tenet of Alcoholics Anonymous is to make members aware of the
acronym HALT. The letters stand for Hungry, Angry, Lonely, and Tired. AA
emphasises that these are conditions under which an individual is most likely
to lose control and resume drinking. These are not the only vulnerability
factors. Others include chronic pain, acute pain or illness, substance abuse,
any major life loss, or a major life change. The patient can be asked to rate
each factor on a scale of 1 to 5. One represents “doesn’t affect me at all”. Five
represents “bothers me greatly”. The patient can also be asked to rate these
separately for how they affect their feelings (Do they sense an emotional
change?), their thoughts (Do thoughts about this factor tend to occupy their
mind?), and their behaviour (Do they act differently when this factor is present?). The higher their score on an individual factor, the more important that
factor is to them.
Arthur Freeman and James Jackson
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1. Hunger
2. Anger
3. Substance abuse
4. Loneliness
5. Fatigue
6. Pain
7. Illness
8. Major loss (job, etc.)
9. Lack of sleep
10. Major life change
A cognitive behavioural conceptualisation of
suicidal behaviour
In fact, when the relationship between hopelessness and suicide is taken into
account, the relationship between depression and suicide seems more apparent than real, with the apparent relationship due primarily to the high
incidence of hopelessness among depressed individuals. Everson and her colleagues (Everson, Goldberg, Kaplan, Cohen, Pukkala, Tuomilehto, Salonen,
& Jenkins, 1996) found that when all risk factors were controlled, men who
evidenced higher levels of hopelessness had a higher mortality rate, increased
chances for myocardial infarction, a greater chance of dying in an accident or
due to violence.
Clinical observation and study from any theoretical perspective would
show that clinically depressed individuals systematically view themselves,
their world, and their future in a negative manner. The individual’s cognitive
processes are characterised by a sensitivity to several reactions including
feelings of loss or feelings of abandonment. Suicidality, however, is believed
to result from consequent feelings of hopelessness, in conjunction with a
belief that current difficulties are unendurable, or from a desire to manipulate or rapidly gain control of a frustrating or threatening situation. These
Cognitive behavioural treatment of suicidal behaviour
difficulties are compounded by a perceived lack of alternative choices, supports, or coping mechanisms. Suicidal patients tend to view their world in a
“constricted” manner, in that they are relatively incapable of identifying alternative courses of action, or of rationally examining the validity of their belief
that their problems are serious or unendurable. While suicide is an option for
anyone, the majority of individuals never exercise this option because they see
more promising options for dealing with their problems. At the bottom of
most people’s list of options, suicide only becomes an issue as the individual
exhausts other options and gets closer to the bottom of their list.
Although research suggests that it is the most robust predictor of suicide,
hopelessness is not the only factor which can lead to suicidality. A discussion
of a number of variations on the hopelessness theme may help the therapist
gain a better understanding of suicidal thinking and behaviour. We would
divide suicidal behaviour into four broad types: hopeless suiciders, histrionic
or impulsive suiciders, psychotic suiciders, and rational suiciders. None of
these types is mutually exclusive with any of the others.
The first type, the hopeless suicider, believes that there are few, if any,
options for them in life. The single option that they see as the most effective
measure for coping is to kill themselves. What is interesting is that each of us
has a number of options that we might exercise in any situation. One person
may have one hundred and fifty options. Another may see themselves as
having fifteen options and another may see themselves as having five options.
For the first person, suicide is a far distant option that does not enter their
mind or play a part in their decision making. For the second individual it is
a frequent thought and plays a part in their decision making. For the third
individual, it is a constant part of their cognition. If for reasons beyond their
control, each of these individuals loses four options, person one remains at
ease, person two is in an increased state of upset, person three sees no options
and may be acutely suicidal.
The histrionic or impulsive type of suicide attempt is motivated by a desire
for arousal, excitement, and/or attention. They will often seek increasing
levels of stimulation. Some individuals crave activity and excitement and
when feeling anxious, nervous, “itchy”, or bored, will seek out high risk or
“exciting” activities such as consuming drugs or alcohol in quantity, speeding
in cars or motorcycles, or deliberately entering dangerous situations. The net
result may very well be physical damage or loss of life. This type of individual may even use the suicide attempt as a source of stimulation or excitement.
Part of the overall symptom picture of the histrionic attempter is that the
suicide attempts are flamboyant and may be repetitive. These attempts may be
questioned as actual suicide attempts and be classified by the clinician as
manipulative or motivated by needs for attention. Even when this is true, the
possibility of a histrionic attempt being lethal exists, so that the ideation and
attempts still need to be taken seriously. The following case serves to illustrate
this type of attempter:
Arthur Freeman and James Jackson
A 27-year-old man recounted several severe “suicide attempts” (labelled as
such by a previous therapist). He reported that he often would be in his home
at night and would start feeling what he termed “itchy” or nervous. His
manner of coping with nervousness was to do one of two things. The first was
to drive his car at great speeds on a highway at night, often exceeding 100
miles an hour. At times he would turn his headlights off and drive only by
moonlight. He reported a great relief after these driving episodes. His “anxiety” was relieved, and he could then return home to sleep. His second
strategy for relieving his nervousness was to drive along back roads to small
highway bridges over streams or creeks and to jump from bridges. He would
get wet and muddy, but, in spite of the potential for danger, was never
injured. These attempts may be questioned as actual suicide attempts, but the
ideation and attempts must be taken seriously as the possibility of lethality
clearly exists.
A third group of individuals attempt suicide as a direct result of command hallucinations, or voices from within (Roy, Mazonson, & Pickar, 1984;
Gardner & Cowdry, 1985). It is very important to assess whether the attempt
is psychotic or not, for in psychotic individuals it is not hopelessness per se
that must be addressed but rather the voices or impulses that are prompting
them to consider or act on the command. The primary intervention with
patients who are experiencing command hallucinations would be pharmacological (i.e., the use of antipsychotic medication that would have as its function
a reduction in the delusional system and/or hallucinatory phenomena).
In addition, however, the therapist can help the patient learn skills to gain
power over internal stimuli by teaching the patient to forcefully counter the
commands by generating effective self statements. The patient can be taught
to view the commands as “not all powerful” requiring no immediate response.
The fourth type is the rational suicider. These are the individuals who have
chosen to die on the basis of some rational consideration. These individuals
rarely seek therapy to discuss their rational decision, so that therapists generally see these individuals after a failed attempt. The type of situation
generally offered as the model for rational suicide is that of the terminally ill
cancer patient in intractable pain. These patients come under the broad heading of “right to die”. Whenever a patient demands that life support systems
be terminated, the intended result is that death would follow shortly. One
manifestation of the right to die comes with the patient’s decision to ask the
medical staff to agree to affix the label DNR (do not resuscitate) on the
patient’s medical chart. The patient has made the choice, often in conjunction
with family and significant others, that should the patient’s condition deteriorate, and they need resuscitation, none would be given. No ambulance
would be called to a convalescent home or care facility, and no extraordinary
measures would be employed to keep the patient alive.
The issue of an individual’s right to die is a bio-medical-ethical-legal issue
that is still hotly debated by ethicists, physicians, legislators, theologians,
Cognitive behavioural treatment of suicidal behaviour
hospital administrators, attorneys, and hospital risk managers. We have found
that many individuals who think that their suicidal thoughts are the most
rational, reasonable, and intelligent course of action can, with therapy, see
other options. We are not, however, ruling out the possibility of an individual
making a rational choice and the need for the therapist to aid the client in
making that choice. The need for the therapist to be prepared for sensitive
discussions, and for a testing of the therapist’s own schema regarding death
and dying, is quite powerful.
Strategies for intervention
A full understanding of the cognitive model is essential for any therapist
planning to use cognitive therapy (the reader is referred to Beck, Rush, Shaw,
& Emery, 1979b; Freeman, 1988; Freeman, Pretzer, Fleming, & Simon, 1990;
and Freeman & Reinecke, 1993). Therapy cannot be a mere collection of
strategies and techniques. Rather, an understanding of the cognitive underpinnings of suicidal ideation and intent is required. With that conceptual
framework, the cognitive therapist can understand quickly the nature of the
suicidality and develop interventions, both inter- and intrapersonally.
Specifically, cognitive therapists work in a very direct manner with patients,
proposing hypotheses, developing strategies for testing the hypotheses, developing a range of specific skills as needed, and teaching the patient a model for
more effective coping/adapting to the world. Probably no patient population
requires a direct problem-solving approach as much as the suicidal patient.
Such individuals have been found, for example, to demonstrate deficits in
their ability to generate and evaluate alternative solutions or viewpoints. This
“cognitive rigidity” is reflected in their relatively poor performance on measures of social problem-solving, such as the Means-Ends Problem Solving
Task (Platt, Spivak, & Bloom, 1975; Reinecke, 1987; Schotte & Clum, 1987).
The process of cognitive therapy is based on collaboration between patient
and therapist. With the severely depressed and suicidal individual, the therapist’s activity level must be high enough to supply the initial energy to develop
the therapy work, so that the collaboration might start out 80–20, or even
90–10. Because of the seriousness of the patient’s condition, and the severity
of the consequences, the therapist cannot rely simply on offering a restatement of the patient’s problems but must use an active restructuring of
thoughts, behaviours, and affect.
A problem focus is essential with the suicidal patient to help supply a direction for therapy rather than encourage a vague and aimless wandering about
the broad issue of hopelessness. The initial goal is to work quickly to establish rapport. The therapist must be perceived as an individual who can be
trusted, supportive, confident, resourceful, and available, and someone who
is perceived by the patient as an ally. The therapist’s openness and lack of selfconsciousness in directly questioning the nature of the patient’s hopelessness
Arthur Freeman and James Jackson
and thoughts of suicide, the utilisation of the data from the psychological
measures, integrating the patient’s history, and level of depression, can all
serve to put the patient at greater relative ease. They will have the confidence
that their problems are not so great that even the therapist is overwhelmed.
Having established rapport, the therapist needs to work actively and
directly on the hopelessness. The patients must be worked with rather than on,
so that he or she feels part of a therapeutic team. This is especially important
with suicidal patients who must see that they can, as a result of therapy,
develop alternatives and options. They need to appreciate that it is not merely
the therapist telling them what to do or giving them instructions. This might
feed into their hopelessness with the belief, “See I can’t even manage my life,
I need to be told what to do.” The therapist should bear this in mind when
working with the suicidal patient whose energy level is low, who feels paralysed, and whose general level of motivation may be lacking. For the
individuals who have settled upon suicide as the option of choice, the therapist may need to contribute more to the collaboration until the patient is
able to make the decision that there might be a future, that there may be
things that the patient can do, and that it is possible to change. Simply being
a “cheerleader” who tries to distract the patient into looking at the positive
side of things is not enough.
If it is possible to reach the point where the patient makes a believable commitment to refrain from suicide attempts while the therapist and patient try
other approaches to overcoming the patient’s problems, the therapist and
patient can then take steps to minimise the risks of a suicide attempt should
a crisis arise, and begin working on the patient’s problems using the usual
cognitive therapy approach. If the patient will not make a believable commitment to refrain from suicide, is not willing to take steps to dismantle his or
her suicide plan, or if the patient makes it clear that he or she is still planning
to attempt suicide, the therapist must take decisive action. The options at that
point include voluntary or involuntary hospitalisation, and contacting the
patient’s significant others to involve them in intervention. It is the therapist’s
responsibility to do all that is within his or her power to minimise the risk of
Initially, the therapist and his or her patient are likely to have conflicting
goals in mind since the patient is at least considering suicide and the therapist’s primary goal is to keep the patient alive. This obviously makes it
difficult to use a collaborative approach unless therapist and patient can
identify a goal towards which both are willing to work. Often the goal of
trying to determine whether suicide is a good idea or not is a good starting
place. For example: a therapist might say, “It sounds like you’re pretty certain
that suicide’s the best option you have in this situation. This is something I
think is important to take seriously. With most decisions people have the
option of changing their minds if it turns out that they’ve made a poor
choice but with suicide you don’t get to try something else if it turns out you
Cognitive behavioural treatment of suicidal behaviour
weren’t thinking clearly. Would you be willing to take a look at whether suicide is really the best option you have?” With this rationale, it is usually
possible to take a collaborative approach with even seriously suicidal patients.
The therapist is then in a position to clarify the patient’s motivation for suicide and his or her expectations regarding the likely consequences of suicide.
The full range of interventions which are used in looking critically at automatic thoughts can be used in looking critically at the patient’s views
regarding suicide. Whatever the motivation for suicide, it can be quite valuable to help the patient to look carefully at the evidence supporting his or her
conclusion that suicide is necessary and will accomplish the desired ends, as
well as looking at the alternatives to suicide. An intervention at this point
might be contracting with the patient to act in a non-suicidal manner. This
will be discussed later in the chapter. It is important to help the patient verbalise his or her hopelessness and then to look critically at his or her
conviction that the situation is hopeless. What evidence convinces the patient
that the situation is hopeless? Will the hopeless situation last for ever? Is it
totally unchangeable? Might there be options for dealing with his or her
problems that the patient has overlooked? When patients are helped to examine their situation, they are often able to see the distortions in their logic and
discover that the situation is not nearly as hopeless as it appeared. For example: When Kathy, a divorced mother of one, first described her situation to
her therapist, she was convinced that since she felt she couldn’t return to her
job but couldn’t support herself and her son without a job, the situation
seemed truly hopeless. However, when she and her therapist carefully examined the work and life situations in detail, it became clear that Kathy and her
son would not perish if she quit her job. Actually she had a number of alternatives: she could use her savings for a few months and look for a new job,
she could work on a part-time basis, she could ask her parents to help her out
financially if she really needed it, or any combination of the above.
Once it was clear that the situation was difficult rather than hopeless, her
suicidality subsided and her mood improved considerably. Other assumptions such as, “They’ll be better off without me”, “Nobody will miss me”, or
“I’d be better off dead” can often be handled in a similar way.
In addition to questioning what would be accomplished by suicide, it is
important for the therapist to work on significant reasons not to commit
suicide. It is obvious that one of the major drawbacks to suicide is that the
individual forfeits the rest of his or her life. However, this is seen as a good
reason to refrain from suicide only if the individual has a significant amount
of hope that life can be worth living. With hopeless individuals, in particular,
it is important to identify reasons to refrain from suicide that do not rely on
hope for the future. These deterrents might include the likely effects of the
patient’s suicide on family and friends, religious prohibitions regarding suicide, fear of surviving an attempt but being seriously injured, concern about
what others will think, and so on. It is usually necessary for the therapist to
Arthur Freeman and James Jackson
take an active role in generating possible deterrents, but this can be done most
effectively if the therapist works to engage the patient in the process rather
than simply listing the reasons he or she sees for the patient not to commit
Explicitly listing the advantages and disadvantages of continuing to live
and separately the advantages and disadvantages of suicide can be an effective way of integrating the results of the above interventions. This will have
the additional benefit of providing the patient with a concise summary of the
conclusions reached during the therapy session, to which he or she can refer
if suicide should again start to seem like a promising option. For example, the
thought, “I would be better off dead” can have an enormous impact as long
as it is accepted without critical examination and patients may have difficulty
challenging such thoughts on their own if they have not been in treatment
very long. A concise summary of the major conclusions reached in each therapy session can be quite useful to patients when suicidal thinking re-emerges
between sessions.
In initial interventions with hopeless patients, it is not necessary for the
therapist to attempt to convince the patient that all problems will be overcome, that the alternatives to suicide will definitely be successful, or even
that suicide is always unacceptable as an option. All that is necessary is (1) to
raise doubt regarding the merits of suicide and, (2) to identify sufficiently
promising alternatives to suicide so that (3) the patient is willing to make a
commitment to refrain from suicide attempts while (4) the therapist and
patient explore other options. It is important for the therapist to accept the
patient’s scepticism and not to encourage unrealistically optimistic expectations which are likely to lead to sudden disappointment. Reluctant patients
are often more willing to refrain from suicide for a reasonable period of time
if the therapist points out that by agreeing to this approach the patient is not
giving up suicide as an option. For better or worse, the patient will always
have the option of choosing to commit suicide later should it ever turn out
that suicide is the best option available to him or her.
Cognitive therapy generally emphasises a guided discovery approach rather
than a more confrontational, disputational approach. However, when the
therapist is faced with a hopeless patient who is not willing to participate
actively in the process described above, it is important to actively dispute the
patient’s distortions and misconceptions, and to present possible alternatives
to suicide even if this must be done with minimal participation by the patient.
While active disputing can be useful, the therapist must walk the very fine line
of not arguing with the patient. There are important advantages to involving
the patient in this process as much as possible, but if guided discovery is not
feasible, direct disputation may prove effective. If it is effective, then the therapist should be able to shift to a more collaborative approach as the patient
becomes more willing to look at alternatives to suicide. Once it is clear that
suicide is not a promising option and that there are important reasons not to
Cognitive behavioural treatment of suicidal behaviour
commit suicide, the patient may still see no viable alternatives to suicide. It is
also important for the therapist to help the patient to identify the possible
alternatives. If the therapist only takes the approach of trying to elicit options
from the patient, a rather limited list is likely to be generated. If the therapist
takes a brainstorming approach and raises possibilities of his or her own and
encourages the patient to consider options that, at first glance, seem absurd or
unworkable, it is possible to generate a much larger pool of possible alternatives to suicide to choose from. Options which strike the patient as
unworkable may well prove to have more potential than was immediately
apparent or may suggest other, more feasible options.
Having perceived the advantages and disadvantages of suicide as well as
having identified alternatives to suicide, the therapist and patient can agree on
a course of action and pursue it. An important part of this agreement is the
patient’s making a believable commitment or contract to refrain from suicide
for a reasonable period of time during which therapist and patient will work
to overcome his or her problems. The agreement should also include the
patient’s agreeing to call and talk with the therapist (not just leaving a message) before actually doing anything to harm him- or herself. Some therapists
make a practice of having the patient sign a written contract containing these
and other provisions, and doing so would have an advantage with patients
who take written agreements more seriously than verbal agreements.
However, the key element is the agreement and the clinician’s judgement as to
whether the patient’s commitment is genuine, rather than the contract per se.
This point is emphasised by one patient’s response to the therapist’s suggestion that he sign a written contract. “So what are you going to do if I kill
myself, sue me?” The contract, whether spoken or written, is not intended to
be enforceable by law, but is one stage of a collaborative approach to dealing
with suicidality. The therapist and patient should try to anticipate any situations which would be likely to produce a sudden increase in suicidality and
plan how the client can best cope with them should they arise.
An important early intervention is to work with the patient to dispose of
any available means for suicide that the patient may have selected. This might
include steps such as asking an individual who collects guns and who had
planned to shoot himself to turn the guns over to the police, to place the guns
in the custody of a reliable significant other, or even to bring them to the therapist. The purpose of such precautions is not to make suicide impossible but
to decrease the risk of an impulsive suicide attempt by making the means of
suicide less accessible. It is best to design precautions so that it is possible to
confirm that the patient has complied with them, since otherwise the therapist
may face some difficult decisions. For example: One patient reported that he
had three handguns loaded and available to use for a suicide attempt. After a
rather lengthy discussion, he agreed to turn the guns over to his brother who
would keep them indefinitely. The patient was asked to call the therapist that
evening to confirm that the guns had indeed been turned over to his brother.
Arthur Freeman and James Jackson
Instead, what the patient reported was that he had changed his mind and
rather than turning the guns over to his brother, he had gone down to the
river, tossed the guns in a paper bag into the river and watched them sink
beneath the waves. The therapist had no way of confirming whether the guns
had been disposed of or not and therefore had to decide whether the patient’s
assertions were true on the basis of little or no data.
If the preceding interventions have been effective, and hospitalisation is not
needed, the recently suicidal patient is likely to need closer follow-up than
most patients. It is not unusual for cognitive therapists to meet with a patient
two or three times per week during times of crisis or to arrange telephone
contacts between sessions. It is important for the therapist or a colleague to
be accessible to handle crises as they arise even if that means the patient
calls late at night or on weekends. If sufficient therapist patient contact is
scheduled throughout the week, emergency phone calls should be held to a
With the above foundation, cognitive therapy can then proceed much as it
would if the patient had not been suicidal. It is usually best for therapist and
patient to work first on issues which are related to the motivation for suicide,
which are important to the patient, and on which there is a good chance of
making noticeable progress quickly. In addition, it is important for the therapist to be alert to any indications of increasing suicidality and to repeat the
above interventions if a setback or crisis should produce a renewed risk of
When suicidal impulses are a product of intense anger at oneself or others,
it is clear that the optimal solution is to help the patient develop more adaptive ways of handling intense anger. However, since it is likely to take
considerably more than a single session to accomplish this, it is important to
deal effectively with the immediate crisis first.
Once it is clear to therapist and patient that suicide would be an attempt to
punish oneself or others, therapist and patient are in a good position to consider whether suicide is likely to be the best option for doing so. This is likely
to include an examination of the patient’s expectations about the consequences of a suicide attempt, the degree to which he or she is certain that
suicide will have the desired impact, the deterrents to suicide, and alternative
ways to accomplish the desired results. It is also important to question
whether the desired results are important enough to be worth the patient’s
risking his or her life. The patient may not have considered the fact that suicide attempts which are not intended to be fatal can still be lethal.
It is possible to identify alternatives to suicide which the patient would find
emotionally satisfying and would be willing to try; these can be substituted
for suicide as a way of “buying time” so that it is possible to work to help the
patient develop more adaptive ways of handling anger. Even alternatives
which the therapist would not normally suggest are worth considering such as
throwing a temper tantrum, writing a nasty letter to the person who is the
Cognitive behavioural treatment of suicidal behaviour
object of his or her anger, or marking his or her wrists with a marking pen
rather than cutting them. While these are not very appropriate ways of handling anger, they are much better than suicide. Once the client has agreed to
refrain from suicide for a certain period of time, it is important to proceed
with agreeing on a certain treatment plan, dismantling any preparations for
suicide, and periodically monitoring suicidality, as discussed above.
Many patients who consider suicide out of anger, rather than hopelessness,
manifest characteristics of borderline personality disorder. Such patients are
likely to have problems with impulse control and methods and techniques for
increasing impulse control are likely to be helpful.
As with the angry suicidal patient, in working with the histrionic suicidal
individual, it is important to identify the functions which would be served by
a suicide attempt and to consider whether suicide is really a promising means
for accomplishing those ends. Whether the goal of a suicide attempt is to
reduce anxiety, to achieve a desired response from significant others, or
simply to obtain stimulation and excitement, the process of exploring the pros
and cons of a suicide attempt, the deterrents to suicide, and alternatives to
suicide discussed in the above can be quite useful.
In working with these patients, it is important for the therapist to be aware
of his or her reactions to them. On the one hand, when the patient’ s talk of
suicide seems manipulative, particularly if there is a history of apparently
manipulative suicide attempts, it is easy to conclude that he or she is not
“really” suicidal but is just being manipulative. One must remember that if the
patient feels that his or her threats of suicide are not being taken seriously, he
or she may feel that it is necessary to take more extreme steps in order to be
taken seriously. On the other hand, histrionic patients can sometimes be quite
skilled at inducing others to come to their aid, and the therapist can easily slip
into trying to “rescue” the patient rather than working to get the patient to
take an active part in therapy. To be effective, the therapist needs to avoid
both extremes.
As briefly discussed in the above, intervention with patients who are suicidal due to command hallucinations is quite different from intervening with
other suicidal patients in that the primary intervention is pharmacological.
Often medication alone is effective in reducing command hallucinations, and
cognitive interventions are directed towards increasing the patient’s compliance
with the medication regimen. In addition, it is possible to work cognitively to
increase the patient’s ability to cope effectively with the voices once the medication has substantially reduced their floridly psychotic symptoms.
The therapist working with patients having command hallucinations needs
to know the precise nature of the commands. Thus, the patient must be questioned directly about the content and nature of the commands as well as his
or her ability to resist them. Once the nature of the commands is understood,
it is important to help the patient examine whether obeying the commands is
a good idea. Individuals suffering from command hallucinations usually have
Arthur Freeman and James Jackson
never stopped to consider what would be accomplished by obeying the voices
and what would happen if they resisted. By raising this question, the therapist
can start to lay a foundation for the patient’s choosing not to obey the voices
rather than feeling compelled to obey. Standard cognitive techniques such as
questioning the evidence may be employed in this regard. An approach as
simple as “what evidence do you have as to whether it is a good idea to obey
the voices or not? Have they given you good advice in the past?” can be quite
effective in clearly establishing that resisting the commands is a good policy.
Next the therapist and patient need to develop a plan for coping with the
command hallucinations. If the patient has already discovered some partially
effective strategies such as staying active or keeping his or her mind occupied,
these can be incorporated into the plan. Patients often find it useful to minimise
the amount of unstructured time in their day, to explicitly remind themselves
that they do not have to do what the voices say, and to remind themselves that
the voices give poor advice. Another standard technique known as externalisation of voices may be employed as a means of teaching the patient to “talk
back” to the commands either by refusing directly, e.g., “I don’t have to. I
won’t, I won’t, I won’t” or through more sophisticated responses such as, “I’m
not going to. Suicide is sinful and it would hurt my family. And besides, if I can
hold till my new job starts, money won’t be so tight and I’ll be able to get my
own apartment again.” It can be particularly useful to have the patient write a
summary of the most convincing arguments for resisting the voices and of the
most promising coping strategies to aid him or her on remembering the plan for
coping with the voices. It is also important to take steps to reduce the risk of an
impulsive suicide attempt as discussed above.
If the patient is chronically psychotic, then cognitive therapy is likely to be
of greatest value in increasing the patient’s compliance with his or her medication regimen and in helping the patient deal more effectively with problem
situations that arise. If the psychotic symptoms are acute and subside once
the immediate crisis is over, then the usual cognitive approach to the patient’s
remaining problems should prove effective.
Use of significant others in therapy
In any emotional dysfunction or distress, there are significant implications for
the families, significant others, children, parents, spouses, extended family,
friends, neighbours, co-workers and colleagues, students, fellow patients, therapists, physicians, police, and clergy (Dunne, Mcintosh, & Dunne-Maxim,
1987). Given the potential impact on family dynamics and overall functioning, it is important, useful and often essential to involve significant others in
several aspects of the therapy. They may be part of the referral, assessment,
treatment, and relapse prevention work.
Cognitive therapists advocate early contact with significant others (Beck et
al., 1979b; Bedrosian, 1981). Beck and colleagues believe that, in the absence
Cognitive behavioural treatment of suicidal behaviour
of any obvious contraindications, the significant others should be interviewed
immediately after the initial interview with a suicidal patient. Such an interview would yield data regarding the patient’s symptoms and level of
functioning, the reactions of those close to the patient, and the nature of their
interactions with the patient. This information may help identify sources of
distress and alert the therapist, family, and patient to the types of experiences
or situations which might trigger impulsive and potentially self-damaging
The significant others as sources of data
The family members and other individuals that are significant and meaningful
to the patient can be important sources of information about the patient’s life,
personal history, medical or psychiatric history, social or developmental history,
and the family schema. This can serve to provide the therapist with a more balanced view of the patient’s life. When patients are too young to report major life
events, when there is some neurological disability, or when information is
simply not available to the patient, the significant others can offer details that
might otherwise be lost. During the therapy, family members can offer feedback to the therapist about the therapy and its immediate effects on the patient.
The family’s involvement can foster mutual support or it can foster divisiveness. Family members may deny the seriousness of the patient’s behaviour,
may disagree with the need for hospitalisation, may punish the patient for
particular behaviours by criticising or withdrawing from them, or may label
the patient or another family member as the problem. Others may deeply
wish to be helpful, but lack the skills to communicate effectively with the
patient or may behave in an oversolicitous manner. It is therefore necessary to
assess both the strengths and weaknesses of those individuals making up the
patient’s social environment. Such assessment will help the therapist decide
whether to include couples work or family therapy in the treatment plan.
With suicidal patients, it will help the therapist judge the risk of allowing the
patient to remain in the company of those significant others. Significant
others play a substantial role as the patient’s social environment, responding
to him or her in ways that support treatment gains.
Significant others may assist in therapy to the point of acting as auxiliary
therapists, helping the patient to identify negative cognitions and respond to
them. Because they tend to know the patient’s history, they can recall evidence the patient may forget or ignore.
Cognitive therapy is ideally suited for the treatment of hopelessness and
suicidality for a number of reasons. Cognitive therapy’s short-term, problemfocused orientation lends itself to the initiation of the kind of effective
Arthur Freeman and James Jackson
problem-solving interventions required in treating the suicidal client. A problem focus is essential to help supply a direction for therapy versus
encouraging a vague and aimless wandering about the broad issues of hopelessness. In addition, cognitive therapy enables the therapist to make use of a
variety of strategies and techniques that have proved useful in instilling in suicidal patients a sense of future and hope. It provides the therapist with a
format for understanding the problems of the suicidal individual in terms of
the individual’s idiosyncratic and negative beliefs about self, the world and the
future. These factors exert a powerful influence on the individual’s decision to
take his or her own life. By bringing into conscious awareness those aspects of
the individual’s personal meaning system which generate feelings of depression and hopelessness, the therapist is provided with a specific focus for
intervention. The model provides a methodology for the rather quick and
accurate assessment and conceptualisation of the client’s problem, to be
followed by a number of intervention strategies and techniques which have
proved effective in the treatment of depression and hopelessness. Use of
strategies such as Socratic questioning enable the therapist and client to work
collaboratively in developing adaptive responses to dysfunctional thinking. In
addition to cognitive interventions, a number of behavioural interventions
may be employed as initial strategies with the more depressed and vegetative
Once the client’s feelings of hopelessness are sufficiently under control,
the therapist may then target other factors known to contribute to suicidal
behaviour. Many suicidal clients have long-standing problems with poor
impulse control and may have significant problem-solving and coping skill
deficits. Because it is based on both a “coping” and a “mastery” model of
therapy, cognitive therapy is highly suited for teaching clients more effective
problem-solving and coping skills, thereby reducing their overall vulnerability to stress.
Finally cognitive therapy incorporates a strong relapse prevention component as part of its comprehensive intervention strategy. The termination of
formal treatment does not mean the end of therapy for the suicidal client.
Trained to identify specific situations, events, cognitions and feelings which
place him or her at risk for a return to suicidal thinking, the client is also
trained in effective coping and problem-solving skills needed for successful
intervention and interruption of the process.
Empirical testing of the short-term, active, directive, focused, problemoriented, structured, collaborative and psychoeducational nature of cognitive
therapy will undoubtedly result in changes to the basic model of treating
suicidal behaviour. Since the therapist is often the only person standing
between the client’s life and death, it is hoped that the strategies for assessment and intervention included in this chapter will help to provide the
therapist with additional hope in undertaking what is often a stressful and
daunting task.
Cognitive behavioural treatment of suicidal behaviour
Beck, A.T., (1996). Beck Depression Inventory, 2nd Edition. San Antonio: The
Psychological Corporation.
Beck, A.T., Kovaks, M., & Weissman, A. (1979a). Assessment of suicidal intention:
The Scale for Suicidal Ideation. Journal of Clinical and Consulting Psychology, 47,
Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979b). Cognitive Therapy of
Depression. New York: Guilford Press.
Beck, A.T., Steer, R.A., Kovacs, M., & Garrison, B. (1985). Hopelessness and eventual
suicide: A 10-year prospective study of patients hospitalized with suicidal ideation.
American Journal of Psychiatry, 142, 559–563.
Beck, A.T., Weissman, A., Lester, D., & Trexler, L. (1975). The measurement of pessimism: The Hopelessness Scale. Journal of Counseling and Clinical Psychology, 42,
Bedrosian, R. (1981). Ecological factors in cognitive therapy: The use of significant
others. In G. Emery, S. Hollon, & R. Bedrosian (Eds.), New Directions in Cognitive
Therapy. New York: Guilford.
Christensen, R. (1984). The misdiagnosis of holiday and winter complaints: An
unconscious shift in criteria? Psychotherapy, 21, 401.
Dunne, E.J., Mcintosh, J.L., & Dunne-Maxim, K. (Eds.) (1987). Suicide and its
Aftermath. New York: W. W. Norton.
Everson, S.A., Goldberg, D.E., Kaplan, G.A., Cohen, R.D., Pukkala, E., Tuomilehto,
J., Salonen, J.T., & Jenkins, C.D. (1996). Hopelessness and risk of mortality and
incidence of myocardial infraction and cancer. Psychosomatic Medicine, 58,
Freeman, A. (1988). Cognitive therapy of personality disorders. In C. Perris, H. Perris,
& I. Blackburn (Eds.), The Theory and Practice of Cognitive Therapy. Heidelberg:
Springer Verlag.
Freeman, A. & Reinecke, M. (1993). Cognitive Therapy of Suicidal Behavior. New
York: Springer Publishers.
Freeman, A. & White, D. (1989). The treatment of suicidal behavior. In A. Freeman,
K. Simon, L. Beutler, & H. Arkowitz (Eds.), Comprehensive Handbook of Cognitive
Therapy. New York: Plenum Press.
Freeman, A., Pretzer, J., Fleming, B., & Simon, K.M. (1990). Clinical Application of
Cognitive Therapy. New York: Plenum Press.
Gardner, D.L. & Cowdry, R.W. (1985). Suicidal and parasuicidal behavior in borderline personality disorder. Psychiatric Clinics of North America, 8, 389–403.
Garfinkel, B. D., Froese, A. P., & Hood, J. (1982). Suicide attempts in children and
adolescents. American Journal of Psychiatry, 139, 1257–1261.
Juel-Nielsen, N. & Videbeck, T. (1970). A twin study of suicide. Acta Geneticae
Medicae et Gemmellologiae, 19, 307–310.
Lester, D. & Beck, A.T. (1975). Suicide in the spring. Psychological Reports, 35, 893–894.
Platt, J., Spivak, G., & Bloom, W. (1975). Manual for the Means Problem Solving
Procedure (MEPS): A Measure for Interpersonal Problem-solving Skill.
Philadelphia: Hahneman Medical College.
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Reinecke, M. (1987). Advances in cognitive therapy of emotional disorders. Paper presented at the Sixth National Congress of Clinical Psychology, Santiago, Chile.
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Chapter 3
Cognitive therapy of bipolar
Cory F. Newman
Bipolar disorder (BD) is one of the most chronic, severe, lethal, and difficult
to treat of the psychiatric disorders (Goldberg & Harrow, 1999; Goodwin &
Jamison, 1990; Nilsson, 1995). In spite of the initial optimism generated by
the introduction of lithium treatments in the United States in the 1970s, BD
continues to subject many of its sufferers to long-term, serious dysfunction.
Newer pharmacological developments, such as the use of anti-convulsants,
have added helpful new dimensions to the treatment of BD (Sachs, Printz,
Kahn, Carpenter, & Docherty, 2000). However, medications have not been a
panacea. Some patients are refractory to medications such as lithium, carbamazepine, and valproate (Calabrese et al., 1999; Post, Leverich, Altshuler, &
Mikalauskas, 1992). Others cannot tolerate the side-effects of medications,
and therefore discontinue their use (Goodwin & Jamison, 1990; Jamison,
Gerner, & Goodwin, 1979; Keck, McElroy, & Bennett, 1994; Ketter & Post,
1994). Still other patients are prohibited from taking these medications, due
to concomitant conditions ranging from hypertension, to kidney dysfunction,
to pregnancy (Chor, Mercier, & Halper, 1988; Sachs et al., 2000). Finally,
many BD patients report negative feelings and attitudes regarding their medications (Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, 2001; Jamison,
1995; Scott, 1996), and therefore are at constant risk of abandoning their use
prematurely. Clearly, powerful psychosocial approaches are necessary as well
in order to address the treatment of BD more completely.
Bipolar disorder is well identified as a “diathesis-stress” disorder (Bauer &
McBride, 1996; Goodwin & Jamison, 1990; Post, 1992). In other words, there
are compelling data that indicate a hereditary component, leading to biochemical abnormalities that put patients at risk for the full expression of the
disorder. At the same time, high genetic loading does not guarantee that a
patient will develop BD. Environmental factors play a role as well, including
the demands that are made upon the patient’s coping skills. Greater degrees
of stress, over a more chronic course, increase the likelihood that a patient
will develop the full symptomatology of BD.
Therefore, one of the goals of therapy is to decrease the patient’s level of
stress (Newman et al., 2001). This, by definition, will decrease the probability
Cory F. Newman
of incurring (or recurring) the expression of the disorder. This observation
leads to the following question – what is stress, and how do we reduce it?
In many respects, stress is a subjective phenomenon. For example, two
people are presented with an identical life problem (e.g., the loss of employment). One person views it as a catastrophic, personal failure, while the
second person views it as an unfortunate situation that nevertheless presents
him with an opportunity to find more suitable employment. The first person
is more likely to become depressed, while the second person is more likely to
maintain a high level of psychological functioning (Pretzer, Beck, &
Newman, 1989). As this example illustrates, the first person’s highly negative,
subjective view interacted with the situation to produce a depressive reaction.
The loss of the job, in and of itself, was insufficient to cause the “stress”.
However, coupled with the person’s negative, internal, global attribution, the
person experienced a great deal of stress, resulting in depressive symptoms.
Indeed, recent studies provide striking evidence that such attributional styles
are predictive of both depressive and manic episodes (Alloy, ReillyHarrington, Fresco, Whitehouse, & Zechmeister, 1999; Reilly-Harrington,
Alloy, Fresco, & Whitehouse, 1999).
The above example demonstrates how a person may become depressed in
the aftermath of experiencing – and negatively construing – an environmental stressor. This conceptualisation is at the heart of the theory of cognitive
therapy of the emotional disorders (Beck, Rush, Shaw, & Emery, 1979). The
theory states that people who evince systematic, negative biases in their thinking processes are at risk for exaggerations and exacerbations of negative
affect, such as dysphoria, anxiety, anger, and others. The risk of experiencing
a clinical depression increases if this thinking style is stable over time, and if
it discolours people’s views of themselves, their lives (and the world at large),
and their future – the so-called “cognitive triad” (Beck et al., 1979).
While this may explain the depressive phase of BD, how does it address the
manic side of the equation? To begin, not all thinking that is biased is negative (Leahy & Beck, 1988; Leahy, 1999). As we will see, thinking that is
excessively expansive, and grandiose, as it often is in people who are hypomanic, is problematic as well. Such thinking can induce people to engage in
undercontrolled activities, such as overspending, imprudent sexual behaviour, and impulsive decision-making, that serve to create problems for these
people. This, in turn, puts more demands on their lives. As the negative consequences accumulate, the need for advanced problem-solving exceeds the
hypomanic person’s ability to cope. Often, this then leads to a marked depressive episode, as the person recognises the disturbing fallout of his or her
undercontrolled behaviour.
Clearly, a person in this situation needs to be at his or her best in order to
deal effectively with many real-life problems. However, a BD patient who is
depressed typically will feel lethargic, and hopeless, and will be in a poor position to do good problem-solving. The result is that the problems will continue
Cognitive therapy of bipolar disorder
to grow, and the BD patient’s overall levels of stress – both actual and perceived – will not diminish. As noted above, an efficacious psychosocial therapy
for BD must help patients to decrease their stress (Basco & Rush, 1996).
Additionally, stress can be a physiological factor. For example, people who
maintain erratic sleep–wake patterns place a burden on the functioning of
their organ systems, including the central nervous system. Similarly, people
who abuse substances (e.g., alcohol, stimulants, analgesics), or who engage in
suboptimal eating patterns, disrupt normal biochemical homeostasis. Patients
who suffer from BD are especially prone to such disruptions of physiological
functioning, and therefore are at risk of perpetuating a vicious cycle of behavioural and biochemical dyscontrol (Basco & Rush, 1996: Bauer & McBride,
1996). Therefore, part of the role of a psychosocial therapy is to teach
patients to regulate their sleeping, eating, patterns of activity, and ingestion
of psychoactive substances (Ehlers, Kupfer, Frank, & Monk, 1993; Tohen &
Zarate, 1999). If successful, this approach will reduce stress as well.
Basic goals of cognitive therapy for bipolar
As described above, cognitive therapy (CT) is especially well-suited to help
patients decrease their subjective (and physiological) levels of stress, thus
decreasing the probability of their experiencing full-blown, uncontrolled,
affective cycling. This overarching goal can be accomplished via the following
tasks. Therapists should:
Educate patients about their bipolar illness. Help them to understand the
aetiology, and course of the disorder. Give them information that will
help them to make informed, practical decisions about their treatment.
Explain their role in helping themselves to combat the disorder, to
increase their sense of empowerment.
Test the reality of patients’ thinking. Show patients how they may monitor their own thinking, so that they may keep it within normal limits.
Give them exercises that will assist them in reconstruing thoughts that are
either too pessimistic, or too positively inflated.
Instruct patients in the principles and practices of problem-solving, so
that they may effectively address the actual problems that they otherwise
may neglect, or exacerbate.
Control a patient’s tendency to be reckless and impulsive when hypomanic. Give tactful, corrective feedback about their behaviour in session.
Help patients to perform techniques of self-monitoring between sessions.
Explain the rationale for – and benefits of – self-restraint, patience, and
reflective delay.
Modulate the patient’s expressions of affect, through modelling, roleplaying, audio-video feedback, relaxation, and other techniques.
Cory F. Newman
Counteract the patient’s disorganisation and distractibility by using
strategies that maximise planning, focusing, and repetition.
These are ambitious goals, but it is just such a broad range of aims that are necessary in order to address a disorder of the magnitude of BD. In the following
sections, further details about each of the six aims are provided. Most of the
focus will be on hypomania, and mania, as there is a wealth of literature on CT
for depression that need not be reproduced at length in the present chapter.
Educate the patient
The more that BD patients know about their disorder, the better they will be
able to serve as collaborators in their treatment. For example, a patient who
understands that BD is a chronic disorder that can be managed, but perhaps
not cured, will be more likely to remain faithful to their therapeutic plan
(including medication), even if they feel well, and normal. This will reduce the
chance of relapse that is induced by patients’ impulsive abandonment of
treatment. By the same token, they will be less apt to feel demoralised and
hopeless when symptoms recur. They will understand that this does not mean
that all treatment is useless, and that they are inevitably trapped in a life
filled with suffering. Instead, the patients will be ready to apply a wide range
of techniques in response to an unfortunate appearance of symptoms that
cannot always be predicted.
It is very important for patients to learn about the influence of sleeping,
eating, and activity patterns on their moods. These are some of the “zeitgebers”, or time-givers (Ehlers et al., 1993), that regulate people’s overall
levels of functioning. BD patients are extremely sensitive to disruptions in
sleep, eating, and activity level, and irregularities in these areas can produce
biochemical changes that are associated with mood swings (Basco & Rush,
1996). For example, BD patients need to be instructed to take great care
about adjusting to “jet lag” when their travels take them across multiple time
zones. Similarly, therapists must discourage their BD patients from volunteering for jobs that involve rotating shifts, and conversely support their BD
patients’ efforts at keeping their work schedules stable. In general, therapists
greatly help their BD patients when they help them to achieve greater levels of
constancy, stability, and predictability in their basic, daily functioning.
Therapists and BD patients should attempt to ascertain the “early warning
signs” of the patients’ problematic mood shifts (Lam, Jones, Hayward, &
Bright, 1999; Lam & Wong, 1997). Patients often report that it is exceedingly
difficult to apply the self-help, self-correcting techniques of CT (e.g.,
Greenberger & Padesky, 1995) once they are fully immersed in a manic state.
However, they note that they can help themselves if they “catch themselves”
in the early stages of hypomania. Clearly, self-awareness is of paramount
importance. For example, one of the author’s patients noted that her
Cognitive therapy of bipolar disorder
increased irritability was one of her chief warning signs of an impending
manic episode. When she would get angry, she would sit down, engage in
relaxation exercises, and either read or listen to chamber music. Another
patient ascertained that an early warning sign of mania was his having sexual
fantasies about many different women. As he stated, “If I can’t even hear
what a woman is trying to say to me, because I’m thinking about making love
to her, I know I have to slow myself down immediately.” This same patient
also offered that an “absence of anxiety” signalled an impending manic
episode. At such times, he would try to focus his attention on his responsibilities and tasks, such as the upcoming deadline on his thesis. His goal was
to increase his anxiety just enough to care about attending to his work.
Another aspect of educating the patient involves a discussion of the differences between “normal good mood” and hypomania. We, as clinicians, do
not want BD patients to come to distrust and fear their own pleasant moods.
This undesirable outcome would lead BD patients to feel troubled, no matter
what their actual condition. Instead, we want to help BD patients systematically to differentiate between “healthy” affect and “inflated” affect. The
following are some of the criteria that the author and his BD patients have
generated as indicative of “healthy, positive” affect:
The patient’s good mood is congruent with the situation, including the
moods of others in the immediate environment.
The patient is able to engage in an enjoyable activity, without being
unduly distracted or beckoned by other activities.
The patient is able to sit comfortably, relax, and engage in sedate conversation with others, without experiencing boredom, or pronounced
urges to spring into action.
The patient is able to read at length if alone, and able to listen intently to
others if he or she is in their company. Focused concentration is readily
The patient is content with a trouble-free situation, and does not feel a
strong impulse to “stir up trouble” in order to create stimulation.
The patient can successfully balance work and play, without becoming
totally absorbed in one, at the expense of the other.
The patient’s good moods do not prevent him or her from falling asleep
at night.
The patient can exercise good social judgement, such as refraining from
telephoning a friend very late at night in order to tell him a “great new
The patient’s good mood does not stop him or her from remembering
lessons that were learned during moments of distress, and strife.
Therefore, the patient remains aware of the actual benefits and consequences of a full range of behaviours, and chooses to engage in
behaviours in a wise fashion.
Cory F. Newman
The patient does not increase his or her use of chemical substances,
including nicotine, alcohol, stimulants, analgesics, hallucinogens, and
The patient does not dwell on suicide, and does not romanticise death.
The patient is able to accept constructive criticism without become highly
The patient can exercise patience, and can delay gratification.
When BD patients notice that their elevated moods fail to meet many of the
above criteria, this serves as a further “early warning sign”, and signifies the
need to utilise CT self-help interventions (to be described throughout this
A most important part of educating BD patients involves the utilisation of
their own life experience. By the time that most BD patients present for treatment, they have experienced many, serious consequences as a result of their
erratic moods, thoughts, and behaviours. This is unfortunate in its own right.
However, these experiences all too often fail to serve the purpose of helping
BD patients to make reparative corrections in their lives. Instead, they tend to
induce a sense of hopelessness and shame in BD sufferers at the one extreme,
and minimisation and denial at the other extreme. Without a doubt, the
former problem exacerbates a patient’s dysphoria, while the latter problem
puts the patient at risk for repeating old mistakes.
Therefore, it is useful for therapists to show respect for their BD patients’
life experiences, especially the negative ones. Rather than risk insulting, or
patronising, a patient by saying, “Now, now, Mr. Smith, you cannot go on
that adventure holiday; after all, don’t you remember the disaster you created
the last time you took such a trip?”, instead, the therapist must encourage the
patient to demonstrate caution by appealing to the patient’s own recollections.
For example, the therapist can say, “I know that you would greatly enjoy
taking that trip to the Himalayas, and I am certainly in favour of your having
a high quality of life. However, Mr. Smith, in your valuable, personal experience, have you learned reasons why it might be a good idea to postpone this
trip, or at least to modify it somewhat?” If the patient is not able to remember the negative consequences that occurred in similar, past situations, the
therapist can provide a prompt, such as, “Is this vacation plan similar to the
trip you took in 1992, when you spent all your money, and then got lost in the
wilderness for four days? How can you safeguard yourself against such a
traumatic outcome now, and in the future?” The goal is to tactfully help BD
patients to focus on the potential, negative consequences of some of their
more grandiose plans. The ability to weigh pros and cons, to anticipate problems, and to be flexible in making plans, are among the most important skills
of the mentally healthy person. The CT therapist should help their BD
patients to practise these skills, with the “raw data” coming from the patient’s
own natural education in life.
Cognitive therapy of bipolar disorder
Finally, bibliotherapy can be most helpful as an adjunct to the work of CT.
Patients benefit by reading some of the popular (as well as professional) literature on BD. Books such as Fieve’s Moodswing (1975), and Jamison’s An
Unquiet Mind (1995) are worth their weight in gold in terms of teaching BD
sufferers about their disorder in a compassionate, informed, cost-effective
manner. Therapists can maximise the benefits of sources such as these by
reading these books themselves, and discussing their contents with BD
patients as part of the therapy session. This will facilitate the sense of collaboration between patient and therapist, and will assist the therapist in
correcting any misinterpretations that patients may be making about the contents of the literature.
Likewise, the families of bipolar patients can take part in learning about
their family member’s problems. For example, therapists can distribute and
discuss the authoritative guidebook published by Kahn, Ross, Printz, and
Sachs (2000), which spells out in clear, everyday language how bipolar disorder manifests itself, and how it can be treated. When patients and their
families can communicate more knowledgeably and effectively, the likelihood
of both discord in the household and exacerbation of the patients’ symptoms
can be reduced (Miklowitz & Goldstein, 1997).
Test the reality of the patient’s hyper-positive thinking
When therapists notice in session (or on the phone) that their BD patients are
showing signs of expansive, or grandiose thinking, they have an important
responsibility to help the patients to evaluate their thinking. Understandably,
therapists may be loath to question their patients’ good moods, enthusiasm,
and active behavioural plans, especially in the aftermath of a depressive
phase. Therapists may be concerned that the patients will feel invalidated, or
punished for their “positive” behaviour, and that this will damage the therapeutic relationship. Therefore, therapists may give their hypomanic patients
insufficient feedback, and the early warning signs of mania will be ignored. In
spite of these concerns, therapists do more harm than good if they remain
passive in such instances. Instead, therapists must find a gentle, tactful way to
address the patients’ potentially problematic thinking.
A useful method to accomplish the above goal is essentially the same
method that therapists use to challenge negatively biased thinking – Socratic
questioning (Overholser, 1988). The use of the Socratic method accomplishes
a number of useful goals. First, it minimises the likelihood that the hypomanic patients will believe that their therapists are trying to control their
behaviour. This will diminish the probability that the patients will rebel
against the therapist’s suggestions. Second, the method shows respect for the
patients’ thinking, and reasoning skills. Socratic questioning does not dictate
to the patients. Rather, it asks them to ponder, and consider a wide range of
evidence, and alternatives. Third, Socratic questioning helps patients to stop
Cory F. Newman
and think, instead of acting on impulse. Finally, Socratic questions may help
patients to arrive at their own conclusions, which will boost their self-efficacy
in a more enduring fashion than if the patients simply rely on the therapists’
For example, one of the author’s BD patients stated that she wished to start
her own marketing business. This patient, who had recently been depressed
and suicidal, was now brimming with confidence and enthusiasm. However,
the therapist knew that this patient did not have sufficient money, and other
resources, to start her own business. Instead, it would be much more prudent
for this patient to work for an employer, and to earn a stable salary. The
therapist did not wish to criticise the patient’s thinking, as he was concerned
that she would feel unsupported, and become angry and defiant. At the same
time, the therapist understood that it was of critical importance to help this
patient to think through her decisions very carefully before acting. Therefore,
instead of saying, “Emily, I do not think it is wise for you to invest in your
own business; you should work for someone else”, the therapist used a series
of Socratic questions. For example, he asked Emily (with a positive tone):
I can see that you are very happy with this idea. Do you have all of the
financial details worked out in advance?
Who are the consultants and advisers that you have chosen? Do they
have some good ideas that you can use?
How much money will you need to borrow in order to start your business? Are you eligible for a business loan? Do you believe that you are in
a position to take this risk?
What are the pros and cons of having your own business, as opposed
to working for someone else? What have you concluded about this basic
By asking these questions in a respectful manner, the therapist succeeded in
getting Emily to discuss the relevant issues, before acting. Emily acknowledged that she did not have any advisers, and wondered if she should talk to
other people in the business world first. Emily admitted that she had not yet
determined how much money she would need, and that she had not considered whether or not she was eligible for a loan. She added that she had not
weighed the pros and cons of being her own boss, versus working for someone else. Emily was able to conclude – for herself – that her original plans
needed to be revised. Although she was not willing to abandon the notion of
having a business of her own, Emily did state that she would need to minimise
her costs, and that she may have to work for someone else first, in order to
begin saving money.
A related technique is the Devil’s advocacy role-play. When the therapist
notes that the BD patient’s ideas are becoming too extreme, yet are resistant to
modification, the therapist introduces the following challenge. The therapist
Cognitive therapy of bipolar disorder
and patient will engage in a friendly debate about the matter, with the therapist taking the patient’s position, and the patient taking the more conservative
position. At first, some BD patients may decline to take part in this exercise,
reasoning that they do not wish to argue against their actual viewpoint.
However, the therapist can make the exercise more attractive by reminding the
patient that “it is the mark of a sharp mind, and the essence of an expert
debater, to be able to convincingly argue the merits of any issue, whether you
believe it or not”.
As an illustration, “Lanny”, a college student, tended to neglect his studies when he became hypomanic. He reasoned that it was more important to
spend all of his time talking about philosophical issues with his friends in the
dormitory, rather than read and write by himself. As a result, he was in
danger of failing two of his courses. Lanny stated that he did not care if he
failed, because he was “getting an education in life, and that is all that really
matters”. The therapist persuaded Lanny to take part in a Devil’s advocacy
role-play, where Lanny had to argue the benefits of studying, and the therapist took the position that talking with friends was more important. The
role-play was very spirited, and both parties were amused (which solidified
the therapeutic bond between them). When the role-play concluded, the therapist asked Lanny what he had learned. To summarise, Lanny learned that:
(1) it is possible to talk to friends, and still leave sufficient time to study for
courses, (2) receiving passing grades actually is very important, because it is
a means to an end – a college degree, with all of the practical benefits that go
with it, (3) the therapist truly understood him, because he debated Lanny’s
position so well, and (4) he may be bothering other people when they are
trying to study; therefore it is in Lanny’s best interest to leave them alone
more often.
It is critically important for BD patients to learn to self-monitor and test
their hyper-positive thinking in everyday life, when the therapist is not there
to provide feedback. Here, the therapist’s role is to prepare and prompt the
patients to exercise caution in their day-to-day decision-making. For example,
therapists teach their BD patients that they will benefit greatly by consulting
with others, prior to enacting plans. The author recommends that his BD
patients seek the advice and feedback of at least two others, one of whom
may be the therapist. Therefore, if a BD patient suddenly gets the idea that he
wants to buy a new car, he may choose to speak with his wife, and his brother
(and others of his choosing), before following through with the purchase.
When the therapist teaches BD patients this technique, the therapist must
bear in mind that BD patients are very sensitive to issues of interpersonal
control (Newman et al., 2001). Therefore, the manner in which the therapist
presents this procedure is critical to its success. If the therapist implies that
the BD patient is incapable of making his or her own decisions, the patient
will probably resist, and will not use the technique. On the other hand, the
therapist can support the BD patient’s somewhat fragile self-esteem (Winters
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& Neale, 1985) by noting that “all of the world’s most influential and powerful people have a team of advisers, because they are smart enough to make
use of all of their external resources, including the valuable feedback of
esteemed others”. This conceptualisation of the benefits of consulting with
others is more palatable to BD patients who might otherwise seek complete
autonomy, to their detriment.
Therapists also ask their BD patients to practise filling out Daily Thought
Records1 (DTRs: Beck et al., 1979) between sessions, as part of their cognitive therapy homework. In the same way that depressed patients are taught to
spot all-or-none thinking, overgeneralisation, fortune-telling, and the like,
hypomanic patients are instructed to monitor distortions in their thinking
processes. For example, BD patients may become angry when they assume
that other people are deliberately denying them what they want. This is the
cognitive distortion of “mind-reading” (Burns, 1980). In order to change this
attribution, and perhaps diminish their anger, the BD patients can complete
a DTR that addresses this scenario. In a similar vein, a BD patient may disqualify the negative (the polar opposite of the depressive process of
disqualifying the positive), as Lanny had done when he claimed failing his
college courses was of no consequence to him. Using a DTR, this patient can
remind himself of the negative consequences of his intended actions, and
thus give himself the opportunity to change his behavioural strategy, before
he actually fails.
A vital part of the strategy to reduce the BD patients’ levels of stress is to
teach them to become more effective problem-solvers (Basco & Rush, 1996).
It is a truism that all people face problems in life, but the more successful,
happy people are those who skilfully and promptly deal with their problems.
This notion takes on added significance for people who suffer from BD.
When BD patients experience difficulties in their lives, they are at risk for
incurring mood abnormalities. It is often the case that BD patients will report
retrospectively that previous manic or depressive episodes seemed to be triggered by negative events (or series of such events) in their lives. Similarly,
major life changes can tax a patient’s ability to cope, and may signal the start
of a mood swing (Johnson & Roberts, 1995). Common, major stressors of
this sort include: (1) death of a friend or family member, (2) pregnancy and
childbirth, (3) starting school, (4) changing jobs, (5) moving to a new
1 Beck et al. (1979) originally called these forms “Daily Records of Dysfunctional Thoughts”.
Later, the term was shortened in practice to “Dysfunctional Thought Records”. The author
prefers to call them “Daily Thought Records”, as this designation may be seen by patients
as potentially less pejorative, while still maintaining the recognisable acronym of “DTR”.
Cognitive therapy of bipolar disorder
geographic location, (6) financial setbacks, (7) medical illness, and (8) relationship discord and divorce.
It is not only the case that major life stressors can induce the onset of
severe mood disturbances in BD patients. It is also likely that the BD patient’s
erratic behaviours will result in further serious problems. When patients act
with manic recklessness, they often incur numerous difficulties in their relationships, their work, their health, and other major life areas. These
additional problems will further strain the BD patient’s ability to cope. Often
the patient’s condition worsens, and spirals downward as moods, behaviours,
and problems become exacerbated by each other.
Clearly, BD patients who practise and refine their problem-solving skills
will be in a much better position to weather times of strife in their lives.
Therefore, they may avert the onset of manic or depressive recurrence.
Further, by utilising good problem-solving skills, BD patients can prevent
downward spirals that otherwise are common in patients who neglect or add
to their problems.
BD patients are in the best position to learn, and execute effective problemsolving when they are in euthymic mood states. Therefore, it is important for
therapists to seize the opportunity provided by the BD patients’ quiescent
times in order to teach them the principles of problem-solving. Along similar
lines, it is important for therapists to recognise when hypomanic patients are
getting themselves into troublesome situations (e.g., spending too much
money on unnecessary things), and to help the patients contain and limit the
problems before they worsen.
The process of teaching BD patients to do comprehensive problem-solving
involves the following components. Therapists should:
Assist the patients in studying their past crises; how they started, how
they became difficult to manage, and what the patients could have done
differently in order to prevent, or limit their occurrence.
Give patients the assignment of setting short-term goals in major life
areas, such as work, relationships, and self-improvement; and show them
how to monitor their progress across these domains on a regular basis.
Brainstorm the steps that are necessary in order to achieve the above goals.
Identify potential complications or obstacles to taking the above steps.
Teach the patients such fundamental techniques as defining their problems, generating potential solutions, evaluating the pros and cons of each
proposed solution, choosing the most advantageous (often the most conservative) of these solutions, acting on the solution in a prompt fashion,
and monitoring the outcome, so that the patient can make changes, if necessary (Nezu, Nezu, & Perri, 1989).
In order for BD patients to make the best use of problem-solving skills, they
must avoid having an all-or-nothing attitude (a form of biased thinking that
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is common in affective disorders). For example, it is dysfunctional for patients
to believe that they have no problems that require their attention. This attitude bespeaks hypomanic overconfidence, often leading to lack of vigilance,
and a problematic absence of self-monitoring.
At the opposite extreme, it is harmful if BD patients become so discouraged by their problems that they conclude that “there is nothing I can do, so
I might as well give up (or keep adding to my problems, because I don’t care
anymore)”. This attitude puts patients at risk for getting into downward spirals, exacerbating the risk of suicide (Ellis & Newman, 1996; Newman, in
Therefore, it is extremely important for therapists to assist their BD
patients in seeing the benefits of a “middle-ground” approach to problemsolving. In this mindset, the patients always look for potential problems
before they act, they take pride in their ability to self-monitor, and understand
the benefits of “damage control”. As the author tells his patients, “It is almost
never too late to try to correct a problem, and it is almost always beneficial to
care enough about what will happen to you, so that you change your
Control impulsivity and recklessness
Patients who are hypomanic, or who are in the early stages of a full-blown
manic episode, often feel exuberant and “spontaneous”. They feel driven to
act on their feelings and impulses, without thinking things through carefully.
This can lead to unwise or dangerous behaviours that the patients (and/or the
patients’ loved ones) later regret (Jamison, 1995). Therefore, it is useful for
therapists to collaborate with their BD patients to utilise techniques that provide them with time to reflect, and benign restrictions (it is necessary that the
restrictions be “benign,” otherwise the BD patients may resist the technique
in order to maintain their sense of autonomy and control).
One such technique instructs BD patients to list their own “wise sayings”
on flashcards. These “wise sayings” are recommendations to engage in careful, methodical, conservative behaviour, especially under conditions in which
the patients have an urge to do something highly stimulating. Patients keep
these flashcards in convenient locations for easy access, such as tacked on the
refrigerator, in their wallet or handbag, taped under the bathroom mirror,
propped up beside the alarm clock, or in the glove compartment of the car.
Some of the “wise sayings” that the author’s BD patients have generated
include the following:
I can be in greater control of a situation if I think things through slowly
and carefully.
Don’t get into conflicts with people. Just walk away. I will keep my dignity that way.
Cognitive therapy of bipolar disorder
It is smart to consult with other people. I shouldn’t make snap decisions
on my own.
Do one thing at a time. Don’t try to do everything. Proceed step by step.
Always think of the potential consequences. Don’t try to be Superman.
Patients are more receptive to these constraints when they are self-generated,
as compared to when other people tell them what to do.
A simple behavioural technique, called the “48 hour waiting period” rule,
is based on the principle that one should not enact any big, life decisions if one
is in a very aroused state, whether positive or negative. For example, it is unwise
to gamble large sums of money, based on “feeling lucky tonight”. Similarly,
it is self-defeating to drop out of school in reaction to disappointment with a
test grade.
Therapists ask their patients to keep a logbook of the day and times when
they wish to do something that is “bold, risky, wild, extraordinarily funfilled, or involves a major life change (such as quitting a job, or proposing
marriage)”. Then, they are to wait at least two full days (including at least one
full night of sleep) before acting on this wish. The rationale is as follows: if
the patient’s ideas and plans are good, they will still be good after the passage
of two days. Nothing will be lost by waiting. On the other hand, if the ideas
and plans are flawed, this may become apparent to the patient during the
waiting period, and the patient can abandon his or her intentions before
harm is done.
Therapists should emphasise that this technique requires “uncommon
patience and foresight”, and that only very few patients can succeed in utilising this technique optimally. Aside from being a statement of fact, it also sets
up the sort of challenge that many hypomanic patients are eager to accept, if
for no other reason than to prove their special abilities. Therapists also may
choose to instruct their patients to use the 48 hour waiting period as an excellent opportunity in which to consult with others about their ideas and plans.
A very simple, but effective technique asks patients to do more sitting and
listening, and less standing and talking. This behavioural manœuvre should
be applied to social situations in which the BD patients notice that they are
speaking or gesticulating rapidly. The intention is to interrupt the patients’
overactivated sympathetic nervous system activity, along with its concomitant rapid, energetic behaviour. By silently reminding themselves to sit
down, and to listen more intently to others, BD patients can decrease the
risk of acting in socially inappropriate ways. Further, the technique orients
patients to attend more to their environment, and less to their own racing
In order to facilitate their using the above strategy, patients can practise the
use of covert self-instruction. Examples include the patients telling themselves to:
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Pay attention. Listen to [other person’s name in the social situation].
Recognise that this is a meaningful conversation. Don’t miss hearing
Be a good friend. Be quietly supportive.
Let the other person have the “stage”. I will be noble and altruistic.
Recklessness and impulsivity also can be reduced via the use of Daily Activity
Schedules (DAS; see Beck et al., 1979). By planning their schedules, and
respecting the importance of adhering to the schedule, BD patients are less
likely to do “spur of the moment” things. This strategy encourages the patient
to be more systematic and methodical. It can be extremely beneficial for BD
patients to lower the level of unpredictability in their daily lives.
An important caveat about the use of the DAS: hypomanic and manic
patients tend to be overactive (Bauer, Crits-Christoph, Ball et al., 1991).
Therefore, they may misuse the DAS to schedule too many activities, thus
driving them to exacerbate their symptoms (e.g., via not getting enough sleep).
To safeguard against this, therapists can ask the patients to prioritise their
activities (Palmer, Williams, & Adams, 1995), and to identify the “20% or 30%
of the activities that you can strike off your schedule, with little consequence”.
The author exhorts his BD patients to heed the words of the great early
American statesman (and founder of the University of Pennsylvania) Benjamin
Franklin, who extolled the virtues of doing “all things in moderation”.
Additionally, it is wise to make arrangements in the BD patients’ lives that
make it inconvenient for them to enact risky behaviours. This tactic is a form
of the behavioural strategy known as “stimulus control”. Again, there is a
much greater chance that the patients will comply with this method if they
actively participate in its planning.
Similar to patients who are prone to substance abuse (Beck, Wright,
Newman, & Liese, 1993) – and, in fact, many BD patients experience this
problem as well (Bauer & McBride, 1996; Tohen & Zarate, 1999) – BD
patients have “high risk situations” that are associated with manic behaviours.
In addition to the abuse of alcohol and substances (which ideally should not
be kept in the household of a BP sufferer), typical high risk situations include:
places where large sums of money can be spent, such as upscale restaurants,
casinos, expensive boutiques, race tracks, auto dealerships, malls, etc.,
activities that entail the use of weapons, such as hunting, target shooting,
recreational explosives (also known as “fireworks”), etc.,
socialising with people who are stimulation-seekers, and/or who have a
personal history of associating with the BD patient in risky activities (e.g.,
former extramarital lover, drug cohorts, gambling buddies, etc.), and
work situations that require the BD patient to push the limits of
endurance, and therefore disrupt sleep–wake cycles, eating patterns, and
induce driven behaviours.
Cognitive therapy of bipolar disorder
These are but a few of the most common classes of high-risk situations.
Others include jet travel across multiple time zones, recreational pursuits that
produce “rushes” of excitement (e.g., rock climbing, skydiving, and other
activities popularly known in the United States as “extreme sports”), nightclubs, and any social event that encourages the person to try to become the
centre of attention.
Therapists and their BD patients generate lists of the above high-risk situations, as well as others that may be more idiosyncratic to the individual
patient. Then, the patients make a verbal contract to voluntarily refrain from
seeking out such situations, or purposely remaining in such situations.
Alternatively, BD patients may promise to take part in these activities only
when in the presence of a trusted companion, such as going to the mall with
a spouse. Then, as a sign of good will, and empathy, the therapist helps the
BD patient to discover substitute activities that the patient will enjoy, but that
entail far less risk.
Affect modulation
In the same manner that panic disorder patients benefit from learning to
control their breathing (Clark, Salkovskis, & Chalkley, 1985), hypomanic
and manic patients can modulate their high affect by decreasing their rate,
and volume of breathing. This technique is most effective when used in combination with relaxation exercises. Therapists teach their BD patients to spot
their intense emotionality as a cue to sit down, close their eyes, and to breathe
slowly, smoothly, but not deeply. Unless they are in conspicuous social situations that make the technique impractical, BD patients then can proceed to
implement the “tense and relax” procedures of Jacobsonian relaxation (see
Goldfried & Davison, 1976, chapter 5, pp. 81–111). Here, patients systematically go through the various muscle groups in their body, tensing or flexing
them for five seconds, then releasing, one group at a time. The resulting sense
of contrast accentuates the perception of relaxation, and lowers overall
A very basic way that therapists can help their BD patients to keep their
moods and behaviours within normal limits is to model a moderate level of
energy and emotionality. If a BD patient becomes overly animated, or excessively irritable in session, it is vitally important for the therapist not to
respond in kind. Instead, the therapist must maintain a calm, pleasant, levelheaded approach. Therapists who demonstrate a strong, caring, dignified
demeanour serve as the best calming influence.
When BD patients feel a sense of inflated energy, and euphoria, they find
it difficult to demonstrate patience. Instead, they often exhibit low frustration
tolerance when they are blocked from doing what they wish. Therapists can
discourage their BD patients from acting on impulse by noting that it requires
great skill and maturity to wait for what they want. Similarly, it is often quite
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noble to make sacrifices, and to experience a sense of deprivation. In this
manner, the therapist reframes the BD patient’s acceptance of the inevitability of frustration as a sign of high level functioning.
Self-statements that include “shoulds” and “musts” sometimes drive impulsive behaviour. For example, the patient may think, “I should be allowed to
control my own life”, “I must get everything done as soon as possible in
order to feel relief from this tension”, or “I should get what I need right
away”. Therapists can teach their BD patients to self-monitor their sense of
frustration, and desires to act impulsively, and to ask themselves, “What
‘should statement’ am I thinking right now?” The patient is instructed to formulate a rational response that runs counter to the “should statement”, such
as “I would like to control my own life, but sometimes this entails being cautious, and listening to the advice of people who care about me.” Ideally, the
patient will write down these rational responses, for long-term reference.
Sometimes BD patients act out in response to extremely intense emotions,
regardless of how unstable, and unrepresentative those emotions may be. For
example, they may angrily assail someone in public, even though they generally have a high regard for that person. Similarly, they may become involved
in an illicit sexual relationship, based on a momentary surge of feelings after
a warm conversation with someone. As a result, BD patients are prone to
regret that they acted on their feelings.
In order to reduce the likelihood of these unfortunate scenarios, therapists instruct their BD patients to monitor the longevity of their feelings, and
to compare this with the intensity of their feelings. The following guideline is
applied: act on the emotions on the basis of their longevity, not the intensity.
Therefore, if the strong feelings are fleeting, the BD patient will not act in a
way that brings regret later. If the feelings are long-lasting, then the patient
must still consider the pros and cons of expressing these feelings openly.
Therapists validate their patients’ feelings, but recommend that patients act on
these feelings only after evaluating their staying power, as well as the pros and
cons of expressing them.
Counteracting disorganisation and distractibility
Many BD patients evidence markedly unfocused thinking (Goodwin &
Jamison, 1990). This is typified by flights of ideas and speech, difficulty in
answering direct questions with direct answers, and a propensity for starting
and discontinuing personal projects and therapy homework alike. Therapists
witness these symptoms in their BD patients when they fail to follow session
agendas, show deficits in their ability to understand what their therapists are
saying, and remember very little of the contents of the therapy sessions once
they leave the office.
To some degree, the structure of a cognitive therapy session helps the BD
patients to stay reasonably on task. For example, therapists use periodic
Cognitive therapy of bipolar disorder
summary statements, highlight and repeat their main points, and frequently
ask for feedback to check for the patients’ understanding. Additionally, some
benefits are achieved through medications. However, these factors are not
always sufficient to help BD patients maintain their concentration and focus.
Therefore, it is wise for BD patients to take notes while they are in session,
and to make audiotaped recordings of their sessions, so that they may listen
again later. In everyday life, BD patients can practise the skill of completing
one task before starting another, and can spend a good deal of time writing
as part of their therapy homework. Additionally, BD patients should be
advised to make activity schedules, lists of important tasks, and to make use
of planning and problem-solving as often as possible.
Sometimes, the simple act of slowing down may help patients to be less distractible. This will help patients to process information more effectively, thus
helping them in their social interactions, and their work-related tasks.
Further, their self-esteem will be enhanced as well.
Special considerations in the treatment of bipolar
Conceptualisation of the individual patient
The symptoms of mania often are so marked, and so difficult to manage clinically, that there is a tendency for clinicians to focus on the disorder, but to
neglect to understand the individual patient. While it certainly is important to
practise the general strategies of “mania management” – indeed, the entire
chapter to this point has outlined such global techniques – it is vital to formulate a conceptualisation of each patient (J.S. Beck, 1995; Needleman,
One of the most basic, and useful, methods of cognitive case conceptualisation is the cognitive triad (Beck et al., 1979). This comprises the patient’s
beliefs about: (1) him- or herself, (2) others, the world, and life in general, and
(3) the future. Therapists can ascertain their patients’ beliefs in these three
important domains via a number of simple methods:
direct questioning,
homework assignments that ask the patients to write short essays about
their views of themselves, their lives, and their futures,
taking a personal (and psychiatric) history of the patient, and generating
hypotheses about “what life experience has taught the patient to believe”,
generating hypotheses about the patients’ beliefs based on their spontaneous comments in session, and
generating hypotheses about the patients’ beliefs based on the nature
and quality of the therapeutic relationship.
Cory F. Newman
When therapists attempt to understand the patients’ individual life experiences, and concomitant belief systems, they are in a much better position to
form a positive, working alliance with their patients. Therapists who conceptualise each patient have the best chance of demonstrating accurate empathy,
and the patients will be more apt to feel understood. The resultant strengthening of the therapeutic bond will increase the chance that the BD patient
will engage more effectively in the therapeutic process (Newman, 1994). It will
also decrease the chance that a temporary misunderstanding between the
therapist and patient will result in a damaging rupture in the alliance.
To illustrate the importance of individual case conceptualisation, let us
consider the following two BD patients. “Valery” is a 40-year-old married,
mother of three children, and “Lanny” is a 22-year-old college student. Both
patients evidence marked irritability, difficulty concentrating, impulsive
behaviour, and hopelessness about the future. These characteristics represent
the similarities between the two patients, based on their shared diagnosis.
However, there are important differences between them that must be ascertained through individual case conceptualisation, in order to fit the treatment
in specific ways to each patient.
For example, Valery views herself as a “weak” person who is too easily controlled by others. Her anger becomes more pronounced as she feels more
and more helpless. She views other people as malevolent, and therefore she
distrusts them. Because she believes she cannot assert herself, Valery attempts
to gain control by being passive–aggressive. This causes others, including her
husband, to exert greater control over Valery’s behaviour, which “confirms”
her belief that she is weak, and that others are malevolent. In explaining why
she sometimes wished that she could be left alone for ever, Valery stated the
following personal credo – “no people equals no problems”.
Valery’s views took on added significance when the therapist learned
(through taking a psychiatric history) that Valery had been sexually abused by
her grandfather. Indeed, this traumatic experience made her feel weak and
helpless, influenced her to distrust others, and inspired her to wish to be left
entirely alone. By understanding these experiences and views, Valery’s therapist was able to show accurate empathy for her position. He was able to
validate her anger, her desire for a large amount of personal space, and her
impulse to want to leave therapy altogether. This approach somewhat reduced
Valery’s mistrust, helped her to feel more comfortable, increased her level of
hope, and concomitantly led her to be more vigilant in taking her medications.
By contrast, Lanny’s irritability was based on feeling thwarted in accomplishing his goals. He believed that he had special abilities that were
unappreciated by others. Furthermore, he believed that others were jealous of
him, and therefore were trying to prevent him from succeeding in life. His
hopelessness was based on the belief that he was destined to be one of the
“geniuses whose spirit is crushed by the ignorance of others”. Lanny cited a
number of famous people who had become embittered by the hardships of
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life, and who had ultimately committed suicide, and he hinted that a similar
fate would be in store for him.
This belief system made sense in the context of Lanny’s history, in which he
was the only child of a father who suffered from BD, and a mother who
fought with recurrent depression. Lanny was given a tremendous amount of
conflicting information by his parents. On the one hand, they could be
extremely supportive, telling Lanny that he could do no wrong. On the other
hand, they could be neglectful, inasmuch as they were dealing with their
own, serious affective disorders. Therefore, Lanny felt very special, but absent
of guidance to help him succeed in life. This contributed to his agitation, and
insecurity. Further, Lanny witnessed his parents’ failures to achieve their
goals, and saw how they had become cynical. Lanny wished to succeed where
they had failed, but he could not shake the belief that he would become
exactly like them, and that the future held little promise for any of them.
This knowledge about Lanny helped guide the therapist in taking a therapeutic stance that was tailor-made for him. The therapist knew that he would
have to help Lanny curb his impulsive behaviour, but was very careful not to
reinforce Lanny’s belief that he was being thwarted once again. The therapist
often asked for feedback, to determine whether Lanny felt he was being sufficiently supported by the therapist. The therapist attempted to provide
Lanny with the sort of explicit advice that he had not received from his parents; but the therapist balanced this approach with Socratic questioning, so
that Lanny could learn to problem-solve for himself. In addition, the therapist
encouraged Lanny to “slow down, so that you do not burn out like a shooting star, and so you may have a more secure future”. This led to therapeutic
discussions about how to strive for long-term goals, and how to remain hopeful in spite of temporary hardships.
Making peace with psychotropic medications
BD entails a biochemical abnormality, therefore medication is a vital part of
the treatment regimen (unless specifically contraindicated, as in the event of
renal dysfunction). However, it is a fact of clinical life that BD patients often
have difficulties in maintaining a steady, vigilant, long-term compliance with
their pharmacotherapy (Cochran, 1984; Goodwin & Jamison, 1990; Jamison,
1995; Jamison & Akiskal, 1983).
There are many reasons why patients experience this difficulty. Some of the
reasons are a matter of practicality. For example, some medication regimens
(e.g., those that involve multiple agents, and multiple daily dosages) require
the patient to demonstrate high levels of concentration, self-monitoring, and
routinisation. Unfortunately, these are among the very cognitive skills with
which BD sufferers have the most trouble. Therefore the cognitive therapist
must assist the BD patient in learning and utilising the skills of planning,
cueing, scheduling, and self-instruction (Wright & Schrodt, 1988). For
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example, one of the BD patient’s homework assignments can be to design and
construct a written chart, on which he or she will record the times and
dosages of the relevant medications. Then, the patient marks a “check” next
to each item when the medication is taken successfully. If the patient is willing to accept reminders from loved ones, therapists can instruct the patient’s
family to assist in monitoring the patient’s consistency in taking the medications. This must be handled with care, as BD patients often perceive their
family as excessively intrusive in matters such as this.
Another set of reasons for insufficient compliance with pharmacotherapy
has to do with side-effects (Jamison, Gerner, & Goodwin, 1979). Here, the
therapist must show a high level of respect, and empathy for the patient’s feelings. Medications such as lithium, carbamazepine, monoamine oxidase
(MAO) inhibitors, valproate, lamotrigine, and the like can have rather bothersome side-effects, including weight gain, fine motor tremors, acne, and others
(Gorman, 1995). The prescriber must be willing to collaborate with the
patients in helping them to find the right titrations so that side-effects are
reduced, without compromising therapeutic effect.
While it may be evident to patients that side-effects of medications are less
aversive than the symptoms of full-blown BD, it is less apparent to patients
that medications are as useful when BD symptoms are in remission (Jamison,
1995). Therapists must remind their BD patients that medications are still
necessary, even when they “feel fine”. However, therapists must acknowledge
that it is reasonable for the patient to wish to be free of the medications –
indeed, to be free of the disorder altogether.
Additionally, BD patients maintain beliefs about their disorder, and about
pharmacotherapy, that hinder their compliance. Typical problematic beliefs
(Newman et al., 2001; Wright & Schrodt, 1988) include:
Medication will make me lose my creativity, as well as my happiness.
Medication is for people who feel sick. If I feel good, I shouldn’t take
If people see me take medication, they will know all about my problems,
and they will judge and shun me.
If my therapist wants me to take medication, it means that he or she
doesn’t respect, accept, and trust me the way I am “naturally”.
Medication will turn me into a dull, apathetic conformist.
Taking medication infringes on my freedom, which I must maintain at all
Medications will change my brain in dangerous ways. I could become a
“different person”. I could become addicted. I could damage myself for
I don’t like being told what I should do. Therefore, if my doctor (and
others) tell me I must take my medications, then I must resist in order to
maintain my dignity.
Cognitive therapy of bipolar disorder
It is cognitive therapy’s strength in assessing and modifying dysfunctional
beliefs such as the above that make it a psychosocial therapy that is especially
well suited to BD (Lam et al., 1999; Newman et al., 2001). Cognitive therapists help their BD patients to identify these beliefs, and then to evaluate their
validity, their utility, and their consequences. Then, therapists and their BD
patients generate alternative beliefs – in support of taking the required medications – that the patients then test in everyday life. No matter what the
patient’s qualms about taking their prescribed medication, whether they be
based on practical matters, concerns about side-effects, or the types of beliefs
above, it is extremely useful to do a thorough study of the pros and cons of
taking medication (Wright & Schrodt, 1988).
Hopelessness and suicidality
As noted, BD is a chronic disorder, requiring life-long observation, longterm pharmacotherapy, and at least periodic psychosocial therapy as well. If
BD patients are fortunate, and they receive the care they need, there is hope
that they can keep their disorder under sufficient control to experience a high
quality of life.
Unfortunately, many BD patients are undertreated, and/or underutilise
their treatment, which increases the chances of repeated episodes throughout
the life cycle. Further, there is some evidence that with each new cycle of
mood disturbance, the risk of subsequent episodes increases (Post, 1992).
This has been called the “kindling effect” (Bauer & McBride, 1996), and it
represents major difficulty in the lives and treatments of BD patients who
have had a significant history of the effects of the disorder. Therapists recognise such BD patients as those who enter treatment with a record of
numerous, previous therapists, and multiple past hospitalisations.
This state of affairs is discouraging enough for therapists, who must work
very hard and pay extra close attention in order to provide these BD patients
with the very high standard of necessary care. However, it is far more discouraging for the BD patients themselves, many of whom have seen lives of
promise be cruelly interrupted, and high hopes crushed. In such cases, the
depressive phases of the disorder often are quite severe, and the risk for suicide is chronically elevated. Indeed, BD is one of the most lethal psychiatric
disorders (Nilsson, 1995; Simpson & Jamison, 1995).
Therefore, therapists who treat BD patients must always be aware of their
degree of hopelessness, as this variable has been found to be an important predictor of future suicide (Beck, Steer, Beck, & Newman, 1993; Beck, Steer,
Kovacs, & Garrison, 1985; Young, Fogg, Scheftner, Fawcett, Akiskal, &
Maser, 1996). This suggests that therapists must help their BD patients to
generate positive, achievable goals for the future. At the same time, they must
be very empathic regarding their BD patients’ grief over what has been lost,
as well as their fears about setbacks in the future. A verbal contract in which
Cory F. Newman
the patients pledge to do all that is possible to help themselves, and to solicit
help from others (including professionals) before any suicidal action is taken,
should be a routine part of therapy (Ellis & Newman, 1996).
For some patients, their wariness about the future is a disincentive to collaborate in the therapeutic process. They believe that “I am not going to get
better anyway, so there is no point in torturing myself with all these medications, all these appointments, and all these restrictions on my behaviour.”
The therapist’s task – and a challenging one at that – is to help the patients
reframe this belief so that they understand that a long-range plan of treatment and self-help skills offers the best chance for normal, fulfilling life. It
goes without saying that if therapists are to convince their BD patients that
it is worth the effort to try to overcome their disorder, the therapists themselves must demonstrate the same conviction in their own efforts. A high
level of involvement on the parts of both the patient and therapist is one of
the best safeguards against hopelessness and suicidality.
Empirical tests of the treatment model
Perhaps the groundbreaking study was Cochran’s (1984) randomised controlled trial comparing cognitive therapy with treatment-as-usual for bipolar
patients. Her data provided evidence that cognitive therapy could be used to
help these patients adhere more successfully to their medication regimens, and
therefore to maintain better functioning. More recently, there have been a
number of studies confirming the efficacy of cognitive therapy in enhancing
the overall treatment package for bipolar patients. In a group therapy format,
Palmer et al. (1995) and Hirshfeld et al. (1998) independently found support
for the efficacy of cognitive therapy with bipolar patients. In terms of individual treatment, the outcome data of Perry, Tarrier, Morriss, McCarthy,
and Limb (1999), Lam et al. (2000), and Scott, Garland, and Moorhead (in
press) provide further evidence of the promise of cognitive therapy in helping
bipolar patients attain longer periods of euthymia and fewer episodes of
symptoms and hospitalisation.
Currently, a cognitive behavioural approach to the treatment of bipolar
patients is being tested in the context of a 20-site study funded by the National
Institute of Mental Health (NIMH). The Systematic Treatment Enhancement
Program for Bipolar Disorder (STEP-BD; Principal Investigators, Gary S.
Sachs, MD, and Michael E. Thase, MD) is a longitudinal study that will evaluate outcomes associated with combined psychosocial-pharmacological
interventions. The manualised cognitive therapy being used in the STEP-BD
project (Otto, Reilly-Harrington, Kogan, Henin, & Knauz, 1999) will be used
to improve bipolar patients’ quality of life across a wide range of variables,
above and beyond simple measures of mood per se. Given the 5–8 year scope
of the data collection, it will be interesting to assess the staying power of the
therapeutic effects of cognitive therapy.
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cognitive therapy for bipolar disorders. Psychological Medicine.
Simpson, S.G. & Jamison, K.R. (1999). The risk of suicide in patients with bipolar
disorders. Journal of Clinical Psychiatry, 60 (Suppl. 2), 53–56.
Tohen, M. & Zarate, C.A. (1999). Bipolar disorder amd comorbid substance abuse
disorder. In J.F. Goldberg & M. Harrow (Eds.), Bipolar Disorders: Clinical Course
and Outcome (pp. 171–184). Washington, DC: American Psychiatric Press.
Winters, K. & Neale, J. (1985). Mania and low self-esteem. Journal of Abnormal
Psychology, 94, 282–290.
Cory F. Newman
Wright, J.H. & Schrodt, G.R., Jr. (1988). Combined cognitive therapy and pharmacotherapy. In A. Freeman, K.M. Simon, L.E. Beutler, & H. Arkowitz (Eds.),
Comprehensive Handbook of Cognitive Therapy. New York: Plenum.
Young, M.A., Fogg, L.F., Scheftner, W., Fawcett, J., Akiskal, H., & Maser, J. (1996).
Stable trait components of hopelessness: Baseline and sensitivity to depression.
Journal of Abnormal Psychology, 105, 155–165.
Chapter 4
Cognitive behaviour therapy
for panic disorder
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The definition of panic disorder (PD) as a separate nosological entity in the
Diagnostic and Statistical Manual of Mental Disorders, Third Edition –
Revised (DSM-III-R) of the American Psychiatric Association (APA, 1987),
triggered a flood of empirical research into this disorder. Klein’s (1964, 1967,
1981) claim that patients with recurrent panic attacks, contrary to patients
with more diffuse and generalised forms of anxiety, respond to imipramine
but not benzodiazepines – a finding that gave a rather pure biological quality
to the conceptualisation of panic disorder – was particularly influential to the
establishment of panic disorder as a separate diagnostic entity. A large
number of subsequent studies showed that several biochemical and physiological manipulations (infusions of sodium lactate, yohimbine, isoproterenol,
oral or intravenous administration of caffeine, voluntary hyperventilation,
inhalation of carbon dioxide) frequently induce panic attacks in patients
suffering from panic disorder but rarely do so in controls (Appleby, Klein,
Sachar, & Levitt, 1981; Liebowitz, Gorman, Fyer et al., 1985; Charney,
Heninger, & Breier, 1984; Rainey, Pohl, Williams et al, 1984; Charney,
Heninger, & Jatlow, 1985; Uhde, Roy-Byrne, Vittone et al, 1985; Clark,
Salkovskis, & Chalkley, 1985; van den Hout & Griez, 1984).
Biologically orientated researchers have described these procedures as
biological challenge tests and have assumed that pharmacological and physiological manipulations have a direct panic-inducing effect and that
individuals who are susceptible to these manipulations have a neurochemical
Until 1987 panic attacks were considered to be secondary to agoraphobia.
Under this notion, psychological treatments had focused mainly on the
extinction of agoraphobia. Behavioural treatment for agoraphobia had in
many instances proved its effectiveness. Repeated in vivo exposure to agoraphobic situations had as a result rapid decrease in agoraphobic fear and
avoidance; consequently frequency of panic attacks also decreased (Barlow &
Wolfe, 1981; Jansson & Ost, 1982). Comparative evaluation of behaviour
therapy for agoraphobia with other psychological treatments showed that
treatments that do not incorporate exposure to avoided situations do not
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have much efficacy against agoraphobic fears. Agoraphobic fear and avoidance were minimally affected by hypnosis (Marks, Gelder, & Edwards, 1968),
problem-solving therapy (Cullington, Butler, Hibbert, & Gelder, 1984), or
assertiveness training (Emmelkamp, van der Hout, & de Vries, 1983).
Although exposure therapy was found to be the most effective psychological treatment for agoraphobia, and most follow-up studies conducted on an
average of about four years after treatment indicated that most patients
retained their gains (Emmelkamp & Kuipers, 1979; McPherson, Brougham,
& McLaren, 1980; Munby & Johnston, 1980), only about 60–70% of agoraphobics show clinically significant improvement (Jansson & Ost, 1982).
Re-analysis of exposure-based studies of agoraphobia showed an average
clinically significant improvement rate of 58% and average recovery rate of
27%; patients at follow-up had mostly retained treatment gains, whereas some
patients had further improved (Jacobson, Wilson, & Tupper, 1988). Jacobson
et al.’s conclusion that exposure alone did not seem to be a total solution to
the problem of agoraphobia resembled in some way a comment made by
Gelder and Marks much earlier (1966). Gelder and Marks had already
pointed out that apparently unexplained, uncued to external stimuli, and
often extremely difficult to treat, panic attacks could inhibit significant
progress in behaviour therapy for agoraphobia.
This recognition of the significant, yet still limited, effectiveness of behaviour therapy for agoraphobia and panic coincided with the emergence of
new psychological theories on the development and maintenance of panic
attacks and agoraphobia. Goldstein & Chambless (1978) had already proposed that agoraphobics fear panicking in public places, not public places per
se, and suggested a fear-of-fear interoceptive conditioning model of panic disorder with agoraphobia, where symptoms of physiological arousal become
the conditioned stimuli for the powerful conditioned response of a panic
attack. According to their model, people who have suffered one or more
panic attacks become hyperalert to their sensations, interpret feelings of mild
to moderate anxiety as signs of oncoming panic attacks, and react with such
anxiety that the dreaded episode is almost invariably induced.
Aaron Beck had previously suggested (1976) that in anxiety states, individuals systematically overestimate the danger inherent in a given situation.
David Clark (1986, 1988) further elaborating this cognitive concept, proposed that panic attacks result from the catastrophic misinterpretation of
certain bodily sensations. According to Clark (1986), external or internal
stimuli are perceived as a threat, and result in a state of apprehension. A wide
range of bodily sensations that normally accompany apprehension are interpreted in a catastrophic fashion, and a further increase in apprehension
occurs. Further apprehension produces a further increase in bodily sensations
and so on round in a vicious circle which culminates in a panic attack.
Contrary to the interoceptive conditioning model these initial bodily sensations may not only be the symptoms of anxiety, but also sensations caused by
Cognitive behaviour therapy for panic disorder
External stimuli
Agoraphobic places
Internal stimuli
misinterpretation (B)
of anxiety symptoms
Internal stimuli
body sensations,
thoughts, images
misinterpretation (A)
Fearful predictions
Physical and/or
Cognitive symptoms
Figure 4.1 The cognitive model of panic disorder.
different emotional states (excitement, anger), or by some quite innocuous
events (suddenly getting up, exercise, drinking coffee, fatigue, illness, premenstrual tension). These sensations are perceived as much more dangerous
than they really are, and are also interpreted as indicative of an immediate,
impending disaster. The catastrophic appraisal of sensations produces an
immediate anxiety response with further and more intense symptoms, and
very quickly culminates in a panic attack.
The cognitive model of panic disorder is illustrated in Figure 4.1. Based on
Clark’s (1986) original “vicious circle” model of panic, it also incorporates
more recent theorising and elaboration on the cognitive model of panic disorder (Salkovskis, 1991; Rachman, 1991; Salkovskis, Clark, & Gelder, 1996).
According to this model, internal triggering stimuli for a panic attack may be
produced by anxiety sensations, or by non-anxiety sensations (or thoughts
and images). In the first instance, bodily sensations of elevated anxiety are
misinterpreted catastrophically, which in turn produces more symptoms and
leads to a panic attack. Sequence of events is thus: anxiety-produced sensations become anxiety-producing through their misinterpretation:
anxiety-produced sensations ➔ misinterpretation ➔
anxiety-producing sensations ➔ panic.
In the second instance, non-anxiety sensations are interpreted catastrophically,
thus leading to elevated anxiety; symptoms of elevated anxiety are further misinterpreted catastrophically, producing more symptoms and leading to a panic
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attack. In this case, sequence of events is thus: non-anxiety-produced sensations
become anxiety-producing through their misinterpretation, and anxietyproduced sensations become even more anxiety-producing through a further
non-anxiety-produced sensations ➔ first misinterpretation ➔
anxiety-produced sensations ➔ second misinterpretation ➔
anxiety-producing sensations ➔ panic.
In this second case, panic patients become habitually victims of two, at least,
consecutive misinterpretations, something that apparently has implications
for the development of effective interventions.
Panic disorder is maintained by two additional processes: hypervigilance
and safety behaviours. As panic disorder patients develop the tendency to
misinterpret catastrophically, and consequently develop the fear of, certain
bodily sensations, they become hypervigilant and repeatedly scan their body.
Although such an increased self-focused attention reflects patients’ attempts
to control stimuli (Kendall & Ingram, 1987), and patients become capable of
noticing sensations which many other people would not be aware of, these
sensations are taken as further evidence of a serious physical or mental disorder, and may consequently trigger another panic attack.
Safety behaviours tend to maintain patients’ negative cognitions and are
either anticipatory/avoidant or consequent/escape (Salkovskis, 1991). Since
a safety seeking behaviour is perceived to be preventive, and focused on
especially negative consequences (e.g., death, illness, humiliation), spontaneous disconfirmation of threat is made particularly unlikely by such safety
seeking behaviours. Avoidance, either overt in the form of agoraphobia or in
more subtle forms, prevents disconfirmation of panic-related cognitions and
may thus maintain panic disorder. Within-situation safety seeking behaviours result in the maintenance of catastrophic cognitions in the face of
repeated panic, during which the feared catastrophes do not occur (Salkovskis
et al., 1996).
Overt avoidance, on the other hand, is the most common behavioural consequence of panic; the major determinant of panic-related avoidance
behaviour is the person’s present prediction of the probability of experiencing a panic in specified circumstances. While panic episodes in general are
followed by an increase in the prediction of future panics, and expected
panics are followed by little or no change in predictions of panic, unexpected
panics contribute to a significant overprediction of panic (Rachman, 1991).
Since agoraphobic avoidance does not necessarily disconfirm predictions of
panic, and spontaneous panics are by definition unpredicted, an increase in
fearful predictions predisposes to elevated levels of anxiety, and in a selffulfilling prophecy mode, may result in a panic attack.
Cognitive behaviour therapy for panic disorder
Cognitive behavioural treatments of panic
Preliminary cognitive behavioural treatment for panic attacks gave a particular emphasis on the importance of hyperventilation in the production of
panic attacks and, consequently, emphasis on breathing retraining techniques
(Clark, Salkovskis, & Chalkley, 1985; Salkovskis, Jones, & Clark, 1986; Clark,
Since the cognitive behavioural approach involves identifying patients’ negative interpretations of bodily sensations experienced in panic attacks, and
suggests alternative non-catastrophic interpretations of such sensations, the
approach by Clark at al. (1985) and Salkovskis et al. (1986) focused on the
view that the bodily sensations which patients experience in a panic attack are
the results of stress-induced hyperventilation rather than the more catastrophic occurrences which they usually fear, e.g. heart attack, stroke,
fainting, losing control. Hyperventilation was chosen as an alternative explanation, because the bodily sensations which occur in a panic attack are very
similar to those produced by voluntary hyperventilation, and there was evidence that hyperventilation has an important role in the production of some
patients’ panic attacks. This treatment approach has several successive steps.
In the first step, the cognitions and bodily sensations that are associated with
panic are elicited. In the next step the therapist tries to demonstrate that
hyperventilation could have produced the symptoms of panic by asking the
patient to overbreathe for two minutes. Patients are asked to breathe through
their nose and mouth quickly, fully emptying their lungs as they breathe out,
and filling them completely as they breathe in. Patients are not told exactly
what sensations they are likely to experience, and are not told that the effects
of overbreathing might be similar to their panic attacks. The procedure is presented to the patient as a diagnostic exercise. If the patient recognises the
bodily sensations induced by hyperventilation as similar to those experienced
during a panic attack, this observation becomes the basis for a discussion on
the “catastrophic” nature of panic attack symptoms. Therapists can thus
help patients to reappraise their symptoms and reattribute them away from
catastrophic interpretations, and toward the notion that the patient is suffering from stress-induced hyperventilation. The next step in the treatment
involves training of controlled respiration which is incompatible with hyperventilation. Slow (8–12 breaths per minute), shallow, diaphragmatic breathing
is intended to be used as a coping technique when a patient thinks a panic is
about to start or notices that he has started overbreathing. In the last step, the
patient is taught to identify and modify panic triggers.
Clark et al. (1985) and Salkovskis et al. (1986) reported impressive evidence
for the efficacy of breathing retraining combined with cognitive reattribution
in a study of 18, and 9 panic patients, respectively. Substantial reductions in
panic attack frequency were observed during the first weeks of treatment.
Initial gains, which occurred in the absence of exposure to feared external
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situations, were improved with further treatment, including exposure in vivo
if appropriate, and were maintained at 2-year follow-up. A limitation of these
studies was that not all panic patients perceive a marked similarity between
the effects of voluntary overbreathing and naturally occurring panic attacks.
Indeed, in the second study there was evidence that outcome was positively
correlated with the extent to which patients perceived this similarity.
Nevertheless, it was becoming clear that focus on panic attacks seemed to be
more promising than the conventional treatment methods centred on secondary symptoms such as anticipatory anxiety or agoraphobia. Under this
principle a series of cognitive behaviour treatment studies were conducted.
Various therapeutic processes, mainly cognitive, that arose from the above
theories and findings, were used as adjunctive techniques to exposure therapy:
self-instructional training (Meichenbaum, 1977), rational-emotive therapy
(Ellis, 1962), Beck’s cognitive therapy (Beck, Emery, & Greenberg, 1985) and
paradoxical intention (Ascher, 1981), as well as relaxation training and
breathing retraining (Emmelkamp, Kuipers, & Eggeraat, 1978; Emmelkamp
& Mersch, 1982; Emmelkamp, Brilman, Kuiper, & Mersch, 1986; Williams &
Rappoport, 1983; Mavissakalian, Michelson, Greenwald, Kornblith, &
Greenwald, 1983; Marchione, Michelson, Greenwald, & Dancu, 1987;
Michelson, Mavissakalian, & Marchione, 1988).
Findings of the above investigations were interpreted in two different ways.
Marks (1987) contended that these investigations suggest that relaxation and
cognitive procedures add little to exposure in vivo. However, Hoffart (1993)
critically evaluating most of these studies, pointed out that some studies had
not attained a methodological level that made it possible to draw any conclusions, or that in nearly all studies (with the exception of the Marchione et
al. study, 1987, which actually supported the potentiating effect of Beck’s cognitive therapy), the forms of cognitive therapy that were applied had either
not been derived from “true” cognitive models, or had been connected to an
explicit cognitive theory.
Full or “true” cognitive therapy of panic has been investigated in one naturalistic and four controlled studies. Sokol, Beck, Greenberg, Wright, &
Berchick (1989) conducted a naturalistic study with no predetermined duration of treatment in order to examine the effectiveness of cognitive therapy in
the treatment of panic disorder. Seventeen panic disorder patients received a
mean of 18 individual cognitive therapy sessions. Mean number of panic
attacks was reduced significantly to zero at the end of treatment, and there
was also a concomitant reduction in self-report measures of depression and
anxiety. Furthermore, there was a significant reduction on a measure of
cognitive dysfunction during panic attacks, and treatment results were maintained at 12-month follow-up.
In the Beck, Sokol, Clark, Berchick, & Wright (1992) study, researchers
sought to determine the short- and long-term effects of focused cognitive
therapy for panic disorder. Thirty-three psychiatric outpatients with the
Cognitive behaviour therapy for panic disorder
DSM-III (APA, 1980) diagnosis of panic disorder were randomly assigned to
either 12 weeks of individual, focused cognitive therapy or 8 weeks of brief
supportive psychotherapy based on principles of client-centred therapy. The
patients who received supportive psychotherapy were subsequently given the
opportunity to cross over to cognitive therapy for 12 weeks. Patients were
rated for panic and depression before therapy, after 4 and 8 weeks of therapy,
and at 6-month and 1-year follow-up. Clinician ratings and self-ratings of
panic frequency and intensity indicated that the focused cognitive therapy
group achieved significantly greater reductions in panic symptoms and general anxiety after 8 weeks of treatment, than did the group that received brief
supportive psychotherapy. At 8 weeks, 71% of the cognitive therapy group
were panic free, compared to 25% of the psychotherapy group. Moreover,
94% of the psychotherapy patients elected to cross over to 12 weeks of cognitive therapy. At 1-year follow-up, 87% of the group that received cognitive
therapy only, and 79% of the group that crossed over into cognitive therapy,
remained free of panic attacks.
In the study by Clark, Salkovskis, Hackmann, Middleton, Anastasiades, &
Gelder (1994), 64 panic disorder patients were initially assigned to cognitive
therapy, applied relaxation, imipramine (mean 233 mg/day), or a 3-month
wait followed by allocation to treatment. During treatment, patients had up
to 12 sessions in the first 3 months and up to three booster sessions in the next
3 months. Imipramine was gradually withdrawn after 6 months. Each treatment included self-exposure homework assignments. Cognitive therapy and
applied relaxation sessions lasted one hour, while imipramine sessions lasted
25 minutes. Assessments were made before treatment/wait and at 3, 6, and 15
months. Comparisons with the waiting-list showed all three treatments were
effective. Comparisons between treatments showed that at 3 months, cognitive therapy was superior to both applied relaxation and imipramine on most
measures. At 6 months cognitive therapy did not differ from imipramine and
both were superior to applied relaxation on several measures. Since between
6 and 15 months a number of imipramine patients relapsed, at 15 months
cognitive therapy was again superior to both applied relaxation and
imipramine but on fewer measures than at 3 months. Cognitive measures
taken at the end of treatment were significant predictors of outcome at
The Ost & Westling study (1995) investigated the efficacy of a coping technique, applied relaxation (AR) and cognitive behaviour therapy (CBT), in the
treatment of panic disorder. Thirty-eight outpatients fulfilling the DSM-IIIR criteria for panic disorder with no (n = 30) or mild (n = 8) avoidance were
assessed before and after treatment, and at 1-year follow-up. The patients
were treated individually for 12 weekly sessions. The results showed that both
treatments yielded very large improvements, which were maintained or further increased at follow-up. There was no difference between AR and CBT on
any measure. The proportions of panic-free patients were 65 and 74% at
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post-treatment, and 82 and 89% at follow-up, for AR and CBT, respectively.
There were no relapses at follow-up; on the contrary, 55% of the patients who
still had panic attacks at post-treatment were panic-free at follow-up. Besides
affecting panic attacks, the treatments also yielded marked and lasting
changes on generalised anxiety, depression and cognitive misinterpretations.
Ost & Westling (1995) concluded that both AR and CBT are effective treatments for panic disorder without avoidance.
In the Arnz & van den Hout (1996) study, cognitive therapy was compared
with applied relaxation, in a group of panic disorder without agoraphobia
patients. Assessments were at pre-, post-treatment, and 1-month and 6-month
follow-ups. Significantly more cognitive therapy patients than applied relaxation patients were panic free at the end of treatment, and at both follow-ups.
The above studies indicate that properly conducted cognitive therapy is a
highly effective treatment for panic disorder, with intention-to-treat analyses
indicating 74–94% of patients becoming panic free, and these gains being
maintained at follow-ups; effects of the treatment do not seem to be entirely
due to non-specific therapy factors (Clark, 1997).
What is the position of exposure therapy in the contemporary cognitive
behavioural treatment for panic, with or without agoraphobia? Cognitive
therapy has anti-panic effects and exposure has anti-agoraphobic effects,
while it is suggested that agoraphobia is a secondary complication of panic
disorder. It was therefore hypothesised that cognitive therapy reduces not
only panic but also agoraphobia, and that it potentiates the effects of exposure in vivo. This hypothesis was tested in the van den Hout et al. study (van
den Hout, Arntz, & Hoekstra, 1994). One group of 12 severe agoraphobics
were treated with four sessions of cognitive therapy followed by eight sessions
of cognitive therapy combined with in vivo exposure. Another group of 12
patients received four sessions of “associative therapy”, a presumably inert
treatment that controls for therapist attention, followed by eight sessions of in
vivo exposure that was framed in common behavioural terms. The initial
cognitive therapy produced a significant reduction in panic frequency, while
associative therapy did not affect panic. Neither cognitive therapy alone nor
associative therapy alone significantly reduced self-rated agoraphobia or
behavioural avoidance. After adding exposure, however, these parameters
were clearly and significantly reduced. Cognitive therapy did not seem to
potentiate exposure effects.
There is a consensus that panic disorder without agoraphobia should be
treated with cognitive therapy (with or without breathing retraining, with or
without relaxation training), and agoraphobia without a history of panic
disorder should be treated with exposure in vivo. But what happens with
panic disorder with agoraphobia, the most common form of panic disorder
in clinical practice? What actually happens is rather disappointing. Findings
from a multicentre anxiety-disorders study investigating, among other variables, the treatment provided, showed that most panic patients received
Cognitive behaviour therapy for panic disorder
medication, usually benzodiazepines, while psychodynamic psychotherapy
was the most frequent psychosocial treatment; cognitive and behavioural
approaches were less commonly received (Goisman, Warshaw, Peterson et al.,
It seems that panic disorder with agoraphobia can be best perceived as a
complex syndrome with cognitive, behavioural, and physiological disturbances, and treated accordingly with cognitive restructuring and exposure to
both external and interoceptive stimuli.
The above integrative form of cognitive behavioural treatment (cognitive
restructuring plus interoceptive exposure) of panic disorder without agoraphobia, or its variation (cognitive restructuring plus interoceptive exposure
plus exposure in vivo) for panic disorder with agoraphobia was developed
and repeatedly evaluated by Barlow and his colleagues (Barlow, Craske,
Cerny, & Klosko, 1989; Barlow, 1990; Craske, Brown, & Barlow, 1991). This
treatment package includes breathing retraining to correct hyperventilatory
breathing patterns, cognitive restructuring to correct catastrophic misinterpretations of benign somatic sensations, and exposure to somatic cues (also
called interoceptive exposure) through the use of any of a number of provocation procedures, e.g. hyperventilation, carbon dioxide inhalation, running
in place, spinning in a chair (Moras, Craske, & Barlow, 1990).
Barlow et al. (1989) reported the results of a long-term clinical outcome
study, testing variations of behavioural treatments for panic disorder without agoraphobic avoidance. Treatment consisted of either progressive
muscle relaxation, interoceptive exposure therapy plus cognitive restructuring, or a combination of relaxation and interoceptive exposure therapy
plus cognitive restructuring. All three treatments were superior on a variety
of measures to a waiting-list control group. In the two treatment conditions
containing exposure to somatic cues and cognitive therapy, 85% or more of
clients were panic free at post-treatment. These were the only groups significantly better than the waiting-list control group on this measure.
Relaxation, on the other hand, tended to effect greater reductions in generalised anxiety associated with panic attacks, but was associated with high
drop-out rates.
The same group of patients was assessed 6 months and 24 months following treatment completion (Craske et al., 1991). Patients in the interoceptive
exposure plus cognitive therapy condition tended to either maintain or
improve upon their post-treatment status over the 2-year follow-up interval.
Fully 81% of the patients in the latter condition remained panic-free at the
24-month assessment.
Finally, in a comprehensive review of newly developed psychological
approaches for panic, Margraaf, Barlow, Clark, and Telch (1993) conclude
that approximately 80% or more of the patients receiving combined cognitive
behavioural treatments achieved panic-free status as well as strong and clinically significant improvement in general anxiety, panic-related cognitions,
Gregoris Simos
depression, and phobic avoidance, while these gains were maintained at
follow-ups of up to 2 years. Furthermore, the above authors conclude that
success of these psychological treatments compared favourably with the outcome for the established pharmacological treatments.
Key points in the treatment of panic disorder
Although panic disorder patients are exposed to their dreaded panic attacks
and their potentially “catastrophic” consequences countless times, cognitive
change is rather unlikely to happen in the absence of treatment. According
to the cognitive model this means that their catastrophic predictions are not
disconfirmed. This phenomenon is partly explained by the fact that panic
disorder is characterised by interpretive, attentional, memory, and interoceptive biases for processing threat (McNally, 1994). Paul Salkovskis, on the
other hand, has suggested that, according to a more explicit cognitive
hypothesis, safety seeking behaviours may constitute a crucial factor in the
maintenance of panic disorder (Salkovskis, 1991; Salkovskis, Clark, &
Gelder, 1996). Although avoidant or escape behaviours were well recognised and managed by exposure therapy, panic disorder patients also engage
in more subtle or covert avoidant and escape behaviours, e.g. the patient
that interprets his dizziness as a sign of imminent collapse may lean on the
wall, or the patient that perceives his accelerated heart rate as a sign of an
upcoming heart attack may slow down his breath or lean back in his armchair and try to relax. These subtle safety/avoidant behaviours do not allow
for disconfirmation of catastrophic predictions and are thus further selfenhanced.
Basic principles in the cognitive behaviour therapy
for panic disorder
CBT attempts to treat PD by teaching patients to identify, test, and modify
the thoughts and beliefs that accompany their panic attacks or their anticipatory anxiety, as well as the avoidance behaviours that may be perpetuating
their faulty appraisals and responses. CBT is a collaborative process of investigation, reality testing, and problem-solving between patient and therapist.
The therapist does not forcefully exhort patients to change their views and
their thinking styles, but instead, tries to accurately understand how patients
come to develop their problems, and proceeds to teach patients a set of
durable skills that will help them think more objectively and flexibly. We, as
therapists, ought to not forget that the evidential basis for the misinterpretations of bodily sensations made in a panic attack may be inaccurate, but the
degree of anxiety is rational and proportional to a given patient’s immediate
personal and idiosyncratic appraisal of threat (Salkovskis, 1991). Patients
are taught to view their thoughts and beliefs as testable hypotheses, and
Cognitive behaviour therapy for panic disorder
encouraged to take graded risks in confronting feared situations in order
both to disconfirm their predictions, and to learn to cope actively with
stresses. The therapist does not attempt merely to change the content of a
patient’s thinking, but assists the patient in adopting an improved thinking
process (Newman & Haaga, 1992).
CBT for PD, as is the case for CBT for any other mental disorder, is a
structured and highly active form of treatment with therapy sessions in which
agendas are set, goals are defined, priorities are established, and problems are
concretised (Newman, 1992). The therapist and the patient share the responsibility for the work of therapy, with the therapist being willing to respond to
direct questions with direct answers, but also using Socratic questioning in
order to help the patient to gradually learn to recognise and solve problems
for himself. Further, the implementation of between session homework
assignments helps patients to translate their new hypotheses and goals into
actual behaviours that increase self-esteem, reduce anxiety, fears and avoidance, and improve the patient’s quality of life.
Cognitive behaviour treatment techniques
Although CBT for PD is a highly structured treatment process, and there are
excellent descriptions of the basic elements of this process and on how a
therapist will deal with almost all panic disorder aspects, CBT for PD is
rarely described in a step-by-step or session-by-session manner (Clark &
Salkovskis, 1987a; Beck, 1988; Clark, 1989, 1996, 1997).
From all the above published work, Clark’s 1996 description of specialised
treatment procedures is the briefest and most conclusive, while Clark’s 1989
is the most extensive. Clark’s (1996) delineation of the Oxford Cognitive
Therapy Package for Panic Disorder is as follows:
The Cognitive Therapy Package uses a wide range of cognitive and
behavioural procedures to help patients change their misinterpretations
of bodily sensations and to modify the processes that tend to maintain
the misinterpretations. The cognitive techniques include using review of
a recent panic attack to derive the vicious circle model, identifying and
challenging patients’ evidence for their misinterpretations, substituting
more realistic interpretations and restructuring images. The behavioural
procedures include inducing feared sensations (by hyperventilation, by
reading pairs of words representing feared sensations and catastrophes,
or by focusing attention on the body) in order to demonstrate the true
cause of the panic symptoms, and dropping safety behaviours (such as
holding onto solid objects when feeling dizzy) and entering feared situations in order to allow patients to disconfirm their negative predictions
about the consequences of their symptoms.
(Clark, 1996, p. 328)
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Beck (1988, p. 106) describes nine steps in the treatment of panic disorder: (1)
Explanation of the nonpathological nature of symptoms; (2) reappraisal of the
panicogenic sensations and of the idiosyncratic meaning and interpretations;
(3) eliciting automatic thoughts and images associated with attack; (4) enhancement and re-evaluation of symptoms and responding to automatic thoughts;
(5) relaxation, breathing exercises; (6) induction of miniattacks in office by
hyperventilation, exercise, imagery, etc.; (7) distraction; (8) systematic exposure;
and (9) use of flash cards. Although it is useful to remember all these steps, the
above steps are not always taken in this specific order in clinical practice.
Along the Oxford tradition, Adrian Wells (1997, pp. 131–132), after giving
his account of the cognitive techniques for the treatment of panic disorder,
presents a useful example treatment outline. This example includes gross session-by-session guidelines:
Session 1: (a) Map out panic circle for a recent attack, (b) socialise using
circle and socialisation procedures, (c) identify range of misinterpretations/beliefs/safety behaviours, and (d) homework – fill out panic diary with
misinterpretations, listen to therapy session tape.
Session 2: (a) Map out circle for recent panic recorded in diary, (b) focus on
key beliefs and use behavioural and verbal reattribution, (c) introduce concept of safety behaviours, and (d) homework – cognitive diary, experiment by
dropping safety behaviours, listen to therapy session tape.
Sessions 3–7: (a) Continue to map out circles for panics, including safety
behaviours, focus on key beliefs, (b) in-session induction experiments to challenge different beliefs, (c) verbal reattribution and generation of rational
responses based on this and on behavioural experiments, and (d) homework –
specific exposure experiments/dropping safety behaviours/pushing symptoms.
Continue panic diary, include rational responses, listen to therapy session
tape, write a summary.
Sessions 8–12: (a) Challenge remaining beliefs, (b) identify/eliminate
remaining safety behaviours/avoidance, (c) relapse prevention, and (d) homework – continue pushing symptoms, go in search of a panic to test fears, work
on blueprint.
As Wells (1997, p. 280) notes, therapists should use sessional responses on
the Panic Rating Scale to guide the focus of treatment sessions. (The Panic
Rating Scale serves a similar function to the panic diaries described in the
following page.) It sounds logical that on treating a panic disorder patient, a
therapist has to adhere to the therapy rationale, but must also keep a certain
degree of flexibility in order to tailor treatment procedures to the individual
patient. Development of a patient-specific case formulation seems to emerge
as an integral part of contemporary CBT for panic disorder, with or without
agoraphobia (Taylor, 2000). Such a case formulation requires the clinician to
formulate and test hypotheses about the predisposing, precipitating, and protective factors in the patient’s problems, and to select interventions according
to these hypotheses.
Cognitive behaviour therapy for panic disorder
Beck and his colleagues devised a treatment protocol for panic disorder
called Focused Cognitive Therapy (FCT) for Panic Disorder (Beck, 1992a). A
version of this 12-session treatment protocol was the one that was used in the
controlled study mentioned earlier (Beck et al., 1992). This treatment proved
highly effective, as 71% of the cognitive therapy group were panic free at
week 8, and 87% of this group remained free of panic attacks at 1-year
follow-up. An adapted version for the needs of this book will be presented
The aim of FCT for PD is to reduce belief in patients’ catastrophic misinterpretations, and for this purpose it uses a variety of procedures and
techniques: education, drawing panic scenarios, panic inductions, behavioural
experiments, listing evidence against and disputing evidence supporting misinterpretations, identification and reduction of subtle avoidant behaviours,
daily work on agoraphobic avoidance. FCT also teaches a limited number of
coping skills to panic patients (e.g. controlled breathing, refocusing, relaxation); coping skills are taught in order to control anxiety, although the
therapist emphasises that these skills are not necessary, or an integral part of
therapy, since panic attacks are not dangerous.
Session 1
Introduction of panic diary.
Education about panic: handout, cognitive model of anxiety, panic scenario.
Summary and discussion of therapy plan.
A panic diary is useful for data collection and planning interventions. A
panic diary may have either the form suggested by Clark (1989) or the one
suggested by Beck (1992b). This first form has several columns: day, description of situations where panic attack occurred, a column for each of the
DSM-IV (APA, 1994) physical and cognitive symptoms, severity of panic
(0–100), and number of panic attacks per day. The latter form (Weekly Panic
Log) has six columns:
(a) date, time, and the duration of panic attack;
(b) situation in which panic occurred, severity of panic attack (1–10);
(c) symptoms and sensations during a panic attack (in the bottom of Weekly
Panic Log there is a list of DSM physical and cognitive symptoms, and
the patient writes down in the column symptom numbers);
(d) interpretation of sensations and accompanying thoughts and images;
(e) full-blown/limited symptom panic attack; patient tries to explain why it
was a limited symptom attack and not a full-blown attack, and vice
(f) patient’s response to panic attack, including any medication taken.
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A most complicated form of panic diary is the one where the patient, in
addition to the information provided above, tries to identify the sequence of
symptoms–thoughts in a panic attack. This kind of information is difficult
for the patient to provide at the beginning of treatment, at least, but this
information will help the therapist draw the vicious circle of a panic attack
and introduce the cognitive theory of panic.
From such a detailed diary, therapists are often able to reach a variety of
conclusions and suggest appropriate, and sometimes simple, interventions.
For example, review of a teacher’s diary showed that this patient was experiencing heightened anxiety, and sometimes a panic attack at approximately 11
a.m. Detailed discussion of this finding revealed that “anxiety” related to his
eating habits; as he used to have his dinner early in the evening, and he almost
invariably did not have breakfast, 11 a.m. seemed to be the time of the day
with his lowest blood sugar levels. Introduction of a proper breakfast, as an
experiment to test the low blood sugar hypothesis, reversed this condition.
Review of a housewife’s diary showed that she was having some of her most
severe panics at midday; appropriate investigation showed that during the
morning, and after her children had gone to school, she had the habit of visiting neighbours or inviting them “to have coffee”. It was apparent that by
midday she had already had several cups of coffee, and that misinterpretation
of the autonomic arousal produced by caffeine was the trigger of her panic
attacks. Reduction in the number of coffees consumed in a day resulted in a
significant decrease in her panic attack frequency.
Education about panic seems to be a powerful tool in the management of
panic. Several centres provide the panic patient with written material on the
physiology of anxiety and panic (Clark & Salkovskis, 1987b; Barlow & Cerny,
1988; Craske & Barlow, 1993; Greenberg & Beck, 1987; Simos, 1991) and/or
suggest to the patient to read specific texts. For example, appropriate books for
this purpose are Living with Fear by Isaac Marks (1978) or Panic Disorder: The
Facts by Stanley Rachman and Padmal de Silva (1996). Written material of
this kind provides information about the fight-or-flight response, the adaptive
nature of such a response, the usefulness of non-pathological anxiety, and the
self-regulation of anxiety and panic reactions. Information about the nondangerous nature of panic and the non-catastrophic consequences of anxiety
symptoms help patients understand that the catastrophic misinterpretation of
their panic symptoms has no scientific basis. The recognition, for example, that
people faint when there is a drop both in their heart rate and in their arterial
pressure, and that during a panic attack there is usually a small increase in their
arterial pressure, makes panic patients see that experiencing accelerated heart
rate during an attack is incompatible with collapsing, and their consequent fear
of collapsing. Moreover, patient handouts include information about the
cognitive model in general (thoughts influence emotions, behaviour, and
physiological responses), and the cognitive model of panic in particular (catastrophic misinterpretation of bodily sensations of various origins). Education
Cognitive behaviour therapy for panic disorder
is an integral part of CBT for panic, and it is given throughout the whole therapy. Sometimes it is useful even to refer to some impressive experimental
findings, depending always on the stage of treatment, and the quality of therapeutic relationship. The Ehlers, Margraaf, Roth, Taylor, and Birbaumer
(1988) false heart rate feedback experiment is especially effective. After briefly
presenting the experimental procedure to the patient, the therapist asks the
patient to guess what the results of the experiment were. Interestingly, the
patient’s predictions are almost invariably towards the right direction, showing
that the patient has already understood the way that misinterpretation of
bodily symptoms leads to the development of a panic attack.
Eliciting idiosyncratic data for the construction of the cognitive vicious
circle model or a panic scenario is of primary importance. For this purpose,
therapist and patient scrutinise a specific, probably more recent, and typical
for a given patient panic attack, and through persistent Socratic questioning
they elicit all appropriate information pertaining to sequence of bodily sensations, catastrophic thoughts, and emotional, physiological, and behavioural
reactions. Safety behaviours or subtle avoidance are also important for the
therapist and patient to identify. Safety behaviours not only prevent disconfirmation of the patient’s belief in catastrophic misinterpretation, but may
also directly exacerbate physical and cognitive symptoms. A patient, for
example, who walks around her neighbourhood, perceives that her heart is
beating faster than usual, chooses to go straight back home, and starts walking quickly. The more quickly she walks, the more her heart accelerates – an
apparently normal reaction to increased needs in blood and oxygen supply –
and the more convinced she becomes that she is having a panic attack, her
heart “will break”, and she will collapse. Her heart rate returns to normal
only after she is home, sits in an armchair, or lies in her bed, and such a
safety-behaviour makes her believe that what she did (walk quickly, return
home, lie in bed) was the “right thing”.
In addition to the details given in session by the patient, useful information
about a panic scenario can also be obtained by appropriate questionnaires. The
Body Sensations Questionnaire and Agoraphobic Cognitions Questionnaire
(Chambless, Caputo, Bright, & Gallagher, 1984) access most feared bodily
sensations and most prevalent catastrophic thoughts, respectively, and there is
evidence of significant and meaningful relationships between certain symptoms and specific cognitions (Warren, Zgouridis, & Englert, 1990; Simos,
Dimitriou, Vaiopoulos, & Paraschos, 1994). The Panic Belief Questionnaire
(Greenberg, 1989; Brown, Beck, Greenberg, Newman, Beck, Tran, Clark,
Reilly, & Betz, 1991) assesses beliefs and assumptions related to panic and oneself, and gives the therapist a clear understanding of a panic patient’s thoughts
and behaviours, as well as ideas for appropriate cognitive and behavioural
interventions. The Beck Anxiety Inventory (Beck & Steer, 1991) is another
useful source of information on subjective, neurophysiological, and panic
symptoms related to a patient’s recent anxiety experiences.
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Reading therapy session notes and relevant texts on anxiety and panic is
part of the homework given to the patient at the end of the first session. As
continuous monitoring of panic attacks and appropriate use of the panic
diary are essential ingredients in this part of therapy, patients are especially
instructed for this purpose.
Session 2
Review panic diary and degree of belief in catastrophic misinterpretation.
Review homework.
Panic induction.
Review panic scenario with places/techniques for intervention.
Therapist and patient review panic diary and degree of belief in catastrophic
misinterpretations. Specific panic attacks become the focus of discussion in
order for the patient and therapist to identify precipitating events, sequence of
sensations, thoughts, and behaviours, and especially overt and subtle
avoidant/escape behaviours. The therapist also asks for feedback on topics
discussed in the first session, and especially credibility of the cognitive model.
Such a feedback has already been elicited in the first session; however, after
the patient has experienced his real-life difficulties and some additional panic
attacks, he may have already seen how the cognitive model works, or does not
work, in practice, and thus feedback may be more extensive in this case.
Questions arising from the written material that was given or suggested in the
first session are appropriately answered.
Panic induction techniques have many aims. They are designed to test predictions based on a patient’s beliefs, help patients reattribute their symptoms
to more benign, and less catastrophic, processes, and also reveal subtle
avoidant/escape behaviours. Panic induction is normally presented as a diagnostic experiment and without a clear rationale, since a detailed rationale can
interfere with the impact of the procedure. Panic inductions are implemented
in such a way as to induce symptoms which closely resemble those normally
present and misinterpreted during a panic attack. Panic induction through
hyperventilation or overbreathing is most commonly used because overbreathing usually produces a wide range of panicogenic sensations, such as
palpitations, dizziness, faintness, blurred vision, feeling of unsteadiness, trembling, feelings of unreality, or chest discomfort. Panic induction through
hyperventilation is considered a safe procedure, but it should not be practised
with patients suffering from a narrow range of medical conditions, like
cardiopulmonary problems and epilepsy, or with patients who are pregnant.
Given the young age of most panic patients, these problems are usually rare.
Panic induction through hyperventilation has already been described earlier in this chapter, but some points need to be made. The patient fills out a
Cognitive behaviour therapy for panic disorder
Sensation Checklist or patient and therapist review a recent or typical panic
attack and write down the most common and intense symptoms during such
an attack, before panic induction. Review of a recently completed Beck
Anxiety Inventory (BAI) can also serve the same purpose. The therapist
informs the patient that he may stop the procedure earlier if he wishes to, but
also points out that it is essential for the patient to try as much as he can. The
patient is asked to overbreathe for two minutes, while the therapist models an
appropriate way of deep and rapid breathing. The therapist encourages the
patient to continue, while giving a continuous feedback to the patient on the
time left until the end of the overbreathing period.
After the patient stops overbreathing, the patient is asked to rate on a
0–100% basis similarities between the overbreathing – or any other panic
induction technique – and an actual panic attack. The therapist uses a variety of questions to elicit appropriate information and help the patient arrive
at the right conclusions. Questions like “What emotions did you feel during
this experience?”, “What were you worried might happen?”, “What pictures
or images went through your mind?”, “What sensations made you believe that
the worst could happen?”, “Did you try to make the experience easier or
safer?” “Were you telling yourself anything in order to feel better?”, “What do
you conclude?”, “What do you make of the fact that there is a similarity
between overbreathing and panic attack?”, “What is your breathing like
before or during a panic attack?”
Forced hyperventilation sometimes has powerful effects. There are patients
who stop overbreathing after only a couple of breathing cycles, or suddenly
grip on their chair, or even steadily lean their arm on a nearby wall, in order
to prevent a full-blown panic attack, or the catastrophic consequences of
their experiencing panic-like symptoms through hyperventilation. An excellent example of such reactions, as well as the constructive way that the
therapist handles them, is given by Dattilio and Salas-Auvert (2000) in “the
case of Susan”.
Nevertheless, hyperventilation symptoms do not always match panic attack
symptoms. In such cases the therapist can use other techniques to produce
panic-like symptoms. Spinning in a chair, use of fearful imagery, physical
exercise, reading paragraphs about a disturbing event, reading paired words
where various combinations of bodily sensations and catastrophes are presented (e.g. breathlessness–suffocate, dizziness–fainting, palpitations–dying),
visual distortion grids, staring at a blank wall or a blank sheet of paper are
some of the procedures the therapist may choose to use for this purpose.
Needless to say, the selection of procedures is always based on the possibility
each one of them has to produce specific symptoms for the specific patient.
Sometimes the therapist has to use his imagination to devise a procedure
that matches the patient’s unique panic profile and the idiosyncratic meaning
he ascribes to panic sensations and cognitions.
The identification of subtle avoidant/escape behaviours helps patient and
Gregoris Simos
therapist agree on consequent homework assignments. Repeatedly dropping
safety behaviours whenever a panic attack occurs will help a patient repeatedly disconfirm his catastrophic misinterpretations and his predictions for the
worst happening.
Breathing retraining or training in slow breathing gives the patient a pattern of breathing that is incompatible with hyperventilation, something that
the patient can use as a coping technique when anxious. Breathing retraining
is introduced in the session and then given as homework. Patients are
instructed to practise regularly in a slow, smooth and shallow pattern of
breathing, with a rate of 8–12 breaths per minute. For this purpose patients
can use either their watch – a complete breathing circle in 5 seconds results in
a rate of 12 breaths per minute – or a pacing tape. The aim of this procedure
is for the patient to become familiar with such a breathing rate without using
the tape or his watch, and easily switching to that rate whenever and wherever
it is needed.
Since patients believe that there is something wrong with their physical
health, and depending on the interpretations they make of certain bodily
symptoms (for example, palpitations are indicative of a serious cardiac problem), patients selectively attend to their body. Even a slight change in heart rate
or a transient light-headedness, sensations probably unnoticed under normal
conditions, may thus become the trigger of a panic attack. Manipulating focus
of attention during the session by asking the patient to concentrate for a
couple of minutes on a specific bodily part or function, and asking the patient
to focus on an external situation – e.g. describing a drawing on the wall with
every possible detail – are ways of demonstrating the anxiogenic role of selective attention, and also introduce the patient to refocusing techniques. Patient
and therapist work together to identify what might have worked for the patient
in the past, generate alternatives, and agree on ways for the patient to practise
external refocusing techniques until the next session.
Significant conclusions arising from this session’s experiences are written
down by the patients, and are used either as a homework task where the
patient regularly reviews his notes, or in the form of coping cards for appropriate occasions.
Session 3
Review panic diary and degree of belief in catastrophic misinterpretations.
Reaction to last week’s session/conclusions/further conclusions.
Review homework.
Recent panic scenario/coping techniques.
Additional coping skills (refocusing, coping imagery, rational responding).
Automatic thoughts.
Cognitive behaviour therapy for panic disorder
The panic diary helps the review of recent panic attacks. Triggering events,
panic attack frequency, panic symptom profile, possibly identified sequences
of sensations – thoughts, interpretation of sensations and accompanying
thoughts and images, as well as responses to each panic attack – and effective
coping or escape behaviours are carefully reviewed. The patient’s reactions to
the previous week’s session, and especially reactions to the hyperventilation
provocation test and the resulting conclusions are important topics for a
detailed discussion. The therapist also reviews homework and the agreed
practice and implementation in practice of breathing retraining and refocusing techniques. Instances of successful or unsuccessful use of these techniques
are also examined in detail. Drawing a recent panic scenario may also help
patient and therapist find and discuss where the patient did use or could
have used coping techniques to prevent or arrest a panic attack. Panic induction through the same, or a different, manipulation may also be included in
this session, and refocusing techniques are also practised in the session.
Brief, threatening images are sometimes triggering or maintaining factors in
a panic attack. A feared consequence or outcome may by represented as a
dreadful image, and not as a verbal representation in a panic patient’s mind.
Such images may have a stereotypical and repetitive nature, while specific images
that accompany a panic attack almost invariably stop at their worst moment.
Identifying and responding to spontaneous imagery is a significant task for
these patients. Restructuring and modifying such an image into a less threatening and less catastrophic image can be done by asking the patient to visualise a
more realistic sequence of events. Practising image substitution or image continuation to a non-catastrophic end may result in either the image disappearing
or losing its panicogenic effect. Practising coping imagery, both regularly and as
soon as a frightening image occurs, becomes part of the homework.
In this session the patient is introduced to automatic thoughts and the role
they play in emotions, behaviours, and physiological arousal. By using the
patient’s automatic thoughts, the therapist reviews the relationship of automatic thoughts to anxiety, and the patient is taught how to identify automatic
thoughts. Rationally responding to negative automatic thoughts is introduced as a skill the patient can progressively learn in order to manage
unnecessary emotional, behavioural and bodily reactions.
Session 4
Review panic diary and degree of belief in catastrophic misinterpretations.
Review homework.
Brief treatment review.
Subtle avoidance/exposure hierarchy.
Practise cognitive skills.
Dysfunctional Thought Record (DTR).
Gregoris Simos
A brief treatment review is an essential step in this session. Evaluation of
progress, data collected to date, and degree of patient’s belief in his catastrophic misinterpretations are extensively discussed. The therapist will
probably have to re-conceptualise the patient’s problems in the light of
recently collected data. One problem in this stage of treatment, not pertinent
to cognitive behaviour therapy only, but to almost any other kind of therapy,
is the therapist’s inclination to fit a patient’s problems into the therapist’s theoretical orientation and available treatment options, instead of adjusting his
conceptualisation to the patient’s presenting problem. Relevant problems
that may already be evident at this stage are those related to the patient’s
compliance with assigned homework. Extensive discussion on the patient’s
feedback on the way he perceives treatment rationale, the credibility he gives
to the conceptualisation of his problem in cognitive behavioural terms, and
the way he perceives his progress are essential steps toward resolving such
Having already drawn and re-drawn panic scenarios with the patient, and
having already reviewed several panic attacks in the panic diary, the therapist
may already have clearly identified a patient’s forms of safety and avoidance
behaviours. By reviewing a recent panic scenario with the patient, the therapist helps the patient understand the role that safety and avoidant behaviours
play in maintaining catastrophic beliefs and consequently panic attacks. The
therapist presents his observations not in the form of an unchallenged truth,
but as a rather testable hypothesis. This kind of attitude will also effectively
help implementation of consequent behavioural experiments. Behavioural
experiments can start in session. Induction of anxiety or panic reactions in
session through hyperventilation or other techniques, and dropping safety
behaviours, is a way to test an agreed hypothesis. For example, the patient who
is afraid of dizziness is asked to hyperventilate, reproduce his fearful bodily
sensations in a standing position and, instead of letting himself sit down or
lean on the wall in order to prevent himself from collapsing, is asked to remain
in that position, or even stand on one leg. Specific behavioural experiments
targeting specific symptom misinterpretations can be agreed upon with the
patient, practised both in session, and as homework assignments.
Principles of progressive exposure to feared situations in the case where a
panic patient is also agoraphobic are introduced in that session. The way
that agoraphobic avoidance maintains fears and prevents disconfirmation of
catastrophic predictions is also explained. The patient is also encouraged to
enter agoraphobic conditions, try out his new skills for dealing with panic,
and also practise and enhance his control and reappraisal techniques. An
exposure hierarchy will help patient and therapist devise appropriate exposure
assignments as part of the following week’s homework.
Having already socialised the patient to negative automatic thoughts, and
to rationally responding to them in the previous session, helps the therapist
proceed to the verbal challenging of the automatic thoughts part of therapy.
Cognitive behaviour therapy for panic disorder
A necessary tool for this purpose is the Dysfunctional Thought Record
(DTR) developed by Judith Beck (1995). The DTR allows patients to monitor (a) situations that trigger automatic thoughts, (b) automatic thoughts,
(c) resulting emotions, (d) rational and adaptive responses to automatic
thoughts, and (e) related outcomes (change in beliefs and emotional
responses). Appropriate questions, like “What evidence do I have for this
thought?”, “Is there any alternative explanation?”, or “Am I thinking in allor-nothing terms?”, help patients question the evidence for a particular
misinterpretation or validity of specific safety behaviours, explore counterevidence, and adopt alternative appraisals. Rationally responding to
automatic thoughts is a skill the patient can learn through continuous reasoning and practice, and appropriate feedback by the therapist. Negative
automatic thoughts related to a recent panic attack are dealt with first in
session, and also as part of the homework.
Sessions 5–12
Review panic diary and degree of belief in catastrophic misinterpretations.
Review homework.
Dysfunctional beliefs/anxious imagery/cognitive restructuring.
Review of the panic diary and DTRs is an opportunity for continuous work
on the reduction of catastrophic misinterpretations. Eliciting and responding
to the patient’s idiosyncratic evidence, identifying relevant dysfunctional
beliefs, and consequent cognitive restructuring are parts of the ongoing cognitive change process. Panic inductions, behavioural experiments, dropping
safety behaviours, exposure to feared situations, use of coping imagery and
coping cards, as well as controlled breathing, refocusing, or relaxation, are
additional therapeutic techniques.
Identification and modification of stressors, management of concurrent
real life difficulties, and application of problem-solving techniques, are also
possible areas for appropriate interventions.
Effects of treatment become evident in the reduction and elimination of
panics and general anxiety, reduction and elimination of agoraphobic avoidance, the patient’s increased self-reliance, and ultimately in the patient’s
improved quality of life (Telch, Schmidt, Jaimez, Jacquin, & Harrington,
Final sessions also orient patients toward termination of therapy and
relapse prevention. Discussion of skills acquired in therapy and the way they
can be utilised and applied in the case of future attacks, as well as a jointly
developed self-programme for this case, are necessary steps in prevention of
Gregoris Simos
relapses. Scheduled booster sessions help patient and therapist manage nonanticipated problems, and review maintenance of therapeutic results and
further progress.
The above structured treatment plan does not include a formal interoceptive exposure (i.e. repeated exposure to feared bodily sensations) procedure,
although repeated panic induction in sessions, described above, may also
function as such. Recent evidence suggests that the addition of interoceptive
exposure to cognitive restructuring and in vivo exposure to agoraphobic situations is more effective than the addition of breathing retraining to cognitive
restructuring and in vivo exposure to agoraphobic situations (Craske, Rowe,
Lewin, & Noriega-Dimitri, 1997). However, a somewhat contrasting finding
was also recently reported (Brown, Beck, Newman, Beck, & Tran, 1997).
Focused cognitive therapy (FCT), described above, was compared with standard cognitive therapy (SCT). SCT focused primarily on the cognitions and
beliefs relevant to interpersonal concerns involved in generalized anxiety,
and contrary to FCT did not include induced in-office panic exposure specific
to the patient’s panicogenic cognitions. Both treatment conditions proved
equally effective in reducing panic attack frequency, anxiety, and depression,
with 89.5% of the SCT group and 84.2% of the FCT group being free of
panic attacks at 1-year follow-up. However, for a more detailed description of
regular interoceptive exposure see Barlow and Cerny (1988, pp. 151–170).
Concluding remarks
Although a panic attack may present with a variety of different symptoms,
panic attacks seem to have some uniqueness; the six most frequent symptoms
reported by a group of 41 agoraphobics with panic from Albany, USA, were
palpitations, dizziness, sweating, fear of going crazy or losing control, dyspnoea, and shaking (Barlow & Craske, 1988), while those reported by a similar
group of 71 patients from Thessaloniki, Greece, were palpitations, dizziness,
fear of dying, dyspnoea, shaking, and tingling sensations (Simos, Bitsios,
Dimitriou, & Paraschos, 1995). While the most intense panic symptoms in the
Albany group were palpitations, fear of dying, dizziness, trembling, dyspnoea, and hot and cold flushes, the most intense panic symptoms in a similar
group of 29 patients from Manchester, UK, were palpitations, hot and cold
flushes, sweating, fear of losing control, trembling, and fear of going crazy
(Kalpakoglou, 1993). These findings support not only the uniqueness of
panic attacks, but also their universality.
DSM-IV (APA, 1994) requires 4 symptoms out of a list of 11 physical and
2 cognitive symptoms for the diagnosis of a panic attack. It is obvious from
this definition that one can generate 715 possible four-symptom combinations
or phenotypic expressions of a panic attack. Some of these symptom clusters
may have similarities, if they share two or three common symptoms, but a
panic attack characterised by “palpitations, shortness of breath, hot and cold
Cognitive behaviour therapy for panic disorder
flushes, and nausea” is completely different from an attack with “dizziness,
trembling, sweating, and depersonalisation” or from an attack with “lightheadedness, chest pain, heart pounding, and fear of losing control”.
It is apparent from these examples that DSM-IV leaves quite ample room
for non-cognitive panic attacks (330 symptom combinations of the above
715 do not include at least one cognitive symptom), something that may be a
weakness of DSM-IV, a weakness of cognitive theory, or a weakness of both,
in their conceptualisation of panic. Cox, Swinson, Endler, and Norton (1994)
have found a three-factor model of panic symptomatology consisting of
dizziness-related symptoms, cardiorespiratory distress, and cognitive factors,
and concluded that some symptoms are more likely to be present in a panic
attack than others, suggesting thus that the present phenomenological classification (DSM) of panic is rather inaccurate.
A second consequence of these numerous panic-symptom profiles is that
panic disorder patients may constitute a quite heterogeneous group. As a
result, standardised or focused cognitive behaviour therapies for panic disorder cannot have, and actually do not have, a total and unique therapeutic
application and success. Cognitive theory of panic has been very influential
in the way contemporary therapists understand and treat panic; cognitive
behaviour therapy “is a highly effective treatment for panic, with intention-totreat analyses indicating 74–94% of patients becoming panic free and these
gains being maintained at follow-up” (Clark, 1997, p. 145). However, there are
still 6–26% of panic patients that, although treated by pioneering and highly
skilful therapists, remain symptomatic. The recognition that, although CBT
is highly effective both in the short and long term, there are still patients who
continue to experience some exacerbations and remissions over the long term,
creates considerable scepticism (Barlow, 1997). On the other hand, convincing evidence suggests that panic disorder is a chronic and recurring condition,
often requiring ongoing maintenance pharmacotherapy (Pollack & Otto,
1997; Davidson, 1998). Finally, sufficient data are not available to determine
whether the effects of CBT combined with pharmacotherapy are additive in
treating panic disorder, while CBT is not widely offered to patients because of
cost considerations (Gelder, 1998).
A possible answer to these challenges will perhaps show that there is still
something missing, and hopefully a more accurate conceptualisation of
panic, as well as more powerful cognitive behavioural treatments for panic
disorder, with or without agoraphobia, will develop.
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Chapter 5
Psychosocial treatment for
Combining cognitive and
behavioural treatments
Maureen L. Whittal, S. Rachman, and Peter D. McLean
Obsessive compulsive disorder (OCD) is no longer seen as a problem that is
untreatable. In the 30 years since behavioural treatments for OCD were introduced (Meyer, 1966) they have become the psychosocial treatment of choice
(Foa & Franklin, 1998). Foa and Kozak (1996) reported that 83% of people
who completed treatment benefited from it. Of those studies that reported
long-term treatment outcome (i.e., an average of 2.5 years), 79% of people
continued to be considered treatment responders (Foa & Kozak, 1996).
Medications given alone or in combination with exposure and response prevention (ERP) are not more effective than ERP alone (Foa, Franklin, &
Kozak, 1998). Given the high rate of relapse associated with medication
withdrawal (Pigott & Saey, 1998) there is some suggestion that ERP is a
more cost-effective treatment (Foa, Franklin, & Kozak, 1998) for OCD sufferers. As there are variations in how ERP is conducted, Abramowitz (1996)
reported that effect sizes for ERP were larger when the treatment was conducted with the aid of a therapist as opposed to being self-directed, involved
complete and not partial response prevention, and included both in-vivo and
imaginal exposure.
Despite the promising treatment outcomes associated with ERP, a number
of caveats must be considered which include residual symptoms, treatment
refusal/dropout, and treatment non-response. Moreover, ERP is not particularly helpful with obsessions in the absence of overt compulsions (Salkovskis
& Westbrook, 1989; Rachman, 1983). Salkovskis and Westbrook (1989)
reported that in a review of seven studies, using 50% decline in symptom
severity as a cut-off to separate improved from not improved, only 46% of the
subjects met that criterion. Rachman (1983) suggested that the difficulty
behaviour therapists encountered when working with “pure” obsessionals
(as opposed to obsessive-compulsives) was due to a technical failure and a
lack of effective therapeutic strategies.
In their review of treatment efficacy in OCD, Foa, Steketee, and Ozarow
(1985) used a 30% decline in symptom severity pre- to post-treatment to differentiate those who benefited from treatment from those who did not. Foa et
al. (1985) reported that approximately half of the subjects reported at least a
Maureen L. Whittal, S. Rachman, and Peter D. McLean
70% decline in symptoms and approximately 40% reported a moderate
response to treatment. The remaining subjects, approximately 10%, did not
benefit from treatment (i.e., less than 30% decline in symptoms). Although
these figures are impressive, they also indicate that some people are leaving
treatment with considerable residual symptoms. In a review of follow-up
studies, O’Sullivan and Marks (1991) reported that 1–6 years following treatment, subjects reported an average of 60% decline in symptoms compared to
pre-treatment severity. Although it is encouraging that treatment gains are
maintained long after completion of treatment, it also suggests that further
improvements are not made and that people continue to live with residual
symptoms. Moreover, as an indirect indicator of continued impairment following treatment, O’Sullivan and Marks (1991) reported that approximately
33% of the sample sought treatment for comorbid depression and approximately 15% received further treatment for their OCD.
For some people ERP can be difficult to tolerate. Stanley and Turner
(1995) reported that 20–30% of people either refuse to commit to treatment
or drop out after treatment has been initiated. When drop-outs and refusers
are considered, the conservative estimate of those people who will respond to
treatment decreases to 63% at post-treatment and 55% at follow-up (Stanley
& Turner, 1995).
Despite the substantial percentage of people who either do not respond to
treatment or terminate prematurely, there have been no consistent predictors
of failure or drop-out. Variables that have been investigated include pretreatment severity, duration of disorder, age of onset, severity of comorbid
depression, overvalued ideation, treatment expectancies, homework compliance and the presence of personality disorders (Foa, Franklin, & Kozak,
1998; Stanley & Turner, 1995). Rachman and Hodgson (1980) reported that
“OCD lifestyle” was the only factor that predicted a negative outcome.
Given that it was independent of severity, the extent to which an individual’s
life revolved around his/her OCD was a negative predictor of treatment
A cognitive alternative to ERP
Salkovskis (1985) proposed a cognitive theory of OCD that has stimulated
research in the area. Although he is not the first to suggest the importance of
a cognitive conceptualisation of intrusive thoughts (e.g., Carr, 1974; McFall
& Wollersheim, 1979), the theory put forward by Salkovskis has been the
most comprehensive to date and has stimulated a great deal of subsequent
The cornerstone of the cognitive model rests on the premise that intrusive
thoughts are essentially a universal human experience. Rachman and de Silva
(1978) initially reported that over 90% of a community sample reported occasional intrusive, repugnant, unwanted thoughts, images, or impulses. Salkovskis
Psychosocial treatment for OCD
and Harrison (1984) replicated this finding. The intrusions reported by the
non-clinical sample did not differ in content from those experienced by
people diagnosed with OCD. However, what did differ was the meaning
attributed to the intrusive thought. People without OCD appraised these
intrusive thoughts as having no special significance, whereas people diagnosed with OCD appraised these thoughts as threatening and personally
relevant. According to Salkovskis (1985), the threat simultaneously produces emotional distress and the urge to engage in overt or covert
compulsive behaviour that functions to reduce the threat. For example, a
common intrusive thought reported in Rachman and de Silva’s (1978)
sample was the thought of one’s family being killed in a car accident. A nonOCD person would not place any special significance on that thought but
somebody with OCD may appraise the same thought as indicative of future
danger and to ignore it would be tantamount to causing the car crash. This
threatening appraisal would clearly lead to anxiety and the urge to warn
family members about the danger associated with automobile travel. The
threatening appraisal is what maintains the behaviour; without it, the emotional distress would be minimal or non-existent and the urge to engage in a
behaviour that functions to decrease the threat would be unnecessary. Given
the pivotal importance of the appraisal process, it is the target of cognitive
behavioural treatment and will be discussed in detail in later sections of the
In the initial theoretical paper, Salkovskis (1985) discussed the advantages
of his theory and treatment in terms of the disadvantages associated with
ERP, namely the high drop-out and refusal rate. He reasoned that a treatment
that did not rely so heavily upon exposure and habituation would be less
taxing upon patients and would lead to lower drop-out rates. More importantly, cognitive treatment allows therapists to focus on appraisals and the
underlying beliefs thought to be precursors to appraisals that may remain
unaddressed in a purely behavioural paradigm.
Salkovskis (1985) reasoned that the appraisals thought to be of central
importance are those that focus on responsibility. Although there have been
various definitions of responsibility, Salkovskis (1996) regards responsibility
as “the belief that one has power which is pivotal to bring about or prevent
subjectively crucial negative outcomes”. In the above example of the car accident, Salkovskis would say that the threat associated with intrusive thought
is not the possibility of the car accident, but rather the appraisal that the
OCD person would feel, or fear being held, responsible for the outcome
because he or she did not act on the thought. The function of the compulsive
behaviour (i.e., warning the family) decreases the possibility of being held
responsible. The theory has been modified (Salkovskis, 1996) and expanded
but the central thesis, responsibility appraisals driving behaviour, has been
Maureen L. Whittal, S. Rachman, and Peter D. McLean
Other belief domains in OCD
Other theorists have suggested additional appraisals aside from inflated
responsibility that may function to maintain obsessive compulsive behaviour. For example, the Obsessive-Compulsive Cognitions Working Group
(OCCWG), an international group of researchers in OCD, have suggested
five appraisal domains in addition to responsibility (OCCWG, 1997).
Specifically, the beliefs thought to be important are (1) overimportance of
thoughts, (2) excessive concern about the importance of controlling one’s
thoughts, (3) overestimation of threat, (4) intolerance of uncertainty, and
(5) perfectionism (OCCWG, 1997).
Overimportance of thoughts
Overimportance of thoughts has also been discussed by other researchers
(e.g., Freeston, Rheume, & Ladouceur, 1996; McFall & Wollersheim, 1979;
Shafran, Thordarson, & Rachman, 1996) and can be summarised as giving a
thought merit because it was experienced (i.e., the thought was important,
which is why it occurred and it is thought about because it is important). The
reasoning behind overimportance of thoughts is circular and is easily illustrated using a variety of examples (e.g., fresh food is in high demand and it is
in high demand because it is fresh).
An additional concept is thought–action fusion (TAF) (Rachman &
Shafran, 1997; Shafran, Thordarson, & Rachman, 1996). As the name suggests, TAF is thought to be operating when thoughts and actions are
inappropriately fused together. There are two suggested components to TAF:
(1) moral TAF and (2) likelihood TAF. In moral TAF, having the thought and
engaging in the action are seen as the same (e.g., having an unwanted, unacceptable sexual intrusion is equivalent to carrying out the act). Likelihood
TAF entails a higher probability of an event happening because the thought
occurred (e.g., the probability of a car crash increases because of an intrusive
thought of a loved one dying in an automobile accident). Both moral and
likelihood TAF can be associated with guilt and shame and can co-occur
within the same person and in response to the same trigger. For example,
after a recent US school massacre, a patient with aggressive obsessions experienced both moral and likelihood TAF. He drew a comparison between
himself and the boys who did the killing and used the massacre as evidence
that, without great resistance on his part, when he experienced aggressive
obsessions, he could lose control of his behaviour and begin randomly killing
people (likelihood TAF). And because of the likelihood TAF, he continued to
view himself as evil for having the aggressive intrusions (moral TAF).
An extreme version of TAF is the reasoning process that accompanies the
subgroup of OCD people who engage in magical thinking (e.g., unless the
lights are turned on and off five times when leaving a room, someone will
Psychosocial treatment for OCD
die). The implicit appraisal in overimportance of thoughts is responsibility
(the responsibility for the outcome in a particular situation rests with the person
who initially experienced the thought). However, amongst others, Freeston et
al. (1996) agree that there may be some merit, both theoretical and practical, in
separating overimportance of thoughts from inflated responsibility.
Control over thoughts
A concept that is similar to overimportance of thoughts and TAF is the perceived need for control over thoughts. Clark and Purdon (1993) reported a
correlation between the inability to control/dismiss thoughts and the frequency
and severity of intrusions. The distress is hypothesised to be produced by the
perceived catastrophic consequences if the intrusive thought is not controlled
(Clark & Purdon, 1993). A typical response to thoughts that are perceived as
uncontrollable is an effort to suppress the thought. This strategy has been
demonstrated to further increase the frequency of unwanted thoughts (Purdon,
1999; Wegner, 1989), which further increases the use of suppression and so on.
Overestimation of threat
Overestimation of threat, the tendency to predict negative consequences more
so than others, is a cognitive style that may be a common denominator across
the anxiety disorders (Salkovskis, 1991). It has been suggested that a faulty
reasoning process is at the heart of threat overestimation (Foa & Kozak,
1986). Specifically, most people assume that a situation is not dangerous
until it is proven otherwise whereas people with OCD (and perhaps all those
with an anxiety disorder) assume danger until it is demonstrated that a situation is proven to be safe. Within OCD, some investigators have differentiated
between overpredicting the occurrence of the event and overpredicting the
awful consequences associated with the event (van Oppen & Arntz, 1994).
These authors reiterated that risk = chance × consequence and to adequately
reduce risk, both chance and consequence must be addressed. Van Oppen and
Arntz (1994) further suggested that issues of responsibility underlie the
unacceptable consequences that might be inflating perceived risk. Thus,
appropriate cognitive therapy for OCD would target danger and responsibility. As threat overestimation may be a common cognitive process in the
anxiety disorders, lasting therapeutic change may depend upon challenging
those appraisals that may be unique to OCD (e.g., overimportance of
thoughts and need to control thoughts).
Intolerance of uncertainty
Although it is a feature of other anxiety disorders (e.g., generalized anxiety
disorder) it has long been acknowledged to be part of OCD (e.g., Carr, 1974;
Maureen L. Whittal, S. Rachman, and Peter D. McLean
McFall & Wollersheim, 1979) in that it is difficult for people to make decisions secondary to certainty concerns. It is commonplace for people with
OCD to report that they know the behaviour (e.g., locking the door) was
done as they watched themselves lock the door. However, because it doesn’t
“feel right” or they are not absolutely certain, the behaviour must be
repeated (“it’s almost as if I don’t believe what I see or hear” (the locked
door or the deadbolt turning)). For people with OCD and perhaps other
anxiety disorders, it appears that even the smallest seed of doubt is unacceptable, likely due to the consequences associated with being uncertain
(e.g., the door being left unlocked creating an easy entry for a thief). Again,
the underlying appraisal that may make uncertainty particularly intolerable
is responsibility.
Striving for perfection is not unique to OCD and has been hypothesised to be
a significant factor in eating disorders (Srinivasagam, Kaye, Plotnicov,
Greeno, Weltzin, & Rao, 1995), depression (Hewitt & Flett, 1991, 1993), and
other anxiety disorders (Antony, Purdon, Huta, & Swinson, 1998). However,
with respect to OCD, the role of perfectionism is evident in people with symmetry/exactness compulsions, cleaning that is not contamination driven, and
more subtly in the need to know (e.g., the OCD patient who obsessed about
the meaning of life and the necessary components to be happy).
The cognitive domains presented in the preceding paragraphs reflect
those thought to be important according to the OCCWG (1997). It is possible that other cognitive domains are significant but as yet unidentified. It
is also evident that the domains discussed thus far are not mutually exclusive. The importance of the various cognitive domains awaits empirical
validation. However, the hypothesised cognitive domains are prominently
featured in the cognitive behavioural treatment of OCD, which is described
The overlap between the cognitive and
behavioural approaches
Prior to discussing the specific techniques associated with a cognitive behavioural approach to OCD, it is necessary to discuss the common denominator,
exposure. Although exposure is common to both a purely behavioural and a
cognitive behavioural treatment, the function and duration of it varies. In a
behavioural paradigm, exposure is the primary tool used to alter dysfunctional behaviour. OCD is thought to be maintained by the escape from and
avoidance of anxiety, which is accomplished by typically overt, and occasionally covert, compulsions. Allowing the person to tolerate gradually more
intense levels of anxiety by preventing the completion or initiation of
Psychosocial treatment for OCD
compulsions and allowing the individual to observe that anxiety habituates
both within and between exposures has been the core of behavioural
Exposure also plays a role in cognitive behavioural treatments, but it is one
of many tools that therapists have at their disposal to change appraisal and is
used primarily to disprove feared consequences. As will be described, the
goal of cognitive behavioural treatment (CBT) for OCD is to give the patient
alternative(s) regarding how they interpret/appraise their intrusive thoughts.
Having patients engage in behavioural experiments to test their appraisals is
only one of the many avenues therapists can utilise. What is implied by the
difference between the treatments is the centrality of anxiety. In the behavioural model, anxiety is the driving force behind the behaviour. In the
cognitive behavioural model, anxiety plays a role but it is secondary to
appraisal; the emotion experienced is epi-phenomenal to the interpretation
provided by the individual.
Foa and colleagues (e.g., Foa & Franklin, 1998; Foa, Franklin, & Kozak,
1998) have stated that the differences between behavioural (i.e., ERP) and
cognitive behavioural treatments are essentially moot as therapists appropriately trained in ERP routinely discuss probability overestimation and
risk assessment in an effort to alter patient’s beliefs. In our view the differences between ERP and CBT therapies are clear. As we will demonstrate,
CBT for OCD is complex and requires a primary focus on appraisal.
Exposure is a small but important part of CBT and is conceptualised as one
of many possible tools to use to change appraisal/beliefs. We aim to establish that there is much more to CBT for OCD than discussing risk
assessment and probability overestimation in the context of exposure.
Having stated the difference between the therapies, it has yet to be established if they produce outcomes that are significantly different. It is possible
that CBT and ERP may reach a common therapeutic end point having
used alternative routes to get there.
Guiding principles of treatment
The principles of CBT, collaborative empiricism, guided discovery, and
Socratic questioning, form the foundation of CBT with OCD sufferers. It is
crucial in the initial sessions to establish a working alliance with patients.
This working alliance continues throughout therapy as the clinician endeavours to provide an alternative interpretation(s) of the intrusive thoughts
rather than disconfirm the OCD interpretations/appraisals. The goal is to
provide patients with some flexibility in how they view their triggers and
how they interpret their intrusive thoughts. Use of the guiding principles of
CBT may prevent the clinician from adopting an argumentative stance with
patients (i.e., debating the validity of the intrusive thoughts). The social
psychological literature is replete with data suggesting that arguing for or
Maureen L. Whittal, S. Rachman, and Peter D. McLean
having to support your opinion in a debate functions to strengthen that
Likewise, collaborative empiricism begins during the assessment and continues throughout the duration of the treatment. The clinician’s job during
the assessment is to provide a conceptualisation of the OCD that is agreeable
to the patient and establishes the importance of one or more of the cognitive
domains discussed above. As is true for panic disorder (Cox, Fergus, &
Swinson, 1994), understanding and agreeing with the cognitive behavioural
conceptualisation of the disorder and the treatment rationales that come
from the theory is probably an important component in a successful treatment. If patients understand/accept the model for treatment, it is likely that
they will be more active in challenging OCD appraisals.
Guided discovery as established through Socratic questioning is a tool that
therapists can use to establish and maintain the working alliance. Rather
than a didactic style, the collaborative relationship can be protected by guiding patients to their own answers with a series of questions. For example,
rather than telling patients the definitions of obsessions and compulsions,
they should be asked to identify characteristics that would describe obsessions and compulsions, the form in which they are experienced (thoughts,
images, and/or impulses) and examples of each from their own OCD.
Allowing patients to reach their own conclusions is probably more powerful
than directly supplying the information. The goal of the clinician during
treatment is to teach the patient to be his or her own therapist. A Socratic
style may be more beneficial than a didactic style in allowing patients to continue to help themselves after treatment is completed.
Faulty appraisals
Intrusive thought
1. Overimportance of thoughts
2. Overestimations of danger
3. Overestimations of the
consequences of danger
4. Inflated responsibility
5. Overestimations of the
consequences of responsibility
6. Need for certainty and control
over thoughts
OCD maintained by failure to
evaluate and consider alternative
appraisals and beliefs in light of
contrary experience
Urge to
Figure 5.1 Cognitive behavioural model of obsessive compulsive disorder.
Psychosocial treatment for OCD
Cognitive behavioural treatment strategies for OCD
The initial sessions: presentation of the model and
treatment rationale and identifying appraisals
Following a thorough assessment regarding the extent and severity of the
OCD, the first task of treatment is to provide patients with an alternative in
conceptualising their symptoms using a cognitive behavioural model (Figure
5.1). Although we use a template when describing the model, the explanation
must be idiosyncratic to the patient’s intrusive thoughts, appraisals, and
compulsions. As with all subsequent interventions, the information that we
provide is presented as a possibility. We never imply or directly state that
patients are wrong in their thinking and that we are right, but rather that
there is an alternative.
In the case of a man who has contamination fears, a typical trigger might
be touching money or something in public. Touching these items would likely
trigger intrusive thoughts about contamination which is, according to the
cognitive behavioural model, followed by an appraisal or interpretation about
the possible meaning of being contaminated (e.g., “I’ll pass it on to my children and it will be my fault when they get sick”). As a consequence of this
threatening, personally relevant appraisal, the person feels emotional distress (typically anxiety but sometimes guilt, shame, or anger) and the
compulsive urge to check to decrease the threat. Once the threat has been
neutralised by checking the anxiety decreases. In the above example, engaging
in the compulsion functions as a reward in that it allows the OCD person to
avoid being responsible for a fire or break-in, which subsequently reduces the
anxiety. The OCD person learns that to continue to avoid being responsible
for potential catastrophic consequences these compulsive behaviours must be
completed when similar appraisals arise in the future. In the absence of contradictory information, OCD patients use their “rewarding non-punishment”
(Salkovskis, 1985) as evidence that the situation is indeed dangerous and
requires their attention and action. For example, with a doubter/checker,
assuming no break-ins or fires and thus nothing for which to feel responsible,
they would tend to assume it was due to their efforts at checking and that they
should continue to be vigilant and continue to check.
After explaining the model the next logical step is to discuss the rationale
for treatment. Given that intrusive thoughts are nearly universal (Rachman &
de Silva, 1978; Salkovskis & Harrison, 1984) the obsessions are not the target
for treatment. It would be impossible to stop thoughts that are a normal
experience of being human. However, it is reasonable to target the way in
which these intrusive thoughts are interpreted (i.e., appraisals). By way of
illustrating the importance of the appraisal process, the patient and therapist
collaborate on a non-threatening appraisal that may serve as an alternative to
the previously identified OCD appraisal (e.g., responsibility for a fire or
Maureen L. Whittal, S. Rachman, and Peter D. McLean
break-in would be shared among members of the household and/or the perpetrator). Assuming the patient believes this alternative appraisal (the
therapist should acknowledge that they know that the patient does not believe
it now, at the beginning of treatment, but if they believed it), the urge to
engage in the compulsion and the distress would decrease.
Throughout treatment therapists should take every opportunity to normalise the patient’s behaviour, beginning with emphasising the ubiquity of
intrusive thoughts. We routinely ask patients to conduct a survey of the frequency of intrusive thoughts amongst their friends and/or family members.
To accomplish this task we provide patients with multiple copies of a list of
intrusive thoughts reported by a non-clinical sample (Rachman & de Silva,
1978). In session, if the therapist is comfortable, he or she can complete the list
with the patient and identify his or her own intrusions. The more people and
the wider the variety of people (e.g., peers, people in authority) that complete
the list, the more this may aid the patient in realising that experiencing occasional unwanted, repugnant, intrusive thoughts is normal. Explaining the
differences between the frequency, intensity, and severity of the thoughts experienced by OCD people and those without OCD, which are all higher in the
former group, can be done using the model and emphasising the importance
of the appraisal. If an intrusive thought is experienced but appraised in a
non-threatening way, there will be no need to attend to it in the future or
prevent it from occurring. On the other hand, the same intrusion that is associated with a threatening appraisal can lead to a compulsion, an effort to
suppress, distract, or avoid future occurrences of the thought. These strategies,
which seem useful in the short term, are damaging in the long term in that they
increase the frequency, intensity, and severity of intrusive thoughts.
The list of intrusive thoughts reported by a non-clinical sample can have an
additional purpose. There will invariably be items on the list that the patient
has experienced, but not frequently. The appraisals associated with these
intermittent intrusive thoughts would likely be non-threatening and contain
no personally relevant meaning. The appraisals associated with infrequent
intrusive thoughts can be compared to the appraisals associated with obsessional intrusive thoughts to demonstrate the pivotal role of the appraisal
As with CBT in other disorders, the first skill to be mastered is identifying
the appraisals as they occur during an episode of obsessive compulsive behaviour. Monitoring appraisals and differentiating them from intrusive thoughts
is a typical homework assignment that is given after the first treatment session. Accurately identifying appraisals and differentiating them from
intrusions often requires a few attempts, as it can be a difficult concept for
patients to understand. However, once the initial appraisals are identified, it is
often instructive to complete a downward arrow, a process of successive questioning, to identify additional appraisals and/or the core feared consequences.
Completing downward arrows can often be difficult for patients as the
Psychosocial treatment for OCD
Initial Appraisal
Not organising receipts would lead to
financial mayhem and irresponsible spending
⇓ If that were true, what would it mean to me?
I would be an irresponsible person
⇓ If that were true, what would it mean to me?
I would be reckless and stupid
⇓ If that were true, what would it mean to me?
I’d lose my apartment, car, etc.
⇓ If that were true, what would it mean to me?
Become a homeless person – down and out
⇓ If that were true, what would it mean to me?
I’d be a failure
Figure 5.2 Downward arrow of a man obsessed with accuracy.
material can be either emotional or hard to access as the information that is
uncovered is often material that patients typically avoid. Figure 5.2 illustrates
a downward arrow completed with a man who was obsessed with accuracy
and as a result engaged in a number of behaviours that included saving and
cataloguing receipts, recording his weight, the room temperature, his urine
output, organising his belongings to maximise efficiency, and extensively
researching a product prior to purchasing it.
The downward arrow often produces other appraisals that need to be
addressed that may have otherwise been unidentified. For example, in the
example presented in Figure 5.2 two themes are apparent: inflated responsibility and the overriding theme of perfectionism. Introduction of the
downward arrows is typically done in session 2.
Rather than provide a session by session outline, which can be difficult to
accomplish, given the idiosyncratic nature of OCD and the associated
appraisals, we will provide strategies to cognitively challenge the various cognitive domains (e.g., overimportance of thoughts, need to control thoughts,
etc.). In a recent treatment outcome study completed at our centre, we used
the outline listed in Table 5.1 to direct our treatment.
As indicated in Table 5.1, the first two sessions are relatively standard,
with the first one involving presentation of the model, treatment rationale, and
Maureen L. Whittal, S. Rachman, and Peter D. McLean
Table 5.1 Overview of CBT for OCD
Session 1
Establish goals
OCD education
Review CBT model and treatment rationale
Assess patient understanding of intrusions versus appraisals (provide written examples
of each)
Homework – self-monitoring of intrusions and appraisals
Session 2
Review model and treatment rationale
Review homework
Introduce general cognitive errors and relation to appraisals
Identification of core fears using the downward arrow technique
Homework – self-monitoring of intrusions and appraisals and completing a downward
arrow for each OCD appraisal
Sessions 3–7
Review model and homework
Introduction and discussion of one of the belief domains (e.g., overimportance of
thought, inflated responsibility) and potential challenge strategies
Identifying alternative appraisals that are typically not as threatening as the original OCD
Collaborating on homework – specific assignment is idiographic and typically involves a
behavioral experiment and/or other strategies that assist in reappraisal (e.g., survey,
information from an expert, etc.)
Sessions 8–10
Review of the model and homework
Review of OCD appraisals and challenge strategies discussed to date
Identification and discussion of OCD assumptions/beliefs
Challenging OCD assumptions/beliefs and development of alternative assumptions/beliefs
Homework – behavioural experiments to gather evidence for and against alternative
Sessions 11–12
Review model and homework
Review treatment to date
Transition to being own therapist (e.g., what to do when an intrusion is experienced)
Relapse prevention
Collaborating on homework (session 11 only)
introduction to appraisal monitoring. Goal setting also occurs in the first session. Patients are asked to establish a minimal level of decline in symptom
severity for which they would consider treatment a success. They are discouraged from expecting to be “cured” of their OCD and encouraged to adopt a
management stance. Specifically, patients are told to expect a decline in severity, but that at the termination of treatment there will likely be remaining
Psychosocial treatment for OCD
symptoms. However, they will have the skills to continue to help themselves
after treatment is completed (i.e., function as their own therapist).
The second session involves review of the model and treatment rationale
and clarifying problems encountered with the previous week’s homework.
As time usually permits in a 50–60 minute session, downward arrows are
introduced and one is completed in treatment. The third session, as do the
remaining sessions, begins with a review of the model and homework. Prior
to beginning the cognitive challenging of appraisals, the various cognitive
domains (i.e., typical OCD appraisals) are introduced and explained to the
patient. Together the patient and the therapist decide on which cognitive
domains are central to the patient’s OCD. What follows are suggestions regarding how to cognitively challenge appraisals that are categorised in one of the
domains discussed earlier. It should be noted that the cognitive challenge
strategies represent the work of a number of investigators in the field including Freeston et al. (1996), van Oppen and Arntz (1994), Salkovskis and
colleagues (e.g., Salkovskis & Kirk, 1997), and Whittal and McLean (1999).
Challenging responsibility appraisals
As has been suggested earlier, responsibility may be a central appraisal in
OCD. If a responsibility appraisal is not immediately apparent, it can often
be found during a downward arrow analysis. Occasionally a responsibility
appraisal can be inferred from the emotion reported by the patient. Guilt
and/or shame are strong clues that responsibility appraisals may be present.
Freeston et al. (1996) suggested a courtroom procedure where an individual
patient takes the roles of both the prosecuting and the defence attorneys. This
strategy allows the patient to think critically about the reasoning behind their
OCD beliefs as they are required to put forward “arguments” that are evidence-based and not emotion-based (i.e., emotional reasoning).
An additional strategy that functions to challenge appraisals of inflated
responsibility and has been described by a number of investigators is the piechart technique (e.g., van Oppen & Arntz, 1994). Figure 5.3 illustrates a
pie-chart that was completed with a doubter/checker. In this example, an
obsessional doubter was concerned with a basketball hoop he had put up for
his son. The hoop had fallen over and caused a scrape on his son’s arm.
Because the patient had put up the hoop, he blamed himself 100% for the
accident. When completing a pie-chart the patient and therapist collaborate
to determine all possible people or situational variables that may play a role
in a particular event (e.g., a break-in). If the patient has responsibility
appraisals, it is likely that he or she will automatically assume a large percentage, if not all, of the responsibility for the event. In dividing up the
pie-chart, it is important to place other potential sources of responsibility in
the pie first before placing the patient’s responsibility. Pie-charting with
patients who have appraisals of inflated responsibility provides the tool for
Maureen L. Whittal, S. Rachman, and Peter D. McLean
Toy makers
My son
Figure 5.3 The pie-chart technique.
them to critically evaluate situations and hopefully establish more flexible
guidelines to direct behaviour. A shorthand alternative to pie-charting that
accomplishes the same goal is training patients to ask themselves the following question after they have assumed responsibility for an event or situation:
“That’s one possibility (i.e., that I’m to blame), what are some others?”
Challenging overimportance of thoughts
Freeston et al. (1996) have provided an extensive discussion of challenging
overimportance of thoughts. Attaching overimportance to one’s thoughts
takes various forms: (1) my having the thought means it is important, (2) my
having the thought increases the probability of the action, and (3) my having
the thought and engaging in the action are morally equivalent. Collaboratively,
the patient and therapist decide which of these three points are relevant.
Examples of circular reasoning involved in appraising the thought as overimportant, and the process by which it developed, are discussed. Specifically,
the natural reaction to appraising a thought as important is to dwell on the
thought. Dwelling on the thought provides evidence that it is indeed important (i.e., why else would a person dwell on a thought unless it had some
meaning and was important). Patients are asked to adopt a “come and go
style” (i.e., non-dwelling) and test it in a behavioural experiment. On alternate
days patients are asked to let intrusive thoughts “come and go” and on the
other days to engage in their typical “fight and dwell” style. The outcome
measure that patients are asked to record is the time spent engaging in obsessional thinking. Typically what patients report is a lower frequency, intensity,
and duration of obsessions on the “come and go” days.
Patients who have likelihood thought–action fusion appraisals often recall
Psychosocial treatment for OCD
instances in which a thought was followed by the relevant event (e.g., thinking about an old friend and receiving a phone call from that person the same
day) and overinterpret the significance of such events. These events can lead
the person to believe that they have a special ability to predict the future. A
strategy to normalise these “premonitions” is a survey conducted by the
patient. Establish the patient’s predicted outcome for the survey and have
them ask 10 friends if they experienced a situation similar to the example
stated above. Freeston et al. (1996) also suggest conducting behavioural
experiments to determine the power of thoughts (e.g., buy a lottery ticket and
think about winning, attempt to kill a goldfish or break a reliable appliance
by thinking about it). However, some patients may find these behavioural
experiments too artificial (i.e., “because I purposely thought about it, the
meaning is not the same”). In these cases patients should be required to keep
a list of all naturally occurring episodes of likelihood TAF and the outcome
(i.e., did the thought come true?). Frequently, due to selective attention, only
those scenarios that support the hypothesis are remembered while those that
provide evidence against it are forgotten. Keeping a running list of all likelihood TAFs and their outcomes can provide an accurate picture of the power
of thoughts.
Equating thoughts and action is particularly prevalent in people who have
sexual, aggressive, or blasphemous intrusions. For example, a patient
appraised his aggressive images that followed a mild confrontation as evidence “that somewhere deep down inside I have the ability to be like Hitler”.
The continuum technique (Beck, Rush, Shaw, & Emery, 1979) may help challenge these appraisals. Draw a visual analogue scale with the anchors “best
person ever” and “worst person ever” and ask patients to place people at
these anchors and then place themselves on the continuum. Put a variety of
other people on the continuum that reflect varying levels of “goodness” (e.g.,
a tax evader, someone who murders in self-defence, someone who cheats on
their spouse, someone who has thoughts about cheating on their spouse but
doesn’t do it, etc.). Subsequently, ask the patient to re-evaluate their own
“goodness” (e.g., “because you have unwanted, unacceptable thoughts but
never engaged in the action, does that make you as bad as someone who has
purposely acted in a way to hurt another person?”). Freeston et al. (1996)
have also suggested that thoughts can be disassociated from actions by establishing that morality is related to action and not thought. Define morality as
using values and principles to guide behaviour. Thus morality is then equated
to action and not thought.
Challenging need to control thoughts
The challenges associated with the need to control are similar to those associated with overimportance of thoughts and also may reflect appraisals of
responsibility. Suppression (of the thought) is a common coping strategy for
Maureen L. Whittal, S. Rachman, and Peter D. McLean
people who have these appraisals. The consequences of suppression are illustrated using the model and a behavioural experiment is devised such that
patients are asked to alternate between suppressing the intrusive thoughts as
they normally would and not fighting the thoughts. The dependent measure
is the frequency, severity, and duration of intrusive thoughts. This behavioural experiment is very similar, if not identical, to alternating between
“come and go” and “fight and dwell”.
Challenging overestimation of threat
The tendency to see danger or expect negative outcomes is readily apparent
in OCD, but it is not as easily challenged compared to other anxiety disorders. For example, in panic disorder the feared consequences are typically
imminent (e.g., “I’m about to have a heart attack”) and thus are open to
disconfirmation. However, as noted by Salkovskis (1996) the feared consequences (and therefore the appraisals) of OCD patients are generally not
open to disconfirmation because the threat is often future oriented (e.g., “I’ll
go to hell because of my blasphemous thoughts”). Thus, challenges that
focus on disconfirmation can be of limited usefulness.
Occasionally, OCD patients report feared consequences that are associated
with a finite, and therefore testable, time limit. For example, the contamination/washer who feared the onset of illness within one week following contact
with a contaminate. In these situations, it is reasonable to attempt disconfirmation with a behavioural experiment or other cognitive challenges. Van
Oppen and Arntz (1994) have discussed logical versus subjective probability
estimation. Table 5.2 illustrates an example of the steps needed in calculating
the logical probability.
Table 5.2 An example of a cumulative odds ratio for a compulsive checker (initial chance
of the house burning down was 20%)
Cumulative chance
1/100 000
1/10 000 000
Not extinguish cigarette
Spark falls on the floor
Carpet catches on fire
Carpet starts to burn and it is not noticed
Patient notices the fire too late and can do nothing
Subjective probability (20%) is compared to the logical probability (0.000 01%).
For example, in the case of a checker who was concerned about causing a
fire that would burn the house down, all steps required prior to the ultimate
feared consequences are listed and the individual probabilities associated with
each step are estimated. The probability of the final outcome (i.e., burning
Psychosocial treatment for OCD
down the house) is the product of the previous steps (i.e., multiply previous
steps with each other). This logical probability is compared to the subjective
probability, the patient’s initial estimate prior to the cognitive challenge.
Challenging intolerance for uncertainty
Compared to people without OCD who assume a situation is safe until
proven otherwise, Foa and Kozak (1986) have suggested that until disproven,
people with OCD tend to assume that a situation is dangerous. Similarly, we
have noticed that when some OCD people (e.g., doubters/checkers) cannot
remember completing an action, they tend to assume it was not completed.
Surveys can also be a useful tool to normalise and challenge certainty
appraisals. Specifically, we have asked patients to survey non-OCD friends if
they remembered locking their door when they last left their house. If they
did not remember, patients ask how confident they are that the door is locked.
If they did remember locking the door they are asked if it was due to an
unusual occurrence (e.g., difficulty locking door). Typically, most non-OCD
people cannot remember completing everyday, routine activities, thus hopefully normalising non-remembering. As with all surveys, patients should
make a prediction about what they will expect to find and compare it to the
results of their survey. However, caution must be used when assigning surveys
Initial Appraisal
My surroundings are not in order
and it’s a reflection on me
⇓ If that were true, what would it mean to me?
I’m embarrassed, feel guilty, unclean and not tidy
⇓ If that were true, what would it mean to me?
I’m failing – not meeting standards set by others
⇓ If that were true, what would it mean to me?
People would think I don’t care
⇓ If that were true, what would it mean to me?
I’m not a good person
⇓ If that were true, what would it mean to me?
Not worthy of living
Figure 5.4 Downward arrow of a compulsive cleaner/organiser.
Maureen L. Whittal, S. Rachman, and Peter D. McLean
such that they do not become a method for patients to seek reassurance
rather than an information gathering exercise.
As with all initial appraisals, it needs to be determined why uncertainty is
particularly difficult. A downward arrow should be completed and may reveal
underlying appraisals of threat overestimation and/or responsibility that if
left unaddressed may result in less than satisfactory change.
Challenging perfectionism
Freeston et al. (1996) have discussed perfectionism in terms of need for certainty, need to know, and the need for control. In the patients we have worked
with for whom perfection is a central concern the downward arrows typically
reflect issues of self-worth. For example, Figure 5.4 illustrates a downward
arrow of a compulsive cleaner/organiser who did not have contamination
In this case a continuum, as described earlier, was utilised. We also made a
list of character traits of a good and bad person. It revealed the patient’s
double standard; that she did not use cleanliness/neatness to judge other
people’s self-worth but for herself it was the primary indication of her selfworth. This discovery was followed by a survey in which she asked
friends/family to identify character traits associated with a good and a bad
person. We also completed some behavioural experiments that entailed going
outside with small stains on her clothes, leaving dishes in the sink when company was coming over, and altering the arrangement of knick knacks. These
behavioural experiments were not done for the purpose of habituation as they
are in ERP but rather to test the appraisal that cleanliness/neatness does not
equal self-worth. After these behavioural experiments were completed the
patient was debriefed regarding her experience and what she learned with
respect to evidence for or against the alternative appraisal she discovered
with the help of the therapist.
Beliefs/assumptions underlying appraisals
In addition to challenging appraisals, it is also important to address the
beliefs/assumptions that are thought to result in appraisals. The
beliefs/assumptions can be as varied as the appraisals they produce. For
example, the assumptions of a checker we treated included “If I’m not perfect, I’m a failure”; “I can’t trust anybody but myself ”. “The world is
dangerous” and “If I’m not careful something bad will happen” were some of
the assumptions identified by a patient who felt compelled to imagine disasters happening to her family when she heard about such events in the news. If
she did not “play out” these painful images she was convinced they would
occur in real life.
Once these assumptions are identified we have typically asked patients to
Psychosocial treatment for OCD
describe the associated characteristics. Their adjectives have included rigid,
unattainable, unrealistic, absolute, and threatening. Patients are asked if they
can determine a connection between the assumptions and their OCD, the
ways in which these rules have influenced their lives, and possible experiences
that may have resulted in the formation of these rules. Most patients identify
salient experiences that occurred early in their lives that logically relate to the
rules. Alternatives to these rules are developed through cognitive challenging,
which is similar to challenging appraisals. The goal is to develop alternatives
that are flexible and reflect the complexities of adult life. As such, the alternatives that are developed are necessarily more elaborate (e.g., a possible
alternative to “the world is dangerous” may be “there are certain dangerous
things in our environment, but many are safe until demonstrated otherwise”).
A special case of challenging beliefs is considered when working with
patients who are primarily obsessional. The beliefs (and the appraisals) typically reflect some personal significance about the person. These people
typically believe that the presence of the thoughts says something about their
value as a human being. For example, we treated a female patient who had
sexual obsessions and believed that she was a “totally depraved person”.
Although they are generally considered to be more challenging to treat
compared to people who have primary compulsions, obsessionals do benefit
from CBT that focuses on changing the meaning of the intrusive thought
(e.g., Freeston et al., 1996).
Potential hazards for clinicians in using CBT with
Implementing CBT with obsessive-compulsives is complex and as such there
are many places for clinicians who are unfamiliar with the protocol to have
difficulty. Van Oppen and Arntz (1994) thoroughly discussed the pitfalls in
doing CBT with OCD patients. Whittal and McLean (1999) have also discussed ways in which common problems are handled.
One of the most common pitfalls is attempting to challenge the intrusion
(e.g., “Is the stove off ?”) as opposed to the appraisal (e.g., “There will be a
fire and it will be my fault”). Identifying appraisals can be difficult for
patients to accomplish but intrusive thoughts are comparatively easy to identify. When patients are attempting to identify appraisals, they should focus on
the personal meaning associated with the intrusive thought/image/impulse.
Writing the cognitive behavioural model on a dry erase board or piece of
paper and identifying the intrusion and appraisal from an example can also
be helpful in differentiating the two concepts. If the intrusion is challenged
and not the appraisal, it is likely that the clinician will be attempting to convince the patient that their intrusion is not true. Most patients already know
it is not true and this strategy will at best not be helpful and at worst result in
an argument.
Maureen L. Whittal, S. Rachman, and Peter D. McLean
Identifying feared consequences and labelling them as appraisals is another
common problem. For example, with the intrusion “is the stove off ”, we
have had patients initially identify the appraisal as “the house will catch on
fire”, which is the feared consequence. To accurately identify the appraisal,
the meaning behind the feared consequence must be identified (i.e., “what
would it mean to you if the house caught on fire?”).
Of the cognitive domains discussed earlier, clinicians who are unfamiliar
with contemporary CBT with OCD patients may tend to rely too much on
overestimation of threat and focus on reducing probability. Overestimation of
danger is common among the anxiety disorders and calculating logical probabilities is a central feature of panic treatment (e.g., Otto, Pollack, & Barlow,
1996) and is a powerful strategy. Treatment of OCD is more complex compared to panic. Although a reduction of probability (as illustrated in Table
5.2) is part of cognitive challenging, it is not sufficient. As indicated by van
Oppen and Arntz (1994), risk = chance × consequence. Risk will not be
reduced without attending to consequence (which is typically responsibility
related) in addition to probability.
Similarly, clinicians who were trained as behaviourists or those who are
accustomed to doing ERP with OCD patients may rely too heavily upon
behavioural experiments to change appraisal. Contemporary CBT with OCD
patients is much more than doing behavioural experiments to “see what
Treatment outcome using CBT
To date there have only been two published controlled trials using the contemporary CBT protocol (Freeston, Ladouceur, Gagnon, Thibodeau, Rheume,
Letarte, & Bujold, 1997; van Oppen, de Haan, van Balkom, Spinhoven,
Hoogduin, & van Dyck, 1995) and a handful of case studies (e.g., Ladouceur,
Freeston, Gagnon, Thibodeau, & Dumont, 1995; Ladouceur, Leger, Rheume,
& Dube, 1996). Emmelkamp and colleagues (e.g., Emmelkamp & Beens, 1991;
Emmelkamp, Visser, & Hoekstra, 1988) have presented treatment outcome
data using an early version of the CBT that is now being advocated.
Freeston et al. (1997) used a contemporary CBT package to treat 29 OCD
patients who exclusively experienced covert compulsions. Treatment involved
a cognitive behavioural explanation of the occurrence and maintenance of
obsessive thoughts, exposure to obsessive thoughts, preventing all neutralising, cognitive challenging of appraisals, and relapse prevention. Compared to
a wait-list condition, the treated group reported a significant decrease in
obsessions and anxiety and an increase in functioning. These gains were
maintained at 6-month follow-up. Although ERP was used in this study,
Freeston et al. (1997) suggest that the cognitive restructuring techniques were
essential to the successful outcome given that obsessional ruminators are
notoriously difficult to treat behaviourally.
Psychosocial treatment for OCD
Van Oppen et al. (1995) reported on 57 patients who were treated with
either cognitive therapy as conceptualised by Salkovskis (1985) or exposure.
Patients in the cognitive therapy group completed behavioural experiments to
test appraisals and thus did receive some exposure. There were no statistical
differences on OCD severity between the groups at post-treatment. However,
a higher percentage of patients in the cognitive therapy group were rated
recovered (50%) compared to the exposure group (28%). As noted by
Steketee, Frost, Rheume and Wilhelm (1998), the post-treatment dependent
measure (Yale-Brown Obsessive-Compulsive Scale – YBOCS; Goodman,
Price, Rasmussen, Mazure, Fleishmann, Hill, Heninger, & Charney, 1989)
was higher compared to studies that used similar protocols, which suggests
that the exposure was not as powerful as in previous studies.
A treatment trial has recently been completed at the University of British
Columbia comparing the CBT package described in this chapter and ERP
(Whittal, McLean, Thordarson, Koch, Taylor, & Sochting, 1998). Patients
were treated in small groups with two therapists; 31 patients completed the
CBT condition and 32 completed the ERP condition. Patients in both conditions reported a significant decrease in YBOCS score pre to post treatment.
However, at post-treatment YBOCS scores of patients in the ERP condition
(13.2) were significantly lower compared to patients in the CBT condition
(16.1). It is possible that the nature of group treatment did not allow for the
idiosyncratic OCD appraisals to be properly addressed, thereby making treatment less effective. To address this issue, the same protocol was used to treat
patients individually. Data collection is currently ongoing. At the time of
writing this chapter 14 patients have completed the CBT condition and 23
have completed the ERP condition. Although the sample size is relatively
small, YBOCS scores are lower for subjects in the CBT condition (7.9) compared to the ERP condition (10.1). Although the results of the individual
study are tentative, it appears that ERP works equally well in groups or individually, whereas CBT is more effective individually than in groups.
Case studies or case series have also pointed to the effectiveness of a cognitively focused OCD treatment. For example, Ladouceur et al. (1995)
completed CBT on three patients who experienced obsessions and covert
compulsions. Subjects were treated in a multiple baseline design where treatment was initiated on different days for each of the three patients. Treatment
involved a combination of exposure and response prevention using a “loop
tape” and cognitive restructuring that focused on inflated responsibility, perfectionism, overimportance of thoughts, and overestimations of danger. All
patients responded positively to the cognitive behavioural intervention and
maintained their gains at follow-up. Ladouceur et al. (1995) indicated that it
was impossible to determine if the behavioural elements or the cognitive
components or the combination were responsible for the successful outcomes.
Exposure may function to provide evidence that the original OCD appraisals
are not valid (i.e., that the situation is not as dangerous as was originally
Maureen L. Whittal, S. Rachman, and Peter D. McLean
appraised). To determine the utility of a cognitive treatment approach, it
would need to be tested in the absence of exposure.
Ladouceur et al. (1996) treated four checkers with a purely cognitive protocol that focused on appraisals of inflated responsibility. These patients
were given no exposure homework during the course of treatment.
Ladouceur et al. (1996) reported a significant decrease in pre- to postYBOCS scores for all participants. Gains were maintained at 6- and
12-month follow-ups for three of the four patients.
Exposure and response prevention has been the psychosocial treatment of
choice for OCD, resulting in well-documented and consistent therapeutic
outcomes. However, fear generated by the rigours of exposure-based treatment has resulted in relatively high levels of treatment refusal and drop-outs,
and obsessions without overt rituals have proven difficult to engage with
ERP. Such limitations have encouraged exploration of alternative models of
OCD. Following Salkovskis’ (1985) influential cognitive theory of OCD in
which it was proposed that beliefs about personal responsibility form threatening appraisals of intrusive thoughts in OCD sufferers, the work of a
number of investigators systematically articulated other distorted beliefs and
implicated their role in OCD.
In the CBT protocol for OCD outlined in this chapter, five types of distorted beliefs, identified by consensus amongst investigators, are defined and
illustrated. It is expected that the structure and function of such beliefs will be
further clarified over time. We have outlined a CBT protocol for OCD that
addresses some of the intricacies of this treatment as well as typical difficulties faced by therapists and have suggested ways around the challenges. Early
CBT case studies and controlled trials have been promising, posting results
generally equivalent to ERP and in several studies superior.
The mechanisms by which ERP and CBT effect change are probably more
complex than habituation and insight, respectively. Patients undergoing ERP
may well be doing self-directed cognitive therapy, unbeknownst to the therapist, as a function of interpreting their exposure-based experiences. And it
appears that CBT induced improvements are the result of much more than
insight and depend upon a skilled and systematic consideration of alternative
explanations to invalidate fearful appraisals of intrusive thoughts and images.
CBT is well received by OCD patients and holds considerable hope for those
who cannot tolerate, or who are unresponsive to, ERP. Interestingly, treatment
effectiveness may be a question of individual differences in matching patients to
type and modality of treatment. More concrete and less psychologically minded
OCD patients may do better with ERP, while others benefit more from CBT.
Our preliminary evidence is that ERP is easier to deliver in group format than
CBT, but is less effective than CBT when delivered on an individual basis.
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Chapter 6
Cognitive behavioural therapy
for worry and generalised
anxiety disorder
Michelle G. Newman and Thomas D. Borkovec
The goal of this chapter is to present an overview of cognitive behavioural
therapy (CBT) for generalised anxiety disorder (GAD). The symptomatic
picture of GAD is first described. Specific techniques developed by cognitive
behaviour therapists to reduce GAD symptoms are then presented. In addition, the empirical evidence supporting the effectiveness of CBT for GAD is
reviewed. Although CBT is the only current form of therapy for GAD that
has been empirically supported (Chambless, Sanderson, Shoham, Johnson,
Pope, Crits-Christoph et al., 1996), this chapter also addresses the limitations
of this treatment and suggests research directions for improving its
According to the fourth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV; American Psychiatric Association, 1994), the
current definition for GAD is excessive and uncontrollable worry about a
number of events or activities. To be diagnosed, the person has to worry
more days than not for at least 6 months and the worry must be associated
with significant distress or impaired functioning. In addition, the person’s
symptoms cannot be due to a drug, a general medical condition, or another
Axis I condition. Throughout most of the time period the person is uncontrollably worrying, he or she must also be experiencing three of six symptoms
(restless/keyed-up/on-edge, fatigue, difficulty concentrating, irritability,
muscle tension, and sleep disturbance) that are associated with autonomic
nervous system activity. The selection of these particular symptoms was
based on psychophysiological research showing reduced variability in autonomic nervous system activity of GAD clients (e.g., Hoehn-Saric, McLeod,
& Zimmerli, 1989).
Prior to DSM-IV, the diagnostic criteria for GAD went through several
changes. It first appeared in 1980 in the third edition of the DSM (American
Psychiatric Association, 1980) as a subdivision of the previous category of
anxiety neurosis. At this time, the diagnostic criteria focused on chronic
Cognitive behavioural therapy for worry and GAD
diffuse anxiety, symptoms of apprehensive expectation (worry), vigilance or
scanning, motor tension, and autonomic hyperactivity. However, GAD was
not diagnosed if the individual also met criteria for any other Axis I condition. When DSM-III was revised to DSM-III-R (American Psychiatric
Association, 1987), GAD was made a primary diagnosis even if the person
met criteria for other Axis I disorders. Another change was that its central
component was considered to be apprehensive expectation (worry). For diagnosis to occur, the person also had to experience six of eighteen symptoms
associated with motor tension, autonomic hyperactivity, and vigilance (e.g.,
restlessness, frequent urination, and exaggerated startle response).
Although the diagnosis of GAD has only been recognised recently,
research evidence suggests that a significant number of individuals suffer
from this disorder, with prevalence rates of 3.6 to 5.1% for lifetime and 3.1%
for one year (Kendler, Neale, Kessler, Heath, & Eaves, 1992; Wittchen, Zhao,
Kessler, & Eaton, 1994). GAD is also one of the most frequent additional
diagnoses to other anxiety and mood disorders (Brown & Barlow, 1992). In
addition to being a frequent primary or secondary disorder, the central feature of GAD, excessive or uncontrollable worry, is a common symptom in all
of the anxiety and mood disorders (Barlow, 1988). Moreover, when GAD is
successfully treated, comorbid diagnoses are diminished or eliminated
(Borkovec, Abel, and Newman, 1995). In fact, its early onset, chronicity, and
resistance to change has led researchers to suggest that GAD forms the basis
of other anxiety disorders (Brown, Barlow, & Liebowitz, 1994). Moreover,
GAD may play a role in the maintenance of many disorders. Research suggests that worry prevents emotional processing. Worry may thus interfere
with the treatment of psychological problems, such as anxiety disorders, for
which such processing is crucial for therapeutic change (Borkovec, 1994;
Borkovec & Newman, 1998; Newman, 2000b). The development of effective
therapies for GAD may therefore lead to advances in the treatment or prevention of other disorders.
Cognitive behavioural therapy techniques
The symptoms of GAD are thought to result from spiralling, habitual, inflexible interactions of cognitive, imaginal, and physiological responses to
constantly perceived threat (Barlow, 1988; Borkovec & Inz, 1990). Cognitive
behavioural therapists have developed a series of techniques meant to target
each of the cognitive, imaginal, and physiological response systems
(Newman, 2000a; Newman & Borkovec, 1995). These interventions are aimed
at providing the client with numerous coping skills, with the goal that it might
help them develop a flexible, adaptive lifestyle conducive to reduced anxious
experience. The specific techniques that are part of the clinical repertoire of
CBT therapists include self-monitoring, stimulus control, relaxation, selfcontrol desensitisation, and cognitive therapy. This section will provide a
Michelle G. Newman and Thomas D. Borkovec
detailed description of each of these techniques. Before doing so, however, it
is important to present a brief description of the overarching rationale and
guidelines underlying this treatment.
Cognitive behavioural therapy is based on the premise that most of the
therapeutic change takes place between sessions and is the consequence of
client practice and application of CBT techniques. Therefore, the therapist
must ensure that clients fully understand the value and method of application
of each technique as well as the importance of regular practice. In therapy for
GAD, clients are told that worry is the result of habits from the past and that
therapy is focused on teaching them new skills. As with any skill, therapy
techniques require frequent practice before they can be mastered. Each time
a new cognitive or behavioural technique is introduced in therapy, it is helpful for the therapist to practise it with the client in an attempt to create an
immediate, noticeable, and positive effect, however slight. Such a demonstration may help clients develop confidence that the technique can make a
difference for them with further practice and application. The more confidence clients have in any one technique, the more motivated they will be to
practise it routinely and the more helpful it will be.
Self-monitoring and early cue detection
The first step in therapy is the detection of cues that trigger anxiety. These
cues can be either internal or external. Important internal cues may include
attention, thoughts, images, bodily sensations (especially muscle tension),
emotions, and behaviours. External cues refer to stressful events in a client’s
life. These can include such things as a subtle comment or gesture made by
another person or unexpected financial or work demands, as well as ambiguous situations in which the client lacks information. In CBT, more attention
is placed on internal cues than external cues. Clients are told that it is not
their reactions to events that are the problem. Their reactions to their reactions are the problem. The goal of therapy is to change their reactions to their
reactions and to strengthen new coping responses.
Therapy emphasises detection of initial cues of anxiety. These early cues
typically lead to a spiralling up of anxiety involving, for example, the perception of stressful events (e.g., an ambiguous comment made by their boss)
followed by an anxious thought (“he thinks I’m not doing a good job”),
which leads to a physiological response (e.g., increased muscular tension),
which in turn creates another worrisome thought (“maybe he will fire me”),
leading to a negative emotion (e.g., anxiety and depression), which then generates more anxious thoughts (e.g., “I’m a failure and I will never be able to
provide for my family”). By intervening in response to early cues for anxiety,
therapists teach clients how to cut off the anxiety spiral before it reaches a
high level of intensity. The earlier clients can identify initial cues for anxiety,
the earlier they can intervene.
Cognitive behavioural therapy for worry and GAD
There are many approaches that can be used by therapists to help clients
identify early anxiety cues. One of them is to ask clients to give a detailed
description of a situation that created worry in terms of what they attended
to, did, thought, imagined, and physically and emotionally felt. Alternatively,
the therapist can ask them to imagine themselves in a past or upcoming
anxiety-provoking situation. Another method is to have clients recreate their
worry process by worrying silently about a topic of concern. Clients may
also worry out loud to provide the therapist with information on the nature
and content of their worry. Moreover, the therapist can help clients identify
early cues by looking for any detectable shift in their affective state and asking
them to describe what is occurring at that moment. In addition, clients can be
encouraged to tell the therapist when they notice the beginning of anxiety
cues. It is also helpful to have clients regularly record information about
worry periods as they are happening. Clients can document the first external
or internal cue that they noticed, the content of the worry, their highest level
of anxiety, and the length of time that they worried. This method can help
them gather an accurate record.
Self-monitoring of anxiety cues on a moment-to-moment basis forms
the foundation for CBT with GAD. In addition to aiding the identification
of anxiety triggers, such self-monitoring helps the therapist identify particular patterns that are idiosyncratic to any one client and to track the impact
of therapy. Moreover, clients can use self-monitoring to identify and attend
to additional emotions other than anxiety such as anger, frustration, and
depression. Such emotions are frequently involved as an initial cue or integral part of an anxiety spiral and could therefore be specific targets for CBT
Remembering to record information at the time it happens is a difficult
challenge for clients. However, the therapist can help the client by suggesting
ways to create reminders in their environment. For example, the client can
monitor their anxiety every hour or at every change in activity. Over time, the
client can begin to identify more specific reminder cues that are stressful to
them, such as whenever the phone rings, or whenever a particular co-worker
is seen during the day. The important thing is to establish an ample number
of effective cues so that clients are repeatedly reminded to observe their inner
processes. The ultimate goal is to develop a habit of recognising early anxiety
and to intervene at that moment with all the coping responses that have been
learned up to that point.
Stimulus control methods
GAD clients develop the habit of worrying in multiple situations. Such a
habit creates numerous internal and external cues that over time come to
trigger worry responses in and of themselves. Stimulus control techniques can
help the client reduce the association between worry and these specific cues
Michelle G. Newman and Thomas D. Borkovec
(i.e., the discriminative stimuli), which in turn can reduce the intensity and
frequency of the worry response. As a first step, clients are instructed to
schedule a daily 30-minute period during which they will worry. This period
should occur at the same time and place every day and may not be associated
with work or relaxation. At all other times and places, they must actively
postpone any worrying until this 30-minute period. To achieve this task
clients must pay attention to the internal and external events that start the
spiral cycle of worrisome thoughts and anxiety responses (e.g., walking into
their office and sitting down in front of the computer as they prepare to
write a paper). Whenever they detect such a cue they can postpone their
worry (“Okay, I know that I usually get very anxious when I start writing a
paper, but this time I will postpone my worry until my designated worry
period. At that time, I can worry as much as I want”) and concentrate on the
task that they had planned to do (e.g., writing for an hour) or focus their
attention on what is going on in their environment (i.e., to focus on steps
necessary to write, but this time without worrying). When the worry period
arrives, the client can go to the designated place and worry intensively. If, for
any reason, they have difficulty controlling or postponing their worry during
specific times of the day (e.g., while lying in bed at night prior to going to
sleep), they should go immediately to the designated “worry” spot, and worry
intensively until their worry is under control. Only then are they allowed to go
back to their previous destination.
These procedures provide the client with a sense of control over their
worry. With practice, they learn that they can intentionally reduce their worry
in specific situations, as well as increase it when they decide to do so. As the
therapy progresses, therapists also use the client’s ability to create worry on
demand to help them practise cognitive behavioural techniques to reduce the
worry response. The effectiveness of these stimulus control methods has been
supported with college samples of chronic worriers (Borkovec, Wilkinson,
Folensbee, & Lerman, 1983).
Relaxation methods
The physiological process of GAD clients is characterised by autonomic
rigidity. Methods that can increase autonomic flexibility may therefore be
beneficial to individuals with GAD. In the clinical repertoire of CBT are a
number of relaxation methods that are designed to increase such flexibility.
Therapists, for example, may use diaphragmatic breathing, progressive muscle
relaxation, pleasant imagery, meditation, and daily application of applied
relaxation. The variety of these techniques allows the therapist to identify
which methods are most effective for specific individuals who are experiencing anxiety in particular situations.
Cognitive behavioural therapy for worry and GAD
Diaphragmatic breathing and progressive muscle relaxation
A relaxation technique that is easy to teach clients and that often produces a
rapid relaxation response is slowed, paced, diaphragmatic breathing. This
technique can be introduced by telling clients that people with anxiety problems often breathe more from their chest than their diaphragm. Chest
breathing stimulates the sympathetic autonomic nervous system which produces many uncomfortable bodily sensations that people experience when
they are anxious. On the other hand, diaphragmatic breathing stimulates the
parasympathetic nervous system which produces the comfortable feelings
experienced during deeply relaxed states. To demonstrate the anxiety-inducing impact of chest breathing, the therapist can first model and then have
clients practise rapid, shallow, thoracic breathing for 1 minute or until they
begin to feel anxious or uncomfortable. This can be followed by slowed paced
diaphragm breathing to reduce their anxiety. To help clients ensure that they
are breathing from their diaphragm, they can place one hand on their
diaphragm below their belly button and the other hand on their chest. As
they breathe, only the hand on their diaphragm should move. They should
also be told to keep their breathing smooth by inhaling and exhaling an even
amount of air. These exercises help clients understand the impact their
breathing has on how they feel as well as their ability to instantly control their
physiological and psychological response.
Clients are encouraged to shift to diaphragmatic breathing whenever they
notice chest breathing during the session, or in their day-to-day activities.
Monitoring and modifying their breathing habits provide clients with a fastacting and easy-to-learn method to control anxiety spirals upon early cue
detection. Similar to other cognitive behavioural techniques, the key for the
effectiveness of diaphragmatic breathing is repeated rehearsal.
Another helpful relaxation technique is progressive muscle relaxation
(PMR), which involves systematic tension production and subsequent release
of various muscle groups. Initially, clients tense and release 16 separate
muscle groups. The muscle groups that are addressed include the right hand
and lower arm, left hand and lower arm, right biceps, left biceps, upper face,
central face, lower face, neck, chest, shoulders and upper back, abdomen,
right thigh, left thigh, right calf, left calf, right foot and left foot. As therapy
progresses, muscle groups are tensed and relaxed in combinations. Thus, after
16 muscle group PMR is mastered, the client can produce and release tension
in 7 combined muscle groups and then 4 muscle groups each tensed at the
same time (e.g., muscles of the left and right arms, hand and biceps, muscles
of the face and neck, muscles of the chest, shoulders, upper back and
abdomen, and muscles of the left and right thigh, calf and foot). Eventually,
clients learn to relax their muscle groups without tensing them; the muscles
are relaxed by the client remembering the feeling created by repeated exercise
of tension and release. This is caledl “relaxation-by-recall”.
Michelle G. Newman and Thomas D. Borkovec
At the same time clients are taught PMR, they are introduced to the notion
of “letting go” of anxiety. Specifically, the client is taught that during relaxation practice, as they are letting go of physical tension, they can actively let
go of anxious emotions. The process of letting go can also be generalised to
other components of the anxiety response. Clients, for example, can stop
their anxiety spiral by letting go of worrisome thoughts or images. To help
clients master the skill of letting go, the therapist can tell them to focus on
their breathing during PMR and to clear their minds of all other thoughts.
Whenever they become aware of a distracting thought, image, or emotion,
they should not force it away, but rather, imagine it floating out of their head
as though it were a balloon filled with helium. Another helpful technique is
to have clients repeat a particular cue word such as the word “calm” over and
over, similar to a mantra during meditation practice. As they are practising
PMR, their goal is to focus all of their attention on that particular cue word.
Whenever they notice their mind wandering, they can use that word to refocus their attention.
Frequently, diaphragmatic breathing and PMR are not sufficient to allow
GAD clients to achieve a pleasant state of relaxation. This is because the subjective world of these individuals is dominated by worrisome images and
thoughts. Cognitive behaviour therapists therefore often use relaxation techniques which focus on positive mental images. In using pleasant imagery, for
example, therapists invite the client to imagine a person or a place in their life
that is associated with a feeling of serenity, peace, and/or comfort. Whenever
they are feeling anxious, the client can then imagine themselves in that place
with all of the sights, sounds, smells, and tactile sensations that would be present. A client, for example, may imagine him/herself sailing on a calm sea,
enjoying a cool breeze, a warm sun, and the thought of an infinite and serene
journey. The therapist can also apply the technique of guided pleasant
imagery in which the therapist and client work together to construct a relaxing mental scene for the client to imagine and then elaborate on as the client
progressively achieves a deeper state of relaxation. Using the above example,
the client might first imagine setting off on a sailboat in the calm sea and as
the ship moves away from the harbour, they are leaving behind all their troubles, and becoming more and more relaxed as the people, houses, and boats
on the shore get smaller and smaller.
Therapists should be aware, however, that for some GAD clients letting go
of tension to attain a fully relaxed state may, in itself, generate anxiety which
can interfere with that very goal. This is because many GAD clients are perfectionistic, fear losing control, or are uncomfortable with the increased
awareness of feelings sometimes elicited by relaxation (Heide & Borkovec,
1984). If the means for reducing anxiety is itself anxiety-provoking, the probability of a therapeutic impact is minimal. In fact, in the three published
GAD therapy investigations that assessed for relaxation-induced anxiety
(RIA) during training, it negatively predicted outcome (Borkovec & Costello,
Cognitive behavioural therapy for worry and GAD
1993; Borkovec & Mathews, 1988; Borkovec, Mathews, Chambers, Ebrahimi,
Lytle, & Nelson, 1987).
Luckily, there are several techniques available that can help the therapist
work around this problem. In one of these techniques, the therapist can
describe relaxation training in terms of “movement toward relaxation”. The
client can be told that the goal of the treatment is not to achieve a specific end
point where the presence of anxiety has been eradicated from their life. The
essence of the treatment is presented as a gradual process of change which is
aimed at facilitating clients’ mastery over the anxiety spiral pattern that has
invaded their life. Another way to reduce the likelihood that clients will experience RIA is to emphasise repeated applications of brief relaxation responses
to detected anxiety cues in place of twice-a-day formal practice of deep relaxation. Clients can be told that frequency of application is more important
than depth of relaxation. Teaching clients alternative relaxation techniques is
also helpful because clients who experience RIA in response to one relaxation
technique rarely experience it in response to another (Heide & Borkovec,
1983). Moreover, in more difficult cases, RIA can be viewed as comparable to
graduated exposure to a feared situation. Similar to other such exposure
methods, relaxation can be practised by having the client expose themselves
to increasingly deeper relaxation levels as therapy progresses. When these
techniques were used in a recently completed Penn State therapy study
(Borkevec, Newman, Pincus, & Lytle, in press), the initial presence of RIA no
longer predicted treatment outcome.
An important underlying objective of relaxation training is to decrease
the amount of time clients spend worrying about the future or the past by
increasing their focus on the present moment. Focusing excessively on the
future or past is an inattention to the immediate environment. This inattention impedes clients’ ability to process new information which prevents
learning and development. The clients can, however, learn to re-focus their
attention on the present environment. They can begin by closing their eyes
and getting in touch with whatever small sensations they may hear, smell, and
feel. Then, whenever they notice their mind wandering, they can re-focus
their attention on these sensations. After doing this exercise with their eyes
closed, clients can repeat it with their eyes open and eventually as they are
walking around. After they have practised this exercise with the therapist,
clients can also try this exercise as a homework assignment whenever they
notice that they are not focused on the present moment.
Another goal of relaxation is to increase the clients’ adaptive behaviour.
Since anxiety has been repeatedly shown to reduce performance, it is not
surprising that with increased mastery of relaxation techniques clients report
being more effective at work and more at ease in social situations. Because all
aspects of the human system are in constant interaction, the decrease in
autonomic rigidity created by apparently simple relaxation techniques can
have a synergetic impact on other components of the clients’ functioning. The
Michelle G. Newman and Thomas D. Borkovec
therapeutic benefit of relaxation practice, however, is more than likely to
increase with the addition of applied relaxation.
Applied relaxation (AR)
Applied relaxation is a technique in which clients actively let go of tension on
a moment-to-moment basis whenever they detect initial anxiety cues or subtle
shifts toward anxiety. Clients can be asked to regularly scan their body and
mind for physiological, cognitive, or behavioural anxiety cues, and then to
use diaphragmatic breathing or release of muscular tension as a rapid coping
response to such cues. As opposed to the relaxation techniques described
above, AR is not used by the client at times when they are alone and in a
comfortable situation (e.g., lying in bed while getting ready to read a novel).
It is primarily designed to help clients reduce their anxiety as they are
engaged in day-to-day activities, such as performing a task at work or interacting with others. A specific aspect of this technique is called cue-controlled
applied relaxation. In cue-controlled relaxation, a particular word (e.g.,
“relax”, “calm”, or a word taken from meditational focusing devices) that
was paired with the feeling of “letting go” during the formal practice of
any relaxation technique is used by clients as a signal for applied relaxation
in the midst of stressful situations (internal or external) or in response to any
anxiety trigger.
To facilitate the generalisation of applied relaxation skills to daily living,
clients can practise differential relaxation training. For this technique, clients
are taught to relax themselves when walking and as they engage in various
common activities. The therapist helps clients to differentiate the muscular
tension that is required for specific activities from any excessive or unnecessary tension that clients typically experience when performing these
activities. The client’s task is then to learn how to relax away such excessive
tension, without removing themselves from the activity in which they are
Similar to other CBT techniques, AR should be used frequently between
sessions to help clients adopt a more habitually relaxed lifestyle. They can be
told that stressful events have three phases (anticipation of the event, during
the event, and recovery from the event) and that applied relaxation is particularly helpful when used throughout each of these phases. Using AR in
anticipation of or during the event may well prevent the spiral of anxiety
from reaching a paralysing level. The same coping skills used after the event
can help clients more rapidly achieve a sense of self-control and decrease the
amount of time they may spend worrying about the past event. As they
develop increased mastery of AR, clients can apply this technique to progressively more stressful situations, as would be done in any type of exposure
Cognitive behavioural therapy for worry and GAD
Self-control desensitisation (SCD)
Clients’ physiological reactions to images are similar to their reactions to
real events. In addition, worrying prevents emotional processing, whereas
imagery can be an effective method for engaging such processing. For these
reasons, imagery exposure is particularly important to the treatment of GAD.
Self-control desensitisation (SCD) is an imagery technique that was
designed to be applied to anxiety problems such as GAD, in which there are
no discrete phobic stimuli (Goldfried, 1971). This technique requires less
detailed hierarchy construction than techniques associated with circumscribed anxiety problems (e.g., systematic desensitisation for insect phobia).
Instead of identifying a phobic stimulus, clients identify external situations
that are representative of those associated with anxiety and worry. Within
each situation, the client also identifies physiological, cognitive (especially
worry and catastrophic images), and behavioural cues for their anxiety spirals as well as external triggers. Identified situations are roughly graded as
mild, moderate, or severe in anxiety-provoking value. The client can begin
with mildly anxiety-provoking situations, and as they become more proficient with the technique they can move to situations rated as moderate and
later severe.
The implementation of SCD requires several steps. In the first step,
clients formally practise PMR until they are fully relaxed. Next, they imagine themselves in a circumstance that commonly elicits anxiety. For
example, a client who often worries about being late, might imagine themselves in their house, about to leave for work, and unable to find their car
keys. They continue to imagine themselves in this scene until they notice
anxiety cues. As soon as anxiety is elicited (which can be signalled to the
therapist during in-session practice by raising their finger), they relax it
away as they picture themselves coping effectively with the situation (e.g.,
calmly trying to recall the last place they may have left their car keys).
After they no longer notice the anxiety cues (which can be signalled by
lowering their finger), they continue to imagine themselves relaxed and
coping effectively with the situation (for about another 20 seconds). Finally,
clients stop imagining the situation and return to focusing solely on the
process of relaxation (about 20 seconds).
SCD is aimed at having clients repeatedly practise relaxation applications
to the types of situations that trigger anxiety. Although this technique may
lead to some extinction of the connection between anxiety and specific triggers, its effectiveness is probably due more to the strengthening of adaptive
coping responses to representative anxiety cues. The more clients practise
SCD, the greater the likelihood that they will remember to use their CBT
coping responses during daily living. The paragraph below is an example of
the sort of therapist patter that can be used when conducting formal insession SCD practice.
Michelle G. Newman and Thomas D. Borkovec
When I begin to present the images, try to picture yourself as if you are
actually in the situation, picturing the associated sights, smells, and sounds.
In addition, please raise your finger at the first moment that you begin to
feel any tension or anxiety. Once you have signalled, continue to picture
yourself in the situation that I am depicting, and hold your finger raised
until you are aware that your anxiety is dissipating . . . Visualise yourself at
home near your front door about to leave for work . . . Imagine that as you
reach into your purse to get your keys, they are not in their usual place . . .
Imagine thinking, ‘What if I am late?’ . . . ‘What if my boss goes to look for
me, and he notices I haven’t arrived yet?’ . . . You can feel the anxiety
beginning to increase as your mind is thinking these things . . . Your tension and anxiety are escalating as you continue to worry about being
late . . . Imagine that your heart is racing faster and faster.
When the client raises their finger to indicate that they are feeling anxious, or
after you have been presenting the scene for 60 seconds and they have not signalled anxiety, instruct the client to begin to apply their coping strategies:
Now continue to imagine yourself at home near your front door, as you
imagine yourself letting go of the anxiety . . . Just visualise yourself letting
go of and relaxing away the anxiety completely . . . Calm and peaceful,
quiet and relaxed . . . Imagine that relaxation is reducing the speed of your
heart, the tension in your muscles . . . Anxiety dissipating, just melting
away . . . Your muscles are becoming more and more smooth and regular . . . Breathing becoming more and more even . . . As you imagine
yourself at home, calmly trying to determine where you may have left your
keys . . . Relaxing more and more and focusing on finding your keys . . .
If the client does not signal that the anxiety cues have dissipated, the therapist can continue to present the scene as the client pictures themselves coping
with it for an additional 20 seconds. However, if after an additional 20 seconds, the client still does not indicate relaxation, the therapist can discontinue
their presentation of the image and have the client focus solely on relaxation.
If the client does indicate that their anxiety has dissipated by lowering their
finger, the therapist asks the client to continue picturing themselves in the
scene and coping effectively:
Just continue imagining yourself at home calmly retracing your steps . . .
Relaxing more and more completely . . . Your breathing becoming even
more smooth and regular . . . Loosening up and becoming more and
more comfortably and deeply relaxed . . . Nothing to do but to enjoy the
pleasant sensations of relaxation as the relaxation process continues to
take place as you imagine yourself calmly at home focusing on finding
your keys.
Cognitive behavioural therapy for worry and GAD
Then instruct the client to stop visualising that scene and to continue focusing on the relaxation for another 20 seconds:
Allowing the relaxation process to continue . . . Calm and quiet . . .
Breathing smoothly and slowly, calm, heavy, and relaxed . . . Peaceful
relaxed . . . nothing to do now but to simply enjoy the pleasant feelings of
During each in-session practice, the therapist should present the image at
least three times or until the client indicates the absence of anxiety in response
to two consecutive presentations.
After the client has practised SCD for a period of time, the therapist can
introduce several anxiety cues associated with any one image. The ultimate
goal of this technique is for the client to be able to picture all of the cues that
are representative of his or her anxiety triggers, either with no anxiety or
being able to rapidly terminate the anxiety. Of course, every single cue cannot
be paired with every anxiety-provoking situation. However, the therapist
should make the effort to cover a sample of representative environmental
contexts as well as all of the internal anxiety cues the client typically
Following the first formal SCD practice that is conducted in the session
with the client, he or she is asked to use the technique at the end of his/her
daily relaxation practice sessions. The client starts by using the image that was
introduced in the last therapy session after each relaxation practice. He or she
can use this same image until it is no longer anxiety-provoking, at which
time another anxiety-provoking image can be substituted.
Eventually, when the client has begun to master SCD, the therapist can
introduce some variations of this technique. For example, periodically when
the client is describing a situation that they are worried about (e.g., an upcoming presentation to a group), the therapist may suggest that they briefly close
their eyes and imagine themselves in the situation and then imagine themselves effectively coping with the situation (e.g., “as you relax away your
anxiety, imagine yourself standing in front of the group, giving an excellent
presentation”). Another helpful variation involves the sequential presentation
of a series of representative anxiety-provoking images, with no advance warning to the client. This introduces the same sort of surprise that is prototypical
of real life. As the therapist is presenting the images, clients imagine themselves effectively coping with each one.
Cognitive therapy
Cognitive therapy (CT) is based on the idea that our emotions are often the
result of how we interpret situations around us. The importance of this technique for GAD clients is demonstrated by studies showing that these
Michelle G. Newman and Thomas D. Borkovec
individuals have a tendency to make negative interpretations of and predictions from ambiguous and neutral information (Mathews, 1990; Mathews &
MacLeod, 1994). In addition, the current Penn State GAD project has found
that when clients monitor the actual outcomes of events that they worried
about, 84% of the situations turned out better than they predicted and they
coped better than predicted in 78% of the remaining situations. In only 3% of
all worries did the core feared event (“The predicted bad event will occur, and
I won’t be able to cope with it”) actually happen. This suggests that GAD
clients may be biased toward inaccurately negative interpretations which
remain uncorrected by their positive experiences. Cognitive therapy teaches
clients to actively correct inaccurately negative interpretations by attending to
the evidence around them.
Prior to having clients engage in specific techniques of cognitive therapy,
therapists must help them discover the link between thoughts and anxiety.
This link will become increasingly clearer as clients begin to track and identify the variety of thoughts and images associated with their anxiety and
worry. The therapist can point out that when they are worrying about the
future or the past, they are creating an illusion. Although these future and
past events do not exist now, clients still react emotionally as if the events are
actually occurring. Thus, they create many of their anxious experiences
merely by thinking worrisome thoughts and imagining catastrophic scenes.
CT for anxiety disorders (Beck & Emery, 1985) involves a series of steps
that clients can follow. The first step is for clients to concretely identify the
thoughts, images, predictions, interpretations and beliefs that are creating
anxiety. Next, they treat their thoughts like hypotheses rather than facts and,
as a scientist would, logically gather evidence to support and refute their
thoughts. As part of this evidence, they can estimate the probability that
their feared outcome will actually happen. The probability of something happening in the future is often best estimated by how frequently it has happened
in the past, and clients can search their personal history to come up with a
meaningful estimate of the chances for the occurrence of the feared event.
Distancing methods can also be used by clients to gather evidence. This
method has clients logically analyse the thoughts and predictions of another
person rather than of themselves (e.g., a friend or acquaintance, a hypothetical stranger, or the therapist role-playing someone else). Such distancing
reduces the likelihood of the reliance on habit and allows clients to think
more clearly and to reason more accurately. Once all of the evidence has
been gathered, the next step is to examine it carefully to determine whether
the original thought is accurate (e.g., is there more evidence in support or in
opposition of their thought?). Next, they try to come up with multiple alternative interpretations that are less anxiety-provoking but equally or more
likely to be true based on the evidence they have. They then choose the least
anxiety-provoking, most believable alternative self-statement and substitute it
for the original anxiety-provoking one. In the future, whenever they notice
Cognitive behavioural therapy for worry and GAD
themselves using the old interpretation, they can try to substitute the alternative that may be more true. If they are not convinced that the alternative
view is accurate, they can try testing out the perspective by conducting experiments during their daily life to get the evidence they may need.
The main goal of CT for GAD is to help clients create more balanced
perspectives. CT is not meant to teach clients to look at the world in an unrealistically positive way (e.g., through rose coloured glasses), but rather to
view the world more accurately. The most important therapeutic task is for
the client to objectively view all encountered situations, encode all new information, and to use this information to reconstruct their world view. Our
clinical experience reveals that GAD clients typically show two types of error
thinking that can block this goal. They tend to focus on mental illusions
related to the past or the future, and they excessively attend to negative
aspects of their situation. The therapeutic task, therefore, is to help clients
encode the positive information around them and to become more objective
in their assessment of current, past, and future reality.
To help them determine the accuracy of particular perspectives, clients are
asked to adopt two rules. The first rule is that they should avoid only probable dangers rather than every conceivable outcome. If the danger does not
have a high likelihood of occurrence, there are usually more accurate predictions available. This is a very important rule as GAD clients are very good at
justifying their fears (e.g., “yes, but it is possible that it could happen”). The
therapist can tell clients that there are lots of things that could happen but it
is not advantageous to worry about every single one of those things. One way
to illustrate this point is to describe what life might be like if we worried about
everything that could happen. For example, what if every time I picked up a
pencil, I worried that the point would break, and every time I climbed into a
car, I worried that I would get into a car accident, and every time I took a
shower, I worried that I would slip and fall, etc. In fact, if I didn’t set limits for
myself, I could worry about everything all the time. If the danger does have a
high likelihood of occurrence, the client is asked to rate how well he or she
could cope with the feared outcome. This question is linked with the idea that
even when the feared outcome is likely, we often underestimate our ability to
cope it.
The second rule is that clients should suspend judgement until they have
evidence to support a particular conclusion. This rule can be particularly
difficult to follow since GAD clients often believe that viewing situations in
the most negative light is actually advantageous. For example, a common
belief is that anticipating the worst possible outcome helps them to be more
prepared for it and less disappointed if it actually happens. For such a perspective, the therapist might want to do a cost–benefit analysis. In many
cases the cost of always expecting the worst is sleeplessness, chronic anxiety,
chronic fatigue, depressed mood, etc. In addition, most situations never really
turn out exactly as expected; it is therefore not possible to try to prepare in
Michelle G. Newman and Thomas D. Borkovec
advance. Moreover, even when we expect the worst, we are not able to prevent
feelings of sadness or disappointment when it happens. Thus, we have spent
a longer time period feeling anxious and sad, with no true advantage.
To help GAD clients to become more objective in their assessment of reality, it is useful to ask them to take on the role of scientists in evaluating the
validity of their worries. The clients are invited to monitor the content of
their worry on a daily basis, to test whether their negative predictions have
been valid, and to evaluate how well they were able to cope when their predictions of negative events were correct. Such detailed and specific assessment
of the clients’ worry, predictions, and coping abilities frequently provides a
direct challenge of clients’ distorted thoughts. After such a “scientific assessment” of their worry, clients typically realise that most of their predictions
were unfounded or that they were able to handle the predicted negative event
better than they thought. It is not unusual for a client to realise that even negative events are not all that bad and that sometimes the worst things can turn
out to be the best thing for them. As he had predicted, one client failed to be
offered a job for which he had recently been interviewed. A few weeks later,
however, he was offered what he had for a long time considered to be his
“dream job”. If he had not failed at getting the first job, he would never have
been able to see his dream come true.
At the beginning of CT it may be difficult for clients to generate alternative ways of thinking or believing. Their schematic views of themselves, the
world, and the future have become old and powerful habits that have
allowed them to function well enough in their lives. However, with a greater
number of perspectives available, clients have more choices than when their
perspectives are determined by habit. As they are learning to consider various perspectives, clients may find it helpful to focus first on neutral topics
rather than on internal or external events that generally trigger their anxiety spiral. Therapists may ask their clients to think about the good and bad
things related to a rainy day, or to identify the pros and cons of getting
older. This type of exercise prepares them to approach anxiety-provoking
events from a variety of perspectives, rather than by rigidly committing
themselves to one interpretation. Once clients have agreed to approach
stressful events from a variety of perspectives, the next step is to have them
weigh the advantages and disadvantages of each perspective as well as its
likely accuracy based on logic, probability, and evidence. The final step is to
choose the least anxiety-provoking, most accurate and believable perspective for application.
As clients engage in logical analysis and generate more accurate perspectives, they sometimes report that the alternative perspective just does not feel
true in the way that the old view does, even though it is more logical. There is
very good reason for this. The more one imagines catastrophes, the more
real they feel. In addition, GAD clients have had images of positive outcomes far less frequently, so the “feeling” that these are true is less vivid. To
Cognitive behavioural therapy for worry and GAD
help them make the alternative perspective feel more real, clients will find it
beneficial to integrate some of the more successful realistic perspectives that
they end up adopting about the self and the world into the SCD procedure.
For example, as the client is picturing themselves successfully coping with a
stressful situation and becoming more and more relaxed, they can also substitute a non-anxiety-provoking thought. Using the above SCD example in
which the client was afraid that he or she would be late for work, they might
say to themselves, “Well my boss has also seen me working late quite frequently, so he won’t mind if I’m a few minutes late this morning.”
The cognitive technique of decatastrophising is an important tool when
working with individuals who spend a large portion of their awakened hours
fearing the worst. This involves first specifying what the clients are telling
themselves is the worst outcome. Next, clients delineate the various steps
that it would take to get to that point and the probability that each step
could actually occur. Clients can also specify multiple alternative perspectives
as well as what coping resources exist for each step. Similar to the findings
that result from the “scientific assessment” described above, a detailed analysis of the outcome predicted by clients frequently reveals that the probability
of real catastrophes is low and the risk of a complete lack of coping resources
is virtually absent.
Therapists will also find it useful to set up behavioural experiments to test
clients’ negative predictions. A client who is afraid of being rejected by a
woman, for example, can be invited to test his prediction by purposefully
engaging in a brief conversation with this woman before the following session. In addition to helping such a client to disconfirm his worst fear, this type
of experiment can also be viewed as a form of exposure. Such exposure may
well be therapeutic since research evidence suggests that GAD clients engage
in both cognitive and behavioural avoidance (Butler, Cullington, Hibbert,
Klimes, & Gelder, 1987).
Part of the goal in CT of identifying individual thoughts and images is
eventually to identify recurrent, underlying themes that reflect core beliefs.
One way to access core beliefs is for the therapist to ask clients if they have a
rule for themselves about situations like this. For example, a client who worries about completing housework may have a rule such as, “If my whole
house isn’t spotless at all times, I am a failure as a mother”. Often people
develop such rules for themselves and never bother to question their value or
accuracy. When core beliefs are identified, CT proceeds in similar fashion
using the core beliefs as targets for intervention. The therapist can also use
assessment devices developed to categorise a client’s characteristic styles of
thought. In the current Penn State project, for example, all clients are administered the Dysfunctional Attitude Scale (Beck, Brown, Steer, & Weissman,
1991). This scale is reviewed by all therapists prior to their first therapy session and frequently helps them to quickly identify the core schemata that are
relevant to a particular client. Common schemata included fear of
Michelle G. Newman and Thomas D. Borkovec
disapproval, the idea that they are dependent on others for their happiness, as
well as excessively rigid rules about the way things “should” be.
The ultimate goal of CT with GAD is to help clients create as much freedom as possible within the restraints of their everyday lives. This includes
becoming less influenced by and reactive to other people’s opinions of them
and more flexible with regard to the rules they use to evaluate themselves and
others. At the core of this freedom is helping the client to gradually shift their
attention from extrinsic (e.g., how will other people judge me) to the intrinsic
rewards (e.g., how can I discover joy in this task at the moment I am doing it).
By re-focusing their attention to the joy of the present moment and shifting
away from their focus on the desired outcomes, clients discover that they
spend much less time generating worrisome thoughts about potential consequences and more time enjoying the moments of their lives. For example, a
person who is writing a paper can focus his or her attention on how that
paper may be evaluated by others and the hope that the paper will bring
some concrete reward (e.g., publication, a high grade, funding, a raise in
salary). However, such a focus on potential rewards also brings about the
focus on the fear that the reward may not be given to them. This may lead to
performance anxiety which is likely to interfere with their ability to accomplish the task at hand. On the other hand, clients can focus their attention, on
the task of writing, its intrinsic meaning, or how it can be done in a beautiful, skilful, or joyful manner. The role of the therapist is to help clients
rediscover for each activity or role what it is that is pleasureful or intrinsically
satisfying in them. The client can also apply such an alternative perspective as
they are practising SCD. This can strengthen their inclination to apply such
views on a daily basis.
Once clients have learned to successfully use more adaptive cognitions in
their daily lives, the therapist can introduce the additional goal of expectancyfree living. Of course, certain circumstances do require human beings to
anticipate the future and to make plans. However, GAD clients tend to try to
overplan for almost every possible consequence. Such a continual focus on
the future can interfere with their processing of information and distort what
they store in memory. This focus also creates frequent anxious and depressed
moods in response to negative future predictions. Moreover, it is rare that a
client can accurately predict the exact outcome of any situation. Therefore, as
with muscular tension, the client must learn to discriminate necessary and
helpful planning from future anticipation that is not helpful to them. One
concept that can be introduced is the idea of diminished return. A future
focus is only helpful as long as the person is not feeling anxious and is
engaged in helpful problem-solving. However, once such focus leads to anxiety, such anxiety interferes with their ability to benefit from this focus, and
this is a signal to refocus their attention to the present. Such a present
moment focus means trying to process events as they happen and trusting
that he or she will be able to handle any consequence that happens. As with
Cognitive behavioural therapy for worry and GAD
other CBT tasks, clients can test out a present moment focus, and conduct
behavioural experiments to provide evidence that focusing on the present
does not diminish their ability to cope with the ongoing events in their lives.
Therapists frequently discover that GAD clients often have the ability to
come up with multiple reasons for fearing and planning for the future. They
have spent so much time anticipating every possible negative outcome that
they have developed infinite detailed reasons as to why the world is a dangerous place and why they may not be able to cope. They are thus very good
at countering logic and evidence. As a result, therapists can find themselves in
a non-victorious debate with their clients as they use examples from their
clients’ life in an attempt to teach them how to apply CT. If therapists find
themselves in a situation in which they have come up with multiple alternative
perspectives about a situation that are rejected, it may not be beneficial to
continue to try to “convince” the client that they should believe something
that just does not feel true to them. Such a rigid pursuit can lead to frustration, create alliance ruptures, and ultimately becomes counter-therapeutic
(Safran & Segal, 1990). Instead, it is important for the therapist to be as flexible as possible, to try a number of options, and not to focus on the outcome
of getting the client to accept an alternative perspective after each example.
As they do this, therapists can watch the client to determine whether any of
the options they have tried are helpful. The ultimate outcome is simply to
show the client that there are multiple alternative ways of viewing most situations and that they can learn to think more flexibly.
Treatment outcome research
Controlled investigations of GAD treatment have only occurred recently.
This is because the diagnostic criteria were changed several times. Another
reason is that exposure-based cognitive behavioural therapies for anxiety
were predicated on the theory that anxiety was maintained via escape or
avoidance. However, the maintenance of GAD could not be easily explained
by the same sort of avoidance that had been thought to maintain other
anxiety disorders. Whereas other anxiety disorders were associated with
behavioural avoidance as a means of coping with externally feared situations, GAD clients relied on conceptual activity (i.e., worry) to avoid or
prepare for ways to cope with possible future danger (Beck & Emery, 1985).
Because such danger existed only in their minds, behavioural avoidance was
not an available response. As a result, internal cues were more important,
whereas the therapeutic value of exposure techniques was less clear. To
resolve this dilemma, the first GAD interventions relied primarily on relaxation techniques which clients applied as a general coping response whenever
they felt anxious.
The first clinical trials began with non-DSM-defined “general anxiety”.
These studies generally found that combined anxiety management treatments
Michelle G. Newman and Thomas D. Borkovec
were associated with sustained improvements that were sometimes better
than the effects of individual components. There was also some evidence
that the addition of cognitive therapy techniques led to increments in followup improvement (Durham & Turvey, 1987; Lindsay, Gamsu, McLaughlin,
Hood, & Espie, 1987). Twelve subsequent treatment studies used DSM criteria to select GAD participants. All of these studies included cognitive
behavioural therapies in most or all of their comparison conditions. This
research supported the efficacy of CBT as a treatment that leads to clinically
significant change, with sustained improvement up to a year later (Borkovec
& Whisman, 1996). These studies also indicate that CBT therapies are
associated with low drop-out rates, reductions in use of medication, and the
largest effect sizes when compared to no treatment, analytic psychotherapy,
pill placebo, non-directive therapy, and placebo therapy. Although several
investigations have not found differences between combined CBT and either
cognitive therapy or behaviour therapy alone, others have documented its
superiority immediately after treatment or at long-term follow-up. As we
have mentioned at the start of this chapter, CBT currently stands as the only
therapy method for GAD that has been empirically validated (Chambless et
al., 1996).
Despite support for the effectiveness of CBT, there is still room for
improvement. Only about 50% of treated clients exhibit clinically significant
change at follow-up (Borkovec & Whisman, 1996; Chambless & Gillis, 1993).
In addition, despite the application of fairly stringent research methodology
(e.g., frequent use of manuals, diagnostic interviews, integrity checks, and
expectancy/credibility assessments), a majority of studies have had significant
limitations. For example, GAD is the anxiety disorder with the lowest interrater agreement (Barlow & DiNardo, 1991), yet only three studies required
two independent diagnostic interviews. Such a lapse may have led to the
inclusion of inaccurately diagnosed individuals (as many as 25–30%).
Moreover, the superiority of combined CBT to non-specific or individual
CBT components has not been consistently supported. This may be due to an
inflated number of false positive GAD diagnoses.
The issue of non-specific effects and the contribution of individual CBT
elements was addressed in a recent comparison of applied relaxation, CBT
(applied relaxation, self-control desensitisation, and brief CT), and a reflective listening control condition (Borkovec & Costello, 1993). Contrary to
previous research, GAD was diagnosed using two independent structured
interviews. Moreover, this study employed objective ratings which showed
that therapists adhered to a tightly structured protocol and that the provided
therapy was of a high quality. Results of this study supported the superiority
of applied relaxation and CBT to reflective listening at post-test. At 12month follow-up, however, those treated with reflective listening had
deteriorated, those who received applied relaxation had maintained their
gains, and those in the CBT condition showed even further improvement.
Cognitive behavioural therapy for worry and GAD
A larger number of clients in the combined CBT condition also showed
clinically significant change than in the other two conditions. These findings
supported the view that CBT for GAD was optimal when it employed multiple techniques to target each of the cognitive, physiological, and imaginal
response systems.
In a recently completed therapy study at Penn State (Borkovec et al., in
press), three therapy conditions were compared. One condition was focused
on applied relaxation and self-control desensitisation, the second on cognitive
therapy, and the third on their combination. Therapist contact time was
oubled from the previous trial to determine whether this would lead to a
larger percentage of clients who would achieve high endstate functioning.
Findings suggest that similar to the previous study, no more than 50% of the
clients in the three therapy conditions achieved high endstate functioning,
and all three therapies were equally effective. These results do not support
existing evidence from prior research that long-term maintenance is best produced by a combined CBT that targets the cognitive, physiological, and
imaginal response systems. However, it is possible that this result is due to the
doubling of client contact time, which may have increased the efficacy of the
cognitive therapy and behavioural therapy component conditions.
However, this study also indicates that doubling CBT therapist contact
time does not result in any incremental benefit. The impact of therapy at
follow-up was not significantly different from previous studies using 50%
less therapist contact. Given this result, as well as the current climate of costcontainment, future research might benefit from a determination of the
minimum number of therapy sessions required to achieve the best therapeutic result possible. Research on GAD treatment might also benefit from the
assessment of other techniques to increase the efficiency and costeffectiveness of CBT for GAD (e.g., Newman, 2000b; Newman, Consoli, &
Taylor, 1997). An ongoing study is currently being conducted by the first
author of this chapter examining the effect of computer-assisted CBT combined with reduced therapist contact time in a group setting. In a pilot study
of this approach, three out of three group members no longer met diagnostic criteria for GAD at 6-month follow-up (Newman, 1999). Future research
might also benefit from the examination of therapeutic techniques that have
not yet been empirically tested to develop more potent therapies for GAD.
Evidence from the ongoing Penn State study indicates that a fertile area of
investigation may be therapy techniques that target interpersonal problems
(Newman, Castonguay, Borkovec, & Molnar, in press). Specific types of
interpersonal difficulties, such as being domineering, overly nurturant, and
intrusive, did not improve as a result of therapy and negatively predicted
outcome. This suggests that a therapeutic intervention aimed at interpersonal problems may increase the effectiveness of CBT. A preliminary study is
currently being conducted to test this hypothesis (Newman, Castonguay, &
Borkovec, March 1999).
Michelle G. Newman and Thomas D. Borkovec
This research was supported in part by National Institute of Mental Health
Research Grant MH-39172 to the second author. Correspondence can be
addressed to Michelle G. Newman, Department of Psychology, Penn State
University, University Park, PA 16802, USA.
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(1987). The effects of relaxation training with cognitive therapy or nondirective
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analysis of cognitive behavioral therapy for generalized anxiety disorder and the
role of interpersonal problems. Journal of Consulting and Clinical Psychology.
Borkovec, T. D. & Whisman, M. A. (1996). Psychological treatment for generalized anxiety disorder. In M. R. Mavissakalian & R. F. Prien (Eds.), Long-term Treatments of
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emotional deepening. Paper presented at the Society for the Exploration of
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Psychiatry, 51, 355–364.
Chapter 7
Cognitive behavioural
treatment of eating disorders
David M. Garner and M. Teresa Blanch
The apparent increasing incidence of both anorexia and bulimia nervosa has
resulted in a surge of interest in effective treatment methods among a wide
range of health professionals. The aim of this chapter is to provide a practical overview of treatment principles which have been identified as useful in
the management of these eating disorders. Emphasis will be given to cognitive
behavioural therapy (CBT) methods which may be justified for bulimia nervosa by the growing body of empirical literature indicating that these
methods are effective for many patients (Fairburn, 1985; Fairburn, Marcus, &
Wilson, 1993; Wilson, Fairburn, & Agras, 1997; Walsh, Wilson, Loeb, Devlin,
Pike, Roose, Fleiss, & Waternaux, 1997). There is less empirical evidence for
anorexia nervosa since comparative treatment trials have not been reported.
The rationale for the application of CBT interventions to anorexia nervosa is
based almost entirely on clinical experience (Garner, 1986, 1988; Garner &
Bemis, 1982, 1985; Garner & Rosen, 1990; Garner, Vitousek, & Pike, 1997;
Vitousek & Orimoto, 1993).
Definition of terms
Anorexia nervosa
The diagnostic criteria for anorexia nervosa, according to the Diagnostic and
Statistical Manual of Mental Disorders (APA, 1994), are summarised as
follows: (1) refusal to maintain a body weight over a minimally normal
weight for age and height (e.g., weight loss leading to maintenance of a
body weight less than 85% of that expected, or failure to make expected
weight gain during period of growth, leading to body weight less than 85%
of that expected); (2) intense fear of gaining weight or becoming fat, even
though underweight; (3) disturbance in the way that body weight, size, or
shape is experienced; and (4) amenorrhoea in females (absence of at least
three menstrual cycles). The DSM-IV criteria formalise earlier overlapping
David M. Garner and M. Teresa Blanch
conventions for subtyping anorexia nervosa into restricting and bingeeating/purging types based on the presence or absence of the bingeing and/or
purging (i.e., self-induced vomiting, or the misuse of laxatives, or diuretics).
It is important to note that patients move between these two subtypes with
chronicity leading toward aggregation in the binge-eating/purging subgroup
(Hsu, 1988).
Bulimia nervosa
The diagnostic criteria for bulimia nervosa, according to the Diagnostic and
Statistical Manual of Mental Disorders (APA, 1994), are summarised as follows: (1) recurrent episodes of binge-eating (binge-eating is characterised by
a sense of lack of control over eating a large amount of food in a discrete
period of time); (2) recurrent, inappropriate compensatory behaviour in order
to prevent weight gain (i.e., vomiting; abuse of laxatives, diuretics, or other
medications; fasting or excessive exercise); (3) a minimum average of two
episodes of binge-eating and inappropriate compensatory behaviours per
week for the past three months; (4) self-evaluation unduly influenced by body
shape and weight; and (5) the disturbance does not occur exclusively during
episodes of anorexia nervosa. Bulimia nervosa patients are further subdivided
into purging type and non-purging type, based on the regular use of selfinduced vomiting, laxatives, diuretics or other medications, fasting or
excessive exercise.
Eating disorders not otherwise specified (NOS)
Individuals who have eating disorders that are clinically significant but who
fail to meet one or more of the criteria required for a formal diagnosis of
anorexia nervosa or bulimia nervosa have been given the diagnostic designation “eating disorder not otherwise specified (EDNOS)”. For example, the
EDNOS diagnosis is given for individuals who meet all of the criteria for
anorexia nervosa except that they have regular menses or a weight that is in
the normal range. It is also assigned when all of the criteria for bulimia nervosa are met except that the binge frequency is less than an average of twice
a week for a duration of less than three months. It is also applied to patients
who are at a normal body weight who regularly engage in inappropriate compensatory behaviour after eating small amounts of food (i.e., in the absence
of binge-eating) or who repeatedly chew and spit out large amounts of food.
Finally, the eating disorder NOS category is applied to patients who have
what has been referred to as the “binge-eating disorder”, characterised by
recurrent episodes of binge-eating in the absence of the inappropriate compensatory behaviours evident in bulimia nervosa.
Cognitive behavioural treatment of eating disorders
Causal factors
Earlier psychological theories attributing eating disorders to exclusive developmental, familial, cultural, or personality factors have tended to be replaced
by “multidimensional” models which emphasise that the characteristic symptom picture may evolve from a different blend of predisposing factors for
different individuals. Accordingly, symptom patterns represent final common
pathways resulting from the interplay of three broad classes of predisposing
factors: (1) cultural, (2) individual (psychological and biological), and (3)
familial. These causal factors are presumed to combine with one another in
different ways that lead to the development of eating disorders. The precipitants are less clearly understood, except that dieting is invariably an early
element. Perhaps the most practical advancements in treatment have come
from increased awareness of the perpetuating effects of starvation, with its
psychological, emotional, and physical consequences (Garner, 1997). This
general aetiological model has led to various treatment formulations. The
cognitive behavioural approach will be the focus of this chapter because it has
received comparatively greater empirical and clinical support over the last
Duration and structure of therapy
The duration of treatment for bulimia nervosa is typically about 20 weeks
(Fairburn et al., 1993); however, it is well recognised that difficult patients
may require a longer period of care (Wilson et al., 1997). In contrast, treatment for anorexia nervosa typically lasts 1–2 years (Garner et al., 1997; Pike,
Loeb, & Vitousek, 1996). The longer duration of treatment is required in
most cases of anorexia nervosa because of the time required to overcome
motivational obstacles, achieve appropriate weight gain, and occasionally
implement inpatient or partial hospitalisation.
The structure of individual therapy sessions is similar for bulimia nervosa
(Fairburn et al., 1993) and anorexia nervosa (Garner et al., 1997). In each session: (1) an agenda is set, (2) self-monitoring is reviewed, (3) dysfunctional
behaviours and schemas are identified and changed, (4) the session is summarised, and homework assignments are specified. For anorexia nervosa
additional components are added such as checking the patient’s weight, discussion of weight within the context of goals, review of physical
complications and meal planning (Garner et al., 1997). Also, in anorexia
nervosa, modifications must be made to the format of therapy to take into
consideration the special needs such as the age of the patient and the clinical
circumstances, and to determine the format of meetings as individual, family,
or a mix of family and individual meetings.
David M. Garner and M. Teresa Blanch
General treatment principles
There are several general principles that should be considered central to any
treatment approach to eating disorders and they will only be briefly mentioned here because they have been elaborated in depth elsewhere (Fairburn,
1985; Garner, 1986; Garner & Bemis, 1982, 1985; Garner & Isaacs, 1985;
Garner, Garfinkel, & Bemis, 1982; Garner, Garfinkel, & Irvine, 1986). These
include the importance of the therapeutic relationship, cultivating motivation
for treatment, differences in treatment for the two main eating disorders, and
the two track approach to treatment.
The therapeutic relationship
Although Beck and his colleagues (Beck, 1976; Beck, Rush, Shaw, & Emery,
1979) have emphasised that CBT treatment, as with other approaches, presupposes a trusting, warm, and empathic relationship with the therapist, this
essential ingredient is sometimes overlooked in discussions of the technical
aspects of cognitive therapy. Rather than representing a “non-specific” element in the treatment of eating disorders, a strong therapeutic relationship
should be regarded as integral to change. This is particularly important in
anorexia nervosa where the patient may enter treatment with considerable
resistance to change (Garner et al., 1997).
Motivation for treatment
Enlisting motivation for treatment can be difficult with eating disorder
patients since certain symptoms like restrictive dieting are ego-syntonic. It is
generally agreed that motivation is more difficult to cultivate with anorexia
nervosa since these patients are reluctant to commit to the main goal of treatment, namely weight gain. This contrasts with bulimia nervosa where patients
usually accept elimination of binge-eating as the primary goal of treatment.
Specific strategies for cultivating and sustaining motivation for change with
anorexia nervosa are beyond the scope of this chapter; however, they have
been detailed elsewhere (Garner et al., 1997).
Differences in treatment of anorexia versus bulimia
Anorexia and bulimia nervosa share many features in common so it is not
surprising that cognitive approaches to therapy for both disorders overlap to
a significant degree. Similar cognitive restructuring approaches are recommended for both disorders to address characteristic attitudes about weight
and shape. Education about regular eating patterns, body weight regulation, starvation symptoms, vomiting and laxative abuse is a strategic element
Cognitive behavioural treatment of eating disorders
in the treatment of both disorders. Finally, similar behavioural methods are
also required, particularly for the binge-eating/purging subgroup of
anorexia nervosa patients. However, key distinctions can be made between
these disorders. Standard CBT for bulimia nervosa must be altered to
address specific clinical features more pertinent to anorexia nervosa. For
example, with anorexia nervosa patients, the style, pace, and content of
CBT needs to be modified to address motivational obstacles, weight gain as
a target symptom, the use of meal planning versus self-monitoring, the need
to integrate family therapy for younger patients and interpersonal themes
that emerge over a much longer typical course of treatment. These will not
be discussed in detail here since they have been reviewed elsewhere (Garner
et al., 1997).
Two track approach to treatment
Throughout all stages of treatment we recommend a “two track” approach
in which the first track pertains to issues related to weight, bingeing, vomiting, strenuous dieting, and other behaviours aimed at weight control. The
second addresses the psychological context of the disorder including beliefs
and thematic underlying assumptions which are relevant to the development or maintenance of the disorder. In practice, there is considerable
switching back and forth between these content areas in therapy. Greater
emphasis is placed on track one early in therapy, emphasising the interdependence between mental and physical function. Treatment gradually shifts
to track two issues as progress is made in the areas of eating behaviour and
Selection of treatment approaches
Rather than assume that all treatments are equally applicable to all eating
disorder patients, clinical writers have shown a growing interest in “steppedcare”, “decision-tree” or “integration” models which rely on fixed or variable
rules for the delivery of the various treatment options (see Garner &
Needleman, 1997, for a review). According to the stepped-care model, a
patient is provided with the lowest step intervention, one that is least intrusive, dangerous, and costly, even if the lowest step intervention does not have
the highest probability of success. In contrast, a decision-tree approach provides numerous choice points resulting in different paths for treatment,
depending on the clinical features of the patient as well as the response to
each treatment delivered. Using a combined decision-tree and integration
model, Garner and Needleman (1997) recommend an educational approach
as the initial intervention for the least disturbed bulimia nervosa patients, and
integrate this into other forms of treatment for other eating disorder patients,
including those with anorexia nervosa. Family therapy is recommended as the
David M. Garner and M. Teresa Blanch
primary treatment modality if the patient is young and living at home.
Pharmacotherapy is considered as an option in bulimia nervosa (but not
anorexia nervosa) when patients fail to respond to psychosocial treatments.
For patients with serious medical complications or for those who need to
gain substantial body weight, inpatient treatment is recommended as the
initial intervention. Day treatment is suggested for patients who do not
require hospitalisation but do need a high level of treatment intensity and
meal supervision. This model for the integration and sequencing of treatment represents an attempt to articulate the decision-making process in
delivering different forms of treatment for both of the main eating disorders. At this time, proposals for integrating and sequencing different forms
of treatment have not been empirically tested in the eating disorder area.
This is partly due to the formidable practical and theoretical impediments
to a research protocol required to test complex stepped-care, decision-tree
and integration models. Nevertheless, existing treatment research combined
with current clinical knowledge provides a foundation for rational recommendations regarding the selection of treatments in the management of
eating disorders.
Cognitive behavioural theory
There is now broad agreement that the rationale for CBT for eating disorders
rests primarily on the assumption that restrictive dieting (largely in response
to cultural imperatives to meet unrealistic standards for body weight) is in
direct conflict with the internal biological systems responsible for the homeostatic regulation of body weight (Garner, 1997; Garner, Rockert, Olmsted,
Johnson, & Coscina, 1985). Given the current cultural pressures for thinness, it is not hard to understand how women, particularly those with
persistent self-doubts, could arrive at the conclusion that personal failings are
to some degree related to weight or that the attainment of slenderness would
measurably improve self-estimation. It has been asserted that for some who
develop eating disorders, the motivating factors do not seem to go beyond a
literal or extreme interpretation of the prevailing cultural doctrine glorifying
thinness. For others, however, the impetus is more complicated, with a range
of psychological and interactional factors playing a role. According to the
cognitive behavioural view, the dieter’s steadfast attempts to down-regulate
body weight leads to a myriad of compensatory symptoms including bingeeating. Although the cognitive restructuring component of CBT has taken
various forms, most rely on Beck’s well-known model which has been adapted
for eating disorders (Fairburn, 1985; Fairburn, Marcus & Wilson, 1993;
Garner & Bemis, 1982, 1985; Garner et al., 1997). The initial aim of cognitive
restructuring is to challenge specific reasoning errors or self-destructive attitudes toward weight and shape so that the patient can relax restrictive dieting.
Behavioural strategies such as self-monitoring, meal planning and exposure
Cognitive behavioural treatment of eating disorders
to feared foods serve the overall goal of normalising food intake. The primary
point of emphasis of the cognitive behavioural view has been the analysis of
functional relationships between current distorted beliefs and symptomatic
behaviours related to eating, weight and body shape.
Particularly in the treatment of anorexia nervosa, the cognitive behavioural model has been broadened to address historical, developmental and
family themes more typically described by psychodynamic and family
theorists (Garner et al., 1997). It has been reasoned that motifs such as fears
of separation; engulfment or abandonment; failures in the separation–
individuation process; false-self adaptation; transference; overprotectiveness, enmeshment, conflict avoidance; inappropriate involvement of the
child in parental conflicts; and symptoms functioning to deflect away
from family conflict all involve distorted meaning on the part of theindividual, the family, or both. Although the language, style, and specific
interpretations may differ sharply between the cognitive behavioural
model and the dynamic models that have generated these respective formulations, it is notable that both orientations are specifically concerned with
meaning and meaning systems. Moreover, the respective therapies are aimed
at identifying and correcting misconceptions that are presumed to have
developmental antecedents (Garner & Bemis, 1985; Guidano & Liotti,
1983). The advantage of the cognitive behavioural approach is that it allows
the incorporation of developmental themes when they apply to a particular
patient but does not compel all cases to fit into one restrictive explanatory
Although there is debate about the active ingredients of CBT in the treatment of eating disorders, it is generally recognised that cognitive and
behavioural strategies for normalising eating and weight are fundamental.
Self-monitoring has been recommended in CBT studies as well as treatment
delivered from other orientations achieving the best treatment results
(Garner, Fairburn, & Davis, 1987). Self-monitoring has been considered
an important component of CBT; however, some reports have specified
that affective and interpersonal antecedents of binge-eating should be the
target of the procedure, whereas others have focused on dietary management and changing attitudes toward weight and shape. Although both
approaches to self-monitoring may prove valuable, research is needed to
determine their relative effectiveness across the broad range of symptom
domains. Early CBT reports emphasised the importance of exposing the
patient to avoided foods (in vivo) and then preventing vomiting (Rosen &
Leitenberg, 1985; Wilson, Rossiter, Kleifield, & Lindholm, 1986). Later
studies indicated that the response prevention techniques did not add any
benefit to cognitive procedures that do not involve response prevention
(Agras, Schneider, Arnow, Raeburn, & Telch, 1989; Wilson, Eldredge,
Smith, & Niles, 1991).
Although there are now many studies indicating that CBT can achieve
David M. Garner and M. Teresa Blanch
good results with many patients, recent research has revealed that other forms
of treatment, which do not address eating or weight issues at all, can lead to
the amelioration of binge-eating (Fairburn et al., 1991; Fairburn, Norman,
Welch, et al., 1995; Garner, Olmsted, Davis, Rockert, Goldbloom, & Eagle,
1990). In a comparison between CBT, behavioural treatment, and interpersonal psychotherapy, Fairburn et al. (1991) found that CBT was more
effective than the other treatments in modifying extreme dieting, self-induced
vomiting, and disturbed attitudes toward shape and body weight at the end of
treatment; however, at the 12-month and 6-year follow-up there were no
meaningful differences between CBT and interpersonal therapy in outcome
(Fairburn et al., 1995).
Table 7.1 Major content areas for cognitive therapy
Phase I
Building a positive therapeutic alliance
Assessing key features of the eating disorder
Providing education about starvation symptoms and other selected topics
Evaluating and treating medical complications
Explaining the multiple functions of anorexic symptomatology
Differentiating the “two tracks” of treatment
Presenting the cognitive rationale for treatment
Giving rationale and advice for restoring normal nutrition and weight
Implementing self-monitoring and meal planning
Prescribing normal eating patterns
Interrupting bingeing and vomiting
Implementing initial cognitive interventions
Increasing motivation for change
Challenging cultural values regarding weight and shape
Determining optimal family involvement
Phase II
Continuing the emphasis on weight gain and normalized eating
Reframing relapses
Identifying dysfunctional thoughts, schemas and thinking patterns
Developing cognitive restructuring skills
Modifying self-concept
Developing an interpersonal focus in therapy
Involving the family in therapy
Phase III
Summarizing progress
Reviewing fundamentals of continued progress
Summarizing areas of continued vulnerability
Reviewing the warning signs of relapse
Clarifying when to return to treatment
From: Garner et al. (1997). Reproduced by permission.
Cognitive behavioural treatment of eating disorders
Cognitive behavioural methods
Beck and his colleagues have delineated a number of specific cognitive behavioural procedures for the treatment of depression and other emotional
disorders (Beck, 1976; Beck et al., 1979; Beck & Emery, 1985). For an elaboration of the rationale for selecting CBT methods with eating disorders as
well as the adaptation of standard procedures for anorexia and bulimia
nervosa, we refer the reader to earlier publications (Fairburn et al., 1993;
Garner, 1986; Garner & Bemis, 1982, 1985; Garner et al., 1997; Wilson,
Fairburn, & Agras, 1997). Our aim here is to provide a synopsis of what we
consider to be the critical components of CBT interventions. Table 7.1 contains a summary of the content areas in the treatment of anorexia nervosa
from Garner et al. (1997).
Presenting the cognitive rationale for treatment
The main principles of cognitive therapy govern the conduct and content of
therapy from the beginning: (1) primary reliance on conscious experience
rather than unconscious motivation; (2) explicit emphasis on beliefs,
assumptions, schematic processing and meaning systems as mediating variables accounting for maladaptive behaviours and emotions; (3) use of
questioning as a major therapeutic device; (4) active and directive involvement on the part of the therapist; and (5) emphasis on work outside of the
session as a means for exploring beliefs and patterns of thinking (Beck,
1976; Beck et al., 1979).
Discussion of the cognitive behavioural model of treatment in anorexia nervosa must be tailored to fit the current motivation of the patient. In contrast to
bulimia nervosa where symptoms are usually more distressing to the patient, at
this stage in the treatment of anorexia nervosa, it is advisable to resist “teaching”
the cognitive model or prematurely introducing techniques for identifying and
correcting “dysfunctional beliefs”. Patients are reticent to accept a model for
belief change if they prefer their ego-syntonic symptoms and are not committed
to treatment. It is advisable for cognitive behavioural principles to unfold
gradually in the initial phase of treatment. Education is the first “cognitive” procedure since it is explicitly aimed at changing beliefs through new or corrective
information. Another way to present the cognitive model early in therapy is by
example. The therapist can use the language of cognitive therapy by emphasising the importance of beliefs and assumptions in determining behaviour.
Education as an initial cognitive behavioural
Education was originally recommended as part of early descriptions of cognitive behavioural treatment for eating disorders based on the premise that
David M. Garner and M. Teresa Blanch
certain faulty assumptions evinced by patients were maintained, at least in
part, by misinformation (e.g., Garner & Bemis, 1982). There seems to be
general agreement on the utility of incorporating psychoeducation into most
treatment approaches for eating disorders. There have been a number of
empirical studies of the effectiveness of educational treatments in bulimia
nervosa. One study comparing the presentation of this educational material
in a group “classroom” format (five 90-minute sessions during a one-month
period) with individual CBT indicated that, for the least symptomatic 25% to
45% patients in the sample, both treatments were equally effective on important measures of outcome (Olmsted, Davis, Garner, Eagle, & Rockert, 1991).
Several specific content areas for education are reviewed below and these
have been elaborated elsewhere (Garner, 1997).
Education about starvation symptoms
Eating disorder patients typically fail to interpret their food preoccupations, urges to binge eat, emotional distress, cognitive impairment, and
social withdrawal as secondary to their severe attempts to reduce or control
their weight. These symptoms are commonly thought of as specific to
eating disorders; however, it is useful for the therapist to re-attribute them
to dieting or starvation based on well-established research studies on these
topics (Garner, 1997; Garner & Bemis, 1982). Table 7.2 lists some of the
symptoms of starvation that are commonly reported by eating disorder
Education indicating that restrictive dieting increases the
risk of bingeing
Patients should also be educated about the effects of dieting on the tendency
to engage in binge-eating (Polivy & Herman, 1985; Garner et al., 1985; see
Garner, 1997). The fact that binge-eating can occur in the absence of primary
psychopathology is surprising to many patients and can provide a springboard to a new understanding of the patient’s symptoms.
Education indicating that dieting does not work
Long-term follow-up studies of obesity treatment consistently indicate
that 90–95% of those who lose weight will regain it within several years
(Garner & Wooley, 1991). Patients can benefit from understanding that the
failure of restrictive dieting in permanently lowering body weight is not
related to a lapse in will-power but rather is logically consistent with the
biology of weight regulation, which shows that weight loss leads to metabolic adaptations designed to return body weight to levels normally
Cognitive behavioural treatment of eating disorders
Table 7.2 The effects of semi-starvation from the 1950 Minnesota study
Attitudes and behaviour toward food
Food preoccupation
Collection of recipes, cookbooks, and menus
Unusual eating habits
Increased consumption of coffee, tea, and spices
Gum chewing
Emotional and social changes
Irritability, anger
“Psychotic” episodes
Personality changes on psychological tests
Social withdrawal
Cognitive changes
Decreased concentration
Poor judgement
Physical changes
Sleep disturbances
Gastrointestinal disturbances
Hyperacuity to noise and light
Decreased basal metabolic rate
Decreased sexual interest
Adapted from Garner et al. (1997).
Education about the self-perpetuating cycle of bingeeating and vomiting
Self-induced vomiting and laxative abuse usually begin as methods of preventing weight gain by “undoing” the caloric effects of normal eating or
binge-eating. It becomes self-perpetuating because it allows the patient to
acquiesce to the urge to eat but eliminates the feedback loop that would stem
underlying hunger and food cravings.
Education regarding laxative abuse
Laxative abuse is dangerous because it contributes to electrolyte imbalance
and other physical complications. Perhaps the most compelling argument for
David M. Garner and M. Teresa Blanch
discontinuing their use is that they are an ineffective method of trying to prevent the absorption of Calories.
Education regarding physical complications
Anorexia nervosa patients should have a medical evaluation to determine
overall physical status and to identify or rule out physical complications associated with starvation and certain extreme weight loss behaviours (Mitchell,
Pomeroy, & Adson, 1997; Sharp & Freeman, 1993).
Education about eating disorders
Attention should be given to clarifying myths resulting from inaccurate or
conflicting reports regarding aetiology and complications of eating disorders themselves.
Rationale and advice for normal nutrition and
body weight
Numerous methods have been advocated for helping the patient normalise
eating and weight. Some are specifically designed to interrupt the bingeing and
purging cycle in the subset of patients with this behaviour; others are aimed at
facilitating weight gain in emaciated patients. Still others are generally applicable to patients with both of these symptom patterns. The formulation of
goals related to body weight, eating behaviour and symptomatic control is
dependent on the patient’s current level of motivation. If delineating concrete
weight goals is beyond the patient’s level of commitment or tolerance for
change, then attention needs to shift to increasing motivation for change
(Garner et al., 1997). Several specific methods of normalising eating and body
weight will be briefly outlined; however, the reader is encouraged to consult
other primary source material for fundamentals (Fairburn, 1985; Fairburn,
Marcus, & Wilson, 1993; Garner & Bemis, 1982, 1985; Garner et al., 1997).
Addressing body weight in treatment
The topic of body weight is approached from an entirely different perspective
for anorexia and bulimia nervosa. Fairburn et al. (1993) recommend that
bulimia nervosa patients “should be told that in most cases treatment has
little or no effect on body weight, either during treatment itself or afterwards” (p. 376). Patients who are reluctant to eat meals or snacks due to fear
of weight gain, “should be reassured that this rarely occurs . . . [and they] will
discover that they can eat much more than they thought without gaining
weight” (p. 378). In anorexia nervosa, this reassurance is not available since
weight gain is a major aim of treatment.
Cognitive behavioural treatment of eating disorders
In the treatment of bulimia nervosa, weekly weighing is left up to the
patient, “in part because sessions can become dominated by the subject of
weight at the expense of other more important issues” (Fairburn et al., 1993,
pp. 372–374). In contrast, with anorexia nervosa, weight and weight gain
cannot be sidestepped but must be directly confronted. Weight must be regularly checked by the therapist or another reliable source. In the case of
anorexia nervosa, changes in body weight dramatically effect the interpretation of session content (Garner et al., 1997).
Determine minimal body weight threshold for anorexia
Anorexia nervosa patients need to be told that outpatient treatment can only
proceed if their weight does not fall below a certain minimum (Garner et al.,
1982). If the patient is near this minimum at the initial meetings, then this
weight needs to be clearly stipulated. However, there are no absolute rules
regarding this minimum, since it depends on the patient’s overall health, the
presence of complications and the ability to make progress in outpatient
treatment. If the patient’s weight falls below the established minimum, other
more structured alternatives such as partial or inpatient hospitalisation must
be available, and the focus of therapy shifts to convincing the patient that
these options are necessary.
Setting a target weight range as a goal in the initial meeting is dependent on
the patient’s current level of motivation and commitment to treatment. The
patient needs to understand the enormous biological significance of reaching
a certain minimal body weight threshold and that the achievement of this
weight status is essential to recovery. There are individual differences in this
threshold; however, it generally corresponds to approximately 90% of
expected weight for post-menarcheal women and elicits resumption of
normal hormonal functioning and menstruation.
Self-monitoring has been consistently recommended in cognitive behavioural
research studies with bulimia nervosa (Wilson et al., 1997). Self-monitoring
can be helpful in establishing a regular eating routine as well as gaining control over symptoms such as binge-eating, vomiting, or laxative abuse.
Self-monitoring involves keeping a daily written record of all food and liquid
consumed as well as incidents of binge-eating, vomiting, laxative abuse and
other extreme weight controlling behaviours. Patients are sometimes reluctant
to complete self-monitoring forms because they feel ashamed of their behaviour or they feel that self-monitoring will only increase their preoccupation
with food. These concerns need to be set aside with the knowledge that selfmonitoring is an extremely effective tool in obtaining control over eating
David M. Garner and M. Teresa Blanch
disorder symptoms. Although there is general agreement on the value of
self-monitoring, recommendations related to timing and flexibility in implementing this procedure with anorexia nervosa vary. Patients who require
more structure in complying with advice regarding normalising their eating
patterns may benefit from meal planning in contrast to self-monitoring typically described for bulimia nervosa (Garner et al., 1997).
Meal planning
Meal planning involves specifying the details of eating in advance. It includes
prescribing the precise foods to be consumed and their amounts, as well as
the context, such as the place and times for eating. It is highly recommended that the task of meal planning occur as part of therapy rather
than being necessarily relegated to a dietician or nutritionist. Meal planning
and elements of prescribing normalised eating are not only aimed at renutrition, but also at probing motivation and illuminating beliefs that then
become targets for cognitive interventions. There are several important
components of meal planning that are particularly useful in the treatment
of anorexia nervosa.
Mechanical eating
Eating should be done “mechanically” according to set times and a predetermined plan. Food should be thought of as “medication” prescribed to
“inoculate” the patient against future extreme food cravings and the tendency to engage in binge-eating (Garner et al., 1982). Temporarily taking the
decision-making out of eating is necessary early in treatment when patients
are particularly prone to become overwhelmed by anxiety and guilt in problematic eating situations.
Spacing eating
It is important for meals to be spaced throughout the day (Garner et al.,
1985). Breakfast should never be omitted and it is ideal for there to be 3
meals and 1–2 snacks spread throughout the day). It is best to confine eating
to set times on the clock rather than relying on internal sensations in determining when to eat. The rationale for this type of plan is that it will minimise
food cravings, urges to overeat, undereat, and loss of control.
Quantity of foodstuffs
The number of Calories that patients need to consume daily depends on current weight, metabolic condition, eating patterns, and tolerance for change
(Garner et al., 1985). Some emaciated patients have maintained their weight
Cognitive behavioural treatment of eating disorders
on as few as 600–900 Calories per day (Russell, 1970). Gradually increasing
energy intake to achieve a 1–2 pound weight gain per week is ideal. For
inpatients, the number of Calories should be adjusted to achieve a 2–3 pound
weight gain per week. The prescribed diet for inpatients should never be set
below 1500 Calories per day and is usually increased to 1800 to 2400 Calories
within the first week. All meals need to be completed so that the patient can
gain confidence that Calories prescribed can be assimilated according to the
plan for weight gain or weight stabilisation. As patients shift from a
hypometabolic to a hypermetabolic state, daily consumption may need to be
increased to as high as 3500–4000 Calories. Patient with a personal or family
history of obesity will usually need fewer Calories to accomplish the desired
rate of weight gain. As outpatients, the speed of weight gain is not as important as steadily moving in the direction of gradual weight gain.
Quality of foodstuffs
Most patients begin treatment with considerable confusion about what constitutes “normal” eating. Patients tend to divide food into “good” and “bad”
categories and this is frequently based on “nutritional myths” such as “calories from dietary fat accumulate as body fat in contrast to calories from
protein and carbohydrate that get burned off ”. One goal of treatment is
learning to feel more relaxed eating a wide range of foods. A weekly meal
plan should gradually incorporate small amounts of previously avoided or
forbidden foods. Patients should be encouraged to challenge the tendency to
divide food into “good” and “bad” categories by recognising that the Calories
of those foods previously considered “bad” really have no greater impact on
weight than Calorie-sparing food items. Patients who engage in binge-eating
should consume small amounts of the foodstuffs typically reserved for
episodes of binge-eating. Again, these foods should be redefined as
“medication that will help inoculate against binge-eating” by reducing psychological cravings as well as by establishing new response tendencies to
foods that previously had only denoted a “blown” diet.
Reframing relapses
The therapist needs to prepare patients for vulnerability to relapses in bingeeating and vomiting, particularly during stressful times. After an episode of
binge-eating, patients chastise themselves with conclusions like: “I have blown
it; it doesn’t matter any more; since I binged this morning, the rest of the day
is ruined and I might as well continue bingeing; all of my efforts are spoiled,
now I must start over from square one; bingeing is evidence that I will never
recover.” Patients need to be encouraged to refrain from applying dichotomous and perfectionistic thinking to relapses. They need to reframe relapses
by stepping back and evaluating the episode in light of the “big picture”. The
David M. Garner and M. Teresa Blanch
therapist should encourage the patient to practise the four R’s (Garner et al.,
1997) in reframing relapses:
Reframe the episode as a “slip” not “blown recovery”.
Renew the commitment to long-term recovery.
Return to the plan of regular eating without engaging in compensatory
Re-institute behavioural controls to interrupt future episodes.
Identify and challenge dysfunctional thoughts,
schemas and thinking patterns
Throughout the course of therapy, the therapist needs to assist the patient in
learning to identify dysfunctional thoughts and the processing errors that
influence her perceptions, thoughts, feelings and symptomatic behaviour.
Beliefs and behaviours that direct symptomatic behaviour need to be connected to more general and often implicit schemas referred to as underlying
assumptions (Beck, 1976) or higher order implicit meanings or schematic
models (Teasdale & Barnard, 1993). Guidano and Liotti (1983) described the
progression in therapy from more superficial cognitive structures related to
food and weight to “deep cognitive restructuring implying a modification of
the personal identity” (p. 299).
Develop cognitive restructuring skills
Cognitive restructuring is a method of examining and modifying dysfunctional thinking. It has several steps (Table 7.3). Automatic thoughts, beliefs
and assumptions can be pinpointed by increasing awareness of the thinking
process. They may also be accessed by observing behavioural patterns. For
example, restricting eating to “fat free” foods implies certain beliefs. The
automatic thought may also be identified by focusing on particular situations
and replaying the thinking and feeling associated with that situation. Then,
the patient is encouraged to generate and examine the evidence for and
Table 7.3 Steps in cognitive restructuring
1. Monitor thinking and heighten the awareness of thinking patterns.
2. Identify, clarify, distil and articulate dysfunctional beliefs or thoughts in simplest form.
3. Examine the evidence or arguments for and against the validity and utility of
dysfunctional beliefs.
4. Come to a reasoned conclusion by evaluating the evidence for and against.
5. Make behavioural changes that are consistent with the reasoned conclusion.
6. Develop believable disputing thoughts and more realistic interpretations.
7. Gradually modify underlying assumptions reflected by more specific beliefs.
Adapted from Garner et al. (1997).
Cognitive behavioural treatment of eating disorders
against a particular dysfunctional belief. Most of the following cognitive
strategies have been described in connection with the treatment of other emotional disorders; however, the content and style have been adapted for eating
Articulation of beliefs
Normal verbalisation in therapy tends to be complex, fragmented, disjointed
and often vague. Beliefs and dysfunctional thoughts are embedded in complicated accounts of current and past experiences. Even with some exposure
to the cognitive model, patients require practice in thinking about thinking
and help in distilling specific beliefs from their more complex stream of
thought. Sometimes simplifying or consolidating a belief may make the distortion highly apparent and lead to immediate attitude change.
Decentring involves the process of evaluating a particular belief from a different perspective in order to appraise its validity more objectively. It is
particularly useful in combating egocentric interpretations that the patient is
central to other people’s attention. For example, a patient reported “I can’t
eat in front of others in the residence cafeteria because others will be watching me.” First, it needs to be established that the eating behaviour was not
indeed unusual. If not, the therapist might enquire: “How much do you really
think about others’ eating? Even if you are sensitised to their eating, how
much do you really care about it except in the sense that it reflects back to
your own eating? Even if your behaviour was unusual, do others really care?”
Through the technique of decentring, the patient may be encouraged to
develop a more realistic idea of the impact that most behaviour has on others.
Challenging dichotomous reasoning
Dichotomous reasoning (all-or-none or absolutistic thinking) is a common
problem in anorexia nervosa. Beliefs that foods are either “good” and “bad”,
that deviation from rigid dieting is equivalent to bingeing, and that gaining a
pound is a sign of complete loss of control are all reflections of dichotomous
reasoning. This style of thinking is applied to topics beyond food and weight.
Patients commonly report extreme attitudes in the pursuit of sports, school,
careers, and acceptance from others. This type of reasoning is particularly
evident in the beliefs about self-control. Common examples include: “If I am
not in complete control, I will lose all control; if I learn to enjoy sweets, I will
not be able to restrain myself; if I stop exercising for one day, I will never exercise; if I enjoy sexual contact, I will become promiscuous; if I become angry,
I will devastate others with my rage.” A major therapeutic task is to teach the
David M. Garner and M. Teresa Blanch
patient to recognise this style of thinking, to examine the evidence against it,
to evaluate its maladaptive consequences, and to practise adopting a more
balanced lifestyle.
Ellis (1962) originally described decatastrophising as a strategy for challenging anxiety that stems from magnifying negative outcomes. It involves the
therapist asking the patient to clarify vague and implicit predictions of
calamity by asking: “What if the feared situation did occur? Would it really
be as devastating as imagined? How would you cope if the feared outcome
does occur?” Ironically, catastrophising can actually produce the feared outcome. In an attempt to avoid social rejection and isolation, patients can
withdraw from all social interactions, thus becoming isolated. Fear of failure
can lead to the scrupulous avoidance of risk which results in failure.
Moreover, there is no relief from catastrophic thinking. If a patient believes
that weight gain would be a catastrophe, it is clear why they would be fearful
and anxious when they gain weight. What is less obvious is the fact that they
are usually anxious when they do not gain because they can never be completely free of the risk. In addition to helping the patient temper dire forecasts
about the future, the therapist can facilitate the development of coping plans
for mastering feared situations if they were to occur.
Challenging beliefs through behavioural exercises
A primary goal of cognitive therapy is helping patients alter behaviour by
modifying dysfunctional beliefs and underlying assumptions. However, the
reciprocal effect of behaviour on belief change is at least as important in the
treatment of eating disorders. Anxiety and fear are central to the maintenance
of eating disorder symptoms. Even the most careful cognitive preparation does
not eliminate the fear associated with changed eating patterns and weight gain.
At some point, if patients are to recover, they must begin making behavioural
changes in these areas. Behavioural changes provide the real opportunity to
probe, challenge and correct faulty assumptions regarding eating, weight and
related self-attributions. It is difficult to maintain the belief that you cannot eat
dietary fat or sugar without losing control, if you indeed consume these substances without binge-eating. Similarly, behavioural change can have a
profound effect on beliefs unrelated to food and weight. Social interaction can
attenuate the view of self as socially incompetent. Independent and self-reliant
behaviour interferes with personal and family schemas that foster overprotectiveness and excessive dependence. However, it is common for well-established
beliefs to remain intact, despite an undeniably contradictory behaviour. It is
important for the therapist to make sure that the implications of the behavioural change are integrated at the cognitive level.
Cognitive behavioural treatment of eating disorders
Reattribution techniques
There are no reliable methods for directly modifying body size misperception
in anorexia nervosa. Rather than correcting size misperception reported by
some patients, it is useful to simply reframe the interpretation of the experience. This involves interrupting and overriding self-perceptions of fatness
with higher-order interpretations such as “I know that those with anorexia
nervosa cannot trust their own size perceptions” or “I expect to feel fat during
my recovery, so I must consult the scale to get an accurate reading of my
size.” The therapist asks the patient to attribute these body self-perceptions to
the disorder and to refrain from acting upon intrusive thoughts, images or
body experiences. This approach is contrary to the general therapeutic goal of
encouraging self-trust in the validity and reliability of internal experiences.
Modifying self-concept
Self-concept is a broad and multidimensional construct involving at least
two sub-components: self-esteem and self-awareness. Self-esteem constitutes the
appraisal or evaluation of personal value, including attitudes, feelings, and
perceptions. In contrast, self-awareness relates to the perception and understanding of the internal processes that guide experience. Vitousek and Ewald
(1993) have organised self-concept deficits characteristic of anorexia nervosa
into three broad clusters of variables: the unworthy self, the perfectible self and
the overwhelmed self. The unworthy self is characterised by (1) low self-esteem,
(2) feelings of helplessness, (3) a poorly developed sense of identity, (4) a tendency to seek external verification, (5) extreme sensitivity to criticism, and (6)
conflicts over autonomy/dependence. The second cluster, the perfectible self,
includes (1) perfectionism, (2) grandiosity, (3) asceticism, and 4) a “New Year’s
resolution” cognitive style. The third cluster, the overwhelmed self, is characterised by (1) a preference for simplicity, (2) a preference for certainty, (3) a
tendency to retreat from complex or intense social environments.
Improving self-esteem
It is well recognised that poor self-esteem often predates the appearance of
eating disorder symptoms. The pride and accomplishment of weight control
seem to temporarily alleviate this malady. The correction of low self-esteem,
particularly if pervasive and long-standing, is a formidable task. At some
point in therapy, patients usually reveal that they do not feel worthwhile or
that they lack personal worth. This assumption may emerge in discussing the
meaning of dieting and weight control as markers for constructs such as
competence, control, attractiveness, and self-discipline which in turn reflect
self-worth. It may be expressed in vague terms such as general feeling of ineffectiveness, helplessness or lack of inner direction.
David M. Garner and M. Teresa Blanch
It is useful for the therapist to help the patient distil vague assumptions
about self-worth into a clear and simple statement such as “I feel like a failure”, “I do not feel like a worthwhile person” or “I must be liked by others in
order to feel good about myself ”. Once the patient has expressed the view
that she has low self-worth, it is useful to engage in a more general discussion
about the basis for self-worth, later applying what has been learned back to
particular index situations identified by the patient. It is often useful to begin
by noting how much time and energy most people devote to trying to evaluate
their self-worth. For most patients, weight or shape have become the predominant gauge for inferring self-worth. It is possible to determine the pros
and cons of this frame of reference and then to extend this to other behaviours, traits or characteristics employed in the process of self-evaluation
following the procedures described by Burns (1993).
Decentring can be used to analyse this “balance-sheet” approach to human
worth. Does the patient evaluate others in this same way? Is someone else
considered worthless or inferior if she makes mistakes, is less intelligent, or
does not perform well? The following example from Garner and Bemis (1985)
illustrates the process:
I am terrified I may do worse this year than last year in my studies.
What would it mean if you did do worse?
Well, I guess it would mean that I am not very good as a person.
You mean you are rating your worth as a person by your grades?
Yes, I guess that is right. It is important to do well in everything you
attempt. I feel the same way about sports, hobbies, and my friends. In the
last year losing weight has become the way for me to feel good about myself.
The way that you are looking at your worth sort of relates to a philosophical question. How does one really evaluate or measure self-worth?
[Operationalise belief.] You have implied that you base it on your daily
performance, but this has some distinct disadvantages. [The therapist
then outlines these as listed above.]
Don’t all people judge their worth by what they do?
We may do this to some degree, but not as literally or as harshly as you
seem to do, and not on a moment-to-moment basis. In fact, you might
ask yourself if you rate others’ worth by their performances. Do you
rate your roommate’s worth based on her grades? You haven’t seemed
particularly concerned about my grades in graduate school [decentering.]
I just assumed that you did everything well.
That is hardly the case. If you found that I did things poorly in several
areas, would your evaluation of me decline?
Well, no, but you are different.
The aim of the approach is to help the patient gradually begin to question the
utility of the “balance sheet” concept of self-worth.
Cognitive behavioural treatment of eating disorders
Difficulties in labelling and expressing emotions
Bruch (1962, 1973) considered the “lack of interoceptive awareness”, inability to accurately identify and respond to emotions and other internal
sensations, as fundamental to anorexia nervosa. She observed that patients
with anorexia nervosa “behave as if they had no independent rights, [and
seem to believe] that neither their bodies nor their actions are self-directed, or
not even their own” (p. 39). The failure to identify and respond accurately to
internal sensations has received some empirical support (Bourke, Taylor,
Parker, & Bagby, 1992; Schmidt, Jiwany, & Treasure, 1993). The confusion
surrounding internal state extends to mistrust of the validity and reliability of
attitudes, motives, and behaviour. The lack of confidence in thinking
processes is reflected in exaggerated self-monitoring and rigidity.
Cognitive theorists have attributed this tendency to idiosyncratic beliefs,
assumptions or schemas that anorexia nervosa patients use in evaluating
inner state (Garner & Bemis, 1985). These beliefs commonly centre around
attitudes about the legitimacy, desirability, acceptability, or justification of
inner experiences. The following comments by patients are clues to the operation of this process: “I do not know how I feel; how should I feel?; I do not
experience pleasure; I never feel angry; I am always energetic and never get
tired; I admire others who don’t show their feelings; I can’t stand these feelings – they are too strong; I don’t feel anything – I just binge.” Asked about
feelings in a family interview, one patient appeared confused and responded
by pointing to her mother stating: “Ask her, she knows me better than I do”.
Similar mislabelling can be applied to other sensations like pleasure, relaxation or sexual feelings. Patients commonly interpret these sensations as
“wrong”, frivolous or threatening. One patient reported: “If I give in to the
urge to relax, I will become a degenerate.” Once distorted meanings are
revised, it is important for the therapist to encourage behavioural exercises to
reinforce and legitimise the new interpretations.
Interpersonal focus in therapy
Interpersonal concerns are inevitably expressed by anorexia nervosa patients
during the protracted course of therapy. The prominence of interpersonal
schemas has been the basis for their inclusion in earlier cognitive approaches
to the disorder (Garner et al., 1982; Garner & Bemis, 1985; Guidano & Liotti,
1983). Fairburn (1993) has cautioned that combining cognitive behavioural
and interpersonal therapy methods is “difficult, if not impossible, because
their style and focus are so different” (p. 374) in the treatment of bulimia nervosa. He has suggested different pathways to explain the effectiveness of
both forms of therapy in bulimia nervosa:
David M. Garner and M. Teresa Blanch
Cognitive Therapy ➔ Improved eating habits and attitudes ➔ Improved
interpersonal functioning.
Interpersonal Therapy ➔ Improved interpersonal functioning ➔
Improved eating habits and attitudes.
Although there are stylistic differences in the two approaches, and it may be
technically possible to exclude discussion of the interpersonal domain from
cognitive therapy, the theoretical justification for this separation is not obvious. Self-schemas and interpersonal schemas both influence and are
influenced by interactions with others. Although the interpersonal focus to
therapy requires a shift in therapy content, the systematic reliance on standard cognitive procedures continues. Patients tend to apply the same types of
schematic processing errors and dysfunctional assumptions to interpersonal
relationships as those displayed in other areas.
Cognitive therapy generally eschews the exploration of historical material;
however, this approach can be therapeutic in examining interpersonal
schemas. First, it is sometimes necessary to examine historical relationships to
find recurrent interpersonal patterns. Second, it can be useful for patients to
develop some understanding of the historical events and relationships that
may have made particular interpersonal schemas “adaptive”. Understanding
the earlier adaptive context can allow the patient to make sense of current
dysfunctional interpersonal schemas. Therapy sessions provide in vivo opportunities to assess dysfunctional interpersonal schemas that may generalise
outside of therapy. For example, the patient might be encouraged to examine
beliefs that interfere with assertiveness and then practise assertiveness in the
therapy session. The therapist and the patient then need to plan out-of-session opportunities to apply this newly acquired skill outside of the therapy
Family therapy
Support for involving the family in the treatment of eating disorders comes
from a number of sources. First, there are ethical, financial and practical
grounds for including the parents in the treatment of younger anorexia nervosa patients. Second, recovered patients consider resolution of family and
interpersonal problems as pivotal to recovery (Hsu, Crisp, & Callender, 1992;
Rorty, Yager, & Rossotto, 1993). Third, though early reports may have overstated the effectiveness of family therapy (Martin, 1983; Minuchin et al.,
1978; Selvini-Palazzoli, 1974), this mode of intervention has had an enduring
impact in the treatment of anorexia nervosa (Vandereycken, Kog, &
Vanderlinden, 1989) and has received empirical support in controlled trials
(Crisp, Norton, Gowers et al., 1991; Russell, Szmukler, Dare, & Eisler, 1987).
Practical factors are sufficiently compelling to justify the family approach
with some patients; however, our primary impetus for integrating family and
Cognitive behavioural treatment of eating disorders
cognitive approaches to anorexia nervosa is the conceptual harmony that
can be achieved in integrating these two treatment models (Garner et al.,
1982, 1986). On a fundamental level, there is agreement between models that
“meaning” is the primary locus of clinical concern. Also, both models assume
symptoms are adaptive on one level of meaning and dysfunctional on
another. Nevertheless, attempts to find common theoretical ground between
cognitive and family therapy have revealed key differences as well as
significant areas of overlap (Epstein, Schlesinger, & Dryden, 1988; Leslie,
1988). Some contrasts relate to intervention tactics and style while others pertain to the language and conceptualisation of the change process (Epstein et
al., 1988). Epstein et al. (1988) define the role of the cognitive therapist as a
consultant to clients who generate, accept or reject new cognitions based on
rational evaluation of the evidence. This differs from the systems and structural therapist who provides new meaning to symptoms and prescribes
behavioural change. However, the evolution of cognitive theory toward
including different levels of meaning tends to blur these distinctions. The
central question remains – how is family therapy conducted from a cognitive
One issue that often bitterly divides the family and individual therapy
camps may actually be illusory. It pertains to the mistaken assumption that
family therapists rely exclusively on the family format for sessions. Although
the point has not been widely publicised, Minuchin et al. (1978) recommended family therapy sessions only in the beginning for older adolescents,
“moving quickly to separate the patient into individual sessions and the parents into marital sessions in order to foster disengagement” (p. 132). Family
therapists argue that an eating disorder can maintain certain dysfunctional
roles, alliances, conflicts or interactional patterns within the family. Eating
symptoms may be functional by directing attention away from basic conflicts in the family. For example, eating symptoms may prevent parents from
addressing serious marital discord. Whether the format is individual or
family, the conceptual framework offered by systems theorists can be directly
translated into terms consistent with modern cognitive theory. The cornerstone of systemic and structural family theory is the recognition that
symptoms and behaviours function on different levels, adaptive at one level
but maladaptive at another. In both cognitive and family therapy, the primary
objective is to expose and alter meanings, generally by achieving shifts in
interactional patterns. A premise of both orientations to family therapy is
that an eating disorder can deflect members of the family away from the
developmental tensions that naturally emerge with the transition to puberty
and the attendant preparation for emancipation. In this case, the eating disorder serves as a maladaptive solution to the child’s struggle to achieve
autonomy. Moves toward independence are perceived as a threat to family
unity and activate behaviours aimed at preserving the status quo. This view is
consistent with other major theories of anorexia nervosa including the
David M. Garner and M. Teresa Blanch
cognitive formulations we presented earlier. The only difference is the degree
of emphasis on the individual’s versus the family’s reaction to this same
The cognitive therapist does not assume the specific meaning behind interactional patterns, but tries to assist the patient and the family in identifying
dysfunctional assumptions through questioning and the prescription of
behavioural change. Some examples illustrate multi-level beliefs. One patient
did not know why she was so angry at her mother’s cheerful and congenial
manner until she realised that it was really insincere. This same patient communicated her anger in her conflict-avoidant family by vomiting, claiming
that her behaviour was involuntary. The clue to the meaning of her behaviour
was that she always left the bathroom door open and retched so that all
could hear. By defining her vomiting as involuntary, she denied its hostile
intent and avoided reprisals.
This chapter has provided a broad overview of the cognitive behavioural
approach to the treatment of eating disorders. Specific components of treatment have been recommended such as self-monitoring, introduction of
avoided foods, and normalising body weight where appropriate. Assumptions
that typically become the focus of cognitive restructuring were reviewed, and
a sampling of strategies for addressing these have been provided. One of the
major benefits of CBT methods is that they are not necessarily incompatible
with other models for understanding eating disorders. In light of the growing
body of empirical support for the effectiveness of CBT methods in the treatment of bulimia nervosa, they should be considered the standard against
which other methods are measured. The conclusions for the value of CBT
treatment for anorexia nervosa must be tentative at present because there has
been insufficient empirical research in which its efficacy has been systematically examined.
Portions of this chapter have been adapted with permission from: Garner,
D.M., Vitousek, K., & Pike, K. (1997). Cognitive-behavioral therapy for
anorexia nervosa. Handbook of Treatment for Eating Disorders (pp. 94–144).
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Garner, D.M., Fairburn, C.G., & Davis, R. (1987). Cognitive-behavioral treatment of
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(1990). The association between bulimic symptoms and reported psychopathology.
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(1993). Comparison of cognitive-behavioral and supportive-expressive therapy for
bulimia nervosa. American Journal of Psychiatry, 150, 37–46.
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dietary treatments for obesity. Clinical Psychology Review, 11, 729–780.
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patient’s perspective. International Journal of Eating Disorders, 11, 341–350.
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brief psychoeducational intervention for bulimia nervosa. Behavior Research and
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Chapter 8
Schema-focused therapy for
personality disorders
Jeffrey E. Young
The emergence of cognitive behavioural therapy (CBT) has led to new methods
of treating patients with a character pathology or what DSM-IV (American
Psychiatric Association (APA), 1997) refers to as personality disorders. As cognitive therapists have become more interested in examining core structures and
the factors which affect personal growth negatively and positively, they have
moved from treating only Axis I disorders like depression or anxiety to working
with the more deep-seated characterological disorders of Axis II. Paralleling and
influenced by the constructivist movement within cognitive therapy, Young has
proposed an integrative model called schema-focused therapy (SFT), designed
to extend rather than replace Beck’s original model and specifically address the
needs of patients with long-standing characterological problems.
The intention of this chapter is to describe the practical applications of
schema-focused therapy against a background of its theoretical postulates.
Historical roots of schema-focused therapy
Cognitive therapy was developed as a movement away from the limitations of
psychoanalysis and the restrictive nature of radical behaviourism (Dobson,
1988). Beck’s cognitive therapy derived directly from his efforts to test Freud’s
theory that, at its core, depression is anger turned back on itself. Studying his
depressed patients, Beck concluded that depression is characterised by a consistent bias towards negative interpretations of the self, the environment, and
the future. Emotions were explained as the result of ongoing cognitive
appraisals: distorted appraisals and the negative emotions which result from
these distortions became the focus of the cognitive model.
In contrast to the psychoanalytic model and the strict behavioural tradition, Beck proposed that dysfunctional beliefs could readily be brought into
conscious awareness. He theorised that core assumptions about the self, the
future, and the environment seem unconscious because of the same nonpathological mechanisms by which other habits of thinking and behaving
Jeffrey E. Young
become automatic. He advocated active dialogue with patients through which
he trained his patients to develop empirical, reality-based arguments to
combat distortions in their thinking. Because the patient and the therapist
work together as a team, systematically testing the patient’s thoughts and
beliefs, this working style was called “collaborative empiricism”.
One of the most widely researched of the psychotherapies, there is promising evidence that cognitive therapy may be superior to pharmacology and
non-behavioural psychotherapies in preventing relapse (Dobson, 1989), and
there is growing evidence that it is also effective for anxiety and other disorders. The questions of process and outcome are still being actively researched
(Beckman & Watkins, 1989; Robins & Hayes, 1993).
The clinical impact of cognitive therapy has been enormous. However,
rather than a single integrated method, by 1990 more than twenty different
types of cognitive therapy had been identified (Haaga & Davidson, 1991).
Limitations of cognitive therapy and the constructivist
Therapists working with personality disorders and other chronic problems
found limitations in Beck’s original model. Young (1994a) proposed that several conditions had to be met for patients to succeed with Beck’s model:
that patients have ready access to their thoughts and feelings;
that patients have identifiable life problems to focus on;
that patients are able and willing to do homework assignments;
that patients can engage in a collaborative relationship with the therapist;
that patients’ cognitions be flexible enough to be modified through established cognitive-behavioural procedures.
Patients with personality disorders often do not meet these conditions, and,
to the extent that they do not, Young discovered that the therapy with them
would often fail without significant alterations.
This thinking coincides with the constructivist movement within cognitive
therapy. Several developments in psychology challenged many of the assumptions and intervention strategies of mainstream cognitive therapy (Mahoney,
1993). These include: new research findings on the nature of emotions, the
incorporation of experiential techniques into clinical practice, the study of
unconscious processes in cognitive therapy, an increasing focus on self-organising and self-protective processes in personality and life-span development,
and social, biological, and embodiment processes in therapy.
For constructivists, human cognition is seen as proactive and anticipatory
rather than passive and determined. As a consequence, constructivists tend to
challenge broader systems of personal constructs rather than disputing
Schema-focused therapy for personality disorders
circumscribed units of thought (Neimeyer, 1993). Because these systems are
believed to have enduring continuity over time, developmental dimensions of
patients’ psychopathology are emphasised, with particular attention to primary attachment relationships.
The goal of the constructivist therapist is creative rather than corrective.
The interventions are likely to be reflective and intensely personal rather
than analytic or technically instructive. Emotions are viewed as informative,
reflecting patients’ attempts to construct meaning out of their experiences.
Resistance is seen as self-protective when the therapist seems to threaten
patients’ core ordering processes.
The development of schema-focused therapy
Faced with the problems of treating patients with long-standing characterological disorders, Young developed schema-focused therapy. Young
(1994a) proposed that such patients have certain characteristics which make
them unsuitable for standard cognitive therapy. He identified four important
Diffuse presentation
Patients with characterological problems often lack the kind of readily identifiable problems which can become the focus of treatment. Such patients
often exhibit significant disturbance in personal adjustment yet present vague,
ill-defined, or generalised complaints. With no specific target, the standard
techniques of cognitive therapy require modification.
Interpersonal problems
Interpersonal difficulties are emphasised in DSM-IV (APA, 1994) for Axis II
patients and are often the core problem for these patients. In traditional cognitive therapy, patients are expected to engage in a collaborative relationship
with the therapist in a few sessions. This may be difficult for some of these
patients while others may become overly dependent on their therapist. If
these difficulties are viewed as a barrier to the real tasks of therapy, the core
problems may be missed.
In traditional cognitive therapy, patients are assumed to have a certain flexibility which enables them to modify their thoughts and behaviours through
empirical analysis, logical discourse, experimentation, gradual steps, and
practice. Because one of the hallmarks of personality disorders is the presence of rigid, inflexible traits, standard cognitive therapy techniques alone
Jeffrey E. Young
may meet with limited or no success. Patients with entrenched patterns of
thinking and behaving may not yield to months of therapeutic work; even
those patients able to acknowledge their maladaptive thoughts or actions
may still maintain a sense of hopelessness about changing their core feelings,
behaviours, or beliefs.
Since patients with characterological problems chronically block or avoid
painful feelings (affective avoidance; see Young, 1994a) and thoughts (cognitive avoidance), standard cognitive techniques are often unsuccessful in
gaining access to their thoughts and feelings. Young theorises that this
avoidance develops as a result of aversive conditioning: anxiety and
depression become associated with memories and cognitions, leading to
Although patients with uncomplicated Axis I disorders also exhibit avoidance, they have relatively free access to their thoughts and feelings. For
instance, patients with panic disorder may avoid looking at their catastrophic
thoughts, but, with sufficient training, they generally are able to access their
automatic thoughts, and thus challenge and modify their thoughts and
The schema-focused model: theoretical
In the schema-focused model, four main constructs are proposed: early
maladaptive schemas, schema processes, schema domains, and schema
modes. This model is not intended as a comprehensive theory of psychopathology but rather as a working theory to guide clinical interventions
with patients who present with character disorders and other chronic
Early maladaptive schemas
Schemas have been defined as “organized elements of past reactions and
experience that form a relatively cohesive and persistent body of knowledge
capable of guiding subsequent perceptions and appraisals” (Segal, 1988).
Beck noted the importance of schemas in some of his earliest work. “On the
basis of the matrix of schemas, the individual is able to orient himself in relation to time and space and to categorize and interpret his experiences in a
meaningful way” (Beck, 1967).
Rather than present a competing theory of schemas, Young (1994a) proposes a subset of schemas called “early maladaptive schemas (EMS)”. Instead
of concentrating on automatic thoughts and underlying assumptions, the
Schema-focused therapy for personality disorders
schema-focused approach proposes a primary emphasis on the deepest level
of cognition, the early maladaptive schema1.
The schema-focused model defines schemas as “broad, pervasive themes
regarding oneself and one’s relationship with others, developed during
childhood and elaborated throughout one’s lifetime” and dysfunctional to
a significant degree (Young, 1994a). Schemas are essentially implicit,
unconditional motifs held by individuals. They are perceived as irrefutable
and are taken for granted. Schemas serve as a template for processing experience and, as a result, become elaborated throughout life and define an
individual’s behaviours, thoughts, feelings, and relationships with other
people. In contrast with underlying assumptions, schemas are usually
unconditional and, therefore, far more rigid. Essentially, schemas are usually valid representations of the noxious experiences of childhood. The
problem is that schemas over time become deeply entrenched patterns of
distorted thinking and dysfunctional behaviour. Because schemas develop
early in life, they become habitual and unquestioned, often defining selfconcepts and views of our world. Even when presented with evidence that
refutes the schema, many individuals distort information to confirm the
validity of the schema.
By definition, schemas are significantly dysfunctional. They interfere with
the individual’s ability to satisfy basic needs for stability and connection,
autonomy, desirability, and self-expression, or the capacity to accept reasonable limits. The threat of schematic change is too disruptive to the core
organisation to be tolerated and, hence, a variety of cognitive and behavioural manœuvres arise that ultimately reinforce the schema. These are called
schema processes.
Schema processes
Three schema processes are proposed: maintenance, avoidance, and compensation. These are automatic processes which overlap with the psychoanalytic
concepts of resistance and defence mechanisms. They are maladaptive styles
of coping used by the individual that are activated by and, in turn, reinforce
the schemas.
Schema maintenance
Schema maintenance refers to cognitive distortions and maladaptive behaviour that directly reinforce and perpetuate a schema. For instance, individuals
with defectiveness schemas may settle for a menial job rather than seek one
that will demonstrate their gifts.
1 The term “schema” will be used to refer to “early maladaptive schemas” in this paper.
Jeffrey E. Young
Schema avoidance
Schema avoidance refers to the cognitive, behavioural, and emotional strategies by which the individual attempts to avoid triggering a schema and the
inherent intense affect. This involves distracting oneself from thinking
about schema-connected issues or avoiding situations likely to trigger them.
For example, a patient with the Failure schema may avoid working on a
project because he fears it will be poorly evaluated; by doing so, he makes
it likely that he will obtain a negative evaluation, thus further reinforcing
the schema.
Schema compensation
Schema compensation refers to behaviours or cognitions which overcompensate for a schema; they appear to be the opposite of what one would
expect from a knowledge of patients’ early schemas. Schema compensation
represents early functional attempts of the child to redress and cope with the
pain of mistreatment by parents, siblings, and peers. However, schema compensations are often too extreme for an adult environment and ultimately
backfire, serving to reinforce the schema. An individual with the Emotional
Deprivation schema may demand too much of others, alienating them and
thus feeling even more deprived.
Schema domains and developmental origins
Young has identified eighteen schemas and has outlined specific cognitive,
behavioural, and interpersonal strategies for treatment of each schema
(Bricker, Young, & Flanagan, 1993; Young, 1994a). Each schema is grouped
in one of five broad categories or domains, and each domain is believed to
interfere with a core need of childhood. This section provides a description
of each schema domain. A list of domains and schemas is presented in
Table 8.12.
Disconnection and Rejection
Patients with these schemas expect that their needs for security, stability, nurturance, empathy, sharing of feelings, acceptance, and respect will not be met
in a predictable manner. Schemas in this domain (Abandonment/Instability,
2 This listing is tentative and constantly open to modification and elaboration based on our
growing work within this model. Recent studies generally confirm the factor structure of the
Schema Questionnaire, a self-report questionnaire derived through clinical experience and
designed to assess the early maladaptive schemas (Young & Brown, 1994; Schmidt, Joiner,
Young, & Telch, 1995; Schmidt, 1994).
Schema-focused therapy for personality disorders
Mistrust/Abuse, Emotional Deprivation, Defectiveness/Shame, and Social
Isolation/Alienation) typically result from a detached, cold, rejecting, withholding, lonely, explosive, or abusive family environment.
Impaired Autonomy and Performance
Patients with these schemas (Dependence/Incompetence, Vulnerability to
Danger, Enmeshment/Undeveloped Self, and Failure) have expectations
about themselves and the environment that interfere with their perceived
ability to separate, survive, function independently, or perform successfully.
The typical family in this schema domain is enmeshed, undermining of the
child’s confidence, overprotective, or may fail to reinforce the child for performing competently outside the family.
Impaired Limits
Schemas within this domain (Entitlement/Grandiosity, Insufficient SelfControl/Self-Discipline) pertain to deficiency in internal limits, responsibility
to others, or long-term goal orientation. These schemas lead to difficulty
respecting the rights of others, cooperating, keeping commitments, or setting
and meeting realistic personal goals. Patients with these schemas typically
have families characterised by permissiveness, indulgence, a lack of direction,
or a sense of superiority, rather than appropriate confrontation, discipline,
and limits. In some cases the child may not have been pushed to tolerate
normal levels of discomfort or may not have been given adequate supervision,
direction, or guidance.
Within this domain, there is an excessive focus on the desires, feelings, and
approval of others at the expense of one’s own needs, in order to gain love
and approval, maintain one’s sense of connection, or avoid retaliation.
Patients with these schemas (Subjugation, Self-Sacrifice, and ApprovalSeeking/Recognition-Seeking) often suppress or lack awareness of their own
anger and natural inclinations. Typical of the family origin for these patients
is conditional acceptance; children need to suppress important aspects of
themselves to gain love, attention, and approval.
Overvigilance and Inhibition
Schemas within this domain include Negativity/Vulnerability to Error,
Overcontrol/Emotional Inhibition, Unrelenting Standards/Hypercriticalness,
and Punitiveness. Within this domain there is an excessive emphasis on controlling one’s spontaneous feelings, impulses, and choices in order to avoid
Jeffrey E. Young
Table 8.1 Schema domains
Domain I. Disconnection and Rejection
Emotional Deprivation
Social Isolation/Alienation
Domain II. Impaired Autonomy and Performance
Vulnerability to Danger
Enmeshment/Undeveloped Self
Domain III. Impaired Limits
Insufficient Self-Control/Self-Discipline
Domain IV. Other-Directedness
Domain V. Overvigilance and Inhibition
Negativity/Vulnerability to Error
Overcontrol/Emotional Inhibition
Unrelenting Standards/Hypercriticalness
making mistakes; or on meeting rigid, internalised rules about performance
and ethical behaviour, often at the expense of happiness, self-expression,
relaxation, close relationships, or health. The typical family origin tends to be
grim and sometimes punitive: performance, duty, perfectionism, following the
rules, and avoiding mistakes predominate over pleasure, joy, and relaxation.
There is usually an undercurrent of pessimism and worry that things may fall
apart if one fails to be vigilant at all times.
Schema modes
Young defines a schema mode as “a facet of the self, involving a natural
grouping of schemas and schemas processes, that are not integrated with
other facets” (Young & Flanagan, 1994). Although more than one schema
may underlie an individual’s behaviour, all the schemas may not be active at
the same time. Some schemas may be triggered while others remain
Patients with severe characterological problems, such as those with borderline personality disorder, abruptly flip from one mode to another,
Schema-focused therapy for personality disorders
primarily in response to life events or environmental circumstances. These
schema modes are more or less cut off from each other, and patients may display different behaviours, cognitions, and emotions in each mode.
Schema modes are different from personality traits in that they are coping
mechanisms which are triggered by schematic events and correspond to “ego
states” in psychoanalysis. Many patients understand schema modes more
easily than they do the schemas that trigger them, and thus they may recognise the actions of the schema more comfortably.
The principal modes are (Young & First, 1996):
Child modes
1 Vulnerable Child
2 Angry Child
3 Impulsive/Undisciplined Child
4 Happy Child
Maladaptive coping modes
5 Compliant Surrender
6 Detached Protector
7 Overcompensator
8 Punitive Parent Modes
9 Demanding Parent
Healthy adult mode
10 Healthy Adult
Clinicians must not only distinguish between the different modes, they must
also be alert to triggers which activate each mode and note the different cognitions, emotions, and behaviours displayed by the patient in each schema
Practical applications of schema-focused therapy
Schema-focused therapy is divided into two distinct phases: assessment and
change. The assessment phase focuses on the identification and activation of
the particular schemas which are most relevant for each patient. The change
phase attempts to modify the relevant schemas by altering the distorted view
of the self and others. SFT is an integrated therapy, using techniques from
experiential and gestalt methods and object relations models as well as from
the strictly cognitive behavioural model. It is also both objective and subjective, focusing on both the rational and the emotional.
While it is useful to the practitioner to conceptualise assessment and
change as distinct processes, in fact they may often overlap. Many patients
find the venting which can take place during assessment therapeutic, while
Jeffrey E. Young
therapists continue to assess in the change phase even while they may be
empathising with the distress which the patient is expressing.
The assessment phase entails several components. In schema identification,
relevant schemas are identified via clinical analysis of the presenting problems
and a life review, using inventories such as Young Schema Questionnaire
(YSQ), the Multimodal Life History (MLH), the Young Parenting Inventory
(YPI), the Young Compensation Inventory (YCI), and the Young–Rygh
Avoidance Inventory (YRAI). The therapist also carefully observes the patterns in the therapy relationship. The Schema Grid (Young, 1990) helps the
therapist view the relative power of the patient’s schemas. This form uses a
count of the high scores on the Young Schema Index to make a sort of graph
which illuminates the relationship of the various schemas.
In schema activation, the therapist triggers identified schemas and affect
through role-playing, dialogues, and imagery in order to confirm the role of
the schemas and to overcome affective avoidance. In schema conceptualisation, to prepare for the change phase, the therapist develops a treatment plan
with an overall conceptualisation of the relevant schemas. In schema education, the therapist discusses the conceptualisation of the problem in schema
terms with the patient and they agree on a plan for change. These components are expanded below.
Schema identification
The first task of the schema-focused therapist is to identify the patient’s relevant schemas. This begins with an interview, as the patient describes the
presenting problems. The therapist derives supporting information from other
sources. The Young Schema Questionnaire (Young & Brown, 1994) is a 205item inventory that consists of a series of self-statements related to each
EMS. The Multimodal Life History Inventory (Lazarus & Lazarus, 1991) is
a record of important historical events in the patient’s life which helps the
clinician generate hypotheses about schema origins and life patterns. The
Young Parenting Inventory (Young, 1994b) illuminates the origin of schemas
by asking clients to rate their parents separately on many statements regarding their childhoods (e.g., “criticised me a lot, spoiled me,” or “was
overindulgent, in many respects”). This inventory can also be very helpful
with patients who are out of touch with or avoidant of their feelings. Often
the therapist is able to infer from the information provided by the questionnaire what the feelings probably are that the patient is avoiding. The Young
Compensation Inventory taps into the degree and type of compensation.
The Young–Rygh Avoidance Inventory measures the degree and type of
schema avoidance.
Schema-focused therapy for personality disorders
Once specific EMS are identified, the clinician must explore how the
patient characteristically maintains, avoids, or compensates for the schemas.
For example, a patient with a defectiveness schema may enter into a relationship with someone who is overly critical and thereby may come to feel even
more defective. Identifying these schema processes helps the clinician determine how the patient perpetuates the schema while also providing important
information about the primacy of certain schemas over others. Finally the
therapist identifies the most relevant schema modes at this time.
Schema activation
As part of the assessment process, the therapist focuses on activating the
primary schemas. One of the most valuable methods involves the use of experiential techniques, such as asking the patient to image early childhood scenes
that come to mind, first with the mother, then with the father, and finally with
any other significant adults or siblings from childhood. The purpose is to trigger affect associated with the identified schemas.
The goal is two-fold. First, activating schemas during assessment confirms
the primacy of identified schemas. That is to say that those schemas which
elicit high levels of affect during schema activation sessions are usually considered primary while those that do not elicit such strong affect may be
considered secondary for the patient.
As mentioned earlier, patients with characterological disorders exhibit
tremendous affective, cognitive, and behavioural avoidance. As long as a
patient continues to avoid the thoughts and memories that cause painful
emotions, keeping vital information out of awareness, therapy cannot proceed efficiently. Activating EMS enables such patients to tolerate painful
feelings without withdrawing so that the change process may proceed effectively. The clinician also uses schema activation to overcome schema
avoidance. This process is not intended to modify the schemas but merely to
facilitate modification during the change phase. In essence, the role of the
therapist is to help the patient tolerate low levels of schema-related affect
and then gradually intensify the experience until the patient is able to tolerate the full imagery exercise without retreating from the image. This
ultimately enables the patient to gain access to previously avoided thoughts
and emotions which facilitates the modification of the underlying schemas
during the change phase.
Before the change phase can begin, the therapist must organise the material obtained during the assessment phase. It may require several sessions to
get to this point, depending on the complexity of the issues involved and how
wounded, self-protective, or avoidant the patient is. Two patients with the core
schema of Defectiveness may exhibit vastly different clinical pictures. As well as
being different in age, intelligence, ethnicity, talents, and so on, one patient with
Defectiveness may come across as flamboyant, self-absorbed, and eager to talk
Jeffrey E. Young
about superficial aspects of himself while another might be very guarded, shy,
and threatened by any personal question, no matter how gently posed. The tool
that finally integrates the information into a road map is the Schema
Conceptualization Form (Young, 1992). This form guides the therapist
through the complicated process of viewing the patient’s problem in schema
terms and helps form an effective treatment plan so that there is a clear direction during the ensuing change phase. The form lists the schemas involved,
the presenting problems with the schemas’ links, and schema triggers. It also
looks at core memories, cognitive distortions, maintenance behaviours, avoidance strategies, and compensatory strategies. Then, taking into account the
therapeutic relationship, the therapist lists the strategy for change linked to
the problems at hand. Hence the conceptualisation is always tailored to the
individual patient because the patterning of schemas and the particular way
they interact is unique to each individual.
Schema education
Finally, before change is initiated, it is essential to explain the nature of EMS,
domains, process, and modes to the patient in order to develop a shared
understanding of the problems and core issues involved. This allows the
patient and the therapist to agree on a conceptualisation of the problem and
a treatment plan in the context of the schema model. To further consolidate
their understanding of schemas, the therapist routinely recommends that
patients read Reinventing Your Life (Young & Klosko, 1993), a self-help book
based on the schema-focused approach.
The change phase
As stated earlier, the schema-focused model is an integrative approach to the
treatment of patients with characterological disorders and incorporates
experiential and interpersonal techniques within a cognitive behavioural
framework. Since many of the cognitive and behavioural strategies used are
similar to the ones used in standard cognitive therapy, this chapter will focus
on techniques specific to this model.
Cognitive techniques
The overall aim of cognitive techniques is to alter the distorted view of the
self and others which stem from the schema by presenting contrary objective
evidence to refute it. Cognitive exercises are intended to improve the way
patients habitually process information.
Cognitive exercises include the “life review”, where patients are asked to
provide evidence from their lives that supports or contradicts the schema. The
goal of the life review is (a) to help the patient appreciate how their schemas
Schema-focused therapy for personality disorders
distort their perceptions and feelings, thereby rigidly maintaining the schema
and (b) to begin the process of distancing from, rather than identifying, with
the schema.
The Schema Therapy FlashCard (Young, 1996) is a form which replaces
index cards on which the therapist can summarise and incorporate the most
powerful evidence and counter-arguments against the patient’s schemas. This
form is a four-step guide to be used in fighting schemas when they arise in
everyday situations. The patient is urged to carry the flashcards and to review
them frequently to continue the distancing process from the schema outside
Furthermore the Schema Diary (Young, 1994c) helps the patient to view
the role that schemas play in life in general and allows patients to understand
what it is possible for them to do about them. Patients use these forms when
feeling negative emotions. The therapist encourages patients to carry these
tools wherever they may go and to read them repeatedly, especially when
schemas are triggered (that is when there is a “schema attack”). The constant
repetition of rational responses and the acknowledgement of evidence contrary to the schema at the time of its activation helps patients to gain distance
from the schema and its related feelings as well as to identify increasingly with
the newer, healthier, and more objective voice.
Experiential techniques
Experiential techniques have been increasingly incorporated into cognitive
therapy in recent years (Daldrup, Beutler, Engle, & Greenberg, 1988; Safran
& Segal, 1990) and are utilised to bring the patient’s emotions in sync with
cognitive changes. These techniques appear to be among the most useful of
all strategies in schema-focused therapy and appear to change the underlying schemas in a fundamental way that is usually more powerful than
cognitive techniques alone. Experiential techniques enable the patient to
experience the affective arousal associated with the schema. Among the
two most commonly used experiential techniques are imagery and schema
In a schema dialogue, the patient learns to reject the feelings elicited by the
schema and to strengthen the healthy side of themselves. The therapist helps
the patient to confront the schema by providing contradictory evidence to
refute it. Just as the life review enables the patient to experience cognitive distance from the schema, the schema dialogue helps the patient to learn to
fight the schemas and can promote freedom and self-efficacy.
This technique requires two chairs so the patients can move back and forth
between one and the other as they assume different personae. One chair is for
Jeffrey E. Young
the schema; the other one is the healthy, rational voice. Generally, the patient
has little or no trouble giving the schema its “voice”; the difficult part is usually finding the voice of the emerging healthy side as the schema is often so
deeply embedded and accepted. The therapist may need to coach the healthy
side; in the beginning patients may have little spontaneous material to refute
the schema when they hold strongly felt negative beliefs.
A variation of this technique is to have the patient pretend to confront a
person who has played a particularly difficult role in his or her life. Again the
patient is often adept at playing the detractor; the difficulty for the patient
usually arises in finding the words for the refutation mode. Again coaching is
often necessary. Also it can be useful to have the healthy schema mode challenge one of the maladaptive schema modes. In this case one chair represents
the maladaptive mode while the other is the healthy mode, the patient moving
back and forth between the two. With sufficient practice, patients gradually
learn to assume the role of the healthy voice and almost automatically contradict the voice of the schema. When a patient gets to this stage, the ability
to ventilate feelings and to reject the schemas provides a sense of liberation
from this habitual way of thinking and facilitates a newer, healthier way of
thinking and feeling.
Many patients feel that studying the negative role is almost as helpful as
learning the healthy role as the negative voice becomes more clearly identified
as something extraneous. This demonstrates that the schema voice is not a
valid one but only a maladaptive remnant of childhood.
Imagery techniques are among the most powerful approaches to changing
schemas. Whereas in the assessment phase patients focus on recalling and tolerating the pain and discomfort of schemas, working in the change phase, the
therapist encourages the patient to recall an image from real life and to
modify the image by acting in a more functional manner. The patient is asked
to visualise the scene as vividly as possible. To this end, the therapist may ask
patients to describe explicit details of the painful situation, such as how they
looked at that age, the clothes they were wearing, how parents, siblings, or
peers appeared, what the scene looked like, the time of day, and other such
minutiae. During the imagery procedure, particular attention is paid to assessing feelings and thoughts relevant to the visualised scene. Patients are
encouraged to stay with their feelings and ultimately to respond to the image
with the newer, healthier pictures of themselves.
For instance, during an imagery exercise, a female patient with the
Defectiveness schema may be encouraged to express to her critical father
how he made her feel and to defend herself. If this proves too difficult, the
therapist may ask the patient’s permission to enter the image to help in the confrontation and provide a feeling of protection. Confronting the critical father in
Schema-focused therapy for personality disorders
imagery may enable a patient to recognise the parent’s role in forming her
Defectiveness schema, instead of attributing all the criticism to herself.
Guided imagery can help patients to visualise a different experience from
that which they knew; this can show that a different interpretation, or even a
different experience, is possible. This again can weaken the power of the
Interpersonal techniques
Since many patients with characterological disorders have difficulty establishing a therapeutic relationship, and since interpersonal problems are often
the presenting problem for these patients, the therapeutic relationship is often
a potent vehicle for schema modification. When patients who feel lonely and
isolated or ones who feel mistrustful come to rely on the therapist, there is a
powerful leverage for change. For instance, when patients with the
Unrelenting Standards schema find the therapist accepting and empathic,
they may begin to relent on their perfectionism.
One can construe one aspect of the therapist’s task as “limited reparenting”
where the therapist attempts to provide a therapeutic relationship that counteracts the schemas. The patient’s schemas and schema domains guide the
therapist in deciding what aspects of the reparenting process might be especially
important. Limited reparenting is most valuable for patients with schemas in
the Disconnection and Rejection domain, particularly those who experienced
extreme criticism, abuse, instability, deprivation, or rejection as children. For
example, if a patient’s parents were extremely critical, the therapist attempts to
be as accepting as possible. The therapist might make a point of praising the
patient and helping to recast events in a positive light. If the patient’s parents
were withholding, the therapist attempts to be as nurturing as possible. The
therapist can empathise with the painful experiences in the patients’ lives.
Besides the general attitude of concern, the therapist’s supporting role within
the images when that is appropriate and his or her support during the patient’s
crises can give the patient the feeling of having a substitute or proxy parent.
A young man with the Deprivation Schema who had feelings of hopelessness
about finding a decent job and organising his life imaged the overwhelming difficulty he had had with homework in the home of his demanding but neglectful
parents. He allowed the therapist to enter the image and help him with his
assignment. The young man felt more optimistic and empowered.
Of course, the therapist offers only an approximation of the missed emotional experience, maintaining the ethical and professional boundaries of the
therapeutic relationship. No attempt is made to re-enact being the parent
nor to regress the patient to a state of childlike dependency.
Jeffrey E. Young
Patients’ thoughts and feelings about the therapist also become relevant
material in identifying, triggering, and modifying schemas. It is important to
make the patient as comfortable as possible in discussing any feelings, especially negative feelings, about the therapist.
Contrary to traditional psychoanalytic practice, the schema-focused therapist works collaboratively, directly, and openly with patients to identify the
schema and the schema triggers when they arise during session. When a
schema seems to be activated in relation to the therapist, the therapist gives
patients the opportunity to test the validity of their beliefs. This can involve
self-disclosure on the therapist’s part to correct a patient’s distortions. Often
the therapist offers direct feedback that contradicts the patient’s schemadriven beliefs and expectations, and provides the patient with the opportunity
to express highly charged feelings directly in session. Through repeated
empathic confrontation – that is, contradicting patients’ negative ideas in an
empathic and accepting manner which does not denigrate the patient –
patients are taught to understand the role of the schemas in maintaining
thoughts and expectations and to challenge and modify them as they arise
during sessions.
On the other hand, when the therapist has indeed done something which
hurts or displeases the patient no matter how inadvertently, it is often helpful
for the therapist to admit it. This can make the bond stronger.
Schemas are also maintained by patients’ current interpersonal environment,
including intimate partners, friendships, and work. Patients gradually are
made aware of their role in their schemas in affecting interpersonal relationships. Patterns that rise within the therapeutic relationship may also be true
of interpersonal relationships in the patients’ life experience.
At times, it may be helpful to invite those close to the patients like partners
or friends to a session to help a patient assess the validity of the schemas and
to modify dysfunctional relationships. During these sessions, the therapist
identifies the patient’s schema-driven thoughts and expectations and helps the
patient to draw accurate inferences about others. Such sessions also enable
patients to communicate their previously unexpressed thoughts and feelings
in a safe environment. The results of such meetings can often be dramatic,
particularly when the participants can see how their schemas interact to produce conflict and disappointment. A woman with a Mistrust/Abuse schema
can come to understand that her partner is devoted and that his occasional
exasperation with her is not an excuse to desert her but only the normal friction of married life. Or, contrariwise, partners may be able to see where
behaviour they see as normal may be hurtful to the patient.
Schema-focused therapy for personality disorders
Behavioural techniques
Behavioural techniques are used in schema-focused therapy to modify selfdefeating patterns of behavioural avoidance, maintenance, and compensation
that perpetuate the patient’s schema. Although cognitive exercises weaken the
schema, schematic thoughts may still be triggered in specific situations, causing the patient to continue to behave in ways that reinforce the schema.
Therefore, the therapist uses behavioural exercises in conjunction with
cognitive exercises to further challenge thoughts and behaviours. When
appropriate, schema-focused therapy incorporates many well-established
behavioural and operant techniques such as systematic exposure, teaching
social skills, assertiveness training, and behavioural training to change behaviours that reinforce the schema.
Sometimes the patient and the therapist jointly construct an exposure
hierarchy to enable the patient to challenge the maladaptive thoughts systematically and to acquire and perform new behaviours which contradict the
schema. Before in vivo exposure takes place, the patient rehearses each step
in the hierarchy during the therapy session. This can be done by role playing
or with guided imagery or both. This process reduces anxiety and increases
the likelihood of success in the real life situation. This is because the patient
will see these new behaviours as more familiar than if they were to try them
“cold”. In fact, once patients have successfully completed each step in imaging, they are required to perform it outside the session (in vivo exposure).
If patients perform the exercise successfully outside the session, they are
reinforced during the next session. The therapist then guides the patient
through the next, more difficult exercise in the hierarchy. A woman who
feared panic attacks while driving in the city started by imaging driving on
quiet streets with the therapist at her side. As she came to accept such images,
the scene little by little included more threatening situations. Eventually
patient and therapist used an actual automobile and finally the patient was
able to drive the circumference of the city without difficulty. If the patient is
unsuccessful, the situation is discussed at length during the next session to
pinpoint exactly how and where it failed. The patient has a chance to discuss
the event and vent any feelings about it. Once the source of the failure is identified, the appropriate exercises are rehearsed again during session before the
patient attempts it again outside therapy. Often flashcards are helpful in
fighting schemas in these circumstances.
Jeffrey E. Young
In addition to exercises that focus on adding new behaviours to their repertoire, patients are encouraged to stop behaving in ways that reinforce the
schema. For example, since patients with the Defectiveness schema often
perceive well-intentioned suggestions or casual remarks as harsh criticism
(schema maintenance), they may be helped to distinguish useful suggestions
from derogatory criticism. Once they are able to make this distinction, they
are taught to confront partners who are inappropriately critical and terminate the relationship if the partner does not change. They might also learn
to respond more appropriately to friends who offer feedback instead of
becoming defensive or depressed. Likewise, if patients have the Subjugation
schema and have an exploitative employer, they might consider finding
employment with someone who treats the staff with respect. There can be
similar strategies for most of the other schemas, depending on the patient’s
Homework is very helpful in fighting schemas. It keeps the work present in
the patient’s mind and helps to focus during the week on what has been
accomplished during session. There are many possible kinds of homework.
We have already discussed the life review. It is sometimes helpful to assign
reading as, for instance, Reinventing Your Life. The patient may write a rebuttal to some schematic thought which emerged during session. The assignment
of homework can often be a challenge to the therapist as ideally each assignment is tailor-made to the peculiar needs of that particular patient. This can
tax the resourcefulness of the therapist, but the rewards in patient improvement can more than repay any effort in that direction. Commonly the
therapist will ask the patient to list supposedly defective traits, following each
in the next column with confirming evidence, and finally filling in a column
with evidence that contradicts the schematic thought. The patient and the
therapist go over this in the next session. Generally, in the beginning, the
patient has difficulty with the contradicting evidence and needs considerable
coaching from the therapist. A woman who has earned an MFA (Master of
Fine Arts) and holds a highly responsible, well paying job saw herself as
“lazy”. As she had come from a deprived blue collar background in which few
of her relatives had even graduated from high school, the therapist was finally
able to convince her that the idea that she was lazy came from some judgemental adults, family and teachers who helped bring her up. A lazy person
could never have accomplished all that she had.
Schema-focused therapy for personality disorders
Difficult cases
Patients with borderline personality disorder may switch between four modes:
the Detached Protector, the Vulnerable Child, the Angry Child, and the
Punitive Parent. The Detached Protector is the default mode for most of
these patients, and it serves to detach them from people and from the pain of
experiencing emotions. Patients with borderline personality disorder usually
experience a sense of depersonalisation, emptiness, or boredom and may
appear excessively obedient or compliant. Substance abuse, bingeing, selfmutilation, and psychosomatic complaints are characteristic of this mode.
Such patients may flip into the Abandoned Child mode if they feel threatened
by fears of harm or abandonment. They then experience intense depression,
hopelessness, fear, worthlessness, unloveability, victimisation, and great neediness. They may engage in frantic efforts to avoid abandonment and may
even attempt suicide. A shift to the Punitive Parent mode, when patients with
borderline personality disorder believe they have done something wrong (for
example, having “inappropriate” feelings like anger), makes them begin to
experience self-hatred and self-directed anger and they tend to punish themselves harshly for making mistakes. In severe cases they may even cut or
mutilate themselves.
The Detached Protector and Abandoned Child modes create tremendous
anger in these patients because they involve the suppression of intense needs
and feelings. When anger builds up to a point when it can no longer be contained, these individuals flip into the Angry Child mode. Their previously
pent-up emotions are unleashed, and they often become enraged, demanding,
devaluing, manipulative, controlling, and abusive. They now become focused
on getting their needs met, but they do so in destructive ways – they become
impulsive, make suicide attempts, engage in pent-up rage and acting out, and
so forth.
A patient with narcissistic personality disorder may often flip between
three modes, the Special Self, the Deprived Child, and the Self Soother. Many
narcissists spend the majority of their time in the Special Self mode, which
comprises the Entitlement, Approval Seeking, Unrelenting Standards, and
Mistrust schemas. In this mode they act superior, status oriented, entitled,
and critical of others, showing little empathy. They may flip to the Deprived
Child mode – comprising the Defectiveness, Emotional Deprivation, and
Subjugation schemas – if they are cut off from sources of approval and validation when, for instance, they receive criticism. In this mode these
individuals experience acutely the loss of special status and feel devalued.
Finally, to escape the pain of being average, narcissists either switch back to
the Special Self, or, failing attempts to regain approval and validation, they
switch into a third mode, the Self Soother. This mode is a form of schema
avoidance; its purpose is to distract or numb themselves from the pain of the
Emotional Deprivation or the Defectiveness schemas. Self soothing can take
Jeffrey E. Young
many forms, including drug and alcohol abuse, compulsive sexual activity,
stimulation seeking – high stakes gambling or investing – overeating, extravagance, fantasies of grandiosity, and workaholism.
As schema modes or facets of the self are more or less cut off from one
another, and characterological patients display different cognitions, behaviours, and emotions in each one, the therapist must use different treatment
strategies in response to each mode. The therapeutic goal is to integrate the
different facets of the self by making the transition from one mode to another
a seamless process.
Clinical and empirical validation of schemafocused therapy
In our clinical experience, Young’s schema-focused model has been successfully applied to patients with a range of DSM-IV disorders including
prevention of relapse in depression and anxiety disorders (Young, Beck, &
Weinberger, 1993); avoidant, dependent, compulsive, histrionic, and narcissistic personality disorders; substance abuse during the recovery phase; and to
patients with a history of eating disorders, chronic pain, or childhood abuse
(McGinn, Young, & Sanderson, 1995). However, controlled clinical outcome
studies comparing the relative efficacy of schema-focused therapy versus
standard cognitive therapy for the treatment of these disorders have yet to be
Schema-focused therapy is a promising new integrative model of treatment
for a wide selection of lifelong patterns. It was proposed to meet the needs of
patients with personality disorders who did not benefit fully from Beck’s
early model of cognitive therapy. Schema-focused therapy adapts techniques
used in traditional cognitive therapy but goes beyond the short-term
approach by combining interpersonal and experiential techniques within a
cognitive behavioural framework, utilising the concept of the early maladaptive schema as the unifying element.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental
Disorders (4th edition). Washington, DC: Author.
Beck, A.T. (1967). Depression: Clinical, Experimental, and Theoretical Aspects. New
York: Harper & Row.
Beckman, E.E. & Watkins, J.T. (1989). Process and outcome in cognitive therapy.
In A. Freeman, K. Simon, L. Buetler, & H. Arkowitz (Eds.), Comprehensive
Handbook of Cognitive Therapy. New York: Plenum Press
Schema-focused therapy for personality disorders
Bricker, D.C., Young, J.E., & Flanagan, C.M. (1993). Schema-focused cognitive
therapy: A comprehensive framework for characterological problems. In K.T.
Kuehlwein & H. Rosen (Eds.), Cognitive Therapies in Action. San Francisco:
Daldrup, R.J., Beutler, L.E., Engle, D., & Greenberg, L.S. (1998). Focused Expressive
Psychotherapy: Freeing the Overcontrolled Patient. New York: Guilford Press.
Dobson, K.S. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Clinical and Consulting Psychology, 57, 414–419.
Dobson, K.S. (Ed.) (1988). Handbook of Cognitive-behavioral Therapies. New York:
Guilford Press.
Haaga, D.A. & Davison, G.C. (1991). Disappearing differences do not always reflect
healthy integration: an analysis of cognitive therapy and rational-emotive therapy.
Journal of Psychotherapy Integration, 1, 287–303.
Lazarus, A.A. & Lazarus, C.N. (1991). Multimodal Life History Inventory (2nd edition). Champagne, IL: Research Press.
Mahoney, M.J. (1993). Introduction to special section: Theoretical developments in
the cognitive therapies. Journal of Consulting and Clinical Psychology, 2, 187–212.
McGinn, L.K., Young, J.E., & Sanderson, W.C. (1995). When and how to do longerterm therapies without feeling guilty. Cognitive and Behavioral Practice, 2, 187–212.
Neimeyer, R.A. (1993). An appraisal of constructivist therapies. Journal of Consulting
and Clinical Psychology, 2, 221–234.
Robins, C.J. & Hayes, A.M. (1993). An appraisal of cognitive therapy. Journal of
Consulting and Clinical Psychology, 6, 205–214.
Safran, J.D. & Segal, Z.V. (1990). Interpersonal Processes in Cognitive Therapy. New
York: Basic Books.
Schmidt, N.B. (1994). The Schema Questionnaire and The Schema Avoidance
Questionnaire. Behavior Therapist, 17, 90–92.
Schmidt, N.B., Joiner, T.E., Young, J.E., & Telch, M.J. (1995). The Schema
Questionnaire: Investigation of psychometric properties and the hierarchical structure of a measure of maladaptive schemas. Cognitive Therapy and Research, 19,
Segal, Z.V. (1988). Appraisal of the self-schema constructs in cognitive models of
depression. Psychological Bulletin, 103, 147–162.
Young J.E. (1990). Schema Grid. (Available from the Cognitive Therapy Center of
New York, Suite 530, 120 East 56 Street, New York, NY 10022.)
Young, J.E. (1992). Schema Conceptualization Form. (Available from the Cognitive
Therapy Center of New York, Suite 530,120 East 56 Street, New York, NY 10022.)
Young, J.E. (1994a). Cognitive Therapy for Personality Disorders: A Schema Focused
Approach (Revised edition). Sarasota, FL: Professional Resource Press.
Young, J.E. (1994b). Young Parenting Inventory. (Available from the Cognitive Therapy
Center of New York, Suite 530, 120 East 56 Street, New York, NY 10022.)
Young, J.E. (1994c). Schema Diary. (Available from the Cognitive Therapy Center of
New York, Suite 530, 120 East 56 Street, New York, NY 10022.)
Young, J.E. (1996). Schema FlashCard. (Available from the Cognitive Therapy Center
of New York, Suite 530, 120 East 56 Street, New York, NY 10022.)
Young, J.E. & Brown, G. (1994). Young schema questionnaire (2nd edition). In J.E.
Young, Cognitive Therapy for Personality Disorders: A Schema Focused Approach
(Revised edition). Sarasota, FL: Professional Resource Press.
Jeffrey E. Young
Young, J.E. & First, M. (1996). Schema Modes. (Available from the Cognitive Therapy
Center of New York, Suite 530, 120 East 56 Street, New York, NY 10022.)
Young, J.E. & Flanagan, C. (1994). Schema-focused therapy for narcissistic patients.
In E. Ronningstam (Ed.), Disorders of Narcissism – Theoretical, Empirical, and
Clinical Implications. Washington, DC: American Psychiatric Press.
Young, J.E., & Klosko, J. (1993). Reinventing Your Life. New York: Plume.
Young, J.E., Beck, A.T., & Weinberger, A. (1993). Depression. In D.H. Barlow (Ed.),
Clinical Handbook of Psychological Disorders (2nd edition). New York: Guilford
Chapter 9
Letting it go
Using cognitive therapy to treat
borderline personality disorder
Susan B. Morse
Cognitive therapy has been proven to be effective for the treatment of unipolar depression (Beck, Rush, Shaw, & Emery, 1979) and anxiety disorders
(Beck, Emery, & Greenberg, 1985). This theory and some of the techniques
have also been applied to the treatment of personality disorders (Beck,
Freeman, & Associates, 1990; Young, 1990; Layden, Newman, Freeman, &
Morse, 1993). This chapter will focus on what may be the most complex of all
the personality disorders: the borderline.
Many of the same issues arise in the treatment of the borderline patient as
in the treatment of depression and anxiety. However, there are some additional problems which occur with this special and challenging patient. This
chapter will attempt to address those issues which are different from the more
standard cognitive therapies and give the reader a conceptualisation and
techniques which will light a path toward health for these patients.
Diagnosis and identification of the borderline
Some therapists can spot a borderline patient immediately, but they may also
be overdiagnosing this disorder. There are many signs that lead to a diagnosis of borderline personality disorder (BPD). The DSM-IV (APA, 1994)
defines a BPD as “A pervasive pattern of instability of mood, interpersonal
relationships, and self-image, beginning by early adulthood and present in a
variety of contexts”, as indicated by at least five of the following:
1 A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of overidealisation and
2 Impulsiveness in at least two areas that are potentially self-damaging,
such as spending, sex, substance abuse, shoplifting, reckless driving, or
binge-eating (do not include suicidal or self-mutilating behaviour covered
in criterion 5).
3 Affective instability: marked shifts from baseline mood to depression,
Susan B. Morse
irritability, or anxiety, usually lasting a few hours and only rarely more
than a few days.
Inappropriate, intense anger or lack of control of anger – for example,
frequent displays of temper, constant anger, recurrent physical fights.
Recurrent suicidal threats, gestures, or behaviours, or self-mutilating
Marked and consistent identity disturbance manifested by uncertainty
about at least two of the following: self-image, sexual orientation, longterm goals or career choice, type of friends desired, preferred values.
Chronic feelings of emptiness or boredom.
Frantic efforts to avoid real or imagined abandonment (do not include
suicidal or self-mutilating behaviour covered in criterion 5).
In addition to these criteria, there are some other signs identified by Layden
et al. (1993), which may serve as markers or signposts leading the way to
1 The patient states, “I’ve always been this way. This is who I am.”
2 The patient demonstrates ongoing non-compliance with the therapeutic
regimen (especially indicative of BPD when the patient is uncooperative
in a hostile manner).
3 Therapeutic progress seems to come to a sudden halt for no apparent
4 The patients seem entirely unaware of the negative effects of their behaviour on others.
5 The patients’ personality problems appear to be acceptable to them.
Motivation for change is very low.
6 The therapist has very powerful, potentially antitherapeutic reactions to
the patient. This feeds into the BPD patient’s propensity for mistrusting
the therapist.
7 The patient misses many therapy sessions, arrives late for many sessions,
and sometimes leaves abruptly during sessions.
8 The patient exhibits an extreme all or none thinking style.
9 The patients have difficulty moderating or modulating their emotional
reactions, especially outbursts of anger.
10 The patient frequently does things that cause some sort of self-harm.
These signs may indicate the existence of any personality disorder but, taken
in combination with the DSM-IV criteria, are very helpful in identification of
the BPD patient. There is a large intradiagnostic variability within the BPD
group. It has been suggested by Kernberg (1975, 1984), Meissner (1988) and
Layden et al. (1993) that BPD is more of a spectrum than a single discrete
entity. The three subtypes identified by Layden et al. (1993) are:
Cognitive behaviour in borderline personality disorder
These hypothetical subdivisions of BPD have been extremely helpful in conceptualising these patients more clearly. The subdivisions also help to
prioritise goals for these patients when the things they need to work on can
seem overwhelming. Understanding these distinctions has critical implications for conceptualisation.
The borderline–avoidant/dependent patient displays high levels of anxiety,
low levels of competence (often due to avoidance), and very low self-esteem.
They often have an underdeveloped sense of self and have difficulty maintaining boundaries in any relationship, including therapy. They alternate
between distancing people and the need for constant reassurance. This movement between mistrust of intimacy and extreme dependency causes this type
of patient to appear highly anxious and often dysthymic. The behavioural
strategies they engage in are avoidance, withdrawal, clinging, and neediness,
and they will display high levels of anxiety.
The borderline–histrionic/narcissistic patient displays mood lability, stormy
relationships, and overwhelming need for affection and attention. Their fears
related to abandonment and unloveability decrease their ability to understand and respect interpersonal boundaries. These patients appear to desire
stimulation but its focus is external. The need for changes within the self is
not recognised. They are therefore resistant to therapy and often use all of
their resources to thwart progress. The behavioural strategies they engage in
are rage reactions, impulsivity, impatience, low frustration tolerance and overinvestment in relationships which have not yet matured.
The borderline–antisocial/paranoid patient shows a marked disregard for
the rules that govern behaviour; whether these rules are formal (laws, religious
mores) or informal (moral, polite, socially based) makes no difference to this
patient. They put themselves first because there is no recognition of others’
rights. They display a chronic and pervasive distrust of the motives of others
and are hypervigilant to any sign of threat. These patients, although they may
look the same as “pure” antisocial/paranoid, are motivated out of extreme
emotional pain and helplessness. These patients display hostility, suspiciousness and recklessness. They have a low tolerance for boredom which often
leads to substance abuse. The behavioural strategies these patients display are
aggression, substance abuse, low impulse control and destructive behaviours
which may be directed inward or outward.
Once you diagnose a borderline personality disorder and identify the subtype they resemble most closely then it is time to begin the work of cognitive
Susan B. Morse
Cognitive conceptualisation of borderline
personality disorder
The cognitive components which truly define a borderline personality disorder are the nature of their schematic systems. Schemas in this sense refer to
unconditional beliefs about the self in relationship to the world. These core
beliefs or schemas are based on a person’s perception of events and assist in
the maintenance of negative behaviours. These schemas are developed early
in life and are maintained through negative cognitive sets and emotions. It is
through identification, challenge and modification of these belief systems
that the borderline patient can change. Schemas can be dormant or active.
These beliefs are often activated by a trigger or any event which is perceived
by the patient as traumatic. For example, a patient may not believe that they
are unloveable if they are in a relationship. When the relationship ends, the
schema may be triggered and they then believe at 100% that they are not loveable. One of the first goals in cognitive therapy is to help the patient identify
their schemas and the situations, emotions, or thoughts which trigger them.
In order to do this you must teach each patient to identify and understand the
levels of cognition.
Levels of cognition
There are three levels of cognition which must be addressed in the treatment
of any personality disorder. Patients must be able to identify all levels of
cognition as they begin to help themselves with therapy.
One of the easiest ways to remember these levels and to teach them to
patients is with the “tree” example shown in Figure 9.1. It goes like this: the
Conditional beliefs
and assumptions
Schemas or
core beliefs
Figure 9.1 Levels of cognition.
Cognitive behaviour in borderline personality disorder
first level of cognition or thought is the automatic thought level. It is like the
leaves and the branches of the tree. You can see all the different shapes and
sizes. You can see the whole shape or look at each little leaf. The branches and
leaves blow in the wind, get wet when it rains and in general are very reactive
to the environment. They are easy to access, you can pluck them from the tree
or break off a branch. Automatic thoughts are like this in that you can access
them, they are reactive to the environment and you can change them with relative ease.
The second level of thought is the conditional beliefs or assumptions. They
are like the trunk of the tree. You can see the shape and size but to see each
growth ring you must look inside. It responds to the environment but not as
easily. It connects the roots to the branches and leaves. You must use a tool
like a saw or a knife to change the trunk. Conditional beliefs are like the
trunk of the tree. You must look for them, they are harder to change than
automatic thoughts and they come in “If . . . then” form which connects the
schema to the automatic thoughts.
The lowest level of cognition is the schema or core belief. These thoughts
are like the roots of the tree. You cannot see the size or the shape. You do not
know the number. They filter all the information and nutrients to the upper
levels. They are as old as the tree and have grown and modified over the life
of the tree. To identify and change them you often need to uproot the entire
tree. Schemas are like the roots of the tree, you must look hard for them,
they “hold” the personality together and all information is filtered through
As the therapist you will need to hypothesise which beliefs and thoughts are
giving the patient trouble. Once you have identified these cognitions you must
help the patient learn to respond to these thoughts. Before you can challenge
and change the hypothetical schema you have identified, you must stabilise
your patient’s behaviour and emotions. You can do this by decreasing the
responses that are generated at a schematic level. This needs to be done by
working on the automatic thought level with the patient on standard cognitive therapy for Axis I issues. The ability to identify and challenge automatic
thoughts builds a “buffer” between the patient and the environment. One
patient described it as “feeling like I have skin for the first time”. These
patients react with such strong emotion because schemas have been activated
by a trigger. As they increase their ability to identify and respond to daily
stressors they decrease their reactive responses. When schemas remain protected they do not force the use of the dysfunctional behaviour strategies.
Therefore if a patient can respond to triggers, situations and negative emotions such as depression and anxiety on an automatic thought level they will
be less likely to respond at a schematic level.
Once the patient can keep the “present in the present” and the “past in the
past”, they can begin to change their schemas. You have a much more difficult time changing schemas when they are being activated than when they are
Susan B. Morse
dormant. In addition to the levels of cognition, you must teach the borderline
patient about schema development.
Schema development
Educating yourself and your patients about the impact of schemas is the
beginning of understanding their behaviour. You want to help the patient
identify their schemas and to look at how they came to believe these things
about themselves. Looking at their developmental history often provides the
answers to this question. There are several developmental issues which apply
to the development of borderline personality disorder.
Content of the schema.
The Eriksonian stages of the patient’s life relevant to the times when the
schemas were acquired and reinforced.
The perceptual channels through which the schema building information
was received and stored.
The Piagetian level of cognitive processing relevant to the schemas.
This information needs to be collected so that the development and maintenance of the schemas can be understood by both therapist and patient.
Content of schemas
One of the most useful components of cognitive therapy is that the therapist
uses the client’s materials to build a conceptualisation. One is not bound by
a static theory into which all patients must fit. Schema content is as individual as the patient. The words the patient uses to describe their experiences
make up the schema content. If, however, some assistance in identification of
schemas is needed, Schema-focused Cognitive Therapy for Personality
Disorders: A Schema-focused Approach by Jeffrey Young (1990) provides a
self-report list of potential schemas for the client to complete. Some of these
fall into the following categories:
Subjugation/lack of individuation
Vulnerability to harm and illness
Fear of losing control
Emotional deprivation
Social isolation/alienation
Social undesirability
Cognitive behaviour in borderline personality disorder
Unrelenting standards
Loss of emotional control
Entitlement/insufficient limits
In addition to these categories, Aaron T. Beck hypothesises that there are two
underlying themes for schemas – unloveability and competence. As your
patient presents you with information about their belief system you can refer
to these content areas.
Eriksonian stages associated with schema
Eriksonian theory provides us with a frame for schema development which
uses the same language as the patient to describe their belief system (Erikson,
1963). There are two ways to look for this developmental information. First,
when the BPD patient uses words like trust or competence you can explore
the patient’s history in an attempt to explain the origin and process by which
the patient came to believe the schema. The way Eriksonian stages are associated with schema development is illustrated in Table 9.1.
Table 9.1 Eriksonian stages associated with schema development
0–18 months
18 months to 3 years
3 years to 6 years 6 years to puberty
Trust versus
Autonomy versus
shame and doubt
Initiative versus
versus inferiority
Abandonment Lack of individuation
Unloveability and defectiveness
For example, Sally believes that she “isn’t good enough”. As this statement
was explored further she stated she believed “I am bad”. By looking at her
developmental history we identified that she was two and one half years old
when her brother was born prematurely and there were expectations that she
“behave” because her brother and mother were ill. During this stage of development (18 months to 3 years) it is the child’s “job” to explore their world,
work on toilet training and begin to separate from the mother. It is easy to see
how parents with a sick baby may not have been extremely patient with an
exploring two year old. She was verbally reprimanded and took on this
Susan B. Morse
information in the form of a core belief. Her behaviours also mimic this stage
of development. She displayed extreme anxiety whenever she tried anything
new and she would switch between dependence and defiance in relationships
at work and at home.
Once this information was presented to the patient we could begin to work
on challenging it rather than constantly responding to it. Each stage needs to
be explored in order to identify beliefs and behaviours which may have developed in each phase. After identification the process of change and decreasing
reinforcement begins. The procedures used to facilitate this change will be
covered in the techniques for treatment section.
Channels of input
In order to remediate and challenge a belief you must be able to “get to it”.
In other words, to address the belief through the channel of development.
There are several methods by which information is processed.
Sensory: This is all the information that comes into a child’s world through
the senses. Sights, smells, sounds, taste, and tactile memories may be part of
this channel of input. We process information less in the sensory mode as we
grow older, so triggers and schemas stored in this way reflect early experiences
(Figure 9.2).
Images: This is the visual channel and can involve all sorts of visual information, faces, expressions, pictures, even images from the media or movies.
When accessing images, you need to look for two types of visual pictures. The
first type is like a snapshot and is frozen in time. The other type of image presents itself in movie form.
Age (years)
Figure 9.2 Channels of input in relation to age.
Cognitive behaviour in borderline personality disorder
Verbal: this is the most common channel through which information is
expressed – the use of words and abstract concepts. Most developmental
information from 8 years of age will be stored in verbal memory unless there
was a severe trauma that decreased processing ability.
When children are developing they receive information on a variety of
levels. In order to remediate a belief the therapist must understand how the
child came to believe this schema. Many patients will say that they feel things
but do not have the words for these feelings. This may be because they (the
feelings) are stored in modalities other than verbal.
The type of input affects the choice of intervention. Triggers and strategies
are also related to channel of input. I once treated a patient who had been the
victim of severe emotional, physical, and sexual abuse as a child. She had
been diagnosed as borderline with psychotic features. She had gone through
years of therapy and had made little progress. She was only 25 and had used
up her lifetime medical supplement. We began working on her issues while
she was in inpatient treatment. One day after a session we were walking
toward the hospital cafeteria. Unlike many hospitals this one had a wonderful chef who baked a chocolate chip pie for the patients and staff on special
occasions. Most of the people in the hospital responded positively to the
smell of the pies baking. The patient and I were walking and talking after
what we thought was a productive session. As we neared the door to the
cafeteria, she broke out into a sweat, started screaming and ran toward the
bathroom. I followed her and found her in the fetal position in the corner of
the toilet. After making sure she was safe and moving her to a more comfortable room, I began to question her about what had happened. “Was it
something that happened in session?” “No.” Was it someone we saw in the
hall?” “No.” “Was it the temperature? Something I said?” I was desperately
searching for a trigger for this outburst. “Was it a smell?” Then there were
many tears and she was able to recall that while she was being sexually abused
by her father and his friends, her father’s girlfriend would bake chocolate chip
cookies to keep the kids quiet. She had no words to explain her outburst but
when she was able to focus on the sensory triggers she was able to identify the
source of her distress. To everyone else and to herself this behaviour looked
crazy but once she understood the trigger she could understand her reaction.
A year later around Christmas time she placed an emergency call to me. She
had been out shopping with a friend and he was trying on cologne. She ran
out of the store disoriented and stopped herself to call me. She told me in a
breathless voice, “He (her father) wore Old Spice. I’m not crazy.” So after a
year of identification of triggers and learning to cope with the response, she
was able to identify, attribute and cope with her response rather than to use
the incident to reinforce her negative schema (I’m crazy).
By giving the patient some type of explanation for their reactions and
behaviours you can decrease the negative outcomes as well as reduce the
schema reinforcement.
Susan B. Morse
Piagetian stages
The Piagetian interpretation provides yet another necessary piece to the BPD
puzzle (Piaget, 1952). We expect that people develop according to the normal
course of development. When someone deviates from that course we expect
to see across the board, consistent arrested development. The borderline
patient, however, often handles some problems very well, but uses extremely
immature and maladaptive strategies for other problems. This can be very
frustrating to the therapist and many cause the patient to be labelled as “in
denial” or “repressing”. These labels imply intent and they result in negative
reactions from therapists and other support people. It is a hypothesis in cognitive therapy that these behaviours represent a skills deficit which originated
in an unnegotiated stage of development. Table 9.2 shows the stages of development according to Piaget and the corresponding borderline characteristics.
Table 9.2 Parallels between Piagetian and borderline characteristics
Piagetian stage
Piagetian characteristic
Similar borderline characteristic
(0 to 2 years)
Enmeshment, fear of engulfment, fear
of loss of identity, dependency, sense
of entitlement, egocentrism in speech
Lack of empathy, inability to conceive
of alternative explanations, no search
for evidence
Abandonment schema
Lack of empathy
Lack of object permanence
(2 to 7 years)
Affective realism
Overgeneralisation, confusion of “the
then with the now”, confusion of sex
with intimacy
Dichotomous thinking,
catastrophising, perfectionism,
unloveability schema
Inability to generalise conclusions,
vacillation between schemas
Emotional reasoning
Logical thinking
Inability to be logical
Theoretical thinking
Lack of theory construction
No metathought, inability to see
Inability to seriate
Transductive reasoning
Concrete and
formal operations
When these behaviours are present it is likely that a schema has been activated. This will often render standard cognitive therapy techniques useless. It
Cognitive behaviour in borderline personality disorder
is the job of the patient and therapist to identify the stage of development
where the patient is stuck and develop a treatment plan for the remediation of
this problem area. Treatment of the borderline patient is not extremely difficult but in order to address all these issues (along with the crisis of the day),
the therapist needs an arsenal of techniques and a clear treatment plan.
Case conceptualisation
The first step in good cognitive therapy is a clear understanding of the
patient. We have just discussed the stages of development and issues connected with schema activation in theory. Case conceptualisation involves
combining a specific patient’s information with this theoretical data to
develop a treatment plan.
You need to identify which area of the patient’s problems are the most
destructive to the patient and also find an area that may be easy to change.
The reason you need to enter the conceptualisation in two areas is to keep the
borderline patient safe from any destructive behaviours and to address the
hopelessness with some positive movement. If you can help the patient
change just one thing then you can decrease the level of hopelessness and
increase the likelihood that they will comply with more intense behavioural
In order to choose where to start, it may be helpful to complete a case conceptualisation worksheet on each patient. It may seem like it is a lot of work
outside the session but it will save you effort and problems throughout the
course of treatment. The following is a sample of a case conceptualisation
Patient’s initials:
I. Identifying information
II. Diagnoses:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
III. Objective scores:
Intake Session 1
Session 2
Session 3
Session 4
Session 5
Susan B. Morse
General trend of scores:
IV. Presenting problem and current functioning
V. Developmental profile
A. History (family, social, educational, medical, psychiatric, vocational)
B. Relationships (parents, siblings, peers, authority figures, significant
C. Significant events and traumas (combine with stage of development
and channels of input)
VI. Cognitive profile
A. The cognitive model as applied to this patient:
1. Typical current problems and problematic situations
2. Typical automatic thoughts, affect, and behaviours in these situations
B. Core beliefs/schemas (Unconditional statements about the self in relationship to the world and others)
C. Conditional beliefs (If–then statements which connect the schemas to
the present automatic thoughts)
D. Rules (shoulds/musts applied to self–others)
VII. Integration and conceptualisation of cognitive and developmental
A. Formulation of self-concept and concepts of others
B. Interaction of life events and cognitive vulnerabilities
C. Compensatory and coping strategies
D. Development and maintenance of current disorder
VIII. Implications for therapy
A. Suitability for cognitive interventions (rate low, medium, or high,
and add comments if applicable)
1. Psychological mindedness
2. Objectivity
3. Awareness
4. Belief in cognitive model
5. Accessibility and plasticity of automatic thoughts and beliefs
6. Adaptiveness
7. Humour
B. Personality interaction with external environment
1. Sociotropic (focus and emphasis of life on other people)
Cognitive behaviour in borderline personality disorder
2. Autonomous (focus and emphasis on power and independent functioning)
C. Patient’s motivation, goals, and expectations for therapy
D. Therapist’s goals
1. Most dangerous problem for this patient:
2. Problem most likely to change with relative ease
3. Skills training stages
E. Predicted difficulties and modifications of standard cognitive therapy
This worksheet will assist you in addressing the concerns you may have as
to how to begin your treatment with this difficult population. Clarification of
the patient’s history and current level of functioning will provide you with a
place to start.
The next section on treatment will assist you in how to modify standard
cognitive therapy for these patients.
Techniques for the treatment of the borderline
There is a greater use of the therapeutic relationship as a vehicle for change
in the treatment of the borderline patient. Many therapists learning cognitive
therapy for the borderline patient become worried that they are not doing
enough thought records or that the patient is not compliant with their homework. Although these are both important elements of the treatment, you
must take time to build a relationship with this patient. This does not mean
just sitting and listening but helping them begin to change the things that are
easier for them to change. People begin to trust therapy and the process more
quickly if the benefits are concrete and noticeable.
The course of treatment in cognitive therapy has been a topic for
researchers looking for the best and shortest intervention time for disorders
like depression and anxiety. The treatment of the borderline patient has yet to
be researched in this way. There are, however, some adjustments which need
to be made to standard cognitive therapy for this population.
In the treatment of Axis I disorders such as anxiety and depression, the
therapist has to socialise (or teach the cognitive model of thoughts–
feelings–behaviours) the patient only at the beginning of treatment. With the
borderline patient the therapist must continue to explain the cognitive model
in a variety of situations; it appears that these patients are less likely to generalise this concept than other patients. For example, if you teach a depressed
patient to monitor his thoughts at work, he may return the next week and tell
you he monitored his thoughts in a fight with his wife and it was helpful.
Generalisation has occurred and he is able to use his skills in order to handle
his thought in a variety of situations. A BPD patient with the same socialisation may not even be able to see how it works in a situation which is very
Susan B. Morse
similar to the practice situation. Each piece of information contains different
clues to the patient and it is too difficult to see the similarities. Therapists have
a tendency to think that the patient is being difficult when obvious connections are not made. This does not seem to be the case and this should be seen
as an opportunity to resocialise the patient with this particular set of circumstances.
The use of an agenda in cognitive therapy is something that separates it
from other types of therapy. The use of structure and agenda setting is a very
powerful tool in the treatment of the borderline patient. Structure in the
session provides an opportunity for the patient to practise prioritising their
emotional turmoil and to begin to make some progress in changing their
behaviours. Therapists are often unsure as to whether to be structured with
these patients as their emotional needs seem to overpower any other items
which may need to be talked about. It is very important to stick to your
agenda setting, giving homework, teaching skills, and prioritising your topics
with this population.
Cognitive therapy with this group is less Socratic and more confrontive. It
is not necessary in the treatment of Axis I patients to “tell” or “interpret”
their thoughts or perceptions for them. It is the therapist’s job to ask questions in a Socratic fashion in order to allow the patient to answer and
interpret his own thoughts and motivations. With the borderline patient, it is
often necessary to be more direct and to guide them in a concrete fashion to
an understanding of their thoughts. One note of caution here is not to “lead”
a patient to a hypothetical explanation of the origins of their schemas or
behaviours. The false memory syndrome is created by therapists doing just
that. There are many explanations for developmental problems and it is not
always necessary to “know for sure” what caused these beliefs. It is more
important to buffer the schemas and increase the patient’s functioning in the
Therapy for the borderline patient focuses on the historical and developmental factors for each patient. You should gather this information in a
timely fashion, for example sending home to the patient a packet of questions
which would provide you with the information you require to develop a conceptualisation and begin treatment. You do not need to gather an entire
history in person or allow the patient to talk through these historical issues.
They are extremely important in your treatment but the emphasis needs to be
on the here and now and problem-solving techniques in the present. Talking
about their history is not something that will help this patient at the beginning
of therapy.
The first set of techniques you should teach a borderline patient is anxiety
management. Any change will cause anxiety and schemas will be activated by
anxiety. These patients do not manage their anxiety well and this often leads
to their most problematic behaviours. If you spend the first few sessions
working on anxiety management skills it will decrease some of the avoidance
Cognitive behaviour in borderline personality disorder
and will increase the likelihood that therapy will not come to a mysterious
halt. If you want the patient to begin to feel competent, you should teach
them how to deal with this anxiety and do not move into intense schema
work or behavioural change work until you know that the patient has a minimal level of skill in this area.
There needs to be a focus on the strategies that borderline patients use to
decrease their discomfort. Try to identify all the methods that these patients
use to “calm” themselves down. The patient’s dysfunctional strategies to
manage problems (such as cutting, drinking, rages) may be activated by anxiety. It is important to assist the patient to develop the skills to manage these
Next you will need to teach the patient the difference between anger and
anxiety. These two emotional states manifest themselves in a similar fashion
physically. Often the borderline patient cannot tell the difference and will
respond with anger when they are really anxious about something. The one
main difference between anger and anxiety is the content of the cognitions.
The thoughts which precede anxiety have a theme of dangerousness and the
thoughts which precede anger have a theme of injustice. If you can assist the
patient in telling the difference between the two, you will see a reduction in the
degree of anger the patient displays.
So you have worked on anxiety versus anger, anxiety management skills,
collected some objective data (scores on the Beck Depression Inventory, Beck
Anxiety Inventory, Hopelessness Scale, etc.), you have gathered your history
and are always working on a therapeutic relationship. Now you are ready to
begin the cognitive techniques in earnest.
The BPD patient’s cognitions are idiosyncratic and often quite distressing
to the patient as well as the therapist. Therefore it was necessary to modify the
Dysfunctional Thought Record (Beck et al., 1979) to fit the cognitive set of
the borderline patient. Instead of just asking that the patient record their
automatic thoughts or stream of consciousness you will need to ask for specific information.
For example, there was a BPD patient who was in treatment for a number
of years with many therapists. She continued to have problems and difficulties with her daily life and was unable to do normal activities, which made her
life very complicated. She needed a new car but was terrified to go to the car
dealer to buy one. Because she was unable to do that her car broke down
often, making her late for work and she would miss appointments and dates.
She began to get negative feedback from her supervisor at work and her
friends were always upset with her. This activated her schemas of unacceptability and unloveability and she engaged in her negative strategies to try to
make herself feel better. The first step was to get her to solve the problem of
the car. Her homework was to go to the car dealer and fill out a thought
record with whatever went through her mind. Figure 9.3 shows the thought
record, Part 1, completed by her for that assignment (Figure 9.3).
Susan B. Morse
Sitting in car dealership remembering miscellaneous events of sexual,
emotional or physical abuse over the years.
DEGREE = 100%
2. Sad
DEGREE = 100%
DEGREE = 100%
AUTOMATIC THOUGHTS: I am ready to give up. No therapy can release all the pain. I know I
have the right to live and be happy, but the planet earth seemingly
insists by its practices that I don’t have the right.
The car dealer puts his hand over my mouth and throws me down.
He rapes me. I just lie there.
Can’t get my breath.
Pressure on my chest.
Pain in my back.
Being grabbed and thrown to the ground by assailant.
Father grabbing my arm and almost breaking it.
Figure 9.3 Thought record – Part 1.
It can be seen from the figure that if the therapist had focused on just the
thoughts, there would have been little progress. These thoughts are hopeless
but are not related to the situation and would be extremely difficult to challenge as we do not know the motivation of “planet earth”. But looking at the
images gives us a clear picture of why the patient would not go into the
dealer. Remember that people only act on the thoughts they believe and no
one would do something if they believed that rape would be the outcome.
This patient had been raped in the past and the sensations she records here
are sensations that she recalls from the rape. So once she had the image and
her body reinforced the memory she was unable to force herself to go and buy
a car. By completing this thought record we gathered a great deal more information and information which allows us to solve the problem. We increased
her safety factors (going with a friend, staying in the showroom, not being
alone with the salesman), had her do some standard image work to generate
some positive images, used relaxation to decrease the body sensations, and she
was then able to go into the dealer and purchase a car. This not only solved
the problem with the car but all the resulting difficulties from its unreliability.
In addition, we looked at her thoughts in a more specific and here and now
fashion. After some questioning about the situation at the car dealer she was
able to generate the thought, “I will always be taken advantage of ”. This was
a thought which occurred frequently and to which she was unable to respond.
We completed a thought record, Part 2, in order to help her develop an adaptive response to this thought (Figure 9.4).
It is often difficult for the patient to generate the evidence against their own
negative thoughts and that is where the skill of the therapist comes into play.
You must assist the patient in finding a way to look at their history in an
objective fashion.
When you are challenging the cognitive process in a borderline patient, you
Cognitive behaviour in borderline personality disorder
AUTOMATIC THOUGHT: I will always be taken advantage of
(0–100) = 100%
1. What’s the evidence? (pro) I have been raped, abused, used for other people’s whims
(con) I have been able to take some steps in life WITHOUT ABUSE
(Rent an apartment)
2. What are the errors in thinking? Overgeneralisation, selective abstraction
3. What’s an alternative viewpoint? Sometimes I will do all right and not be taken advantage
of. But I may be taken advantage of at other times
4. What’s the worst that can happen? I will live just to provide others with a scapegoat
What’s the best that can happen? Nobody will ever take advantage of me again
What’s the most realistic outcome? Some people will continue to try to take advantage of me
5. What positive action can I take to make change? Assertively state what I need to do for
me. Avoid certain people and situations when I feel weak
6. What’s the effect of my thinking? Anger, fear, become immobilised, punish myself
DEGREE (0–100) = 100%
SUMMARY OF ADAPTIVE RESPONSES: Even though I have had people take advantage
of me throughout my life, it may change. I have been able to deal with some people and
not feel taken advantage of in the past few years. If I can be assertive about my needs and
adaptively respond to my thoughts, I may be able to increase the positive things that can
occur in my life.
Figure 9.4 Adaptive responses: Thought record – Part 2.
need to use a response that fits each level. For thoughts, respond with words.
For images, use image work. For sensations, use anxiety management and
comforting sensory techniques. For memories, use a method of exploring
the memories which allows the patient to put these memories in their place
and keep them from being activated in daily situations.
The above techniques will be the majority of your treatment with the borderline patient but you will need to modify your treatment to fit the patient’s
specific need. Make a list of all the diagnoses, the negative behaviours, the
problematic situations and any goals the patient has and begin with one
problem at a time. It will be slow work but very rewarding; if you can keep
yourself and the patient from getting overwhelmed or giving up you will have
a chance at successful treatment of the borderline patient. Here is a poem
written by a patient after completing treatment.
I walk down the street.
There is a deep hole in the sidewalk.
I fall in
I am lost . . . I am helpless
It isn’t my fault.
It takes forever to find a way out.
Susan B. Morse
I walk down the same street.
There is a deep hole in the sidewalk.
I pretend I don’t see it.
I fall in again.
I can’t believe I am in the same place
but it isn’t my fault.
It still takes a long time to get out.
I walk down the same street.
There is a deep hole in the sidewalk.
I see it there.
I still fall in . . . It’s a habit
My eyes are open.
I know where I am.
It is my fault,
I get out immediately,
I walk down the same street.
There is a deep hole in the sidewalk.
I walk around it.
I walk down another street
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition. Washington, DC: Author.
Beck, A.T., Emery, G., & Greenberg, R. (1985). Anxiety Disorders and Phobias: A
Cognitive Perspective. New York: Basic Books,
Beck, A.T., Freeman, A., & Associates (1990). Cognitive Therapy of Personality
Disorders. New York: Guilford Press.
Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive Therapy of
Depression. New York: Guilford Press.
Erikson, E.H. (1963). Childhood and Society. New York: Norton.
Kernberg, O.F. (1975). Borderline Conditions and Pathological Narcissism. New York:
Jason Aronson.
Kernberg, O.F. (1984). Severe Personality Disorders. New Haven, CT: Yale University
Layden, M.A., Newman, C., Freeman, A., & Morse, S. (1993). Cognitive Therapy of
Borderline Personality Disorder. Boston: Allyn and Bacon.
Cognitive behaviour in borderline personality disorder
Meissner, W.W. (1988). Treatment of the Borderline Spectrum. Northvale, NJ: Jason
Piaget, J. (1952). The Origins of Intelligence in Children. New York: International
University Press.
Young, J.E. (1990). Schema-focused Cognitive Therapy for Personality Disorders: A
Schema-focused Approach. Sarasota, FL: Professional Resource Exchange.
Chapter 10
Techniques and strategies with
couples and families
Frank M. Dattilio
Cognitive therapy as applied to couples and families has evolved out of the
behavioural school of thought, when theorists of this school first began to
apply their techniques to couples in the 1960s. While there are reports that
cognitive techniques were being applied to couples as early as the late 1950s
(Ellis, Sichel, Yeager, DiMatlia, & DiGuisseppe, 1989), it was not until the
late 1960s/early 1970s that the first published studies using behaviour therapy
with couples appeared in the professional literature (Stuart, 1969; Liberman,
1970). The implementation of cognitive techniques in clinically controlled
outcome studies actually occurred much later (Margolin & Weiss, 1978), with
increasing attention attributed to the cognitive component during the 1980s
and early 1990s.
Initially, principles of behaviour modification were applied to the interactional patterns of family members, specifically to the marital dyad (Patterson
& Hops, 1972). Behavioural therapy with couples was originally referred to as
behaviour exchange theory and has more recently been referred to as the
social learning model (Jacobson, 1991). Initially, behavioural treatment
approaches placed emphasis on the components of social exchange and contingency contracting with couples (Bandura, 1977; Stuart, 1969, 1976) and
later emphasised communications training (Jacobson, 1991).
The eventual introduction of cognitive components (Ellis, 1977;
Margolin & Weiss, 1978) sparked additional literature in the subsequent
decade focusing on cognitive-behavioural techniques with dysfunctional
couples (Baucom & Epstein, 1990; Beck, 1988; Dattilio, 1989, 1990a, 1990b;
1990; Dattilio & Padesky, 1990; Doherty, 1981; Epstein, 1992; Epstein &
Baucom, 1998; Fincham & O’Leary, 1983; Margolin, Christensen and
Weiss, 1975; Revenstorf, 1984; Schindler & Vollmer, 1984; Weiss, 1980,
1984). This movement in couples therapy underscored the need for treatment to focus on the cognitions that were held by couples regarding each
other’s actions, suggesting that it should be an integral part of the change
process. The underlying philosophy contends that behaviour change alone
is insufficient to correct the dysfunctional interactions that are so often
experienced by couples; thus, more emphasis must be placed on thethinking
Techniques and strategies with couples and families 243
styles of individuals in relationships as well as the maladaptive behaviour
patterns (Dattilio, 1990a, 1994).
Cognitive theory and couples
Ellis, one of the first theorists to suggest a predominantly cognitive approach
with couples, proposed that marital dysfunction occurs when partners maintain unrealistic beliefs about the relationship and make extreme negative
evaluations once dissatisfied. Ellis’s Rational Emotive Behaviour Approach
(REBT) proposes that disturbed feelings in relationships are not caused
merely by one mate’s wrongdoing or other adverse events, but by the views
that partners take of each other’s actions and of life’s rough breaks (Ellis et
al., 1989). He further contends that disturbed marriages result when one or
both spouses hold irrational beliefs – irrational being defined as highly exaggerated, inappropriately rigid, illogical and absolutist. As a result of this
irrational thinking, unrealistic and demanding expectations develop, producing disappointment and frustration when they are perceived as being
violated. These responses, in turn, give rise to negative thoughts which contribute to negative emotions, leading to a vicious cycle of disturbance. Ellis
promotes the challenge of the validity of spouses’ irrational beliefs and aims
to teach them how to replace their faulty thinking with more realistic
thoughts about themselves and their partners.
Beck’s cognitive therapy with couples differs from Ellis’s theory by combining many of the insights from the psychodynamic therapies, along with
several of the strategies first established by behaviour theorists (Beck, 1988).
The more conventional approaches are combined within a cognitive framework with an emphasis on specific concepts involving general thinking styles,
underlying beliefs about the relationship, and the nature of current interactions between partners.
The fact that cognitive therapy is in part derived from classical psychoanalysis as well as cognitive psychology, behavioural theory and other
contemporary systems of psychotherapy makes it a very integrable theory
(Alford & Beck, 1997). Moreover, due to the fact that cognitive therapy draws
its theoretical structure from such a wide variety of sources, Beck maintains
that cognitive therapy is “the integrative therapy” (Beck, 1991).
The primary tenets of cognitive-behaviour therapy as applied to couples
involve: (a) the modification of unrealistic expectations in the relationship, (b)
correction of faulty attributions in relationship interactions, and (c) the use of
self-instructional procedures to decrease destructive interaction. A primary
agenda of cognitive-behaviour therapy is identifying partners’ schemata or
beliefs about relationships in general and, more specifically, their thoughts
about their own relationship (Beck, 1988; Epstein, 1986) and how this effects
their emotions and behaviours.
Basic beliefs about relationships and the nature of couple interaction are
Frank M. Dattilio
often learned early in life from primary sources such as parents, local cultural
mores, the media, and early dating experiences. These schemata or dysfunctional beliefs about relationships are often not articulated clearly in an
individual’s mind but may exist as vague concepts of what should be (Beck,
1988). These beliefs can, however, be uncovered by examining the logic and
themes of one’s automatic thoughts.
Automatic thoughts are defined as “surface thoughts” or ideas, beliefs or
images that individuals have from moment to moment that are situation-specific (e.g., “My wife is late again; she doesn’t care about my feelings.”)
Automatic thoughts usually stem from the individual’s schemata, which are
underlying or more core beliefs that are inflexible and unconditional in character. Schemata develop early in life as a result of personal experiences as well
as through parental and societal influences. They constitute the basis for
coding, categorising, and evaluating experiences during the course of one’s
The therapist working with couples from a cognitive perspective must focus
equally on each partner’s expectations about the nature of an intimate relationship. In addition, the distortions in evaluations of experience derived
from those expectations are critically important. For example, a husband
who believes that his wife should be interested in everything that he has to say
might expect her always to be attentive to him regardless of what else may be
going on in her life.
Cognitive therapy assumes that unrealistic expectations about relationships can erode satisfaction and elicit dysfunctional responses. For example,
many couples enter a relationship with the belief that love spontaneously
occurs between two people and exists that way forever without further effort.
As a result, couples may experience a decrease in satisfaction once they realise
that hard work is necessary to maintain their relationship. This expectation
may also lead to inaccurate appraisals such as, “We probably were not right
for each other from the start.” Epstein and Eidelson (1981) found that adherence to unrealistic beliefs concerning the nature of intimate relationships was
predictive of distress level in relationships. Therefore, cognitive content is
extremely important in accounting for dysfunctional responses to relationship
Cognitive distortions may be evident in the automatic thoughts that couples report and may be uncovered by means of systematic or Socratic
questioning regarding the meaning that a partner attaches to a specific event.
Spouses’ automatic thoughts about their interactions with one another commonly include inferences about the causes of pleasant and unpleasant events
that occur between them.
In his book Love is Never Enough, Beck (1988) has described several systematic distortions in information processing that occur frequently in
automatic thoughts concerning relationships. For example, the thought “He
always puts me down” is more likely to be an instance of generalisation than
Techniques and strategies with couples and families 245
an accurate accounting of a spouse’s invariant behaviour. As another example, in the absence of concrete evidence, the thought “She thinks I am
ignorant” would be an arbitrary inference.
Cognitive therapy with couples focuses on the cognitions that are identified
as components of relationship discord and as contributing to each partner’s
subjective dissatisfaction with the relationship (Schlesinger & Epstein, 1986).
This approach moves to the core of relationship difficulty by focusing on
hidden as well as obvious here-and-now problems, rather than by dwelling on
early childhood traumas. A wife, for example, may show explosive rage
toward her husband. If he is not in fact responsible for provoking such
intense anger, she may find that her rage has other meanings. One woman discovered by tracing her automatic thoughts and emotions that her rage was
preceded by a feeling of helplessness. In fact, she had an image of herself as
a young child, screaming to be heard by her mother. Once the therapy helped
her identify this underlying fear that she would not be heard unless she
screamed, she was able to begin to explore alternative methods of expressing
her feelings to her husband.
There are several major focal areas in the cognitive model that are essential
when addressing the issue of change in relationships. These are described below.
Beliefs about the relationship
Basic beliefs are the foundation for individuals’ automatic thoughts and
actions in any relationship. In order to understand these thoughts and
actions, the therapist must work to uncover the basic belief system or
“schema” and develop a clear understanding of how each spouse views the
relationship and his or her role in relationships in general. As in the example
of the wife who responded with destructive rage, the emphasis is placed on
hidden, as well as obvious, here-and-now problems, as opposed to dwelling on
early childhood traumas. Beneath her anger was a sense of vulnerability and
helplessness. By uncovering this basic schema, the therapist was able to help
her define ways in which she could be heard and share some control of her
relationship without verbally attacking her husband. By discovering this
underlying issue, she was further able to see that she viewed many relationships as manipulative and controlling even when they were not. Her view of
herself as helpless and childlike had prevented her from being assertive about
her own needs until she reached the point of expressing them in rage. By
learning to assert her needs more consistently and to express her dissatisfaction in ways that her husband would comprehend, she was able not only to
reduce her anger, but also to feel more empowered in the relationship.
One method for achieving this behavioural change is the use of the “downward arrow technique”. This exercise was developed by Beck, Rush, Shaw,
and Emery (1979) to track the anticipated outcome of automatic thoughts in
order to help couples evaluate whether the expected catastrophe is likely to
Frank M. Dattilio
occur. It is also used to identify the underlying assumption beneath one’s
automatic thoughts and to uncover the hidden or core beliefs which we call
schemata. This is done by identifying the initial thought; for example, “Harry
doesn’t always listen to me,” and then asking the individual, “If so, then
what?” in order to help the individual realise that such flaws are not necessarily fatal to the relationship.
As Figure 10.1 shows, it is clear that screaming was this woman’s way of
avoiding her perceived vulnerability. The use of the downward arrow exercise
has served to uncover an underlying belief of vulnerability and helplessness
along with her fear of losing control. This technique allows both the spouse
and the therapist to see the chaining of thoughts and how they lead to erroneous conclusions and reinforce distorted beliefs. This technique is
demonstrated very clearly on video by Dattilio (1996).
Much of the cognitive approach involves ferreting out a couple’s basic
beliefs and then collaboratively redefining key principles and restructuring the
couple’s belief system. The amount of restructuring that is required varies,
but it is recommended that the restructuring process be done with each
person in the presence of their mate. By witnessing the testing and restructuring of beliefs, each partner is better able to provide support to the other
later in the treatment process. Basic beliefs about the relationship are thus
important in attempting to promote change with couples. Uncovering the
basic belief system, then, allows the therapist to teach individuals the first
step in altering their view of the relationship.
Alternative versus distorted beliefs
When working with couples, there is often disagreement over whether
thoughts are balanced or distorted. In the cognitive approach, beliefs are designated as balanced if they have substantiating or supportive evidence. These
are beliefs that are not convoluted by an individual’s biases or misperceptions.
“Harry doesn’t always listen to me”
“I’ll never be heard”
“If I am not heard, I am a nobody”
“If I am a nobody, I’ll be helpless”
“If I am helpless, people will run over me”
Figure 10.1 The downward arrow technique.
Techniques and strategies with couples and families 247
Distorted beliefs, on the other hand, are beliefs which are based on misinformation or faulty thinking and are usually rooted in circumstantial evidence.
An example of a common distorted belief is the statement, “All men are
alike.” In the context of a relationship, this view carries negative connotations
and represents a class of cognitive distortion called generalisation. If maintained under all circumstances, such a belief represents distorted thinking.
Another example might be a husband who believes, “I must help my wife
resolve every one of her dilemmas in order to be a good husband.” This
again becomes a distorted belief when adhered to steadfastly.
The alternative version of such statements usually includes more explanations with conditions attached. For example, for the belief, “All men are
alike,” the more balanced view might be, “All men are alike in many ways, yet
each is also unique.” In the example of the statement, “I must help my wife
resolve every one of her dilemmas in order to be a good husband,” a more
balanced alternative statement might be, “It’s important that I offer assistance
to my wife when I can or be there for her when she needs me.”
Distorted beliefs are often the basis of much dissension in relationships and
need to be addressed quite specifically in order to introduce change in the
relationship. They usually develop as a result of faulty thought patterns that
become a part of the individual’s ordinary thought processes. Regardless of
how they developed, the therapist’s role is to help weigh the existing evidence
and test predictions made on the basis of the belief in order to assess its reasonableness.
Unrealistic expectations
The expectations that each person brings to the relationship create important
dynamics in each union and have been a focus for most cognitive therapists
treating distressed couples (Epstein, 1982; Jacobson & Margolin, 1979).
With almost every relationship, individuals hold some anticipation with
regard to the multitude of needs their partner will fulfil for them. The social
learning model (Jacobson, 1991) refers to this as the “interaction between the
stimulus value of behaviours received by each spouse and the way these stimuli are received and interpreted by the receiver” (p. 559). Very often, these
expectations or anticipations lead to distortions and are transformed into
unrealistic demands. It may take a while for some of these expectations to
assert themselves in the relationship, which would account for why they often
become issues only after a period of time, as opposed to during the courtship
period. Beck (1988) and Ellis et al. (1989) contend that unrealistic or demanding expectations inevitably produce disappointment and frustration, which is
often associated with negative interactions (e.g., hostility, badgering, etc.). A
common example of this pattern occurs in the couple who enter a relationship with the expectation that love spontaneously occurs between two people
and exists that way forever with virtually little or no further effort on either
Frank M. Dattilio
partner’s part. Such couples experience deep disappointment and hurt when
problems arise and may even erroneously conclude that their difficulties
signal that the relationship was never really a good one. In this example, the
unrealistic expectation is held by both spouses simultaneously; however, in
many cases unrealistic expectations are held by one person in direct conflict
with the other’s viewpoint.
For example, one man who came from an environment where the father
was the sole breadwinner expected his wife to be content in remaining home
and not working outside the home. However, his wife was reared to believe
that partners have equal rights, and this created a conflict over her wish to
seek employment. Such expectations emanate from early conceptualisations
about relationships, spousal roles, and individual needs. These conceptualisations are derived from primary sources such as parents, the media, and
early dating experiences. They are usually blended with each partner’s personal ideas of how he or she would like the relationship to be.
In addressing unrealistic expectations, the therapist must again refer to the
root of both partners’ belief systems. The therapist identifies their cognitive
schemata and teaches them first to label erroneous beliefs via comparisons
and then to test these beliefs against alternative evidence. This is usually done
one step at a time. It is important to go slowly and not to do this too abruptly.
It is essential to remember that individuals have become dependent on these
underlying belief structures, and attempting to remove them too quickly may
elicit resistance from either partner.
Causal attributions and misattributions
Causal attribution is a formal term for “directing blame” in the relationship.
It is not uncommon for spouses to arrive for therapy in a vicious blaming
cycle which is propelled by anger, resentment, and the refusal of both to
accept responsibility for the dysfunction in the relationship. Consequently,
there exists an externalisation of blame and a misattribution of the problem
to the actions of the partner. If they are both stubborn individuals, then the
couple remain in a deadlock in which they inadvertently attempt to place the
therapist in the uncomfortable position of determining who is to blame.
Some authors believe (Abrahms, 1982) that conflict resolution or communication training is impossible unless both partners are willing to collaborate.
The term “collaborative set” was coined by Jacobson and Margolin (1979) to
indicate the need for both partners to behave in a manner that suggests that
they view their conflicts as mutual and to realise that the conflicts are likely
to be resolved only by working conjointly to solve them. Even if this stance
is adopted overtly, couples may individually harbour thoughts about the
attribution of blame which will later infiltrate the relationship. Therefore,
another important step in the restructuring process involves helping both
partners to accept responsibility for the distress in the relationship. This
Techniques and strategies with couples and families 249
requires discussions and evaluation of the causal attributions each partner
has made for the relationship problems.
Because of the high rate of divorce and the heavy media emphasis on troubled relationships, most of the existing literature on cognitive-behavioural
assessment of intimate relationships has focused on couples; relatively little
has been published regarding the assessment of families. Although cognitivebehavioural family assessment is similar to that with couples, less emphasis is
placed on the use of structured inventories and questionnaires, particularly
because some family members may be too young to complete such forms or
simply may find this to be a monotonous process. Nevertheless, inventories
may be useful with older family members who can appreciate the benefit of
identifying cognitions and behavioural interaction patterns on paper. There
are numerous self-report and behavioural methods for assessing couples and
families. Unfortunately, space limitations preclude a detailed presentation in
this text. For a more comprehensive overview, the reader is referred to
Baucom and Epstein (1990) and Dattilio, Epstein, and Baucom (1998).
Assessment of relationship cognition
Self-report questionnaires
Considering the rapid growth of cognitive-behavioural couples and family
therapy, there are relatively few self-report scales available for assessing the
major types of relationship cognitions mentioned previously. Eidelson and
Epstein’s (1981) Relationship Belief Inventory (RBI) was developed to tap
unrealistic beliefs about close relationships, and it includes subscales assessing the assumptions that partners cannot change a relationship, that
disagreement is always destructive, and that heterosexual relationship problems are due to innate differences between men and women, as well as
standards that partners should be able to mindread each other’s thoughts and
emotions and that one should be a perfect sexual partner. Although the RBI
covers a limited range of potentially problematic assumptions and standards,
it has been used widely in research and clinical practice, and therapists can
use it as a springboard for broader discussions with couples concerning their
personal beliefs.
Baucom, Epstein, Rankin, and Burnett’s (1996) Inventory of Specific
Relationship Standards (ISRS) assesses an individual’s personal standards
concerning major relationship themes, including the nature of boundaries
between partners (autonomy versus sharing), distribution of control (equal
versus skewed) and partners’ levels of instrumental and expressive investment
in their relationship, as the individual applies the standards to his or her own
Frank M. Dattilio
relationship. Furthermore, each standard is assessed within twelve major areas
of relationship functioning, such as leisure activities, career and job issues,
household tasks and management, and affection. The respondent is asked to
indicate his or her belief about how often the couple should act according to
each standard, whether or not he or she is satisfied with how the standard is
being met in their relationship, and how upset he or she becomes when the standard is not met. Baucom et al. (1996) found that high “relationship-oriented”
standards (i.e., focused on minimal or diffuse boundaries between partners,
shared control, and high investment) were associated with higher relationship
satisfaction. Another key finding was that individuals who were satisfied with
(i.e., accepted) the ways in which their standards were met were happier in
their relationships. The breadth of the ISRS makes it a useful clinical screening
instrument. Although the ISRS has been validated only with couples, it seems
reasonable that similar types of items could be useful for assessing boundary,
investment, and control standards in parent–child relationships.
The Family Beliefs Inventory (FBI) (Vincent-Roehling & Robin, 1986)
assesses ten potentially unrealistic beliefs that parents and adolescents maintain about their relationships, and which are likely to contribute to
parent–adolescent conflict. Respondents read vignettes describing areas of
conflict (e.g., choice of friends, spending time away from home) and then
indicate their degree of agreement or disagreement with each of several
beliefs. The parents’ version of the FBI includes subscales assessing beliefs
concerning (a) ruination (by engaging in a proscribed behaviour, the adolescent will ruin his or her life, or cause harm to the family), (b) perfectionism
(the child should behave in a perfect manner), (c) approval/love (family members who love each other confide in each other and always approve of each
other’s behaviour), (d) obedience (teenagers should never challenge parental
rules or opinions), (e) self-blame (a child’s misbehaviour is due to poor parenting), and (f) malicious intent (the adolescent’s misbehaviour is intended to
upset or punish the parents). The adolescent’s version includes subscales for
(a) ruination (parental restrictions will ruin the child’s life), (b) autonomy
(teenagers should have as much freedom as they want), (c) approval/love
(loving parents should always approve of their children’s behaviour), and (d)
unfairness (parents should never treat their children in ways that adolescents
consider unfair). The FBI is based on the premise that extreme beliefs exacerbate conflict in parent–child interactions, and that identifying such beliefs
helps therapists design cognitive interventions for developing more collaborative and constructive problem-solving among family members. Although all
of the cognitions assessed by the FBI are referred to as beliefs, within
Baucom et al.’s (1989) taxonomy, it appears that perfectionism, unfairness,
approval/love, obedience, and autonomy are standards, malicious intent and
self-blame are attributions, and ruination is an expectancy.
Several attribution scales have been developed for use in clinical research,
and these can be applied in clinical practice as well. Pretzer, Epstein, and
Techniques and strategies with couples and families 251
Fleming’s (1991) Marital Attitude Survey (MAS) includes subscales assessing
attributions for relationship problems to one’s own behaviour, one’s own personality, the partner’s behaviour, the partner’s personality, the partner’s lack
of love, and the partner’s malicious intent. Fincham and Bradbury’s (1992)
Relationship Attribution Measure (RAM) asks the respondent to rate his or
her agreement with statements reflecting attributions about ten hypothetical
negative partner behaviours (e.g., “Your husband/wife criticises something
you say”). Three statements assess the degree to which the cause of the problem is viewed as residing in the person’s partner, is stable versus unstable, and
affects other areas of the relationship in a global way versus being specific to
the one problem area. Three items assess “responsibility” attributions, including intentionality, selfish motivation, and blameworthiness. Fincham and
Bradbury chose hypothetical situations for the RAM because they provide a
standardised measure across individuals and because previous studies indicated that couples make similar attributions about hypothetical and real
relationship events. Baucom, Epstein, Daiuto, Carels, Rankin, and Burnett
(1996) developed a Relationship Attribution Questionnaire with which the
respondent rates causal and responsibility attributions for real problems in his
or her relationship, as well as the degrees to which the problems are attributed
to boundary, control and investment factors similar to those assessed in relationship standards by the ISRS.
Numerous other self-report questionnaires have been developed to assess
aspects of parent–child relationships and general family functioning, and
excellent reviews of these measures can be found in texts by Grotevant and
Carlson (1989), Touliatos, Perlmutter, and Straus (1990), and Jacob and
Tennenbaum (1988). Some instruments, such as the Family Environment
Scale (Moos & Moos, 1986), the McMaster Family Assessment Device
(Epstein, Baldwin, & Bishop, 1983), and the Family Adaptability and
Cohesion Evaluation Scales III (Olson, Portner, & Lavee, 1985) assess family
members’ global perceptions of family characteristics such as cohesion, problem-solving, communication quality, role clarity, emotional expression, and
values. Other scales, such as the Family Inventory of Life Events and
Changes (McCubbin, Patterson, & Wilson, 1985) and the Family CrisisOriented Personal Evaluation Scales (McCubbin, Larsen, & Olson, 1985)
provide more specialised assessment of family functioning (e.g., members’
perceptions of particular stressors and family coping strategies). Because
family of origin is also an important aspect of the cognitive-behavioural
approach, the Family-of-Origin Scale (FOS) (Hovestadt, Anderson, Piercy,
Cochran, & Fine, 1985) is an excellent tool to measure the self-perceived
levels of health in one’s family of origin. In general, these scales do not provide data about specific cognitive, behavioural, and affective variables central
to a cognitive-behavioural assessment, but they do tap a variety of important
components of family functioning likely to be of interest to all family therapists. A few instruments tap family members’ attitudes about parenting roles
Frank M. Dattilio
and thus are more directly relevant to cognitive assessment. For example,
the Parental Authority Questionnaire (Buri, 1991) assesses parental authority or disciplinary practices from the point of view of the children. This
measure allows clinicians to better understand the cognitions of the offspring
and how they view their parents.
Interview assessment of cognitions
Clinical interviews with members of a couple or family, together or individually, provide the opportunity to elicit idiosyncratic cognitions and to track
inferential processes that cannot be assessed by standardised questionnaires.
Using Socratic questioning methods that are the hallmark of cognitive therapy (Beck, 1995; Beck et al., 1979), the clinician inquires about the chains of
thoughts that [often] mediate between events in the relationship and the individual’s emotional and behavioural responses. Beck et al. (1979) developed
the “downward arrow technique” to identify the underlying schemata (e.g.,
assumptions and standards) beneath an individual’s automatic thoughts. This
is explained earlier in this chapter.
In addition, the therapist also needs to collaborate with both partners to
gather information for testing the validity of spouses’ or family members’
attributions and expectancies. The goals of the treatment plan will depend on
how much of their inferences about each other’s actions reflect real negative
motives versus cognitive distortions.
The clinician usually attempts to gather information about spouses’ or family
members’ cognitions as they occur during family interactions, rather than relying on the clients’ retrospective accounts about what they might have been
thinking about each other. The therapist can look for behavioural cues of individuals’ emotional responses as the couple or family interacts during sessions
and can interrupt them selectively in order to inquire about the emotions and
any associated cognitions. Family members also can be given forms for recording distressing events between sessions, with instructions to write details about
the situation, their cognitions, their emotions, and their behavioural responses
to each other (see Baucom and Epstein’s 1990 text for details).
Assessment of couple and family behavioural interactions
Given the consistent evidence that exchanges of negative behaviour among
family members are associated with relationship distress, traditional behavioural marital and family therapy methods of assessment and modification of
behavioural interactions remain an important component of a cognitivebehavioural approach. However, there is empirical evidence that members of
distressed couples often behave in more positive ways with people other than
their partners (e.g., Vincent, Weiss, & Birchler, 1975), and an important question to be answered is whether a family’s excesses of negative exchanges or
Techniques and strategies with couples and families 253
deficits in positive exchanges are due to skill deficits or other factors. For
example, some individuals readily report that their communication with coworkers, friends, and other people is more positive than with their family
members. At times, when the therapist conducts a careful inquiry about the
sequence of internal and external events leading up to an aversive exchange,
it becomes clear that the process of “sentiment override” (Weiss, 1980) is
operating, wherein the pre-existing general sentiment that an individual experiences toward a family member influences the affective and behavioural
responses to that person’s current behaviour more than the objective qualities
of the person’s behaviour. Thus, if an individual has developed general negative emotions and attitudes toward a relative based on their past
interactions, this general negative sentiment may lead the individual to feel
irritated toward that person in present situations when the relative is attempting to behave in positive ways (and may be judged to be behaving positively
by a therapist or other outside observer).
Therefore, when assessing a family’s exchanges of positive and negative
behaviour, it is important to gather information about situation-specificity of
any negative interactions. The basic question to be answered is the degree to
which the negative interactions have generalised over time and settings. For
example, when asked systematically for details, many couples and families
report that there have been times in the past when they have behaved more
positively; or, they may report instances in which they have behaved more
positively with other people. The clinician can conduct a “functional analysis”, collecting information about antecedent events/conditions and
consequences that are associated with more positive and less negative behaviour. Evidence that negative behaviours are less likely to occur under
particular circumstances suggests that family members possess constructive
skills that are elicited by certain conditions but not by others. The fact that
each member of a couple or family uses good communication skills when
talking with the therapist often provides this sort of data. The therapist can
point to such contrasting behaviour when providing a rationale to the family
for exploring changes in their relationships that could create conditions more
likely to elicit the types of positive behaviour that they direct toward therapists and other people. Some aspects of the more favourable conditions may
involve physical qualities of the setting (e.g., the absence of daily stressors
such as interruptions from ringing telephones and distractions such as television), and other aspects may involve different cognitive sets concerning
situations (e.g., a belief that it is impolite to criticise strangers, but it is one’s
right to be less guarded and to exercise uncensored expression at all times
with one’s intimates). A third aspect of conditions more favourable to positive
communication may be the existence of more positive “sentiment” toward
other people than toward one’s family members, as noted above.
Thus, the assessment of a couple’s or family’s behavioural interactions
includes collecting information about the frequencies and reciprocal patterns
Frank M. Dattilio
of positive and negative behaviours that the individuals exchange, situational
variations in those behaviours, and any non-behavioural factors (cognitions
and emotions) that influence the behavioural variations. Behavioural assessment typically includes both self-report questionnaires administered to the
family members and some form of behavioural observation conducted by the
Behavioural observation
Because of the limitations of self-report assessments, it is important for the
clinician to observe samples of a family’s interactions directly. A common
misconception about behaviour therapy is that it is a “technology of techniques”. Actually, one of behaviour therapy’s essential ingredients is careful
and detailed observation of behaviour and its consequences. Opportunities
for behavioural observation exist from the first moment that a couple or
family enters the therapist’s office, and experienced family therapists become
adept at noticing the process of verbal and nonverbal behaviours that occur
among the family members as they talk to the therapist and to each other.
Although the topics (content) of family discussions are important (and are
foci of cognitive assessment and intervention), the goal of systematic behavioural observation is to identify specific acts by each individual, and the
sequences of acts among family members, that are constructive and pleasing
or destructive and aversive. The observation of family interactions can vary
according to (a) the amount of structure the clinician imposes on the interaction and (b) the amount of structure in the clinician’s observational criteria
or coding system.
Even though a family’s behaviour in the therapist’s office is likely to differ
to some degree from their typical interactions at home, many families reveal
significant patterns when given an opportunity to talk about issues in their
relationship with minimal intervention by the therapist. We have found that
as couples and families become more comfortable with the office setting and
with our presence, they tend to focus their attention on each other and
respond more spontaneously to each other. If the therapist “fades into the
background” for a while, he or she can observe the behavioural interactions.
The goal of imposing little structure on the interaction is to sample the
couple’s or family’s communication in as naturalistic a way as possible in the
office setting. This can sometimes be achieved through specific homework
assignments (Dattilio, in press).
In contrast to relatively unstructured couple interactions, the clinician can
provide a family with specific topics for their discussions and even a goal,
such as trying to understand each other’s thoughts and feelings, or to resolve
a particular relationship problem. For example, one can ask each member of
a couple to complete an inventory, such as Spanier’s (1976) Dyadic
Adjustment Scale (DAS), with which they rate the degree to which there is
Techniques and strategies with couples and families 255
conflict in their relationship in each of several areas (e.g., demonstration of
affection, household tasks, amount of time spent together). The clinician
then selects a topic for which both partners reported at least moderate disagreement and asks the couple to spend ten minutes trying to resolve their
conflict. Similarly, parents and adolescents can be given a topic that they
identified as a source of conflict on the Issues Checklist (Robin & Foster,
1989) and asked either to discuss their feelings about the issue or to try to find
a solution to the issue.
Often it is only when a couple or family has been instructed to engage in a
problem-solving discussion that the clinician is able to identify a specific difficulty that they have with this specialised form of communication. This is similar
to the “enactment” that Minuchin and Fishman use with their structural family
therapy. A difference, however, is that cognitive-behaviour therapists may be
more directive in this process than the structural family therapist. For example,
some clients fail to define a problem in specific behavioural terms, which handicaps them when they attempt to generate a feasible solution. Others fail to
evaluate advantages and disadvantages of a proposed solution, and subsequently become discouraged when they try to carry out the solution and
encounter unanticipated obstacles or drawbacks. By observing the clients’ discussion in the therapy session, the clinician can identify the specific problematic
behaviours and can plan interventions to improve their problem-solving skills.
The clinician’s own observational criteria for assessing a couple’s interactions can vary in detail and structure as well. On the one hand, the clinician
can begin the observation with no predetermined categories of behaviour to
focus on, and can look for repetitive patterns that appear to play roles in a
couple’s presenting complaints. Using the basic principle of functional analysis, the clinician observes antecedent events and consequences that may be
controlling the occurrence of each partner’s negative behaviour. For example,
a husband may have complained that his wife rarely reveals or talks about her
feelings, but the clinician may observe that whenever the wife does express her
feelings, the husband turns away. Similarly, circular causal processes in couple
interaction can be observed, as when a clinician identifies how one partner’s
tendency to pursue tends to prompt the other’s withdrawal, and vice versa.
Techniques in therapy
Identifying cognitive distortions and labelling them
Because cognitive distortions are an integral part of the therapy process, it is
essential that the couple learn not only to recognise them, but also to identify
them readily. An essential part of treatment then is for the therapist to make
sure the couple understand this clearly. One exercise is to have each partner
keep a log of negative thoughts during the week and label any distortions in
those thoughts. This log should be reviewed by the individual and the therapist
Frank M. Dattilio
until the individual can do this exercise successfully. This will be important
later when it will be necessary for the therapist to rely on the couple’s ability
to recognise and identify distortions. When the couple come in for their sessions, the log of negative thoughts should be reviewed with both partners
identifying the distortions described below.
Identifying cognitive distortions involves a type of self-monitoring that is
imperative in cognitive therapy for restructuring thought processes. The same
cognitive distortions that were identified in early writings on cognitive therapy as contributing to depression (Beck, et al., 1979) are also sources of
relationship discord. Below is a list of ten of the most common cognitive distortions made by couples:
1 Arbitrary inference. Conclusions are made in the absence of supporting
substantiating evidence. For example, a man whose wife arrives home a
half-hour late from work concludes, “She must be having an affair.”
2 Selective abstraction. Information is taken out of context; certain details
are highlighted while other important information is ignored. For example, a woman whose husband fails to answer her greeting the first thing
in the morning concludes, “He must be angry at me again.”
3 Overgeneralisation. An isolated incident or two is allowed to serve as a
representation of similar situations everywhere, related or unrelated. For
example, after being stood up for an initial date, a young woman concludes, “All men are alike. They’re insensitive!”
4 Magnification and minimisation. A case or circumstance is perceived in
greater or lesser light than is appropriate. For example, an angry husband
“blows his top” upon discovering that his wife has overspent the budgeted
amount for groceries and catastrophises, “We’re doomed financially.”
5 Personalisation. External events are attributed to oneself when insufficient evidence exists to render a conclusion. For example, a woman finds
her husband remaking the bed after she previously spent time making it
herself concludes, “He is dissatisfied with my housekeeping.”
6 Dichotomous thinking. Experiences are codified as either all or nothing, a
complete success or a total failure. This is otherwise known as “polarised
thinking”. For example, a wife who states to her husband as he paints the
living room, “I wonder whether a lighter shade would have been nicer,”
elicits the reaction from her husband, “She’s never happy with anything.”
7 Labelling and mislabelling. Imperfections and mistakes made in the past
are allowed to define one’s self. For example, subsequent to making
repeated errors in balancing the chequebook, a partner states, “I am
really stupid,” as opposed to recognising the errors as being human.
8 Tunnel vision. Sometimes partners see only what they want to see or what
fits their current state of mind. A man who believes that his lover is
totally self-centred may accuse him of making all choices based on purely
selfish motives.
Techniques and strategies with couples and families 257
9 Biased explanations. This is an almost suspicious type of thinking that
partners develop during times of distress, during which there is an automatic assumption that their mate holds a negative ulterior motive for
actions. For example; a woman states to herself, “He’s acting real `loveydovey’ because he’ll later probably want me to do something that he
knows I hate to do.”
10 Mind reading. This is the magical gift of being able to know what the
other is thinking without the aid of verbal communication. Couples end
up ascribing negative intentions to their partners. For example; a woman
says to herself, “I know what Dimitri is going to say when he sees what I
spent on this suit.”
These distortions have been found to occur frequently among couples in
distress and, in fact, may occur in most relationships at one time or
Couples are made aware of these common distortions and are then
instructed to identify where their own thinking may fit with these distortions. Each time a person experiences an automatic thought about his or
her partner and identifies it as a negative or dysfunctional thought, he or
she then attempts to label it as an instance of one of the aforementioned
distortions. When couples learn to assign a label to their cognitive distortions, they are then able to set the stage for re-evaluating the structure of
their thinking.
It should be made clear at this point that the expertise of the clinician is
important in determining whether or not additional psychopathology is evident in an individual’s thought process. If not detected during the assessment
phase, any disorder in thinking, behaviour, or affect may clearly manifest
itself here. Should this be the case, alternative types of treatment may need to
be considered. Depending on whether or not the problem is severe, couples
therapy may or may not be continued.
When there are no severe interfering problems, such as a formal thought
disorder, the partners are instructed to keep track of their automatic thoughts
and begin to identify the distortions by labelling them. The following is an
Automatic thoughts and cognitive distortions
Automatic thought
“My wife should know by now that I hate to
be interrupted while I am reading the paper.”
Automatic thought
“It’s too late to do anything about this marriage.”
“My husband is well beyond change.”
Mind reading
Frank M. Dattilio
The purpose of these exercises is to aid the couple to recognise that their
thinking may be distorted due to insufficient information and to help them
monitor the kind and frequency of distortions they use. This conscious monitoring of their thoughts and distortions enables them to become more aware
of how their thinking affects their partner and themselves.
Faulty information processing
Cognitive theorists believe dysfunctional thinking and distortions develop
from faulty information processing. It is thought that individuals learn maladaptive ways of processing information as a result of early environment
and experience, as well as by a biological tendency to categorise and group
observations. These processes involve perceptions of, and inferences made
from, certain stimuli. The stereotypic scenario of a woman who is afraid of a
mouse illustrates this process. Every time she comes in contact with a mouse,
regardless of its size, the cartoon depiction of a woman begins to scream irrationally and climbs for the highest ground. Her underlying belief or schema
is that mice are something to be fearful of. If questioned, she might say she is
uncertain as to exactly why, but it is something that she has been raised to
believe; she almost instinctively fears mice. If pressed, she may disclose to you
that she has learned through a parent that mice are dirty or contaminated
with germs. Yet, this still leaves insufficient information to support such an
exaggerated fear reaction. This is an example of a belief that is supported by
insufficient or faulty information – a distorted belief that is devoid of substantiating information.
Negative framing
It is interesting to note that the complaints of couples during the intake
phase often include particular characteristics of their partners that are the
inverse, negative side of those characteristics that once attracted them to
their partner (Abrahms & Spring, 1989). For example, in the case of Ana and
Tomas, Ana stated that the characteristics of Tomas that she finds to be most
intolerable are that he is lazy, demanding, picky and absent-minded.
Ironically, when asked later for some of the characteristics that originally
attracted Ana to Tomas, she listed the following adjectives: laid-back, knows
his expectations of others, precise, and carefree.
When these characteristics were listed juxtaposed on paper, Ana could
clearly see that her negative impressions of Tomas were merely the negative
aspects of traits she was originally attracted to.
Techniques and strategies with couples and families 259
Initial redeeming
qualities about Tomas
Knows his expectations
of others
Current irritating
qualities about Tomas
Always wants sex
Outlining this concept for couples directly in the session serves as a powerful tool to help them begin to understand negative framing and how the
negative frame itself is often merely a distortion of what were once considered
attractive qualities and have been transformed over time in the partner’s mind
to be negative attributes. This perspective often gives individuals some hope,
and it also encourages them to investigate their distortions. More importantly, they can begin to change their perceptions by questioning and
weighing the evidence for their thinking.
Once couples accept the concept of negative framing, it reinforces the cognitive model. This technique is used with both partners, preferably during a
conjoint session. Alternatively, it might be constructed during an individual
session, and then reviewed during a conjoint session with an emphasis on
demonstrating for the spouse the process of restructuring the negative frame
to a more positive frame.
Teaching couples to identify automatic thoughts
The crux of the cognitive model is the identification of partners’ automatic
thoughts about themselves and, most importantly, about the relationship.
Once again, automatic thoughts are defined as thoughts which occur spontaneously in the individual’s mind about certain life circumstances or
individuals in the environment. These automatic thoughts may be either negative or positive; however, in most conflictual situations, they are negative.
Some of the most common negative automatic thoughts include:
“If he loved me, then he would agree with me.”
“She only cares about her own interests.”
“The relationship is hopeless.”
“Nothing I do is right.”
When couples learn to observe their thinking style and their patterns of
thought, they develop the skill of identifying automatic thoughts that
spontaneously flash through their minds. These are the cognitions that
can trigger charged emotional responses and actions that often result in
Frank M. Dattilio
Since many of these automatic thoughts arise from underlying beliefs or
schemata that have developed slowly over time, they are corrected and
restructured over time through the use of identification and practice. In lay
terms, such identification allows individuals to “think about what they are
telling themselves” about the situation or circumstance and learn new or
alternative ways of processing what they perceive.
In order to improve the skill of identifying automatic thoughts, clients are
typically instructed to keep a pad or notebook handy and to jot down a brief
description of the circumstances surrounding a conflict period. Included in
this notation should be a description of the situation, the automatic thought
that came to mind, and the resulting emotional response. A modified version
of the “Daily Dysfunctional Thought Record” (Center for Cognitive
Therapy, Philadelphia) may be used for this purpose. Below is an example of
excerpts extrapolated from clients’ notebooks:
Relevant situation/event
Automatic thought
Emotional response
“John came home and
started to recut the
chicken parts that I had
previously cut for dinner
without saying a word
to me.”
“The way I cut them
wasn’t good enough
for John.”
“I can’t do anything
Relevant situation/event
Automatic thought
Emotional response
“Maria failed to take
the dog out for a walk
again last night.”
“She really expects
me to do her job.”
“She couldn’t be
bothered to stoop to
such a menial task.”
Through this type of record keeping, the therapist is able to demonstrate to
the couple how their automatic thoughts are linked to emotional responses
and how this contributes to their negative frame concerning their partner.
Linking emotions with automatic thoughts
Once spouses have learned to identify automatic thoughts accurately, more
emphasis is placed on linking thoughts to emotional responses. This is
important because it has been found that, very often, impulsive behaviours
that create damage in relationships occur as a result of charged emotions. In
addition, spouses will often chalk up certain experiences or situations as a
result of “just how I feel,” disowning any responsibility for being able to
Techniques and strategies with couples and families 261
influence how they feel. For example, one husband stated that he failed to
see the point of trying to work out his marital problems because he simply
did not feel emotion for his wife anymore. This response can be linked to certain automatic thoughts that may explain more clearly why his feeling is
An exercise that often proves quite useful for couples is to have them review
their log books and indicate the links between thought and emotion. Then
they use a method of alternative responding or thought correction to effect
emotional change.
The use of imagery and role play techniques
When identifying their automatic thoughts and underlying beliefs, couples
may sometimes have difficulty recalling pertinent information regarding
conflict areas, particularly during emotionally charged situations. Imagery
and/or role play techniques may be extremely helpful in jogging memories
regarding such situations. In addition, these techniques may also be useful
in helping partners revive their positive feelings about one another. The use
of fantasy recollection to revive old affection toward one another during
dating periods may help couples see that those feelings were there at one
time and may be regenerated depending on their efforts in working on the
Therapists can utilise these cognitive-behavioural techniques throughout
therapy. They may be useful in the early stages of therapy, when one or both
partners are claiming they cannot recall happier times. The therapist may
suggest to one or both (in a conjoint visit or individually) to focus on past
scenes or images, such as early anniversaries, birthdays, their wedding day,
dating periods, and so forth. This imagery session may be more successful if
the therapist has the individuals recall specifically on what they or their partner were wearing at the time, what the room was like that they were in,
specific recollection of other people who were present, and so on. Details
such as these may serve to jog memories of old feelings. These exercises are
meant to serve as primers of motivation to rekindle positive feelings, or feelings believed to be lost. Once the therapist is able to facilitate the recreation
of a positive image of each other, the couple can begin to link emotions and
positive automatic thoughts to those images.
Imagery techniques are certainly not for everyone and may even backfire at
times, depending on the individual. Therefore, they should be used with caution. Role play techniques are also used to flush out feelings or thoughts,
particularly in those couples who are non-communicative in therapy or treatment sessions. The therapist should use discretion in determining when these
techniques are appropriate (Dattilio & Padesky, 1990).
Frank M. Dattilio
Dispelling automatic thoughts and reframing/testing
automatic thoughts
The process of restructuring automatic thoughts involves considering alternative explanations and adopting them as part of the individual’s cognitive
repertoire. In order to accomplish this, the dysfunctional automatic thought
has to be tested by the client. Once this is accomplished, a reframing of perception occurs which may allow the client to view his or her partner or
situation in a different light.
An example of this is a woman who developed the belief that her husband
was no longer in love with her as a result of his withdrawal. Her thoughts
occurred in the following sequence:
Automatic thought
1. “Alex has been increasingly
withdrawn from me over the
past week and a half. This
has to mean something
about our relationship.”
Cognitive distortion
2. “I am wondering if he has
another woman in his life.”
Mind reading
Arbitrary inference
In the example above, automatic thought 1 is accompanied by an emotion of
worry and is an example of personalisation because she interprets Alex’s behaviour as relating only to herself. In fact, it is possible he may be withdrawing from
everyone. She then draws an arbitrary inference from what she observes and
makes a global negative statement, “He doesn’t love me anymore.”
The next step is to ask her to test her thoughts by weighing the existing evidence and considering alternative explanations. For example:
What evidence exists to
substantiate this thought?
Might there be an alternative
explanation for this behaviour?
1. “He doesn’t appear to
be excited to see me
when I come home.”
1. “Perhaps something else is
bothering him. Work or finances
or maybe a midlife crisis.”
2. “He is less amorous than
he used to be with me.”
2. “He might just need some space
from me right now – time to
By weighing the evidence that exists and seeing that it actually is insufficient to draw any strong conclusion, the individual is able to consider an
Techniques and strategies with couples and families 263
alternative explanation. This will very likely reduce her negative frame until
she has the opportunity to gather additional data. She can collect additional
data by observing for a longer period of time or inquiring, in a nonthreatening manner, what may be causing him to withdraw. The latter, of
course, may also require communication training for both spouses. This exercise will at least help set the tone for her approach, making her inquiry to him
much less accusatory.
Rating the alternative explanation for alternative
Individuals should next be asked to rate the credibility of the alternative
explanation. This is important because it may not become assimilated as a
new part of their thinking unless they place some degree of belief in it. For
example, with the woman in the previous scenario, on a scale of 0%–100%,
she rated her alternative beliefs 50%.
Over time, the therapist should look for an improvement in the rating of
the belief if new evidence supports it.
The use of evidence in correcting distorted thinking
As mentioned previously, when restructuring thought processes and underlying beliefs, it is essential to help the individual learn to rely on evidence to
support the correction of distorted thoughts. It is the collection of evidence
that allows an individual to weigh contrasting information against the
schemata that are being used to formulate the individual’s current thoughts
and beliefs. Since most distorted thoughts come from faulty or erroneous
information, then it stands that new, competing evidence is required to test
and change existing thoughts. Gathering and weighing the evidence for one’s
thought are an integral part of cognitive therapy.
Weighing the evidence and testing predictions
Weighing the evidence is actually a skill which needs to be developed over
time. Just as a prosecuting attorney or a forensic pathologist needs to carefully weigh each piece of evidence prior to rendering an opinion or gathering
more data, each partner must act in a similar manner. By spending time to
review each piece of information, the individual has leisure to consider carefully its validity. Writing this reasoning process down is especially helpful for
the individual to see what actually is known.
The other side of restructuring is testing predictions. When the evidence
appears insufficient, it is often a good idea to formulate a hypothesis, think
about what might occur in any given situation, and test the prediction. This
is another form of gathering data. For example, suppose a woman who feared
Frank M. Dattilio
rejection by her husband because she overdrew their checking account tested
her prediction to see if her husband would actually reject her. She could
intentionally question him about her fear and gather hard-core evidence in
order to evaluate her thoughts and decide whether or not they were viable.
Testing predictions is another means of dispelling dysfunctional thoughts.
Practising alternative explanations
Couples thus learn to defend themselves against distorted thinking by information gathering and practising their new thoughts daily. With repeated
practice, couples can learn to restructure their thinking and balance out the
distortions denied from faulty information. The therapist can then have couples practice these alternative responses and explanations as homework
assignments until they are assimilated as a regular part of their thought
Reframing – considering the negatives in a positive light
Reframing involves taking all of the data gathered, weighing the evidence,
and developing alternative explanations and a new view of the partner. This
then replaces the negative frame once held by the client. Another way to
accomplish this change is to view the negative attributes in a positive light.
This should not be confused with “the power of positive thinking.” Since it
involves weighing actual evidence, it is instead a more systematic and confirmative way of viewing people or situations in a different and more realistic
light. It is also something that does not happen overnight; couples should be
cautioned to expect gradual change.
The therapist teaches couples to integrate all of the newly gathered data
and practice viewing it cohesively. This is demonstrated in the example in
Figure 10.2.
Increasing positives in the relationship
In addition to cognitive interventions, cognitive therapy emphasises behavioural change. Behavioural homework assignments may be given to couples at
any point in treatment to improve the quality of the relationship, strengthen
new skills, or test the validity of beliefs as described previously. This type of
behavioural assignment was first described in detail by Stuart (1980) as
“Caring Days”.
Techniques and strategies with families
Cognitive-behaviour family therapy is virtually in its infancy, with almost no
reference to empirical outcome studies present in the literature as of this
Automatic thought
After confronting John about
his actions he stated that he
felt that it would be a nice
gesture to start helping me
with dinner preparations
without me having to ask him.
I may have jumped the gun!
Maybe he didn’t realise that I
had already cut up the chicken
to completion – or maybe he
just wanted to help! Maybe he
was trying to subtly state that
he was displeased! I had better
ask him about his reasons for
cutting it, so I get a more
clearer idea.
Figure 10.2 Reframing.
Gather more evidence
John came home and started
The way that I cut them
recutting the chicken parts that wasn’t good enough for him.
I had previously cut for dinner
without saying a word to me.
I can’t do anything that
satisfies him.
Could he have just been trying to
Is it enough for me to assume that his
cutting the chicken parts automatically
means that he is so displeased with
what I do?
Weigh and question the evidence
I did jump the gun.This
I rate this belief 80%
was actually a very nice
gesture. One in fact that I
have been requesting of
him for years.
Relieved – more appreciative. Still
guarded somewhat, because John has
changed other things that I have done
in the past. However, if I check out my
inferences with him each time in the
future, we should have a better
understanding between us.
Rate the degree of
Emotional Response
belief (%) for the revised
All or nothing thinking
Alternative response
Mind reading
Cognitive distortion
Emotional response
Techniques and strategies with couples and families 265
Frank M. Dattilio
writing (Alexander, 1988; Epstein, Schlesinger & Dryden, 1988; Teichman,
1992; Dattilio, 1994, 1996b, 1997, 1998, 2001; Schwebel & Fine, 1994). As is
the case with couples therapy, cognitive-behaviour therapy with families
developed out of behavioural marital theory, which had its inception in the
late 1950s and early 1960s. Several single case studies were published involving family interventions in treating children, in which family members were
recognised as highly influential factors in the child’s natural environment
(Faloon, 1991). It was not until later that a more comprehensive style of
intervention with the family unit was implemented with families in distress.
(Patterson, McNeal, Hawkins, & Phelps, 1967; Patterson, 1971). Since that
time, applications of behavioural therapy to family systems have become
more visible in the professional literature, with an emphasis on contingency
contracting and negotiative strategies (Gordon & Davidson, 1981; Jacobson
& Margolin, 1979; Liberman, 1970).
The cognitive-behavioural approach to families applies many of the aforementioned strategies with couples in an expanded model in order to address
family schemata, or members’ beliefs about each other. Therapists also look
at family constructs that are jointly used to interpret the world and circumstances in their environment (Teichman, 1992; Dattilio, 1994, 1998, 2001).
This is underscored by the philosophy that family members’ behaviours
toward each other will not change unless their specific views or frames of
each other change (Barton & Alexander, 1981).
The focus of the cognitive-behavioural theory in family therapy is basically
twofold: (1) It serves to explain family members’ expectations of one another
and how they affect multiple interactions within the family context; and (2) it
considers the impact that all of this has on the family’s ability to cope with
crises, change, and other unexpected life events. This twofold focus constitutes
much of the premise on which behavioural family therapy is based (Faloon,
1991) with an increased emphasis on styles of thinking. Epstein, Schlesinger,
and Dryden (1988) suggest that in applying this concept to distress in family
relationships, the particular combination of emotions that each family
member feels regarding each other member is determined by the specific content of his or her perceptions of the nature of the interactions between the
self and the other person (p. 6). The specific content of a family member’s
perception of his or her interaction with other family members affects both
the quality and intensity of emotional distress as well as behavioural
responses toward other members, and serves to shape their attributions. These
attributions are believed to develop initially not only by family interaction,
but also by cognitions that then exacerbate dysfunctional interaction
(Fincham, Beach, & Nelson, 1987).
The basic tenet of cognitive family therapy contends that individual family
members maintain beliefs or schemata about every other member of the
family unit in addition to possessing a conceptualisation of family interaction
in general. These schemata are conscious and are overtly expressed during
Techniques and strategies with couples and families 267
day-to-day interactions. They develop as a result of the schema that each
spouse in the relationship brings from the family of origin, which then
becomes modified to fit into a relationship as spouses begin to function as a
dyad. This dyad is further modified with the birth of offspring and the development of a triad or family unit. Here the development of triangles becomes
important, since they contribute profoundly to the development of family
members’ cognitions (Procter, 1985). This aspect of cognitive-behaviour
family therapy is clearly borrowed from systems theory and is integrated with
the basic tenets of the cognitive-behavioural approach.
Each one of these belief systems also contributes to jointly held beliefs that
form as a result of years of integrated interaction among family members
which is identified as a “family schema” (Dattilio, 1994, 1997, 1998). These
beliefs also involve distortions which serve to contribute to faulty perception
of family members and result in dysfunctional interaction.
Just as the basic cognitive-behavioural techniques are applied to the management of depression and other emotional disorders, they are also applied to
couples and families in changing dysfunctional interactional patterns.
Therefore, cognitive restructuring procedures are also used in helping family
members test the validity of their own thoughts about family interactions.
Emphasis is placed on encouraging family members to become conscientious
observers of their own interpretations and evaluations of family transactions. Hence, the therapist works directly in the family unit, having each
member test the validity of his or her attributions, expectancies or schemata
about their relationships and about what each perceives regarding each
other’s actions. The question asked most frequently by the therapist is, “What
is going through your mind right now and what evidence exists to support
your beliefs?” In this way, the therapist helps family members test the reality
of their thought processes and weigh the evidence that supports them. This
allows family members to begin to challenge some of their own behaviours
and gain a different perspective on how they may be affecting the family
Epstein, Schlesinger, and Dryden (1988) emphasise the notion of counteracting the feedback loops that serve to reinforce dysfunctional thinking by
working conjointly with individual family members to track ongoing interactions and identify sources of feedback that strengthen a member’s negative
expectancy, attribution or belief (p. 36). This is done by making family members confront each other and challenge distorted thoughts in a constructive
manner that provides them with alternative information. Individual members
are instructed to process their automatic thoughts in the same fashion that
couples are, as illustrated in Figure 10.2.
Since destructive interaction is so much a common occurrence in dysfunctional families, such techniques as “self-instructional training” are used in
providing them with covert instructions for controlling impulsive reactions
toward one another. This technique is borrowed from Meichenbaum’s (1977)
Frank M. Dattilio
work in stress inoculation. Epstein (1982) also suggests the use of self-instructional training to control aversive exchanges between spouses, which can be
also applied within the family constellation.
In addition to cognitive restructuring techniques, cognitive-behaviour therapy utilises several behavioural interventions such as assertiveness training,
behaviour-exchange procedures, communication training and problem-solving techniques (Dattilio, Epstein, & Baucom, 1998). The specific use of these
interventions in conjunction with cognitive techniques depends on the assessment of the family needs, which the therapist assesses in a collaborative
fashion during the intake and as therapy proceeds.
Compatibility of cognitive-behaviour therapy as
an integrative model
Several components of cognitive-behaviour therapy appear highly adaptable
to other modalities of marital and family intervention (Dattilio, 1998). For
one, the use of communications training and problem-solving is one aspect
found within the systems domain as well as in other approaches. Secondly, the
notion of identifying core beliefs and patterns of thought may blend nicely
with other approaches, as the focus involves changing interactional patterns
among couples and family members and dealing with issues of rule-guided
behaviour and problem-solving strategies.
A comprehensive exploration of the integrability of cognitive therapy is
illustrated by numerous case examples in an edited volume by Dattilio (1998).
Even those approaches that appear to be the most antithetical to cognitive
therapy show some compatibility to its integration.
Hence, cognitive therapy combined with behavioural techniques appears to
have much to offer other modalities of treatment and, if implemented carefully, may serve to broaden the scope of other modalities and techniques
and increase the effectiveness of treatment.
Behavioural interventions
Because of space limitations, only an overview of the major forms of behavioural intervention in cognitive-behavioural couples and family therapy will
be provided. More detailed descriptions of therapeutic procedures can be
found in texts by Baucom and Epstein (1990), Falloon (1991), Jacobson and
Margolin (1979), Robin and Foster (1989), Sanders and Dadds (1993), and
Stuart (1980). The degree to which any of these interventions is used with a
particular couple or family varies considerably, depending on the clients’
needs. The major forms of behavioural intervention are communication training, problem-solving training, and behaviour change agreements designed to
increase exchanges of positive behaviours and decrease negative exchanges
among family members. In addition, in families characterised by coercive
Techniques and strategies with couples and families 269
exchanges between parents and children, training in parenting skills is likely
to be appropriate.
Communication training
The goals of communication training are to increase family members’ skills in
expressing their thoughts and emotions clearly, listening to each other’s messages effectively, and sending constructive rather than aversive messages.
Central to achieving these goals is training the partners in expressive and listening skills. Guerney’s (1977) educational approach is widely used by couple
and family therapists for teaching clients to take turns as expresser and
empathic listener, following specific behavioural guidelines. For example, in
the expresser role one’s job is to state views as subjective rather than as facts,
to include any positive feelings about the listener when expressing criticisms,
to use brief, specific descriptions of thoughts and feelings, and to convey
empathy for the other person’s feelings as well. In turn, the listener is to try to
empathise with the expresser’s thoughts and emotions (even though this need
not indicate agreement with the expresser’s ideas) and convey that empathy to
the expresser. The listener is to avoid distracting the expresser by asking questions or giving opinions that shift the topic, avoid judging the expresser’s
ideas and emotions, and convey understanding of the expresser’s experience
by reflecting back (summarising and restating) the key thoughts and emotions expressed. Detailed guidelines for the expresser and empathic listener, as
well as procedures for teaching these skills, can be found in Baucom and
Epstein (1990) and Guerney (1977). The therapist typically presents instructions about the specific behaviours involved in each type of skill orally and by
means of written handouts that the family members can take home. The
therapist can model expressive and listening skills or show the clients videotaped samples such as the tape that accompanies Markman, Stanley and
Blumberg’s (1994) Fighting for Your Marriage text. The clients then practice
the communication skills repeatedly, with the therapist coaching them in following the guidelines. Typically, a therapist asks the couple or family
members to begin their practice of the skills with relatively benign topics, so
that any strong emotions associated with highly conflictual topics do not
produce sentiment override and interfere with the learning process. Once the
family members are able to enact expressive and listening skills effectively,
they proceed to more difficult topics.
In addition to reducing misunderstandings among family members, use of
expressive and listening skills reduces the emotional intensity of conflictual
discussions, and increases each person’s perception that the others are willing
to respect his or her ideas and emotions. Even when family members are
expressing negative feelings about each other’s actions, the polite and structured interactions created by the procedures often reduce destructive
Frank M. Dattilio
Problem-solving training
Problem-solving skills constitute a special class of communication that a
couple or family can use to identify a specific problem in their relationship
that requires a solution, generate a potential solution that is feasible and
attractive to both partners, and implement the chosen solution. Problemsolving is cognitive and oriented toward resolving issues, in contrast to the
skills described above that focus on emotional and empathic listening.
As in teaching expressive and listening skills, cognitive-behavioural therapists use verbal and written instructions, modelling, and behavioural
rehearsal with coaching to help family members develop effective problemsolving communication. The major steps involved in problem-solving include
(a) achieving a clear, specific definition of the problem, in terms of behaviours that are or are not occurring (and that family members agree is a
problem in their relationships); (b) generating one or more specific behavioural solutions to the problem (using a creative “brainstorming” period if
necessary), without evaluating one’s own or other family members’ ideas; (c)
evaluating each alternative solution that has been proposed, identifying
advantages and disadvantages to it, and selecting a solution that appears to
be feasible and attractive to all of the involved parties; and (d) agreeing on a
trial period for implementing the solution and evaluating its effectiveness.
Details on conducting problem-solving training can be found in texts such as
Baucom and Epstein (1990) and Robin and Foster (1989).
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Therapy. New York: Guilford.
Teichman, Y. (1992). Cognitive Therapy with Families – A Case Study. In A. Freeman
& F.M. Dattilio (Eds.), Comprehensive Casebook of Cognitive Therapy. New York:
Touliatos, J., Perlmutter, B.E, & Straus, M.A. (Eds.), (1990). Handbook of Family
Measurement Techniques. Newbury Park, CA: Sage.
Vincent-Roehling, P.V., & Robin, A.L. (1986). Development and validation of the
Family Beliefs Inventory: A Measure of Unrealistic Beliefs Among Parents and
Adolescents. Journal of Consulting and Clinical Psychology, 54, 693–697.
Weiss, R. L. (1980). Strategic Behavioral Marital Therapy: Toward A Model for
Assessment and Intervention. In J.P. Vincent (Ed.), Advances in Family
Intervention, Assessment, and Theory (Vol. 1, pp. 229–271), Greenwich, CT: JAI
Weiss, R.L. (1984). Cognitive and Strategic Interventions in Behavioral Marital
Therapy. In K. Hahlweg & N.S. Jacobson (Eds.), Marital Interaction: Analysis and
Modification. New York: Guilford.
Chapter 11
Cognitive behavioural therapy
with children and adolescents
Aude Henin, Melissa Warman, and Philip C . Kendall
Despite its relatively young age, cognitive behavioural therapy (CBT) is one
of the most widely researched approaches for treating psychological problems in youth. This chapter provides an overview of CBT from both a
procedural and empirical point of view and promotes the increased use of
CBT with the problems for which there is demonstrated efficacy. We begin by
briefly discussing the cognitive behavioural theoretical framework on which
interventions are based, and illustrate the general guiding principles. We
then consider CBT’s application with several specific clinical problems in
Historical précis and theoretical overview
CBT represents an interactional perspective, integrating the cognitive and
behavioural schools of therapy into a useful amalgam. The interaction of
affect, behaviour, social factors, cognition, and environmental influences is
recognised and considered within a comprehensive treatment approach.
Learning becomes important not only as it relates to environmental consequences but also as it relates to the information processing occurring within
the individual (Kendall, 1985); thus CBT remains consistent with both information-processing and social learning theories (Kendall & Bacon, 1988). At
the same time, CBT maintains an empiricist tradition, striving for clinical
sensitivity with empirical soundness.
Concerning psychopathology and its treatment, the CB approach views
psychological problems as stemming primarily from behavioural and cognitive antecedents. Behavioural factors afforded primary consideration by CB
theory include a child’s familial and extra-familial environmental experiences
(Southam-Gerow, Henin, Chu, Marrs, & Kendall, 1997). These events are
examined for evidence of limited learning opportunities or potentially pathgenic experiences (e.g., trauma). In terms of cognitive factors, CB theory
emphasises cognitive dysfunction and distinguishes between cognitive distortion and cognitive deficiency (Kendall & MacDonald, 1993). Children
either process information in a distorted fashion (e.g., misinterpreting the
Aude Henin, Melissa Warman, and Philip C. Kendall
intentionality of others) or their cognitive-processing ability is somehow
deficient, leading to action that does not benefit from forethought (Kendall
& MacDonald, 1993). These cognitive-processing dysfunctions have been
differentially associated with various childhood disorders. Cognitive distortions are thought to underlie anxiety and depression whereas impulsivity and
attention problems are linked to cognitive deficiencies. Aggressive and antisocial behaviour have been found to reflect both cognitive distortions and
cognitive deficiencies (Kendall & MacDonald, 1993). The therapeutic pathway thus lies in remedying the identified cognitive dysfunction, and providing
skills and opportunities to practise these skills, beginning new learning
trajectories. Before describing and discussing examples of CB treatment
strategies, we first review two additional issues that are considered critical in
the formulation of an adequate treatment plan.
Knowledge from the field of child development receives particular
emphasis in CBT with youth. CB interventions are designed with developmental considerations in mind. For example, the current developmental
level of the child (i.e., cognitive ability, current developmental challenges) is
assessed to inform the specific intervention. A young, cognitively immature
child might benefit less from long, didactic sessions and would be better
served by brief, active sessions, often with the cognitive content of the session occurring in vivo. Another developmental consideration involves
sensitivity to the context of the developmental challenges facing the child.
Therefore, a CB therapist seeing a child dealing with separation anxiety at
age nine intervenes within the appropriate developmental challenge (i.e.,
issues of autonomy). With older children, other themes present themselves
as more opportune for the aim of an intervention (e.g., peer-related,
CB interventions are active, time-limited, and structured. They are implemented with the therapist as consultant, diagnostician, and educator
(Kendall, 1991). The client and therapist engage in a collaborative process in
which the client often becomes a “personal scientist” (Mahoney, 1974) once
the client and therapist have developed an agreed-upon conceptualisation of
the problem. Clients are helped to understand how their inner conversations,
thoughts, expectations, and assumptions mediate their behaviour. They are
encouraged to perform “in-vivo personal experiments” to test out the results
of modifications in their cognitive processes. The resulting behaviour serves
as evidence that one’s cognitive structures should not always be held as
“truths” and leads to reprocessing and reappraisal of events (FlannerySchroeder, Henin, & Kendall, 1996). In this way, the therapist guides the
client in the learning of new skills in behavioural, cognitive, interpersonal,
and emotional domains and coaches the client in the use of these new skills
(Meichenbaum, 1986).
Cognitive behavioural therapy with children and adolescents
Cognitive-behavioural treatment strategies and
A main treatment aim of CBT is to help the child construct a coping template
(Kendall, 1993, 1994). This is done by developing a new, or modifying an
existing cognitive structure for processing information about the world. An
important aspect of this process is achieved by having the child learn about
his/her own thinking and practise the new ways of thinking in the company
of the therapist. This allows the therapist to help the child in altering his/her
attributions about past experience and expectations about events in the
future. Accomplishing this goal necessitates the utilisation of several treatment strategies and techniques: (a) affective education, (b) relaxation
training, (c) social problem-solving, (d) cognitive restructuring/attribution
retraining, (e) contingent reinforcement, (f) modelling, and (g) role-plays
(Kendall, 1993, 1994; Southam-Gerow et al., 1997). These techniques are
tailored for each case, some cases requiring a more comprehensive application
than others. The therapist selects among these alternatives in structuring the
treatment to fit the presenting problem(s) of the child (Kendall, 1993, 1994;
Southam-Gerow et al., 1997).
At the beginning of treatment, the problems are identified by both the
child and the therapist. This process involves teaching the child to recognise,
label, and monitor physiological and emotional cues and then ultimately to
control behavioural reactions that accompany these cues (Southam-Gerow et
al., 1997). This also involves teaching the child to acknowledge his/her own
body reactions. Activities provided in therapy workbooks (e.g., Kendall, 1990;
Nelson & Finch, 1996) are aimed at developing the child’s awareness of feelings and situations that produce difficulties for him/her and using the
experience as a means to more adaptive coping (Kendall, 1993; SouthamGerow et al., 1997).
Once the child is able to identify internal and external situations that produce stress, teaching relaxation skills may be helpful. Cue-controlled and
progressive relaxation techniques are used with children. Cue-controlled
relaxation involves associating the relaxed state with a cue word generated by
the child, such as “calm”. In practice, the child repeatedly vocalises within
him/herself the cue word while in the relaxed state. In progressive relaxation,
one after the other, major muscle groups are relaxed through systematic
tension-release exercises (King, Hamilton, & Ollendick, 1988). This helps
the child to recognise bodily tension, allowing him/her to use that arousal as
a cue to relax. Relaxation exercises frequently involve relaxation scripts to
which the child listens while practising, and may be additionally enhanced by
the incorporation of imagery into the scripts. An effective alternative for use
in public situations is diaphragmatic breathing exercises, which can also be
introduced into the child’s relaxation routine.
The process of changing “faulty” thinking to cognitive processes which are
Aude Henin, Melissa Warman, and Philip C. Kendall
more functional is sometimes called cognitive restructuring. The first step
involves identifying the child’s self-talk, whereby the child is encouraged to
express his/her thoughts as “thought bubbles”, similar to those seen in comic
strips. Once the content of the child’s self-talk has been identified, the therapist can help him/her replace the non-functional cognition with more
adaptive options. Attribution retraining is similar and involves teaching
the child to differentiate between internal–external, global–local, and
stable–unstable causal attributions. Once a child has identified her/his attributions for a given event, the child and therapist can generate alternative
explanations for the circumstances under consideration.
Conceptualising therapy as a problem-solving endeavour has many benefits
(Kendall & Siqueland, 1989). For example, it helps the child to understand
that his/her problems are neither unmanageable nor catastrophic. In addition,
a problem-solving approach encourages the child to focus on and evaluate
several possible options and solutions to the problem. Problem-solving can be
thought of as a sequence (D’Zurilla, 1986; D’Zurilla & Goldfried, 1971),
where the child works to describe the problem and the major goals for the
solution. Then the child generates alternative solutions and weighs each of
these alternatives, considering each in terms of how beneficial it would be in
achieving his/her goal. Finally, he/she considers the nature of the outcome,
focusing on the attempt at problem-solving, rather than an emphasis on a
“perfect” result.
Another important technique in CB therapy role playing requires the child
and therapist to act out challenging situations. Role playing offers an opportunity for the child to actually practise coping skills and to use solutions
already considered for the problematic situations. The therapeutic stance is
supportive and the environment is non-threatening. As a result, the child can
take his/her first steps towards attempting and ultimately mastering the skills
learned in therapy (Kendall, 1993, 1994; Southam-Gerow et al., 1997). After
the teaching and practice of problem-solving and/or social skills in the therapy room, it is beneficial for the child to approach and experience in vivo the
situations that are stress-producing. Using the tenets from behaviour therapy,
this is systematically accomplished by beginning with a less intense stressor
and building to situations that are most intense for the child. The exposure
can begin imaginally whereby the child, guided by the therapist, imagines
him/herself in the situation and then having achieved some mastery, progresses to an actual in-vivo exposure.
When a child attempts to face the situations and does so without relying on
avoidance behaviours, he/she is rewarded. A cornerstone of behaviour therapy, contingent reinforcement, allows the therapist to shape the child’s
behaviour. The child may be helped to behave more adaptively by breaking
down the desired outcome into smaller, more manageable steps (i.e., shaping
by successive approximations), with the ultimate goal being to teach the child
to evaluate his/her own behaviour and provide rewards accordingly (Kendall,
Cognitive behavioural therapy with children and adolescents
1993, 1994; Southam-Gerow et al., 1997). Rewards may also be useful in
encouraging the child to complete homework assignments outside of the session. These homework assignments are designed to provide further practice
with the new coping techniques within a real-life context. In addition, they
provide another opportunity for the child to experience mastery.
A powerful tenet in CBT is modelling, which is based on the understanding that behaviour can be reduced, acquired, eliminated or enhanced through
observation. Several different types of modelling are frequently used by CB
therapists: symbolic, live, and participant modelling. Symbolic modelling
involves exposure to a video tape of another person facing the same situation
with which the child is having trouble. This type of repeated observation of
the same sequence enables the child to understand different aspects of the
other person’s behaviour on each viewing. As for live modelling, the child
observes another person coping directly with a difficult situation. Participant
modelling involves the child’s copying of the model, rather than simple observation. The therapist has a unique role in that he/she can act as a coping
model throughout sessions by demonstrating coping behaviours as difficulties
arise. Rather than provide a model of total and easy success (mastery model)
the therapist illustrates the difficulties that may be faced in a situation (coping
model). In coping modelling, a full success is not experienced every time but
rather, the therapist exemplifies how errors and mistakes can be managed
(Kendall, 1993, 1994).
A CB therapist, in practice, does not inflexibly follow procedures in manuals
or rigidly apply all the delineated strategies and techniques. Rather, therapists
carefully select those most suitable and necessary for each child, often restructuring and refocusing as change and progress become more evident.
CBT: Applications with particular disorders
In the following sections, we consider applications of the CBT approach with
four childhood problems: anxiety, depression, aggression, and attentiondeficit hyperactivity disorder (ADHD). We emphasise the differential
application of the more general CB strategies as they are intentionally tailored for each particular type of problem. Additionally, we review empirical
studies examining the efficacy of these approaches and describe in some
detail the more successful programmes.
Internalising versus externalising disorders
The difference between internalising (e.g., anxiety, depression) and externalising childhood disorders (e.g., ADHD, aggression) burgeoned out of the
research of Achenbach and colleagues (Achenbach, 1985, 1988; Achenbach
& Edelbrock, 1978; Achenbach & McConaughy, 1987). Internalising disorders are understood to be inner-directed and are characterised by
Aude Henin, Melissa Warman, and Philip C. Kendall
overcontrolled behaviour patterns. Externalising disorders, on the other hand,
are outer-directed and undercontrolled. The division may also be represented
as children with self-focused problems versus children whose problems disturb others or are environment-focused in nature (Achenbach, 1982).
Internalising disorders present significant difficulties in their identification and treatment as children suffering from internalising disorders may be
easily overlooked because the disorders, anxiety in particular, have symptoms such as inhibition and withdrawal (Flannery-Schroeder et al., 1996).
These behavioural tendencies are sharply disparate with the acting-out behaviours of children with externalising disorders. The majority of research
studies investigating psychopathology in children and adolescents have
focused on externalising behaviour problems (see Kendall & MacDonald,
1993), yet the high frequency of occurrence of internalising disorders
(Bernstein & Borchardt, 1991), as well as their significant implications for
social (e.g., Rubin, 1985; Strauss, Forehand, Smith, & Frame, 1986), academic
(e.g., Benjamin, Costello & Warren, 1990; King & Ollendick, 1989), and
future adjustment (e.g., Feehan, McGee, & Williams, 1993; Kovacs, Feinberg,
Crouse-Novak, Paulauskas, Pollack, & Finkelstein, 1984a, 1984b), have
resulted in a growing shift in research interests toward internalising problems.
Anxiety disorders in youth
Anxiety disorders appear to be a relatively common form of psychopathology
among children and adolescents. Kashani and Orvaschel (1990), studying a
sample of 210 youths (age groups were 8, 12, and 17 years), reported anxiety
disorders to be the most common disorder diagnosed across the three age
groups. In addition, in a New Zealand sample of over 960 children, anxiety
disorders were found to exist most frequently, relative to mood disorders,
conduct/oppositional disorders, attention-deficit hyperactivity disorder, and
substance abuse (Fergusson, Horwood, & Lynsky, 1993). Benjamin et al.
(1990) found anxiety disorders to appear four times as often as behavioural
disorders by children’s report (9.9% versus 2.6%) but only slightly more often
according to parent report (5.6% versus 4.1%).
It should be noted that not all anxiety in children is abnormal. A limited
number of short-lived fears and worries are a part of normal development
(Barrios & Hartmann, 1988). Within a normal range, fear and worry are
actually adaptive in development and keep children from harm and potential
danger. Children’s fears often take a common trajectory during the course of
development, moving from fear of strangers and separation in young children, to fears about personal harm, school, and supernatural events in
school-aged children. Concern arises, however, when a child does not move
beyond the fears associated with a particular developmental stage or when the
worry or fear at a particular stage interferes significantly with the child’s
normal functioning (Morris & Kratchowill, 1983).
Cognitive behavioural therapy with children and adolescents
Childhood anxiety is a multidimensional construct manifesting physiological, behavioural, and cognitive symptoms. Accordingly, physiological,
behavioural, and cognitive models are useful in conceptualising the disorder.
Physiologically, the autonomic nervous system produces physical symptoms
such as flushed face, perspiration, trembling, and stomach pains (Barrios &
Hartmann, 1988). Children with anxiety have also been shown to have
increased heart and respiration rates. Behaviourally, anxious children often
avoid feared stimuli and situations and display shaky voice, rigid posture,
crying, nail-biting, or thumb-sucking.
Cognitive theorists hold that anxiety is the product of dysfunctional efforts
to make sense of the world (Kendall, 1993, 1994). With anxiety disorders, the
nature of cognitive functioning has been characterised as an automatic questioning process (Kendall & Ingram, 1989). This questioning tends to be
future oriented, focusing on concerns about possibilities, impending situations, and potential consequences, in conjunction with questions about
personal efficacy or one’s ability to deal with these anticipated situations
(Kendall & Ingram, 1989). Anxious children focus on social and environmental cues in a distorted manner and appear preoccupied with evaluations
by self or others and the likelihood of severe negative consequences (Kendall
& Chansky, 1991). Furthermore, anxious children tend to endorse more
threat-related self-statements than do non-anxious children when responding
to self-statement questionnaires (Ronan, Kendall, & Rowe, 1994) and provide
excessive, non-functional coping self-talk on thought-listing tasks (Kendall &
Chansky, 1991).
Consistent with a multicomponent conceptualisation of anxiety, there is
growing acknowledgement that a combination of treatment strategies is most
beneficial in treating children with anxiety disorders. In addition, ageappropriate applications of successful strategies can serve as a first step in
refining intervention strategies for children (Southam-Gerow et al., 1997).
Multicomponent CB intervention programmes for anxiety generally
involve children attending 50- to 60-minute weekly sessions, for 16–20
weeks. The first half of the protocol is educational, teaching the child the
cognitive skills necessary to alter anxious reactions to anxiety-provoking situations. The therapist’s goal is to help the child build a coping template
which can be implemented whenever anxiety-producing situations arise. To
accomplish this aim, CB strategies are tailored to target anxious arousal
and cognition. Affective education focuses on the recognition of anxious
emotions and the accompanying physiological arousal, so that the children
can use these symptoms as cues to enact the subsequent phase of their
coping plans (Kendall, Kane, Howard, & Siqueland, 1990, for a review, see
Kendall et al., 1992).
As children continue to practise the skills learned through affective education, they are encouraged to (a) identify and modify the anxious self-talk
associated with anticipated negative outcomes, and (b) generate new, more
Aude Henin, Melissa Warman, and Philip C. Kendall
adaptive, non-anxious self-talk to challenge their anxious cognition. In addition, problem-solving is encouraged to generate, evaluate, and implement a
number of alternative behaviours for use in anxiety-provoking situations.
Reinforcement (e.g., tangible rewards or therapist praise) is linked to the
child generating realistic appraisals of his/her performance and, eventually,
developing the ability for self-praise/self-reinforcement.
The second half of treatment focuses on having the children practise their
newly learned coping steps in increasingly anxiety-provoking situations. The
situations are tailored to each child and are based on his/her own fear hierarchy. Thus, each session gradually focuses on applying the newly learned
coping template to another anxiety-producing situation. Throughout treatment, children are encouraged to practise the steps from their coping
template outside of the sessions, so as to generalise treatment gains.
One strategy developed at Temple University’s Child and Adolescent
Anxiety Disorders Clinic (CAADC), where this CB treatment has been developed and evaluated, is to have the child plan and orchestrate a video in which
the child gives advice to others about how to cope with anxiety. This casts the
child in the role of “expert”, allowing him/her to recognise his/her accomplishments and gain a sense of mastery. It also gives the child the opportunity
to organise the material learned during therapy and encourages generalisation
of skills.
Several studies have investigated the efficacy of CB interventions for children’s phobias and fears (e.g., Hagopian, West, & Ollendick, 1990; Kanfer,
Karoly, & Newman, 1975; Singer, Ambuel, Wade, & Jaffe, 1992), medical
and dental fears (e.g., Heitkemper, Layne & Sullivan, 1993; Melamed &
Siegel, 1975; Peterson & Shigetomi, 1981), and social and evaluative anxiety
(e.g., Fox & Houston, 1981; van der Ploeg-Stapert & van der Ploeg, 1986).
These studies are important; however, a majority of the studies have not
included samples of children diagnosed with anxiety based on structured
diagnostic interviews, but instead, have used children with elevated scores on
various dependent measures of anxiety. Nevertheless, more recently, several
studies have considered the efficacy of CB interventions with children diagnosed with an anxiety disorder. This review will focus on the research
examining CB treatments of the following anxiety disorders: (a) separation
anxiety disorder (SAD), generalised anxiety disorder (GAD)/ overanxious
disorder (OAD), social phobia (SP)/avoidant disorder (AD); (b) obsessive
compulsive disorder (OCD); (c) panic disorder; and (d) post-traumatic stress
disorder (PTSD).
As for OAD, two studies (Kane & Kendall, 1989; Eisen & Silverman, 1993)
evaluated CB therapy using a multiple-baseline design. Both studies followed
a multi-trait, multi-measure design with self-, parent-, teacher-, and clinicianreport of children’s functioning. At post-treatment assessment, children
demonstrated improvement on self-, parent-, and clinician-reports, with many
indices of anxious symptomatology falling to within normative levels
Cognitive behavioural therapy with children and adolescents
(Kendall & Grove, 1988). Follow-up results were favourable with most children maintaining treatment gains (only one child continued to experience
distress in limited domains). The Eisen and Silverman (1993) study served as
a partial replication of the Kane and Kendall (1989) study. However, additional aims were to investigate the relative contributions of cognitive therapy
and relaxation training over exposure. Results, though unclear, suggested
that cognitive therapy may be more effective than relaxation training.
Kendall (1994) conducted and reported the first randomised clinical trial of
CB therapy for the treatment of childhood anxiety disorders. Participants
were 47 young people (aged 9–13) diagnosed with one of three childhood
anxiety disorders (SAD, AD, OAD) using a structured diagnostic interview
and were randomly assigned to either a treatment or a waitlist condition. All
waitlisted children were treated at the end of the waitlist period. The CB
treatment consisted of four major components: (1) recognising anxious feelings and physical reactions to anxiety; (2) identifying and modifying negative
self-statements; (3) generating strategies to cope effectively in anxietyprovoking situations; and (4) rating and rewarding attempts at coping
behaviour. The treatment was conducted in two parts: (1) instruction in
coping skills and (2) practice in the use of those skills in increasingly anxietyprovoking situations (see treatment manual by Kendall et al., 1990).
Dependent measures included a multi-method assessment approach including
self-, parent-, and teacher- reports of children’s behaviour, as well as cognitive
assessments and behavioural observations. Measures were collected at preand post-treatment, as well as at one-year follow-up. Analyses of the data
indicated significant reductions in anxiety for the treated children compared
to the waitlist (across nearly all dependent measures). Importantly, 65% of
treated children no longer met criteria for their primary anxiety disorder at
post-treatment. Examination of clinical significance (Kendall & Grove, 1988)
revealed that a significant proportion of children reported levels of anxiety
and internalising behaviours falling within the normative range at posttreatment, and follow-up data demonstrated maintenance of treatment gains.
Kendall and Southam-Gerow (1996) reported a 3- to 5-year follow-up (average > 3 years) on these participants, which found long-term maintenance of
treatment gains.
In a second randomised clinical trial, Kendall, Flannery-Schroeder,
Panichelli-Mindel, Southam-Gerow, Henin, and Warman (1997) examined
the efficacy of the CB treatment procedures with children diagnosed with
SAD, OAD, and/or AD. The results were again favourable with over 70% of
children no longer having their primary anxiety disorder diagnosis as primary
at post-treatment,. Self- and parent-reports, also evidenced improvement,
confirming the benefits of the treatment.
There have been adaptations of the treatment programme developed by
Kendall and colleagues for use with families of children with anxiety disorders. Because of the likelihood of parental involvement in the maintenance of
Aude Henin, Melissa Warman, and Philip C. Kendall
children’s behaviours, family-focused treatments have been recommended
(e.g., Ginsburg, Silverman, & Kurtines, 1995). In a multiple-baseline study of
six anxiety-disordered children and their families, Howard and Kendall
(1996) reported that CB procedures produced significant treatment gains
which were maintained at 4-month follow-up. Barrett, Dadds, and Rapee
(1996) adapted the Kendall (1994) programme and compared individual,
family, and waitlist control conditions in a sample of 79 children and their
parents. At post-treatment, significantly fewer children in treatment than on
waitlist met criteria for diagnosis. In addition, the proportion of children no
longer meeting diagnoses in the child plus family treatment (84%) was higher
than that in the individual treatment (57.1%). Self-, parent-, and clinicianreport measures indicated greater efficacy of the child plus family treatment,
compared to the individual treatment. At a one-year follow-up, gains were
maintained for both treatments. The results of the study indicate the added
benefits of a family focus in CB interventions with anxious children.
Research on CBT with anxious youth serves, not only as an illustration of
the efficacy of CB techniques, but also as a template for treatment outcome
research with other disorders. Specifically, research on CBT with anxious
youth is distinguished by its use of standardised assessment tools, standardised treatment procedures, and the application and evaluation of similar CB
treatments by independent research teams. This in turn, has warranted the
distinction of “empirically validated treatment” (Kazdin & Weisz, 1998).
Obsessive compulsive disorder
The efficacy of CB treatment with adult OCD clients has been established
(e.g., Foa, Steketee, & Ozarow, 1985; Stanley & Turner, 1995); however, the
use of these treatments with children has not been as systematically addressed
(for a review, see Henin & Kendall, 1997). Although more than 35 reports of
behavioural interventions have been reported in the child OCD literature,
the majority have been case reports (e.g., Fisman & Walsh, 1994) or singlecase designs (Hollingsworth, Tanguay, Grossman, & Pabst, 1980; Kearney &
Silverman, 1990; for a review, see March, 1995). Randomised clinical trials
are needed.
An evaluation of a standardised CB treatment for OCD children and
adolescents was reported by Piacentini, Gitow, Jaffer, Graae, and Whitaker
(1994). The authors assessed the effectiveness of an outpatient treatment
that employed therapist-supervised exposure and response prevention. Three
children (aged 9, 12, 13) were assessed via structured interviews and child-,
parent-, and clinician-reports at pre- and post-treatment, and one year following treatment. Treatment consisted of 10, 2-hour sessions held once per
week. In addition to exposure/response prevention, the following treatment
strategies were also utilised: (1) coping strategies to manage anxiety during
exposure (e.g., cognitive self-statements), (2) a contingency management
Cognitive behavioural therapy with children and adolescents
programme (in which children were systematically rewarded for completing
in-session tasks), and (3) homework assignments. In addition, the treatment
incorporated family sessions designed to educate the family about OCD and
help them in developing more adaptive family interactions. Results suggested that two of the three cases showed marked improvement in obsessive
compulsive symptoms at post-treatment, as rated on self-report and
herapist-report inventories. In addition, gains were maintained at one-year
follow-up. In the third case, only minimal improvement was found, although
the authors suggest that the patient’s comorbid conditions and high level of
associated family psychopathology may have contributed to the difficulties
in treatment.
A protocol-driven, CB treatment, “How I Ran OCD Off My Land” has
recently been developed by March, Mulle, and Herbel (1994) for the treatment of OCD. The 16-week treatment, a compilation of anxiety management
training and behavioural exposure/response prevention, comprises four
phases: (1) psychoeducation to externalise the OCD (e.g., viewing it as a
medical illness, giving it a “nasty nickname”) and a cartographic metaphor to
map the child’s experience with OCD; (2) identification of areas where the
child has already had some success in resisting OCD, and development of a
stimulus hierarchy; (3) anxiety management training (e.g., relaxation training,
teaching of adaptive self-talk); and (4) exposure/response prevention in which
children practise by selecting items from the stimulus hierarchy.
Evaluation of this intervention with 15 children diagnosed with OCD indicated clear treatment gains across multiple self-rated and clinician-rated
measures. These gains were maintained at follow-up. Specifically, 10 of the 15
children experienced a greater than 50% reduction in self-report scores at
follow-up; six patients were judged asymptomatic at post-treatment, whereas
9 were asymptomatic at follow-up. Despite these promising findings, several
aspects of the study limit the conclusions that can be drawn, not the least of
which is that the concurrent treatment of 14 of the 15 children with medication prevents clear identification of the active treatment ingredients. Future
work with this potentially promising approach requires larger sample sizes
and use of comparison and control conditions.
Panic disorder
There exists a dearth of studies examing panic disorder in children and adolescents. Until recently, there were questions as to whether or not panic
disorder occurred in childhood or adolescence. Although reported prevalence rates of the disorder have ranged from 0.6% (Whitaker et al., 1990) to
12% (Hayward, Killen, & Taylor, 1989), these findings should be considered
preliminary due to methodological differences (see Moreau & Weissman,
1992). Nevertheless, retrospective reports of adults with panic disorder
suggest that the panic attacks began in childhood (e.g., Sheehan, Sheehan, &
Aude Henin, Melissa Warman, and Philip C. Kendall
Minichiello, 1981; Thyer, Parris, Curtis, Nesse, & Cameron, 1985). In addition, case studies have been reported in which the authors describe cases of
panic disorder in children (e.g., Black & Robbins, 1990; Biederman, 1987;
Moreau, Weissman, & Warner, 1989); however, these reports are few in
number and several have failed to use structured diagnostic interviews.
CB therapies with adult panic sufferers hold promise (e.g., Craske, 1988) and
have been recommended in the treatment of panic disordered children.
However, few empirical or controlled studies have been conducted with children
or adolescents. To date, the only systematic study involved a multiple-baseline
design with four adolescents diagnosed with panic disorder with agoraphobia
(Ollendick, 1995). Treatment included relaxation exercises, cognitive coping
skills training, and exposure. Results demonstrated enhancement of selfefficacy and reductions in panic attack frequency and agoraphobic avoidance.
Self-report measures post-treatment also indicated lowered levels of anxiety
and depression. Generally, treatment gains were maintained at 6-month followup. These findings are positive but preliminary, and research is needed to
substantiate the validity of panic disorder diagnoses in children and to further
investigate efficacious treatment programmes.
Post-traumatic stress disorder (PTSD)
PTSD symptomatology has been observed in children and adolescents following traumatic events including death, fires, natural disasters, and physical
or sexual abuse, and treatment approaches have been varied. There are
approaches rooted in the behavioural, cognitive behavioural, psychodynamic,
family, and group traditions; yet the utility, or relative utility, of these procedures with children remains largely unexplored (Lyons, 1988) with one
exception (Deblinger, McLeer, & Henry, 1990). Nevertheless, results of studies of adults with PTSD have been promising and point toward the efficacy of
CB procedures (Fairbank & Keane, 1982; Frank & Stewart, 1983; Kilpatrick,
Veronen, & Resick, 1982).
The only study to date investigating CB strategies with children examined
the treatment of sexually abused children suffering from PTSD (Deblinger et
al., 1990). Participants were 19 girls (aged 3–16) and their non-offending
parent(s). Parents and children participated in structured diagnostic interviews and completed various self-report measures of the children’s adaptive
functioning. The 12-session intervention included techniques such as gradual
exposure, modelling, coping, and prevention skills training. Findings demonstrated significant improvements in PTSD symptomatology. Furthermore,
at post-treatment all subjects failed to meet PTSD diagnostic criteria. These
results are favourable and suggest that CB therapy may be quite promising for
sexually abused PTSD children. However, strong conclusions are not yet
possible. Future research should include larger sample sizes, follow-up assessments, samples of children with PTSD arising from traumas other than
Cognitive behavioural therapy with children and adolescents
sexual abuse, and comparisons of CB and other forms of treatment (for a
review, see Lyons, 1988).
Across the disorders reviewed thus far, CB treatment of anxiety disorders
appears to be an effective approach in the alleviation of such disorders. CB
treatments hold promise with SAD, OAD, AD, and OCD, although the
apparent differential efficacy may be due to the disproportionate amount of
research using samples with these disorders compared with other anxiety
disorders such as panic and PTSD. Treatment development and evaluation is
still needed for panic disorder and PTSD in youth.
Unipolar depression in children and adolescents
The recent interest in affective disorders in youth has been prompted in part
by the finding of significantly higher rates of these disorders in children than
previously believed, and in part because adolescent depression appears to predict subsequent adult maladjustment. A number of rigorous epidemiological
studies of affective disorders have yielded prevalence rates for children around
the 2% mark (Anderson, Williams, McGee, & Silva, 1987; Costello et al.,
1988). Among clinic-referred children, rates of depression are significantly
higher – approximately 13–15% meet diagnostic criteria for depression
(Kashani, Cantwell, Shekim, & Reid, 1982; Kazdin, French, Unis, & EsveldtDawson, 1983). Among adolescents, depressed mood is a very common
occurrence with approximately 40–80% of adolescents reporting feelings of
misery and depression (Kashani et al., 1987; Rutter, Tizard, & Whitmore,
1970; Gotlib, Lewinsohn, & Seeley, 1995). The prevalence of clinical mood
disorders in adolescents is also more elevated than in children, with rates of
major depressive disorder (MDD) and dysthymia approaching 3–5%
(Kashani et al., 1987). Importantly, although there appear to be no gender
differences in the rates of mood disorders among younger children, rates of
depression increase dramatically among girls as they approach early adolescence. Among adolescents, the prevalence of MDD in girls is nearly twice as
high as that of adolescent boys (e.g., 3.8% for girls versus 2.0% for boys;
Lewinsohn et al., 1993).
Although early onset MDD may represent a more serious form of affective
illness (Kovacs, 1996), the presentation of MDD in children is very similar to
that of adults. Children with depression experience significant impairments in
psychosocial functioning (e.g., Gotlib & Hammen, 1992; Lewinsohn, Clarke,
& Rohde, 1994) including lower peer status and impaired social functioning
(Cole, 1991; Hops, Lewinsohn, Andrews, & Roberts, 1990; Larson, Raffaelli,
Richards, Ham, & Jewell, 1990; Shah & Morgan, 1996; Wierzbicki &
McCabe, 1988) and may be more vulnerable to the effects of subsequent
Aude Henin, Melissa Warman, and Philip C. Kendall
stressful life events (Asarnow, Carlson, & Guthrie, 1987), and suicidality
(Andrews & Lewinsohn, 1992). Depression in youth is associated with a high
rate of comorbid conditions, most notably, anxiety disorders, substance
abuse, and conduct disorders (Brady & Kendall, 1992; Lewinsohn et al.,
1993; Strauss, Last, Hersen, & Kazdin, 1988). Furthermore, the families of
these children are marked by lower family cohesion (Garrison, Jackson,
Marsteller, McKeown, & Addy, 1990) and negative parent–child interactions
(Cook, Asarnow, Goldstein, Marshall, & Weber, 1990; Dadds & Barrett,
Supporting the downward extension of adult models of depression (e.g.,
Abramson, Seligman, & Teasdale, 1978; Beck, 1967, 1976), the cognitive processing of depressed children is characterised by distortions in attributions,
self-evaluations, and information-processing. Depressed children tend to
attribute failure to internal, stable, and global causes and successes to external, transient, and specific causes. They distort experience in a manner
consistent with a negative view of the world (Curry & Craighead, 1990;
Kaslow, Stark, Prinz, Livingston, & Tsai, 1992; Joiner & Wagner, 1995) and
display information-processing errors such as catastrophising the consequences of negative events, and selectively attending to the negative features
of events (Kendall & MacDonald, 1993; Leitenberg, Yost, & Carroll-Wilson,
1986). The self-perceptions and self-evaluations of depressed children reflect
these information-processing distortions. For example, depressed youth set
more stringent standards for their performance, evaluate themselves more
negatively, and tend to self-reinforce less than their non-depressed peers
(Kaslow, Rehm, & Siegel, 1984; Kendall, Stark, & Adam, 1990; FlannerySchroeder et al., 1996).
Most CB treatment interventions contain multiple components designed to
address the diverse range of possible contributing factors to the depression.
CB models for the treatment of childhood depression adapt strategies from
adult CB treatments (Hops & Lewinsohn, 1995; Stark & Kendall, 1996) and
integrate cognitive restructuring techniques, social skills training, self-control
skills, and traditional behavioural techniques into a comprehensive treatment package. Although these various components are taught in a logical,
additive sequence, flexibility in the treatment programme is maintained so
that the components of the treatment programme reflect the particular concerns of the child or adolescent. The central goal of therapy is to help the
child recognise his/her depressotypic beliefs and causal attributions
(Lewinsohn et al., 1996; Stark & Kendall, 1996) to help him/her adopt an
active role in influencing his/her moods.
Cognitive procedures (Beck, Rush, Shaw, & Emery, 1979) such as cognitive
restructuring are employed to modify the child’s thinking and to foster more
adaptive information-processing. The therapist and child work together to
recognise maladaptive cognitions and irrational beliefs, which are then
challenged and evaluated (Beck et al., 1979). The therapist monitors the
Cognitive behavioural therapy with children and adolescents
child’s speech throughout the session for evidence of depressogenic thinking
and explores the context in which the thought occurs. The therapist and
child then collaborate in exploring alternative, more realistic interpretations
(Stark, Brookman, & Frazier, 1990). To enhance this skill, the child is given
examples of other depressogenic cognitions for which he or she must practise developing constructive coping responses (Stark et al., 1990). Similarly,
the relationship between the child’s tendency to make unrealistic causal
attributions and his/her depressed mood is examined with reattribution
training. Maladaptive causal attributions for events are challenged in an
effort to demonstrate that the interpretation of events is within the child’s
Given the difficulties experienced by depressed children with self-reinforcement, training in self-control skills (i.e., self-monitoring, self-evaluation
and self-reinforcement) is emphasised. Children are taught to self-monitor or
observe their own behaviour to serve both as a means of assessment and as a
means of developing accurate, more positive self-appraisals. In self-evaluation
training, children are instructed to set realistic expectations for their performance, to critically examine their depressotypic beliefs, to evaluate themselves
less negatively, and to develop the necessary skills to improve their performance. Finally, self-reinforcement is emphasised to help children learn to
reward themselves for accomplishing relevant tasks, and to punish themselves less frequently (Hops & Lewinsohn, 1995; Stark et al., 1990).
In addition to these cognitive techniques, a number of behavioural procedures are incorporated into the treatment including (a) activity planning to
increase the frequency of pleasurable activities, (b) assertiveness training and
conflict resolution, (c) social skills training (conversation skills, planning
social activities, strategies in initiating and maintaining friendships, and dealing with conflict), (d) future planning (teaching the child to use his or her
newly acquired skills to anticipate and prepare to cope with future problems
and prevent relapse), and (e) anxiety reduction techniques such as relaxation
and imagery training (Hops & Lewinsohn, 1995; Nezu, Nezu, & Perri, 1989;
Stark et al., 1990.
Several outcome studies have documented the efficacy of CB treatment for
depressed youth (e.g., Reynolds & Coats, 1986; Stark, Brookman, & Frazier,
1990; Stark, Reynolds & Kaslow, 1987). Lewinsohn and his colleagues (i.e.,
Lewinsohn, Clarke, Hops, & Andrews, 1990; Lewinsohn, Clarke, & Rhode,
1994; see Lewinsohn et al., 1996 for a review) have developed a manualised
CB treatment for depressed adolescents: the Adolescent Coping With
Depression course. In one clinical trial, 59 adolescents diagnosed with MDD
or intermittent depression (DSM-III) were assigned to either group treatment (GRP), group treatment with a concurrent parent group treatment
(GRP + parent), or waitlist. Treatment consisted of a 16-week protocol
including social skills training, negotiation, and problem-solving compoents.
Results indicated that adolescents in both treatment conditions evinced
Aude Henin, Melissa Warman, and Philip C. Kendall
significant changes across dependent measures (e.g., Beck Depression
Inventory) from pre- to post-treatment (no significant differences were found
between the treatment conditions). Importantly, 46% of treated participants
(versus 5% of waitlist controls) no longer met criteria for an affective disorder at post-treatment (Lewinsohn et al., 1990).
A second clinical trial replicated the findings of the first: the two treatments did not differ significantly but both resulted in significant changes in
self-reported levels of depression and percentages of children no longer meeting diagnostic criteria. In this study, 65% of the adolescents in the GRP
condition and 69% in the GRP + parent condition (versus 48% of the waitlist) no longer met DSM criteria for depression at post-treatment (Lewinsohn
et al., 1994).
When compared with other treatment approaches, CB treatment appears
to be more successful in treating adolescent depression. In a study directly
comparing CBT to a traditional counselling programme, the CB treatment
led to greater improvements in depression and reductions in depressive thinking (Stark, Rouse, & Livingston, 1991). CBT has also demonstrated
superiority in reducing adolescent depression, as compared to a relaxation
training programme (Wood, Harrington, & Moore, 1996). Kahn, Kehle,
Jenson, and Clark (1990) compared the efficacy of various psychological
interventions (i.e., CBT, relaxation training, self-modelling) to a waitlist control group and reported that although all three treatment groups evidenced
significant gains on a number of paper-and-pencil assessments at posttreatment, the CB therapy and relaxation training modalities exhibited the
greatest benefits. Additional studies assessing the relative efficacy of CB
therapy, systemic-behavioural, and non-directive supportive treatments for
suicidally depressed youth are currently under way (Brent et al., 1996).
Given the success of CB interventions in the treatment of depressed youth
and the increased risk for depression among youth with elevated depressive
symptomatology, work has been directed toward developing preventative
interventions. Clarke et al. (1995) developed the “Coping with Stress Course”
consisting of group sessions in which at-risk adolescents are taught cognitive
techniques to identify and challenge negative, irrational thinking. One hundred and seventy-two adolescents identified as at-risk for future depressive
episodes were assigned to either the prevention intervention or a usual-care
control condition (participants were free to continue with any pre-existing
interventions). Results indicated that adolescents receiving the cognitive
group intervention were less likely to develop clinical depression, displaying
an incidence of depressive disorder of 14.5% over a 12-month period versus
25.7% for the control condition. These findings support the use of CB interventions in the prevention of depression but, as the authors note, the rates of
affective disorder in the treatment condition were still greatly elevated
(approximately twice the rate in the general population). As suggested by a
recent study of a manualised, psychoeducational programme, prevention
Cognitive behavioural therapy with children and adolescents
efforts which link cognitive strategies to family life experiences, for example
by targeting family communication and parental understanding of depression, may also serve to increase behavioural and attitudinal change and help
produce long-term changes in depressive symptomatology (Beardslee et al.,
The long-term effects of CB therapy for depressed children have received
somewhat mixed support. Although several studies have shown maintenance
of treatment gains over short-term follow-up periods of 4 to 8 weeks (e.g.,
Kahn et al., 1990; Reynolds & Coats, 1986; Stark et al., 1987), longer-term
assessments have yielded inconsistent results. For example, Stark et al. (1991)
noted that some treatment gains were not maintained at 7-month follow-up.
Conversely, Lewinsohn et al. (1994) reported an increase in the rate of recovery over a 2-year follow-up period for depressed adolescents who received CB
treatment. For example, 81.3% of adolescents receiving CB treatment had
recovered at 12-months post-treatment, and 97.5% had recovered at 24
months. Although recent studies have suggested that CBT may also be successfully applied to relapse-prevention (Gillham, Reivich, Jaycox, &
Seligman, 1995; Kroll, Harrington, Jayson, Eraser et al., 1996), these inconsistent results point to the need for a greater understanding of the individual
and contextual factors that may place depressed youth at risk for relapse
(Sanford, Szatmari, Spinner, Munroe-Blum et al., 1995).
Aggressive behaviour in youth
Although most children occasionally display aggressive behaviour, concern
about the aggression arises when it is severe and frequent or occurs across
multiple settings. Aggression in children is predictive of subsequent aggression and maladjustment (Wilson & Marcotte, 1996), with these children
evincing increased levels of peer rejection (Coie, Dodge, & Coppotelli, 1982),
drug use and difficulties in school. The impact of aggression on family life is
highlighted by the finding that one-third to one-half of all child treatment
referrals by parents or teachers are for aggressive behaviours (Patterson,
Reid, Jones et al., 1975). With regard to the long-term effects, aggression
tends to remain stable over time (Dumas, Neese, Prinz, & Blechman, 1996;
Fergusson, Lynskey, & Horwood, 1996; Olweus, 1984) and has been associated with adult antisocial behaviours, marital discord, and subsequent
familial transmission (Eron, Huesmann, Dubow, Romanoff, & Yarmel, 1987;
Huesmann & Eron, 1984; Huesmann, Lefkowitz, Eron, & Walder, 1984;
Olweus, 1979).
Although there is evidence to suggest that biological forces may impact the
expression of aggression in children (Bates, Bayles, Bennett et al., 1991;
Brennan, Mednick, & Kandel, 1991; Pincus, 1987; Raine, Brennan, &
Mednick, 1994; Tremblay, Pihl, Vitaro et al., 1994), the cognitive behavioural
approach has proven useful in both conceptualisation and treatment of
Aude Henin, Melissa Warman, and Philip C. Kendall
childhood aggression and conduct disorder. As in other disorders, it is the
child’s appraisal and expectations of the environment that are believed to
mediate the connection between environmental events and anger arousal
(Kendall, Ronan, & Epps, 1991). In particular, Dodge’s (1980, 1986) fivestage model of social information processing has received support in
explaining the distortions and deficiencies that characterise the cognitive processing of aggressive children. The first two steps in Dodge’s model consist of
social-cognitive appraisals in which social cues are encoded, processed and
interpreted (Kendall & MacDonald, 1993; Lochman, White, & Wayland,
1991). The next three stages in the model constitute social problem-solving
and require the generation of potential alternative responses, the evaluation
of probable consequences and selection of the most desirable response, and
the enactment of the chosen response and social behaviour. Aggressive children are believed to experience difficulties at each of these five stages,
resulting in deviant or hostile social behaviours. For example, studies have
demonstrated that aggressive boys attend to fewer relevant social cues than do
non-aggressive boys and demonstrate a bias towards the selective recall of
hostile cues (Dodge & Newman, 1981; Milich & Dodge, 1984). Moreover, the
social processing of these children is characterised by a “hostile attributional
bias” (Milich & Dodge, 1984, p. 472), in which they overestimate the amount
of hostile intent by others in ambiguous interpersonal situations (Milich &
Dodge, 1984; Dodge, 1980; Dodge & Newman, 1981).
With regard to their problem-solving skills, aggressive boys have consistently been shown to generate less mature or verbally assertive, and more
aggressive responses (Deluty, 1981; Lochman & Lampron, 1986; Milich &
Dodge, 1984; Rabiner, Lenhart, & Lochman, 1990; Richard & Dodge, 1982).
Aggressive boys place greater value on achieving control over other children,
value aggression as a legitimate means to obtain tangible rewards or social
dominance, express greater confidence in their ability to aggress, view aggression as increasing self-esteem, and minimise the negative outcomes of
aggression (e.g., victim’s suffering; Boldizar, Perry, & Perry, 1989; Erdley &
Asher, 1996; Huesmann & Guerra, 1997; Perry, Perry, & Rasmussen, 1986;
Slaby & Guerra, 1988). A distinction has been made between reactively and
proactively aggressive children, with boys identified as proactively aggressive
displaying lower adjustment and greater criminality in adulthood (Pulkkinen,
1996). Reactively aggressive boys have also been shown to display inadequate
encoding and problem-solving processing patterns, whereas proactively
aggressive youths tend to demonstrate anticipation of positive outcomes for
aggression and fewer relationship-enhancing goals during social interaction
(Crick & Dodge, 1996; Dodge, Lochman, Hamish, Bates et al., 1997).
Given these difficulties, CB approaches in the treatment of childhood
aggression have focused primarily on teaching social problem-solving skills to
be used in situations where interpersonal conflicts arise. Social skills training
is particularly amenable to group as well as individual treatment. Children are
Cognitive behavioural therapy with children and adolescents
taught a series of problem-solving steps to identify environmental social cues,
practise perspective-taking, analyse options in solving interpersonal problems, and consider the consequences of the chosen solutions. Kendall and his
colleagues (Kendall, 1992; Kendall & Braswell, 1982, 1985, 1993) have
described a programme for impulsive children that presents social problemsolving steps as self-instructions to “Stop and Think”. Children are
encouraged to: (a) define the problem, “What can I do?”; (b) approach the
problem, “I have to look at all the possibilities”; (c) focus their attention, “I’d
better concentrate and focus and think only of what I’m doing now”; (d)
select an answer, “I think it’s this one”; and (e) reinforce themselves, “I did a
good job”. Coping self-statements are also employed when children experience difficulty applying the steps or arrive at undesirable solutions (for
example, “Next time I’ll try to go slower and maybe I’ll find a more positive
solution”). To promote the generalisation of skills outside of the sessions, the
“Stop and Think” steps are individualised for each child, in that the child
works together with the therapist to develop personally meaningful coping
self-statements. Recently, Kazdin and his colleagues (Kazdin, Bass, Siegel, &
Thomas, 1989; Kazdin, Esveldt-Dawson, French, & Unis, 1987) have integrated Kendall and Braswell’s (1982, 1985) approach with earlier work by
Spivack and Shure (1974) into a more comprehensive treatment package for
aggressive children.
Behavioural contingencies are a particularly important feature of the CBT
programme given the frequent aversiveness of aggressive children’s behaviours. Thus, in addition to self-evaluation and self-reward both inside and
outside the session, emphasis is placed on social rewards such as praise or
encouragement from the therapist. A response-cost contingency may be
implemented whereby “points” are earned by the child for accomplishing
various in-session tasks, or are lost for failing to perform these tasks (e.g.,
answering task questions incorrectly, going too fast). The points can then be
exchanged for a small prize or reward at the end of the session. Time-out and
seclusion contingencies may also be incorporated into the treatment to
manage uncontrollable behaviours (Kazdin et al., 1987).
In addition to social problem-solving skills training and behavioural contingency training, affective education has been incorporated into several CBT
treatment packages. For example, Lochman and colleagues have developed
the Anger Coping Program (Lochman, Lampron, Gemmer, Harris, &
Wyckoff, 1989) and Nelson and Finch (1996) have designed the “Keeping
Your Cool” workbook, to teach children to identify physiological and affective cues and environmental precipitants of anger arousal. Children are aided
in the recognition and labelling of their emotional experiences and are
instructed in self-monitoring/self-control strategies such as self-talk.
Videotapes of children applying the coping strategies are employed to provide
a model of awareness of physiological reactivity and to exemplify problemsolving strategies. Feindler (1991) has elaborated a similar programme,
Aude Henin, Melissa Warman, and Philip C. Kendall
including arousal management, cognitive restructuring, and problem-solving
and prosocial skills training components. Relaxation training and visual
imagery may be introduced as an additional means of controlling physiological arousal, and the application of these various strategies in difficult
interpersonal situations is emphasised and rehearsed in session (Baum, Dark,
McCarthy, Sandier, & Carpenter, 1986; Feindler, Ecton, Kingsley, & Dubey,
1986; Garrison & Stolberg, 1983).
The application of standardised CB treatments to aggressive youth has
been supported by the findings of several programmatic research efforts.
Lochman and colleagues have demonstrated the efficacy of their “Anger
Coping Program” with aggressive children (Lochman, 1992; Lochman,
Burch, Curry, & Lampron, 1984; Lochman & Lenhart, 1993; Lochman,
Nelson, & Sims, 1981). Similar treatment effects have been reported for clinical samples of aggressive children. For example, Kazdin and his colleagues
examined the effectiveness of problem-solving skills training with psychiatric inpatient children referred for antisocial behaviours (Kazdin et al., 1987,
1989). Results indicated that children receiving the problem-solving skills
training treatment displayed greater decreases in externalising and aggressive
behaviours, and increases in prosocial behavioural and overall adjustment,
than did children in the control condition or children receiving non-directive
relationship therapy (Kazdin et al., 1987a). The efficacy of social cognitive
interventions in reducing aggression and increasing socially appropriate
behaviours has also been demonstrated with behaviourally disordered adolescents (Etscheidt, 1991), conduct-disordered youths attending a day
treatment programme (Kendall, Reber, McLeer, Epps, & Ronan, 1990), incarcerated juvenile delinquents (Hawkins, Jenson, Catalano, & Wells, 1991), and
male adolescents hospitalised at psychiatric facilities for behaviourally disordered youth (Feindler et al., 1986; Maag, Parks, & Rutherford, 1988).
Although CBT’s emphasis on cognitive and social problems appears to be
a promising approach, the evidence for its effectiveness with aggressive young
people has not been entirely supportive. In particular, the short-term success
of CBT in the treatment of aggressive children has been tempered by difficulties with generalisation of treatment effects and persistently elevated levels
of disruptive behaviours in normative comparisons. For example, long-term
follow-up assessments suggest that decreases in aggressive or delinquent
behaviours are often not maintained over time (Kazdin, 1987a; Kendall &
Braswell, 1985; Lochman, 1992) or are not generalised across situations (e.g.,
classroom behaviours; Baum et al., 1986; Lochman, Burch, Curry, &
Lampron, 1984). Moreover, although treated children may display improvements in the social-cognitive processes believed to mediate aggressive
behaviours, these do not always translate into decreases in observable aggression (Camp, Blom, Herbert, et al., 1977; Coats, 1979). Similarly, treated
children may demonstrate positive changes on some measures of aggression
(e.g., disciplining for fighting) or improvements in interpersonal skills, while
Cognitive behavioural therapy with children and adolescents
evidencing little or no change on other measures of aggressive behaviour
such as teacher ratings (Baum et al., 1986; Garrison & Stolberg, 1983;
Kettlewell & Kausch, 1983; Lochman et al., 1991).
These potential limitations with child-focused CB treatment have prompted
investigators to examine the child and therapy variables that may impact treatment efficacy. For example, Lochman and his colleagues have found that
longer treatment (i.e., 18 weeks versus 12 weeks) and higher initial levels of disruptive or aggressive behaviours may be associated with greater decreases in
aggression at post-treatment (Lochman, 1985; Lochman, Lampron, Burch, &
Curry, 1985). Although these studies represent a first step, they point to the
need for a greater understanding of the various client characteristics that can
impact treatment and underscore the need for a flexible treatment approach.
It may also be that short-term, child-focused interventions are not the
optimal solution for aggressive young people, and that CBT may need to
add a focus on the familial variables implicated in the development and maintenance of antisocial behaviour in children (Patterson, 1982). Additionally,
there has been a failure to consider the larger societal context in the expression of disorder (Staub, 1996). Adopting a broader-based treatment strategy
in which social-cognitive training interventions are integrated within a family
or societal framework may result in greater generalisation or maintenance of
treatment effects (Estrada & Pinsoff, 1995; Kazdin, 1987b). Although CBT
has consistently demonstrated greater treatment effects than parent-focused
treatments alone, recent studies have suggested that a combined treatment
approach may be particularly effective (Frankel, Myatt, & Cantwell, 1995;
Kazdin et al., 1987). Children receiving CBT in combination with parenttraining tend to display greater improvements in family interactions than
those receiving CBT alone, and maintenance of these improvements at
follow-up (Webster-Stratton, & Hammond, 1997). Parents participating in
family-based interventions may also directly benefit from treatment by themselves experiencing attitudinal changes and by improving their child
management skills (Estrada & Pinsof, 1995).
Given that children with aggressive behaviours often evince a range of
behaviour problems, as well as concomitant academic and emotional difficulties or family dysfunction, a multifaceted treatment approach combining
child-focused CBT with academic tutoring, parent management training
and/or family therapy, and medication may be recommended (SouthamGerow et al., 1997). Ideally, treatment could intervene in multiple settings,
including the home, school, peer group, and community (Miller & Prinz,
1990). In addition, interventions aimed at parents’ own problems may represent another useful component to the treatment of antisocial young people.
At this time, few studies have systematically evaluated an integrative treatment approach, although some investigators have reported promising
findings (Frankel et al., 1995; Henggeler, Melton, & Smith, 1992; Horn &
Sayger, 1990; Kazdin, Siegel, & Bass, 1992; Webster-Stratton, 1994).
Aude Henin, Melissa Warman, and Philip C. Kendall
In addition to a multisystemic treatment approach, some researchers,
noting the stability of aggression across the lifespan, have advocated a
“chronic disease” model for the antisocial or aggressive child (Kazdin, 1987b,
1993; Miller, London, & Prinz, 1991; Tolan, Guerra, & Kendall, 1995; Wolf,
Braukmann, & Ramp, 1987). Such a model may increase treatment efficacy
by emphasising preventative efforts for at-risk young people, and may provide
the most cost-effective way for society to deal with the potentially chronic
nature of antisocial behaviour. Such programmes, which often emphasise
interpersonal relationships, limit-setting and problem-solving, have been
implemented with inner-city children and adolescents with behavioural or
academic problems (Spivack & Shure, 1974). Results have been positive
though preliminary. Further research is required to clarify the long-term
impact of such a community-based approach.
Attention-deficit hyperactivity disorder (ADHD)
ADHD represents one of the most common reasons for a child’s referral to
a clinic or school psychologist, affecting approximately 3 to 5% of children
(Szatmaris, Offord, & Boyle, 1989). In addition to the three core symptom
clusters of inattention, impulsivity, and hyperactivity (American Psychiatric
Association, 1994; Anastopoulos & Barkley, 1992), children with ADHD
often evince a number of associated difficulties, including (a) academic underachievement; (b) cognitive and language performance deficits; (c) inconsistent
task performance; (d) limited performance in rule-governed situations; (e)
impaired social functioning in peer and family settings; (f) comorbid behaviour problems like conduct disorder (CD) and oppositional defiant disorder
(ODD); and (g) comorbid internalising disorders like generalised anxietydisorder (GAD) and depression (Anastopoulos & Barkley, 1992; August,
Realmuto, MacDonald, Nugent et al., 1996; Barkley, 1990; Biederman,
Faraone, Milberger, & Guite, 1996b; Erhardt & Hinshaw, 1994; Frederick &
Olmi, 1994; Hinshaw, 1987, 1992; Kendall, 1994; Landau & Moore, 1991;
Pennington, Groisser, & Welsh, 1993; Wilson & Marcotte, 1996). Although
the disorder must be present before age 7 to be diagnosed, ADHD typically
follows a chronic course, often persisting into adolescence. Historically
ignored, diagnoses of ADHD in adulthood are increasing (Barkley, 1990;
Biederman, Faraone, Milberger, Curtis et al., 1996a; Wender, 1987).
CBT initially appeared to be a theoretically-consistent treatment option to
address the numerous cognitive and behavioural difficulties associated with
ADHD. Several CB packages such as the “Stop and Think” treatment programme designed by Kendall and Braswell (1982, 1985) were applied to
address these children’s difficulties in rule-governed situations, impulsivity,
and socially-related problems. As noted above, these interventions typically
emphasise rewards and response-cost contingencies, modelling of problemsolving strategies, affective education, homework tasks, self-evaluation
Cognitive behavioural therapy with children and adolescents
training, perspective-taking activities, and ample in-session and extra-session
practice of these skills (Kendall & Reber, 1987). The overarching goal lies in
assisting children in the application of problem-solving to reduce impulsive
behavioural responses and promote consideration of alternative, more adjustment-enhancing responses. The restless nature of children with ADHD
requires less didactic, more action-oriented sessions, in which skills are
modelled and practised “on-the-run”. (Meichenbaum & Goodman, 1971;
Southam-Gerow et al., 1997).
Despite initial enthusiasm, outcomes of the CBT approach have been
somewhat disappointing. Although CBT appears to be most effective in
addressing certain features of ADHD such as impulsivity, changes in the
other important symptoms of ADHD have been modest, at best. In addition,
early studies documenting success of CB interventions typically treated nonclinical samples of impulsive children, limiting their generalisability to an
ADHD population (Kendall & Braswell, 1985; for review, see Baer & Nietzel,
1991). Other studies using clinical samples have documented limited success
(Abikoff, 1991; Abikoff & Klein, 1987; for a review, see Miller, 1994).
A reason for the limited success of CBT may lie in the heterogeneity of the
problems displayed by children who receive the diagnosis of ADHD. ADHD
has a high rate of comorbidity with a wide range of both internalising and
externalising disorders (e.g., ADHD and CD occur in tandem from 30% to
50% of the time in clinical samples; Biederman, Newcorn, & Sprich, 1991;
Hinshaw, 1992), as well as learning difficulties and substance abuse, leading
several researchers to question the existence of an “independent” ADHD
(Abikoff, 1991; Hinshaw, 1987).
As with aggression in youth, comorbidity figures imply that interventions
with a highly restricted focus may not be best suited to address the multiplicity
of problems accompanying the diagnosis of ADHD. CBT has demonstrated
efficacy for impulsivity in children and perhaps may be indicated when impulsivity plays a primary role in a child’s dysfunction. Additional approaches may
need to be integrated within the treatment protocol to address supplementary
issues. CBT has demonstrated success with other childhood disorders such as
anxiety (Kendall, 1994; Kendall et al., 1997); thus it may be advantageous to
include these treatment strategies when working with a child with both ADHD
and anxiety. Failure of any treatment approach to recognise the diversity of
ADHD youth will likely result in limited success.
Poorer outcomes may also be, in part, attributable to the failure of CBT to
address issues of inattention in the treatment of young people with ADHD.
The attentional deficits present in most children with ADHD mean that their
ability to learn, apply, and generalise problem-solving skills may be greatly
limited. Early treatment gains may fail to generalise outside the therapy room
where strict contingencies are not in place. In fact, no extant treatment can
claim comprehensive change in the multiple domains of problems evidenced
in many ADHD children (Southam-Gerow et al., 1997).
Aude Henin, Melissa Warman, and Philip C. Kendall
The limited success of CBT alone, and the demonstrated success of medications like methylphenidate and imipramine (for a review see Spencer,
Biederman, Wilens, Harding, et al., 1996), has led to the combining of CBT
with medications in the treatment of ADHD (Whalen & Henker, 1991).
Medication can manage the symptomatic behaviour of ADHD children
and conceivably, the implementation of CBT along with medication could
lead to increased treatment efficacy. The increased attentional ability and
task persistence of children receiving medication may increase their ability
to acquire the skills taught in CB interventions. Moreover, integrating these
two treatment approaches may enable lower doses of medication to be as
effective as higher doses of medication alone, possibly reducing the likelihood of undesirable medication effects (e.g., increases in tic behaviour or
sleep disturbances; Horn, Ialongo, Pascoe et al., 1991). Finally, the combination of CB and medication may lead to improvements in areas that have
not been demonstrated when the therapies are used separately. For example,
although medication may be successful in increasing attentional capacity,
gains in academic domains and social problem-solving have not been
demonstrated. Ostensibly, CBT addresses these areas (Southam-Gerow et
al., 1997).
Unfortunately, results of some combined interventions have not been as
strong as hoped. Although a two-case study analysis provided evidence for the
possibility that combined interventions may allow lower doses of medication
(Abramowitz, Eckstrand, O’Leary et al., 1992), other studies have failed to
find increased efficacy of a combined intervention (Brown, Wynnen, &
Medenis, 1985; Hinshaw, Henker, & Whalen, 1984; Nathan, 1992). In a largescale randomised clinical trial (n = 96), Horn and colleagues (1991)
investigated the effects of a combined intervention including methylphenidate,
child-focused CBT (based on Camp & Bash, 1981; Kendall & Braswell, 1982;
Meichenbaum, 1977), and a behavioural parent-training programme (Barkley,
1981; Forehand & McMahon, 1981; Patterson, 1976). Similar to Abramowitz
et al.’s (1992) findings, lower doses of methylphenidate in combination with
the psychosocial interventions led to gains equivalent to those achieved by
higher doses of medication alone. However, no evidence was found for the
superiority of the combined treatment relative to medication alone. Overall,
the extant results led Anastopoulos and Barkley (1992) to conclude that
“despite the intuitive appeal of [combined interventions] . . . there presently
exists little empirical justification for utilising such combinations”. (p. 425).
These findings suggest that simple linear models of ADHD must be
replaced by models that do not rely on single causal explanations. Such multimodal approaches are found in the combination of parent-training
approaches with medication and child-focused CBT (Horn et al., 1987;
Sheridan, Dee, Morgan, McCormick et al., 1996), and the use of group(Braswell, 1993) and school-based (Bloomquist, August, & Ostrander, 1991)
interventions. Parent- and school-based interventions in particular have
Cognitive behavioural therapy with children and adolescents
theoretical importance. Given the ADHD child’s self-regulation difficulties,
consistent, firm, and loving environmental regulation may enhance a child’s
ability to self-regulate. This possibility may be further enhanced by the use of
medication. Additionally, future designs could also consider the peer-related
difficulties demonstrated by ADHD children. Although these children appear
to “know” appropriate social skills, they tend not to exercise those skills
(Landau & Moore, 1991). Given the importance of peer relations in development and adjustment, and the demonstrated peer-relations disturbances of
ADHD children, remedies along this line are sorely needed (Erhardt &
Hinshaw, 1994; Parker & Asher, 1987).
Moving forward
The internal workings of CBT with youth have been developed and
advanced – they are developmentally sensitive, include age-appropriate materials (e.g., workbooks) and have empirical support documenting that the
treatment can be efficacious in reducing symptomatology. The efficacy is not
universal, however, as some disorders are more and others less responsive to
the treatment. In contrast, the external or contextual forces that influence
treatment outcomes require additional attention. Clinical implementation
and research evaluation are needed to assess (a) the merits of increased
family/parent involvement; (b) the factors that moderate the benefits of
family/parent involvement; (c) the role of peers and the school settings; and
(d) the use of groups and systems interventions. In one sense, CBT is ready to
move forward on the road from treatment development and evaluation to
community applications with evaluations of effectiveness.
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abandonment 56, 179, 206, 219, 224;
fears related to 225
Abrahms, L. 248
Abramowitz, A. J. 298
Abramowitz, J. S. 125
abuse 207, 216; alcohol 84, 220; child 51;
emotional 231; laxative 174, 176,
183–4, 185; physical 231; sexual 30,
88, 231, 286; substance 7, 9, 10, 55, 73,
84, 220, 223, 225, 280, 288
acceptance 189, 207
accidents 56, 127
accomplishment 20, 282, 289
Achenbach, T. M. 279
Activity Charts 20–1
AD (avoidant disorder) 282, 283, 287
adaptation 181; false-self 179; metabolic
adaptiveness 5, 11, 14, 15, 17, 19, 23, 29,
110, 194; increasing 157; ways of
handling anger 64; see also RAR
addiction 90
adequacy 26
ADHD (attention-deficit hyperactivity
disorder) 279, 280, 296–9
adjunctive techniques 102
adolescents 195, 250, 275–313
advantages 18, 62, 63, 164, 255
aetiology 73, 175, 184
affect modulation 73, 85–6
affection 8, 225, 255
affective instability/illness 223, 287
agenda setting 14–16, 107
aggression 225, 276, 279, 291–6, 297
agitation 89
agoraphobia 97–8, 100, 102, 105, 108,
116, 118, 286; severe 104
agreements 63
alcohol 7, 57, 73, 76, 84, 220
Alcoholics Anonymous 36, 55
altruism 84
amenorrhoea 173
analgesics 73, 76
analytic psychotherapy 168
Anastiades, P. 103
Anastopoulos, A. D. 298
anger 64–5, 72, 78, 80, 99, 133, 153, 245;
anxiety and 237; awareness of own
207; lack of control of 224; selfdirected 219; validated 88; vicious
blaming cycle propelled by 248
Anger Coping Program 294
Angry Child mode 219
anorexia nervosa 173–4, 175, 176–7,
177–8, 179, 193; adaptation of
standard procedures for 181; body
weight 184, 185, 191; common
problem in 189; family therapy in
194–6; self-monitoring 186
anti-convulsants 71
anticipation 100, 102, 247
antidepressants 52
antisocial behaviour 276, 291, 295, 296
anxiety 57, 65, 72, 97, 106, 111, 131, 186;
absence of 75; anger and 237;
anticipatory 102; associated with
memories and cognition 204;
automatic thoughts and 115;
childhood 279, 281, 282–3, 284, 285,
297; chronic 163; cognitive distortions
thought to underlie 276; cognitive
therapy effective for 202; common
denominator across disorders 129,
130; controlling 109, 155; elevated 99,
100; extreme 230; general 105, 117,
118; heightened 110; high levels 22,
anxiety, continued
225; induction of 112–13, 116; mild to
moderate 98; non-dangerous nature of
109, 110; non-patholog- ical 110;
reducing 107, 155, 156, 289; relapse
prevention 220; relieved 58; schemas
activated by 236; self-regulation of
110; separation 276; shifts from
baseline mood to 224; symptoms
98–100, 103; youth 280–7; see also
AD; eating disorders; GAD; OAD;
APA (American Psychiatric Association)
37, 97; see also DSM-III
appraisals 117, 128, 129, 130, 131, 132,
204, 292; beliefs/assumptions
underlying 142–3; catastrophic 99;
certainty 141; cognitive 196;
identifying 133–7, 143, 144;
idiosyncratic 145; inaccurate 244;
likelihood thought-action fusion
138–9; responsibility 137–8, 139–40,
142; self 289; threatening 106, 127
apprehension 98, 151
approval 207, 219, 250
Arntz, A. 104, 129, 137, 140, 143, 144
arousal 83, 85; anger 292, 293;
autonomic 110; physiological 98, 115,
281, 293
arterial pressure 110
asceticism 191
assertiveness training 289
assessment: depression 9; personality
disorders 210–12; relationships
249–55; scientific 165; suicidal risk 51,
associative therapy 104
assumptions 12, 13, 61, 111, 181, 227,
252; core 196; dysfunctional 194, 196;
faulty 182; problematic 249;
underlying 16, 142–3, 188, 204, 205,
246; vague 192
ATs (automatic thoughts) 11, 18, 20, 25;
accessing 204, 227; anticipated
outcome of 245–6; anxiety and 115;
dispelling and reframing 262–3;
dysfunctional 12, 262; effect of
believing 24; eliciting 108; fairly
accurate 17; identifying 22, 188,
259–60; linking emotions with 260–1;
logic and themes of 244; negative 28,
116, 117; obvious 23; responding to
108, 115, 117; situations that trigger
117; situation-specific 12; social
embarrassment 35; spouses/partners
244, 257; tracing 245; underlying
schemata behind 252
attention 55, 85, 207, 225; selective 114,
139; self-focused 100; see also ADHD
attitudes 179, 180, 194, 251; all-ornothing 81; characteristic 176;
extreme 189; negative 71, 253; selfdestructive 178; underlying 17–18; see
also Dysfunctional Attitude Scale
attributions 252, 267, 277; causal 248–9,
251, 278, 288, 289; responsibility 251
autonomic nervous system 155, 281
autonomy 80, 82, 205, 250; conflicts over
191; impaired 207
auxiliary therapists 67
avoidance 97, 98, 103, 104, 112, 113–14,
204, 225; agoraphobic 100, 105, 109,
116; anxiety maintained via 167;
behavioural 165, 211, 217; behaviours
that reduce 107; cognitive 165, 211;
decreased 236–7; effective 204; phobic
106; risk 190; schema 206, 209, 211,
219; subtle 111
awareness 201, 211, 277, 293;
interoceptive 193; self 74, 191
Axis I disorders 9, 151, 201, 204, 227,
235, 236
background information 9
Baer, R. A. 297
BAI (Beck Anxiety Inventory) 113
Barkley, R. A. 298
Barlow, D. H. 105, 118
Barrett, P. 284
Baucom, D. H. 249, 250, 251, 252, 268,
269, 270
BD (bipolar disorder) 4, 71–96
BDI (Beck Depression Inventory) 10,
33, 53–4, 290
Beck, A. T. 4–5, 12, 36, 66–7, 98, 102–3,
108, 109, 118, 178, 181, 201, 202, 204,
229, 243, 244–5, 252; see also BAI;
BDI; BHS; cognitive triad; DAS;
Dysfunctional Attitude Scale
Beck, J. S. 6–7, 22, 36; see also DTRs
behavioural exercises 190, 193, 217
beliefs 26, 57, 87, 106, 142–3, 188, 216;
adaptive 19, 27, 32; alternative 91,
247, 263; articulation of 189; assessed
111; catastrophic 116; challenging
190; conditional 227; depressotypic
288, 289; distorted 179, 246–7;
experiential testing of 12; explicit
emphasis on 181; irrational 243, 288;
multi-level 196; nascent positive 26;
negative 49, 214; problematic 90;
reframing 92; relationship 245–6; tools
to use to change 131; unconditional
226; underlying 10, 246, 248, 260, 261;
unrealistic 243, 244, 250; verbalised
31–2; see also core beliefs;
dysfunctional beliefs
Bemis, K. M. 192
benign restrictions 82
Benjamin, R. S. 280
benzodiazapines 97, 105
Berchick, R. J. 102–3
BHS (Beck Hopelessness Scale) 10, 33,
biases 77, 81–2, 106, 246, 257; hostile
attributional 292; negative 72
bibliotherapy 16, 77
binge eating 174, 177, 178, 182, 184, 185,
186, 193, 223; affective and
interpersonal antecedents of 179;
consuming without 190; education
about 183; elimination of 176;
inoculation against 187; issues that
can lead to amelioration of 180; urges
biochemical factors: abnormalities 71,
89; changes 74; dyscontrol 73;
homeostasis 73; manipulations 97
biology 97, 291
bipolar disorder see BD
Birbaumer, N. 111
Birchler, G. R. 252
blame 248, 251; self 7, 11, 20, 138, 250
blood sugar 110
Blumberg, S. L. 269
blurred vision 112
bodily sensations 98–100, 101, 106, 107,
110, 238; combinations of 113; feared
111, 116, 118; interpretation of 115;
uncomfortable 155
body weight 173, 176, 177, 184–7, 190,
192; attitudes towards 179, 180;
homeostatic regulation of 178; need to
gain 178; permanently lowering 182;
unrealistic standards for 178
booster sessions 103, 118
boredom 57, 219, 224, 225
boundaries 215, 225, 249, 250, 251
Bourne, E. J. 22
BPD (borderline personality disorder)
65, 208, 219, 223–41
Bradbury, T. N. 251
brainstorming approach 63, 270
Braswell, L. 296
breathing 85, 106, 108; controlled 109,
117; deep and rapid 113;
diaphragmatic 101, 154, 155–8, 277;
retraining 101, 102, 104, 105, 114, 115,
118; see also hyperventilation
breathlessness 113
Brown, G. K. 118
Brown, T. A. 105
Bruch, H. 193
bulimia nervosa 174, 175, 176–7, 178,
193–4; adaptation of standard
procedures for 181; body weight
184–5; educational treatments 182;
self- monitoring 186
Burnett, C. K. 249, 251
caffeine 97, 110
calm 85, 156, 158, 159, 160, 161, 237
calories 183, 184, 186–7
carbon dioxide 97, 105
cardiopulmonary problems 112
Carels, R. A. 251
Carlson, C. I. 251
Carr, A. T. 126, 129
catastrophes 106, 111, 159, 164, 165,
288; expected 245–6; see also
catastrophic misinterpretation;
catastrophic misinterpretation 98,
99–100, 101, 107, 109, 110; degree of
belief in 112, 114, 116, 117;
disconfirming 114; reduction of 117
treatment to correct 105
causal attributions/misattributions
causal factors: depression 5; eating
disorders 175
central nervous system 73; see also
autonomic nervous system;
sympathetic nervous system
Cerny, J. A. 105, 118
certainty 141, 191
Chambless, D. L. 98
chance 129
change 5–6, 129, 152, 209–10, 212–18,
230; affective 13; attitudinal 291, 295;
behavioural 13, 190, 195, 196, 291;
clinically significant 168; cognitive
106, 117; commitment or tolerance for
184; life 55, 80; motivation for 176,
184, 224; positive 14; powerful
leverage for 215; resistance to 176;
schematic 205
channels of input 230–1
character traits 142
characterological disorders 203, 204,
208, 211, 215, 220
checklists 10, 15, 113, 255
chest breathing 155
child abuse 51
childhood/children 205, 211, 214, 245,
250, 252, 275–313; family
interventions 266
choice 57, 58, 60, 207; freedom of 52–3;
rational 59
‘chronic disease’ model 296
Clark, D. A. 98, 99, 101, 102–3, 107,
109, 119, 129
Cochran, S. 92
cognition 32, 57, 195; adaptive 166;
catastrophic 100; depressogenic 289;
dysfunctional 12; interview assessment
of 252; levels of 226–8; maladaptive
288; negative 67, 100; non-functional
278; relationship 249–52
cognitive-affective-behavioural patterns
cognitive distortions 12, 16, 29, 31, 212,
262; cognitive deficiency and 275;
identifying and labelling 255–8
cognitive restructuring 27, 105, 118, 176,
188–91, 267, 268, 277, 278, 288, 293;
initial aim of 178
cognitive therapy 102–4, 161–7, 223–41;
basic rules for homework 17–18;
defining 4–5; emphasis on guided
discovery approach 62; goals for
11–12, 73–87, 190; imagery and 29;
limitations of 202–3; staying power of
therapeutic effects of 92; structure of
86–7; suicidality and 34, 49, 67–8
cognitive triad 49, 72, 87; negative 5
cohesion 251, 288
collaboration 13, 17, 22, 35, 53, 59, 60,
63, 82, 106, 202, 203, 216, 268;
disincentive to 92; facilitated 77
‘collaborative set’ term 248
collapse 106, 110
‘come and go’ style 138
commands 58, 65–6
comments 152
commitment 63
communications training 242, 268, 269
comordic disorders 9, 126, 285, 288, 296,
compensatory strategies/behaviours 7,
174, 178, 188, 212
competence 18, 36, 229, 237
compulsions see OCD
computers 36–7, 269
concentration 75, 87, 88, 150
conceptualisation: anxiety 281; BD 72,
87–9; BPD 225, 226–8, 233–5, 236;
childhood aggression 291; depression
8, 12, 18, 19, 35, 36; eating disorders
195; OCD 132, 133; panic disorder 97,
116, 119; personality disorders 209;
suicidal behaviour 54, 56–9
conditioning 98; aversive 204
conduct disorder 291, 294, 296
confidence 22, 78, 152, 292; lack of 193
conflict avoidance 179, 196
conflicts 27, 250
confrontation 139, 214, 218; empathic 216
confusion 193
constancy 74
constructions 5; dysfunctional 6
constructivist movement 202–3
containment 81
contamination 130, 133, 140
contingencies 293, 297
continuum method 29–31, 34, 139, 142
contracts 63; verbal 91–2
contradictory behaviour 190
coping 7, 12, 26, 27, 57, 58, 71, 101, 103,
107, 114, 115, 117, 167; adaptive 159,
277; applying strategies 160;
childhood anxiety 281, 282, 286;
common strategy, responsibility
appraisals 139–40; complete lack of
resources 165; development of plans
190; effective 65, 159, 160, 161; FCT
and 109; good 8; helping the child
construct a template 277;
interventions providing skills 151; life
changes and 80; maladaptive styles of
205, 209; new responses 152;
opportunity for child to practise 278;
promising strategies 66; strained 81;
successful 36, 165
core beliefs 165, 227, 230, 246; negative
7, 26; revising 26–7; rigid,
dysfunctional 12
cost-benefit analysis 163
costs 3, 4, 169
countertransference 18; frustrating 19
couples 243–7, 248, 249, 252–9, 261, 264,
Cox, B. J. 119
Craske, M. G. 105
creativity 90
criticism 17, 19–20, 215, 219, 269;
constructive 76; derogatory 218;
extreme sensitivity 191; self 7
cues 85, 277; affective 293; anxiety 157,
158, 159, 160, 161; behavioural 252;
early detection of 152–3;
environmental 281; hostile 292;
physiological 293; social 281, 292;
somatic 105
cyberspace 37
cycles 91; breathing 113; negative 6, 11
Dadds, M. R. 268, 284
Daiuto, A. D. 251
danger 82, 98, 99, 127, 129, 141, 142,
143, 237; future 167; overestimation of
144, 145
DAS (Daily Activity Schedules) 84
DAS (Dyadic Adjustment Scale) 254
Dattilio, F. M. 113, 246, 249, 268
Davidson, G. C. 85
death 7, 53, 59, 100
decatastrophising 165, 190
decentring 5, 189
decision-making 57, 130, 178, 186; dayto-day 79; impulsive 72; snap 83
decision-tree model 177, 178
defeat 5
defectiveness 205, 207, 211–12, 214, 215,
218, 219
defiance 78, 230
deficiency 10
deficits 54–5; see also ADHD
delinquent behaviour 294
delusion 5, 58
demoralisation 6, 33, 74
denial 20, 76, 232
dependence 191, 207, 215, 225, 230
depersonalisation 119, 219
depression 3–48, 72, 74, 77, 80, 103, 104,
106, 153, 296; adolescent 287;
associated with memories and
cognition 204; childhood 279, 288;
clinical 290; cognitive distortions
contributing to 256, 276; comordic
126; Freud and 201; intermittent 289;
management of 267; perfection- ism
and 130; reducing 118; relapse
prevention 220, 291; shifts from
baseline mood to 223; specific
procedures for treatment of 181;
suicidality and 49, 51, 56, 59, 60, 78,
89; bipolar 287–91; youth 288; see also
deprivation 86, 215; emotional 219
Detached Protector mode 219
deterrents to suicide 61, 62, 64, 65
detoxification 9
diabetes 3
diagnosis: ADHD 296, 297; anorexia
nervosa 173; anxiety disorder 283,
284; BD 88; BPD 223–5; depression 3,
9, 287; GAD 150–1, 168; OCD 127;
panic disorder 286; see also DSM-III
diathesis-stress disorder 71
dieting 176, 178, 179, 180, 182–3, 189, 191
difficult cases 219–20
diffuse presentation 203
dignity 82, 85, 90
disadvantages 18, 62, 63, 127, 164, 192,
disappointment 83, 164, 216, 247, 248
disapproval 166
disaster 99
discomfort 207, 214
disconnection 206–7, 215
disengagement 195
disequilibrium 22
disorganisation 74, 86–7
disputation 62
disruptive behaviour 294
distancing methods 162, 213, 225
distractibility 74, 86–7
distraction 108
distress 7, 10, 24, 27, 36, 66, 129, 134;
alleviating and preventing 9; emotional
127, 182; future 13; identification of
sources of 67; images associated with
16, 29; lessons learned during moments
of 75; relationship 244, 247, 248, 252,
257, 266; significant 150
distrust 88, 225
divisiveness 67
dizygotic twins 51
dizziness 106, 107, 112, 113, 116, 118,
Dodge, K. A. 292
downward-arrow technique 134–5, 137,
141–2, 245–6, 252
downward spirals 81
drinking 7, 55
drugs 54, 57, 220
Dryden, W. 266, 267
DSM-III (Diagnostic and Statistical
Manual of Mental Disorders): anxiety
150–1, 168; BPD 223, 224–5;
depression 289, 290; eating disorders
173–4; panic disorder 97, 103, 109,
118–19; personality disorders 201,
203, 220
DTRs (Daily/Dysfunctional Thought
Records) 19, 24–6, 80, 115, 117, 237,
dying 113, 118, 128
dynamic models 179
dysfunction 66, 82, 175, 195, 205, 227,
237, 297; cognitive-processing 276;
family 295; long-term, serious 71;
marital/relationship 243, 244, 248; see
also assumptions; cognition;
constructions; dysfunctional beliefs;
DTR; images; interpret- ations;
Dysfunctional Attitude Scale 165–6
dysfunctional beliefs 5, 8, 14, 18, 19, 32,
36, 117; CT’s strength in assessing and
modifying 91; examining evidence for
and against 188–9; identifying and
correcting 181; relationships 244
dysphoria 21, 72, 76
dyspnoea 118
dysthmia 287
early warning signs 74, 76, 77
eating disorders 130, 173–200, 220; see
also anorexia; bulimia
eating patterns/habits 74, 84, 110, 186,
190, 194; regular 188; suboptimal 73
education 73, 74–7, 109, 110–11, 181–4;
affective 277, 281, 293, 296; schema
212, 228
Ehlers, A. 111
Eidelson, R. J. 244, 249
Eisen, A. R. 282, 283
Ellis, A. 190, 243
Ellis, T. 34
embarrassment 35
Emery, G. 245
emotions 13, 25, 99, 115, 161, 201, 202,
226, 236, 252; anxious 156; ATs and
260–1, 262; difficulties in expressing
193; family 266; inability to identify
and respond to 193; intense 85, 86;
maladaptive 181; negative 152, 213,
243, 253; pent-up 219; previously
avoided 211; stabilising 227; thoughts
influence 110; tracing 245; viewed as
informative 203
empathy 8, 90, 91, 215, 216, 269;
accurate 88
empiricism 21, 22–4, 92; collaborative
131, 132, 202
empowerment 73, 215, 245
emptiness 219, 224
EMS (early maladaptive schemas)
204–5, 210, 211
enactment 255
encouragement 33, 35, 63
Endler, N. S. 119
engulfment 179
enjoyable activities 75
enmeshment 179, 207
enthusiasm 77, 78
entitlement 219
environmental situations 9, 67, 71
epilepsy 112
Epstein, N. 195, 244, 249, 250, 251, 252,
266, 267, 268, 269, 270
Erikson, E. H. 229–30
ERP (exposure and response prevention)
125–7, 131, 145
erratic behaviour 76, 81
escape 100, 106, 112, 113–14; anxiety
maintained via 167
ethics 58, 208
euphoria 85
Everson, S. A. 56
evidence 26, 67, 77, 88, 109, 128, 137,
162; contradictory 213; countering
167; examining 188–9, 190;
idiosyncratic 117; rational evaluation
of 195; substantiating 246, 256;
weighing 263–4
Ewald, L. S. 191
exaggerations 72
excitement 57, 65, 85, 99
exercise 10, 22, 99, 108, 113; excessive
174; repeated 155
expectations 9, 61, 64, 229, 292;
apprehension 151; optimistic 62;
schema-driven 216; unrealistic 243,
244, 247–9
experiential techniques 202, 209, 210,
experiments 108, 111, 163; behavioural
31–2, 116, 138, 139, 140, 142, 144,
145, 165, 167
explanations: alternative 117, 262, 263,
264–5, 278; biased 257
exposure 98, 101–2, 103, 104, 106, 130,
158; experiment viewed as a form of
165; imagery 159; interoceptive 105,
118; prevention 284; progressive 116;
role in CB treatment 131; systematic
108; therapeutic value of 167; see also
externalising disorders 279, 280; see also
ADHD; aggression
extreme sports 85
exuberance 82
failure 3, 5, 7, 10, 11, 72, 89, 165, 207,
faintness 112, 113
Fairburn, C. G. 185
Falloon, I. R. H. 268
families 66, 67, 77, 242–74, 291, 299;
intrusive 90; suicide runs in 51
family therapy 67, 177–8, 194–6, 266,
fantasies 220, 261; sexual 75
fasting 174
fatigue 7, 99, 150; chronic 163
FBI (Family Beliefs Inventory) 250
FCT (Focused Cognitive Therapy) 109,
fears 21, 26, 49, 91, 116, 118, 144, 162,
165–6; agoraphobic 97–8; behaviours
that reduce 107; catastrophic 100, 101;
children’s 282; confronting 107;
contamination 133, 140; justifying
163; related to abandonment 225;
separation 179; short-lived 280
feedback 15, 79, 87, 89, 111, 116, 117,
183, 216, 218; completing the loop 32;
continuous 113; corrective 73;
counteracting the loop 267; extensive
112; honest 19; insufficient 77; key 35;
valuable 80
Feindler, E. L. 293
Fieve, R. 77
‘fight and dwell’ style 138
fight-or-flight response 110
Fincham, F. D. 251
Finch, A. J. 277
Fishman, H. C. 255
Flannery-Schroeder, E. C. 283
flashcards 82–3, 108, 213, 217
Fleming, B, 251
Foa, E. B. 125–6, 131, 141, 284
fond memories 8
food 174, 182, 183, 185, 186; fat-free
188; feared, exposure to 178–9;
quality of 187; quantity of 186–7
forgetting 31
FOS (Family-of-Origin Scale) 251
Foster, S. L. 268, 270
Franklin, Benjamin 84
Franklin, M. E. 131
free will 53
Freeston, M. H. 128, 129, 137, 138, 139,
142, 143, 144
Freud, Sigmund 196
friendships 289
Frost, R. O. 145
frustration 19, 56, 85, 153, 167, 247;
inevitability of 86; low tolerance 225
GAD (generalised anxiety disorder)
150–72, 282, 296
Garland, A. 92
Garner, D. M. 177, 181, 192
Gelder, M. G. 98, 103
genetics 51, 71
gestalt 209
gestures 152, 224; suicidal 50, 55
Gitow, A. 284
global techniques 87
goals 11–12, 34, 65, 71, 73–87, 88, 191,
211, 278; central 288; conflicting 60;
defined 107; failure to achieve 89;
functional 33; long-term 89, 224;
overarching 297; positive, achievable
91; setting 136; vague 10
Goebbels, Joseph 26
Goldfried, M. R. 85
Goldstein, A. J. 98
‘goodness’ 139
Graae, F. 284
grandiosity 72, 76, 77, 191, 220
gratification 76
Greenberg, R. L. 102–3
grief 91
Grotevant, H.D. 251
groups 36–7, 92, 169, 289–90, 298, 299
Guerney, B. G. 269
Guidano, V. F. 188
guilt 17, 25, 128, 133, 137, 186
habit 162
habituation 127
Hackmann, A. 103
hallucinations 5, 58, 65–6
hallucinogens 76
HALT (Hungry, Angry, Lonely, and
Tired) 55–6
happiness 10, 19, 90, 130, 166
hardships 88–9
harm 83, 250, 280; self 33, 49, 224
Harrison, J. 127
headaches 7, 23
heart attacks 106, 140
heart disease 3
heart rate 106, 110, 111, 114, 160, 281
helplessness 6, 88, 191, 225, 245, 246;
perceived 14, 21; reducing 21–2
Henin, A. 283, 284
Herbel, B. 285
heredity 71
high-risk situations 84–5
Hirshfeld, D. R. 92
history 67, 91; psychiatric 87, 88
histrionic suiciders 57–8, 65
Hodgson, R. 126
Hoffart, A. 102
holidays 51, 76
homework 15, 16–18, 35–6, 87, 108, 113,
117, 157, 175, 285; compliance with
116, 126; difficulty with 215;
discontinuing 86; many possible kinds
218; problems encountered with 137;
reviewed 115; rewards and 279; selfexposure 103; typical assignment
hope 12
hopefulness 51
hopelessness 11, 15, 215, 238; BD and
72, 74, 76, 88, 91; suicidality and 49,
50, 52–4 passim, 56–62 passim, 65, 67,
68, 91–2; see also BHS
hormonal functioning 185
hospitalisation 51, 52, 55, 60, 64, 178,
185, 294; disagreement with need for
67; partial 175; past, multiple 91
hostility 225, 247
hot and cold flushes 118–19
Howard, B. 284
humiliation 100
hurt 248
hyperactivity 151; see also ADHD
hyperalertness 98
hypertension 3, 71
hyperventilation 97, 101, 105, 107,
108, 115; breathing incompatible with
114; panic induction through 112–13,
hypervigilance 100, 225
hypnosis 98
hypomania 72, 73, 74, 75, 77, 79, 80, 83;
breathing control 85; overactive
tendency 84; overconfidence 82
ideation: overvalued 126; suicidal 16, 49,
53, 57, 58, 59
identity 188, 191, 224
ignorance 88
illusions 163
imagery 29, 108, 159, 210, 211, 213, 261,
277; anxious 117; coping 117; fearful
113; guided 215, 217; pleasant 154,
156; spontaneous 115; techniques
214–15; training 289
images 7, 8, 12, 18, 20, 24, 109, 113;
accessing 230; anxiety-provoking 159,
160, 161, 162; automatic 11; brief,
threatening 115; catastrophic 159;
distracting 156; dreadful 115;
dysfunctional 23, 29; individual 165;
positive 156, 261; real life 214;
restructuring 107; unwanted 126
imaginal response systems 169
imagination 34
imipramine 97, 103, 298
impasses 34
impulses 126, 132, 207
impulsive behaviour 73, 74, 88, 89, 223,
225, 267, 293, 296, 297
impulsive behaviour control 52, 55, 65,
impulsive suiciders 57, 63, 67
inadequacy 18
inattention 296, 297
incompetence 27, 190, 207
inferences 216, 245; arbitrary 256
information-processing 87, 230–1,
275–6; errors 288; faulty 5, 258
infusions 97
inhibition 207–8, 280
inner-city children 296
insecurity 89
inspiration 33
integration model 177, 178
integrative models 268
intention-to-treat analyses 104
intentionality 251
intentions: negative 257; paradoxical 102
interactions 36, 67, 151, 157, 195, 196;
couple and family 243–4, 247, 249,
250, 252–67 passim, 285; negative 247;
social 87, 190, 292
interests 8
internalising disorders 279–80; see also
anxiety; depression
Internet 37
interoceptive conditioning model 98
interpersonal situations 36, 118, 177,
179, 180, 194, 292, 294; boundaries
225; control 79; focus 193–4; problems
169, 194, 203, 293; relations 216–17,
223, 296; techniques 212, 215
interpretations 25, 27, 107, 108, 114,
131, 179, 193; anxiety-provoking
162–3; dysfunctional 11; negative 162,
interrelationships 9
intervention 35, 100, 108, 110, 117, 145,
177; behavioural 21, 111, 268–70;
child-focused 295; cognitive 32, 65,
111; core beliefs as targets for 165;
exposure 158; family 266, 268, 295;
multicomponent 281; planning 109;
poor result from 8; prevention 290;
providing coping skills 151; reflective
203; self-help 76; specific targets for
153; suicidality 53, 59–66
interviews 67, 252, 286
intimacy 225
intravenous administration 97
intrusions 126–7, 129, 134, 144;
challenging 143; sexual 128, 139
inventories see BAI; BDI; FBI; ISRS;
RBI; Young
irritability 75, 76, 85, 88, 150; shifts from
baseline mood to 224
isolation 7, 190, 207
ISRS (Inventory of Specific
Relationship Standards) 249, 250, 251
Issues Checklist 255
Jacob, T. 251
Jacobson, N. S. 98, 248, 268
Jaffer, M. 284
Jamison, K. R. 77
jealousy 88
jet travel 74, 85
Kahn, D. A. 77
Kane, M. T. 282, 283
Kashani, J. H. 280
Kazdin, A. E. 293
Kendall, P. C. 277, 280, 282, 283, 284,
Kernberg, O. F. 224
‘kindling effect’ 91
Kirk, J. 137
Klein, D. F. 97
Klosko, J. S. 105
Kozak, M. J. 125, 131, 141
labelling 18, 67, 144, 193, 255–8, 293
Ladouceur, R. 128, 145, 146
Lam, D. H. 92
laxative abuse 174, 176, 183–4, 185
Layden, M. A. 7, 224–5
lethargy 72
light-headedness 114, 119
Limb, K. 92
limited reparenting 215
Liotti, G. 188
listening 83, 84, 269; reflective 168
lithium 71, 90
Lochman, J. E. 293, 294
logbooks 83
loss 5, 54; major 55, 56; parental 51;
tragic 7
love 207, 244, 250, 262; partner’s lack of
McCarthy, E. 92
MacDonald, J. 280
McFall, M. E. 126, 128, 130
McLean, P. D. 137, 143
McMaster Family Assessment Device
McMullin, R. E. 22
magnification 256, 257
Mahoney, M. J. 276
maladaptiveness 5, 14, 22, 24, 27, 232,
288; causal attributions 289;
consequences 190; emotions 181;
schemas 204–5, 209, 210, 214;
thoughts 204, 217; see also EMS
maladjustment 291
malevolence 88
malicious intent 250, 251
mania 74; early warning signs 77; see
also hypomania
mania management 87
manic episodes 72, 74, 80, 81, 84; early
stages 82; warning signs 75
manipulative suicide attempts 54, 55, 65
Marchione, K. 102
March, J. S. 285
Margolin, G. 248, 268
Margraaf, J. 105, 111
marital problems 261, 291
Markman, H. J. 269
Marks, I. M. 98, 102, 110, 126
MAS (Marital Attitude Survey) 251
mastery 278, 279, 282
MDD major depressive disorder) 287,
meal planning 175, 178, 186–7
meanings 7, 24, 53, 195, 196; co-creation
of 22; deeper 12, 13; distorted 179,
193; idiosyncratic 108, 113; implicit,
higher-order 188; personal
construction of 6
mechanical eating 186–7
medication: ADHD 298, 299;
antipsychotic 58; anxiety 168; BD 71,
74, 88, 89, 90, 91; depression 4; eating
disorders 174, 187; OCD 125; panic
104–5, 109; psychotropic 89–91;
suicidal behaviour and 52, 55, 65
meditation 154, 156, 158
Meichenbaum, D. 267–8
Meissner, W. W. 224
memory 166, 204, 261; see also fond
menstruation 173, 185
mental illness 3
mental pictures 14
metacognition 22–4
metaphors 8, 12
methylphenidate 298
Middleton, H. 103
Miller, L. S. 297
mind reading 80, 249, 257
minimisation 76, 256
Minuchin, S. 195, 255
misery 7, 34
mislabelling 256
mistakes 25, 28, 33, 208; repeating 76
mistrust 88, 207, 216, 219, 224, 225
MLH (Multimodal Life History) 210
modelling 73, 279, 296
moderation 84
monozygotic twins 51
mood 6, 10, 15, 17, 61, 91, 151, 225, 280;
abnormalities 80; clinical disorders
287; depressed 20, 163, 166;
downturns 13, 14; early warning signs
of problematic shifts 74; elevated 76;
erratic 76; good 75, 77; hypomania
and 75; instability of 223; negative
shift in 23; positive effects on 21;
severe disturbances 81; upswings
Moorhead, S. 92
morality 139
Moras, K. 105
Morriss, R. 92
mortality 56
mothers: bad 29, 30, 31; good 30
motivation 61, 64, 175, 177, 186, 236; for
change 176, 184, 224; selfish 251;
unconscious 181
Mulle, K. 285
multidimensional models 175
multisystemic treatment 296
muscle relaxation 85, 105, 155–8
myocardial infection 56
narcissistic personality disorder 219,
220, 225
nausea 119
Needleman, L. 177
negative framing 258–9, 264
Nelson, W. M. 277
nervousness 57, 58
neurochemical disorder 97
neurological disability 67
‘New Year’s resolution’ style 191
New Zealand 280
Newman, C. F. 34, 118
nicotine 76
Nietzel, M. T. 297
non-compliance 17–18, 35–6, 224
non-directive therapy 168
Norton, G. R. 119
nutrition 10, 184–7
OAD (overanxious disorder) 282, 283,
obedience 250
object relations 209
observation: behavioural 254–5, 283;
clinical 56
obsessions 54; sexual 143; see also
obstacles 255
OCCWG (Obsessive-Compulsive
Cognitions Working Group) 128
OCD (obsessive compulsive disorder) 9,
125–49, 282, 284–5, 287
ODD (oppositional defiant disorder)
Orvaschel, H. 280
Ost, J.-G. 103, 104
O’Sullivan, G. 126
other-directedness 207
outcomes see treatment outcomes
overbreathing 101, 102, 112, 113
overconfidence 82
overdoses 52
overgeneralisation 256
overidealisation 223
overprediction 100, 129
overprotectivenesss 179
overvigilance 207–8
Oxford Cognitive Therapy Package 107,
Ozarow, B. J. 125, 284
pain 19, 33, 206; acute 55; cessation of
34; chronic 55, 220; emotional 225;
intractable 58; stomach 7; paired
words 113
Palmer, A. G. 92
palpitations 112, 113, 114, 118
panic disorder 9, 97–124, 132, 140, 282,
285–6; breathing control 85; central
feature of treatment 144; feared
Panichelli-Mindell, S. 283
paradoxical intention 102
paranoia 225
parent-training approaches 298
Parental Authority Questionnaire 252
passions 8
passive-aggressive behaviour 88
patience 73, 83, 85
Penn State therapy study 157, 162, 165,
perception 53, 188, 204, 213, 259, 266;
biased 28; faulty 267; self 191, 251,
perfectionism 128, 130, 135, 145, 156,
187, 191, 208, 215, 250; challenging
performance 166, 192, 208, 288;
impaired 207; inconsistent 296
Perlmutter, B. E. 251
Perry, A. 92
personalisation 256, 262
personality 251
personality disorders 126; schemafocused therapy for 201–22; see also
Persons, J. 7
pessimism 208
pharmacotherapy 4, 37, 97, 106, 119,
178; compliance with 89, 90; longterm 91
phobias 159, 282
physical complications 184
physiological factors 10, 73, 97, 110, 151,
152, 155; arousal 98, 115, 281, 293;
disturbances 105
Piacenti, J. 284
Piaget, J. 232–3
pie-chart technique 137–8
pills 49, 55
placebo therapy 168
pleasure 20, 21, 30, 193, 208
PMR (progressive muscle relaxation)
155–6, 159
point-counterpoint 28
positives 264
Possible Reasons for Not Doing
Homework Assignments Sheet 35–6
precautions 63
predictability 74
predictions 139, 141, 162; accurate 163,
166; catastrophic 106, 116;
disconfirming 107, 116; fearful 100;
implicit 190; incorrect 32; negative
107, 164, 165, 166, 169; testing 263–4;
see also overprediction
predisposition 7, 35, 175
premonitions 139
Pretzer, J. L. 250
Printz, D. J. 77
priorities 107
problem-solving 12, 13, 87, 89, 98, 107,
236, 268; advanced 72; application of
techniques 117; assessing 251;
collaborative and constructive 250;
effective 5, 49, 80, 81, 294;
exemplifying 293; exploring options in
terms of 34; helpful 166; improving
skills 255; ‘middle-ground’ approach
82; modelling of strategies 296–7;
poor strategies 54; practical 32–3;
principles/practices 73, 81; social 59,
277, 292; thought of as a sequence
278; training 270
procrastination 7
protection 12, 214
provocation procedures 105
psychiatric problems 5, 91; comordic
disorders 9; inpatient children 294
psychoactive substances 73
psychoanalysis 196, 205, 216, 243
psychodynamic therapy 105, 179, 243,
psychological treatments 97–8, 105, 106
psychology 202; social 131–2
psychopathology 182, 203, 204, 280, 285
psychosocial treatment 71, 73, 105,
125–49; failure to respond to 178;
periodic 91
psychotic features 231
psychotic suiciders 57, 58, 65, 66
PTSD (post-traumatic stress disorder)
282, 286–7
public places 98
punishment 289
Punitive Parent mode 219
Purdon, C. 129
quality of life 76, 91, 107, 117
Rachman, S. 110, 125, 126, 124, 128
rage 189, 225, 245; pent-up 219
RAM (Relationship Attribution
Measure) 251
random killing 128
Rankin, L. A. 249, 251
rape 238
Rapee, R. 284
rapport 59, 60
RAR (reasonable adaptive response) 25,
26, 28, 29
rational-emotional therapy 27, 102; see
also REBT
rational suiciders 57, 58
RBI (Relationship Belief Inventory) 249
reactions 34, 67, 111, 113, 115, 116, 152,
204, 231; antitherapeutical 224; child’s
body 277; exaggerated 258; impulsive
267; physiological 159; rage 225
reading impairment 16
reality 73, 77–80, 163, 164; construction
of 6
reappraisal 116, 276
reasonableness 247
reasoning 77, 117, 128, 178;
dichotomous 189–90; emotional 21,
137; faulty 129
reassurance 225
reattribution 108, 191
REBT (Rational-Emotive Behaviour
Therapy) 243
recklessness 73, 82–5, 225; manic 81
reflective delay 73
refocusing 109, 114, 115, 117, 157, 166
reframing 92, 187–8, 262–3, 264
regression 215
regret 86
reinforcement 282; contingent 277; self
288, 289
rejection 25, 206–7, 215; peer 291; social
relapse 4, 104, 125; prevention 36, 108,
117, 144, 202, 220, 289, 291;
protection against 12; reframing 187–8
Relationship Attribution Questionnaire
relationships 9–10, 19, 226; assessment
249–55; beliefs about 245–6;
collaborative 202, 203; difficulties in
80; functional 179; historical 194;
integral 12; interpersonal 216–17, 223,
296; primary attachment 203; sexual,
illicit 86 see also couples: families
relaxation 22, 73, 75, 102, 108, 109, 117,
151, 165, 285, 286, 294; applied 103,
104, 154, 158, 168; Jacobsian 85;
methods 154–61; progressive 277
relief 10–11, 86
remission 90
reparative corrections 76
repetition 26, 156, 213
representation 205; mental 29; verbal
‘rescue’ 65
resentment 248
resistance 28, 79, 176, 203, 225, 248
respect 90
responsibility 127, 133–4, 139–40, 248,
251; disowning 260–1; inflated 128,
129, 135, 137–8, 145
restlessness 151
resuscitation 58
‘rewarding non-punishment’ 133
rewards 166, 278–9, 289, 292; self 293
Rheume, J. 128, 145
RIA (relaxation-induced anxiety) 156,
rights 193, 225; equal 248; suicidal
patients 52–3, 58
rigidity 193, 203–4; cognitive 59
risk 84–5, 107, 129, 131; avoidance of
190; mood abnormalities 80; suicidal
50, 51, 53–5, 56, 57, 64, 67, 82
Robin, A. L. 268, 270
role play 28, 73, 162, 209, 261, 277, 278;
Devil’s advocacy 78–9; rationalemotional 27
Ross, R. 77
Roth, W. T. 111
Rubin, K. H. 280
ruination 250
Rush, A. J. 245
Sachs, G. S. 77, 92
sacrifices 86
SAD (separation anxiety disorder) 282,
283, 287
sadness 164
safety behaviours 7, 49, 54, 100, 106–8
passim, 111, 114; dropping 116, 117
Safran, J. D. 5–6
Salas-Auvert, J. A. 113
Salkovskis, P. M. 103, 106, 125, 126–7,
137, 140, 145
Sanders, M. R. 268
satisfaction 244
scanning 151
SCD (self-control desensitisation) 151,
159–61, 165, 166
schema compensation 206
schemas 66, 175, 188, 216, 226, 227–30;
activated by anxiety 236; family 190;
interpersonal 193, 194; maladaptive
204–5, 209, 210, 214
schizophrenia 5
Schlesinger, S. E. 266, 267
Scott, J. 92
screaming 245, 246
Segal, Z. V. 5–6, 204
selective abstraction 256
self: distorted view of 212; negative
interpretations of 201; overwhelmed
191; perfectible 191; underdeveloped
sense of 225; unworthy 191
self-attributions 190
self-compassion 6
self-concept 191–2
self-consciousness 59
self-control 52, 289, 293; see also SCD
self-damage 49, 67, 223
self-defence 139
self-destruction 49, 178
self-doubt 178
self-efficacy 6, 22, 78, 213
self-esteem 191, 292; behaviours that
increase 107; fragile 79–80; improving
191–2; very low 225
self-estimation 178
self-evaluation 288, 289, 293, 296
self-focus 100, 280
self-fulfilling prophecy 100
self-hatred 219
self-help 14, 36–7, 74, 76, 92
self-image 223
self-instruction 83–4, 89, 102, 267
self-monitoring 73, 86, 89, 151, 178, 179,
185–6, 289; early cue detection and
152–3; exaggerated 193; problematic
absence of 82
self-mutilating behaviour 223, 224
self-programmes 117
self-regulation 110, 299
self-reliance 117
self-reports 53, 54, 249–52, 254, 283, 285
self-restraint 73
Self Soother mode 219, 220
self-statements 86, 281, 293
self-talk 278, 282, 285
self-worth 142, 191; ‘balance sheet’
concept of 192; vague assumptions
about 192
sensations 193; panicogenic 108, 112,
115; somatic 105; see also bodily
sensory channel 230
sentiment 253
separation-individuation 179
serious affective disorders 89
sexual abuse 30, 88, 231, 286
SFT (schema-focused therapy) 201–22
Shafran, R. 128
shaking 118
shame 29, 76, 128, 133, 137, 207
Shaw, B. F. 245
Shure, M. B. 293
side-effects 71, 90, 91
sights 156, 160
significant others 51, 58, 60; reliable 63;
use of, in therapy 66–7
Silva, P. de 110, 126, 127
Silverman, W. K. 282, 283
simplicity 191
sleep 73, 74, 75, 154, 163; disturbances
22, 150, 298
slowing down 87, 89
smell 8, 156, 160
snacks 184, 186
social contact 7
social environments 191
social learning model 242, 275
social skills 12, 288, 289, 299
socialisation 13–14, 84, 108, 235
sociocultural effects 6
Socratic questioning 19, 24, 29–30, 68,
77–8, 89, 107, 236, 252; guided
discovery as established through 132;
persistent 111
Sokol, L. 102–3
somatic sensations 105
sounds 156, 160
Southam-Gerow, M. A. 283
spacing eating 186
Spanier, G. B. 254
Special Self mode 219
specific techniques 19–20
Spivack, G. 293
spontaneity 82, 87, 207
SSI (Scale of Suicidal Ideation) 54
stability 74
standards 249–50, 252, 288
Stanley, S. 269
Stark, K. D. 291
startle response 151
starvation 175, 176, 182; physical
complications associated with 184
Steketee, G. 125, 145, 284
stepped-care model 177, 178
STEP-BD project 92
stigma 3
stimulants 76
stimulation 57, 65, 75, 84, 220, 225
stimuli 55, 258, 285; conditioned 98;
discriminative 154; external 98, 105;
feared 281; internal triggering 99;
interoceptive 105; phobic 159
stimulus control 84, 100, 151, 153–4
‘Stop and Think’ treatment 296
Straus, M. A. 251
stream of consciousness 237
stress 7, 10, 55, 71–2, 73, 80–1, 278;
coping with 8, 107; hyperventilation
induced by 101; identification and
modification of stressors 117; see also
strife 75
Stuart, R. B. 264, 268
Subjugation schema 218, 219
substance abuse 7, 9, 10, 55, 73, 84, 220,
223, 225, 280, 288
success 18, 19, 33
suffering 30, 33
suffocation 113
suicidality 16, 49–70, 78, 82, 89, 224,
290; addressing 33–4; hopelessness
and 49, 50, 52–4 passim, 56–62 passim,
65, 67, 68, 91–2
superiority 207, 219
support mechanisms 10, 67
suppression 129, 139
suspicion 225
sweating 119
Swinson, R. P. 119
symmetry/exactness compulsions 130
sympathetic nervous system 83, 155
symptoms: ADHD 296, 297, 298, 299;
anxiety/panic 98–103 passim, 107–15
passim, 118, 119, 280, 281; BD 71, 74,
77, 84, 86, 92; depressive 4, 6, 9,
10–11, 13, 15, 72, 291; eating disorders
175–9 passim, 182, 184, 185–6, 190,
191, 194, 195; GAD 150–1;
hyperventilation 113;
neurophysiological 111; OCD 125–6,
136–7; physiological arousal 98;
psychotic 65, 66; suicidality 67; PTSD
286; starvation 176, 182
TAF (thought-action fusion) 128, 138–9
target problems 11–12
Tarrier, N. 92
Taylor, C. B. 111
teenagers 250
Telch, M. J. 105
temper tantrums 64
Temple University 282
Tennenbaum, D. 251
tension 86, 156, 160, 277; motor 151;
muscle 150, 152, 155, 158, 166
Thase, M. E. 92
therapeutic alliance see therapeutic
therapeutic relationship 11, 88, 131, 176,
212, 235; boundaries of 215;
distortions in 20; importance of 176;
nature of 87; nurturing 34–5; quality
of 87, 111; ruptures in 167; schemas
triggered within 216; strong 176
thinness 178
Thordarson, D. S. 128
‘thought bubbles’ 278
thoughts/thinking 6, 16, 34, 106, 109,
110, 115, 162; active restructuring of
59; adaptive 10, 28; alternative 164;
biased 72, 77, 81–2; blasphemous 140;
catastrophic 111, 190, 204; control
over 129, 139–40; depressogenic 289,
290; dichotomous 187, 256; distorted
5, 205, 263; distracting 156;
dysfunctional 5, 23, 53, 188, 189, 257,
264; erratic 76; extreme or all-ornothing 224; faulty 243, 247, 277;
hyper-positive 77–80; improved
process 107; individual 165; intrusive
126, 127, 131, 133, 134, 138, 140, 143;
irrational 243; maladaptive 204, 217;
mindreading 249; monitored 235;
negative 243; non-anxiety-provoking
165; obsessive 144; overimportance of
128–9, 135, 138–9, 145; perfectionist
187; pessimistic 73; powerful
impediments to 28; previously avoided
211; problematic 77; reality testing of
73; schema-driven 216; suicidal 49, 54,
55, 57, 59, 60, 62; threatening 127;
unfocused 86; unwanted 126, 129, 134,
139; worrisome 154, 156, 166; see also
ATs; TAF threat 56, 106, 127, 225;
neutralised 133; over- estimation of
128, 129, 140–1, 144; tolerance 85,
184, 225
Touliatos, J. 251
Tran, G. Q. 118
transference 179
trauma 76, 88, 231, 275; early childhood
245; see also PTSD
treatment outcomes depression 8; GAD
156, 157, 167–9; OCD 125, 126, 140,
144–6; PD 103, 105
trembling 118, 119
tricyclics 52
triggers 36, 67, 117, 226, 227, 231, 259;
anxiety 152, 153, 158, 159, 161; OCD
133; panic attacks 99, 100, 110, 115;
schema 206, 209–11 passim, 213, 216,
trust 7, 88, 235; self 191
truth 12, 26, 116, 276
tunnel vision 256
turbulence 8
twins 51
ulterior motives 257
uncertainty 224; intolerance of 128,
129–30, 141–2
uncontrollable behaviours 293
undercontrolled behaviour 72
understanding 6, 11, 49, 233, 236;
limited 50; self 8
unfairness 250
unhappiness 10
United Kingdom 3, 118
United States: BD 71; depression 3, 4;
OCD 128; panic attacks 118
University of British Columbia 145
unloveability 225, 226, 229
unpredictability 84
unreality 112
Unrelenting Standards schema 215, 219
urges 133, 182
urination 151
validity and reliability 193
van den Hout, M. 104
van Oppen, P. 129, 137, 140, 143, 144,
verbal channel 231
‘vicious circle’ model 99
vigilance 82, 151; see also hypervigilance;
Vincent, J. T. 252
visual impairment 16
visualisation 28–9, 161, 215
Vitousek, K. B. 191
voices 58, 66
vomiting 176, 177, 185, 187; involuntary
196; preventing 179; self-induced 174,
180, 183
vulnerability 6, 54–5, 187, 207, 245;
perceived 246; suicidal patients 55–6
Vulnerable Child mode 219
Warman, M. 283
weakness 3, 67, 88
Weiss, R. L. 252
well-being 22
Wells, A. 108
Westbrook, D. 125
Westling, B. E. 103, 104
Whitaker, A. 284
Whittal, M. L. 137, 143
Wilhelm, S. 145
‘wise sayings’ 82–3
withdrawal 7, 182, 225, 262, 263, 280;
medication 125
Wollersheim, J. P. 126, 128, 130
work schedules 74
workaholism 220
World Wide Web 37
worry 150–72, 280
Wright, F. D. 102–3
YBOCS (Yale-Brown ObsessiveCompulsive Scale) 145, 146
Young, J. E. 202, 203, 204, 206, 208, 220,
228; Inventories 210
‘zeitgebers’ 74